Balighi K, Hatami P, Daneshpazhooh M, et al. - Findings demonstrate effectiveness of rituximab (RTX) in treating pemphigus (PV) even in cases with refractory disease, and with each subsequent cycle, an increase in its therapeutic effect was evident. Late RTX prescription during disease course might have a role in the presence of a more resistant form of disease.

• In this retrospective cross-sectional study, a total of 45 patients with pemphigus vulgaris (21 men and 24 women) who received at least 3 cycles of rituximab were included to unveil hard-to-treat patients' characteristics which might lead to consider more prompt protocols for treatment of them.

• Women, vs men, required RTX about 2 years later in their course of disease and were about 8 years older.

• The most frequently involved locations include buccal, truncal and scalp regions.

• Last visit revealed a significant decrease in both anti-Dsg1, 3 relative to baseline, but the amount of this reduction was not significantly different between them.

• Of patients, 31.11% and 24.44% achieved partial and complete remission, respectively, and 15.56% relapsed, and partial remission on treatment in 15.56% and complete remission on treatment in 13.33% were noted at the last follow-up.

• More probable signs of refractory PV include: male gender, severe oral mucosal involvement on disease onset and extensive scalp and truncal lesions as first cutaneous manifestation of disease; thus, it makes sense to consider more prompt protocols for treatment of these cases.