Gold Therapy For Pemphigus And Cutaneous Lupus: Dosing, Risks
Gold compounds in dermatology: Therapeutic uses, administration, precautions, and side effects for skin diseases like pemphigus.
Gold compounds are primarily used in the treatment of rheumatoid arthritis. However, they may be useful in the treatment of some skin diseases, including
pemphigus vulgaris
,epidermolysis bullosa acquisita
, and severe or resistantcutaneous lupus erythematosus
.Introduction
Chrysotherapy, or gold therapy, involves the administration of gold salts to modulate immune responses in autoimmune and inflammatory conditions. Historically rooted in rheumatoid arthritis management, its application has extended to dermatology due to observed immunomodulatory effects. In skin diseases, gold compounds act as steroid-sparing agents, particularly in blistering disorders like pemphigus, where high-dose corticosteroids pose significant risks.
Pemphigus vulgaris, an autoimmune blistering disease characterized by acantholysis due to anti-desmoglein antibodies, responds to gold in approximately 62% of cases as primary therapy or adjunct, allowing prednisone dose reduction after an average of 3 months. This efficacy stems from gold’s ability to suppress autoantibody production and inflammatory cascades, though mechanisms remain incompletely understood.
Beyond pemphigus, limited evidence supports use in epidermolysis bullosa acquisita (an anti-collagen VII mediated subepidermal blistering disorder) and refractory lupus erythematosus, where gold aids in controlling cutaneous manifestations resistant to conventional immunosuppressants. Recent reemphasis on chrysotherapy highlights its role in tapering corticosteroids faster in steroid-responsive dermatoses.
How to use
Gold therapy mirrors rheumatoid arthritis protocols, administered intramuscularly as gold sodium thiomalate or aurothioglucose. Oral auranofin, with distinct pharmacokinetics, shows promise but lacks extensive dermatological data.
Baseline assessment prior to initiation:
- Complete blood count (CBC) including platelets
- Urinalysis for protein and blood
- Renal and liver function tests
- Chest X-ray to exclude tuberculosis or interstitial lung disease
Dosing regimen: Start with test dose of 10 mg, followed by 25 mg weekly, escalating to 50 mg weekly if tolerated. Maintenance at 50 mg every 2-4 weeks. Total cumulative dose should not exceed 1-1.5 g without reassessment; discontinue if no improvement by 1 g.
Concomitant steroids are standard initially due to gold’s delayed onset (2-3 months). In a study of 26 pemphigus patients (81% vulgaris), gold enabled steroid tapering in 62%, with 15% achieving complete remission off all therapy.
| Phase | Dose | Frequency | Cumulative Goal |
|---|---|---|---|
| Test | 10 mg | Single | – |
| Induction | 25-50 mg | Weekly | 1 g |
| Maintenance | 50 mg | Every 2-4 weeks | Assess response |
Regular monitoring: CBC, urinalysis, and biochem weekly initially, then biweekly. Eosinophilia or proteinuria warrants pause.
Contraindications
Gold compounds should not be used in the following circumstances:
- Severe uncontrolled diabetes
- Heart failure or significant cardiovascular disease
- Systemic lupus erythematosus (active)
- Previous gold-induced toxicity (nitritoid crisis, bone marrow suppression, renal failure)
- Pregnancy or lactation
- Active infections, including hepatitis B/C or HIV
- History of colchicine toxicity
In pemphigus cohorts, patients with steroid complications like ulcers or diabetes were cautiously selected for gold monotherapy if feasible.
Precautions
Before starting treatment, consider:
- Patient compliance for weekly injections and monitoring
- Cost and availability of gold salts
- Potential for delayed toxicity (monitor beyond 4 months)
- Combination with DMARDs increases toxicity risk
Toxicity emerges in 42% within 4 months, primarily mucocutaneous (pruritus, dermatitis), renal (proteinuria), or hematologic (eosinophilia, thrombocytopenia). Restart possible after minor effects resolve. Rheumatologist consultation aids but dermatologist leads skin-directed decisions.
In contact allergy contexts, gold sensitivity (prevalence 14.1% in dermatitis patients) via patch testing with gold sodium thiosulfate does not preclude therapy, as systemic administration differs from topical exposure.
Side effects
In addition to helpful effects, gold compounds cause many side effects, some serious:
- Mucocutaneous: Pruritus (most common), maculopapular rash, lichenoid eruptions, pityriasis rosea-like (frequent in studies).
- Renal: Proteinuria (up to 10%), nephrotic syndrome (rare).
- Hematologic: Thrombocytopenia, aplastic anemia, eosinophilia (heralds complications).
- Nitritoid reactions: Flushing, hypotension post-injection.
- Pulmonary: Interstitial pneumonitis.
- Ocular: Corneal gold deposits (asymptomatic).
In pemphigus trial, 42% experienced toxicity (9/26 discontinued); responders tolerated long-term (up to 108 months). Antibody titers decreased in monitored cases (1:160 to <1:10).
Gold dermatitis histopathology shows lichenoid infiltrates or spongiotic changes.
Drug interactions
- Avoid with penicillamine, antimalarials (additive toxicity).
- NSAIDs may mask early toxicity.
- Monitor closely with immunosuppressants.
Frequently Asked Questions
What skin conditions benefit from gold therapy?
Primarily pemphigus vulgaris (62% response), epidermolysis bullosa acquisita, and resistant cutaneous lupus erythematosus.
How long until gold works in pemphigus?
Average 3 months to halve steroids; full effect delayed.
Is gold safe long-term?
Toxicity usually early (<4 months); tolerant patients may continue years.
Does gold contact allergy contraindicate therapy?
No; prevalence 14.1% but poor correlation with systemic reactions.
Monitoring requirements?
Weekly CBC, UA initially; baseline CXR, renal/liver tests.
References
- Treatment of Pemphigus With Gold — JAMA Dermatology. 1990-04-01. https://jamanetwork.com/journals/jamadermatology/fullarticle/189343
- Gold therapy and its indications in dermatology. A review — PubMed. 1987-05-01. https://pubmed.ncbi.nlm.nih.gov/3553248/
- Gold – DermNet — DermNet NZ. 2003. https://dermnetnz.org/topics/gold
- Prevalence of contact allergy to gold in dermatitis patients from 2010… — Contact Dermatitis (PubMed). 2024. https://pubmed.ncbi.nlm.nih.gov/?otool=iaufhhslib&term=39340195
- Gold Dermatitis: A Clinical and Histopathological Study — JAMA Dermatology. 1984. https://jamanetwork.com/journals/jamadermatology/fullarticle/533840
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