The therapeutic landscape of pediatric dermatology has evolved considerably with the introduction of biologic agents targeting specific immune pathways. Rituximab is a 145-kDa chimeric murine–human monoclonal antibody that selectively binds the CD20 antigen on B lymphocytes, resulting in targeted B-cell depletion. Since its introduction for B-cell lymphomas, its clinical applications have expanded to include numerous autoimmune and inflammatory disorders.1 Initially approved for the treatment of B-cell non-Hodgkin lymphoma, rituximab has subsequently gained widespread acceptance in rheumatology, nephrology, neurology, and dermatology.2 By inducing selective B-cell depletion, rituximab offers a targeted therapeutic approach that can induce prolonged remission while reducing cumulative corticosteroid exposure and the burden of conventional immunosuppressive therapy. In the pediatric population, rituximab (RTX) has been increasingly employed as an off-label therapeutic option for several immune-mediated and lymphoproliferative disorders, including chronic immune thrombocytopenia, nephrotic syndrome, and post-transplant lymphoproliferative disease.3 Although individual reports have documented favorable outcomes, comprehensive evaluations of RTX use in pediatric dermatology remain limited. However, accumulating evidence suggests that earlier introduction of RTX in selected cases may improve disease control, reduce progression to treatment-refractory disease, and minimize the long-term adverse effects associated with prolonged use of conventional systemic agents. A comprehensive literature search was performed independently by the authors using PubMed/MEDLINE, Scopus, Web of Science, Google Scholar, and the Cochrane Library from database inception to July 2026. The search strategy combined the terms "rituximab", "pediatric", "children", "dermatology", "autoimmune blistering diseases", "pemphigus", "bullous pemphigoid", "linear IgA bullous dermatosis", "epidermolysis bullosa acquisita", "systemic lupus erythematosus", "dermatomyositis", "systemic sclerosis", and other relevant dermatologic disorders using Boolean operators. Reference lists of eligible articles were also manually searched to identify additional relevant publications. The literature search yielded 287 records from PubMed/MEDLINE, Scopus, and Google Scholar. Following removal of duplicate records, titles and abstracts were screened for relevance, and eligible full-text articles were reviewed. A total of 43 publications, including systematic reviews, observational studies, case series, case reports, clinical trials, and relevant guidelines, were ultimately included in this review. Inclusion criteria: English-language randomized controlled trials, observational studies, systematic reviews, case series, and case reports describing rituximab use in patients ≤18 years with dermatologic disorders or immune-mediated diseases with significant cutaneous manifestations. Exclusion criteria: Studies involving exclusively adult populations, articles unrelated to dermatologic indications, duplicate publications, conference abstracts lacking sufficient clinical information, editorials, expert opinions, and review articles not providing original clinical data. MECHANISM OF ACTION CD20 as a Therapeutic Target CD20 is a non-glycosylated transmembrane phosphoprotein expressed almost exclusively on B lymphocytes, from the pre-B cell stage through mature, activated, and memory B cells.4,5 In contrast, hematopoietic stem cells, pro-B cells, plasmablasts, and terminally differentiated plasma cells lack CD20 expression and are therefore not directly targeted by rituximab. However, short-lived plasmablasts may be indirectly reduced through depletion of their CD20-positive precursor B cells. The restricted expression of CD20 on the B-cell lineage, together with its absence on stem cells, permits effective B-cell depletion while allowing subsequent B-cell reconstitution, making CD20 an attractive therapeutic target in autoimmune and inflammatory disorders.6 Mechanisms of B-cell Depletion and Immunomodulation Binding of rituximab to the CD20 antigen initiates multiple complementary mechanisms that eliminate B lymphocytes, including complement-mediated cytotoxicity, antibody-dependent cellular cytotoxicity, and activation of intracellular apoptotic pathways. Following CD20 engagement, rituximab activates the classical complement cascade, recruits immune effector cells through Fcγ receptor interactions, and triggers signalling pathways that culminate in programmed cell death.7 Beyond direct B-cell depletion, rituximab also exerts