Rituximab vs Prednisone: Clinical Outcomes

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Questions and Answers

What type of skin lesions are characterized by flaccid bullae that may develop into crusty erosions?

Pemphigus foliaceus (correct)

Eczema

Psoriasis

Seborrheic keratosis

In which areas of the body are the lesions predominantly found?

Neck and arms

Hands and feet

Seborrheic areas like chest and face (correct)

Lower back and abdomen

What is a common histopathological finding in pemphigus vulgaris?

Acantholysis at the granular layer

Absence of inflammatory cells

Intraepidermal suprabasal acantholysis (correct)

Dyskeratotic keratinocytes

What is noted about the itchiness associated with the lesions in this condition?

Itching is absent Signup and view all the answers

Which of the following best describes the transformation of lesions in pemphigus foliaceus?

From flaccid bullae to crusty erosions Signup and view all the answers

What kind of changes can be observed in the epidermis during histopathological examination?

Suprabasal cleft formation Signup and view all the answers

What involvement may occur in pemphigus that affects the nails?

Fingernail involvement Signup and view all the answers

What is the recommended method for obtaining samples for histopathological analysis?

Skin biopsy of perilesional skin or mucosa Signup and view all the answers

What is the primary goal of starting treatment in pemphigus patients?

To achieve disease control and complete remission as soon as possible Signup and view all the answers

Which scoring system is used to measure the extent and severity of pemphigus lesions?

Autoimmune Bullous Skin Intensity and Severity Score (ABSIS) Signup and view all the answers

What factors should be evaluated to assess prognosis in pemphigus patients?

General condition and the type of initial involvement Signup and view all the answers

Which treatment is almost no longer used for drug-induced pemphigus?

D-penicillamine Signup and view all the answers

Which type of clinical involvement is critical to specify in pemphigus patients?

Type of skin and mucosal involvement Signup and view all the answers

What is the recommended starting dosage of prednisone for tapering?

15–25 mg/day Signup and view all the answers

Which medications should be reviewed for potential induction of pemphigus?

Angiotensin-converting enzyme (ACE) inhibitors and beta-blockers Signup and view all the answers

What is a contraindication for the use of live vaccines?

Use of adjuvant immunosuppressants Signup and view all the answers

What measure is important for assessing the quality of life in pemphigus patients?

Dermatology-specific score (DLQI) Signup and view all the answers

How can the tapering of prednisolone be performed?

Using varying rates of tapering depending on patient condition Signup and view all the answers

What is considered a significant risk factor when evaluating pemphigus patients?

Age of the patient and general condition Signup and view all the answers

In which situation is the risk of skin relapse increased?

When anti-Dsg 1 levels are greater than 50 IU/mL Signup and view all the answers

What does the tapering schedule of prednisone usually involve?

Using a gradual reduction in dosage Signup and view all the answers

What should be done if a relapse occurs after stopping prednisone following rituximab treatment?

Consultation with an expert in pemphigus Signup and view all the answers

Which method is recommended for serological monitoring of disease activity?

Evaluation of serum autoantibodies at specific intervals Signup and view all the answers

What should be done if ELISA for anti-Dsg1 and/or Dsg3 is not available?

Utilize IIF microscopy with monkey oesophagus or Dsg 1/3-expressing cells Signup and view all the answers

In non-rituximab treated patients, what is the recommended action during tapering of corticosteroids when a relapse occurs?

Initiate rituximab treatment at 1 g two weeks apart Signup and view all the answers

How do serum concentrations of IgG autoantibodies correlate with pemphigus?

They correlate with the clinical activity of pemphigus Signup and view all the answers

What is considered the first-line treatment for severe pemphigus when rituximab is ineffective?

Intravenous immunoglobulins (IVIG) Signup and view all the answers

When might cyclophosphamide be considered in the treatment of pemphigus?

As a third-line treatment Signup and view all the answers

What is the recommended dosage of intravenous immunoglobulins (IVIG) for treatment cycles?

2 g/kg every cycle over 2-5 days Signup and view all the answers

What precaution should patients on oral corticosteroids or immunosuppressive therapy take?

Get vaccinated against seasonal influenza and pneumococci Signup and view all the answers

What type of corticosteroid injections may be used for isolated lesions of the oral mucosa in pemphigus patients?

Triamcinolone acetonide Signup and view all the answers

What topical treatment may be applied to oral erosions in some pemphigus patients?

Super-potent corticosteroids Signup and view all the answers

In which situation is rituximab applied as a second-line treatment?

If patients do not respond to conventional immunosuppressants Signup and view all the answers

Which of the following is NOT a standard recommended vaccination for patients on immunosuppressive therapy?

Hepatitis B Signup and view all the answers

Study Notes

Pemphigus Treatment and Management

Rituximab demonstrates higher complete remission rates compared to prednisone, with up to 58% achieving remission off therapy versus 34% with prednisone.
Primary treatment options include steroids and steroid-sparing agents such as azathioprine and mycophenolate.
Initial assessment of disease should include evaluating the extent of skin and mucosal involvement and any existing comorbidities.
Prognosis is influenced by patient age and overall health status; complications can arise from immunosuppressive treatments.
Lesion assessment using the Autoimmune Bullous Skin Intensity and Severity Score (ABSIS) or Pemphigus Disease Area Index (PDAI) is crucial for treatment planning.
Dermatology-specific quality of life impacts should be measured using DLQI and other tools tailored to autoimmune blistering diseases.

Clinical Evaluation

Record hematological, oncological, endocrine, and infectious histories to identify risk factors.
Pemphigus typically features flaccid bullae that may progress to erosions, especially in seborrhoeic areas like the chest and scalp; it is usually not itchy.
Nail involvement is possible, and lesions can emerge at mechanically stressed sites.

Histopathological Analysis

Skin biopsies should be collected from perilesional areas for routine histopathology analysis to confirm diagnosis.
Pemphigus vulgaris (PV) shows intraepidermal suprabasal acantholysis, while pemphigus foliaceus (PF) displays acantholysis at the granular layer.

Treatment Protocols

In severe or refractory cases, adjunctive treatments such as intravenous immunoglobulins (IVIG) may be considered.
High-potency topical corticosteroids (like clobetasol) can be applied directly to local oral erosions for symptomatic relief.
Careful management of corticosteroid dosing is recommended, considering the risk of relapse correlated with anti-Dsg1 levels.

Monitoring and Follow-Up

Regular serological monitoring for anti-Dsg1 and Dsg3 autoantibodies helps assess disease activity and guide treatment adjustments.
If relapses occur during corticosteroid tapering, consider reintroducing rituximab treatments.
Patients receiving immunosuppressive therapy should be vaccinated against common pathogens, avoiding live vaccines.

General Recommendations

Adjust prednisone tapering schedules based on individual risk assessments and relapse history.
Evaluate treatment response regularly to accommodate changes in disease activity and patient condition.

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Description

Explore the effectiveness of Rituximab compared to Prednisone in achieving complete remission in patients. This quiz focuses on identifying risk factors, severity factors, and potential co-morbidities based on clinical evaluations and historical data as reported in the JEADV 2020 study.