A retrospective chart review of patients with ocular mucous membrane pemphigoid (OcMMP) suggests that using mycophenolate or a mycophenolate–rituximab combination treatment may result in superior outcomes in comparison to treatment with other immunomodulators.
Study design
Ocular mucous membrane pemphigoid (ocular cicatricial pemphigoid) is a rare autoimmune condition that results in chronic conjunctivitis and can ultimately cause severe scarring and visual impairment. This 10-year retrospective analysis looked at the clinical outcomes of 22 patients diagnosed with OcMMP who were treated with various systemic immunomodulatory agents, including dapsone, mycophenolate, methotrexate, azathioprine, cyclophosphamide, rituximab, intravenous immunoglobulin, and apremilast. Efficacy was evaluated after 3 months of treatment, with the results classified as “complete response,” “response,” or “treatment failure” based on assessment of ocular surface inflammatory activity and/or the presence of adverse events.
Outcomes
The mycophenolate (n = 16) and combined mycophenolate–rituximab (n = 6) treatment groups were the only medication classes with no reported treatment failures. The group that received dapsone (n = 8) had the greatest percentage of treatment failures (50%).
Limitations
Overall prevalence of this (admittedly rare) disease is low and, accordingly, there were relatively few patients treated with each immunomodulator in this study. In addition, dosing was not consistent within each medication group; for example, some patients in the methotrexate group received 10–20 mg orally each week while others were given weekly subcutaneous doses of 10–20 mg. The positive-biopsy rate was 66%, which is quite typical for this disease, but it does open the possibility that OcMMP-negative individuals may have been included. Lastly, the criteria for disease progression were not standardized and were determined by the same 2 doctors in an unmasked fashion.
Clinical significance
This study offers a unique private practice perspective on OcMMP, and the authors highlight the aggressiveness of OcMMP and the need for rapid systemic treatment initiation. There is currently no consensus on which immunomodulatory agent is the best option for this severe and often visually disabling disease. Whereas dapsone has historically been recommended as a first-line agent, based on the results of this study the authors propose a treatment algorithm that recommends using mycophenolate for mild-to-moderate disease. This study highlights the need for prospective randomized control trials of OcMMP comparing treatment efficacy.
Financial Disclosures: Dr. Gerami Seitzman discloses a financial relationship with Dompe (Consultant/Advisor).