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DERMATOLOGY PRACTICE DURING COVID-19 PANDEMIC - CASE REPORTS
Year : 2021  |  Volume : 5  |  Issue : 1  |  Page : 27-29

Treating pemphigus foliaceus-a telemedicine way


Department of Dermatology, JNMC, Sawangi, Wardha, Maharashtra, India

Date of Submission12-May-2020
Date of Decision05-Jul-2020
Date of Acceptance15-Jul-2020
Date of Web Publication19-Feb-2021

Correspondence Address:
Vikrant Saoji
22, Dandige Layout, Shankar Nagar, Nagpur, Maharashtra
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/CDR.CDR_76_20

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  Abstract 


To control the COVID pandemic, lockdown was ordered by the government, leading to travel restrictions which affected the access to the medical facility. A 63-year-old male staying 200 km away in a remote area without dermatological facility was diagnosed and treated successfully by telemedicine. Diagnosis of pemphigus foliaceus was made on clinical photograph. The patient had extensive involvement. The patient was treated with tablet betamethasone tapered over 4 weeks along with tablet cyclophosphamide 100 mg OD. Clinical photographs along with the laboratory reports were sent by the patient weekly. By the end of the 1st week, the patient started noticing improvement which continued for next 4 weeks. A good clinical improvement was achieved in 4 weeks. No side effects were reported. The improvement achieved in 4 weeks will be maintained with tablet cyclophosphamide. Telemedicine can play an important role in offering medical help to the remote rural area where the health facilities are lacking.

Keywords: Betamethasone, cyclophosphamide, pemphigus foliaceus, telemedicine


How to cite this article:
Saoji V. Treating pemphigus foliaceus-a telemedicine way. Clin Dermatol Rev 2021;5:27-9

How to cite this URL:
Saoji V. Treating pemphigus foliaceus-a telemedicine way. Clin Dermatol Rev [serial online] 2021 [cited 2021 Apr 21];5:27-9. Available from: https://www.cdriadvlkn.org/text.asp?2021/5/1/27/309775




  Introduction Top


Severe acute respiratory syndrome coronavirus 2 is a highly infectious virus responsible for causing coronavirus disease 2019, and to control the rapidly spreading infection, lockdown is ordered by the government. During lockdown, even the routine nonemergengy medical facilities are restricted. Being mostly a nonemergency branch, most of the dermatology outpatient departments are closed and teleconsultation is being advised whenever possible. Dermatology being a visual specialty, diagnosis and treatment by telemedicine is possible in many cases. However, treating serious disorders such as toxic epidermal necrolysis/Stevens–Johnson syndrome and vesiculobullous disorders by telemedicine can pose a problem as it requires high dose of steroid and immunosuppressants.

Here, we present a case of pemphigus foliaceus successfully treated with the use of telemedicine.


  Case Report Top


A call was received on March 27, 2020, from a patient who stays 200 km away in a small town in MP without availability of the dermatologist. The patient's cousin was treated for his skin problem by the author a year back. The patient was suffering from crusted skin lesions for the last 2 months for which he consulted a dermatologist in nearby area (100 km) who thought of pustular psoriasis and was started on methotrexate and later on steroid was added due to unsatisfactory response. With steroid, the patient experienced temporary improvement, but it recurred again. The patient's old prescriptions and the current photographs were sent on WhatsApp. The photograph showed extensive crusted lesions with moist scales and erosions covering almost the entire trunk, face, neck, and the extremities partially [Figure 1] and [Figure 2]. It appears to have involved around 75% of body surface area. There was no mucosal involvement. Looking at the lesions on the abdomen with moist scales and somewhat vesicular border [Figure 1], the diagnosis of pemphigus foliaceus was made. Although the patient was uncomfortable due to his skin lesions, the general condition appears to be stable. Because the city and state borders were sealed, it was not possible for the patient to travel. Biopsy was not possible. After extensive telephonic talk, it was decided to treat him with the help of local general practitioner (GP). Investigations were ordered along with the visit to the GP. Complete blood count, urine examination, blood sugar, serum bilirubin, Serum glutamic oxaloacetic transaminase (SGOT), Serum glutamic pyruvic transaminase (SGPT), and blood urea were within normal limits. Blood pressure was normal. The patient was started on tablet betamethasone forte, 4 mg daily in 2 divided doses for 1 week, tapered weekly to 3 mg daily, 2 mg daily, and 1 mg daily over a period of 4 weeks and tablet cyclophosphamide 100 mg OD. Clinical photographs along with laboratory reports were sent by the patient every week. By the 1st week, the patient reported improvement which continued till 4 weeks (till writing this report). By the end of the 4th week (April 30, 2020), most of the lesions were healed, with good clearance of skin lesions [Figure 3] and [Figure 4]. The general condition also improved. Crusted lesions were still present on the scalp, back, and lower limbs. All the investigations were within normal limits. Steroids are stopped and now planning to maintain the clinical benefit with oral cyclophosphamide. With our clinical experience, we are sure with cyclophosphamide, the patient will continue to improve. The patient is asked to visit once the lockdown is over.
Figure 1: Scaly crusted lesions with erosions on the chest and abdomen before treatment

