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Year : 2004  |  Volume : 70  |  Issue : 4  |  Page : 249-250

Response by Dr. Pasricha

Department of Dermatology and Venereology, AIIMS, New Delhi - 110029, India

Correspondence Address:
Skin Diseases Centre, 1-A, Masjid Moth, DDA Flats, Phase-I, Outer Ring Road, Near Chirag Delhi Flyover, New Delhi - 110048, India

How to cite this article:
Pasricha J S. Response by Dr. Pasricha. Indian J Dermatol Venereol Leprol 2004;70:249-50

How to cite this URL:
Pasricha J S. Response by Dr. Pasricha. Indian J Dermatol Venereol Leprol [serial online] 2004 [cited 2020 May 30];70:249-50. Available from: http://www.ijdvl.com/text.asp?2004/70/4/249/12371

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:
1. 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.
2. Use of azathioprine or methotrexate at Hyderabad is a welcome modification[2] and deserves to be assessed further.
3. 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.
4. 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.
5. 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.
6. 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 Top

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    


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