Prediction of survival for patients with pemphigus vulgaris and pemphigus foliaceus: a retrospective cohort study

Combination therapy for management of pemphigus patients with unexpected therapeutic response to rituximab: A report of five cases

Key Clinical Message

The immunosuppressant agents should be considered earlier in the course of treatment with rituximab, possibly after the unfavorable response at first cycle of treatment, especially in male patients and those with high BMI.

Abstract

Rituximab (RTX) has recently been proposed as an alternative first-line therapy for pemphigus patients. However, there are some rare reports of worsening of pemphigus following RTX therapy in the literature. This study aimed to evaluate the efficacy and safety of using a combination treatment of mycophenolate mofetil or dapsone and methotrexate in case of nonresponse, exacerbation or development of allergic reactions following rituximab therapy in pemphigus patients. In this case series, archive files of pemphigus patient in a tertiary care hospital from 2016 to 2021 who were treated with rituximab were reviewed and those with failure in treatment process including nonresponsiveness, exacerbation or development of allergic reactions to rituximab were identified and assessed. The study includes five patients out of 1245 RTX-treated patients, who did not respond to RTX (one patient) or experienced an exacerbation of disease (two patients) or development of allergic reactions (two patients). Male patients with high BMI (BMI > 25) whose response to rituximab was not good at first cycle and happened to receive rituximab later in the course of disease, had highest number of relapses and benefited the most from this combination immunosuppressive treatment as an alternative for repeating rituximab cycles. The lower risk of relapse and a better chance of remission might indicate the efficacy of adjuvant immunosuppressant therapy in patients with no-response, exacerbation, or allergic reaction to rituximab. These therapeutic effects were better observed in patients who received lower doses of rituximab which could suggest that the immunosuppressant agents should be considered earlier in the course of the disease, possibly after the first failed trial of rituximab therapy.

The Role of Sex and Gender in Dermatology - From Pathogenesis to Clinical Implications

BACKGROUND

Sex and gender have increasingly been recognized as significant risk factors for many diseases, including dermatological conditions. Historically, sex and gender have often been grouped together as a single risk factor in the scientific literature. However, both may have a distinct impact on disease incidence, prevalence, clinical presentation, severity, therapeutic response, and associated psychological distress.

OBJECTIVES AND PROJECT DESCRIPTION

The mechanisms that underlie differences in skin diseases between males, females, men, and women remain largely unknown. The specific objectives of this review paper are:To highlight the biological differences between males and females (sex), as well as the sociocultural differences between men and women (gender) and how they impact the integumentary system.To perform a literature review to identify important sex- and gender-related epidemiological and clinical differences for various skin conditions belonging to a range of disease categories and to discuss possible biological and sociocultural factors that could explain the observed differences.To discuss dermatological skin conditions and gender-affirming treatments within the transgender community, a population of individuals who have a gender identity which is different than the gender identity they were assigned at birth.

FUTURE IMPACT

With the rising number of individuals that identify as non-binary or transgender within our increasingly diverse communities, it is imperative to recognize gender identity, gender, and sex as distinct entities. By doing so, clinicians will be able to better risk-stratify their patients and select treatments that are most aligned with their values. To our knowledge, very few studies have separated sex and gender as two distinct risk factors within the dermatology literature. Our article also has the potential to help guide future prevention strategies that are patient-tailored rather than using a universal approach.

Pemphigus foliaceus: A rare blistering skin lesion

Pemphigus foliaceus is a benign variety of pemphigus group. It is a rare autoimmune blistering disease that affects the skin without mucosal involvement. It can present in endemic and sporadic form; whereby endemic form is common in Brazil and Tunisia, known as fogo selvagem. There was no previous case reported in Malaysia. We report a case of a 43-year-old man, who presented with generalized extensive blisters and vesicles that form crust and scale. The full evaluation established the diagnosis of pemphigus foliaceous. Delay in diagnosis can lead to poor outcomes. Primary care practitioners should be aware of this since the condition can mimic eczema, specifically photodermatitis.

