Lamina Lucida Research Articles

Adhesive stripping to remove epidermis in junctional epidermolysis bullosa for revertant cell therapy

Replacing mutant skin in epidermolysis bullosa (EB) by epithelial sheets of transduced autologous keratinocytes is the essential surgical step of ex vivo gene therapy. The same applies for revertant cell therapy in which epithelial sheets of revertant autologous keratinocytes are used. Revertant cells can be found in patches of normal skin in patients with junctional EB (JEB) due to revertant mosaicism caused by in vivo reversions. To develop a technique of adhesive tape stripping as a method for epidermis removal to prepare the acceptor site for revertant cell therapy in a patient with revertant mosaic JEB. We performed revertant cell therapy on a patient with mosaic type XVII collagen-deficient non-Herlitz JEB. Skin biopsies were taken from revertant skin on the wrist. Graft production took place on a 3T3-J2 feeder layer resulting in two 6 x 7 cm grafts. An innovative method that uses the pathological plane of least resistance of JEB skin was developed to prepare the acceptor site. A polyacrylate adhesive plaster was placed on the skin and then pulled off with the epidermis. The epidermis was easily removed with the plaster. The skin separated at the level of the lamina lucida, leaving a bloodless wound bed of naked lamina densa. Transplantation was successful; the acceptor site healed without scarring. However, blistering could be provoked. The functional repair was not achieved due to the low percentage of revertant cells in the graft. We conclude that adhesive stripping is a simple, effective and almost painless procedure for removing epidermis for ex vivo cell therapy in EB.

Epidermolysis bullosa acquisita: concise review and practical considerations

Introduction Epidermolysis bullosa acquisita (EBA) is a cutaneous subepi-dermal autoimmune blistering disorder (CSEAIBD) that resultsfrom the effects of IgG autoantibodies directed against the145-kDa noncollagenous amino-terminal (NC-1) domain ofcollagen VII, a major component of anchoring fibrils (Fig. 1).

Type XVII Collagen is a Key Player in Tooth Enamel Formation

Inherited tooth enamel hypoplasia occurs due to mutations in genes that encode major enamel components. Enamel hypoplasia also has been reported in junctional epidermolysis bullosa, caused by mutations in the genes that encode type XVII collagen (COL17), a component of the epithelial-mesenchymal junction. To elucidate the pathological mechanisms of the enamel hypoplasia that arise from the deficiency of epithelial-mesenchymal junction molecules, such as COL17, we investigated tooth formation in our recently established Col17(-/-) and Col17 rescued mice. Compared with wild-type mice, the incisors of the Col17(-/-) mice exhibited reduced yellow pigmentation, diminished iron deposition, delayed calcification, and markedly irregular enamel prisms, indicating the presence of enamel hypoplasia. The molars of the Col17(-/-) mice demonstrated advanced occlusal wear. These abnormalities were corrected in the Col17 rescued humanized mice. Thus, the Col17(-/-) mice clearly reproduced the enamel hypoplasia in human patients with junctional epidermolysis bullosa. We were able to investigate tooth formation in the Col17(-/-) mice because the Col17(-/-) genotype is not lethal. Col17(-/-) mouse incisors had poorly differentiated ameloblasts that lacked enamel protein-secreting Tomes' processes and reduced mRNA expression of amelogenin, ameloblastin, and of other enamel genes. These findings indicated that COL17 regulates ameloblast differentiation and is essential for normal formation of Tomes' processes. In conclusion, COL17 deficiency disrupts the epithelial-mesenchymal interactions, leading to both defective ameloblast differentiation and enamel malformation.

A Structure Resembing Basal/External Lamina on the Surface of Plasma Cells, and a Discussion on Intercellular Contacts Between Hemolymphoid Cells

Basal/external lamina is not found over plasma cells or other hemolymphoid cells, and the feature can have diagnostic value in distinguishing the neoplastic counterparts of such cells from epithelium, endothelium, mesothelium, and so on, which do have this feature. In this paper, a material ultrastructurally indistinguishable from basal or external lamina is reported on reactive plasma cells found in a fibrous pseudotumor, intralobular stroma of normal breast, tumor stroma of squamous cell carcinoma, and submucosa of normal human small intestine. It was focal, followed the contours of the cell-surface membrane, was lightly textured, 40–80 nm thick, and separated from the plasma cell surface membrane by a clear space resembling a lamina lucida. Its function remains uncertain, although it may implement adhesion to other cells, as part of the immune functions that plasma cells and other hemolymphoid cells perform in the gut, for example, and elsewhere.