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Figure 2: Crusted lesions on the back before treatment

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Figure 3: Good improvement at the end of the 4th week

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Figure 4: Good improvement after the 4th week

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The author usually uses similar strategy of short course (6–8 weeks) of oral steroid along with oral cyclophosphamide (for 2–3 year) to treat the pemphigus patients. Rituximab is the new drug for pemphigus with better safety and efficacy and has become the first line of drug for the treatment of pemphigus.[1] We are planning for rituximab once this corona viral pandemic is under control; till that time, cyclophosphamide will be used to control the disease. Cyclophosphamide is a very useful drug for the treatment of autoimmune bullous disorders with powerful effect on antibody-producing B cells;[2] only concern is its effect on fertility in young patients and the risk of malignancy after long-term use.[2] Clinical effect of immunosuppressants such as cyclophosphamide will take few weeks to be evident; till that time, steroid will be used to control the activity of the disease and after that steroid is not required. Cyclophosphamide being a steroid sparing drug, relatively low dose of steroid proved to be useful. Betamethasone is the preferred steroid by the author. Since it is used for 4 weeks, hypothalamic–pituitary–adrenal axis suppression is not an issue (studied in few patients, unpublished data). Because of zero mineralocorticoid activity, blood pressure and electrolytes are not affected.

Challenges

Pemphigus is the serious autoimmune bullous disorder which needs an aggressive treatment with steroid and immunosuppressants which have serious side effects and needs monitoring. Without treatment, the disease can be fatal. Treating a serious disease like pemphigus with toxic drugs without actually examining the patient is very challenging and not treating the severe disease can be dangerous.

Managing challenges

This unique situation created by lockdown is difficult for the doctors and patients. Managing such serious case requires a good understanding between the doctor and the patient. Treating such serious disease by telemedicine involves long telephonic conversation with the patient and relatives. The patient and the relatives were made to understand the serious nature of the disease and the possible side effects of the drugs and need of proper monitoring. Immunosuppression produced by steroid and cyclophosphamide in an elderly patient during this viral pandemic is a major concern; hence, the patient was advised to strictly follow the infection control norms such as social distancing and avoid going out of the house. A role of the local GP was very important for monitoring. Regular communication and sending the images showing improvement by the patient was very reassuring. Behind this success story, lies the years of experience of the treating dermatologist. Earlier successful treatment of the close relative of the patient proved useful to gain the patient's trust. In such situations, it is better to give the routine treatment about which the treating doctor has the experience rather than trying any new drug even for safety concern.

Telemedicine can play an important role in offering medical help to the remote rural area where the health facilities are lacking.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Pascal J, Maho-Vaillant M, Squarcioni CP, Hebert V, Houivet E, Calbo S, et al. First line rituximab combined with short-term prednisone versus prednisone alone for the treatment of pemphigus (Ritux 3): A prospective, multicentre, parallel-group, open-label randomised trial. Lancet 2017;389:2031-40.  Back to cited text no. 1
    
2.
High WA. Cytotoxic agents. In: Wolverton SE, editor.Comprehensive Dermatologic Drug Therapy. 3rd ed. Philadelphia: Elsevier; 2013. p. 212-72..  Back to cited text no. 2
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4]



 

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