Generic selectors
Exact matches only
Search in title
Search in content
Post Type Selectors
Filter by Categories
15th National Conference of the IAOMFP, Chennai, 2006
Abstracts from current literature
Acne in India: Guidelines for management - IAA Consensus Document
Art & Psychiatry
Association Activities
Association Notes
Award Article
Book Review
Brief Report
Case Analysis
Case Letter
Case Letters
Case Notes
Case Report
Case Reports
Clinical and Laboratory Investigations
Clinical Article
Clinical Studies
Clinical Study
Conference Oration
Conference Summary
Continuing Medical Education
Cosmetic Dermatology
Current Best Evidence
Current Issue
Current View
Derma Quest
Dermato Surgery
Dermatosurgery Specials
Dispensing Pearl
Do you know?
Drug Dialogues
Editor Speaks
Editorial Remarks
Editorial Report
Editorial Report - 2007
Editorial report for 2004-2005
Fourth All India Conference Programme
From Our Book Shelf
From the Desk of Chief Editor
Get Set for Net
Get set for the net
Guest Article
Guest Editorial
How I Manage?
IADVL Announcement
IADVL Announcements
IJDVL Awards
IJDVL Awards 2018
IJDVL Awards 2019
IJDVL Awards 2020
IJDVL International Awards 2018
Images in Clinical Practice
In Memorium
Inaugural Address
Knowledge From World Contemporaries
Leprosy Section
Letter in Response to Previous Publication
Letter to Editor
Letter to the Editor
Letter to the Editor - Case Letter
Letter to the Editor - Letter in Response to Published Article
Letter to the Editor - Observation Letter
Letter to the Editor - Study Letter
Letter to the Editor - Therapy Letter
Letter to the Editor: Articles in Response to Previously Published Articles
Letters in Response to Previous Publication
Letters to the Editor
Letters to the Editor - Letter in Response to Previously Published Articles
Letters to the Editor: Case Letters
Letters to the Editor: Letters in Response to Previously Published Articles
Medicolegal Window
Miscellaneous Letter
Net Case
Net case report
Net Image
Net Letter
Net Quiz
Net Study
New Preparations
News & Views
Observation Letter
Observation Letters
Original Article
Original Contributions
Pattern of Skin Diseases
Pediatric Dermatology
Pediatric Rounds
Presedential Address
Presidential Address
Presidents Remarks
Report of chief editor
Report of Hon : Treasurer IADVL
Report of Hon. General Secretary IADVL
Research Methdology
Research Methodology
Resident page
Resident's Page
Resident’s Page
Residents' Corner
Residents' Corner
Residents' Page
Review Article
Review Articles
Revision Corner
Self Assessment Programme
Seminar: Chronic Arsenicosis in India
Seminar: HIV Infection
Short Communication
Short Communications
Short Report
Special Article
Specialty Interface
Study Letter
Study Letters
Symposium - Contact Dermatitis
Symposium - Lasers
Symposium - Pediatric Dermatoses
Symposium - Psoriasis
Symposium - Vesicobullous Disorders
Symposium Aesthetic Surgery
Symposium Dermatopathology
Symposium-Hair Disorders
Symposium-Nails Part I
Symposium-Nails-Part II
Systematic Reviews and Meta-analyses
Systematic Reviews and Meta-analysis
Therapeutic Guideline-IADVL
Therapeutic Guidelines
Therapeutic Guidelines - IADVL
Therapy Letter
View Point
What’s new in Dermatology
View/Download PDF

Translate this page into:

Letter to the Editor
doi: 10.4103/0378-6323.60554
PMID: 20228551

Pulse therapy - Credibility of evidence

Amrinder J Kanwar, Dipankar De
 Department of Dermatology, Venereology and Leprology, Postgraduate Institute of Medical Education and Research, Chandigarh, India

Correspondence Address:
Amrinder J Kanwar
Department of Dermatology, Venereology, and Leprology, Postgraduate Institute of Medical Education and Research, Chandigarh
How to cite this article:
Kanwar AJ, De D. Pulse therapy - Credibility of evidence. Indian J Dermatol Venereol Leprol 2010;76:182-183
Copyright: (C)2010 Indian Journal of Dermatology, Venereology, and Leprology


We read with great interest the letter by Singh and Chaudhary [1] in response to the article by Pasricha and Poonam entitled ′Current regimen of pulse therapy for pemphigus: Minor modifications, improved results′.[2] They meticulously discussed the drawbacks of the study in question and at the end almost dismissed pulse therapy as a treatment option for pemphigus. They have cited the reference of Rose et al.[3] while trying to prove the worthlessness of pulse therapy in pemphigus.

We agree with their views that there are drawbacks in the present protocol proposed by Pasricha and Poonam in treatment of pemphigus. But these are only minor. By judicious use of intervening betamethasone and systemic antibiotics for short periods, these can be taken care of. The concerns about long-term antibiotics and cyclophosphamide in those who wanted to have children have rightly been pointed out and discussed by Ramam in the same issue. [4] By and large, our views on pulse therapy in pemphigus are similar to those of Pasricha and Poonam. Corticosteroids still remain the treatment of choice for treatment of pemphigus. Side-effects associated with long term use of corticosteroids had stimulated the search for steroid sparing adjuvants effective in pemphigus. MEDLINE search with keywords ′corticosteroids in pemphigus, randomized controlled trial′ (accessed 31 st March 2009) yielded only 12 studies, of which only 10 were relevant, the latest being that by Werth et al. [5] However, Werth et al. in their article published in January 2008 in Archives of Dermatology mention that there are only two randomized controlled trials before their study assessing the efficacy of treatment regimens in management of pemphigus. Therefore, randomized controlled trials (RCT), considered the highest level of evidence in scientific literature are rare for management strategy of pemphigus. We must not forget that pemphigus is a rare disease in West and adequate number of patients for RCT may not be available.

