Discoid Lupus Erythematosus 

Updated: Aug 21, 2018
Author: Elizabeth Tkachenko; Chief Editor: William D James, MD 

Overview

Background

Cutaneous lupus erythematosus (CLE) can be divided into three main subtypes: acute, subacute, and chronic, all of which demonstrate photosensitivity. Acute cutaneous lupus erythematosus (ACLE) most commonly presents as symmetric erythema overlying the malar cheeks and nasal bridge with sparing of the nasolabial folds (butterfly rash). However, it can also present as a diffuse morbilliform eruption with erythema and edema of the hands, with prominent sparing of the joints. Subacute cutaneous lupus erythematosus (SCLE) characteristically presents as annular or psoriasiform plaques in a photodistribution. Chronic cutaneous lupus erythematosus (CCLE) can be further divided into three main types: discoid lupus erythematosus (DLE), tumid lupus, and lupus panniculitis. Tumid lupus typically presents with juicy papules and plaques that lack scale and heal without scarring, whereas lupus panniculitis involves the subcutaneous tissue, leading to painful subcutaneous nodules that heal with depression and atrophy.

DLE classically presents with erythematous-to-violaceous, scaly plaques with prominent follicular plugging that often results in scarring and atrophy (see the images below). DLE may occur in the absence of systemic disease, or it may occur in association with systemic lupus erythematosus (SLE).

Discoid lupus erythematosus on the face. Discoid lupus erythematosus on the face.
Chronic scarred lesion of discoid lupus erythemato Chronic scarred lesion of discoid lupus erythematosus.

The risk of progression to SLE in patients with DLE was demonstrated to be higher than previously reported The reported rates were 16.7% progression within 3 years of diagnosis in one study and 17% progression within a mean time of 8 years in a second study,[1, 2] as compared with previous data indicating that less than 5-10% of patients with DLE progress to SLE.[3] Overall, patients with DLE rarely fulfill four or more of the 17 Systemic Lupus International Collaborating Clinics (SLICC) criteria used to classify SLE.[4] Serologic abnormalities are uncommon.

Therapy with sunscreens, topical corticosteroids, and antimalarial agents is often effective. However, immunosuppressive and/or immunomodulatory agents may be required for recalcitrant disease (see Treatment and Medication).

Etiology

Lupus erythematosus is a polygenic autoimmune disease linked to various HLA subtypes, immune signaling, and environmental factors, which ultimately leads to autoantibody production and T-cell dysfunction. However, the exact etiology of discoid lupus erythematosus (DLE) is not well understood. DLE likely occurs in genetically predisposed individuals, but the exact genetic connection has not been determined. It has been suggested that a heat-shock protein is induced in the keratinocyte following ultraviolet (UV) light exposure or stress, and this protein may act as a target for gamma (delta) T-cell–mediated epidermal cell cytotoxicity. Additionally, toll-like receptors may be involved in the pathogenesis.[5]

Emerging research has shown a role for interferons and JAK-STAT (Janus kinase/signal transducers and activators of transcription) signaling in DLE, postulating the potential for treatment with JAK inhibitors.[6] Additionally, fibrosis in DLE has been linked to transforming growth factor (TGF)–β signaling, providing another molecular target for therapy.[7]

Epidemiology

Worldwide, the prevalence of systemic lupus erythematosus (SLE) ranges from 17-48 cases per 100,000 population. The highest prevalence of SLE occurs in persons aged 40-60 years, with SLE onset most often occurring in patients in their 20s and 30s. SLE is approximately 10 times more common in women than in men.[8]

In a 2015 epidemiological study from Olmstead County, Minnesota, Jarukitsopa et al demonstrated that the incidence of cutaneous lupus erythematosus (CLE) (4.2 cases per 100,000 population) is similar to that of SLE (2.9 cases per 100,000 population) and that the incidence of CLE rises steadily with age, peaking at age 60-69 years.[9]

Discoid lupus erythematosus (DLE) is responsible for 50-85% of cases of CLE and occurs 2-3 times more frequently in women than in men. DLE is slightly more common in African Americans than in whites or Asians. Although DLE may occur at any age, it most often develops in persons aged 20-40 years.

