How do you approach the treatment of eosinophilic fasciitis refractory to glucocorticoids and methotrexate?

As rheumatologists, we are accustomed to managing people with rare diseases. Eosinophilic fasciitis (EF) ranks among the rarest of the rare, so it is understandable that there are no carefully designed trials assessing the efficacy of the various immune-modulating drugs. Clearly, corticosteroids are highly effective as first line therapy but as they are tapered, the risk for disease relapse increases. There are scattered case reports and small series of patients who have been treated with methotrexate, azathioprine, mycophenolate, cyclophosphamide, TNF inhibitor drugs, rituximab, and anti- IL-6 therapies, all with variable success. One promising therapeutic avenue may be the use of anti-IL-5 therapies such as mepolizumab and reslizumab sinc...