J C Bystryn

Systemic corticosteroids remain the mainstay of therapy for pemphigus. Their use has transformed what was almost invariably a fatal illness into one whose mortality is now below 10%. Unfortunately, the high doses and prolonged administration of corticosteroids that are often needed to control the disease result in numerous side effects, many of which are serious. Most patients who die of pemphigus at present die of complications of therapy. This has led to a continued search for alternative treatments that might reduce the need for steroids. Those treatments now in use are usually given in combination with steroids and, for that reason, are referred to as adjuvant therapies. This article summarizes progress in the adjuvant therapy of pemphigus since the last review of this subject 10 years ago.

Most patients with active vitiligo (82% of 61) have antibodies to antigens of normal human melanocytes that can be detected by specific immunoprecipitation of radioiodinated, detergent-soluble, melanocyte macromolecules. Such antibodies were present in only 12% of patients with melanoma and in none of 35 patients with nonpigmentary skin diseases. The antibodies were directed to a common antigen(s) on melanocytes that was not present on normal fibroblasts or keratinocytes. These observations suggest that vitiligo is an autoimmune disease mediated by antibodies to melanocyte-associated antigen(s).

Current reports have suggested a role for intracellular adhesion molecule 1 (ICAM-1) in the progression of human malignant melanoma and other cancers. Stage I, II, and III patients with histologically diagnosed malignant melanoma had significantly increased serum levels of circulating ICAM-1 (cICAM-1) and a striking increase in the incidence of positive sera. In Stage II and III patients, the level of cICAM-1 was inversely correlated with survival. Patients with elevated levels of serum cICAM-1 (greater than 2 SD units above control mean) had a significantly shorter mean survival. We suggest that elevated levels of serum cICAM-1 may be of diagnostic and prognostic importance in patients with malignant cutaneous melanoma.