Singh and Chaudhary referred to the trial by Rose et al. [3] which is indeed a randomized clinical trial. However, the dexamethasone cyclophsphamide treatment protocol (D/C) was significantly different from that originally preached by Pasricha et al. [6] Pulses were repeated every two to three weeks initially and then increased gradually to an interval of four, five and six weeks depending upon the response. If no relapse occurred at pulses at six-week intervals, cyclophosphamide pulse was stopped and dexamethasone pulse was continued every 12 weeks and then stopped. How long the dexamethasone is continued is not apparent from the article. After six months of treatment, oral cyclophosphamide is stopped irrespective of response to treatment, fearing long- term side effects.

In the methylprednisolone (MP)-azathioprine group (M/A), patients received 2mg/kg/day methylprednisolone and 2-2.5 mg/kg/day of azathioprine. If there was progression of the disease, MP dose was increased to 3 mg/kg/day. After cessation of new blister formation, MP dose was gradually tapered off and then azathioprine. The basic difference in these two regimens were that in the D/C group, the steroid sparing agent was discontinued after six months of treatment irrespective of disease status while in the M/A group, the MP dose was increased conveniently if there was no response and the steroid sparing agent was tapered off after that. We feel that D/C group might have not been given a level playing field for comparison to the other group.

There is another contradiction in the said study. They have mentioned that if a patient in D/C group was found to have progression of disease after six months of treatment, he was shifted to some other treatment while they have assessed the status of the disease at 24 months of study when it was found that 6/11 patients in D/C group had progression. What happened to these patients between six months and 24 months is not clear.

As far as side-effects are concerned, 15 incidences of side-effects were observed in the D/C group while there were 31 incidences in the M/A group, though the authors mention that they were comparable with p>0.05! Treatment had to be discontinued in one patient in the M/A group due to severity of side effect. It is true that RCT provides highest level of clinical evidence, but it should be properly designed. It is desirable if we do not disregard a particular treatment regimen based upon a RCT, which uses different treatment protocol and results are confusing.

The original dexamethasone-cyclophosphamide pulse (DCP) regimen pioneered by Pasricha et al. is indigenous and has been used in different centers in India since mid 80s with excellent results. Our experience [7],[8] (though we did not perform any RCT, as we do not feel the need for same) is that properly executed and monitored DCP therapy is reasonably safe and effective in treatment of pemphigus and those patients who do not respond to conventional oral prednisolone and steroid sparing agent or those who develop side effects can be effectively treated with DCP therapy. This in itself is a strong point in favor of efficacy of DCP in pemphigus vitiating the need for RCT. By all these studies, cure for pemphigus is shown. Finally, we advise Singh and Chaudhary to be cautious and polite in choice of their words while expressing their views on a scientific platform. Nobody in the present era can take the medical profession to ride just by personality and influence. Pasricha has indeed shown the world that pemphigus, a potentially fatal autoimmune blistering disorder can be cured with pulse therapy which he designed and for which he deserves all the credit.

Singh S, Chaudhary R. Pulse therapy for pemphigus: The burden of proof. Indian J Dermatol Venereol Leprol 2009:75;83-4.
[Google Scholar]
Pasricha JS; Poonam. Current regimen of pulse therapy for pemphigus: Minor modifications, improved results. Indian J Dermatol Venereol Leprol 2008;74:217-21.
[Google Scholar]
Rose E, Wever S, Zilliken D, Linse R, Haustein UF, Bröcker EB. Intravenous dexamethasone-cyclophosphamide pulse therapy in comparison with oral methylprednisolone-azathioprine therapy in patients with pemphigus: results of a multicenter prospectively randomized study. J Dtsch Dermatol Ges 2005;3:200-6.
[Google Scholar]
Ramam M. Prolonged antimicrobial and oral cyclophosphamide therapy in pemphigus: need for caution. Indian J Dermatol Venereol Leprol 2009;75:85.
[Google Scholar]
Werth VP, Fivenson D, Pandya AG, Chen D, Rico MJ, Albrecht J, et al. Multicenter randomized, double-blind, placebo-controlled, clinical trial of dapsone as a glucocorticoid-sparing agent in maintenance-phase pemphigus vulgaris. Arch Dermatol 2008;144:25-32.
[Google Scholar]
Pasricha JS, Thanzama J, Khan UK. Intermittent high-dose dexamethasone-cyclophosphamide therapy for pemphigus. Br J Dermatol 1988;119:73-7.
[Google Scholar]
Kanwar AJ, Kaur S, Thami GP. Long-term efficacy of dexamethasone-cyclophosphamide pulse therapy in pemphigus. Dermatology 2002;204:228-31.
[Google Scholar]
Kanwar AJ, Ajith C, Narang T. Pemphigus in North India. J Cutan Med Surg 2006;10:21-5.
[Google Scholar]

Fulltext Views

PDF downloads
Show Sections