Discoid lupus treatment options
Tips
- All patients with discoid lupus erythematosus should be examined for systemic lupus erythematosus.
- Early diagnosis and active treatment is important to avoid permanent scarring.
- Risk factors for systemic disease include widespread skin lesions, anemia or leukopenia, and a positive ANA, especially when the titer is high.
- Excessive exposure to sunlight should be avoided, a suitable sunscreen should be used.
Investigations
- A skin biopsy and histopathological confirmation may be used to confirm the diagnosis.
- Complete blood cell count with differential, renal function tests, and urinalysis.
- Erythrocyte sedimentation rate.
- Screening for antinuclear antibodies (ANA) and Ro(SSA)/La(SSB) antibodies.
- Assessment of visual acuity is also necessary in those needing systemic therapy before treatment with antimalarials.
- If SLE is suspected, anti-double stranded DNA, extractable nuclear antigen, C3/C4 should be ordered.
- Camouflage may be used for disfigurements.
Topical Treatment
- High-potency Topical steroids ( for localized lesions)
- Fluocinolone 0.025% cream: twice a day
- Clobetasol propionate
- Betamethasone 0.1% 17‐valerate cream.
- Topical calcineurin inhibitors
- Tacrolimus (0.1 %) ointment can be applied twice daily.
- Pimecrolimus 1% cream twice daily.
- Intralesional corticosteroid injections( for resistant, chronic, hyperkeratotic lesions)
- Triamcinolone acetonide 3 mg/mL.
- Injections are repeated every three to four weeks until improvement.
- Consider another line of treatment if no response after 2-3 sessions.
- Topical tocoretinate 0.25 % ointment applied twice daily has been shown to improve erythema after 1 month.
- Topical tazarotene 0.05 % gel applied once daily at bedtime.
- Topical R‐salbutamol 0.5% cream
Systemic Treatment
For widespread, extensive lesions or lesions are not responding to topical treatment.
- Antimalarials
- Hydroxychloroquine : 200 mg/day, then after one or two weeks 200 mg if the drug is tolerated.
- Chloroquine (200 mg/day) can be prescribed.
- Quinacrine 100 mg daily may be used in combination with hydroxychloroquine.
- Antimalarials may be used alone or in association with systemic steroids.
- Systemic steroids
- Oral prednisolone 0.5 mg/kg, rapidly tapered over 6 weeks.
- Methylprednisolone 500–1000 mg/day for 2 or 3 days, given as an intravenous pulse therapy.
Refractory DLE
- Thalidomide : 50–100 mg po daily for clearing and, if necessary, 25–50 mg po daily–twice weekly for maintenance.
- Methotrexate : 7.5–25 mg/week.
- Isotretinoin : 20-8- mg per day.
- Acitretin: 25- 100 mg per day.
- Dapsone: 50 -150 per day
- Auranofin: 3- 9 mg per day.
- Phenytoin: 200-300 mg per day.
- Azathioprine :75-200 mg per day.
- Cyclophosphamide: 50 -200 mg
- Fumaric acid esters
- Intravenous immunoglobulin
- Tofacitinib
References
- Medscape.com
- Dermatology , Edited by Jean L. Bolognia , Julie V. Schaffer , Lorenzo Cerroni Fourth edition: Elsevier, 2018, ISBN 978–0‐7020–6275–9.
- Griffiths, C., Barker, J., Bleiker, T. O., Chalmers, R., & Creamer, D. (Eds.). (2016). Rook’s textbook of dermatology. John Wiley & Sons.
- Katsambas, A. D., Lotti, T. M., Dessinioti, C., & D’Erme, A. M. (Eds.). (2015). European handbook of dermatological treatments. Springer.