Viability of corneal epithelial cells and cleavage of corneal basement after ethanol effect

To evaluate the viability of corneal epithelial cells and to determine the anatomic cleavage on the epithelial basement membrane after various exposure times to 20% ethanol during epithelial flap preparation in laser-assisted subepithelial keratectomy (LASEK) in cadaver eyes. Six human cadaver eyes were exposed to 20% ethanol for 20, 30 and 40 seconds (2 eyes for each group), and another one eye was used as the control. PCNA staining was performed to determine the viability of corneal epithelial cells. Immunofluorescence staining using monoclonal antibodies against collagen VII, and immunohistological staining using monoclonal antibodies against laminin were performed to detect the anatomic location of the cleavage plane on the corneal epithelial flaps created by 20 seconds exposure to 20% ethanol in cadaver eyes. Hematoxylin and eosin staining of epithelial flaps revealed a coherent stratified epithelium. The PCNA positive rates of the epithelial cells in the flap decreased in the 20-second group, 30-second group and 40-second group successively. Immunohistological staining to laminin was patchy in the lifted flap and the remaining corneal basement membrane. Immunofluorescence to collagen VII, the main component of anchoring fibrils remained exclusively in the corneal bed. Viability of the epithelial flap decreased with longer time exposure to ethanol. The cleavage plane of the ethanol-treated corneal epithelial flap is located between the lamina lucida and the lamina densa of the basement membrane where laminin forms hemidesmosome.

Skin Pathology Induced by Snake Venom Metalloproteinase: Acute Damage, Revascularization, and Re-epithelization in a Mouse Ear Model

Viperid snakebite envenomation induces blistering and dermonecrosis. The pathological alterations induced by a snake venom metalloproteinase in the skin were investigated in a mouse ear model. Metalloproteinase BaP1, from Bothrops asper, induced rapid edema, hemorrhage, and blistering; the latter two effects were abrogated by preincubation with the metalloproteinase inhibitor batimastat. Neutrophils did not play a role in the pathology, as depletion of these cells resulted in a similar histological picture. Blisters are likely to result from the direct proteolytic activity of BaP1 of proteins at the dermal-epidermal junction, probably at the lamina lucida, as revealed by immunostaining for type IV collagen and laminin. Widespread apoptosis of keratinocytes was detected by the TUNEL assay, whereas no apoptosis of capillary endothelial cells was observed. BaP1 induced a drastic reduction in the microvessel density, revealed by immunostaining for the endothelial marker vascular endothelial growth factor receptor-2. This was followed by a rapid angiogenic response, leading to a partial revascularization. Skin damage was followed by inflammation and granulation tissue formation. Then, a successful re-epithelization process occurred, and the skin of the ear regained its normal structure by 2 weeks. Venom metalloproteinase-induced skin damage reproduces the pathological changes described in snakebitten patients.

Epi-laser in situ keratomileusis: Comparative evaluation of epithelial separation with 3 microkeratomes

To evaluate the cleavage plane, corneal cytoarchitecture, and cell vitality of separated corneal epithelial sheets created with 3 commonly used microkeratomes. Laboratories of the Regensburg University Medical Center, Regensburg, Germany. Mechanical separation of the epithelial layer in 10 porcine eyes and 2 human eyes was performed with 3 different microkeratomes (Amadeus II, Zyoptix XP, Epivision). Five of 10 porcine corneas and the 2 human corneas treated with each microkeratome were processed for histology, electron microscopy, and immunohistochemistry. In 5 of 10 porcine corneas, the corneal epithelial sheets were separated from the globe and cell vitality was assessed with the trypan blue dye vitality test. A reproducible epithelial separation with a smooth surface was achieved in all eyes. The cleavage plane was located between the lamina lucida and the lamina densa. Damage to epithelial cells was mainly limited to the cut margins. Mechanical separation of the epithelial sheet in epithelial laser in situ keratomileusis (epi-LASIK) was safe and reproducible with all evaluated microkeratomes. Immunohistochemistry and electron microscopy showed the cleavage plane in epi-LASIK was between the basal epithelium and the basement membrane at the level of the lamina lucida.

