Comparative Study of Rituximab Versus Combination of Rituximab and Intravenous Cyclophosphamide in Severe Pemphigus

Inclusion Criteria: * Patients with the diagnosis of pemphigus based on clinical, histopathological and immunological features the following: * Refractory disease defined as continuing extension of old lesions, development of new lesion, or failure of established lesions to begin to heal despite 3 weeks of therapy on 1.5 mg/kg/day of prednisolone or its equivalent with or without the concurrent use of cyclophosphamide 2mg/kg/day for 12 weeks or azathioprine 2.5 mg/kg/day for 12 weeks. Patients who fail to respond to 6 DCP/DP are also considered as refractory disease. Exclusion Criteria: * Infections- Hepatitis B, Hepatitis C, HIV, active tuberculosis or sepsis. * Abnormal liver function tests and renal function tests * Known cardiac arrhythmia or conduction abnormality * Systolic ejection fraction \<40% * Pregnancy and breast feeding * Severely decreased bone marrow functions. * Known history of bladder cancer or hemorrhagic cystitis * Known allergy to cyclophosphamide * Patients of reproductive age group who haven't completed their family * Known hypersensitivity to murine proteins. * Patients who do not consent for the study.