Association of autoimmune blistering disease, and specifically, pemphigus vulgaris, with cardiovascular disease and its risk factors: a systematic review and meta-analysis

Previous studies have found conflicting results about the association of autoimmune blistering disease (AIBD) with cardiovascular disease (CVD) risk. The objective of the study was to systematically review the relationship of AIBD, including pemphigus vulgaris (PV), and its treatment with CVD and CVD risk factors. MEDLINE, EMBASE, Cochrane, LILACS, SCOPUS, and Web of Science were searched. We included all studies of CVD and CVD risk factors in AIBD patients. Two reviewers performed title and/or abstract review and data extraction. Pooled random-effects meta-analysis was performed. Forty papers met inclusion criteria. AIBD was associated with higher odds of diabetes (DM) (odds ratio [95% confidence interval]: 1.809 [1.258-2.601]), hypertension (HTN) (1.393 [1.088-1.784]), dyslipidemia (2.177 [1.163-4.073]) and heart failure (1.919 [1.603-2.298]), but was not associated with obesity, stroke, angina, heart attack, or arrhythmia. The pooled random-effects prevalence for treatment-related adverse events (AEs) in AIBD was 13.7% for DM, 10.7% for HTN, and 17.1% for CVD. Sensitivity analysis of high-quality studies revealed similar results. AIBD patients have increased CVD risk factors and heart failure. Systemic corticosteroid treatment results in CVD-related AEs in AIBD. Increased CVD screening and prevention strategies are warranted in AIBD.

Risk of Atrial Fibrillation in Pemphigus Vulgaris

Background

Pemphigus vulgaris (PV) is a rare immunobullous disease with a higher mortality rate than the general population. The aim of this study was to investigate P-wave duration and P-wave dispersion (PWD) in patients with PV as predictors of atrial fibrillation (AF).

Materials and Methods

In this case-control study, the risk of AF development was determined by measuring maximum and minimum P-wave duration (P-max and P-min) and PWD in 45 PV patients and 45 healthy individuals. The incidence of metabolic syndrome was evaluated.

Results

PWD and P-max values of the study group were significantly higher than those of the control group. No difference was observed between PWD with regards to disease duration and disease phenotype (p > 0.05). There was no significant difference regarding the prevalence of metabolic syndrome in PV patients compared with the control group.

Conclusion

PWD and P-max, which are accepted as risk factors for AF development, were found to be higher in PV patients. Some components of metabolic syndrome were more prevalent in PV patients. It seems that there is an increased risk of CVD and AF in PV patients.

An Updated Review of Pemphigus Diseases

Clinicians may encounter a variety of skin conditions that present with vesiculobullous lesions in their everyday practice. Pemphigus vulgaris, pemphigus foliaceus, IgA pemphigus, and paraneoplastic pemphigus represent the spectrum of autoimmune bullous dermatoses of the pemphigus family. The pemphigus family of diseases is characterized by significant morbidity and mortality. Considering the risks associated with a delayed diagnosis or misdiagnosis and the potential for overlap in clinical features and treatment, evaluation for suspected pemphigus disease often requires thorough clinical assessment and laboratory testing. Diagnosis is focused on individual biopsies for histopathology and direct immunofluorescence. Additional laboratory methods used for diagnosis include indirect immunofluorescence and enzyme-linked immunosorbent assay. Recent advancements, including anti-CD20 therapy, have improved the efficacy and reduced the morbidity of pemphigus treatment. This contribution presents updates on the pathophysiology, clinical features, diagnostic work-up, and medical management of pemphigus. Improved strategies for diagnosis and clinical assessment are reviewed, and newer treatment options are discussed.