Kindler syndrome: a study of five Egyptian cases with evaluation of severity

Kindler syndrome (KS) is a rare genodermatosis characterized by four major features (acral blisters, photosensitivity, poikiloderma, and cutaneous atrophy) and many associated findings. The diagnosis of KS includes clinical features, ultrastructural findings, and, recently, immunostaining and genetic studies. Varying degrees of severity of the syndrome have been described. Five patients with clinical features consistent with KS were included in this study. All patients were subjected to histopathologic and ultrastructural studies. Cases 1 and 2 presented with severe major features, severe mucosal involvement, and many other associated findings. Case 3 presented with severe major features, but mild and limited mucosal involvement and other associated findings. Cases 4 and 5 showed mild major features and few other findings. Histopathology revealed nonspecific poikiloderma. Marked thickening of the lamina densa and splitting of the lamina lucida were the main ultrastructural findings. KS may be classified into mild, moderate, and severe according to the severity of the major features and mucosal involvement. Because histopathologic and ultrastructural findings are not pathognomonic, clinical features remain the mainstay for the diagnosis of KS, and the need for immunostaining with kindlin antibody and genetic studies may be restricted to early cases with incomplete features.

Discovery of Specialized Basement Membrane Zone Proteins and their Alterations in Epidermolysis Bullosa

Based on electron microscopic observations, in the 1970s it was assumed that the hemidesmosome–anchoring filaments–anchoring fibrils complex mediated the stable adhesion of the epithelium to the basement membrane, and that the external surface of the hemidesmosome carried a receptor for unidentified matrix component(s) responsible for hemidesmosome adhesion. However, the chemical nature of the hemidesmosome and that of the anchoring devices was unknown. A crucial milestone was the identification of collagen VII and laminin 5 as the specialized basement membrane zone proteins that compose the anchoring fibrils and anchoring filaments, respectively. In 1986, Sakai et al. (1986) reported the development of a monoclonal antibody specific for collagen VII that was immunoreactive with all the tissues known to synthesize anchoring fibrils. Furthermore, ultrastructural immunolocalization of the monoclonal antibody disclosed the exclusive presence of collagen VII within the anchoring fibrils, and visualization of the antibody–collagen VII complex after rotary shadowing revealed the dimeric nature of the collagen VII molecules. The authors also provided evidence that anchoring fibrils are unstaggered parallel arrays of dimeric collagen VII, which is mainly synthesized by the epithelium. The assumption that collagen VII is the major component of anchoring fibrils was confirmed 3 years later by Bruckner-Tuderman et al. (1989). Using immunoelectron microscopy and immunochemistry approaches, these authors clearly demonstrated that the absence of anchoring fibrils in patients with dystrophic epidermolysis bullosa, a severe inherited skinblistering disease characterized by an extreme fragility of upper papillary dermis, correlated with an impaired expression of collagen VII. This study unveiled the pivotal role of collagen VII in the stability of dermal–epidermal junction and for the first time designated a gene encoding a basement membrane protein, collagen VII, as a candidate in a skin condition characterized by disadhesion of the epithelial cell/basement membrane from the underlying mesenchyme. In 1991, an elegant study by Rousselle et al. (1991) reported the identification of kalinin, a basement membrane protein synthesized by the keratinocytes that predominantly colocalizes with anchoring filaments. Kalinin was characterized using a combination of techniques (immunoelectron microscopy, biochemistry and cell biology) that disclosed the functional complexity of this adhesion ligand, which strongly modulates the motility of epithelial cells. Interestingly, the tissue distribution and the electrophoretic pattern of kalinin resembled that of BM600 (later renamed nicein), a heterotrimeric protein of the dermal– epidermal junction described by Verrando et al. (1991). BM600–nicein was detected in all the epithelial basement membranes that harbor hemidesmosomes, but its expression was found to be strongly reduced in patients with junctional epidermolysis bullosa. This inherited skin disease is characterized by blister formation correlated with the perturbation of hemidesmosomal integrity and cleavage within the lamina lucida of the dermal–epidermal junction, which is where the anchoring filaments are localized. In 1993, a timely work by Marinkovich et al. (1993) provided extensive biochemical and immunologic evidence that kalinin and nicein are identical. This breakthrough clarified the overall picture drawn from the increasing information on the diverse roles of kalinin–nicein (later renamed laminin 5) in cell adhesion, proliferation and differentiation. The papers highlighted above underscore the transition from the ‘classic’ approaches of cutaneous biology, which was essentially based on morphologic analyses, to studies relying on tools and methods allowing exploration at the molecular and genetic levels for the function(s) of the specific components of the cutaneous basement membrane involved in the different forms of epidermolysis bullosa.

