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Pemphigus vulgaris: environmental factors. Occupational, behavioral, medical, and qualitative food frequency questionnaire

Authors

  • Sarah Brenner MD,

    1. From the Department of Dermatology, Tel Aviv Elias Sourasky Medical Center and Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel, Department of Dermatology, 2nd University of Naples, Naples, Italy, Department of Dermatology and Venereology, Faculty of Medicine, Sofia, Bulgaria, Department of Dermatology, Hospital de la Sta. Creu I St. Pau, Barcelona, Spain, Johns Hopkins University, School of Medicine, Baltimore, Maryland, Servico de Dermatologia, Hospital Universitario Clementino Fraga Filho, Faculdade de Medicina, Universidade Federal do Rio de Janeiro, Rio de Janeiro, Brazil, and Department of Dermatology, Venereology, and Leprology, Goa Medical College, Goa, India
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  • Ethel Tur MD,

    1. From the Department of Dermatology, Tel Aviv Elias Sourasky Medical Center and Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel, Department of Dermatology, 2nd University of Naples, Naples, Italy, Department of Dermatology and Venereology, Faculty of Medicine, Sofia, Bulgaria, Department of Dermatology, Hospital de la Sta. Creu I St. Pau, Barcelona, Spain, Johns Hopkins University, School of Medicine, Baltimore, Maryland, Servico de Dermatologia, Hospital Universitario Clementino Fraga Filho, Faculdade de Medicina, Universidade Federal do Rio de Janeiro, Rio de Janeiro, Brazil, and Department of Dermatology, Venereology, and Leprology, Goa Medical College, Goa, India
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  • Jonathan Shapiro MD,

    1. From the Department of Dermatology, Tel Aviv Elias Sourasky Medical Center and Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel, Department of Dermatology, 2nd University of Naples, Naples, Italy, Department of Dermatology and Venereology, Faculty of Medicine, Sofia, Bulgaria, Department of Dermatology, Hospital de la Sta. Creu I St. Pau, Barcelona, Spain, Johns Hopkins University, School of Medicine, Baltimore, Maryland, Servico de Dermatologia, Hospital Universitario Clementino Fraga Filho, Faculdade de Medicina, Universidade Federal do Rio de Janeiro, Rio de Janeiro, Brazil, and Department of Dermatology, Venereology, and Leprology, Goa Medical College, Goa, India
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  • Vincenzo Ruocco MD,

    1. From the Department of Dermatology, Tel Aviv Elias Sourasky Medical Center and Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel, Department of Dermatology, 2nd University of Naples, Naples, Italy, Department of Dermatology and Venereology, Faculty of Medicine, Sofia, Bulgaria, Department of Dermatology, Hospital de la Sta. Creu I St. Pau, Barcelona, Spain, Johns Hopkins University, School of Medicine, Baltimore, Maryland, Servico de Dermatologia, Hospital Universitario Clementino Fraga Filho, Faculdade de Medicina, Universidade Federal do Rio de Janeiro, Rio de Janeiro, Brazil, and Department of Dermatology, Venereology, and Leprology, Goa Medical College, Goa, India
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  • Mariarosaria D'Avino MD,

    1. From the Department of Dermatology, Tel Aviv Elias Sourasky Medical Center and Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel, Department of Dermatology, 2nd University of Naples, Naples, Italy, Department of Dermatology and Venereology, Faculty of Medicine, Sofia, Bulgaria, Department of Dermatology, Hospital de la Sta. Creu I St. Pau, Barcelona, Spain, Johns Hopkins University, School of Medicine, Baltimore, Maryland, Servico de Dermatologia, Hospital Universitario Clementino Fraga Filho, Faculdade de Medicina, Universidade Federal do Rio de Janeiro, Rio de Janeiro, Brazil, and Department of Dermatology, Venereology, and Leprology, Goa Medical College, Goa, India
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  • Eleonora Ruocco MD,

