Steroid-sparing adjuvants may enhance oral glucocorticoid benefits in pemphigus treatment. Selecting the optimal therapeutic option among various first-line steroid-sparing adjuvants is often a clinical challenge due to the lack of head-to-head clinical trials.To determine the best first-line steroid-sparing adjuvants for pemphigus treatment.Randomized control trials comparing different steroid-sparing adjuvants in patients with pemphigus were identified through a systematic literature search and subjected to a network meta-analysis. The primary outcomes were the proportion of remission and the mean cumulative glucocorticoid dose.Ten trials involving 592 patients were analyzed. Among the seven steroid-sparing adjuvants evaluated, rituximab was the most effective for achieving remission and was more effective than steroid alone (odds ratio 14.35; 95% CI, 4.71-43.68). Rituximab, azathioprine, and cyclophosphamide pulse therapy enabled the reduction of the cumulative glucocorticoid doses compared to the use of steroid alone [mean differences, -11830.5 mg (95% CI, -14089.48, -9571.52), -3032.48 mg (-4700.74, -1364.22) and -2469.54 mg (-4128.42, -810.66), respectively].The results were driven primarily by a small number of studies and the effect estimates are imprecise due to indirect comparisons.Network meta-analysis demonstrated that rituximab appears to be an efficacious and safe steroid-sparing adjuvant for pemphigus.