What is the treatment for skin lupus?

Treatment for Skin Lupus

Hydroxychloroquine is the cornerstone treatment for cutaneous lupus erythematosus (CLE), recommended at a dose of 200-400 mg daily for chronic discoid lupus erythematosus. 1

First-Line Treatments

Photoprotection

• Sun protection is essential as most CLE patients are photosensitive
• Recommend:
  • Broad-spectrum sunscreens
  • Protective clothing
  • Behavioral modifications to avoid UV exposure

Topical Therapies

1. Topical Corticosteroids

   • First-line topical treatment for localized lesions
   • Use medium to high potency for body lesions
   • Lower potency for face, intertriginous areas
   • Caution: Limited long-term use due to side effects (skin atrophy, telangiectasia)

2. Topical Calcineurin Inhibitors (tacrolimus, pimecrolimus)

   • Effective alternative, especially for facial lesions
   • Steroid-sparing agents for sensitive areas
   • No risk of skin atrophy

Systemic Therapies

Antimalarials

1. Hydroxychloroquine (HCQ)

   • Dosage: 200-400 mg daily (single dose or divided doses) 1
   • First-line systemic therapy for all forms of CLE
   • Takes 6-8 weeks for full effect
   • Regular ophthalmologic monitoring required

2. Chloroquine

   • Alternative when HCQ is not effective
   • Higher risk of retinal toxicity than HCQ

3. Quinacrine

   • Can be added to HCQ or chloroquine for refractory cases
   • No risk of retinal toxicity

Systemic Corticosteroids

• Reserved for acute flares or severe disease
• Short-term use recommended (lowest effective dose)
• Aim to taper to ≤7.5 mg/day of prednisolone or equivalent 2
• Not recommended for long-term management due to significant side effects

Second-Line Therapies for Refractory Cases

Immunomodulators

1. Methotrexate

   • Effective for recalcitrant CLE
   • Weekly dosing regimen

2. Mycophenolate Mofetil

   • Alternative for refractory cases
   • Particularly useful when there is concurrent lupus nephritis

3. Azathioprine

   • Used as maintenance therapy after initial disease control 2

Other Options

1. Retinoids (acitretin)

   • Effective for hyperkeratotic variants
   • Teratogenic - contraception required

2. Thalidomide/Lenalidomide

   • Reserved for severe, refractory cases
   • Significant risk of peripheral neuropathy
   • Strict contraception required (teratogenic)

3. Dapsone

   • Particularly effective for bullous lupus erythematosus
   • Requires G6PD screening before initiation

Biologic Therapies

• Belimumab has moderate evidence for efficacy in CLE 3
• Consider in cases refractory to conventional therapies

Important Considerations

Contraindications

• UVB phototherapy is contraindicated in patients with lupus erythematosus 4

Lifestyle Modifications

• Smoking cessation is crucial - smoking reduces efficacy of antimalarials
• Vitamin D optimization recommended

Treatment Algorithm

1. Start with photoprotection + topical therapies for limited disease
2. Add hydroxychloroquine for widespread disease or inadequate response to topicals
3. Consider short course of systemic steroids for acute flares
4. For refractory disease: add second antimalarial or switch to immunomodulator
5. Consider biologics or thalidomide for severe recalcitrant disease

Monitoring

• Regular assessment of disease activity
• Ophthalmologic monitoring for patients on antimalarials
• Laboratory monitoring based on specific medications used

The treatment approach should follow a stepwise progression, with careful consideration of disease severity, extent, and individual response to therapy.