Prognosis

Although the prognosis of patients with discoid lupus erythematosus (DLE) is favorable regarding mortality, morbidity can be considerable. Patients may experience pain or burning of their lesions, and many experience disfigurement from the scars or atrophy that can develop. Scarring alopecia is particularly disturbing for patients. Prompt treatment of early lesions may help prevent or lessen the severity of scarring and atrophy. Discoid lupus erythematosus is known to negatively impact patient quality of life.[10] In fact, a 2016 study demonstrated that over one third of patients with cutaneous lupus met criteria for depression or anxiety with need for psychiatric intervention.[11] Furthermore, a significant correlation has been found between skin disease activity in cutaneous lupus and quality of life.[12]

Exacerbation is common with increased sun exposure, particularly in the spring and summer. Serious systemic disease is rare, but when it occurs, patients may develop life-altering sequelae. Malignant degeneration within DLE lesions is uncommon, but may occur. Hence, prompt biopsy of suggestive lesions developing within chronic DLE lesions is warranted.[13, 14]

Patient Education

Instruct patients in sun-avoidance techniques and the proper use of sunscreens, wide-brimmed hats, and protective clothing. Advise patients to quit smoking. Discuss the possibility of systemic involvement with patients. Pamphlets from the Lupus Foundation of America, Inc and JAMA Dermatology Cutaneous Lupus Patient Page[15] concerning skin disease and photosensitivity are useful adjuncts to verbally delivered information. Also see Prognosis and Treatment.

 

Presentation

History

Patients may report mild pruritus or occasional pain within the lesions, but most patients are asymptomatic. According to one study, approximately 16% of patients with discoid lupus erythematosus (DLE) may develop systemic involvement within 3 years of diagnosis.[1] Another cohort study reported that 17% of patients with cutaneous lupus erythematosus (CLE) met criteria for systemic lupus erythematosus (SLE) within a mean time of 8 years.[2] Of note, systemic disease was generally mild in these patients, and the diagnosis of SLE was most commonly established by meeting mucocutaneous and laboratory criteria.

Patients may manifest any sign or symptom of SLE; therefore, the history should include an assessment for serologic and/or hematologic abnormalities, arthralgia or arthritis, pleuritis, pericarditis, neurologic involvement, and renal involvement. A 2013 study demonstrated increased risk of photosensitivity, leukopenia, anti-Smith antibody, and decreased risk of arthritis and pleuritis in patients with SLE and DLE.[16] There was no significant association between DLE and anti-ds DNA antibodies, nephritis, or end-stage renal disease.

Malignant degeneration of chronic lesions of DLE leading to nonmelanoma skin cancer is rare. Dark-skinned individuals may be more prone to skin cancer because of the lack of pigmentation within the chronic lesion, combined with chronic inflammation and continued sun damage. Reported risk factors for the development of squamous cell carcinoma within lesions of chronic DLE include male sex, early age of onset, refractory disease, lip involvement, and tobacco use.[13]

Porphyria cutanea tarda (PCT) appears to be overrepresented in patients with CLE. Often, PCT is discovered when antimalarials are first administered. Lichen planus–like lesions may be due to an overlap between CLE and lichen planus or may occur as a result of antimalarial therapy.

Physical Examination

Discoid lupus erythematosus (DLE) lesions frequently are characteristic. The primary lesion is an erythematous papule or plaque with slight-to-moderate scale (see the images below). As the lesion progresses, the scale may thicken and become adherent. Pigmentary changes may develop, with hypopigmentation in the central, or inactive area, and hyperpigmentation at the active border.

Discoid lupus erythematosus on the face. Discoid lupus erythematosus on the face.
Chronic scarred lesion of discoid lupus erythemato Chronic scarred lesion of discoid lupus erythematosus.

Lesions spread centrifugally and may merge. As lesions age, dilation of follicular openings occurs with a keratinous plug, termed follicular plugging or patulous follicles (see the image below). Resolution of the active lesion results in atrophy and scarring.

Lesions of discoid lupus erythematosus in the conc Lesions of discoid lupus erythematosus in the conchal bowl demonstrate patulous follicles with follicular plugging.

At any time, individual lesions may have any or all of these features. Early lesions may be difficult to distinguish from those of subacute cutaneous lupus erythematosus (SCLE). DLE lesions are often photodistributed, but relatively unexposed skin may also be affected. The conchal bowls and scalp are both common areas of involvement. Permanent scarring alopecia may result (see images below).

Scarring alopecia of discoid lupus erythematosus. Scarring alopecia of discoid lupus erythematosus.
Widespread scarring alopecia. Widespread scarring alopecia.