    1. From the Department of Dermatology, Tel Aviv Elias Sourasky Medical Center and Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel, Department of Dermatology, 2nd University of Naples, Naples, Italy, Department of Dermatology and Venereology, Faculty of Medicine, Sofia, Bulgaria, Department of Dermatology, Hospital de la Sta. Creu I St. Pau, Barcelona, Spain, Johns Hopkins University, School of Medicine, Baltimore, Maryland, Servico de Dermatologia, Hospital Universitario Clementino Fraga Filho, Faculdade de Medicina, Universidade Federal do Rio de Janeiro, Rio de Janeiro, Brazil, and Department of Dermatology, Venereology, and Leprology, Goa Medical College, Goa, India
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  • Nikolai Tsankov MD, PhD,

    1. From the Department of Dermatology, Tel Aviv Elias Sourasky Medical Center and Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel, Department of Dermatology, 2nd University of Naples, Naples, Italy, Department of Dermatology and Venereology, Faculty of Medicine, Sofia, Bulgaria, Department of Dermatology, Hospital de la Sta. Creu I St. Pau, Barcelona, Spain, Johns Hopkins University, School of Medicine, Baltimore, Maryland, Servico de Dermatologia, Hospital Universitario Clementino Fraga Filho, Faculdade de Medicina, Universidade Federal do Rio de Janeiro, Rio de Janeiro, Brazil, and Department of Dermatology, Venereology, and Leprology, Goa Medical College, Goa, India
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  • Snejina Vassileva MD,

    1. From the Department of Dermatology, Tel Aviv Elias Sourasky Medical Center and Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel, Department of Dermatology, 2nd University of Naples, Naples, Italy, Department of Dermatology and Venereology, Faculty of Medicine, Sofia, Bulgaria, Department of Dermatology, Hospital de la Sta. Creu I St. Pau, Barcelona, Spain, Johns Hopkins University, School of Medicine, Baltimore, Maryland, Servico de Dermatologia, Hospital Universitario Clementino Fraga Filho, Faculdade de Medicina, Universidade Federal do Rio de Janeiro, Rio de Janeiro, Brazil, and Department of Dermatology, Venereology, and Leprology, Goa Medical College, Goa, India
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  • Kossara Drenovska MD,

    1. From the Department of Dermatology, Tel Aviv Elias Sourasky Medical Center and Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel, Department of Dermatology, 2nd University of Naples, Naples, Italy, Department of Dermatology and Venereology, Faculty of Medicine, Sofia, Bulgaria, Department of Dermatology, Hospital de la Sta. Creu I St. Pau, Barcelona, Spain, Johns Hopkins University, School of Medicine, Baltimore, Maryland, Servico de Dermatologia, Hospital Universitario Clementino Fraga Filho, Faculdade de Medicina, Universidade Federal do Rio de Janeiro, Rio de Janeiro, Brazil, and Department of Dermatology, Venereology, and Leprology, Goa Medical College, Goa, India
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  • Petjo Brezoev MD,

    1. From the Department of Dermatology, Tel Aviv Elias Sourasky Medical Center and Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel, Department of Dermatology, 2nd University of Naples, Naples, Italy, Department of Dermatology and Venereology, Faculty of Medicine, Sofia, Bulgaria, Department of Dermatology, Hospital de la Sta. Creu I St. Pau, Barcelona, Spain, Johns Hopkins University, School of Medicine, Baltimore, Maryland, Servico de Dermatologia, Hospital Universitario Clementino Fraga Filho, Faculdade de Medicina, Universidade Federal do Rio de Janeiro, Rio de Janeiro, Brazil, and Department of Dermatology, Venereology, and Leprology, Goa Medical College, Goa, India
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  • M. A. Barnadas MD,

