From the Guidelines
Cutaneous lupus should be managed with a combination of sun protection measures, topical corticosteroids, and systemic therapy with antimalarials, such as hydroxychloroquine, as the first line of treatment, with immunosuppressants like methotrexate considered for more severe or resistant cases. Treatment of cutaneous lupus typically begins with non-pharmacological measures, including the use of broad-spectrum sunscreen (SPF 50+), protective clothing, and avoiding peak sun hours.
- First-line pharmacological treatment includes topical corticosteroids, such as fluocinonide 0.05% cream, applied twice daily to affected areas for 2-4 weeks.
- For resistant cases, topical calcineurin inhibitors, such as tacrolimus 0.1% ointment, may be used.
- Systemic therapy often starts with antimalarials, particularly hydroxychloroquine at 200-400mg daily (not exceeding 5mg/kg/day), which may take 2-3 months to show full effect, as recommended by the 2019 EULAR guidelines for the management of systemic lupus erythematosus 1.
- Regular eye exams are needed with hydroxychloroquine to monitor for potential retinal toxicity.
- For more severe disease, oral corticosteroids, like prednisone (0.5-1mg/kg/day), may be used short-term, while immunosuppressants, such as methotrexate (7.5-25mg weekly), are options for maintenance therapy, with evidence supporting its use in cutaneous lupus from a double-blinded, placebo-controlled RCT and retrospective studies 1.
- These medications work by reducing inflammation and modulating immune responses that cause skin damage.
- Patients should be monitored regularly for disease activity and medication side effects, with treatment adjusted based on clinical response.
From the Research
Diagnosis of Cutaneous Lupus
- The diagnosis of cutaneous lupus erythematosus (CLE) is mainly based on the evaluation of clinical and histopathological manifestations, with an exclusion of systemic lupus erythematosus (SLE) by assessment of systemic involvement 2
- CLE encompasses a broad spectrum of subtypes, including acute, subacute, chronic, and intermittent CLE, with chronic CLE further classified into several subclasses such as discoid LE, verrucous LE, LE profundus, chilblain LE, and Blaschko linear LE 2
Treatment Options for Cutaneous Lupus
- Topical corticosteroids and topical calcineurin inhibitors are first-line treatment for localized CLE lesions 2, 3, 4
- For widespread or severe CLE lesions and/or cases resistant to topical treatment, systemic treatment including antimalarials and/or short-term corticosteroids can be added 2, 3, 4
- Antimalarials are the first-line systemic treatment for all types of CLE and can also be used in pregnant patients and pediatric patients 2, 3, 5
- Second-line choices include thalidomide, retinoids, dapsone, and methotrexate (MTX), whereas mycophenolate mofetil (MMF) is third-line treatment 2, 4, 5
- Pulsed-dye laser or surgery can be added as fourth-line treatment for localized, refractory lesions of chronic cutaneous lupus erythematosus (CCLE) in cosmetically unacceptable areas, whereas belimumab may be used as fourth-line treatment for widespread CLE lesions in patients with active SLE, or recurrence of acute CLE during tapering of corticosteroids 2, 6
Management of Cutaneous Lupus
- Patient education and long-term follow-up are necessary for the management of CLE 2
- Disease activity, damage of skin and other organs, quality of life, comorbidities, and possible adverse events should be assessed in every follow-up visit, when appropriate 2
- Sun avoidance and sunscreen are important preventative measures proven to minimize CLE exacerbations 3, 5, 6
- Smoking cessation, sun protection measures, and optimization of vitamin D levels are general measures to be considered in the management of CLE 6