Sir,
Pemphigus vulgaris (PV), a chronic autoimmune blistering disease, is frequently associated with high morbidity and mortality. Currently, there are several treatment options for PV with variable results. Etanercept (ETN), a recombinant fusion protein of the extracellular ligand-binding domain of human 75-kDa tumor necrosis factor (TNF) receptor and the FC portion of human IgG1, acts as a competitive inhibitor of TNF and has several clinical label and off-label indications, the latter include PV.
We included five patients with PV treated with ETN-methotrexate (ETN-MTX). Patients’ characteristics are summarized in Table 1. The patients had been treated for at least 4 months with different treatment options like prednisone plus azathioprine, cyclophosphamide, mycophenolate mofetil or even MTX, with partial remission and relapse.
Table 1.
Characteristics of the patients studied
The patients were treated with ETN (25 mg twice weekly) and MTX (12.5-15 mg weekly) during 16 weeks to achieve disease control (only one patient [No. 2] required 20 weeks of treatment). All patients, at the end of the treatment, received prednisone ≤20 mg/day for 2 months and then tapered and maintaining MTX unmodified. The mean follow-up was 24.33 ± 6.4 months. No adverse events, such as hepatotoxicity, myelosuppression, infections, or malignancies, were evident. The only adverse event reported was injection site reaction (patient 1 and 4).
We determined that ETN-MTX is effective in treating recalcitrant PV with long-term follow-up with no evidence of relapse. Few studies describe the effectiveness of ETN for PV;[1,2,3,4] however, this is the first to determine the effectiveness of ETN-MTX on recalcitrant PV with an excellent clinical response that has been sustained for 24 months.
AUTHOR'S CONTRIBUTION
ATS contributed in the conception of the work, conducting the study, revising the draft, approval of the final version of the manuscript, and agreed for all aspects of the work. AB contributed in the drafting and revising the draft, approval of the final version of the manuscript, and agreed for all aspects of the work. GMO contributed in conducting the study and approval of the final version of the manuscript, and agreed for all aspects of the work. RMPO contributed in revising the draft, approval of the final version of the manuscript, and agreed for all aspects of the work.
REFERENCES
- 1.Fiorentino DF, Garcia MS, Rehmus W, Kimball AB. A pilot study of etanercept treatment for pemphigus vulgaris. Arch Dermatol. 2011;147:117–8. doi: 10.1001/archdermatol.2010.409. [DOI] [PubMed] [Google Scholar]
- 2.Berookhim B, Fischer HD, Weinberg JM. Treatment of recalcitrant pemphigus vulgaris with the tumor necrosis factor alpha antagonist etanercept. Cutis. 2004;74:245–7. [PubMed] [Google Scholar]
- 3.Lin MH, Hsu CK, Lee JY. Successful treatment of recalcitrant pemphigus vulgaris and pemphigus vegetans with etanercept and carbon dioxide laser. Arch Dermatol. 2005;141:680–2. doi: 10.1001/archderm.141.6.680. [DOI] [PubMed] [Google Scholar]
- 4.Shetty A, Marcum CB, Glass LF, Carter JD. Successful treatment of pemphigus vulgaris with etanercept in four patients. J Drugs Dermatol. 2009;8:940–3. [PubMed] [Google Scholar]