Patients with DLE often are divided into two subsets: localized and widespread (disseminated). Localized DLE occurs when the head and neck only are affected, while widespread DLE occurs when other areas are affected, regardless of whether disease of the head and neck is seen. Patients with widespread involvement often have hematologic and serologic abnormalities, are more likely to develop systemic lupus erythematosus (SLE), and are more difficult to treat.

Several unusual variants of chronic cutaneous lupus erythematosus (CCLE), other than DLE, have been reported. Mucosal surfaces may be affected by lesions that appear identical to DLE of the skin or by lesions that may simulate lichen planus. Palms and soles may be affected, but this occurs in less than 2% of patients (see the image below).[17]

Palmar lesions of discoid lupus erythematosus. Palmar lesions of discoid lupus erythematosus.

DLE lesions may become hypertrophic or verrucous (see the image below). This subset is manifested by wartlike lesions, most often on the extensor arms. Hypertrophic lesions of chronic lupus erythematosus must be differentiated from warts, keratoacanthomas, or squamous cell carcinoma. These lesions are more difficult to treat.[18]

Lupus panniculitis, a form of CCLE that manifests with tender, inflammatory nodules in the early phase, results in eventual destruction of the subcutaneous fat with resulting atrophy and contour change. Lupus panniculitis may be accompanied by overlying typical DLE lesions and/or may occur in patients with SLE.[19]

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

Classification Criteria

Development of classification criteria specific for the diagnosis of DLE was initiated by experts using a Delphi method in 2017.[20] While validation of these criteria is required, they provide a preliminary diagnostic classification scheme to be used clinically and for research. The 12 characteristics, stratified by category, include the following:

Morphology is as follows:

  • Erythematous-violaceous in color
  • Atrophic scarring
  • Dyspigmentation
  • Follicular hyperkeratosis/plugging
  • Scarring alopecia

Histopathology is as follows:

  • Interface/vacuolar dermatitis
  • Perivascular and/or periappendageal lymphohistiocytic infiltrate
  • Follicular keratin plugs
  • Mucin deposition
  • Basement membrane thickening

Location is as follows:

  • Location in conchal bowl
  • Preference for head and neck
 

DDx

Diagnostic Considerations

Early lesions in discoid lupus erythematosus (DLE) may be difficult to distinguish from those of subacute cutaneous lupus erythematosus (SCLE). Occasionally, they may be mistaken for actinic keratoses or squamous cell carcinomas. Several unusual variants of chronic cutaneous lupus erythematosus (CCLE), other than DLE, have been reported, and mucosal surfaces may be affected by lesions that appear identical to DLE of the skin or by lesions that may simulate lichen planus.

Differential Diagnoses

 

Workup

Approach Considerations

Screening for systemic lupus erythematosus (SLE) should occur upon diagnosis of discoid lupus erythematosus (DLE). This should consist of a thorough history and physical examination, as well as standard laboratory screening including complete blood cell count, renal function tests, and urinalysis. Hematologic and serologic abnormalities may be present and an elevated sedimentation rate may occur in some patients. Additionally, rheumatoid factor may be positive and complement levels may be decreased. Abnormal renal function tests and/or urinalysis with proteinuria may reflect the presence of renal involvement.

Some patients with DLE (approximately 20%) manifest a positive antinuclear antibody (ANA) when tested with human substrates. HEp-2 cells currently are the most common substrate used in commercial laboratories.

Anti-Ro (SS-A) autoantibodies are present in up to 20% of patients. Antinative deoxyribonucleic acid (DNA, either double-stranded or nDNA) or anti-Sm antibodies usually reflect SLE, and they may occur in some patients (5-20%).[21] In one study, levels of ANA, anti-RNP, anti-dsDNA, and anti-ssDNA IgG were associated with disease activity of DLE as determined by the Cutaneous Lupus Disease Area and Severity Index (CLASI).[22]

Other Tests

Deposition of immunoglobulin and/or complement at the dermoepidermal junction is a characteristic feature of lupus erythematosus. Tissue may be examined from skin lesions (lesional) or normal skin (nonlesional). Nonlesional biopsies may be from photoexposed or nonexposed surfaces. Testing of nonlesional, nonexposed skin is termed the lupus band test (LBT).

The use and interpretation of these tests vary according to the biopsy site. Approximately 90% of patients with discoid lupus erythematosus (DLE) manifest a positive direct immunofluorescence (DIF) test on lesional skin; however, the presence of immunoreactants in the basement membrane zone of lesional skin is not specific for lupus and can be seen in a variety of inflammatory skin diseases. Older lesions or very early lesions may be more likely to be negative on immunofluorescence microscopy.

