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Discoid Lupus Erythematosus Treatment & Management

  • Author: A Brooke W Eastham, MD; Chief Editor: William D James, MD  more...
 
Updated: Feb 26, 2016
 

Approach Considerations

The goals of management of discoid lupus erythematosus (DLE) 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 is usually sufficient to monitor for progression from primary cutaneous disease to 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.

Standard medical therapy includes topical or intralesional corticosteroids and antimalarials. Topical calcineurin inhibitors have also been used in patients with cutaneous lupus erythematosus (CLE). In addition, topical retinoids have been reported to be helpful. Topical imiquimod was reported to be effective in 1 patient. Systemic corticosteroids are typically avoided given that the dose and duration of therapy needed to maintain control of cutaneous disease often results in substantial steroid-related adverse effects. Therefore, for recalcitrant disease, immunosuppressants and immunomodulators, including methotrexate, mycophenolate mofetil, and thalidomide, amongst others, should be considered.

Activity

Since chronic CLE is exacerbated by sunlight and other UV exposure, advise patients to take precautions by limiting exposure to sunlight to the early morning or late afternoon, when the sun is less intense. Even during these times, photoprotective measures should be practiced. 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 for systemic involvement
  • Ophthalmologist - To monitor therapy with hydroxychloroquine or chloroquine
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Antimalarial Therapy

Antimalarial therapy seems to lessen the progression to systemic lupus erythematosus (SLE) and to lower the risk of thrombovascular disease.[12, 13] Alternative therapies include auranofin, thalidomide,[12, 14, 15, 16] oral or topical retinoids, and immunosuppressive agents.[17, 18] 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.[19]

Hydroxychloroquine is the first-line systemic agent for discoid lupus erythematosus (DLE), whereas chloroquine is considered second-line antimalarial therapy in the United States. Quinacrine may be added to either hydroxychloroquine or chloroquine for additional benefit in some patients. Owing to the ability of both hydroxychloroquine and chloroquine to deposit in the retina and cause irreversible retinopathy, these 2 agents should not be used concomitantly because of the increased risk of ocular toxicity when used in combination.[20]

Traditionally, antimalarials have been considered to be less effective in patients who smoke; however, it is also possible that DLE is worse in these patients. A recent study demonstrated that cigarette smoking did not have a significant impact on response to hydroxychloroquine in patients with DLE. Rather, disseminated DLE and the presence of concomitant systemic lupus erythematosus (SLE) were both significantly associated with decreased therapeutic efficacy.[21]

Nonetheless, efforts regarding smoking cessation are advisable in patients who smoke or who are exposed to secondary smoke.[22, 23, 24] Furthermore, a recent study demonstrated that patients with cutaneous lupus erythematosus (CLE) who smoked had more severe cutaneous disease, had inferior quality of life, and were more frequently treated with a combination of hydroxychloroquine and quinacrine than were nonsmokers.[25]

Ocular toxicity is a well-known risk as both hydroxychloroquine and chloroquine can deposit in the retina with subsequent irreversible retinopathy. Thus, these 2 medications should not be used in combination. The American Academy of Ophthalmology recently changed their guidelines to include baseline ocular examinations prior to the initiation of hydroxychloroquine or chloroquine and then annual examinations after 5 years of therapy, as ocular toxicity is a cumulative effect.[20] In practice, ocular examinations are typically recommended at baseline (within 3 months of initiating the antimalarial agent) and annually thereafter.

Quinacrine is known to cause a reversible yellow discoloration of the skin and can rarely induce cytopenias. Thus, a complete blood cell count should be monitored routinely.

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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, solutions, lotions, oil, or foams are preferred for the scalp, weaker agents are used on the face, and superpotent agents are used under occlusion for hypertrophic lesions.

Intralesional injection of corticosteroids (typically, the authors use 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 one 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 clinic visit to avoid systemic toxicity from the steroids; for example, 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, mycophenolate mofetil, and azathioprine may be considered.[26, 27] 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.[28, 29]

In the authors’ experience, systemic corticosteroids are rarely effective and frequently lead to steroid-related adverse effects at the doses needed to manage cutaneous disease.

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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 telangiectasias; however, one must consider the risk of reactivation with 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 patients, at a minimum, a test area should be treated to make certain that the DLE does not flare.[30]

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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 cell count, 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

A Brooke W Eastham, MD Board Certified Dermatologist, Nashville Skin and Cancer

A Brooke W Eastham, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Dermatology, Medical Dermatology Society

Disclosure: Nothing to disclose.

Coauthor(s)

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, American College of Rheumatology

Disclosure: Received income in an amount equal to or greater than $250 from: XOMA; Biogen/IDEC; Novartis; Janssen Biotech, Abbvie, CSL pharma<br/>Received honoraria from UpToDate for author/editor; Received honoraria from JAMA Dermatology for associate editor and intermittent author; Received royalty from Elsevier for book author/editor; Received dividends from trust accounts, but I do not control these accounts, and have directed our managers to divest pharmaceutical stocks as is fiscally prudent from Stock holdings in various trust accounts include some pharmaceutical companies and device makers for i inherited these trust accounts; for: Celgene; Pfizer; 3M; Johnson and Johnson; Merck; Abbott Laboratories; AbbVie; Procter and Gamble; Amgen.

Ruth Ann Vleugels, MD, MPH Assistant Professor of Dermatology, Harvard Medical School; Associate Physician, Department of Dermatology, Brigham and Women's Hospital; Associate Physician, Department of Immunology and Allergy, Children's Hospital Boston

Ruth Ann Vleugels, MD, MPH is a member of the following medical societies: Alpha Omega Alpha, American Academy of Dermatology, American College of Rheumatology, American Medical Association, Society for Investigative Dermatology, Medical Dermatology Society, Dermatology Foundation

Disclosure: Nothing to disclose.

Specialty Editor Board

David F Butler, MD Section Chief of Dermatology, Central Texas Veterans Healthcare System; Professor of Dermatology, Texas A&M University College of Medicine; Founding Chair, Department of Dermatology, Scott and White Clinic

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

Disclosure: Serve(d) as a director, officer, partner, employee, advisor, consultant or trustee for: American Board of Dermatology<br/>Co-Editor for the text Dermatological Manifestations of Kidney Disease .

Chief Editor

William D James, MD Paul R Gross Professor of Dermatology, Vice-Chairman, Residency Program Director, Department of Dermatology, University of Pennsylvania School of Medicine

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

Disclosure: Nothing to disclose.

Additional Contributors

Craig A Elmets, MD Professor and Chair, Department of Dermatology, Director, Chemoprevention Program Director, Comprehensive Cancer Center, 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, Society for Investigative Dermatology

Disclosure: Serve(d) as a director, officer, partner, employee, advisor, consultant or trustee for: University of Alabama at Birmingham; University of Alabama Health Services Foundation<br/>Serve(d) as a speaker or a member of a speakers bureau for: Ferndale Laboratories<br/>Received research grant from: NIH, Veterans Administration, California Grape Assn<br/>Received consulting fee from Astellas for review panel membership; Received salary from Massachusetts Medical Society for employment; Received salary from UpToDate for employment. for: Astellas.

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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 chronic cutaneous lupus erythematosus on the dorsal hands. Characteristic lesions were observed elsewhere.
 
 
 
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