Pemphigus Vulgaris MCQ — NEET PG Practice Question | NEETPGAI
Pemphigus Vulgaris
medium
hand Dermatology
A 52-year-old woman of Ashkenazi Jewish descent presents with a 3-month history of painful oral erosions that were initially misdiagnosed as recurrent aphthous ulcers. Two weeks later, she developed flaccid bullae on her scalp and chest that rupture easily into painful erosions. Nikolsky's sign is positive. Direct immunofluorescence of perilesional skin shows IgG and C3 in a chicken-wire intercellular pattern. ELISA confirms elevated anti-desmoglein 3 and anti-desmoglein 1 antibodies. The management approach marked **A** in the diagram is recommended as first-line therapy. Which of the following best describes why this regimen is preferred over corticosteroid monotherapy?
A. It eliminates the need for any systemic corticosteroid therapy, allowing complete avoidance of steroid side effects
B. It provides faster symptom relief within 24–48 hours compared to prednisolone alone, making it superior for acute flare management
C. It permanently cures the underlying autoimmune disorder by depleting all circulating B cells irreversibly
D. It achieves disease remission with lower cumulative corticosteroid exposure and reduced long-term steroid-related morbidity by targeting B-cell-mediated autoimmunity
Explanation
Why option 1 is correct
The landmark Joly et al. Lancet 2017 trial and the 2020 International Consensus on Pemphigus established that rituximab (anti-CD20 monoclonal antibody) plus prednisolone 0.5–1 mg/kg/day is the first-line regimen for pemphigus vulgaris. Rituximab targets B cells that produce the pathogenic anti-desmoglein IgG autoantibodies, allowing the prednisolone dose to be reduced and tapered faster than with corticosteroid monotherapy. This dual approach achieves disease control while minimizing cumulative corticosteroid exposure and associated long-term toxicities (osteoporosis, infections, metabolic complications), which is the key advantage over prednisolone monotherapy.
Why each distractor is wrong
Option 2: Rituximab is always used in combination with prednisolone, not as a replacement. Corticosteroids remain essential for rapid anti-inflammatory effect and are not eliminated from the regimen; the dose is merely reduced and tapered more quickly.
Option 3: Rituximab's mechanism is immunomodulation via B-cell depletion, not rapid symptom relief. Prednisolone provides faster symptomatic control; rituximab's benefit emerges over weeks to months as anti-desmoglein antibody titers decline. This is not the rationale for preferring the combination.
Option 4: Rituximab causes temporary B-cell depletion (typically 6–12 months), not permanent cure. Pemphigus vulgaris is a chronic autoimmune disease; relapse can occur after B-cell reconstitution. The goal is remission with reduced steroid burden, not irreversible cure.
High-YieldNEET PG
Rituximab + prednisolone is first-line PV therapy because it reduces cumulative corticosteroid exposure while targeting the B-cell source of anti-desmoglein antibodies — the landmark Joly 2017 trial proved superiority over prednisolone monotherapy.
Joly P et al. Lancet 2017; 2020 International Consensus on Pemphigus
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