Only patients with systemic lupus erythematosus (SLE) have a positive LBT, defined as the presence of multiple immunoreactants in the basement membrane zone. The LBT is neither sensitive nor specific and has mostly been replaced by advances in serologic testing.

Histologic Findings

The characteristic histopathologic alterations observed in discoid lupus erythematosus (DLE) include the following:

  • Vacuolar alteration of the basal cell layer

  • Thickening of the basement membrane

  • Follicular plugging

  • Hyperkeratosis

  • Atrophy of the epidermis

  • Incontinence of pigment

  • Inflammatory cell infiltrate (usually lymphocytic) in a perivascular, periappendageal, and subepidermal location

Often, an abundance of mucin is seen within the dermis. The histopathologic features differ depending on the type and age of the lesion.

 

Treatment

Approach Considerations

The goals of management of discoid lupus erythematosus (DLE) are to halt disease activity, thereby preventing 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 with a thorough review of systems 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, wide-brimmed hats, 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 one 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, strict 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 or to evaluate for systemic involvement

  • Nephrologist - For renal involvement

  • Internist - To evaluate for systemic involvement

  • Ophthalmologist - To monitor therapy with hydroxychloroquine or chloroquine

Antimalarial Therapy

Antimalarial therapy seems to lessen the progression to systemic lupus erythematosus (SLE) and to lower the risk of thrombovascular disease.[23, 24] Alternative therapies include thalidomide,[23, 25, 26, 27] oral or topical retinoids, and immunosuppressive agents.[28, 29] 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.[30]

Hydroxychloroquine is the first-line systemic agent for discoid lupus erythematosus (DLE), whereas chloroquine is considered second-line antimalarial therapy in the United States. Owing to the ability of both hydroxychloroquine and chloroquine to deposit in the retina and cause irreversible retinopathy, these two agents should not be used concomitantly because of the increased risk of ocular toxicity when used in combination.[31]

Quinacrine has also been used for recalcitrant cutaneous lupus erythematosus (CLE) as combination therapy with either hydroxychloroquine or chloroquine.[32] A retrospective cohort study demonstrated that the combination of quinacrine with other antimalarials does not increase risk for ocular toxicity compared with monotherapy with hydroxychloroquine or chloroquine.[33] Of note, quinacrine is not associated with retinal toxicity and can be considered in patients who are at risk for or who have experienced antimalarial induced retinopathy. Quinacrine down-regulates responses of toll-like receptor (TLR)–3, TLR-4, and TLR-8.[34] Of note, quinacrine is not commercially available in the United States and is available only from compounding pharmacies.

Traditionally, antimalarials have been considered less effective in patients who smoke; however, it is also possible that DLE is worse in these patients. A 2011 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 SLE were both significantly associated with decreased therapeutic efficacy.[35] However, a 2015 meta-analysis concluded that patients with CLE who smoke have a 2-fold decreased chance of cutaneous improvement with antimalarial therapies.[36]

Efforts regarding smoking cessation are advisable in patients with DLE who smoke or who are exposed to secondary smoke.[37, 38, 39] Furthermore, a 2012 study demonstrated that patients with 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.[40]

Ocular toxicity is a well-known risk of both hydroxychloroquine and chloroquine, as they can deposit in the retina with subsequent irreversible retinopathy. Thus, these two medications should not be used in combination. The American Academy of Ophthalmology 2016 guidelines recommend a baseline fundus examination with subsequent annual screening after 5 years of treatment.[41] High dose and long duration of treatment are the most significant risk factors for retinopathy. The risk of toxicity at the recommended dose up to 5 years is under 1%, and up to 10 years is 2%. After 20 years of treatment, however, risk of toxicity rises to almost 20%. Despite these guidelines, in clinical practice, ocular examinations are still typically recommended at baseline (within 3 months of initiating the antimalarial agent) and annually thereafter.

A large single-center cohort study demonstrated a good safety profile for antimalarials in the treatment of lupus, with less than 20% of patients presenting with at least one adverse effect during treatment.[42] While most common adverse effects were mild-to-moderate cutaneous and gastrointestinal manifestations, ocular alterations were the most common cause for treatment discontinuation.

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, amongst others, may be considered.[43, 44] 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.[45, 46]

Multiple other agents have case reports, case series, or early clinical trials to support their use in cutaneous lupus erythematosus (CLE), including belimumab,[47, 48] lenalidomide,[49, 50] tofacitinib,[6, 51] apremilast,[52] and intravenous immunoglobulin.[53]

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.