Metastatic ovarian carcinoma-associated subepidermal blistering disease with autoantibodies to both the p200 dermal antigen and the γ2 subunit of laminin 5 showing unusual clinical features

Anti-p200 pemphigoid is an autoimmune subepidermal blistering disease characterized by autoantibodies to an unknown 200-kDa acidic noncollagenous glycoprotein of the lower lamina lucida, whereas antilaminin 5 mucous membrane pemphigoid is characterized by autoantibodies to a major basement membrane extracellular matrix, laminin 5. We report a 64-year-old Japanese woman with a subepidermal blistering disease associated with lymph node metastasis of ovarian clear cell carcinoma 10 years after its surgical treatment. Clinical features showed severe blisters and erosions on multiple mucous membranes (i.e. lip, oral cavity, nose, eye, genitalia and anus) and on both the periungual and subungual regions. This is the first report in which an immunoblot analysis revealed the unusual combination of autoantibodies to both the p200 antigen and the gamma 2 subunit of laminin 5.

Histopathology of Anti-p200 Pemphigoid

Anti-p200 pemphigoid is an autoimmune subepidermal blistering disease characterized by circulating and tissue-bound antibodies against a 200-kd glycoprotein (p200) of the human dermis. We reviewed 10 lesional biopsies from seven patients with anti-p200 pemphigoid in an attempt to define typical histopathologic features of this disease. All biopsy specimens showed subepidermal blistering and a moderate to dense inflammatory infiltrate in the upper dermis. Immunohistochemical analysis localized type IV collagen to the dermal side of the blister, suggesting that split formation occurred within the lamina lucida of the cutaneous basement membrane. The inflammatory infiltrate was composed almost exclusively of neutrophils in six biopsies and contained a mixture of neutrophils and eosinophils in the remaining four. In three specimens, microabscess formation in the papillary dermis adjacent to the blister cavity was noted. Neutrophilic and eosinophilic spongiosis was found in five and three biopsies, respectively. We conclude that histopathology of anti-p200 pemphigoid is characterized by subepidermal blistering and a superficial inflammatory infiltrate, which is usually dominated by neutrophils but occasionally contains significant numbers of eosinophils. While this microscopic picture mimics that of linear IgA disease, dermatitis herpetiformis, or bullous pemphigoid, it should also alert a histopathologist to the possibility of anti-p200 pemphigoid and prompt immunofluorescence and immunoblotting studies for definite diagnosis or exclusion of this autoimmune subepidermal blistering disease.

Vesicular pemphigoid with circulating autoantibodies against 230‐kDa and 180‐kDa proteins, and additional autoantibodies against 97‐kDa and 45‐kDa proteins

The vesicular variant of bullous pemphigoid is a clinical entity in which the principal type of lesions are multiple small tense vesicles in a symmetric distribution, instead of the classical large, more randomly distributed large bullae. We describe a 62-year-old female who developed a vesicular variant of bullous pemphigoid, with intensely pruritic vesiculopapular eruptions and erythematous irregularly outlined patches confluent on the face, neck, trunk, extremities and oral mucosa. Direct immunofluorescence revealed a linear deposition of IgG and C3 at the basement membrane zone of the skin, and indirect immunofluorescence detected circulating IgG autoantibodies reacting with antigens located on the epidermal side of skin split with 1 M NaCl. Indirect immunogold electron microscopy revealed IgG deposition at the underneath membrane of the basal cells and in the lamina lucida. In addition to the 230-kDa and 180-kDa bullous pemphigoid antigen, immunoblot analysis also demonstrated the presence of IgG antibodies reactive with 97-kDa and 45-kDa protein. Treatment with systemic corticosteroid, minocycline and antihistamines plus topical steroid resulted in moderate improvement. A few vesicles, however, continued to appear intermittently during the past year of treatment.

Initial Events in Establishing Vaginal Entry and Infection by Human Immunodeficiency Virus Type-1

SummaryUnderstanding the initial events in the establishment of vaginal human immunodeficiency virus type-1 (HIV-1) entry and infection has been hampered by the lack of appropriate experimental models. Here, we show in an ex vivo human organ culture system that upon contact in situ, HIV-1 rapidly penetrated both intraepithelial vaginal Langerhans and CD4+ T cells. HIV-1 entered CD4+ T cells almost exclusively by CD4 and CCR5 receptor-mediated direct fusion, without requiring passage from Langerhans cells, and overt productive infection ensued. By contrast, HIV-1 entered CD1a+ Langerhans cells primarily by endocytosis, by means of multiple receptors, and virions persisted intact within the cytoplasm for several days. Our findings shed light on the very earliest steps of mucosal HIV infection in vivo and may guide the design of effective strategies to block local transmission and prevent HIV-1 spread.

