Persistent Nasal Skin Lesions in Pemphigus Patients and the Role of Methotrexate in Treatment: A Case Series Study
Keywords:
case series , Methotrexate, Nasal Skin, Pemphigus, Persistent, RituximabAbstract
Introduction: Nasal involvement might infrequently happen and some lesions may not respond to conventional treatments.
Objectives: The current case series report aims to describe the characteristics of 10 confirmed pemphigus vulgaris (PV) and pemphigus foliaceus (PF) patients with nasal skin lesions who did not respond to conventional treatment options or relapsed after a while and to evaluate the role of methotrexate in treatment.
Methods: Data regarding patient demographics, disease type and severity, nasal lesion characteristics, and treatment response was obtained from medical records and direct communication with patients between 2019 and 2023.
Results: Eight patients received intravenous rituximab (RTX) and 3 methotrexate. Out of the 8 pemphigus vulgaris (PV) patients who underwent RTX treatment, a total of 18 treatment sessions were carried out. Following RTX therapy, significant improvements in the nasal lesions were observed after 11 (61.1%) sessions, with 8 patients (44.4%) achieving complete resolution within 6 months. Additionally, 3 patients who did not have satisfactory results after RTX treatment, received methotrexate, and all of them experienced complete recovery of their nasal lesions within the same time frame.
Conclusions: All the patients who benefited from methotrexate never experienced complete remission of their nasal lesions before. It seems methotrexate can be an eligible choice for recalcitrant cases.
References
Malik AM, Tupchong S, Huang S, Are A, Hsu S, Motaparthi K. An updated review of pemphigus diseases. Med. 2021;57(10):1-15. DOI:10.3390/medicina57101080
Melchionda V, Harman KE. Pemphigus vulgaris and pemphigus foliaceus: an overview of the clinical presentation, investigations, and management. Clin Exp Dermatol. 2019;44(7):740-746. DOI:10.1111/ced.14041
James KA, Culton DA, Diaz LA. Diagnosis and clinical features of pemphigus foliaceus. Dermatol Clin. 2011;29(3):405-412. DOI:10.1016/j.det.2011.03.012
Maderal AD, Miner A, Nousari C, Alonso-Llamazares J. Localized Pemphigus Foliaceus with Unilateral Facial Involvement. Actas Dermo-Sifiliográficas (English Ed. 2014;105(4):413-417. DOI:10.1016/j.adengl.2013.02.020
Ioannides D, Hytiroglou P, Phelps RG, Bystryn JC. Regional variation in the expression of pemphigus foliaceus, pemphigus erythematosus, and pemphigus vulgaris antigens in human skin. J Invest Dermatol. 1991;96(2).
Safadi MG, Turowski M, Murray T, Zahner S, Aronson I. Pemphigus vulgaris and foliaceus localized to the nose: Report of 2 cases. JAAD Case Reports. 2021;15:129-132. DOI:10.1016/j.jdcr.2021.07.026
Baykal C, Azizlerli G, Thoma-Uszynski S, Hertl M. Pemphigus vulgaris localized to the nose and cheeks. J Am Acad Dermatol. 2002;47(6):875-880. DOI:10.1067/mdj.2002.121359
Zhang C, Goldscheider I, Ruzicka T, Sárdy M. Pemphigus vulgaris persistently localized to the nose with local and systemic response to topical steroids. Acta Derm Venereol. 2017;97(9):1136-1137. DOI:10.2340/00015555-2725
Ghoneim S, Zaiac M. The Use of Intralesional Steroids in a Case of Localized Pemphigus Foliaceus. Case Rep Dermatol. 2017;9(2):91-97. DOI:10.1159/000477959
Feitoza RIC, Santos M, Schettini M da CA, Ferreira S de AD. Pemphigus vegetans with isolated involvement of the nose and chest: Rare variant of pemphigus vulgaris. An Bras Dermatol. 2019;94(4):476-478. DOI:10.1590/abd1806-4841.20198285
Sami, Naveed. “Nasal, pharyngeal, and laryngeal pemphigus vulgaris successfully treated with rituximab.” Ear, nose, & throat journal vol. 96, 4-5 (2017): E35-E38.
Mandel VD, Farnetani F, Vaschieri C, et al. Pemphigus with features of both vulgaris and foliaceus variants localized to the nose. J Dermatol. 2016;43(8):940-943. DOI:10.1111/1346-8138.13314
Aizawa N, Asahina A, Ishii N, Hashimoto T, Nakagawa H. The nose as a predilection site of pemphigus. Clin Exp Dermatol. 2018;43(1):71-72. DOI:10.1111/ced.13275
Wu H, Stanley JR, Cotsarelis G. Desmoglein isotype expression in the hair follicle and its cysts correlates with type of keratinization and degree of differentiation. J Invest Dermatol. 2003;120(6):1052-1057. DOI:10.1046/j.1523-1747.2003.12234.x
Costan VV, Popa C, Hâncu M, Porumb‑Andrese E, Toader M. Comprehensive review on the pathophysiology, clinical variants and management of pemphigus (Review). Exp Ther Med. 2021;22(5):1-13. DOI:10.3892/etm.2021.10770
Kridin K. Emerging treatment options for the management of pemphigus vulgaris. Ther Clin Risk Manag. 2018;14:757-778. DOI:10.2147/TCRM.S142471
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