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Subacute Cutaneous Lupus Erythematosus (SCLE) Treatment & Management

  • Author: Janice Lin, MD, MPH; Chief Editor: William D James, MD  more...
 
Updated: Mar 07, 2016
 

Approach Considerations

The goals of management in subacute cutaneous lupus erythematosus (SCLE) are to improve the patient's appearance, mitigate any associated symptoms, prevent the development of additional lesions, and assess for potential associated systemic disease.[25] Counsel patients regarding the risk of serious systemic disease. Although many patients fulfill the criteria for systemic lupus erythematosus (SLE), the severity of systemic manifestations tends to be more mild, and renal and central nervous system (CNS) disease occur less frequently than in patients with SLE without associated SCLE.

Surgical approaches rarely are needed in patients with SCLE. Cosmetic measures are often less important in patients with this condition than in patients with discoid lupus erythematosus (DLE), given the lack of associated scarring; however, active disease and postinflammatory dyspigmentation may still cause notable cosmetic concerns in patients with SCLE. No special diet is required with SCLE.

Inpatient care

Inpatient care is rarely needed for patients with skin disease; however, since these patients may have SLE, they may occasionally manifest internal complications that require hospitalization. In these instances, consultation with other physicians may be helpful.

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Skin Protection

Therapy begins with sun-protective measures, including sunscreens, protective clothing, and behavior alteration. A sunscreen containing Mexoryl SX and Mexoryl XL, tested in a randomized, placebo-controlled trial, was demonstrated to prevent the development of UV-induced cutaneous lesions.[26, 27]

Another study demonstrated that in an experimental setting, cutaneous lupus erythematosus (CLE) can be prevented by the use of a particular broad-spectrum sunscreen. The use of sunscreens in a clinical setting is not as effective as would be predicted from studies such as this one, perhaps because patients do not perform sunscreen application on a daily basis in a manner that might be effective.[28]

Broad-spectrum sunscreen with a sun protection factor (SPF) of 30 or greater should be applied at least 20 minutes prior to sun exposure and be reapplied every 2-3 hours. Often, sun avoidance and protective clothing are necessary in patients with subcutaneous lupus erythematosus (SCLE). Of note, skin disease in SCLE is often very challenging to control without adequate photoprotection.

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Pharmacologic Therapy

Standard therapy includes topical and/or intralesional corticosteroids and antimalarials such as hydroxychloroquine or chloroquine. In patients with skin lesions refractory to hydroxychloroquine monotherapy, adding quinacrine can improve response.[29] A French multicenter study found that the measurement of hydroxychloroquine blood levels may correlate with the incidence of remission in patients with cutaneous lupus erythematosus. The most practical portion of this study is the potential use of blood levels to demonstrate a lack of compliance with therapy as those patients with very low levels had little clinical response.[30]

Additional therapies that may be considered in selected patients include thalidomide, methotrexate, mycophenolate mofetil, azathioprine, retinoids, dapsone, intravenous immunoglobulin, cyclosporine, auranofin, clofazimine, interferon, immunosuppressive agents such as cyclophosphamide and rituximab, and the monoclonal antibody belimumab.[31, 32, 33, 34, 35]

Lenalidomide, a thalidomide analogue, can be helpful in treating patients with refractory cutaneous lupus erythematosus (CLE) as well. Studies have shown skin improvement measured by CLASI (Cutaneous Lupus Erythematosus Disease Area and Severity Index) scores as early as 2 weeks after treatment initiation, although clinical relapse was common following medication withdrawal.[36]

Avoid systemic corticosteroids except for acute short-term usage or when the presence of systemic disease warrants use. Patients who smoke appear to respond less well to antimalarial therapy. Note that clofazimine is primarily beneficial for cutaneous, not systemic, disease.

Some patients with CLE have been found to be vitamin D deficient, particularly those who use careful photoprotection; therefore, the use of vitamin D and calcium should be considered following an assessment of vitamin D levels.[37]

Several upcoming therapeutic targets focus on type I interferons and receptors, anti-B-cell strategies, the toll-like receptor signaling pathway, and the JAK-STAT signaling pathway and may lead to additional treatment options for patients with cutaneous lupus in the future.[38]

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Consultations

Consultations with the following specialists may be helpful:

  • Rheumatologist - When joints and/or systemic involvement are involved
  • Nephrologist - When renal involvement is present
  • Neurologist - When CNS disease is present
  • Ophthalmologist – Patients treated with antimalarials need periodic ocular evaluations
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Long-Term Monitoring

Follow patients with subacute cutaneous lupus erythematosus (SCLE) at regular intervals. Response to therapy varies, depending on the therapeutic agent prescribed. Avoid changes in therapy until a sufficient period elapses to note a response.

At least once each year, and perhaps twice, assess stable patients using routine laboratory tests, including complete blood count (CBC), renal function tests, and urinalysis. Repeat autoantibody testing is of little use in patients with SCLE, unless they have systemic lupus erythematosus (SLE). Regularly assess historical information concerning additional systemic manifestations.

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Contributor Information and Disclosures
Author

Janice Lin, MD, MPH Clinical Instructor, Department of Immunology and Rheumatology, Stanford University School of Medicine

Janice Lin, MD, MPH is a member of the following medical societies: American College of Physicians, American College of Rheumatology, Medical Dermatology Society, Rheumatologic 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

Michael J Wells, MD, FAAD Associate Professor, Department of Dermatology, Texas Tech University Health Sciences Center, Paul L Foster School of Medicine

Michael J Wells, MD, FAAD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Dermatology, American Medical Association, Texas Medical Association

Disclosure: Nothing to disclose.

Lester F Libow, MD Dermatopathologist, South Texas Dermatopathology Laboratory

Lester F Libow, MD is a member of the following medical societies: American Academy of Dermatology, American Society of Dermatopathology, Texas Medical Association

Disclosure: Nothing to disclose.

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.

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Early lesions of subacute cutaneous lupus erythematosus may simulate polymorphous light eruption.
Papulosquamous lesions of subacute cutaneous lupus erythematosus may simulate psoriasis.
Annular lesions of subacute cutaneous lupus erythematosus.
Tumid lupus erythematosus.
Neonatal lupus erythematosus.
 
 
 
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