Survival of patients with rare diseases: a population-based study in Tuscany (Italy)

Background

Rare diseases (RDs) encompass a heterogeneous group of life-threatening or chronically debilitating conditions that individually affect a small number of subjects but overall represent a major public health issue globally. There are still limited data on RD burden due to the paucity of large population-based epidemiological studies. The aim of this research was to provide survival estimates of patients with a RD residing in Tuscany, Italy.

Methods

Cases collected in the Rare Diseases Registry of Tuscany with diagnosis between 1st January 2000 and 31th December 2018 were linked to the regional health databases in order to retrieve information on mortality of all subjects. Survival at 1, 5 and 10 years from diagnosis with 95% confidence intervals (CI) was estimated by sex, age class, nosological group and subgroup using the Kaplan–Meier method. The effect of sex, age and period of diagnosis (years 2000–2009 or 2010–2018) on survival was estimated using Cox proportional hazards regression.

Results

Survival at 1, 5 and 10 years from diagnosis was 97.3%, 88.8% and 80.8%, respectively. Respiratory diseases and peripheral and central nervous system disorders were characterized by the lowest survival at 5 and 10 years. Despite a modest higher prevalence of RDs among females (54.0% of the total), male cases had a significant increased risk of death (hazard ratio, HR 1.48, 95% CI 1.38–1.58). Cases diagnosed during 2010–2018 period had a risk of death significantly lower than those diagnosed during 2000–2009 (HR 0.81, 95% CI 0.82–0.96), especially for immune system disorders (HR 0.48, 95% CI 0.26–0.87), circulatory system diseases (HR 0.61, 95% CI 0.45–0.84) and diseases of the musculoskeletal system and connective tissue (HR 0.64, 95% CI 0.49–0.84).

Conclusions

An earlier diagnosis as well as the improvement in the efficacy of treatment resulted in a decreased risk of death over the years for specific RDs. The linkage between a population-based registry and other regional databases exploited in this study provides a large and accurate mass of data capable of estimating patients’ life-expectancy and increasing knowledge on the collective burden of RDs.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13023-021-01907-0.

Rituximab exhibits a better safety profile when used as a first line of treatment for pemphigus vulgaris: A retrospective study

BACKGROUND

Pemphigus is an autoimmune disease that is challenging to treat and has few available therapeutic options. Recently, several studies have demonstrated that rituximab may be an efficacious first-line treatment in newest guidelines.

AIM

To compare the side effect profiles of rituximab administered after a course of immunosuppressant agents versus as a first-line therapy and evaluate the impact of patient characteristics and disease severity indices on occurrence of adverse effects.

METHODS

A retrospective cross-sectional study was conducted on 999 patients with pemphigus vulgaris who received rituximab either as a first-line treatment or after conventional adjuvant therapies. The occurrence of partial or complete remission as well as the incidence of drug-related adverse effects were evaluated and compared between the two groups.

RESULTS

Smoking, pulmonary comorbidity, and mucocutaneous phenotype were associated with an increased risk of developing infectious complications by 12.49, 5.79, and 2.37 fold, respectively. These associations were more prominent among those who received rituximab after immunosuppressant agents.

CONCLUSIONS

Early use of rituximab benefits pemphigus patients, especially those with a mucocutaneous phenotype, pulmonary comorbidity, or history of smoking, and reduces their risk of infectious adverse events.

Complementary Chinese Herbal Medicine Therapy Improves Survival in Patients With Pemphigus: A Retrospective Study From a Taiwan-Based Registry

