What is the treatment for cutaneous lupus?

Treatment of Cutaneous Lupus Erythematosus

Hydroxychloroquine is the cornerstone of cutaneous lupus erythematosus treatment and should be prescribed to all patients unless contraindicated. 1

First-Line Therapies

Photoprotection

• Strict sun protection with broad-spectrum sunscreens, protective clothing, and behavioral modifications
• Avoidance of artificial UV light sources
• Smoking cessation (can improve treatment response)

Topical Therapies

1. Topical Corticosteroids

   • First-line for localized lesions
   • Potent to very potent steroids (clobetasol propionate 0.05%) for active lesions
   • Apply twice daily to affected areas
   • Caution with prolonged use on face, intertriginous areas due to atrophy risk

2. Topical Calcineurin Inhibitors

   • Tacrolimus 0.1% or pimecrolimus 1% ointment
   • Particularly useful for facial, intertriginous areas
   • Apply twice daily
   • Alternative for steroid-resistant cases or to avoid steroid side effects

Systemic Therapies

1. Antimalarials (first-line systemic therapy)
   • Hydroxychloroquine: 200-400 mg daily (≤5 mg/kg/day) 2
   • Can be combined with quinacrine in refractory cases
   • Regular ophthalmologic monitoring required
   • May take 2-3 months for full effect

Second-Line Therapies

For Refractory Disease

1. Systemic Corticosteroids

   • For acute flares or severe disease
   • Prednisolone 0.5-1.0 mg/kg/day with gradual taper
   • Short-term use only due to side effect profile

2. Immunosuppressants

   • Methotrexate: 5-15 mg weekly
   • Azathioprine: 1-2.5 mg/kg/day
   • Mycophenolate mofetil: 1-3 g/day
   • Consider for antimalarial-resistant cases

3. Retinoids

   • Acitretin or isotretinoin
   • Particularly effective for hypertrophic discoid lupus
   • Contraindicated in pregnancy

4. Thalidomide/Lenalidomide

   • For severe refractory cases
   • Strict pregnancy prevention required
   • Monitor for peripheral neuropathy

Treatment Algorithm by Subtype

Discoid Lupus Erythematosus (DLE)

1. Topical corticosteroids + hydroxychloroquine
2. Add topical calcineurin inhibitors for facial lesions
3. For refractory cases: add methotrexate or azathioprine
4. Consider thalidomide for severe refractory cases

Subacute Cutaneous Lupus Erythematosus (SCLE)

1. Hydroxychloroquine (first-line)
2. Topical corticosteroids for limited lesions
3. Short course of systemic steroids for flares
4. Methotrexate or mycophenolate mofetil for refractory cases

Acute Cutaneous Lupus Erythematosus (ACLE)

1. Systemic management of underlying SLE
2. Hydroxychloroquine
3. Systemic corticosteroids for active disease
4. Immunosuppressants for maintenance

Special Considerations

Monitoring

• Regular ophthalmologic examinations for patients on antimalarials
• Complete blood count and liver function tests for patients on immunosuppressants
• Assess for signs of systemic disease progression

Treatment-Resistant Cases

• Consider combination therapy with multiple agents
• Specialized formulations like tacrolimus 0.3% in clobetasol propionate 0.05% ointment have shown efficacy in treatment-resistant CLE 3
• Evaluate for medication adherence and exacerbating factors (sun exposure, smoking)

Pregnancy

• Hydroxychloroquine can be continued during pregnancy
• Avoid retinoids, thalidomide, mycophenolate mofetil, methotrexate, and cyclophosphamide
• Topical steroids and calcineurin inhibitors can be used with caution

Common Pitfalls

• Inadequate photoprotection undermining treatment efficacy
• Discontinuing hydroxychloroquine too early (requires 2-3 months for full effect)
• Overreliance on systemic corticosteroids for long-term management
• Failure to address smoking, which can reduce treatment efficacy
• Not monitoring for development of systemic disease

The comprehensive management of cutaneous lupus requires a combination of preventive measures, topical therapies, and systemic medications tailored to disease severity and subtype. Regular monitoring for treatment efficacy, side effects, and development of systemic disease is essential for optimal outcomes.