We appreciate the interest and comments of Machet et al regarding our recent Archives article concerning the use of plasmapheresis in the management of severe cutaneous manifestations of cryoglobulinemia.1
In the case presented by Machet et al, the authors state that "plasmapheresis in this patient was ineffective" for the patient's neurologic involvement, although "purpura and skin ulcers were slightly improved." Neurologic involvement in cryoglobulinemia often does not respond to treatment.2 Although the mechanism of neurologic injury in cryoglobulinemia is unknown, proposed mechanisms include immunologically mediated demyelination, microcirculatory occlusion, and vasa nervorum vasculitis.3 Such irreversible ischemic nerve injury would not respond to any treatment. Our recommendation for the use of plasmapheresis was for the treatment of recalcitrant skin disease associated with cryoglobulinemia, and the patient described by Machet et al did note a slight improvement in cutaneous manifestations.
Let us point out several clinical and therapeutic differences between
McGovern TW, Enzenauer RJ, Fitzpatrick JE. Failure of Plasmapheresis in the Treatment of Recalcitrant Skin Ulcers in a Patient With Mixed Cryoglobulinemia-Reply. Arch Dermatol. 1997;133(3):390-391. doi:10.1001/archderm.1997.03890390134026