Pemphigus is a life-threatening and skin-specific inflammatory autoimmune disease, characterized by intraepidermal blistering between the mucous membranes and skin. Chinese herbal medicine (CHM) has been used as an adjunct therapy for treating many diseases, including pemphigus. However, there are still limited studies in effects of CHM treatment in pemphigus, especially in Taiwan. To more comprehensively explore the effect of long-term CHM treatment on the overall mortality of pemphigus patients, we performed a retrospective analysis of 1,037 pemphigus patients identified from the Registry for Catastrophic Illness Patients database in Taiwan. Among them, 229 and 177 patients were defined as CHM users and non-users, respectively. CHM users were young, predominantly female, and had a lesser Charlson comorbidity index (CCI) than non-CHM users. After adjusting for age, sex, prednisolone use, and CCI, CHM users had a lower overall mortality risk than non-CHM users (multivariate model: hazard ratio (HR): 0.422, 95% confidence interval (CI): 0.242–0.735, p = 0.0023). The cumulative incidence of overall survival was significantly higher in CHM users than in non-users (p = 0.0025, log rank test). Association rule mining and network analysis showed that there was one main CHM cluster with Qi–Ju–Di–Huang–Wan (QJDHW), Dan–Shen (DanS; Radix Salviae miltiorrhizae; Salvia miltiorrhiza Bunge), Jia–Wei–Xiao–Yao-–San (JWXYS), Huang–Lian (HL; Rhizoma coptidis; Coptis chinensis Franch.), and Di–Gu–Pi (DGP; Cortex lycii; Lycium barbarum L.), while the second CHM cluster included Jin–Yin–Hua (JYH; Flos lonicerae; Lonicera hypoglauca Miq.) and Lian–Qiao (LQ; Fructus forsythiae; Forsythia suspensa (Thunb.) Vahl). In Taiwan, CHMs used as an adjunctive therapy reduced the overall mortality to approximately 20% among pemphigus patients after a follow-up of more than 6 years. A comprehensive CHM list may be useful in future clinical trials and further scientific investigations to improve the overall survival in these patients.

Family dermatology life quality index in patients with pemphigus vulgaris: A cross-sectional study

BACKGROUND AND AIMS

Pemphigus vulgaris is a rare autoimmune intraepidermal vesiculobullous disease involving the skin and mucosa. It impacts the quality of life of both patients and their families.

METHODS

A total of 70 patients with pemphigus vulgaris (either outpatient or hospitalized) were enrolled using the simple sampling method between 2016 and 2017 from the dermatology clinic at Faghihi Hospital, Shiraz, Iran. A validated Persian version of the Family Dermatology Life Quality Index (FLDQI) questionnaire was filled by a family caregiver. The questionnaire contained 10 items assessing the quality of life of the family. Demographic variables were recorded in a separate form.

RESULTS

The mean age of the patients was 51 ± 11.3 years and that of the family caregivers was 32 ± 8.8 years. The FLDQI score was higher (poorer quality of life) if the patient was male, older, had shorter disease duration or had fewer disease recurrences (P = 0.046, 0.01, 0.001 and >0.001, respectively). Higher scores were also obtained in the less-educated caregivers (P = 0.026) but there was no association with either gender or age (P = 0.399, 0.1).

CONCLUSION

Pemphigus vulgaris significantly affects the Family Dermatology Life Quality Index. Education and counseling of family caregivers by various support groups such as Pemphigus Family Associations could be effective in improving the quality of life of the caregivers.

LIMITATIONS

This study did not assess the effect of comprising domain analysis, severity of disease, patients' Dermatology Life Quality Index (DLQI), mucosal involvement, response to treatment, outpatient or admitted status, socioeconomic status, or the quality of life among the various family members.

[Ultrastructure of epidermocytes in true pemphigus acantholysis]

OBJECTIVE

To investigate the ultrastructure of epidermocytes in skin biopsy specimens, by taking into account an update on the pathomorphogenesis of true pemphigus acantholysis.

MATERIAL AND METHODS

Affected skin biopsy specimens from 4 patients with Pemphigus vulgaris (a mixed mucosal-epidermal variant) and from 1 patient with P. foliaceus at the onset of the disease in the absence of therapy were examined by light microscopy of semifine sections and by transmission electron microscopy.

