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Greater than 50% of pemphigus patients experience relapse, which complicates long\u2010term medical management, including risks associated with re\u2010treatment and complications such as infection and dehydration. This review aims to elucidate mechanisms, risk factors, and medications associated with pemphigus relapse. Mechanisms of relapse include the persistence of auto\u2010reactive B\u2010cell populations post\u2010treatment and CD20\u2010 B\u2010cell populations that reactivate after B\u2010cell depletion therapy. Risk factors for relapse include high body surface area (BSA) of pemphigus involvement, high body mass index, high severity according to the Pemphigus Disease Area Index (PDAI) at onset, treatment delay, and high anti\u2010DSG1 and DSG3 titers post\u2010treatment. Targeted B\u2010cell localization is associated with better clinical outcomes, including less frequent relapses. Rituximab is currently the gold standard of treatment for moderate\u2013severe pemphigus and has relapse rates of 11%\u201344% in selected studies, with a mean time to relapse of 5.8\u2009months to 36\u2009months following treatment. Relapse rates across lymphoma dosing (375\u2009mg\/m\n                    <jats:sup>2<\/jats:sup>\n                    ) versus rheumatoid arthritis dosing (1\u2009g dosing weekly) was inconsistent; however, more frequent dosing, earlier treatment, and higher cumulative dosing were associated with lower relapse rates. Alternative agents that have clinical efficacy include corticosteroid monotherapy, mycophenolate mofetil, azathioprine, and intravenous immunoglobulin. Future studies should include head\u2010to\u2010head comparators over long follow\u2010up periods to identify the best treatment agents associated with the least relapse risk.\n                  <\/jats:p>","DOI":"10.1111\/1346-8138.17505","type":"journal-article","created":{"date-parts":[[2024,10,26]],"date-time":"2024-10-26T03:29:56Z","timestamp":1729913396000},"page":"1533-1546","update-policy":"https:\/\/doi.org\/10.1002\/crossmark_policy","source":"Crossref","is-referenced-by-count":15,"title":["Pemphigus relapse: Mechanisms, risk factors, and agents associated with disease recurrence"],"prefix":"10.1111","volume":"51","author":[{"ORCID":"https:\/\/orcid.org\/0000-0002-8383-4451","authenticated-orcid":false,"given":"Gaurav N.","family":"Pathak","sequence":"first","affiliation":[{"name":"Department of Dermatology Rutgers Robert Wood Johnson Medical School  Somerset New Jersey 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