    1. From the Department of Dermatology, Tel Aviv Elias Sourasky Medical Center and Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel, Department of Dermatology, 2nd University of Naples, Naples, Italy, Department of Dermatology and Venereology, Faculty of Medicine, Sofia, Bulgaria, Department of Dermatology, Hospital de la Sta. Creu I St. Pau, Barcelona, Spain, Johns Hopkins University, School of Medicine, Baltimore, Maryland, Servico de Dermatologia, Hospital Universitario Clementino Fraga Filho, Faculdade de Medicina, Universidade Federal do Rio de Janeiro, Rio de Janeiro, Brazil, and Department of Dermatology, Venereology, and Leprology, Goa Medical College, Goa, India
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  • M. J. Gonzalez MD,

    1. From the Department of Dermatology, Tel Aviv Elias Sourasky Medical Center and Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel, Department of Dermatology, 2nd University of Naples, Naples, Italy, Department of Dermatology and Venereology, Faculty of Medicine, Sofia, Bulgaria, Department of Dermatology, Hospital de la Sta. Creu I St. Pau, Barcelona, Spain, Johns Hopkins University, School of Medicine, Baltimore, Maryland, Servico de Dermatologia, Hospital Universitario Clementino Fraga Filho, Faculdade de Medicina, Universidade Federal do Rio de Janeiro, Rio de Janeiro, Brazil, and Department of Dermatology, Venereology, and Leprology, Goa Medical College, Goa, India
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  • Grant Anhalt MD,

    1. From the Department of Dermatology, Tel Aviv Elias Sourasky Medical Center and Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel, Department of Dermatology, 2nd University of Naples, Naples, Italy, Department of Dermatology and Venereology, Faculty of Medicine, Sofia, Bulgaria, Department of Dermatology, Hospital de la Sta. Creu I St. Pau, Barcelona, Spain, Johns Hopkins University, School of Medicine, Baltimore, Maryland, Servico de Dermatologia, Hospital Universitario Clementino Fraga Filho, Faculdade de Medicina, Universidade Federal do Rio de Janeiro, Rio de Janeiro, Brazil, and Department of Dermatology, Venereology, and Leprology, Goa Medical College, Goa, India
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  • Hossein Nousari MD,

    1. From the Department of Dermatology, Tel Aviv Elias Sourasky Medical Center and Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel, Department of Dermatology, 2nd University of Naples, Naples, Italy, Department of Dermatology and Venereology, Faculty of Medicine, Sofia, Bulgaria, Department of Dermatology, Hospital de la Sta. Creu I St. Pau, Barcelona, Spain, Johns Hopkins University, School of Medicine, Baltimore, Maryland, Servico de Dermatologia, Hospital Universitario Clementino Fraga Filho, Faculdade de Medicina, Universidade Federal do Rio de Janeiro, Rio de Janeiro, Brazil, and Department of Dermatology, Venereology, and Leprology, Goa Medical College, Goa, India
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  • Marcia Ramos- E Silva MD, PhD,

    1. From the Department of Dermatology, Tel Aviv Elias Sourasky Medical Center and Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel, Department of Dermatology, 2nd University of Naples, Naples, Italy, Department of Dermatology and Venereology, Faculty of Medicine, Sofia, Bulgaria, Department of Dermatology, Hospital de la Sta. Creu I St. Pau, Barcelona, Spain, Johns Hopkins University, School of Medicine, Baltimore, Maryland, Servico de Dermatologia, Hospital Universitario Clementino Fraga Filho, Faculdade de Medicina, Universidade Federal do Rio de Janeiro, Rio de Janeiro, Brazil, and Department of Dermatology, Venereology, and Leprology, Goa Medical College, Goa, India
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  • Katia Teixeira Pinto MD,

    1. From the Department of Dermatology, Tel Aviv Elias Sourasky Medical Center and Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel, Department of Dermatology, 2nd University of Naples, Naples, Italy, Department of Dermatology and Venereology, Faculty of Medicine, Sofia, Bulgaria, Department of Dermatology, Hospital de la Sta. Creu I St. Pau, Barcelona, Spain, Johns Hopkins University, School of Medicine, Baltimore, Maryland, Servico de Dermatologia, Hospital Universitario Clementino Fraga Filho, Faculdade de Medicina, Universidade Federal do Rio de Janeiro, Rio de Janeiro, Brazil, and Department of Dermatology, Venereology, and Leprology, Goa Medical College, Goa, India
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  • Maria Flora Miranda MD

