title: The role of adjuvant therapy in pemphigus: A systematic review and meta-analysis.
abstract: BACKGROUND
  The assumption that adjuvant modalities have added value to oral glucocorticoids in the treatment of pemphigus is intuitively sound but has not been conclusively proven.
  
  
  OBJECTIVE
  We sought to compare the efficacy and safety of oral glucocorticoid treatment with or without adjuvants for pemphigus vulgaris and pemphigus foliaceus.
  
  
  METHODS
  We performed a systematic review and meta-analysis of randomized controlled trials. The primary outcome was remission. Secondary outcomes were disease control, time to disease control, relapse, time to relapse, cumulative glucocorticoid dose, withdrawal because of adverse events, and all-cause death. Trials were pooled irrespective of adjuvant type evaluated.
  
  
  RESULTS
  Ten trials (559 participants) were included. Adjuvants evaluated were azathioprine, mycophenolate mofetil, cyclophosphamide, cyclosporine, intravenous immunoglobulin, plasma exchange, and infliximab; not all were included in every analysis. Although adjuvants were not beneficial for achieving remission, they were found to collectively decrease the risk of relapse by 29% (relative risk 0.71, 95% confidence interval 0.53-0.95).
  
  
  CONCLUSIONS
  Different adjuvants were pooled together.
  
  
  CONCLUSIONS
  Adjuvants have a role in pemphigus treatment, at least in reducing the risk of relapse. Further randomized controlled trials of other promising modalities are warranted.
authors.affiliation: Department of Dermatology, Rabin Medical Center, Beilinson Hospital, Petach Tikva, Israel.
authors.forename: Lihi
authors.initials: L
authors.lastname: Atzmony
authors.affiliation: Department of Dermatology, Rabin Medical Center, Beilinson Hospital, Petach Tikva, Israel; Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.
authors.forename: Emmilia
authors.initials: E
authors.lastname: Hodak
authors.affiliation: Department of Dermatology, Oregon Health and Science University, Portland, Oregon.
authors.forename: Yael A
authors.initials: YA
authors.lastname: Leshem
authors.affiliation: Department of Dermatology, Rabin Medical Center, Beilinson Hospital, Petach Tikva, Israel.
authors.forename: Omer
authors.initials: O
authors.lastname: Rosenbaum
authors.affiliation: Faculty of Health Sciences, Ben-Gurion University of the Negev and South District Health Office, Ministry of Health, Beer Sheva, Israel.
authors.forename: Michael
authors.initials: M
authors.lastname: Gdalevich
authors.affiliation: Department of Dermatology, Johns Hopkins University, School of Medicine, Baltimore, Maryland.
authors.forename: Grant J
authors.initials: GJ
authors.lastname: Anhalt
authors.affiliation: Department of Dermatology, Rabin Medical Center, Beilinson Hospital, Petach Tikva, Israel; Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel. Electronic address: mimouni@post.tau.ac.il.
authors.forename: Daniel
authors.initials: D
authors.lastname: Mimouni
mesh_terms: D000970:Antineoplastic Agents / Q000008:administration & dosage*; D004359:Drug Therapy, Combination; D005260:Female; D005500:Follow-Up Studies; D005938:Glucocorticoids / Q000008:administration & dosage*; D006801:Humans; D007166:Immunosuppressive Agents / Q000008:administration & dosage*; D008297:Male; D010392:Pemphigus / Q000175:diagnosis* / Q000188:drug therapy*; D016032:Randomized Controlled Trials as Topic; D012008:Recurrence; D012074:Remission Induction; D018570:Risk Assessment; D012380:Role; D012720:Severity of Illness Index; D016896:Treatment Outcome
chemical_list: D000970:Antineoplastic Agents; D005938:Glucocorticoids; D007166:Immunosuppressive Agents
keywords: adjuvant; glucocorticoids; meta-analysis; pemphigus; pemphigus vulgaris; systematic review; therapy