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In the treatment of skin diseases, antihistamines and antiallergic agents are among the most frequently used oral medications, and are available as a wide variety of products. We investigated what criteria dermatological specialists use to select antihistamines and antiallergic agents, as well as the use objectives and expected benefits. The present investigation was conducted in a total of 1448 patients, including 336 patients with urticaria, 944 patients with eczema/dermatitis, and 199 patients with atopic dermatitis, in 6 dermatological clinics and 1 university hospital. A Case Card to record the prescription motives and clinical evaluation was used, and the results were tabulated and analyzed. As a result, it was found that the expected result was obtained in more than 80% of cases prescribed for by dermatologists based on the prescription motives for individual cases.

Patients showing coexistent linear IgG and IgA deposition along the basement membrane zone on direct immunofluorescence have been described as either bullous pemphigoid, epidermolysis bullosa acquisita, linear IgA bullous dermatosis, or cicatricial pemphigoid, depending on the clinical features and laboratory findings. In the present report, we describe two cases showing atypical clinical features distinct from those of other known bullous diseases. No circulating antibodies were detected by indirect immunofluorescence of normal human skin. Indirect immunofluorescence of 1 M NaCl split skin revealed IgG and/or IgA antibodies reactive with the dermal side of the split. Immunoblotting of normal human epidermal and dermal extracts showed no apparent reactivity with known autoantigens. The results suggest that there may be a unique and distinct bullous disease with linear IgG and IgA deposition at the basement membrane zone.

Three cases of granuloma annulare which did not exhibit a self-limited course were treated with tranilast at the dose of 300 mg/daily. The treatment resulted in the resolution of skin lesions within three months of administration. Although spontaneous resolution is often observed in granuloma annulare, tranilast may provide an alternative therapy for the treatment of cases resistant to spontaneous healing.

Complement-fixing intercellular antibodies were detected in 10 of 17 sera from untreated pemphigus patients. The role of complement in the organ culture system was investigated using these sera. Ten sera possessing complement-fixing intercellular antibodies showed IgG binding to the intercellular substance in the organ-cultured skin and acantholysis-like changes were observed in eight cases. C3 deposition was not seen in any case. However, after treatment of the sections of cultured skin with fresh normal human serum, complement fixation of the intercellular substance by bound IgG was revealed in all the ten cases. No significant differences in the grade of acantholysis-like changes between the complement-depleted system and the complement-supplied system were observed. Complement does not appear to be necessary in the acantholytic process in the in vitro organ culture system, even though we considered the presence of complement-fixing intercellular antibodies.

Summary Skin biopsy was performed in five cases of pemphigus; direct immunofluorescence (IF) studies demonstrated intercellularly bound IgG and C3 in each case. Sections of lesional skin, containing in vivo bound IgG were, in two cases, capable of further binding C3in vitro from normal human serum, an effect most marked in relation to areas of acantholysis. This work provides additional evidence that the complement system is involved in the process of pemphigus acantholysis.

By in vitro complement immunofluorescence, 6 sera from pemphigus with intercellular antibodies were tested for their capability to fix C1q, C4, C3, and properdin. All 6 serum samples yielded positive reaction for C3 staining. Three serum samples gave positive staining for C1q, 5 serum samples for C4, and 3 serum samples for properdin, respectively. Substitution of C2 deficient serum as a complement source inhibited C3 and properdin staining but not positive C1q and C4 staining. These results are best explained by the concept that complement activation in vitro by intercellular antibodies occurs via the classical pathway followed by assembly of the C3 amplification mechanism.

Eight out of 12 serum samples from patients with bullous pemphigoid having basement membrane zone antibodies gave positive binding not only to the basement membrane zone but also to the basal cell membrane and/or cytoplasm as observed by complement immunofluorescence. Reaction of fluorescein labeled pemphigus vulgaris gamma-globulins, binding mainly to the lower intercellular spaces of the epidermis, was greatly reduced by the prior incubation of high-titered bullous pemphigoid sera having the reactivity to the basal cells, while that of fluorescein labeled pemphigus foliaceus gamma-globulins binding mainly to the upper and middle intercellular spaces, was not influenced by the prior application of these bullous pemphigoid sera. These results indicate that bullous pemphigoid antibodies are heterogenous and can be classified into 2 types and that some cross reaction is present between pemphigus antibodies and bullous pemphigoid antibodies having the reactivity to the basal cells.

• The serum of a patient with a typical case of pemphigus vulgaris contained complement-fixing intercellular autoantibodies (pemphigus antibodies). Complement-fixing pemphigus antibodies were demonstrated only during the untreated active stage of the disease and titrated lower than corresponding IgG autoantibodies, which paralleled well with the disease activity. Pemphigus lesional skin, which contained in-vivo-bound IgG, showed the capability of further binding C3 in vitro from normal human serum. It was suggested from these findings that the complement system may play an active role in pemphigus acantholysis through complement-fixing pemphigus antibodies. ( Arch Dermatol 114:1191-1192, 1978)

The capability of complement fixation of pemphigus antibodies was tested using combined in vitro complement immunofluorescent (IF) staining methods. Three sera out of 25 serum samples from 22 pemphigus patients revealed positive reactions, while all other sera gave negative results. Specificity control tests confirmed the positive reactions to be specific for complement staining. Complement fixing pemphigus antibodies were titrated lower than corresponding IgG antibodies and were demonstrable only in the extensive stage of the disease. Thus, the present work supplied evidence that pemphigus antibodies fix complement in vitro. However, the discrepancy still remains between the in vivo deposition of complement in most cases of pemphigus and in vitro capability of complement fixation in only few cases. More investigations should be needed to explain the exact role of complement in pemphigus acantholysis.

Summary A 79-year-old female developed a generalized pruritic annular erythematous eruption without bullae. Histologically there was eosinophilic spongiosis but no associated acantholysis. Using direct immunofluorescence, the deposition of IgG and C3 was detected in the intercellular space, but circulating anti-intercellular-antibodies were not demonstrated. We considered this case to have atypical pemphigus. The eruption responded well to oral administration of Diaminodiphenyl sulphone 75 mg daily.

A positive correlation between complement-fixing pemphigoid antibody titre and disease activity was observed in 4 of 8 patients with bullous pemphigoid using complement immunofluorescence. The fact that this correlation cannot always be demonstrated seems to contradict the active role of complement-fixing pemphigoid antibodies in the pathogenesis of bulla formation. The similarity of bullous pemphigoid and herpes gestationis is discussed.

To the Editor.— According to the recent report by Kumar et al in the July 1980Archives(116:812-814), complementfixing (CF) intercellular (IC) antibodies in titers comparable to those seen by the ordinary indirect IgG test are a characteristic of pemphigus-like antibodies. Recently, 51 serum samples from untreated patients with pemphigus (clinically, histologically, and immunopathologically confirmed) were tested in our laboratory for the presence of CF IC antibodies. Six serum samples were found to have positive CF IC antibodies in titers greater than 1:20. In one case diagnosed as herpetiform pemphigus, the titer of CF IC antibodies (1:20) did not differ substantially from the titer of ordinary IgG antibodies (1:40). In addition, we could demonstrate IgG deposition in the IC spaces of organ-cultured human skin using pemphigus serum samples including CF IC antibodies; no C3 deposition was found. These bound IC antibodies were able to fix complement. We believe that the