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.[54]

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.

 

Medication

Medication Summary

Hydroxychloroquine and chloroquine phosphate have shown beneficial effects in treating discoid lupus erythematosus (DLE). Additionally, The antimalarial drugs may prevent the development of systemic lupus erythematosus (SLE) in patients with DLE, and they might decrease the risk of cardiovascular disease.[23]  Alternative therapies, anecdotal reports, and small, open-label trials (as reported by Callen[55] ) suggest that the following agents may be useful in some patients:

  • Dapsone
  • Thalidomide [28, 29, 56, 57]
  • Isotretinoin [58]
  • Acitretin
  • Azathioprine [44]
  • Mycophenolate mofetil [45]
  • Methotrexate [43]
  • Auranofin
  • Phenytoin
  • Fumaric acid esters [59]
  • Photodynamic therapy [60]
  • Imiquimod cream 5% [61]
  • Lenalidomide [49, 50]
  • Intravenous immunoglobulin [53]
  • Belimumab [47, 48]
  • Tofacitinib [6, 51]
  • Apremilast [52]

Antimalarial agents

Class Summary

Antimalarial agents may have immunomodulatory properties. Hydroxychloroquine is the drug of choice when a systemic agent is needed for discoid lupus erythematosus (DLE). Chloroquine is second-line antimalarial therapy. Chloroquine and hydroxychloroquine should not be used in combination due to the increased risk of ocular toxicity. The antimalarial drugs may prevent the development of systemic lupus erythematosus (SLE) in patients with DLE, and they might decrease the risk of cardiovascular disease.

Hydroxychloroquine (Plaquenil)

Hydroxychloroquine is used for the treatment of DLE and SLE. It inhibits chemotaxis of eosinophils and locomotion of neutrophils and impairs complement-dependent antigen-antibody reactions. Hydroxychloroquine sulfate 200 mg is equivalent to 155 mg hydroxychloroquine base and 250 mg chloroquine phosphate.

Chloroquine (Aralen)

Chloroquine inhibits chemotaxis of eosinophils and locomotion of neutrophils and impairs complement-dependent antigen-antibody reactions.

Leprostatic agents

Class Summary

Leprostatic agents may modulate the immune system.

Dapsone

Dapsone's mechanism of action is similar to that of sulfonamides, in which competitive antagonists of para-aminobenzoic acid (PABA) prevent the formation of folic acid, inhibiting bacterial growth. The anti-inflammatory action may relate to suppression of neutrophil function by inhibition of the halide-myeloperoxidase system.

Gold compounds

Class Summary

Gold compounds have proven effective in the treatment of inflammation with autoimmune etiology.

Auranofin (Ridaura)

Gold is taken up by macrophages, which, in turn, inhibit phagocytosis and lysosomal membrane stabilization. Gold alters immunoglobulins, decreasing prostaglandin synthesis and lysosomal enzyme activity.

Immunomodulators

Class Summary

Immunomodulators affect factors that regulate the immune system.

Methotrexate (Rheumatrex, Trexall)

Methotrexate reversibly inhibits dihydrofolate reductase; it limits the availability of 1-carbon fragments necessary for the synthesis of purines and the conversion of deoxyuridylate to thymidylate in the synthesis of DNA and cell reproduction. Methotrexate is extensively used to treat cancer, rheumatoid arthritis, and psoriasis and is used as a steroid-sparing agent in various autoimmune conditions.

Thalidomide (Thalomid)

Thalidomide is an immunomodulatory agent that may suppress excessive production of tumor necrosis factor (TNF)-alpha and may down-regulate selected cell-surface adhesion molecules involved in leukocyte migration. If the patient weighs less than 50 kg (110 lb), start the individual at the low end of the dose regimen.

Azathioprine (Imuran, Azasan)

Azathioprine antagonizes purine metabolism and inhibits the synthesis of DNA, ribonucleic acid (RNA), and proteins. It may decrease the proliferation of immune cells, which results in lower autoimmune activity.

Mycophenolate (CellCept, Myfortic)

Mycophenolate inhibits inosine monophosphate dehydrogenase and suppresses de novo purine synthesis by lymphocytes, thereby inhibiting their proliferation. It inhibits antibody production.

Corticosteroids

Class Summary

Corticosteroids are anti-inflammatory agents that suppress the immune system at several levels, including through the inhibition of inflammatory cells and the production of antibodies.

