Safety and efficacy of low-dose rituximab in pemphigus: insights from a systematic review and a single-arm meta-analysis

Pemphigus is an autoimmune blistering condition that significantly impacts patient morbidity and quality of life. Rituximab has revolutionized treatment, but high-dose regimens are associated with considerable side effects and costs. Low-dose (LD) Rituximab has emerged as a promising alternative, offering the potential for comparable efficacy with reduced adverse events. To identify the efficacy and safety of LD Rituximab in pemphigus cases, with a focus on different dosing regimens. A total of 16 studies comprising 228 subjects were enrolled. All included studies evaluated the efficacy of LD Rituximab in pemphigus individuals, covering research conducted from inception through January 2025. Pooled proportions for complete remission and adverse events were calculated, and subgroup analyses were performed based on Rituximab dosing regimens. The overall rate of pooled remission was 72.9% (95% CI: 64.2%–81.7%, p < 0.001), with the 500 mg × 2 regimens achieving the highest remission rate (74.8%). The pooled adverse event rate was 28.1% (95% CI: 16.4%–39.8%), with the ultra-LD regimen showing the lowest rate (15.5%). Significant heterogeneity was noted across studies. LD Rituximab is a highly effective and relatively safe therapy for pemphigus vulgaris. The 500 mg × 2 regimen offers the best balance of efficacy and safety, but further high-quality research is required to confirm such findings and identify long-term outcomes.