What is the recommended treatment for discoid lupus erythematosus?

Treatment of Discoid Lupus Erythematosus

All patients with discoid lupus erythematosus should receive hydroxychloroquine at ≤5 mg/kg real body weight combined with topical corticosteroids and strict photoprotection as first-line therapy. 1, 2

Foundation Therapy (All Patients)

• Hydroxychloroquine is mandatory for all DLE patients unless contraindicated, dosed at 200-400 mg daily (not exceeding 5 mg/kg real body weight), as it serves as the cornerstone of treatment for all forms of cutaneous lupus 1, 2
• Ophthalmological screening must be performed at baseline, after 5 years, then yearly thereafter using visual fields examination and/or spectral domain-optical coherence tomography to monitor for retinal toxicity 1, 3
• Strict photoprotection with broad-spectrum sunscreens (SPF 30+) and protective clothing is essential, as UV exposure induces and exacerbates lesions 1, 4, 5
• Aggressive smoking cessation counseling is critical, as smoking reduces antimalarial efficacy and worsens cutaneous lupus 1

First-Line Topical Treatment

• Apply medium- to high-potency topical corticosteroids (triamcinolone 0.1% or clobetasol 0.05%) twice daily to affected areas, using low-potency hydrocortisone 1% on facial lesions to avoid skin atrophy 1, 4
• Topical calcineurin inhibitors (tacrolimus 0.1% or pimecrolimus 1%) are effective alternatives for facial involvement, particularly when prolonged treatment is needed to avoid steroid-induced atrophy 1, 6

Second-Line Systemic Therapy for Refractory Disease

When patients fail to respond adequately to hydroxychloroquine plus topical therapy after 2-3 months, escalate according to disease severity:

• Methotrexate 10-25 mg weekly is effective for widespread or refractory cutaneous manifestations, particularly for hyperkeratotic lesions 1, 4
• Mycophenolate mofetil 1-3 g daily is highly effective for refractory cutaneous disease that has not responded to antimalarials 1, 4
• Retinoids (acitretin 25-50 mg daily) are particularly useful for hyperkeratotic and hypertrophic lesions 1
• Dapsone 50-100 mg daily is particularly effective for bullous lupus and urticarial vasculitis 1

Third-Line Therapy for Severe Refractory Cases

• Short-term systemic glucocorticoids (prednisone 0.5-1 mg/kg daily) should be added for widespread or severe disease, with aggressive tapering to <7.5 mg/day and withdrawal when possible 1
• Thalidomide 50-100 mg daily produces rapid responses in refractory generalized DLE, but requires strict pregnancy prevention due to teratogenicity and monitoring for peripheral neuropathy 7
• Biologics such as belimumab or rituximab should be considered for cases unresponsive to standard therapies 1

Critical Treatment Algorithm

1. Start all patients on hydroxychloroquine + topical corticosteroids + photoprotection immediately 1, 2
2. If inadequate response after 2-3 months, add methotrexate or switch to mycophenolate mofetil 1, 4
3. For severe widespread disease, add short-term systemic glucocorticoids while initiating immunomodulatory agents 1
4. For refractory disease despite above measures, consider thalidomide or biologics 1, 7

Common Pitfalls to Avoid

• Never use low-potency topical steroids on thick, hyperkeratotic DLE plaques, as they will be ineffective; use high-potency formulations instead 4
• Do not exceed 5 mg/kg real body weight for hydroxychloroquine dosing, as higher doses substantially increase retinal toxicity risk 1, 2
• Avoid prolonged high-potency topical steroid use on facial lesions without transitioning to calcineurin inhibitors, as this causes irreversible skin atrophy 6
• Do not delay escalation to systemic therapy in patients with progressive scarring, as early aggressive treatment prevents permanent disfigurement 4

Monitoring Requirements

• Assess lesion extent and activity at each visit using clinical photography to document response 1
• Monitor complete blood count, anti-dsDNA, and complement levels every 3-6 months to detect progression to systemic lupus erythematosus 1
• Screen for systemic symptoms (arthritis, serositis, renal involvement) at each visit, as 5-10% of DLE patients develop SLE 4