What are the types and treatments of skin lupus on the hands?

Types and Treatments of Skin Lupus on Hands

Cutaneous manifestations of lupus on the hands require prompt evaluation by an experienced dermatologist and often a skin biopsy for accurate diagnosis and appropriate treatment selection. 1

Types of Cutaneous Lupus on Hands

• Acute Cutaneous Lupus Erythematosus (ACLE)

  • Characterized by malar rash that can extend to hands
  • Often associated with systemic disease activity
  • May present with photosensitive erythema on dorsal hands 1

• Subacute Cutaneous Lupus Erythematosus (SCLE)

  • Presents as papulosquamous (psoriasiform) or annular polycyclic lesions
  • Commonly affects sun-exposed areas including dorsal hands
  • Associated with anti-Ro/SSA antibodies
  • Generally has good prognosis with less systemic involvement 2, 3

• Chronic Cutaneous Lupus Erythematosus (CCLE)/Discoid Lupus

  • Well-defined, erythematous, scaly plaques with follicular plugging
  • Can affect hands, particularly knuckles and fingers
  • May lead to scarring, atrophy, and permanent damage if untreated 1, 4

• Tumid Lupus Erythematosus

  • Indurated, edematous plaques without surface changes
  • Can appear on hands but less common than other sites
  • Characterized by dermal perivascular lymphocytic infiltrate with mucin deposition 3

• Lupus Profundus/Panniculitis

  • Deep inflammatory process affecting subcutaneous fat
  • Can present as firm nodules on hands
  • May result in lipoatrophy and depression of the skin 3, 4

Diagnosis

• Diagnosis requires evaluation by an experienced dermatologist and often a skin biopsy for histological analysis 1
• Follow-up repeat biopsy is recommended if there is a change in clinical morphology or lack of response to treatment 1
• The Cutaneous Lupus Disease Area and Severity Index (CLASI) may be used to assess disease activity and damage 1, 2
• Laboratory tests including anti-dsDNA, anti-Ro/SSA, anti-La/SSB, and complement levels may help determine systemic involvement 1

Treatment Approach

First-Line Treatments

• Photoprotection

  • Crucial for all cutaneous lupus patients with hand involvement
  • Includes sunscreens, protective clothing, and behavioral modifications
  • Should be advised for prevention of flares 1, 5

• Topical Therapies

  • Topical corticosteroids (first-line for localized lesions)
  • Calcineurin inhibitors (tacrolimus, pimecrolimus) for steroid-sparing effect
  • Can be used for mild to moderate disease 1, 5

• Antimalarials

  • Hydroxychloroquine (200-400 mg daily) is the cornerstone of treatment
  • Effective for all types of cutaneous lupus
  • Can be used as monotherapy or in combination with other agents
  • Regular ophthalmological screening is required (baseline, after 5 years, then yearly) 1, 6

Second-Line Treatments

• Systemic Corticosteroids

  • Used for acute flares or severe disease
  • Should be minimized to less than 7.5 mg/day for chronic use
  • Prompt initiation of steroid-sparing agents is recommended 1

• Immunosuppressive Agents

  • Methotrexate (15 mg/m²/week) for non-responsive cases
  • Mycophenolate mofetil for severe or methotrexate-refractory disease
  • Azathioprine as an alternative immunosuppressant 1, 7

Refractory Disease Options

• Biologics

  • Belimumab for inadequate response to standard therapy
  • Rituximab for refractory cases
  • Consider for persistent disease activity despite conventional treatments 1, 7

• Other Therapies

  • Retinoids for hyperkeratotic lesions
  • Dapsone for neutrophilic variants
  • Thalidomide for severe refractory cutaneous lupus (with careful monitoring) 1, 3

Special Considerations for Hand Involvement

• Manual Lymph Drainage

  • May improve hand function in patients with puffy hands 1

• Physical Exercise

  • Should be considered to maintain hand function and reduce stiffness
  • Helps improve overall quality of life 1

• Management of Raynaud's Phenomenon

  • Common complication affecting hands in lupus patients
  • Use of gloves and heating devices
  • Avoidance of cold exposure
  • May require vasodilators in severe cases 1

Treatment Algorithm

1. Initial Assessment:

   • Determine type and severity of cutaneous lupus
   • Assess for systemic involvement
   • Perform skin biopsy if diagnosis is uncertain 1

2. Mild Disease:

   • Strict photoprotection
   • Topical corticosteroids or calcineurin inhibitors
   • Consider hydroxychloroquine if multiple lesions 1, 6

3. Moderate-Severe Disease:

   • Hydroxychloroquine (200-400 mg daily)
   • Add short course of systemic corticosteroids for flares
   • Consider methotrexate or mycophenolate mofetil if inadequate response 1, 7

4. Refractory Disease:

   • Switch to or add alternative immunosuppressant
   • Consider biologics (belimumab or rituximab)
   • Evaluate for clinical trial eligibility 1, 7

5. Maintenance:

   • Continue effective therapy for at least 12 months before tapering
   • Regular monitoring for disease activity and medication side effects
   • Ongoing photoprotection and lifestyle modifications 1, 6

Monitoring

• Regular assessment of disease activity using validated tools like CLASI 1, 2
• Monitoring for medication side effects (e.g., ophthalmologic screening for antimalarials) 1, 6
• Evaluation for development of systemic disease 1