A case of pemphigus vulgaris improved by cigarette smoking.

A 27-year-old white man presented to our clinic with a 3-year history of pemphigus vulgaris. The initial treatment for erosions of the buccal mucosa and blisters on his face and body included oral prednisone, intramuscular gold salts, and oral auranofin. After the patient was given a course of aurothioglucose (Solganol) by intramuscular injection, treatment with oral prednisone (100 mg every other day) and oral auranofin (6 mg/d) was initiated, during which all blisters cleared. Eventually, this regimen proved ineffective. In retrospect, the patient recalled that he began to smoke cigarettes because of stress prior to the improvement of his disease. He also reported that he stopped smoking at the time of disease exacerbation. When his disease flared again, he was treated with intramuscular injections of aurothioglucose (75 mg weekly), without improvement. Examination revealed a 4 3 4-cm erosive plaque with yellow crusting on the patient’s right cheek and a 2 3 2cm area of erosion on his left cheek (Figure 1, left). A punch biopsy specimen from the lesion on the right cheek demonstrated an epidermis with a split that extended to adnexal structures, as well as mild acute and chronic inflammation in the superficial dermis (Figure 2). Indirect immunoflorescence was positive for epidermal antibodies at a titer of 1:240. The dosage of prednisone was increased to 80 mg/d, and cyclophosphamide was added to the regimen at a dosage of 25 mg/d. Because of the lack of clinical effect, the dosage of cyclophosphamide was increased to 100 mg/d, and dapsone was added to the regimen at a dosage of 75 mg/d. Despite this aggressive regimen, our patient’s condition failed to improve.