Síndrome de Bart asociado a epidermólisis ampollosa hereditaria letal (Herlitz)

We present the case of a newborn with congenital absence of skin in the anterior part of the left leg that shortly after developed bulla and erosions in hands, feet, ears, buttocks and mouth. The cutaneous biopsy and ultrastructural and immunohistochemical studies showed a subepidermal bulla in the lamina lucida, absence of hemidesmosomes and marked decrease of laminin 5, thus establishing the diagnosis of Bart syndrome associated to the Herlitz form of lethal junctional epidermolysis bullosa. Bart syndrome consists of congenital and localized absence of skin, nail abnormalities and mucoc-cutaneous bullae. It is usually associated to dystrophic epidermolysis bullosa. The Herlitz form of junctional epidermolysis bullosa is a rare variant, usually lethal that is produced by mutations in the genes coding for the anchor protein laminin 5. To our knowledge this is the second case that reports an association between Bart syndrome and lethal junctional epidermolysis bullosa and the first in which the results of immunofluorescence mapping are published.

Observations on the actual structural conditions in the stratum superficiale dermidis of porcine ear skin, with special reference to its use as model for human skin

The results obtained from the outer ear skin of female pigs (German Landrace) by light microscopy (LM), transmission electron microscopy (TEM), and cryo scanning electron microscopy (cryo SEM) methods, in particular relying on careful and artefact-free tissue processing, exhibited that the stratum superficiale dermidis of the auricle had a very homogeneous and compact construction, especially in one area (central dorsum auriculae). Based upon the important measurements made [average thickness of stratum superficiale dermidis: 94 (+/-16) microm, region A: 81 (+/-10); average thickness of collagen fibre bundles: 12 (+/-2) microm, region A: 13 (+/-0.5); average density of subepidermal capillaries: 3134 (+/-459) loops/cm2, region A: 3497 (+/-247)], this impression was confirmed by low standard deviations for all parameters, in comparison to marginal locations studied. The capillary system present was analysed by LM and TEM for specific structural features, whereby it generally compared to the microvasculature in human skin. Moreover, a regular pattern of diffusion-relevant punctiform contacts of the capillary loop apex with the epidermal basement membrane became obvious. Cryo SEM, particularly offering the advantages of dispensation of chemical fixation, dehydration and solvents during processing, highlighted delicate structures without shrinkage and without loss of soluble sample components. Thus rather real spatial conditions in the region of the epidermo-dermal junction and the upper dermis were visualized, whereby very regular arrangements of the structures present became obvious. This pertained also to a correct demonstration of all components of the epidermal basement membrane, in particular the lamina lucida. In addition, the water-based stable character of the entire stratum superficiale dermidis could be emphasized as a basic feature for controlled diffusion processes.

Urethral meatal stenosis in junctional epidermolysis bullosa: a rare complication effectively treated with a novel and simple modality

A 10-year-old boy was diagnosed with non-Herlitz junctional epidermolysis bullosa (nh-JEB) shortly after birth when he developed blisters on his feet and under the toenails. His younger brother was also affected by nh-JEB. Their parents were first cousins. Immunofluorescence mapping showed a blister in the lamina lucida and reduced staining with GB3 antibody against laminin V. Molecular analysis showed a homozygous mutation in the LAMC2 gene. The patient complained of intermittent inability to pass urine, causing significant suprapubic pain, anxiety, and general discomfort. He reported the development of blisters and erosions at the urethral meatus, which caused fusion of the meatal opening. In order to micturate, he had to tear apart the fused tissue, resulting in considerable pain. Physical examination revealed multiple healing erosions and atrophic scars, mainly on the legs (Fig. 1), and anonychia of most of the toenails. The walls of the urethral meatus were adherent (Fig. 2). The urethral meatus could not be opened using a moderate amount of pressure by the examining physicians. Prevention of re-stenosis of the urethral meatus was accomplished with the application of Mepilex (Mölnlycke, Sweden) to the urethral meatus after each micturition, where it remained until the next episode of micturition. Since the institution of this care regimen 10 months ago, there has been no recurrence of the stenosis.

