Medication Summary
The basic therapy of skin disease uses sun-protection methods, such as sunscreens, sun-protective clothing, and alteration of sun exposure during times of high-intensity ultraviolet light. Topical corticosteroids are frequently used. Select the appropriate strength for the area of the body affected. Intralesional injection of triamcinolone acetonide may be useful for individual recalcitrant lesions. Antimalarials are the mainstay of systemic therapy and are associated with lower rates of disease progression and lower risk of thrombovascular disease in patients with systemic lupus erythematosus (SLE). [41, 42]
Anecdotal reports or small, open-label trials, as reported by Callen, suggest that the following agents may be of use in some patients [32, 43, 44, 45, 46, 47, 48, 49] :
-
Thalidomide
-
Dapsone
-
Quinacrine combined with either hydroxychloroquine or chloroquine
-
Isotretinoin
-
Acitretin
-
Azathioprine
-
Methotrexate
-
Mycophenolate mofetil
-
Phenytoin
-
Auranofin
-
Clofazimine
-
Lenalidomide
-
Intravenous immunoglobulin
-
Rituximab
Antimalarials
Class Summary
Antimalarials have immunomodulatory effects that may improve symptoms of the disease. Hydroxychloroquine is the drug of choice for systemic therapy of subacute cutaneous lupus erythematosus (SCLE). Chloroquine is second line. The lowest possible dose needed to control the patient’s disease should be used.
Hydroxychloroquine (Plaquenil)
Hydroxychloroquine inhibits chemotaxis of eosinophils and locomotion of neutrophils, and it 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 the effects of immune cells, impairing complement-dependent antigen-antibody reactions.
Leprostatic agents
Class Summary
Leprostatic agents may have immunomodulatory effects.
Dapsone
Dapsone's mechanism of action is similar to that of sulfonamides, with competitive antagonism of para-aminobenzoic acid (PABA) preventing the formation of folic acid, inhibiting bacterial growth.
Immunomodulators
Class Summary
Immunomodulators are effective in the treatment of diseases with autoimmune etiology.
Azathioprine (Azasan, Imuran)
Azathioprine antagonizes purine metabolism and inhibits the synthesis of DNA, RNA, and proteins. It may decrease the proliferation of immune cells, which results in lower autoimmune activity.
Thalidomide (Thalomid)
Thalidomide may suppress the excessive production of tumor necrosis factor alpha (TNF-alpha), and it may down-regulate selected cell-surface adhesion molecules involved in leukocyte migration.
Thalidomide can cause severe, life-threatening birth defects and is contraindicated in pregnant women. It is also contraindicated in women of childbearing potential unless they are using 2 forms of reliable contraception and are complying with serial pregnancy testing while on therapy. In addition, thalidomide is contraindicated in sexually active men who are not using latex condoms as barrier contraception.
The drug is available only under a special, restricted distribution program called the STEPS (System for Thalidomide Education and Prescribing Safety) Program. Only prescribers and pharmacists registered with this program may prescribe and dispense thalidomide. For more information, contact the Celgene Corporation at 1-888-423-5436.
Mycophenolate (CellCept, Myfortic)
Mycophenolate inhibits inosine monophosphate dehydrogenase (IMPDH) and suppresses de novo purine synthesis by lymphocytes, thereby inhibiting their proliferation. The drug inhibits antibody production.
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. The drug is extensively used for cancer treatment, rheumatoid arthritis, and psoriasis and as a steroid-sparing agent in various autoimmune conditions.
Gold compounds
Class Summary
Gold compounds may regulate immune cell function.
Auranofin (Ridaura)
Gold is taken up by macrophages, which in turn inhibit phagocytosis and lysosomal membrane stabilization. It alters immunoglobulins, decreasing prostaglandin synthesis and lysosomal enzyme activity.
Retinoids
Class Summary
Retinoids play a role in cell growth and differentiation.
Acitretin (Soriatane)
Acitretin is a retinoic acid analogue 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, Amnesteem, Sotret)
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 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.
-
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.
