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Indian Journal of Dermatology, Venereology and Leprology
Medknow Publications on behalf of The Indian Association of Dermatologists, Venereologists and Leprologists (IADVL)
ISSN: 0378-6323 EISSN: 0973-3922
Vol. 70, Num. 4, 2004, pp. 249-250
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Indian Journal of Dermatology, Venereology, Leprology, Vol. 70, No. 4, July-August, 2004, pp. 249-250
Letter To Editor
Response by Dr. Pasricha
Pasricha JS
Department of Dermatology and Venereology, AIIMS, New Delhi - 110029
Correspondence Address:Skin Diseases Centre, 1-A, Masjid Moth,
DDA Flats, Phase-I, Outer Ring Road, Near Chirag Delhi Flyover, New Delhi
- 110048 j_s_pasricha@hotmail.com
Code Number: dv04086
Sir,
This is to thank Dr. Navin Modi and Dr. Gandhi et al for their comments/suggestions
on the articles on pulse therapy in pemphigus published in the IJDVL.[1],[2],[3],[4]
My response to the comments is as follows:
- The duration of infusion of dexamethasone between 1 to 2 hours has
been found to be safe. In case the infusion is more rapid it can
produce some disturbances in the heart rate, while if it is too slow
it may
not produce the peak levels as produced by the 2-hour infusion. The
same is true of the oral pulse.
- Use of azathioprine or methotrexate at Hyderabad is a welcome modification[2] and
deserves to be assessed further.
- The suggestion to use cyclophosphamide pulses instead of daily
cyclophosphamide[4] needs
to be evaluated to see if it will produce equal or better results.
I feel the patients would prefer to swallow a tablet daily rather
than have a drip. Cyclophosphamide toxicity among our patients
is already
negligible because our patients drink a lot of water. In an occasional
patient who develops toxicity, MESNA and other measures may be
used. I am not in favor of using too many drugs as a routine
in every patient.
- Should one depend upon the results of direct immunofluorescence
(DIF) and indirect immunofluorescence (IIF) to decide the duration
of phase
II and phase III? This needs to be assessed. Most of our patients
show negative or low titers at the end of phase III, but I
have also found
positive DIF/IIF even 5 years post-treatment even when there
had been no clinical relapse. I find it very difficult to assess
which
patient
requires more treatment and which one requires less. Neither
the percentage of body area of involvement at the start of
the treatment
nor the IIF
titer seem to have any bearing on the promptness of the recovery
in each case.
- Shortening the duration of phase II and phase III seems
to lead to a higher rate of relapse as also the administration
of
the pulses
at
irregular intervals rather than the exact 28 day cycles.
- I feel the use of immunoablative high dose of cyclophosphamide
is more risky and would not like to use it.
In conclusion, every worker has a right to modify the original
regimen and any regimen which produces better results
in the form of a quicker
recovery, a lower relapse rate, fewer side effects or
a shorter duration of treatment is welcome. The patient should
be the
ultimate beneficiary.
REFERENCES
| 1. | Pasricha JS. Pulse therapy as a cure for autoimmune diseases. Indian J Dermatol Venereol Leprol 2003;69:323-8. Back to cited text no. 1 |
| 2. | Rao PN, Lakshmi TS. Pulse therapy and its modifications in pemphigus: A six year study. Indian J Dermatol Venereol Leprol 2003;69:329-33. Back to cited text no. 2 |
| 3. | Ramam M. Dexamethasone pulse therapy in dermatology. Indian J Dermatol Venereol Leprol 2003;69:319-22. Back to cited text no. 3 |
| 4. | Gokhale NR, Mahajan PM, Sule RR, Belgaumkar VA, Jain SM. Treatment of pemphigus with intravenous pulse cyclophosphamide. Indian J Dermatol Venereol Leprol 2003;69:334-7. Back to cited text no. 4 |
Copyright 2004 - Indian Journal of Dermatology, Venereology, Leprology
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