Junctional Epidermolysis Bullosa

Epidermolysis bullosa (EB) encompasses a heterogeneous group of genodermatoses, characterized by fragility and blistering of the skin, often associated with extracutaneous manifestations. The level of vesiculation within the skin defines 3 major subtypes of EB: EB simplex, junctional EB, and dystrophic EB. We present the case of a male neonate of 36 weeks of gestation, who was born with a few blisters with erosions and who rapidly developed extensive blistering of the skin. Histopathology revealed subepidermal blistering. Electron microscopy confirmed the cleavage of epidermis from dermis within the lamina lucida. Junctional EB was the diagnosis. The patient was discharged after hospitalization for 28 days. The development of new blisters with erosions were gradually improved after AQUACEL Ag dressing, and the general condition was much better than at admission. The patient likely has a subtype of junctional EB termed generalized atrophic benign EB that clinically improves with age. He has the potential to father children and has a normal life expectancy.

Clinical and immunopathologic findings in oral lichen planus pemphigoides

Lichen planus pemphigoides (LPP) is a rare, acquired, immunobullous disorder of skin that occasionally involves oral mucous membranes. Clinical, histologic, and immunopathologic findings of the oral manifestations of LPP are described. Clinical features are lichenoid striae, erosions, and ulcerations involving gingiva and buccal mucosae. Histopathologic features are similar to those of ora lichen planus. Direct immunofluorescence demonstrates linear deposits of immunoglobulin G and complement component C3 along the basement membrane with fibrillar deposits of fibrin at the epithelial/lamina propria junction. Fluorescence overlay antigen mapping and laser scanning confocal microscopy of the biopsy specimen exhibits colocalization of in situ antibodies with beta4 integrin, a marker of the keratinocyte basal plasma membrane and upper lamina lucida, consistent with the location of the bullous pemphigoid antigens. This case report describes a case of LPP that presented exclusively as an oral condition. Lichen planus pemphigoides should be considered in the clinical differential diagnosis of vesiculoerosive oral mucosal diseases.

The basement membrane zone of the nail.

The anatomy of the epidermis, dermis and subcutaneous tissues of the nail apparatus is distinct from that of non-appendageal skin. Apart from the demonstration of the longitudinal configuration of the dermal-epidermal junction of the nail bed, there have been no studies of the composition of the basement membrane zone of the nail apparatus. We obtained three human accessory digits, including one thumb, all of which had been amputated for cosmetic reasons, and were without known pathology. Specimens were stained with a battery of monoclonal and polyclonal antibodies which target normal basement membrane zone antigens, and studied by indirect immunofluorescence. This study demonstrated that the four distinct regions of the nail, namely the proximal nail fold, the nail matrix, the nail bed and the hyponychium expressed all the target antigens found in the normal non-appendageal basement membrane. In particular, there was normal expression of the epidermal-associated antigens, the 220- and 180-kDa bullous pemphigoid antigens, and the alpha 6 beta 4 integrin. There was also normal expression of the lamina lucida antigens LH39, GB3 and laminin. It is of interest that the dermal-associated components, namely the 285-kDa linear IgA antigen, the extracellular matrix glycoproteins chondroitin sulphate, type VII collagen and its closely associated proteins, and the poorly characterized antigen for LH24 and LH39 were all normally expressed. Fibronectin, which is not a normal basement membrane zone component, was diffusely expressed in the extracellular matrix, but did not accentuate the basement membrane zone.(ABSTRACT TRUNCATED AT 250 WORDS)

Minimizing cicatricial pemphigoid orodynia with minocycline.

Cicatricial pemphigoid is a rare autoimmune blistering disease of the elderly. It predominantly affects the mucosae, causing pain and scarring. the target antigen is within the lamina lucida of the basement membrane zone. Potential complications of systemic steroid and other immunosuppressive therapy have prompted trials of other means of treatment. We describe a series of seven patients treated with minocycline, six of whom derived sustained alleviation of orodynia. Four patients developed hyperpigmentation, and two complained of gastrointestinal discomfort which necessitated cessation of minocycline. Complete steroid withdrawal was achieved in two cases. Neither the disease progression nor the response to treatment was influenced by the immunoglobulin isotype or titre. The role of minocycline as a useful adjunct to therapy is discussed.