Rituximab combined with a shorter, lower-dose course of oral corticosteroid achieves more complete remissions off therapy and less steroid toxicity than steroids alone, and current European guidance places it first-line for moderate-to-severe pemphigus. Starting it early, rather than after steroid failure, is the point.
Before the first infusion, screen for hepatitis B and update inactivated vaccines where time allows. Live vaccines should be avoided after rituximab.
- Offer rituximab with a corticosteroid at diagnosis of moderate-to-severe pemphigus, not only after steroid failure.
- Screen for hepatitis B before the first dose.
- Give inactivated vaccines before rituximab where possible; avoid live vaccines afterwards.
- Plan the steroid taper from the first visit.
Why it matters
Steroid toxicity, not pemphigus itself, drives much of the long-term harm in these patients.
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