Trichoscopy of pemphigus vulgaris in remission. A tool for treatment-cessation decision making. Preliminary results

Abstract

Background: One of the controversies in the treatment of Pemphigus Vulgaris (PV), is the time of treatment cessation. Scalp involvement is often the most stubborn to treatment human area and may reflect disease activity. Trichoscopy (Dermoscopy of hair and scalp) features have not been studied in clinically “healthy-looking” skin of PV patients in full remission. Aims and Objectives:To find out if there are any trichoscopy features in PV patients in clinical and immunologic remission, and accommodate treatment decision. Methods: The age and disease duration of  3 women with PV were correspondingly 62, 63, 55 and 5, 6, 15 years. Treatment at examination was 2,5 mg prednisone(Pr), for the last 22, 5 and 7 months. The 2nd patient was also taking 1 mg/kg/d of Azathioprine. Anti Desmoglein antibodies turned to negative since Oct/2017, Feb/2017, Sept/2015. Contact dermoscopy and hand lens X10 magnifier for clinical evaluation, were used. Results: A red hue background, peripillar scales and tubular casts were observed by trichoscopy in the first 2 patients. Only peripilar scales on a small brown round area were the features in the 3rd patient. Treatment cessation was decided only in this patient, since casts observed in the other two patients, were considered as a consequence of outer root sheath acantholysis and a sign of disease activity. Patients’ follow up justified the aforementioned treatment decisions. Conclusions: Areas of red hue skin background and movable cylindical scales (casts) around hair shafts may be observed, even in the absence of apparent scalp clinical involvement, in PV patients in remission. Since these features may drive physicians to treatment continuation, dermoscopy of the scalp is required in clinically “healthy-looking” PV patients, before a decision of treatment cessation is made. Future studies with greater number of patients, furtherly validated by long term disease course outcome, are needed.