Tuesday, November 17, 2009

Equine Pemphigus Foliaceus

Pemph.... what?

Pemphigus foliaceus (pem-fi-gus foli-a-shus) is an auto immune disease that affects humans and dogs and, to a lesser extent, cats and horses.
In horses, it is characterized by primary lesions that often begin on the head and lower extremities; secondary lesions spread to other areas, with an exudate that dries to a crust. There may be extensive edema (swelling) in the legs and abdomen (called "ventral" edema).
Equine pemphigus foliaceus (EPF) is considered rare and signs and symptoms may resemble those of other conditions such as insect bite allergies (crusty lesions), pigeon fever (ventral edema) or other skin conditions.
The primary way to diagnose EPF is by punch biopsy of the skin which is examined by a veterinary pathologist. The pathologist looks for changes consistent with this diagnosis, while also ruling out other causes.
Horses with EPF may also have systemic signs of illness - fever, depression, loss of appetite, lethargy and weight loss. The skin may be painful to touch and swelling can make it difficult to walk or lie down.

Currently, treatment options are limited, mainly focused on corticosteroids (dexamethasone, prednisolone and prednisone) to limit inflammation; prognosis is generally guarded at best with many cases ending in euthanasia. Little is known about specific causes of EPF and what supportive treatments might be useful.
The Equine Pemphigus Foliaceus (EPF) group is hoping to change this. Two horse owners who have been looking for information and answers have recently teamed up with Eleanor Kellon, VMD to look at triggers, what's working and what's not, and how these horses can be supported to continue leading productive, comfortable lives. Dr. Kellon has a long history of developing cutting edge science-based supportive therapies for horses, with an emphasis on precise diagnostics by field veterinarians. By identifying and bringing together owners of afflicted horses, reviewing and comparing their histories, diagnostics, treatment and outcomes, and utilizing available research, a comprehensive picture of how to optimize support will emerge.
If you have a horse who has been diagnosed with EPF - currently or in the past - share your history with others by joining the EPF group. The group will provide information and support for owners, and is focused on improving science-based diagnostics, treatment protocols and outcomes for the horse.


  1. My horse has PF and has been receiving gold salt injections. The drug company is no longer making them. Does anyone know where I could purchase them? Also, How do I contact Dr. Kellon? Thanks, Patti

  2. Hi -
    Have you joined the EPF group? http://pets.groups.yahoo.com/group/EquinePemphigusFoliaceus/ I don't think anyone there is using gold salts because of the expense and side effects. But someone there may know of a source. This would be an appropriate discussion on the group.
    Dr. Kellon answers questions on the group (if she doesn't reply in a reasonable length of time one of us will give her a "heads up".

  3. haha love the intro to the article. Pemph what?! my horse actually had EPF but I put him on some equine supplements and he is doing much better.

  4. If your horse actually has EPF (diagnosis supported by multiple punch biopsies) putting him on Platinum Performance will help support his immune system because of the high level of flax these supplements contain. However, Platinum Performance is not at all balanced to match with your hay or other forage. For long term support and help prevent relapse you might want to learn more about mineral balanced diets and some of the other information on the group at http://pets.groups.yahoo.com/group/EquinePemphigusFoliaceus/ .

    Best regards and hope your horse continues to do well.

  5. The National Institute of Arthritis and Musculoskeletal and Skin Diseases (NIAMS), supports a broad range of research on pemphigus to better understand what causes various forms of the disease and to develop better treatments. When researchers began to understand that pemphigus is an autoimmune disease, they were able to target their laboratory studies on immune function and to apply research advances in other autoimmune diseases to pemphigus. They have already clarified that effective therapies against this disease must stop production of the antibodies that attack the skin cells.

  6. The direct link to the NIH research info is http://www.niams.nih.gov/Health_info/Pemphigus/default.asp#11.
    Thanks Margla Clark for this information.

  7. I am awaiting biopsy results on my mare for PF after 2 months of trying to determine the cause of her skin lesions, hair and weight loss and stalking up. Steroids helped the swelling in her legs,but did not help the lesions,scally skin and weight loss. After my vet talked to me about PF, and I see photos of others horses suffering with this diagnosis,I am pretty confident my vet has come to the correct diagnosis. I am so sad, but it helps to know there is a support group out there to help with treatment and medical info. Thank You for sharing this information.

  8. Good afternoon!

    I have a mini gelding who we suspect may have this. We have done every type of diagnostic test available (except for a biopsy because he was doing so poorly that my vet wanted to wait to see if we could get him in better health before we did that) with no results. I am going crazy trying to nurse him back to health. He has had every type of antibiotic available, to no avail. He is not getting any better. Every person I contact about PF tells me they don't think that's what we are dealing with since we have been struggling for 2 years and it comes and goes. I have tried to join the yahoo group with no luck. Is it still active? We are very interested in holistic management without the use of steroids if possible. Thank you!

    1. I'm trying to check with the group owner to ensure if the group is still active.

      The primary treatment for pemphigus has pretty much been steroids but a few have reported success using Transfer Factor while others have had little success with it.
      Antibiotics are not effective - except possibly for secondary infection - as pemphigus is not caused by any infectious agent.

      As pemphigus is related to immune problems, basically an overstimulation of the immune system secondary to some (usually unknown) trigger, we want to support but not "stimulate" the immune system. My preferred approach as a base is to mineral balance the diet, feeding in a similar fashion as we would for insulin resistance, avoid anything which might increase inflammation (excess sugar/starch, "added" iron, being overweight), and ensure adequate levels of Omega-3, vitamin E and other anti-oxidants. Adequate salt and iodine also are factors often overlooked. I would tend to avoid any pre-mixed or bagged feeds.