broader immunomodulatory effects by altering antigen presentation, modulating cytokine production, and disrupting B-cell–T-cell interactions, thereby contributing to restoration of immune tolerance and suppression of autoimmune responses.8 PHARMACOLOGY Pharmacokinetics Following intravenous administration, rituximab selectively binds to CD20-positive B lymphocytes and is distributed primarily within lymphoid tissues. It exhibits nonlinear pharmacokinetics with a terminal half-life of approximately 18–32 days after repeated infusions. Children demonstrate pharmacokinetic profiles broadly comparable to adults. Rituximab is eliminated predominantly through reticuloendothelial catabolism and generally does not require dose adjustment in renal or hepatic impairment. Clinically significant drug–drug interactions have not been reported. Dosing Regimens Several dosing regimens have been employed in pediatric dermatology, largely extrapolated from oncology and rheumatology practice: Lymphoma protocol: 375 mg/m² administered intravenously once weekly for four consecutive weeks. Rheumatoid arthritis protocol: Two intravenous infusions administered two weeks apart (typically 1000 mg on days 1 and 15 in adults). Modified pediatric regimens: Various reduced-dose and individualized schedules have been reported depending on age, body surface area, disease severity, and therapeutic indication. Considerable heterogeneity exists in rituximab dosing regimens used in pediatric dermatology, and the optimal dosing schedule remains undefined. Administration and Premedication Rituximab is administered as a slow intravenous infusion under close clinical supervision. Pre-infusion prophylaxis with an antipyretic, antihistamine, and corticosteroid is commonly employed to decrease the likelihood of infusion-associated reactions. Patients should remain under close clinical supervision throughout the infusion and for a short period afterward to identify hypersensitivity or other infusion-associated adverse events promptly. REGULATORY STATUS AND APPROVED INDICATIONS Despite its widespread off-label use in children, regulatory approval for rituximab remains confined to a limited number of hematologic, oncologic, and rheumatologic conditions. Current regulatory approvals include the treatment of granulomatosis with polyangiitis and microscopic polyangiitis in pediatric patients aged 2 years or older. In dermatology, it is approved for moderate-to-severe pemphigus vulgaris in adults; however, no pediatric dermatologic indication has received regulatory approval. Consequently, its use in pediatric dermatology remains predominantly off-label and is guided by available evidence and expert consensus. INDICATIONS IN PEDIATRIC DERMATOLOGY Autoimmune Blistering Diseases Pemphigus Vulgaris Pemphigus vulgaris (PV) is a rare but potentially life-threatening autoimmune blistering disorder characterized by the production of pathogenic autoantibodies against desmoglein 3 and, in some cases, desmoglein 1. Pediatric pemphigus vulgaris is uncommon, accounting for approximately 1.4%–3.7% of all cases,9 however, consolidated evidence regarding the use of rituximab in this population remains limited. The pathogenic role of B lymphocytes and autoantibodies in PV provides a strong rationale for the use of rituximab. By selectively depleting CD20-positive B cells, rituximab reduces autoantibody production and interrupts the autoimmune cascade responsible for acantholysis and blister formation.10 Over the past decade, accumulating evidence has established rituximab as one of the most effective therapies for refractory and severe pemphigus vulgaris, including pediatric cases. Although randomized controlled trials are lacking in children, numerous case reports, case series, and systematic reviews have demonstrated favorable outcomes. A systematic review by Patel et al. comprising 43 pediatric patients with pemphigus (36 PV and 7 PF) demonstrated favorable outcomes with rituximab therapy, with complete remission achieved in over three-quarters of patients (77%) and partial remission in an additional 21%.11 Most adverse events were mild and infusion-related, although rare cases of severe infection, including sepsis, were reported. In a retrospective case series by Kianfar et al., the majority of 12 pediatric patients with pemphigus (10 PV and 2 PF) achieved remission within 2–6 months after the first rituximab cycle, highlighting its rapid onset of action in treatment-resistant disease.12 Several dosing regimens have been employed. The most commonly used schedules include the lymphoma protocol (375 mg/m² administered weekly