What is the treatment for a malar rash?

Treatment of Malar Rash

The treatment of malar rash in systemic lupus erythematosus (SLE) should begin with strict photoprotection and topical corticosteroids, followed by hydroxychloroquine 200-400 mg daily as the cornerstone systemic therapy if topical measures are insufficient. 1

Initial Management Approach

Photoprotection (Essential First Step)

• Apply broad-spectrum sunscreen daily and avoid sun exposure between peak hours, as photosensitivity is a hallmark feature of SLE cutaneous manifestations 2, 3
• This preventive measure is critical before escalating to pharmacologic interventions 3

Topical Therapy (First-Line)

• Start with topical corticosteroids of low to moderate potency applied to affected areas twice daily 3
• Topical tacrolimus 0.1% ointment is an effective alternative, particularly for facial involvement where prolonged corticosteroid use causes adverse effects (skin atrophy, telangiectasia) 4
  • Apply twice daily for 3 weeks in conjunction with sunscreen 4
  • This avoids the cutaneous side effects associated with chronic topical steroid use 4

Systemic Therapy (When Topical Measures Fail)

Hydroxychloroquine (Primary Systemic Agent)

Hydroxychloroquine is the most commonly beneficial oral antimalarial agent for cutaneous LE not controlled with topical interventions 3

Dosing for SLE:

• 200 mg once daily, or 400 mg once daily or in two divided doses 1
• Administer with food or milk; do not crush or divide tablets 1
• Daily doses exceeding 5 mg/kg actual body weight increase the incidence of retinopathy 1

Important Considerations:

• The action is cumulative and may require weeks to months for maximum therapeutic effect 1
• This is FDA-approved specifically for treatment of systemic lupus erythematosus and chronic discoid lupus erythematosus 1

Escalation for Refractory Cases

If malar rash persists despite hydroxychloroquine and topical therapy, additional systemic options include:

Conventional Immunosuppressive Agents:

• Methotrexate for steroid-sparing effect 3
• Systemic corticosteroids (e.g., prednisone) for acute flares 3
• Azathioprine as a steroid-sparing agent 3
• Dapsone for specific cutaneous manifestations 3

Newer Immunomodulatory Therapies (Severe/Refractory):

• Rituximab, intravenous immunoglobulin, or biologic agents may be considered 3
• These require specialist consultation and are reserved for cases unresponsive to conventional therapy 3

Critical Diagnostic Caveat

Before initiating treatment, confirm the diagnosis is truly SLE malar rash, as several conditions mimic this presentation:

• Erythematotelangiectatic rosacea (distinguished by vascular polygons on dermoscopy vs. "inverse strawberry" pattern in SLE) 5
• Secondary syphilis (can present with malar rash, fever, alopecia, and photosensitivity) 6
• Seborrheic dermatitis, contact dermatitis, polymorphous light eruption 6

Dermoscopy showing reddish/salmon-colored follicular dots surrounded by white halos ("inverse strawberry" pattern) has 86.7% specificity for SLE malar rash 5

Treatment Algorithm Summary

1. Confirm diagnosis (clinical presentation, serology, consider dermoscopy if uncertain) 6, 5
2. Institute photoprotection immediately (sunscreen, sun avoidance) 2, 3
3. Apply topical corticosteroids or tacrolimus 0.1% twice daily 4, 3
4. If inadequate response after 2-3 weeks, initiate hydroxychloroquine 200-400 mg daily 1, 3
5. Monitor for therapeutic response over weeks to months 1
6. Escalate to additional immunosuppressives only if refractory to hydroxychloroquine 3