From the Guidelines
Methotrexate is the most effective treatment for discoid lupus, with a significant decline in disease activity and at least partial remission in most patients, as evidenced by a study showing 98% of patients achieving significant decline in disease activity by 8 weeks 1. Discoid lupus erythematosus (DLE) is a chronic skin condition characterized by red, inflamed, scaly patches that can lead to scarring and permanent hair loss if left untreated. Treatment typically begins with sun protection measures including broad-spectrum sunscreen (SPF 50+) applied every 2 hours when outdoors, wide-brimmed hats, and sun-protective clothing. First-line therapy involves potent topical corticosteroids like fluocinonide 0.05% or clobetasol 0.05% applied twice daily to affected areas for 2-4 weeks, then tapered to maintenance use. For resistant cases, topical calcineurin inhibitors such as tacrolimus 0.1% ointment can be added. If skin lesions don't respond adequately, oral antimalarials are recommended, typically hydroxychloroquine 200-400mg daily (not exceeding 5mg/kg/day) for at least 3 months to assess efficacy. However, methotrexate 10-25mg weekly is a highly effective steroid-sparing agent for treating discoid lupus, allowing for significant reduction in corticosteroid dose and achieving at least partial remission in 10 out of 12 patients in a case series 1. Regular dermatology follow-up is essential to monitor treatment response and adjust therapy as needed, with blood work monitoring, including complete blood count and liver function tests, performed before starting antimalarials or methotrexate and periodically during treatment. Key points to consider when treating discoid lupus include:
- Sun protection measures to prevent disease exacerbation
- Topical corticosteroids as first-line therapy
- Oral antimalarials for resistant cases
- Methotrexate as a highly effective treatment option for severe or widespread disease
- Regular monitoring and follow-up to adjust therapy as needed.
From the Research
Discoid Lupus Erythematosus
- Discoid lupus erythematosus is a chronic form of cutaneous lupus that can cause permanent scarring if treatment is inadequate 2, 3, 4.
- Many drugs have been used to treat this disease, and some of these are potentially very toxic 2, 3, 4.
Treatment Options
- Lifestyle measures and topical treatment (corticosteroids and topical calcineurin inhibitors) remain the therapeutic strategies with the highest evidence level 5.
- Antimalarial drugs are still the first-line therapy for systemic treatment approaches 5.
- Fluocinonide cream may be more effective than hydrocortisone in treating people with discoid lupus erythematosus 2, 3, 4.
- Hydroxychloroquine and acitretin appear to be of equal efficacy, although adverse effects are more frequent and more severe with acitretin 2, 3, 4.
Adverse Effects
- Adverse effects of acitretin include dry lips, gastrointestinal disturbance, and increased serum triglyceride 4.
- Adverse effects of hydroxychloroquine are less frequent and less severe compared to acitretin 4.
- Topical calcineurin inhibitors (pimecrolimus and tacrolimus) may cause burning, itching, and reactivation of herpes simplex infection 4.