Multiple cycles of rituximab therapy for pemphigus: A group of patients with difficult‐ to‐treat disease or a consequence of late rituximab initiation?

Abstract

Pemphigus is a serious autoimmune disease with few appropriate therapeutic options. Although rituximab (RTX) has recently shown great promise in this regard, the best protocol of its administration is remains to be elucidated. This study aimed to evaluate the patients who need at least 3 cycles of treatment with RTX to identify hard-to-treat patients' characteristics, which might lead to consider more prompt protocols for treatment of them. A retrospective cross-sectional study was conducted on 45 patients with pemphigus vulgaris who received at least 3 cycles of RTX. Their demographic, clinical, and laboratory data as well as details of treatment protocol and final clinical situation of patients were evaluated. Totally, 45 patients (21 men and 24 women) with mean age of 44.33 years were included in this paper.Women were about 8 years older than men (mean age: 48.1 years versus 40.1 years, p: 0.011) and needed RTX approximately 2 years later in their course of disease (gap: 41.04 months vs. 14.85 months, p: 0.003). Buccal, truncal, and scalp regions were the most frequent sites of involvement respectively. A significant decrease in both anti-Dsg1, 3 was seen at last visit compared to baseline. However, the amount of this decrement was not significantly different between them (p: 0.083). Partial remission in 31.11%, complete remission in 24.44%, relapse in 15.56%, partial remission on treatment in 15.56% and complete remission on treatment in 13.33% were seen at the last follow-up session. RTX is an effective medication for PV even in patients with refractory disease and its therapeutic effect is increased with each subsequent cycle. Male gender, severe oral mucosal involvement on disease onset and extensive scalp and truncal lesions as first cutaneous manifestation of disease are more likely to be signs of refractory PV. Hence, it is reasonable to consider more prompt protocols for treatment of these cases. Moreover, late prescription of RTX during the course of disease might play a role in presence of more resistant form of disease.

New‐onset pemphigus foliaceus following SARS‐CoV‐2 infection and unmasking multiple sclerosis: A case report

“…It is interesting to know that new guidelines focus on the administration of rituximab as the first‐line treatment for pemphigus, since it leads to more cases of remission even after one cycle 19–22 . Our patient received rituximab for her underlying neurological disorder, MS, but this had done her favor as it led to complete resolution of cutaneous eruptions.…”

“…Another important issue was the contribution of SARS-CoV-2 in triggering new onset or exacerbations of neuro-immunological disease like MS. 18 This phenomenon occurred in our patient who was probably a case of It is interesting to know that new guidelines focus on the administration of rituximab as the first-line treatment for pemphigus, since it leads to more cases of remission even after one cycle. [19][20][21][22] Our patient received rituximab for her underlying neurological disorder, MS, but this had done her favor as it led to complete resolution of cutaneous eruptions. 4 | CONCLUSION SARS-Cov-2 infection could have led to any dermatologic condition, including insignificant and critical ones.…”

Cutaneous Manifestations of COVID-19 in Children: Practical Points for Clinicians

“…The authors of this study have focused on the immunologic aspects of various topics in dermatology and recently turned their focus on COVID-19-associated dermatologic topics (22)(23)(24)(25)(26)(27)(28) as an issue of great importance discussed in this paper. Since the vaccination of children was not started across the world until the last update of this review, vaccine-related cutaneous reactions in children should be dealt with in future studies.…”

SARS‐CoV‐2 vaccination and practical points in psoriasis patients: A narrative review

“…95 The issue may be somewhat different for timing of treatment with monoclonal antibodies such as rituximab which have seldom been used to treat psoriasis, compared to other dermatoses. [96][97][98][99] It is advised to give space between the last rituximab infusion and vaccination, in order for the immune system to reconstitute B cells and achieve higher seroconversion. If patients are not at risk of organ damage or disease relapse, it is better to delay rituximab administration until completion of COVID-19 vaccination.…”