title: Two decades of using the combination of tetracycline derivatives and niacinamide as steroid-sparing agents in the management of pemphigus: defining a niche for these low toxicity agents.
abstract: BACKGROUND
  The twin goals of long-term disease control and minimizing toxicities related to immunosuppression necessitate efforts to find effective steroid-sparing agents in the management of patients with autoimmune bullous diseases. Pemphigus especially requires a long view, because the disease can persist throughout a patient's lifetime, yet few clinical trial reports exist to guide the practitioner.
  
  
  OBJECTIVE
  We review the response of pemphigus patients to tetracycline, doxycycline, or minocycline plus niacinamide (TCN/NAM) as steroid-sparing therapy and to determine the effects of TCN/NAM on autoantibody levels during the long-term treatment of pemphigus.
  
  
  METHODS
  This was a retrospective chart review in a private medical dermatology practice setting of all pemphigus patients treated between 1993 and 2013. Clinical responses to TCN/NAM therapy after initial high-dose steroid induction therapy and pemphigus antibody levels were recorded over the course of disease flares and treatment cycles along with any related side effects. Anti-desmoglein 1 and 3 titers were compared in a subset of patients over time, and a statistical analysis was performed to correlate the clinical response with antibody levels.
  
  
  RESULTS
  Fifty-one pemphigus patients (43 with pemphigus vulgaris, 7 with pemphigus foliaceous, and 1 with pemphigus erythematosus) received at least 3 months of TCN/NAM, and 16 patients with pemphigus vulgaris had 1 set of pemphigus antibody titers correlating to a baseline/flare and clinical remission. TCN/NAM was associated with disease control in 43 of 51 patients, with a duration of response ranging from 1 to 13 years (mean, 3.14 ± 2.97 years). Thirteen of 51 patients needed no additional treatment for complete disease control, while 33 of 51 needed intermittent topical clobetasol or short courses of oral steroids for long-term management. There were 5 nonresponders. Antidesmoglein titers trended lower in TCN/NAM responders, but only desmoglein 3 approached statistical significance (anti-desmoglein 1, P = .21; anti-desmoglein 3, P = .02).
  
  
  CONCLUSIONS
  This is a retrospective analysis from a single practice. A lack of serial autoantibody titers limited statistical analyses.
  
  
  CONCLUSIONS
  TCN/NAM may be useful as a steroid-sparing therapy for pemphigus.
authors.affiliation: Dermatology Residency Program, Saint Joseph Mercy Health System, Ann Arbor, Michigan.
authors.forename: Morgan
authors.initials: M
authors.lastname: McCarty
authors.affiliation: David Fivenson, MD, Dermatology PLLC, Ann Arbor, Michigan. Electronic address: dfivenson@comcast.net.
authors.forename: David
authors.initials: D
authors.lastname: Fivenson
mesh_terms: D000893:Anti-Inflammatory Agents / Q000627:therapeutic use; D002990:Clobetasol / Q000627:therapeutic use; D004318:Doxycycline / Q000627:therapeutic use*; D004359:Drug Therapy, Combination; D006801:Humans; D008911:Minocycline / Q000627:therapeutic use*; D009536:Niacinamide / Q000627:therapeutic use*; D010392:Pemphigus / Q000188:drug therapy*; D012189:Retrospective Studies; D013752:Tetracycline / Q000627:therapeutic use*; D016896:Treatment Outcome
chemical_list: D000893:Anti-Inflammatory Agents; D009536:Niacinamide; D002990:Clobetasol; D013752:Tetracycline; D008911:Minocycline; D004318:Doxycycline
keywords: autoimmune; bullous diseases; cadherins; desmoglein 1; desmoglein 3; doxycycline; minocycline; niacinamide; nicotinamide; pemphigus; steroid-sparing; tetracycline