RESULTS

Skin biopsy specimens from pemphigus patients from the foci with a positive Nikolsky's sign were characterized by acantholysis and dilated intercellular spaces in the basal and spinous layers of the epidermis in combination with desmosomal hypoplasia and destruction. The reduction in the organelles of mitochondrial protein synthesis, which causes a decrease in the cytoplasm of the perikaryon and especially in the processes of a number of tonofilaments involved in the formation of desmosomes engaged our attention when studying the ultrastructure of epidermocytes.

CONCLUSION

A marked reduction in the number and size of desmosomes in P. vulgaris and P. foliaceus starts in the basal layer of the epidermis; however, acanthosis occurs in the suprabasal and spinous layers, respectively. The universal manifestations of pathology of cytoskeletal elements involved in the formation of desmosomes, as well as their underproduction must be considered in the concept of the pathogenesis of true pemphigus acantholysis.

Incidence and death rate of pemphigus vulgaris and pemphigus foliaceus in Korea: A nationwide, population-based study (2006-2015)

The epidemiology of pemphigus varies among racial populations worldwide. Trends in the incidence of pemphigus have not been investigated based on the Korean National Health Insurance database. This study investigated the incidence and death rate of pemphigus with age using nationwide population data in South Korea. A nationwide population-based cohort study was performed using the Korean National Health Insurance Claims Database from 2006 to 2015. The incidence of pemphigus vulgaris (PV) per 1 000 000 person-years was 2.059 (1.885 for males and 2.234 for females), and for pemphigus foliaceus (PF) 1.138 (1.205 males and 1.07 for females). The incidence of PV and PF increased with age. The incidence was not different between the habitat and household income. These incidence of PV and PF was significantly higher in subjects with comorbid metabolic conditions, such as diabetes mellitus, hypertension and dyslipidemia. The death rate per 1000 person-years in PV and PF patients increased with age after adjustment for the presence of comorbidities compared with standard death rate. This study showed that age is an important factor in PV and PF patients in Korea.

Bacteremia in autoimmune bullous disease patients undergoing double-filtration plasmapheresis

Background: Plasmapheresis is one of the treatment options for autoimmune bullous disease (AIBD). Objective: To evaluate the incidence of adverse events occurring during a course of plasmapheresis. Methods: This study enrolled 42 courses of double-filtration plasmapheresis (DFPP) from 28 patients with AIBD treated in Kurume University Hospital between 2007 and 2016. We examined the frequency of adverse events during the course of DFPP and associated features. Results: The most frequent adverse event was bacteremia (13 of 42 courses, 31.0%), followed by subcutaneous hemorrhage (1 course, 2.4%), and an abscess at the catheterization sites (1 course, 2.4%). No adverse event-related death was recorded. In the analysis of bacteremia occurrence, the erosion at the catheterization sites, the use of central venous catheter (CVC), and the number of DFPP cycles per course were significantly more or greater in the bacteremia group than in the non-bacteremia group (p = .0474, .0005, and .0035, respectively). Conclusions: Although DFPP is a good treatment option for AIBD, attention needs to be paid for the development of possible risks during a DFPP course. We believe that our results can be applied to other plasmaphereses in AIBD management.

Electrocardiographic changes after high-dose corticosteroid pulse therapy in pemphigus patients

PURPOSE

The objective of the current study was to evaluate the effect of intravenous methylprednisolone pulse therapy on myocardial repolarization alterations, especially QT dispersion in anticipation of cardiovascular risks in patients with pemphigus vulgaris.

METHODS

The current study is a prospective-controlled study on the electrocardiographic changes after methylprednisolone pulse therapy in 50 patients with pemphigus vulgaris.

RESULTS

A total of 50 patients (28 female and 22 male) were included in our study. The mean heart rate was significantly higher in male patients both before (92 ± 10.80 versus 82.75 ± 12.01 ms) and after pulse therapy (102.73 ± 14.26 versus 91.07 ± 15.02 ms) (p value < .01). The value of heart rate was significantly greater after receiving steroid pulse therapy. Corrected QT dispersion before pulse therapy was 19.92 ± 8.2 ms that increased to 40.68 ± 18.12 ms after treatment (p value < .001).

