Discoid Lupus Erythematosus Treatment & Management

  • Author: Jeffrey P Callen, MD; Chief Editor: William D James, MD   more...
 
Updated: Dec 15, 2011
 

Approach Considerations

The goals of discoid lupus erythematosus (DLE) management are to improve the patient's appearance, to control existing lesions and limit scarring, and to prevent the development of further lesions. Advise patients that the development of serious systemic disease is possible, although rare. Regular repeat clinical evaluation accompanied by simple laboratory studies usually is sufficient to evaluate the possible progression from the primary cutaneous disorder to the disorder accompanied by systemic involvement.

Therapy begins with the use of sun-protective measures, including sunscreens, protective clothing, and behavior alteration. Cosmetic measures, such as cover-up makeup or wigs, may be suggested for appropriately selected patients. Makeup used for camouflage includes Covermark and Dermablend.[7]

Standard medical therapy includes corticosteroids (topical or intralesional) and antimalarials. Topical calcineurin inhibitors have also been used in patients with cutaneous lesions of LE. In addition, topical retinoids have been reported to be helpful. Lastly, topical imiquimod was reported to be effective in 1 patient.

Activity

Since chronic CLE is exacerbated by sunlight or other UV exposure, advise patients to take precautions, eg, to limit exposure to sunlight to the early morning or late afternoon, when the sun is less intense. Advise patients to avoid artificial light sources, such as tanning beds.

Consultations

Consultation with the following specialists may be helpful:

  • Rheumatologist - For joint involvement
  • Nephrologist - For renal involvement
  • Internist - To evaluate systemic involvement
  • Ophthalmologist - To monitor therapy with hydroxychloroquine or chloroquine
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Antimalarial Therapy

Antimalarial therapy seems to lessen the progression to SLE and to lower the risk of thrombovascular disease.[8, 9] Alternative therapies include auranofin, thalidomide,[10, 11, 12, 13] oral or topical retinoids, and immunosuppressive agents.[14, 15] Thalidomide is regularly used in antimalarial-resistant patients. In most patients, the antimalarial should be continued during thalidomide therapy, unless a complication due to the antimalarial occurs. In addition, lenalidomide may be useful in some patients.[16]

Quinacrine may be added to either hydroxychloroquine or chloroquine.[17] The antimalarial drugs might also prevent the development of SLE in patients with DLE, and they might decrease the risk of cardiovascular disease.[18, 19]

Antimalarials appear to be less effective in patients who smoke; however, DLE possibly is worse in these patients. Efforts regarding smoking cessation are advisable in patients who smoke or who are exposed to secondary smoke.[20, 21, 22]

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Corticosteroid and Immunomodulator Therapy

Topical corticosteroids are selected for the type of lesion under treatment and for the site of involvement. For example, lotions or foams are preferred for the scalp, weaker agents are used on the face, and superpotent agents are used for hypertrophic lesions.

Intralesional injection of corticosteroids (typically, this author uses triamcinolone acetonide 3 mg/mL) is useful as adjunctive therapy for individual lesions. Potential for atrophy relates to the amount of corticosteroid injected in any 1 area; therefore, dilute concentrations are preferred. In addition, the treating physician must take care to limit the total dose of the injections at any given office/clinic visit to avoid systemic toxicity from the steroids; eg, if a patient is given 10 mL of triamcinolone 3 mg/mL, this means that the patient has received a total of 30 mg, and toxicity is the same as if it had been delivered orally or by intramuscular injection.

Among immunosuppressives, methotrexate may be considered.[23] In this author's experience, azathioprine and mycophenolate mofetil have been more successful than methotrexate, while systemic corticosteroids are rarely effective.[24] Two reports have documented the value of mycophenolate mofetil for treatment of cutaneous lesions of lupus erythematosus, including one study that used mycophenolate mofetil in antimalarial-resistant subjects.[25, 26]

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Excision and Laser Therapy

Excision of burned-out, scarred lesions is possible; however, reactivation of inactive lesions has been reported in some patients.

