Plasmapheresis and Pulse Cyclophosphamide Therapy in Pemphigus Vulgaris: A Novelty or a Reappraisal?-Reply

In Reply.—  The rationale behind the "synchronization" concept of plasmapheresis with subsequent pulse cyclophosphamide therapy is to utilize the increased vulnerability of pathogenic B cells by applying high-dose cytotoxic drugs shortly after antibody depletion during the period of maximum antibody rebound, ie, during the period of maximum depletion-induced B-cell proliferation and vulnerability. This basic concept was applied experimentally as early as 1971.¹ It was first applied clinically in myasthenia gravis in 1980,² in systemic lupus erythematosus in 1981,³ and in Goodpasture's syndrome in 1982.⁴ It was suggested for severe pemphigus⁵ in 1983, and it was first applied clinically in pemphigus vulgaris in one of seven briefly reported cases in a 1984 article by Ruocco and coworkers.⁶ We regret that none of us had seen that article.However, though the basic rationale is the same as in our report,⁷ there are some major differences concerning the strictness