Journal of Clinical and Diagnostic Research, 2018, Oct, Vol-12(10): WC01-WC03 1 1 DOI: 10.7860/JCDR/2018/37164.12270 Original Article Dermatology Section A Comparative Study on the Efficacy of i.v. Cyclophosphamide Pulse Versus Oral Cyclophosphamide in Bullous Pemphigoid INTRODUCTION Bullous pemphigoid is an acquired autoimmune blistering disorder characterized by subepidermal bullae and deposition of complements and antibodies along the basement membrane zone. It most commonly affects the elderly and hence frequently associated with co-morbidities [1]. The pathognomonic sign of bullous pemphigoid includes sub-epidermal blisters, lesional and peri lesional polymorphonuclear cell infiltrates in the upper dermis and Immunoglobulin (Ig) G and C3 bound to dermo- epidermal junction [2]. The treatment of bullous pemphigoid is aimed at decreasing blister formation and improving the quality of life. Corticosteroids have been the mainstay of treatment [3]. In recalcitrant lesions, in patients with severe co-morbidities where steroids are contra-indicated and to reduce the high dose and duration of steroid exposure, other immunosuppressives like azathioprine, mycophenolate mofetil, methotrexate and cyclophosphamide can be used [3]. But these drugs have adverse effects of their own. Cyclophosphamide has been known to cause haemorrhagic cystitis and malignancies [4,5]. These adverse effects can be reduced with pulse dosing. Apart from the presence of circulating and tissue bound autoantibodies against BP180 and BP230 of IgG subclass, serum levels of IgE type of BP180-NC16A antibodies, were associated with more severe forms of human bullous pemphigoid and it has been found out from research that the serum titre of the later co-related well with the disease activity of corticosteroid-resistant bullous pemphigoid, where it had a direct implication on the extent of cutaneous lesions [6-8]. Probably patients with this particular IgE type of BP180 antibodies experienced the so called recalcitrant variety of bullous pemphigoid and this particular study focuses on the cost-effective cum minimal adverse effect prone treatment strategies. Cyclophosphamide is one of the most effective steroid sparing alkylating agent, that can be given both orally and parenterally, as pulse dosing as well as on a daily basis and hence the present study focuses on the comparison of parenteral versus oral dosing of this alkyating agent, in the treatment of recalcitrant bullous pemphigoid. MATERIALS AND METHODS This is a prospective open-labelled interventional study conducted in the Department of Dermatology at Chengalpattu Medical College, Chengalpattu from May 2017 to April 2018. After obtaining clearance from the Institutional Ethical Committee (31/2017/IEC-CMCH), patients of more than 18 years of age were chosen for the study. A written and informed consent was obtained from the patients before including them in the study. A diagnosis of bullous pemphigoid was made based on the clinical and histopathological findings. A thorough history and detailed physical examination was done. Patients demographics, co-morbidities and treatment history were recorded. All the baseline investigations including complete haemogram, renal and liver function tests, blood glucose levels were recorded. Patients on other immunosuppressive drugs, with renal failure or with active tuberclosis and pregnant and lactating women were excluded from the study. A total of 15 patients with confirmed diagnosis of bullous pemphigoid were chosen for the study. They were divided into two groups by simple random sampling. Both groups were started on tab. Prednisolone 1 mg/kg/day. In group A eight patients were started on i.v. Cyclophosphamide pulse 500 mg at 28 days interval. In group B seven patients were started on tab. Cyclophosphamide 50 mg/ day. Patients were followed with periodical complete haemogram, liver function tests and urine analysis monthly during treatment and for a period of 3 months after achieving remission. The efficacy and safety of the cyclophosphamide in both groups was evaluated. STATISTICAL ANALYSIS Appropriate descriptive and inferential statistical analysis was done. RAJKUMAR KANNAN 1 , JAYAKALYANI VIJAYANANTH 2 , MUTHUSUBRAMANIAN CHANDRASEKAR 3 Keywords: Pulse therapy, Recalcitrant bullous pemphigoid, Steroid sparing ABSTRACT Introduction: Bullous pemphigoid is an acquired autoimmune blistering disorder characterised by subepidermal bullae and deposition of complements and antibodies along the basement membrane zone. It most commonly affects the elderly and hence is frequently associated with co-morbidities. Corticosteroids have been the mainstay of treatment. Aim: To compare the efficacy and safety of i.v. Cyclophosphamide pulse versus oral cyclophosphamide in patients of bullous pemphigoid. Materials and Methods: The study was conducted in the Department of Dermatology at a tertiary care centre from May 2017 to April 2018. A diagnosis of bullous pemphigoid was made based on the clinical and histopathological findings. A thorough history and detailed physical examination was done. Patient’s demographics, co-morbidities and treatment history were recorded. A total of 15 patients were chosen for the study. They were randomly divided into two groups. Both groups were started on tab. Prednisolone 1 mg/kg/day. In group A eight patients were started on i.v. Cyclophosphamide pulse 500 mg intravenous, at 28 days interval. In group B seven patients were started on tab. Cyclophosphamide 50 mg/day. Patients were followed with periodical complete haemogram, liver function tests and urine analysis monthly during treatment and for a period of 3 months after achieving remission. Results: I.v. Cyclophosphamide pulse was found to have shorter duration of treatment and lesser cumulative dose when compared to oral cyclophosphamide. Conclusion: I.v. Cyclophosphamide pulse proves to be an effective drug for bullous pemphigoid than daily oral cyclophosphamide, but warrants close monitoring.