for four consecutive weeks) and the rheumatoid arthritis protocol (two infusions administered two weeks apart, with doses adjusted according to body weight or body surface area in younger children). Modified low-dose regimens have also been reported in selected cases, particularly when concerns regarding cost or adverse effects exist. However, the optimal pediatric dosing schedule remains undefined.11 Current evidence supports rituximab as a valuable therapeutic option in pediatric pemphigus vulgaris, particularly in patients with inadequate response to conventional immunosuppressive therapy. Its excellent steroid-sparing potential and ability to induce durable remission have established it as an increasingly important component of modern pemphigus management. Pemphigus Foliaceus Pemphigus foliaceus (PF) is an uncommon antibody-mediated blistering disease characterized by immune reactivity against desmoglein 1, which causes loss of keratinocyte adhesion within the superficial epidermis and predominantly cutaneous blistering. Pediatric PF is considerably rarer than PV, and available evidence regarding rituximab use is limited to isolated case reports and small case series. Among the earliest pediatric reports, Connelly et al.13 described successful rituximab therapy in a young child with PF and erythroderma, while Reguiai et al.14 reported complete remission in a 4-year-old boy following rituximab treatment. Conventional treatment typically involves systemic corticosteroids with or without adjuvant immunosuppressive agents such as azathioprine, mycophenolate mofetil, or cyclophosphamide. However, refractory disease and treatment-related adverse effects may necessitate alternative therapeutic approaches. Bullous Pemphigoid Bullous pemphigoid (BP) is an acquired autoimmune disorder characterized by autoantibody-mediated injury to the hemidesmosomal proteins BP180 (type XVII collagen) and BP230, leading to subepidermal blister formation. Childhood BP is rare and generally exhibits a more favorable prognosis than the adult disease.15 Most children respond adequately to systemic corticosteroids and conventional immunosuppressive agents; however, severe, generalized, or treatment-resistant cases may pose significant therapeutic challenges. The successful use of rituximab in adult BP has prompted its application in selected pediatric patients with refractory disease. Published pediatric experience remains limited, with only four reported cases of rituximab use in childhood bullous pemphigoid available in the literature.15,16,17,18 Most of these patients had severe disease that was unresponsive to multiple conventional therapies, including systemic corticosteroids and other immunosuppressive agents. Rituximab administration was associated with rapid disease control and complete clinical remission in the majority of reported cases. It has been administered using both lymphoma and rheumatoid arthritis protocols, often in combination with concomitant immunosuppressive therapy. Although current evidence remains limited, rituximab may be considered in severe, recalcitrant childhood BP that fails to respond adequately to conventional treatment. Linear IgA Bullous Dermatosis Among autoimmune blistering disorders affecting children, linear IgA bullous dermatosis (LABD) is the most frequently encountered entity. It is identified by continuous linear IgA deposits at the dermoepidermal junction on direct immunofluorescence.19 While dapsone remains the first-line therapy and is highly effective in most patients, a small subset of children experience severe, refractory, or corticosteroid-dependent disease.20 The rationale for rituximab use in LABD stems from its ability to suppress autoreactive B-cell populations responsible for pathogenic antibody production. Evidence is limited to isolated case reports and small case series. Only a few cases of refractory LABD treated with rituximab have been reported, including pediatric patients, with most demonstrating favorable clinical responses and improved disease control.19,21 Various rituximab dosing schedules have been employed, most commonly the lymphoma protocol. Given the rarity of refractory pediatric LABD, definitive treatment recommendations cannot be made; however, rituximab may represent a valuable therapeutic option in carefully selected cases. Epidermolysis Bullosa Acquisita Epidermolysis bullosa acquisita (EBA) is a rare acquired autoimmune disease in which antibodies against type VII collagen disrupt anchoring fibrils at the dermoepidermal junction, leading to skin fragility and subepidermal blistering.22 Pediatric EBA is an