Laser therapy may be useful for lesions with prominent telangiectases. Reactivation also is a consideration in this form of therapy. An open trial in a small group of patients has demonstrated the efficacy of pulsed dye laser therapy for discoid lupus erythematosus (DLE) lesions. However, before using this therapy in additional patients, at a minimum, a test area should be treated to make certain that the DLE does not flare.[27]

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Long-Term Monitoring

Follow patients with discoid lupus erythematosus (DLE) at regular intervals. Response to therapy varies from several weeks to several months. At each visit, question the patient about new symptoms that may reflect systemic disease. At regular intervals, perhaps annually in otherwise asymptomatic patients, perform routine laboratory studies for assessment, including complete blood count (CBC), renal function tests, and urinalysis. Repeat antibody testing is needed only if a change in symptomatology is noted.

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Contributor Information and Disclosures
Author

Jeffrey P Callen, MD  Professor of Medicine (Dermatology), Chief, Division of Dermatology, University of Louisville School of Medicine

Jeffrey P Callen, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Dermatology, American College of Physicians, and American College of Rheumatology

Disclosure: Amgen Honoraria Consulting; Abbott Honoraria Consulting; Electrical Optical Sciences Consulting fee Consulting; Celgene Honoraria Safety Monitoring Committee; GSK - Glaxo Smith Kline Consulting fee Consulting; TenXBioPharma Consulting fee Safety Monitoring Committee

Specialty Editor Board

Craig A Elmets, MD  Professor and Chair, Department of Dermatology, Director, UAB Skin Diseases Research Center, University of Alabama at Birmingham School of Medicine

Craig A Elmets, MD is a member of the following medical societies: American Academy of Dermatology, American Association of Immunologists, American College of Physicians, American Federation for Medical Research, and Society for Investigative Dermatology

Disclosure: Palomar Medical Technologies Stock None; Astellas Consulting fee Review panel membership; Massachusetts Medical Society Salary Employment; Abbott Laboratories Grant/research funds Independent contractor; UpToDate Salary Employment; Biogen Grant/research funds Independent contractor; Clinuvel Independent contractor; Covan Basilea Pharmaceutical Grant/research funds Independent contractor; ISDIN None Consulting; TenX BIopharma Grant/research funds Independent contractor

David F Butler, MD  Professor of Dermatology, Texas A&M University College of Medicine; Chair, Department of Dermatology, Director, Dermatology Residency Training Program, Scott and White Clinic, Northside Clinic

David F Butler, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Dermatology, American Medical Association, American Society for Dermatologic Surgery, American Society for MOHS Surgery, Association of Military Dermatologists, and Phi Beta Kappa

Disclosure: Nothing to disclose.

Julia R Nunley, MD  Professor, Program Director, Dermatology Residency, Department of Dermatology, Virginia Commonwealth University Medical Center

Julia R Nunley, MD is a member of the following medical societies: American Academy of Dermatology, American College of Physicians, American Society of Nephrology, International Society of Nephrology, Medical Dermatology Society, Medical Society of Virginia, National Kidney Foundation, Phi Beta Kappa, and Women's Dermatologic Society

Disclosure: Nothing to disclose.

Chief Editor

William D James, MD  Paul R Gross Professor of Dermatology, University of Pennsylvania School of Medicine; Vice-Chair, Program Director, Department of Dermatology, University of Pennsylvania Health System

William D James, MD is a member of the following medical societies: American Academy of Dermatology and Society for Investigative Dermatology

Disclosure: Elsevier Royalty Other

References

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Discoid lupus erythematosus on the face.
Chronic scarred lesion of discoid lupus erythematosus.
Lesions of discoid lupus erythematosus in the conchal bowl demonstrate patulous follicles with follicular plugging.
Palmar lesions of discoid lupus erythematosus.
Scarring alopecia of discoid lupus erythematosus.
Widespread scarring alopecia.
Hypertrophic lesions of lupus erythematosus on the dorsal hands. Characteristic lesions were observed elsewhere.
 
 
 
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