Depression in patients with pemphigus vulgaris

In a recent study in Pakistan, patients with pemphigus vulgaris showed a high prevalence of depression of 99.3% with 41.7% of patients suffering from moderate depression and 58% severe depression1

What causes pemphis vulgaris?

Pemphigus vularisis is an autoimmune blistering disease which if left untreated, could lead to mortality. The disease is mediated by circulating autoantibodies directed towards epithelial proteins, desmoglein 1 and 3, which confer cell-cell adhesion within the epidermis. Failure of the epidermal cells to correctly adhere to each other clinically manifests as vesicles, blisters and chronic, painful erosions of the skin and mucuous membranes.2

Epidemiology and management of pemphigus vulgaris

Comprising of up to 70% of all pemphigus cases, pemphigus vulgaris is the most common among the pemphigus diseases, followed by pemphigus foliaceus.3 The two forms can be clinically differentiated based on the depth of the intraepidermal split. Generally, females tend to develop pemphigus vulgaris more frequently than males. The mean age of disease presentation ranges between 37–72 years.3

Corticosteroids are the mainstay of treatment for pemphigus vulgaris; the adjuvant use of immunosuppressants may contribute to better clinical outcomes and prevent mortality.2


Why is depression a concern in patients with pemphigus vulgaris?

Several studies have demonstrated that patients suffering from dermatological diseases are at a higher risk of developing depression owing to the chronic nature of the diseases, their impact on body image and the low likelihood of recovery.4 There is limited literature on the prevalence of mental disorders among patients suffering from pemphigus vulgaris.

A few studies around the globe have demonstrated compromised physical and psychosocial health in patients with pemphigus vulgaris.5-10 In a cross-sectional study conducted across four centres in Hungary, 43% of patients with pemphigus reported to have anxiety/depression. 10  The quality of life in these pemphigus patients, as measured by the EQ-5D questionnaire, was observed to decline with the increasing severity of disease. These results corroborate the results from a previous study where a higher antidesmoglein 3 antibody level was shown to be directly correlated with disease severity and with lower health-related quality of life, as measured by the SF-36 questionnaire.8

In an Iranian study, 74% of patients with pemphigus vulgaris were identified to have a psychiatric comorbidity such as a depressive or anxiety disorder, which was estimated to be three or four times the prevalence of psychiatric disorders in other dermatological conditions.The relationship between pemphigus vulgaris and depression has also been demonstrated in South and East Asian countries like Taiwan, India and Pakistan.1,9,11 In Taiwan for example, patients with pemphigus were shown to be nearly twice as likely to suffer from depression than patients without pemphigus, with higher tendancies among the female population than males.9

One recent study conducted on 290 patients with pemphigus vulgaris in Pakistan showed a prevalence of depression of 99.3% with 0.3% of patients suffering from mild depression, 41.7% moderate depression and 58% severe depression, as measured by the Hamilton Depression rating scale.1


Looking ahead

Depression is a complication in several dermatological diseases and it is not surprising that pemphigus vulgaris, which is associated with significant deformity and disfigurement and its difficult to treat nature, has a substantial impact on the patient’s psychological health and their quality of life.7,12,13 Due to a lack of awareness and social stigma among the general public about depression, patients often miss out on the optimum level of care necessary for their recovery. Complementing the management plan for pemphigus vulgaris patients with measures to prevent depression via a multidisciplinary approach and timely referrals by the treating dermatologist will improve overall clinical outcomes.1


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  1. Ramazan Z, Bhatia MR, Farhan S, Kumar A. Depression in patients with pemphigus vulgaris. Journal of Pakistan Psychiatric Society 2018; 15(4).

    2.    Cholera M, Chainani-Wu N. Management of Pemphigus Vulgaris. Adv Ther 2016; 33(6): 910-58.

    3.    Kridin K. Pemphigus group: overview, epidemiology, mortality, and comorbidities. Immunol Res 2018; 66(2): 255-70.

    4.    Fried RG, Gupta MA, Gupta AK. Depression and skin disease. Dermatol Clin 2005; 23(4): 657-64.

    5.    Paradisi A, Sampogna F, Di Pietro C, et al. Quality-of-life assessment in patients with pemphigus using a minimum set of evaluation tools. J Am Acad Dermatol 2009; 60(2): 261-9.

    6.    Mayrshofer F, Hertl M, Sinkgraven R, et al. [Significant decrease in quality of life in patients with pemphigus vulgaris. Results from the German Bullous Skin Disease (BSD) Study Group]. J Dtsch Dermatol Ges 2005; 3(6): 431-5.

    7.    Arbabi M, Ghodsi Z, Mahdanian A, et al. Mental health in patients with pemphigus: an issue to worth consideration. Indian J Dermatol 2011; 56(5): 541-5.

    8.    Tabolli S, Mozzetta A, Antinone V, Alfani S, Cianchini G, Abeni D. The health impact of pemphigus vulgaris and pemphigus foliaceus assessed using the Medical Outcomes Study 36-item short form health survey questionnaire. Br J Dermatol 2008; 158(5): 1029-34.

    9.    Hsu Y-M, Fang H-Y, Lin C-L, Shieh S-H. The Risk of Depression in Patients with Pemphigus: A Nationwide Cohort Study in Taiwan. Int J Environ Res Public Health 2020; 17(6): 1983.

    10.  Tamási B, Brodszky V, Péntek M, et al. Validity of the EQ-5D in patients with pemphigus vulgaris and pemphigus foliaceus. Br J Dermatol 2019; 180(4): 802-9.

    11.  Kumar V, Mattoo SK, Handa S. Psychiatric morbidity in pemphigus and psoriasis: a comparative study from India. Asian J Psychiatr 2013; 6(2): 151-6.

    12.  Wohl Y, Mashiah J, Kutz A, Hadj-Rabia S, Cohen AD. Pemphigus and depression comorbidity: a case control study. Eur J Dermatol 2015; 25(6): 602-5.

    13.  Metwally D, Fawzy M, ElKalioby M, et al. Assessment of the Quality of Life, Prevalence of Depression, and the Level of Interleukin 6 in Patients with Pemphigus Vulgaris. Acta Dermatovenerol Croat 2020; 28(2): 57-62.