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Letter to the Editor
2009:75:1;85-85
doi: 10.4103/0378-6323.45236
PMID: 19172046

Prolonged antimicrobial and oral cyclophosphamide therapy in pemphigus: Need for caution

M Ramam
 Department of Dermatology and Venereology, All India Institute of Medical Sciences, New Delhi - 110 029, India

Correspondence Address:
M Ramam
Department of Dermatology and Venereology, AllMS, New Delhi - 110 029
India
How to cite this article:
Ramam M. Prolonged antimicrobial and oral cyclophosphamide therapy in pemphigus: Need for caution. Indian J Dermatol Venereol Leprol 2009;75:85
Copyright: (C)2009 Indian Journal of Dermatology, Venereology, and Leprology

Sir,

The report by Dr. Pasricha and Poonam is a welcome confirmation of the effectiveness of DCP regimen for the treatment of pemphigus in the setting of a private clinic. [1] However, I have two concerns about the therapeutic regimen they employed.

One of the modifications made to the standard regimen was the use of systemic antibiotics and anticandidal agents till the skin and oral lesions healed completely. This amounts to use of antibiotics and/or anticandidal agents for a period ranging from less than 3 months to more than 12 months. Clearly, skin lesions secondarily infected with bacteria and oral lesions infected with candida should be treated with appropriate agents till the infection subsides. However, prolonging the treatment till complete healing of skin and oral lesions appears unnecessary and may be harmful both to the patient and the community. Several studies have documented the link between antibiotic use and the development of microbial resistance in the community. [2],[3],[4] In addition, this increases the cost of treatment and the risk of adverse effects for the patient. Short courses, when indicated, may be more appropriate.

My second concern is regarding the use of cyclophosphamide in patients who wished to have children. In view of the gonadotoxicity of cyclophosphamide, intravenous boluses of the drug were omitted. However, these patients were given oral cyclophosphamide, 50 mg daily. Studies have shown that gonadotoxicity occurred in about 30% of women who received low-dose oral cyclophosphamide, 1-2 mg/kg/day. [5],[6] The risk of ovarian failure is related to cumulative dosage of the drug and occurred in 70% of women when the total dose exceeded 30 g. [6] In men, a total cumulative dose exceeding 12 g is considered unsafe. [7] Patients treated with dexamethasone pulse therapy for pemphigus receive at least 18 months of treatment with oral cyclophosphamide after clinical remission and for a few months before remission. This amounts to a total dose exceeding 27 gm, which is likely to adversely affect fertility in both men and women. Thus, it may be wise to omit both intravenous boluses and oral doses of cyclophosphamide in patients who plan to have children.

References
1.
Pasricha JS. Current regimen of pulse therapy for pemphigus: Minor modifications, improved results. Indian J Dermatol Venereol Leprol 2008;74:217-21.
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2.
Arason VA, Kristinsson KG, Sigurdsson JA, Stefαnsdóttir G, Mφlstad S, Gudmundsson S. Do antimicrobials increase the carriage rate of penicillin resistant pneumococci in children? Cross sectional prevalence study. BMJ 1996;313:387-91.
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Chung A, Perera R, Brueggemann AB, Elamin AE, Harnden A, Mayon-White R, et al . Effect of antibiotic prescribing on antibiotic resistance in individual children in primary care: Prospective cohort study. BMJ 2007;335:429.
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Goosens H, Ferech M, Stichele RV, Elseviers M. Outpatient antibiotic uses in Europe and association with resistance: A cross-national database study. Lancet 2005;365:579-87.
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5.
Wang CL, Wang F, Bosco JJ. Ovarian failure in oral cyclophosphamide treatment for systemic lupus erythematosus. Lupus 1995;4:11-4.
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6.
Mok CC, Lau CS, Wong RW. Risk factors for ovarian failure in patients with systemic lupus erythematosus receiving cyclophosphamide therapy. Arthritis Rheum 1998;41:831-7.
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7.
Wetzels JF. Cyclophosphamide-induced gonadal toxicity: A treatment dilemma in patients with lupus nephritis? Neth J Med 2004;62:347-52.
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