|Year : 1992 | Volume
| Issue : 1 | Page : 20-22
Evaluation of oral ulcers appearing in pemphigus patients treated with dexamethasone-cyclophosphamide pulse therapy
J S Pasricha
Twenty cases of pemphigus with oral ulcers who were being treated with dexamethasone-cyclophosphamide pulse therapy were evaluated for the cause of ulcers. The lesions were first classified into pemphigus ulcers, aphthous ulcers, pyogenic infection and candidiasis on the basis of clinical characteristics. Smears from these ulcers were then stained with Giemsa stain to look for acantholytic cells and bacteria. Another smear was mounted in 10% KOH to look for candida.
Seven patients were clinically diagnosed to have pemphigus ulcers, but acantholytic cells were seen in only 2 cases. Both these patients had superadded infection with candida and gram positive bacteria respectively. Of the 9 cases clinically diagnosed to have candidiasis, only 6 revealed candida in 10% KOH smears, while 1 patient revealed acantholytic cells. All the 3 cases clinically considered to have aphthous ulcers, revealed only normal looking epithelial cells. One patient clinically diagnosed to have pyogenic infection revealed pus cells and bacteria on gram stain. It is obvious that oral ulcers in a pemphigus patient may not always be pemphigus ulcers, and some of these may be super-infected with candida, pyogenic or other organisms. A proper evaluation is therefore necessary for appropriate treatment.
Keywords: Pemphigus, Oral ulcers, Evaluation.
|How to cite this article:|
Pasricha J S. Evaluation of oral ulcers appearing in pemphigus patients treated with dexamethasone-cyclophosphamide pulse therapy. Indian J Dermatol Venereol Leprol 1992;58:20-2
|How to cite this URL:|
Pasricha J S. Evaluation of oral ulcers appearing in pemphigus patients treated with dexamethasone-cyclophosphamide pulse therapy. Indian J Dermatol Venereol Leprol [serial online] 1992 [cited 2013 May 23];58:20-2. Available from: http://www.ijdvl.com/text.asp?1992/58/1/20/3733
| Introduction|| |
Pemphigus is a potentially fatal disease in spite of a variety of therapeutic modalities available for its treatment. During the last 10 years however, we have designed a new method of treatment called dexamethasone-cyclophosphamide pulse (DCP) therapy ,,, with which we are able to induce a complete remission in almost every patient and there have been no relapses for prolonged periods even after withdrawing the treatment. It is, however, necessary to complete the course of treatment as per the schedule outlined by us. The time taken to induce a complete clinical remission varies in different patients and in a large proportion of patients the mucosal lesions continue to recur for variable periods even after the skin lesions stop appearing completely. In some patients, the mucosal ulcers reappear after the patient had been in complete remission for a prolonged period. Since DCP therapy is associated with a certain amount of immuno-suppression, and candida and other oral microflora are likely to proliferate more profusely in such states and become pathogenic, it was considered worthwhile to evaluate whether the oral ulcers appearing in these patients, were pemphigus ulcers or these represent candidal, viral or bacterial infections.
| Materials and Methods|| |
Cases of pemphigus being treated with dexamethasone-cyclophosphamide pulse therapy, who presented with ulcers in the mouth were included in the study. All lesions were first evaluated clinically to classify them into: (1) pemphigus ulcers, (2) aphthous ulcers, (3) pyogenic infection, or (4) candidiasis. A lesion was considered to be a pemphigus ulcer, if it was superficial and large without evidence of necrosis, slough, inflammation, pus discharge or a whitish deposit. The clincal diagnosis of aphthous ulcer was applied when the, ulcers were circular, with a central slough and a reddish halo. Such ulcers were generally more painful. The diagnosis of candidiasis was considered when there was a whitish slough/membrane on the .ulcer. Pyogenic infection was considered when the ulcers had a more diffuse inflammation with pus discharge and a bad smell from the mouth.
