A Novel Low-Dose Rituximab and IVIg Protocol for Treating Moderate to Severe Pemphigus: A Prospective Study

Background Pemphigus is a chronic autoimmune disease of skin and mucous membranes which presents with painful blisters. Conventional treatment with high doses of corticosteroids may lead to remission, but this often causes significant side effects. Therefore, steroid-sparing treatments like rituximab (a monoclonal antibody) and intravenous immunoglobulin (IVIg) have been tried and appear to be safe and effective alternatives. This study looked at how well a low-dose combination of rituximab and IVIg works for moderate to severe pemphigus cases. Methods The study involved 25 patients, most of whom (92%) had pemphigus vulgaris, while the rest (8%) had pemphigus foliaceus. All patients had a Pemphigus Disease Area Index (PDAI) score greater than 15. The treatment was initiated with IVIg (2 g/kg), followed by a 500 mg dose of rituximab two weeks later. Patients received prednisolone as premedication. Clinical responses were evaluated at 3 months using PDAI scores and changes in anti-desmoglein (anti-Dsg1 and anti-Dsg3) antibody levels. Results By the end of the study, 48% of patients had complete remission, 44% achieved partial remission, and 8% experienced a relapse, with no significant difference in regard to treatment response between old and new cases. PDAI scores significantly dropped from an average of 21.56 ± 13.46 to 7.12 ± 1.05 (P < 0.001). Antibody levels also fell sharply (P = 0.010 for anti-Dsg1; P = 0.00043 for anti-Dsg3). Side effects were minimal, with 12% of patients reporting mild upper respiratory infections. Conclusion This combination of low-dose rituximab and IVIg seems to be a safe and effective way to manage pemphigus. It helped reduce symptoms and antibody levels while avoiding serious side effects. Even though the results are promising, more research with larger groups and longer follow-up periods is necessary to confirm these findings and improve the treatment.