    1. From the Department of Dermatology, Tel Aviv Elias Sourasky Medical Center and Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel, Department of Dermatology, 2nd University of Naples, Naples, Italy, Department of Dermatology and Venereology, Faculty of Medicine, Sofia, Bulgaria, Department of Dermatology, Hospital de la Sta. Creu I St. Pau, Barcelona, Spain, Johns Hopkins University, School of Medicine, Baltimore, Maryland, Servico de Dermatologia, Hospital Universitario Clementino Fraga Filho, Faculdade de Medicina, Universidade Federal do Rio de Janeiro, Rio de Janeiro, Brazil, and Department of Dermatology, Venereology, and Leprology, Goa Medical College, Goa, India
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Sarah Brenner, MD
Department of Dermatology
Tel Aviv Sourasky Medical Center
6 Weizmann Street
Tel Aviv 64239
Israel
E-mail: derma@tasmc.health.gov.il

Abstract

Abstract

Background  There have been reports suggesting the involvement of environmental factors in the disease process of pemphigus. Factors suggested include exposure to pesticides or certain drugs.

Objective  To analyze the association of pemphigus with environmental exposure to various agents, including smoking, recreational and occupational insults, drugs, and food.

Design and setting In-person interviews of pemphigus patients and control subjects were conducted by trained medical investigators using a structured questionnaire. Questions included occupational, behavioral, medical, and qualitative food frequency details. The multicenter study was conducted at outpatient services of teaching hospitals in Bulgaria, Brazil, India, Israel, Italy, Spain, and the USA.

Participants  A total of 126 pemphigus patients (55 men, 71 women; age, 54 ± 17 years) and 173 healthy controls (87 men, 86 women; age 50 ± 19 years) were interviewed in the period between October 1, 1999 and March 31, 2000. The diagnosis of pemphigus was based on clinical, histologic, immunohistologic, and immunohistochemical criteria. The disease duration was 2–27 years (8.4 ± 7.2 years). Individuals with skin diseases other than pemphigus were selected as control subjects.

Main outcome measure  Information on drugs, foods, and occupational, environmental, constitutional, and other possible risk factors was analyzed by t-tests and chi-squared tests as applicable. A multivariate logistic regression model was applied to the data to study simultaneously the independent relationship between each risk factor and pemphigus vulgaris.

Results  The risk for pemphigus vulgaris was lower for ex-smokers and current smokers than for patients who had never smoked. Exposure to pesticides and occupational exposure to metal vapor were associated with an increased risk of pemphigus. Pemphigus patients had more pregnancies than controls. There were differences in environmental factors between countries, with exposure to gardening materials and pesticides being highest among patients from Bulgaria, followed by Israel. Disease characteristics also exhibited differences between countries. Bulgarian patients less frequently had oral mucous membrane lesions: 66% compared to 92% for Israeli patients and 83% for Italians. The distribution of the disease in skin and mucous membranes was similar among patients from all countries. Exclusive skin involvement was seen in 50% of patients, mucous membranes alone in 23% of patients, and both skin and mucous membranes in 27% of patients.

Conclusions  The beneficial effect of smoking on pemphigus might be explained by its effect on the immune system. In addition, smoking has an antiestrogenic effect, while pesticides have an estrogenic effect. The lower numbers of smokers among patients, the higher exposure rates to pesticides, and the higher number of female patients who had been pregnant may point to the contribution of estrogens to the disease process. It remains to be determined whether measures, such as avoiding exposure to pesticides or metal vapor, may be beneficial in the clinical context. As the present study was a survey, more definitive studies should be conducted to validate the results.

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