After the clinical evaluation, material from these ulcers was scraped to prepare two smears, one of which was stained with Giemsa stain to look for acantholytic cells and/or multi-nucleated giant cells, and the other was stained with Gram stain to look for pus cells and/or bacteria. Another portion of the material was mounted in 10% KOH to look for the presence of candida. All these tests were undertaken in all cases irrespective of the clinical evaluation.
| Results|| |
Out of 20 patients included in this study, 10 patients were in phase I of DCP i. e. still having active disease while receiving DCP, 7 patients were in phase II, meaning that they were in remission but still receiving DCP, 1 patient was in phase III (receiving only oral cyclophosphamide) and 2 patients had completed their treatment and were therefore not on any drugs (phase IV).
Clinically, the oral ulcers were considered to be pemphigus ulcers in 7 patients, 4 of whom were in treatment phase I and 3 in phase II. In 3 cases (1 in phase I and 2 in phase II), the ulcers were considered to be aphthous ulcers. In 9 cases (5 in phase I, 2 in phase II, and 1 each in phase III and IV), the clinical diagnosis was candidiasis. In 1 case in phase IV, the ulcers were considered to be due to pyogenic infection.
By smear examination, of the 7 cases clinically diagnosed to have pemphigus ulcers, acantholytic cells were seen in only 2 cases both of whom were in phase I of treatment. One of these cases in addition, revealed the presence of multi-nucleated giant cells as well as candidal spores and hyphae while the other patient revealed pus cells and bacteria in addition to acantholytic cells. Two other patients clinically diagnosed to have pemphigus ulcers revealed candida while the smears from the remaining 3 cases revealed only epithelial cells and not acantholytic cells, candida or pyogenic organisms. All the 3 cases clinically diagnosed to have aphthous ulcers, also did not reveal any organisms, acantholytic or multi-nucleated giant cells. Of the 9 cases clinically diagnosed to have candidiasis, 6 patients revealed the presence of candida, 1 patient revealed acantholytic cells rather than candida, while the smears from the remaining 2 patients were negative for any cells or organisms, except for normal epithelial cells. The only patient clinically diagnosed to have pyogenic infection, showed the presence of pus cells and gram positive bacteria in the smears.
| Comments|| |
These findings reveal that oral ulcers in a pemphigus patient may not necessarily be pemphigus ulcers. Pemphigus ulcers are characteristically large, irregular and superficial and they take relatively much longer time to heal. Many of these ulcers are likely to be superinfected with candida and/or pyogenic organisms, more so when the patient is being treated with immunosuppressive drugs. Dexamethasone-cyclophosphamide pulse therapy is associated with a more severe immunosuppression compared to the conventional dosage schedules and therefore patients receiving DCP are more prone to develop oral candidiasis and/or pyogenic infections even in the absence of pemphigus ulcers. Viral infections including herpes simplex are also likely to be more frequent. Significance of multi-nucleated giant cells have been recorded in pemphigus ulcers as well. 
After the treatment with DCP has been completed, a pemphigus patient is generally as normal as any other individual. Aphthous ulcers are quite frequent in a large proportion of individuals who are otherwise quite normal and thus even a pemphigus patient may develop an aphthous ulcer. An oral ulcer in a pemphigus patient must be evaluated properly to institute appropriate treatment.
| References|| |
|1.||Pasricha JS, Gupta R. Pulse therapy with dexamethasone-cyclophosphamide in pemphigus. Ind J Dermatol Venereol Leprol 1984, 50: 199-203. |
|2.||Pasricha JS, Srivastava G. Cure in pemphigus - a possibility. Ind J Dermatol Venereol Leprol 1986; 52 : 185-6. |
|3.||Pasricha JS, Thanzama J, Khan UK. Intermittent high dose dexamethasonecyclophosphamide therapy for pemphigus. Br J Dermatol 1988; 119 : 73-7. [PUBMED] |
|4.||Pasricha JS, Seetharam KA, Das U. Further studies on pemphigus patients treated with dexamethasone-cyclophosphamide pulse therapy. Ind J Dermatol Venereol Leprol 1989; 55: 98-104. |
|5.||Wilson Jones E. Cytodiagnosis. In : Textbook of Dermatology (Rook A, Wilkinson DS, Ebling FJG, et al, eds), 4th edn. Oxford : Blackwell Sr.iantific Piihlir.atinns 1 QRR 7Q _ R9 |
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