Intralesional Rituximab in Recalcitrant Oral and Scalp Lesions of Pemphigus: A Retrospective Study

Oral and scalp lesions of pemphigus heal slower than lesions at other sites, leading to an extended duration of oral corticosteroids, thereby contributing to adverse effects. Intravenous rituximab (IV-RTX) has proven to be invaluable in pemphigus management. However, there is limited literature on the use of intralesional rituximab (IL-RTX) in recalcitrant mucocutaneous pemphigus.

In this retrospective observational study, diagnosed cases of pemphigus with refractory oral and/or scalp lesions who had received IL-RTX were included. IL-RTX was administered at a dose of 5 mg/cm² (10 mg/mL), two doses fortnightly with or without concomitant IV-RTX. Response was assessed by mucosal/scalp Pemphigus disease area index (PDAI) and anti-desmoglein antibody (anti-DSG) levels at baseline and 6 months.

Thirty-three patients (M:F = 1:0.94) who met the inclusion criteria were included. The mean age was 45.15 years. Twenty-seven patients (82%) received concurrent IV-RTX, and six patients (18%) received only IL-RTX. At the end of 6 months, a statistically significant decrease was seen in mucosal/scalp PDAI and anti-DSG1 and anti-DSG3 levels in patients who received only IL-RTX as well as patients who received concomitant IV-RTX and IL-RTX. The percentage of patients on concomitant corticosteroids decreased from 88% at baseline to 48% at 6 months. Pain was the only adverse effect, seen in six patients (18%).

IL-RTX is a cost-effective and safe modality for the treatment of localized recalcitrant lesions of pemphigus. It can be considered more beneficial than increasing the dosage of systemic therapy. Intravenous and intralesional rituximab can be used concurrently and synergistically for recalcitrant oral and scalp lesions of pemphigus.