How to manage skin warts in a patient with Systemic Lupus Erythematosus (SLE)?

Management of Skin Warts in Patients with Systemic Lupus Erythematosus (SLE)

For patients with SLE, immunotherapy-based treatments such as contact immunotherapy with diphenylcyclopropenone (DPC) or squaric acid dibutyl ester (SADBE) are recommended as first-line treatments for skin warts due to their high efficacy and acceptable safety profile in immunosuppressed patients. 1

Treatment Algorithm for Warts in SLE Patients

First-Line Options:

1. Contact Immunotherapy

   • DPC or SADBE shows 88% complete clearance rate with median treatment time of 5 months 1
   • Although clearance rates are reduced in immunosuppressed patients, sensitization remains possible and treatment can still be effective 1
   • Apply twice weekly for up to 10 weeks

2. Topical Treatments

   • Salicylic acid (15-40% for plantar warts, 2-10% for facial/plane warts)

     • Apply daily after paring/debriding the wart 2
     • Mean cure rate of 49% (range 0-69%) 2
     • Treatment may need to continue for 3-6 months 2

   • Imiquimod cream

     • Apply twice daily for up to 24 weeks 1
     • Shows >50% clearance in immunocompetent patients and 56% clearance in patients with immunosuppression 1
     • Caution: May potentially trigger lupus flares due to its mechanism of action through toll-like receptor stimulation 3

Second-Line Options:

1. Topical Cidofovir (1-3% cream)

   • Apply under occlusion 5 days/week followed by 1 week off; repeat cycle 1
   • Complete clearance in 4/7 (57%) of patients with long-standing warts after 8 weeks 1
   • Caution: Monitor renal function, especially in patients with pre-existing renal disease 1

2. Intralesional Immunotherapy

   • Candida antigen injections show 47-87% clearance rates 1
   • Consider in patients who failed topical treatments

Special Considerations for SLE Patients

Immune Status Assessment

• Evaluate current immunosuppressive regimen as it may affect treatment response
• Patients on mycophenolate mofetil or prednisolone may have lower response rates to immunotherapies 1

HPV Vaccination

• SLE patients are at higher risk for HPV-related complications including cervical dysplasia and cancer 1
• ACIP recommends HPV vaccination for immunocompromised individuals through age 26 1
• HPV vaccines are safe and immunogenic in SLE patients 1

Treatment Contraindications

• Avoid aggressive destructive treatments due to increased risk of scarring in immunosuppressed patients 2
• Live-attenuated vaccines are contraindicated in immunocompromised SLE patients 1
• Use caution with imiquimod as it may potentially trigger SCLE-like changes 3

Monitoring and Follow-up

• Assess for treatment success by clearance of all treated warts 2
• Check for recurrence at 3 and 6 months following completion of treatment 2
• Monitor for disease flares, especially when using immunomodulatory treatments

Adjunctive Measures

• Sun protection is essential for SLE patients with skin manifestations 1, 4
• Smoking cessation may aid in control of cutaneous lupus and improve treatment response 4, 5
• Optimize vitamin D levels to support immune function 5

Treatment-Resistant Cases

• Consider combination therapy with topical trichloroacetic acid 50% and SADBE immunotherapy 1
• For recalcitrant cases, referral to dermatology for specialized treatments may be necessary 6
• In severe cases, systemic treatments like belimumab may help manage both SLE and cutaneous manifestations 5

Pitfalls and Caveats

• Poor debridement before applying topical treatments can lead to reduced efficacy 2
• Patient compliance is critical but often poor due to irritation and daily application requirements 2
• Wart treatments may cause local irritation, which could potentially be confused with lupus flares
• Treatment may take several months; manage patient expectations accordingly