Endemic Pemphigus Foliaceus (EPF)

Endemic pemphigus foliaceus (EPF) is a rare autoimmune skin disease characterized by chronic and recurrent eruptions of blistering, scaling and crusting skin lesions. It is also known as fogo selvagem or wildfire. EPF is endemic or restricted to specific geographic areas, typically in rural regions of South America, Africa, and the Middle East. The disease affects individuals of all ages and is more common in males. The exact cause of EPF is unknown, but it is believed to be triggered by environmental factors such as insect bites, infections, or exposure to certain chemicals. The disease is characterized by antibodies produced by the immune system that attack and destroy the skin cells causing the formation of blisters and skin lesions.


The exact cause of EPF is unknown, but several factors are believed to contribute to its development, including:

  1. Genetics: EPF is more common in certain populations and is believed to have a genetic component.
  2. Environmental factors: EPF is found in specific regions of the world, and exposure to certain environmental factors such as sunlight, temperature, and humidity may contribute to its development.
  3. Infections: Some studies suggest that infections may trigger the development of EPF, but the exact mechanism is unclear.
  4. Immune system dysfunction: EPF is an autoimmune disease, meaning that the immune system attacks healthy skin cells. This may be due to an overactive immune response, or a failure of the immune system to recognize and tolerate normal skin cells.
  5. Stress: Chronic stress may contribute to the development of autoimmune diseases, including EPF.

Overall, the causes of EPF are complex and multifactorial, and the exact mechanisms remain unclear. Further research is needed to better understand the underlying causes of this disease.


Endemic pemphigus foliaceus is a type of autoimmune skin disease that affects people living in specific regions of the world, particularly in South and Central America. The main symptoms of this condition include:

  1. Rashes and Blisters: A rash or blisters may develop on the face, neck, scalp, and upper trunk. These blisters are filled with fluid and may break open, leading to raw or painful skin.
  2. Scaling and Crusting: The affected skin may become dry and scaly, and crusting may occur around the blisters.
  3. Itching: The skin may be itchy, especially in areas where the blisters are located.
  4. Eyelid Swelling: Swelling of the eyelids may occur, causing vision problems and discomfort.
  5. Hair Loss: Hair loss may occur in areas affected by the blisters and rashes, especially on the scalp.
  6. Nail Changes: The nails may become thick, brittle, and discolored, and the skin around the nails may become red and painful.
  7. Fatigue: People with endemic pemphigus foliaceus may feel tired and have a general feeling of being unwell.

It is important to note that the symptoms of this condition may vary from person to person and may develop slowly over time. If you experience any of these symptoms, it is important to seek medical attention as soon as possible.


The diagnosis of EPF is typically based on clinical examination, laboratory tests, and histopathologic examination of skin biopsies.

Clinical examination: The clinical presentation of EPF is characterized by the presence of multiple crusted and/or non-crusted erosions and blisters on the face, neck, trunk, and extremities. The lesions may be widespread and progressive.

Laboratory tests: Blood tests are performed to help confirm the diagnosis of EPF. Antinuclear antibodies (ANA) and anti-dsDNA antibodies are often positive in EPF patients. Serum levels of immunoglobulins (IgG, IgM, and IgA) may also be elevated.

Histopathologic examination: A skin biopsy is performed to examine the underlying skin tissue for characteristic features of EPF. This includes the presence of acantholysis (the separation of cells in the top layer of the skin), a subcorneal blister, and infiltration of lymphocytes and eosinophils in the dermis.

  1. Skin biopsy: A small sample of the affected skin is taken for examination under a microscope. This can help confirm the presence of EPF and rule out other skin conditions.
  2. Direct immunofluorescence: This test involves applying a special dye to a sample of the affected skin and then examining it under a microscope. The presence of antibodies in the skin can be seen using this test.
  3. Indirect immunofluorescence: This test involves taking a sample of the patient’s blood and examining it under a microscope. The presence of antibodies in the blood can indicate the presence of EPF.
  4. ELISA test: This test involves measuring the levels of antibodies in the blood using a blood sample. Elevated levels of antibodies can indicate the presence of EPF.
  5. PCR test: This test involves taking a sample of the affected skin and examining it for the presence of specific genes that are associated with EPF.

In summary, the diagnosis of EPF is based on a combination of clinical examination, laboratory tests, and histopathologic examination of skin biopsies. Confirming the diagnosis is important for proper treatment and management of the condition.


Endemic pemphigus foliaceus is a rare autoimmune skin disease that affects people living in certain regions of the world. The main treatment for this condition involves a combination of medications and topical treatments.

  1. Systemic Corticosteroids: Corticosteroids are powerful anti-inflammatory drugs that are commonly used to treat autoimmune diseases. They help to suppress the immune system and reduce inflammation in the skin.
  2. Immunosuppressive Drugs: Drugs such as cyclophosphamide, azathioprine, and methotrexate can also be used to suppress the immune system. They are often used in combination with corticosteroids to increase their effectiveness.
  3. Rituximab: This is a monoclonal antibody that targets the B-cells in the immune system. By targeting these cells, it helps to reduce the severity of the autoimmune response.
  4. Topical Treatments: Topical treatments such as corticosteroid creams, ointments, and lotions can be used to treat skin lesions. They can be used in conjunction with systemic treatments to control the symptoms of the disease.
  5. Antihistamines: Antihistamines can be used to relieve itching, which is a common symptom of endemic pemphigus foliaceus.
  6. Phototherapy: Phototherapy, or light therapy, can also be used to treat skin lesions. This involves exposing the skin to ultraviolet light, which can help to reduce inflammation and improve the appearance of the skin.

Topical corticosteroids are usually the first line of treatment and are applied directly to the affected skin areas. Systemic corticosteroids, such as prednisone, may also be used for more severe cases.

In addition to corticosteroids, other immunosuppressive medications may be used to treat pemphigus foliaceus, such as cyclophosphamide or azathioprine. These medications work by suppressing the immune system, which can reduce the production of antibodies that attack the skin.

Plasmapheresis and intravenous immunoglobulin (IVIg) may also be used as treatments for pemphigus foliaceus. Plasmapheresis involves removing the patient’s plasma and replacing it with fresh plasma, which can help to reduce the amount of antibodies in the blood. IVIg is a treatment that involves injecting high doses of immunoglobulins into the patient, which can help to suppress the immune system.

In severe cases of pemphigus foliaceus, treatment may also include antibiotics to prevent skin infections. In addition, patients may be advised to avoid sunlight and use sunscreens, as sun exposure can worsen symptoms.

Overall, the main goal of treatment for endemic pemphigus foliaceus is to reduce inflammation, suppress the immune system, and prevent skin infections. Treatment may require a combination of medications, topical treatments, and lifestyle changes to achieve the best results.