The letter by Vardy and Cohen illustrates one of the many difficulties of judging the effectiveness of adjuvants in the treatment of pemphigus. The particular difficulty posed by this case is that the response to corticosteroids in pemphigus depends not only on the dose, but also on the length of time administered. Response to an optimal dose is usually rapid; response to a suboptimal dose can range from slow through very slow to none at all. The patient described by Vardy and Cohen eventually responded to the combination of corticosteroids and cyclosporine, and the dose of steroids was reduced but not eliminated. How long this took we are not told. The question is, Was the response due to the cyclosporine or simply to the continued administration of a suboptimal dose of steroids? This question cannot be answered in an individual patient, since there is no way of knowing how long it would have taken for a response to occur had no cyclosporine been given. The only way to objectively determine whether the additional drug is effective is through a randomized trial involving a larger number of patients. This is why the study of Ioannides et al1 is so important. It illustrates in a randomized trial that many of our subjective impressions about the effectiveness of cyclosporine (and, by extension, of other adjuvants) in the treatment of pemphigus may be inaccurate.
Bystryn J. Cyclosporine Therapy Should Be Considered for Maintenance of Remission in Patients With Pemphigus. Arch Dermatol. 2001;137(4):505-506. doi: