What is the treatment for an active lupus (Systemic Lupus Erythematosus) rash?

Treatment of Active Lupus Rash

First-line treatment for active lupus rash includes topical agents (glucocorticoids, calcineurin inhibitors), antimalarials (hydroxychloroquine, quinacrine), and/or systemic glucocorticoids. 1

First-Line Treatment Options

Topical Therapies

• Topical glucocorticoids are the mainstay of initial treatment for localized cutaneous lupus manifestations 1, 2
• Topical calcineurin inhibitors (tacrolimus, pimecrolimus) are effective alternatives, especially for facial lesions where prolonged steroid use may cause adverse effects 3, 2
• Apply topical agents twice daily directly to affected areas 3

Antimalarials

• Hydroxychloroquine should be used in all SLE patients with skin manifestations, at a dose not exceeding 5 mg/kg real body weight 1, 4
• The recommended dosage is 200-400 mg daily, given once daily or in two divided doses 4
• Regular ophthalmological screening should be performed at baseline, after 5 years, and yearly thereafter to monitor for retinal toxicity 1
• Quinacrine can be added to hydroxychloroquine in cases with inadequate response 2

Photoprotection

• Sun protection is essential and should be recommended to all patients with cutaneous lupus 5, 2
• Patients should use broad-spectrum sunscreens and protective clothing 5

Second-Line Treatment Options

For non-responsive cases or those requiring high-dose glucocorticoids, the following agents can be added:

• Methotrexate - effective for various cutaneous manifestations 1, 6
• Retinoids - useful for hyperkeratotic and hypertrophic lesions 1
• Dapsone - particularly effective for bullous lupus and urticarial vasculitis 1, 6
• Mycophenolate mofetil - effective for refractory cutaneous disease 1, 7

Treatment Algorithm

1. Initial approach: Start with topical agents (glucocorticoids or calcineurin inhibitors) and hydroxychloroquine 1
2. For widespread or severe disease: Add short-term systemic glucocorticoids (prednisone equivalent) 1, 8
3. For refractory cases: Add immunomodulatory agents (methotrexate, azathioprine, or mycophenolate mofetil) 1, 6
4. For cases unresponsive to standard therapies: Consider biologics such as belimumab or rituximab 1, 6

Important Considerations

• Systemic glucocorticoids should be minimized to less than 7.5 mg/day (prednisone equivalent) for chronic maintenance and, when possible, withdrawn 1, 8
• Prompt initiation of immunomodulatory agents can expedite the tapering/discontinuation of glucocorticoids 1
• Regular monitoring of disease activity using validated indices is essential 5
• Assess for comorbidities and risk factors that may influence treatment choices 5

Pitfalls and Caveats

• Prolonged use of high-potency topical steroids on the face can lead to skin atrophy, telangiectasia, and other adverse effects 2
• Antimalarials may take 2-3 months to show full efficacy; interim treatment with other agents may be needed 7
• Non-adherence to hydroxychloroquine is associated with higher flare rates 9
• Always consider systemic disease activity when treating cutaneous manifestations, as skin involvement may indicate underlying systemic disease activity 5