exceptionally rare autoimmune subepidermal blistering disorder, with only approximately 34 cases reported in the literature. Compared with adults, most affected children respond favorably to conventional therapy and generally have a better long-term prognosis;23,24 however, a small subset develops severe, treatment-refractory disease requiring escalation of therapy. While several studies have demonstrated the efficacy of rituximab in refractory adult EBA, pediatric experience remains limited to only a few published case reports.25,26,27 In these reports, rituximab has been reserved for children with extensive disease who had failed multiple conventional immunosuppressive therapies and has resulted in marked clinical improvement, healing of existing lesions, reduced corticosteroid requirements, and sustained disease control. Although current evidence remains limited, rituximab appears to be a promising therapeutic option for severe, refractory pediatric EBA when conventional treatment strategies are unsuccessful. Mucous Membrane Pemphigoid Mucous membrane pemphigoid (MMP) is a chronic autoimmune blistering disorder characterized by predominant involvement of mucosal surfaces and a risk of permanent scarring.28 Published experience with rituximab remains limited. Successful treatment has been reported in isolated pediatric case reports, including childhood ocular MMP, and rituximab has also been used in a small number of patients in a recent multicenter pediatric series.29,30 Rituximab is generally reserved for severe, refractory disease or sight-threatening involvement that fails to respond adequately to conventional immunosuppressive therapy. Although current evidence is sparse, available reports suggest that rituximab may achieve disease control while limiting corticosteroid exposure in selected patients. Connective Tissue Diseases Pediatric Systemic Lupus Erythematosus Compared with adult-onset SLE, childhood-onset systemic lupus erythematosus (cSLE) is usually characterized by greater disease activity, increased multisystem involvement, and a more aggressive clinical presentation.31 Rituximab has been widely used in adult SLE patients. However, it is an off-label drug in pediatric autoimmune diseases.32 In pediatric practice, rituximab has been employed for severe cutaneous manifestations, lupus nephritis, neuropsychiatric lupus, hematological involvement, and other treatment-resistant manifestations. The largest published pediatric cohort by Watson et al. reported the use of 103 rituximab cycles in 63 children over a 10-year period.33 Pediatric studies have consistently demonstrated reductions in disease activity, significant corticosteroid-sparing effects, and favorable responses in refractory lupus nephritis and severe extra-renal disease. Although current evidence is derived primarily from observational studies and case series, rituximab represents an important therapeutic option for carefully selected children with refractory cSLE who fail to respond adequately to conventional immunosuppressive therapy.32 Juvenile Dermatomyositis Juvenile dermatomyositis (JDM) is a rare immune-mediated inflammatory myopathy of childhood that typically presents with symmetrical proximal muscle weakness accompanied by distinctive cutaneous features.34 Although most children respond to corticosteroids and traditional steroid-sparing immunosuppressive therapies, a subset develops refractory disease requiring biologic therapy. Rituximab has emerged as a therapeutic option for severe or treatment-resistant JDM, particularly in patients with persistent muscle weakness, cutaneous disease, or major organ involvement despite standard treatment. The randomized Rituximab in Myositis (RIM) trial, which included both adult and pediatric patients (48 children with JDM), did not demonstrate a significant difference between early and delayed rituximab administration for the primary or secondary endpoints. Nevertheless, 83% of participants met the predefined definition of clinical improvement during the 44-week study, supporting the potential benefit of rituximab in refractory myositis.35 Subsequent pediatric case series and observational studies have also reported improvements in muscle strength, skin disease, and corticosteroid requirements following rituximab therapy.36 Although evidence in children remains limited, rituximab is increasingly considered for refractory JDM after failure of conventional immunosuppressive therapy. Juvenile Systemic Sclerosis Juvenile systemic sclerosis (jSSc) is an uncommon systemic autoimmune disorder characterized by progressive cutaneous fibrosis, vascular