CHICAGO – A number of treatments can be considered for cutaneous lupus erythematosus.
“Topicals are certainly a good way to start for a less severe patient,” Dr. Victoria P. Werth said at the meeting.
Topical steroids can be used, she said, noting that she often starts with a potent class 1 drug.
A class 1 drug, however, would be impossible to use on the face for more than a few days, added Dr. Werth, a dermatologist and immunologist at the University of Pennsylvania, Philadelphia.
“Often on the face we use Cortaid or something like a Synalar [fluocinolone] or Lidex [fluocinonide] for a short period of time and then taper down to hydrocortisone,” she said.
The more recently available topical nonsteroidal T-cell inhibitors, tacrolimus and pimecrolimus, can be used as adjunctive therapy. These agents aren't perfect, but they may be worth trying in a patient in whom one does not want to use steroids long term, she said.
Intralesional steroids are another treatment option and are particularly useful for scalp lesions and isolated lesions.
Vitamin D replacement also may be helpful. A study published last year showed that cutaneous lupus patients, like many people, had very low vitamin D levels in winter, but levels didn't rise much during the summer as they do in others – likely because patients are following advice about sun avoidance.
As for systemic therapy, data from prospective randomized controlled trials are lacking, and most guidance comes from retrospective case series. But antimalarials are considered first-line treatment in those who can't use topical therapy.
Specifically, hydroxychloroquine is typically given at 6.5 mg/kg per day or less for 6–8 weeks, and quinacrine can be added at 100 mg/day for an additional 6–8 weeks in those who fail to respond to hydroxychloroquine monotherapy.
Not everyone needs the combination, but it is very beneficial in some patients, Dr. Werth noted.
Chloroquine at 3.5 mg/kg per day can be used in those who fail to respond to that combination. Although there are more concerns about toxicity, there are patients who will do better on chloroquine, she said.
Other therapies beyond the topicals and antimalarials include dapsone, retinoids, thalidomide, methotrexate, mycophenolate mofetil, azathioprine, corticosteroids, and cyclophosphamide.
“We use dapsone predominantly for bullous lupus, and in some patients – if they're not too sick with their SLE, and their bullous lupus is not terrible – it's worth trying,” she said, noting that “it's very good on neutrophilic infiltrates, and it can work.”
Retinoids are on the list only because one trial compared them with antimalarials. Retinoids aren't very effective, they have a lot of toxicity, and they're not easy to use, she said.
In contrast, thalidomide can be very effective and is used in refractory patients. Its use is associated with rapid clinical response at 100 mg/day for 2 weeks, with full clinical response in 2–3 months. About 75% of patients who are refractory to antimalarials will respond.
Maintenance doses also can be effective (25–50 mg/day), but rapid relapse can occur on discontinuation.
Thalidomide does not have much effect on systemic lupus. Its use is associated with the risk for serious toxicity, including teratogenicity, neurotoxicity, premature ovarian failure, and hypercoagulable state.
Methotrexate, mycophenolate mofetil, and azathioprine have been shown to be equivalent to thalidomide in many ways, and because they aren't associated with the neurotoxicity that can occur with thalidomide, Dr. Werth said she often uses one of these first.
“I don't really have a preference for one over another,” she added.
She noted, however, that it is important to consider what else may be going on with patients, because those with renal involvement can be treated with mycophenolate mofetil or cyclophosphamide, and both may also help with cutaneous disease.
In addition to medical therapies, patients with cutaneous disease should be advised to avoid heat and drug exacerbations of their condition. It is critical that they use a high SPF sunscreen with good UVA and UVB coverage. Many sunscreens will say they offer both, but most don't have great UVA coverage, Dr. Werth said.
Tell patients to look for a product that has the highest SPF they can find (at least 30), and to ensure that the product contains ecamsule (Mexoryl) or avobenzone/oxybenzone (Helioplex) to provide good UVA protection, she advised.
Dr. Werth disclosed that she has received grants from Celgene Corporation and Amgen, and has served as a consultant to MedImmune, Genentech, Novartis, Pfizer, and Cephalon. She also developed an outcome measure for lupus.