Successful treatment of pemphigus vulgaris and psoriasis vulgaris with methylprednisolone pulse and methotrexate

Abstract

Introduction Psoriasis is associated with an elevated risk of pemphigus [1]. It is one of the most prevalent T-cell-mediated diseases. In contrast, pemphigus is an autoimmune blistering disorder caused by autoantibodies against the keratinocyte cell surface. It is known that methotrexate inhibits epidermal keratinocyte proliferation and reduces T-lymphocytes count in the lesion. For bullous diseases, it is administered as a corticosteroid substitute while for psoriasis it is one of the most effective and important traditional treatment options especially for a moderate or severe form of the disease [2]. We present a case report of both these diseases and their effective management with methylprednisolone pulse and subcutaneous methotrexate. Aims and Objectives We present a rare case report of pemphigus vulgaris associated with psoriasis and their effective management. Materials and methods A 63-year-old patient presented with painful, itchy, widespread, bleeding, non-healing erosions on the whole body. Moreover, the patient has had a history of psoriasis vulgaris that began at the age of 35 years. Psoriasis was treated with topical steroids. The patient's bullous lesions had initially started on the lips and oral cavity and after four months spread to the neck and other parts of the body. More than 50% of the body surface was covered with secreting, bleeding erosions surrounded by epidermal debris. A Nikolsky’s sign was positive. Results The affected skin biopsy with direct immunofluorescence showed a suprabasal bulla with acantholysis and intercellular IgG pattern in the epidermis and linear C3 deposits in the basal membrane. Laboratory tests revealed antibodies against desmoglein 1 and 3 and the diagnosis of the pemphigus vulgaris was made. Other laboratory data showed anemia and hypoalbuminemia. In the culture from erosions MRSA was found. The treatment with intravenous pulse of methylprednisolone (500 mg/day - 3 days) and then subcutaneous methotrexate injections (10mg/week) were prescribed, and vancomycin (15 mg/kg/every 12 hours - 7 days) had been administered. After 3 pulses of methylprednisolone, no new bullae formed, erosions decreased, and more post-inflammatory hyperpigmentation occurred. Conclusions Systemic glucocorticoids are the first-line treatment for pemphigus to achieve rapid control of the disease [3]. Moreover, methotrexate is a useful and well-tolerated therapy for long-term treatment with considerable steroidsparing effect in patients with pemphigus vulgaris [4]. Methotrexate is also approved for use in psoriasis in all the guidelines reviewed [5]. The combined immunosuppressive regimen determined effective management of the coexistence of the pemphigus vulgaris and psoriasis.