Journal Reading

Efficacy and safety of Dexamethason

Cyclophosphamide Pulse therapy in treatment of
pemphigus – An open randomized controlled study
Ramji Gupta, Sachi Gupta, Anil Gupta
Consultant Dermatologist, Department of Dermatology Indraprastha Apollo Hospital, Sarita Cihar, New Delhi

Presented by:
Dwi Ruth Rahayuning Asih Budi, S.Ked

Preceptor :
dr. Resati Nando Panonsih, M.Sc, Sp.KK

Kepaniteraan Klinis Senior Ilmu Penyakit Kulit dan Kelamin

RS Pertamina Bintang Amin
Bandar Lampung
2018
 Backgrounds

Methods
Abstract

Results

Conclusions
 Introduction
• Introduction of corticosteroids, in early 1950s, for the treatment of
pemphigus, led to a decline in mortality rate with better
prognosis.
• Since the introduction of Dexamethasone Cyclophosphamide
Pulse therapy (DCP) in 1984, by Pasricha and Ramji Gupta for the
treatment of pemphigus, it has become the preferred modality for
the treatment of pemphigus.
• The DCP regimen has been proved to be effective in putting
pemphigus in remission for more than 5-10 years after complete
stoppage of the treatment.
Cont...
• However, evidence is lacking as placebo-controlled studies are
unethical and randomized trial or randomized controlled
trial have not been done.
• Hence, recently some dermatologists have questioned the
efficacy of DCP in pemphigus,
• Thus this study, an open randomized controlled study of
DCP compared with oral corticosteroids and
cyclophosphamide.
 Material and Methods
• Forty patients with pemphigus (vulgaris-37, foliaceus-3) were included
in this open randomized study. Diagnosis of pemphigus was made on
the basis of clinical presentation, histopathological finding, and direct
and indirect immunofluoresence test for IgG and desmoglein.
• Before starting the treatment, investigations were done in all patients
which included blood pressure, hemoglobin, total and differential
leukocyte counts, platelets counts, urine examination including
presence of red blood cells, blood sugar levels, serum electrolytes, SGOT
(Serum Glutamic Oxaloacetic Transaminase), SGPT (Serum Glutamic
Pyruvic Transaminase), serum alkaline phosphatase, ECG (Electro
Cardio Gram), Skiagram of the chest, stool examination for occult
blood, ophthalmic examination especially for cataract and weight
charting.
Cont...
• Patients were allocated into two treatment groups each
comprising of 20 patients. All odd number patients, who
came to the outpatient department were put on DCP therapy
(group A), while all the even number patients were given oral
corticosteroids and cyclophosphamide (group B)
 Methods
• DCP therapy consists of transfusing 100mg dexamethason dissolved in
500ml of 5% dextrose over 1,5-2 hours, repeated on three consecutive
days. On day 2, the patient is also given cyclophosphamide 500mg
through the same drip. This is repeated every 28 days. In between pulses,
the patient receives 50mg cyclophosphamide orally daily. This is called
DCP pulse therapy and is divided into 4 phase.
• All patients in group B were given prednisolone 40-120mg/day,
depending on the severity of lesions, along with cyclophosphamide
50mg/day. With the clearance of lesions, prednisolone was tapered slowly
to 10-15mg/day, while cyclophosphamide or azathioprine was continued.
 Cont...
2.1 Statistical analysis
In the present study author has attempted to compare two different
treatment regimens namely Dexamethasone Cyclophosphamide
Pulse (DCP) therapy and corticosteroids with cyclophosphamide.
These two regimens were considered for the treatment of pemphigus
in a group of 20 each during 2009-2013.
On the basis of the analysis about both the treatment regimens
applied on a group of patients of pemphigus, we found that use of
DCP has resulted in early remission (with in 3-4 days).
Results
 Results
• 18 out of 20 patients in DCP group entered into remission, 1-
29 months after complete stoppage of treatment.
• The two patients relapsed, one in phase III and another in
phase IV of DCP. Both were reverted back to phase I and
again treated with IV phase regimen of DCP.
• All the patients in oral corticosteroids and cyclophosphamide
group developed repeated relapses (4-6 times) during the
study period.
 Discussion
• The main problem with DCP is increased susceptibility to
infections, bacterial as well as candidal in phase I of the
treatment when the skin and mucosa are eroded.
• A relapse after receiving complete and regular treatment or
during treatment does not mean that DCP therapy has failed
completely.
 Conclusions
This study shows that DCP therapy can put pemphigus
into prolonged/permanent remission as compared to
corticosteroid-cyclophosphamide group where relapses
are frequent. Lately, some dermatologist have questioned
the efficacy of DCP in treating pemphigus. However, this
could be due to usage of wrong combination of drugs or
short study duration.
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