dysfunction, and variable involvement of internal organs.37 Although conventional therapy with corticosteroids and immunosuppressive agents remains the mainstay of treatment, patients with rapidly progressive or refractory disease may require biologic therapy. Rituximab has shown encouraging results in pediatric jSSc. In a case series by Zulian et al., four children with rapidly progressive disease treated with rituximab (375 mg/m² on days 0 and 14, repeated every 3 months for four yearly cycles) demonstrated improvement in skin fibrosis, pulmonary and cardiac involvement, and overall disease severity during follow-up.37 Earlier reports have also described favorable clinical responses in children with diffuse jSSc.38 Although evidence remains limited to small observational studies and case series, rituximab appears to be a promising therapeutic option for severe, refractory juvenile systemic sclerosis, particularly in patients with progressive skin and pulmonary disease. Other Anecdotal Uses Beyond its established role in autoimmune blistering disorders and connective tissue diseases, rituximab has also been used in several uncommon immune-mediated pediatric dermatoses. Increasing evidence supports its use in refractory IgA vasculitis (Henoch–Schönlein purpura), particularly in children with severe renal involvement or relapsing disease unresponsive to conventional immunosuppressive therapy.39 Isolated reports have also described successful use in a few other rare inflammatory dermatoses like cryoglobulinemic vasculitis40 and eosinophilic fascitis.41 Nevertheless, the available evidence remains limited to case reports and small case series, and rituximab should be reserved for carefully selected refractory cases until larger studies become available. SAFETY PROFILE Although rituximab is generally well tolerated in children, adverse events may occur and require careful monitoring.7,11 Infusion-related reactions are the most frequently reported complications and typically include fever, chills, rigors, rash, dyspnea, hypotension, tachycardia, and, less commonly, angioedema. Most infusion-related adverse events are self-limited and are usually reduced by appropriate premedication together with gradual escalation of the infusion rate.7,11 Infectious complications, including upper respiratory tract infections, bacterial infections, and rarely sepsis, have been reported, particularly in patients receiving concomitant immunosuppressive therapy. Rituximab-induced B-cell depletion may result in hypogammaglobulinemia, which appears to occur more frequently in children than in adults, especially following repeated treatment cycles, thereby increasing susceptibility to infections.42 Other uncommon adverse events include transient neutropenia, late-onset neutropenia, serum sickness-like reactions, hepatitis B virus reactivation, and the exceedingly rare occurrence of progressive multifocal leukoencephalopathy.7 Careful pre-treatment screening, vaccination review, and periodic monitoring of complete blood counts and immunoglobulin levels are therefore recommended throughout therapy. MONITORING AND SPECIAL CONSIDERATIONS Pretreatment Evaluation Prior to initiating rituximab therapy, a comprehensive clinical assessment and laboratory evaluation should be performed. Recommended investigations include complete blood count, liver and renal function tests, hepatitis B and C serology, HIV testing, tuberculosis screening, and baseline serum immunoglobulin levels.1 Monitoring During Therapy Patients should be monitored clinically for treatment response, infusion-related reactions, and evidence of infection. Periodic laboratory monitoring, including complete blood counts and immunoglobulin levels, may help identify hematologic abnormalities and treatment-related immunosuppression. Vaccination Considerations Vaccination status should be assessed before rituximab therapy. Whenever feasible, live attenuated vaccines should be completed at least four weeks before rituximab therapy, whereas inactivated vaccines are preferably administered at least two weeks before treatment. Live vaccines are contraindicated during rituximab-induced B-cell depletion. According to the 2022 American College of Rheumatology guidelines, influenza vaccination may be given as scheduled, whereas other inactivated vaccines are ideally administered approximately 6 months after the last rituximab infusion and at least 2 weeks before the next dose.43 FUTURE DIRECTIONS The expanding use of rituximab in pediatric dermatology has highlighted several important areas for future research. Large prospective multicenter