      The only way to be positive that the issue is pemphigus is by biopsy - early biopsy can avoid the expense and grief of "shotgun" treatment - usually not an effective way to diagnose much of anything.

      (I also pm'd you)

  9. I have a 5yr gelding going through symptoms of this - winter hives, then discharge, then the edema in front legs and chest/scrotum followed - that's when i had an 'ahha' moment. The 'trigger' for this was mild weather. We went from -5 to +10 degrees - this winter has been weird like that. West Ireland. So my ahha moment was the possibility of the sudden mild weather triggering encysted red worms to hatch - which would then trigger an immune response and hives. Also i had the possibility that neck threadworms could also be the culprit - or any parasite for that matter that hatches when milder weather arrives. So i wormed my gelding - moxidectin+ivermectin - the hives disappeared within 48hrs (they were bad - allover) - the edema went away in same timeframe. The serum oozing slowed down during the days after the wormer. Now i have crusty patches of hair falling out, clean skin underneath. He's eating fine, always did, no limb stiffness, the leg edema wasn't horrendous. He acted normally throughout - mucous membranes fine, temp fine, feet fine, coronet bands fine.
    I wanted to try the wormer before using the dreaded laminitis-inducing steroids.
    Despite worming him regularly, i feel that the timing of the wormers is crucial in removing large populations that can build up despite regular worming. Neck threadworms are under-recognised, and encysted small redworms are gaining more recognition but i still think they cause a lot of horses issues when they hatch - the occassional colicy days, being itchy, bitchy and annoyed.
    So do consider using ivermectin (high dose) and moxidectin - check with your vet of course, but IMO parasites are not given enough recognition as triggers of hives in horses.
    EPF is considered auto-immune. We now have come a long way in understanding auto immune diseases in humans and it is being finally understood there is oftentimes an imbalance and issues with the intestines that can trigger autoimmune in humans. Mainly 'leaky gut' or intestinal permeability. What in the horse would cause the gut wall to have holes in it? Red worm migrating larvae! The immune system response is 'housed' in the gut. So as soon as there is a hatching phase of larvae, the gut immune response is immediate - hence why hives can appear very severe in the space of a few hours.
    My gelding had no changes in bedding, diet, feed, routine at all with no access whatsoever during winter to pasture or toxic plants - he's in a dry lot. So the trigger for this serious hives episode came from within his body. Not external factors. The mare he is housed with is fine also (she's older - more reliable worm history too).

  10. continued...

    Also consider - in studies they found a huge percentage of horses with EPF to have suffered the trigger episodes in winter. No biting insects around here at that time to cause such a systemic reaction. Yet a mild spell during winter can trigger parasites to hatch fooling them into thinking its spring.
    It's a theory im running with for the moment as worming him totally turned around his symptoms. I've read about people using steroids, antibiotics and not getting anywhere with this, without the horse being on steroids which of course suppresses the immune system - which isn't the ideal solution as we all must realise. They come into contact with many pathogens as they eat from the ground...suppressing the ability of the immune system is fine for a short while but not a long term treatment IMO.
    I will try to join the group to help add what i experience with my boy as i really think this particular equine disease needs looking at from a whole new angle and approach - management of autoimmune diseases with just steroids is lazy medical care IMO.
    I want to try to find if there have been a bowel autopsy done on a horse PTS due to EPF - if my theory is on the right track there should be bowel inflammation, larvae holes, permeability of bowel lining etc.
    No where else have i read anyone trying wormers during the hives 'episode' so i only have my experience to go by.
    I have my boy on probiotics to help heal the gut lining. He's doing amazingly well - i coldn't believe how far the hives progressed to weeping to edema, then scaling/crusty patches - mainly on his face, ears, between front legs - all down front legs and some back legs. He will be bald in those areas soon as the hair is falling out now. Aloe vera is helpful and is encouraging the hair to grow - helps to act like a barrier to prevent secondary infections too.
    I hope you all get answers - i needed to add this as i see nobody refer to parasites with hives, whereas my experience is showing them to be intimately involved in some bad cases of hives.

  11. Hi Bee ~

    Thank you for your comments. The relationship of inflammation and autoimmune disease is spot on and it's important to try to determine what has initially caused the inflammation. Parasites may be one cause (https://thehorsesback.com/category/neck-threadworms-2/), dietary imbalances another, and environmental insults, toxins, etc. can all be the basis of inflammation.

    Parasites are perhaps one of the simplest and fastest sources to rule out as you did. If inflammation has been established for a long time (considering years) it may take several treatments and other supportive measures to eliminate, or at least lower to tolerable levels, over a period of time. Parasites or some other “trigger” may be the final straw that results in observable signs and symptoms (I know of two where venomous snake bite was the “trigger.)

    Pemphigus, in equine, humans and other animals, is defined and diagnosed by specific findings on biopsy, similar to other atopic dermatological diseases not caused by an identifiable pathogen. The specific findings are similar to the different varieties/locations of pemphigus (skin, coronet, mucous membrane and genital mucous membrane).
    Unfortunately many skin conditions get called “pemphigus” without biopsy which may result in a horse owner not looking at the “basics” - diet balancing, Omega-3, appropriate deworming, inspection of the environment and pastures. (This is also true of “allergies”). Horse owners aren’t the only ones looking for the “quick fix” that comes from steroids - vets are equally as guilty and things like dietary changes can take months to show results.

    For some horses, we may never really identify or totally control the inflammatory process. But your experience is a reminder of how important it is to not overlook the basics.


    1. And I neglected to point out that even when diagnosed unequivocally by biopsy as pemphigus, any underlying issues that can cause or exacerbate inflammation (parasites, high iron, insulin resistance, etc.) still should be addressed despite improvement from medication.