Biochemical-molecular and imaging techniques for diagnosing auto-immune bullous diseases :The three-tier approach

Autoimmune bullous diseases (ABDs) are requiring precise diagnosis as generally aggressive, having potentially lethal side-effects, treatment is necessary. Nowadays, they can be reliably diagnosed using a combination approach with biochemical-molecular and imaging techniques. Taking into account cost effectiveness, I am using an imaging, single-step direct immunofluorescence (DIF) of perilesional tissue and/or of plucked scalp hair for evaluation of IgA, IgG, IgM, C3 as well as IgG4 and IgG1 subclasses deposits visualized with up to three various microscopic systems with an analysis of pattern of deposits. In addition to DIF, still golden standard for diagnosing ABDs, serum studies using biochemical-molecular techniques, namely ELISA, are necessary. Currently, I am using a multi-analyte ELISA enabling the detection of IgG antibodies to desmoglein 1/3, BP180/BP230, envoplakin and type VII collagen in a single procedure. In case of clinical suspicion of dermatitis herpetiformis an ELISA for serum IgA antibodies to tissue transglutaminase, instead of multi-analyte ELISA,  is used in addition to DIF. Such a dual imaging/biochemical-molecular approach is usually sufficient to detect autoimmune nature of a blistering dermatosis in question enabling one to resign from performing H+E histology and indirect immunofluorescence (IIF) studies. Only in cases where it is absolutely necessary, the IIF on a mosaic substrate and/or cells transfected with various epitopes of laminin 332 can be used. Despite substantial progress in diagnosing ABDs heading toward all-in-one methodology encompassing both IgG and IgA autoimmunity, treatment schemes are still unsatisfactory. The aim of future therapeutic efforts should be based on a personalized medicine principle using biotechnology achievements.

Professor Marian Dmochowski MD/PhD  is the Head of Autoimmune Blistering Dermatoses Section, Department of Dermatology, Poznan University of Medical Sciences, Poznan, Poland. His research interests are focusing on autoimmune blistering dermatoses, particularly  issues of improving diagnosing them with imaging and biochemical-molecular techniques, their comorbidities/triggers/sustainers and improving management. His publications were cited almost 1,000 times. He was an active member of the Society for Investigative Dermatology (USA).