CONCLUSION

Our study shows that there is a relationship between pulse steroid infusion and increased predisposition to the occurrence of cardiac arrhythmias. QT dispersion could be a good marker to assess this risk in these patients.

Immunological markers as predictors of developing steroid-induced diabetes mellitus in pemphigus vulgaris patients: An observational study

The aim of this study was to evaluate the clinical importance of autoantibodies in pemphigus vulgaris patients who developed steroid-induced diabetes mellitus (SID) because of the glucocorticoid therapy of pemphigus.A total of 137 patients with pemphigus vulgaris were studied. Patients with SID and pemphigus were compared with those that had only pemphigus. The variables recorded were: age at diagnosis, sex, body mass index, presence of diabetes mellitus (DM), cumulative cortisone dose, treatment duration, value of anti-desmoglein 1 and 3, and anti-glutamic acid decarboxylase autoantibodies.A total of 31 patients (22.62%) that developed steroid-induced DM were identified. Anti-glutamic acid decarboxylase autoantibodies were positive in 20.75% of patients with pemphigus vulgaris and in 25.75% of patients with pemphigus vulgaris and SID.The overall anti-glutamic acid decarboxylase autoantibodies prevalence in pemphigus patients was high, and the risk of developing DM in patients with pemphigus remains a serious problem, being associated with increased risk of mortality.

Cutaneous Drug Reactions in the Elderly

Cutaneous adverse drug reactions comprise a significant proportion of all adverse drug reactions. They may mimic other dermatologic or systemic illnesses and may cause significant morbidity or mortality. Seven morphologic groups encompass the most commonly encountered cutaneous drug reaction syndromes: exanthematous (maculopapular), dermatitic/eczematous, urticarial, pustular, blistering, purpuric, and erythrodermic. Drug reactions may have significant downstream consequences for the older individual.

Inpatient Mortality Resulting from Dermatological Disorders at a Tertiary Care Center in Eastern India: A Record-based Observational Study

Background

Contrary to popular perception, several dermatological conditions may be associated with lethal outcome in the absence of timely intervention or due to complications.

Aims

The aim was to estimate the number of deaths and analyze their causes due to skin disorders at a tertiary level inpatient dermatology ward.

Materials and Methods

We conducted a retrospective, record-based observational study involving 538 patients spanning over 4 years (2013-2016) at our dermatology indoor setup.

Results

There were 45 deaths (male:female = 1.5:1), accounting for 8.4% or total admissions, occurring mostly in patients in their 7^th decade. Vesiculobullous disorders were the most frequent cause of mortality (57.8%), followed by drug reactions accounting for 17.8% of cases. In the former group pemphigus vulgaris accounted for most deaths (31.1%) followed by bullous pemphigoid (17.8%) and pemphigus foliaceus (8.9%), whereas toxic epidermal necrolysis was the most frequent cause of death from drug reactions (8.9%). Almost half of all deaths (48.9%) occurred due to septicemia followed by cardiopulmonary complications (40%). Most of the cases presented to us at an advanced state of the disease previously being treated inappropriately.

Conclusion

Prompt diagnosis and treatment of such dermatological conditions are mandated, preferably in an intensive care set-up, to reduce mortality rates. Advanced age, the area of skin involvement, mucosal involvement, and septicemia were adverse prognostic factors in these patients.

Skin diseases of the nose

OBJECTIVES

The goal of this study was to review the main lesion types of the nasal skin and appropriate treatment strategies rather than to present a comprehensive list of all diseases that affect the skin that can involve the nose.

METHODS

We reviewed the main nasal skin lesion types and available treatment strategies. Nasal skin lesions were classified as benign, premalignant, or malignant.