studies are required to develop standardized treatment protocols, determine optimal dosing schedules, and define evidence-based retreatment strategies for children receiving rituximab. Long-term safety data are also required to better define the risks of prolonged B-cell depletion, hypogammaglobulinemia, and infectious complications. Further research should prioritize the identification of biomarkers that can predict therapeutic response, risk of relapse, and the durability of remission. Comparative studies evaluating rituximab against conventional immunosuppressive agents and newer biologic therapies may further clarify its position within treatment algorithms. The development of next-generation anti-CD20 monoclonal antibodies, including ocrelizumab, obinutuzumab, and ofatumumab, may provide additional therapeutic options with improved efficacy, safety, or dosing convenience. As evidence continues to accumulate, B-cell-targeted therapies are likely to play an increasingly important role in the management of severe pediatric dermatologic disorders.

Rituximab has become an important therapeutic option for managing several severe, treatment-resistant dermatologic disorders in children, particularly autoimmune blistering diseases. Through selective depletion of CD20-expressing B lymphocytes, rituximab modulates pathogenic immune responses, facilitates sustained disease control, and substantially reduces corticosteroid requirements. Although current evidence is derived largely from case reports, case series, and observational studies, available data consistently demonstrate favorable efficacy and an acceptable safety profile. Further prospective studies are required to define optimal dosing regimens, long-term outcomes, and the precise role of rituximab within pediatric dermatology treatment algorithms. Table 1- Reported Use of Rituximab in Pediatric Dermatologic Disorders Disease Category Pediatric Evidence Rituximab Regimen(s) Used Clinical Outcomes Pemphigus vulgaris Autoimmune blistering disease Systematic review of 43 pediatric pemphigus patients (36 PV, 7 PF), multiple case reports and case series. 375 mg/m² weekly × 4 (lymphoma protocol); two doses 2 weeks apart (RA protocol); modified low-dose regimens Complete remission in ~77% and partial remission in ~21% of reported patients; remission often achieved within 2–6 months; marked steroid-sparing effect and prolonged disease control. Pemphigus foliaceus Autoimmune blistering disease 7 patients identified in a systematic review, in addition to isolated case reports Lymphoma and RA protocols Rapid disease control, successful corticosteroid tapering, and sustained remission reported in most published cases. Bullous pemphigoid Autoimmune blistering disease Approximately three reported pediatric cases and small case reports/series Lymphoma and RA protocols Reduction in blister formation, disease control, steroid-sparing benefit Linear IgA bullous dermatosis Autoimmune blistering disease Isolated case reports; only a few refractory cases reported, including two pediatric patients Predominantly lymphoma protocol Improvement in refractory disease and reduction of concomitant immunosuppression Epidermolysis bullosa acquisita Autoimmune blistering disease Few pediatric case reports (EBA itself is exceptionally rare, with ~34 reported pediatric cases overall) Lymphoma protocol; individualized regimens Marked clinical improvement, healing of lesions, steroid-sparing effect, and sustained disease control in refractory cases Mucous membrane pemphigoid Autoimmune blistering disease Isolated pediatric case reports and a recent multicenter pediatric series Variable regimens Disease stabilization and prevention of progressive scarring Systemic lupus erythematosus Connective tissue disease Multiple pediatric observational studies, case series, and cohort studies (largest cohort: 63 patients) Lymphoma protocol, RA protocol, and individualized regimens Improvement in refractory cutaneous and systemic disease, steroid-sparing effect, and reduced disease activity. Juvenile dermatomyositis Connective tissue disease Randomized controlled trial (48 JDM patients), observational studies, and case series Lymphoma and RA protocols Improvement in cutaneous and muscular disease activity, reduction in corticosteroid requirements, and improved disease control Juvenile systemic sclerosis Connective tissue disease Small case series (3–4 patients) 375 mg/m² on days 0 and 14, repeated every 3 months; individualized regimens Stabilization of skin sclerosis and reduced disease progression

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