JEADV ISSN 1468-3083 902 © 2007 The Authors JEADV 2007, 21, 902– 907 Journal compilation © 2007 European Academy of Dermatology and Venereology Blackwell Publishing Ltd ORIGINAL ARTICLE Gold: an old drug still working in refractory pemphigus P Iranzo, M a M Alsina, I Martínez-De Pablo, S Segura, JM Mascaró, C Herrero Department of Dermatology. Hospital Clínic, Barcelona, Spain Keywords gold therapy, chrysotherapy, pemhigus vulgaris *Corresponding author, Pilar Iranzo C/Villarroel 170 Department Dermatology, Hospital Clínic Barcelona 08036, Spain. tel./fax +34 93 2275438; E-mail: piranzo@clinic.ub.es Received: 29 May 2006, accepted 11 August 2006 DOI: 10.1111/j.1468-3083.2006.02074.x Abstract Background The mainstay of treatment for pemphigus is systemic cortico- steroids. Different adjuvants have been used to reduce side-effects of long- term corticotherapy. Gold is an anti-inflammatory drug used in autoimmune diseases, whose use has waned with the advent of new immunosuppressive agents. Objective To study the outcome of the use of intramuscular gold treatment of pemphigus vulgaris refractory to previous therapies. Methods Thirteen patients with pemphigus vulgaris who had failed to respond to several prior therapies were treated with aurothiomalate, as a steroid-sparing agent. Patients were monitored to assess disease activity and gold toxicity. Results Seven patients achieved complete remission. Four patients were able to taper prednisone doses, although pemphigus flared when prednisone was discontinued or reduced. Toxicity was observed in the other two patients. Conclusions In 53.4% of the patients, the use of chrysotherapy resulted in the complete clearing of the disease, discontinuation of all systemic therapies and induced a long-term clinical remission. Prednisone doses were able to be reduced in the remaining 46.6%. Any side-effects were reversible with drug discontinuation. Gold therapy showed efficacy as a secondary line treatment in refractory pemphigus vulgaris. Introduction Pemphigus vulgaris (PV) is an autoimmune blistering disease involving the skin and mucous membranes. Before the advent of corticosteroids, most patients died in the first year of the onset of the disease. Some cases are still difficult to manage in spite of the introduction of corticosteroids and immunosuppressive drugs, and are associated with a estimated mortality rate of 5% to 15%, 1 mostly related to adverse effects of therapy. Safety is therefore as important as efficacy when making a therapeutic decision. The mainstay treatment for PV is systemic corticosteroids and different regimens either with or without adjuvant immunosuppressive therapies have been used. Currently, there is no consensus on the best adjuvant therapy for PV, although guidelines for the management of PV have been published. 2 The therapeutic choice must be individualized on the basis of the severity of the disease, the age and general condition of the patient, and on the compliance prospect and drug tolerance. Becker and Obermayer 3 first mentioned the efficacy of gold therapy for PV and in 1973, Penneys et al. 4 reported the results of a study of 18 patients with PV and foliaceous who had been treated with gold sodium thiomalate. Since then, there have been very few reports of its efficacy in patients with moderate disease. 5–8 Over the years, other drugs have been used as steroid-sparing agents and the use of gold therapy has waned. 9–12 In 1998, Pandya and Dyke 13 retrospectively reviewed 26 patients with PV who had been treated with gold. They found that it was effective as a first-line treatment or as a steroid-sparing agent in 62% of patients. Toxic effects developed in 42% of cases, although they disappeared after therapy discontinuation. This report encouraged us to consider chrysotherapy in patients with PV who were not responding to other therapies. This retrospective study, which was over a