RESULTS

Benign lesions of the nose include nonmalignant tumoral lesions (i.e., freckles, comedo, adenoma sebaceum [Pringle disease], hydrocystoma, fibrous papules, sebaceous hyperplasia, and rhinophyma), autoimmune and inflammatory conditions (i.e., pemphigus, sarcoidosis, systemic lupus erythematosus, facial eosinophilic granuloma, rosacea, herpes zoster infection, leishmaniasis, and leprosy), and vascular lesions (i.e., telangiectasis, hemangioma, and spider nevus). Premalignant lesions are actinic keratosis and keratoacanthoma; and malignant tumors are melanoma, basal cell carcinoma, and squamous cell carcinoma. Regardless of whether or not they are malignant, all facial lesions can yield significant cosmetic discomfort that should be evaluated carefully before commencing any curative or corrective intervention. In general, benign lesions are treated with dermabrasive modalities, such as trichloroacetic acid, phenol, salicylate, and laser ablation. Electrocautery, cryosurgery, and surgical excision are also used, although these methods may result in scar formation, which can sometimes be more problematic than the original lesion itself.

CONCLUSION

Any disease that affects the skin, especially those diseases that are triggered by ultraviolet exposure, can involve the face and nose. Cosmetic defects due both to the lesion itself and the intervention must be discussed with the patient, preferably in the presence of a first-degree relative, before commencement of treatment. As a result of heterogeneity of skin lesions of the nose, appropriate education of general practitioners as well as otorhinolaryngologists is mandatory.

Pemphigus Vulgaris: How to Perform an Oral Biopsy Properly?

Oral biopsy of vesiculobullous diseases such as pemphigus vulgaris often raises questions due to some particularities involving this procedure. The adequate selection of the area to be biopsied defines if the final diagnosis will be reached, being the Achiles heel of the proper management of the patient. Here, the authors report a case of a woman who sought for treatment of generalized oral blisters and ulcers that caused severe pain. She had undergone a previous biopsy by other professionals that was inconclusive. The authors' team diagnosed the patient with pemphigus vulgaris and treated her properly. The authors provide a brief discussion about the adequate oral site to be chosen when dealing with vesiculobullous diseases once it still remains a source of doubts for the dental surgeons.

Management of Pemphigus Vulgaris

INTRODUCTION

Pemphigus vulgaris (PV) is a chronic, autoimmune, vesiculobullous disease. As a result of the relative rarity of PV, published randomized controlled trials (RCTs) are limited, which makes it difficult to evaluate the efficacy of different treatment regimens in this disease. This also precludes conduct of a meta-analysis.

METHODS

English-language publications describing treatment outcomes of patients with PV were identified by searches of electronic databases through May 2015, and additionally by review of the bibliography of these publications. A total of 89 papers, which included 21 case reports, 47 case series, 8 RCTs, and 13 observational studies, were identified. The findings from these publications, including information on disease course and prognosis, medications used, treatment responses, and side effects, are summarized in the tables and text of this review.

RESULTS

Prior to availability of corticosteroid therapy, PV had a high fatality rate. Early publications from the 1970s reported high-dose, prolonged corticosteroid use and significant associated side effects. Later reports described use of corticosteroids along with steroid-sparing adjuvants, which allows a reduction in the total dose of corticosteroids and a reduction in observed mortality and morbidity. For the majority of patients in these reports, a long-term course on medications lasting about 5-10 years was observed; however, subgroups of patients requiring shorter courses or needing longer-term therapy have also been described. Early diagnosis of PV and early initiation of treatment were prognostic factors. In recent publications, commonly used initial regimens include corticosteroids in combination with mycophenolate or azathioprine; whereas, for patients with inadequate response to these regimens, adjuvants such as intravenous immunoglobulin (IVIg) or rituximab are used.

CONCLUSION

The review findings emphasize the importance of early diagnosis, early initiation of treatment, and use of steroid-sparing adjuvants to allow a reduced total dose and duration on corticosteroids. Also highlighted is the need for more RCTs.