Triamcinolone (Kenalog-10)

Triamcinolone can be administered intralesionally in a concentration of 3-5 mg/mL. The amounts injected should be recorded. Systemic adverse effects are uncommon with low doses. Atrophy is possible and is dose dependent.

Retinoids

Class Summary

Retinoids have the ability to regulate cell proliferation and the immune system.

Acitretin (Soriatane)

Acitretin is a retinoic acid analog similar to etretinate and isotretinoin. Etretinate is the main metabolite, and acitretin has demonstrated clinical effects close to those seen with etretinate. The mechanism of action is unknown.

Isotretinoin (Claravis, Sotret, Amnesteem)

Isotretinoin is a synthetic 13-cis isomer of naturally occurring tretinoin (trans -retinoic acid). Both agents are structurally related to vitamin A. Isotretinoin decreases sebaceous gland size and sebum production. It may inhibit sebaceous gland differentiation and abnormal keratinization.

A US Food and Drug Administration (FDA)–mandated registry is now in place for all individuals prescribing, dispensing, or taking isotretinoin. For more information on this registry, see iPLEDGE. This registry aims to decrease the risk of pregnancy and unwanted and potentially dangerous adverse effects during a course of isotretinoin therapy.

 

Questions & Answers

Overview

How is cutaneous lupus erythematosus (CLE) categorized?

What are the signs and symptoms of discoid lupus erythematosus (DLE)?

What is the risk of progression to systemic lupus erythematosus (SLE) in patients with discoid lupus erythematosus (DLE)?

How is discoid lupus erythematosus (DLE) treated?

What causes discoid lupus erythematosus (DLE)?

What is the prevalence of discoid lupus erythematosus (DLE)?

What is the prognosis of discoid lupus erythematosus (DLE)?

What is included in patient education about discoid lupus erythematosus (DLE)?

Presentation

Which clinical history findings are characteristic of discoid lupus erythematosus (DLE)?

Which physical findings are characteristic of discoid lupus erythematosus (DLE)?

How is discoid lupus erythematosus (DLE) differentiated from other variants of chronic cutaneous lupus erythematosus (CCLE)?

What are the classification criteria for the diagnosis of discoid lupus erythematosus (DLE)?

DDX

Which conditions should be included in the differential diagnoses of discoid lupus erythematosus (DLE)?

What are the differential diagnoses for Discoid Lupus Erythematosus?

Workup

What is the role of lab testing in the workup of discoid lupus erythematosus (DLE)?

What is the role of biopsy in the evaluation of discoid lupus erythematosus (DLE)?

Which histologic findings are characteristic of discoid lupus erythematosus (DLE)?

Treatment

How is discoid lupus erythematosus (DLE) treated?

Which activity modifications are used in the treatment of discoid lupus erythematosus (DLE)?

Which specialist consultations are beneficial to patients with discoid lupus erythematosus (DLE)?

What is the role of antimalarial therapy in the treatment of discoid lupus erythematosus (DLE)?

Which antimalarial agents are used in the treatment of discoid lupus erythematosus (DLE)?

What is the efficacy of antimalarial agents in the treatment of discoid lupus erythematosus (DLE)?

What are the adverse effects of antimalarials for the treatment of discoid lupus erythematosus (DLE)?

What is the role of corticosteroid therapy in the treatment of discoid lupus erythematosus (DLE)?

What is the role of immunomodulator therapy in the treatment of discoid lupus erythematosus (DLE)?

What is the efficacy of corticosteroid therapy for the treatment of discoid lupus erythematosus (DLE)?

What is the role of excision in the treatment of discoid lupus erythematosus (DLE)?

What is the role of laser therapy in the treatment of discoid lupus erythematosus (DLE)?

What is included in the long-term monitoring of patients with discoid lupus erythematosus (DLE)?

Medications

Which medications are used in the treatment of discoid lupus erythematosus (DLE)?

Which medications in the drug class Retinoids are used in the treatment of Discoid Lupus Erythematosus?

Which medications in the drug class Corticosteroids are used in the treatment of Discoid Lupus Erythematosus?

Which medications in the drug class Immunomodulators are used in the treatment of Discoid Lupus Erythematosus?

Which medications in the drug class Gold compounds are used in the treatment of Discoid Lupus Erythematosus?

Which medications in the drug class Leprostatic agents are used in the treatment of Discoid Lupus Erythematosus?

Which medications in the drug class Antimalarial agents are used in the treatment of Discoid Lupus Erythematosus?