What is the treatment for nasal ulcers in systemic lupus erythematosus (SLE)?

Treatment of Nasal Ulcers in Systemic Lupus Erythematosus

Hydroxychloroquine (200-400 mg daily) is the cornerstone medication for treating nasal ulcers in SLE patients, combined with topical agents and low-dose glucocorticoids as first-line therapy. 1, 2

First-Line Treatment Approach

1. Hydroxychloroquine (HCQ)

   • Dosage: 200-400 mg daily 1
   • Benefits: Reduces disease flares, decreases morbidity and mortality 2
   • Monitoring: Baseline and periodic ophthalmologic examinations to screen for retinal toxicity 1

2. Topical Therapy

   • Topical corticosteroids (medium to high potency) for nasal mucosal ulcers
   • Application: 1-2 times daily until resolution
   • Consider topical calcineurin inhibitors (tacrolimus 0.1% or pimecrolimus 1%) as steroid-sparing agents

3. Low-Dose Systemic Glucocorticoids

   • Initial dosing: 0.25-0.5 mg/kg/day of prednisone or equivalent 1
   • Target: Lowest effective dose (≤5 mg/day) for shortest duration possible 1
   • Taper: Gradually once symptoms improve

Second-Line Treatment Options

For refractory nasal ulcers that don't respond to first-line therapy:

1. Azathioprine

   • Recommended for milder disease manifestations 1
   • Dosage: 1-2.5 mg/kg/day

2. Methotrexate

   • Particularly effective for mucocutaneous manifestations 1, 3
   • Dosage: 7.5-25 mg weekly

3. Mycophenolate Mofetil

   • Alternative immunosuppressant for refractory cases 1, 3
   • Dosage: 1-3 g/day in divided doses

Treatment Algorithm for Nasal Ulcers in SLE

1. Mild nasal ulcers:

   • Hydroxychloroquine + topical corticosteroids
   • Add short course of low-dose systemic glucocorticoids if needed

2. Moderate to severe or refractory nasal ulcers:

   • Continue hydroxychloroquine
   • Increase systemic glucocorticoids temporarily
   • Add immunosuppressive agent (methotrexate, azathioprine, or mycophenolate mofetil)

3. Severe, treatment-resistant cases:

   • Consider biologics like belimumab or rituximab 3
   • Multidisciplinary approach with rheumatology and ENT specialists

Supportive Measures

• Nasal hygiene: Saline irrigation to keep nasal mucosa moist
• Avoid nasal irritants: Tobacco smoke, strong chemical fumes
• Photoprotection: Sun protection to prevent flares 1
• Patient education: Self-management strategies improve outcomes 1

Monitoring and Follow-up

• Regular assessment of disease activity using validated tools like SLEDAI-2K 1
• Monitor complete blood count every 1-3 months during active disease 1
• Track anti-dsDNA antibodies and complement levels 1

Important Considerations and Pitfalls

• Infection risk: Rule out infectious causes of nasal ulcers before intensifying immunosuppression
• Medication adherence: Emphasize the importance of continuing hydroxychloroquine even after symptom resolution
• Antimalarial toxicity: Regular ophthalmologic monitoring for patients on long-term hydroxychloroquine
• Glucocorticoid dependence: Aim to minimize systemic steroid exposure by optimizing other therapies

The treatment approach should be guided by the severity of nasal ulcers and overall SLE disease activity. Hydroxychloroquine forms the foundation of therapy, with additional treatments added based on clinical response and disease progression.