Subacute cutaneous lupus erythematosus

S2k Guide for the treatment of cutaneous lupus erythematosus – guided by the European Dermatology Forum (EDF) in cooperation with the European Academy of Dermatology and Venereology (EADV)

Kuhn A, Aberer E, Bata-Csörgö, et al. J Eur Acad Dermatol Venereol 2017; 31: 389–404.

Consensus guidelines on the treatment of patients with CLE by a European group of experts developed in 2014 including a treatment algorithm based on an extensive literature review.

Management of cutaneous manifestations of lupus erythematosus: a systematic review

Fairley JK, Oon S, Saracino AM, et al. Semin Arthritis Rheum 2020; 50: 95–127.

A systematic review of clinical trials and observational studies including five or more patients assessing the management of CLE.

The cornerstone of treatment of CLE includes using the safest drugs possible to achieve disease control. The most common therapies utilized include photoprotection , topical corticosteroids , calcineurin inhibitors , and oral antimalarials . Although systemic corticosteroids can be effective, steroid-sparing systemic agents (e.g., methotrexate , mycophenolate mofetil , retinoids, or dapsone ) are preferred to avoid corticosteroid-associated side effects. CLE can affect quality of life. In addition to increased disease control, cosmetic agents used to camouflage lesions or dyspigmentation are important adjuncts.

SCLE can have numerous associations that need to be addressed, including more recalcitrant disease in the setting of tobacco use and a potential risk for neonatal lupus during pregnancy.

Up to 50% of patients with SCLE meet four or more of the criteria of the American College of Rheumatology for classification of SLE. However, they do so by fulfilling the criteria involving skin lesions, photosensitivity, and positive serologies. As a result, those classified as SLE typically only have mild systemic symptoms with major end organ damage occurring in <10%.

Up to 30% of SCLE is induced or exacerbated by a medication. Over 100 different agents have been reported, including antihypertensive agents, statins, antifungals, tumor necrosis factor inhibitors, antiepileptics, and proton pump inhibitors. A complete list of the patient’s medications will assist in the exclusion of drug-induced SCLE. In the setting of treatment for cancer, SCLE can occur as a result of chemotherapy exposure, radiation exposure, or as a paraneoplastic syndrome itself.

There are controversial data regarding whether tobacco affects the effectiveness of antimalarial agents. However, multiple studies have reported that cigarette smokers have more severe disease and that a subset of these patients is more refractory to therapies. Hence, patients should be counseled on smoking cessation for the benefit of their skin as well as the increased risk of cardiovascular disease with SLE and possibly CLE.

Photoprotective effects of a broad-spectrum sunscreen in ultraviolet-induced cutaneous lupus erythematosus: a randomized, vehicle-controlled, double-blind study

Kuhn A, Gensch K, Haust M, et al. J Am Acad Dermatol 2010; 64: 37–48.

Of the 16 CLE patients who had positive provocation study results to ultraviolet A (UVA) or UVB, 88% developed CLE lesions in the vehicle control area, whereas none developed lesions in the broad-spectrum, SPF 60, sunscreen-applied areas.

Discoid lupus erythematosus. Diagnostic features and evaluation of topical corticosteroid therapy

Roenigk HH Jr, Martin JS, Eichorn P, Gilliam JN. Cutis 1980; 25: 281–5.

Despite the longstanding use of high-potency topical corticosteroids as first-line therapy, this is the only randomized controlled trial examining the efficacy in CLE.

Efficacy of tacrolimus 0.1% ointment in cutaneous lupus erythematosus: a multicenter, randomized, double-blind, vehicle-controlled trial

Kuhn A, Gensch K, Haust M, et al. J Am Acad Dermatol 2011; 65: 54–64.

Significant improvement in all end points was noted in all CLE subtypes in a study of 30 patients after 4 and 8 weeks. The four patients with SCLE in this study improved, but this was not statistically significant compared with placebo.

Treatment of cutaneous lupus erythematosus with acitretin and hydroxychloroquine

Ruzicka T, Sommerburg C, Goerz G, et al. Br J Dermatol 1992; 127: 513 – 8.

In this multicenter, randomized controlled trial, 50% of patients treated with hydroxychloroquine (HCQ) improved at 8 weeks.

Low blood concentrations of hydroxychloroquine in patients with refractory cutaneous lupus erythematosus: a French multicenter prospective study

Francés C, Cosnes A, Duhaut P, et al. Arch Dermatol 2012; 148: 479–84.

In this study of 300 patients with CLE, blood HCQ concentrations greater than 755 ng/mL were associated with a better clinical efficacy.

Monitoring hydroxychloroquine (HCQ) blood concentrations may be an alternative to the use of a fixed dose of HCQ or to prescribing based on the patient’s weight.