Subacute cutaneous lupus erythematosus



Subacute cutaneous lupus erythematosus


Jeffrey P. Callen and Courtney R. Schadt


Evidence Levels:  A Double-blind study  B Clinical trial ≥ 20 subjects  C Clinical trial < 20 subjects  D Series ≥ 5 subjects  E Anecdotal case reports


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Subacute cutaneous lupus erythematosus (SCLE) is a non-scarring, non-atrophic variant of lupus erythematosus (LE) that was first distinguished from other cutaneous variants in 1979. At least half of the patients with SCLE have or develop four or more of the features that allow classification as systemic LE using the criteria of the American College of Rheumatology. In general, however, their prognosis is better than that of unselected patients with systemic LE and these patients have less likelihood of having renal or neurologic disease (Black, D.R., et al, 2002. Arch Dermatol 138 (9),1175–1178).



Management strategy


Therapy of cutaneous lesions in patients with LE involves both an empiric and a scientific approach. Unfortunately, there are few double-blind, placebo-controlled trials of drugs used in the treatment of cutaneous LE.


The goals of management of SCLE are to improve the patient’s appearance, relieve the symptomatology, and prevent the development of dyspigmentation. Cosmetic problems are often of major importance to the patient with cutaneous LE. Dyspigmentation may follow SCLE, and may be effectively hidden by agents such as Covermark™ or Dermablend™.


Once a diagnosis of subcutaneous LE has been made, management must involve sun avoidance and sun protection, and elimination of medications that might be responsible for the skin lesions. Treatment with the most benign drugs possible should be stressed. Topical corticosteroids and oral antimalarials are the most commonly prescribed medications. Although systemic corticosteroids may be highly effective, attempts should be made to reduce their dosage and use other medications in their place to avoid corticosteroid-associated side effects.



Specific investigations






The cornerstone of the management of SCLE is correct diagnosis and thorough evaluation. The patient should have a careful history, physical examination, and laboratory studies directed at uncovering systemic manifestations that might occur in LE. The risk of serious systemic involvement (renal, central nervous system, or cardiopulmonary involvement) in patients with SCLE is probably around 10%, though many patients with SCLE – more than 50% – have sufficient criteria to classify them as having systemic lupus erythematosus (SLE).







Subacute cutaneous lupus erythematosus and its association to drugs: a population-based matched case-control study of 234 patients in Sweden.

Grönhagen CM, Fored CM, Linder M, Granath F, Nyberg F. Br J Dermatol 2012; 167: 296–305.


This study is a first in which population-based data for diagnosis of cutaneous LE were compared with a national database on prescription drug use. In this study, the authors linked SCLE to terbinafine (OR [odds ratio]=38.5, 95% CI 6.6–∞), tumor necrosis factor-α (TNF-α) inhibitors (OR=8.0, 95% CI 1.6–37.2), antiepileptics (OR=3.4, 95% CI 1.9–5.8) and proton pump inhibitors (OR=2.9, 95% CI 2.0–4.0). They did not find a significant OR for thiazides, or other antihypertensive agents, which they speculated might be due to a longer latency between the time of prescription and the onset of disease.


A complete list of the patient’s medications will assist in the exclusion of drug-induced cutaneous LE. Drugs that have been linked as causes of SCLE primarily include antihypertensive agents such as hydrochlorothiazide, calcium channel blockers, statins, proton pump inhibitors, terbinafine, tumor necrosis factor-α antagonists, and angiotensin-converting enzyme inhibitors. Because of the growing list of agents linked to SCLE development or exacerbation, any newly introduced drug should be considered as a possible trigger.








First-line therapies
























image Cosmetics E
image Sunscreens and protective clothing C
image Corticosteroids E
image Antimalarials B
image Topical retinoids E
image Topical tacrolimus or pimecrolimus B








Intralesional triamcinolone is effective for discoid lupus erythematosus of the palms and soles.

Callen JP. J Rheumatol 1985; 12: 630–3.


Intralesional injections of corticosteroids are often effective in patients with lesions that are refractory to topical corticosteroids. Small amounts of triamcinolone acetonide 3 mg/mL may be injected with a 30-gauge needle into multiple areas. These injections are often very effective in control of the lesions, but do not prevent the development of new lesions.


The potential for cutaneous atrophy and/or dyspigmentation similar to that seen with the disease should be discussed with the patient; however, in most cases an experienced dermatologist is able to inject without a great risk. Alternative agents for intralesional injection have not been well tested.



The association of the two antimalarials chloroquine and quinacrine for treatment-resistent chronic and subacute cutaneous lupus erythematosus.

Feldmann R, Salomon D, Saurat JH. Dermatology 1994; 189: 425–7.


The first-line therapy is the use of an antimalarial drug. The antimalarial preferred by the authors is hydroxychloroquine sulfate (Plaquenil). This drug is used in doses of 200 mg orally once or twice daily, or in a dose of less than 6.5 mg/kg daily. The onset of action of the antimalarial agents is roughly 4 to 8 weeks, and for this reason some physicians have advocated higher initial loading doses. Hydroxychloroquine is also of benefit for the joint symptoms and malaise that may accompany SCLE. Hydroxychloroquine is less toxic, but also less effective than chloroquine phosphate (Aralen), which is used in doses of 250–500 mg daily. Thus patients who fail to respond fully to hydroxychloroquine may be switched to chloroquine, but the two should not be used together because of the concern that ophthalmologic toxicity may be enhanced. Another antimalarial, quinacrine hydrochloride (Atabrine), may add benefit to either hydroxychloroquine or chloroquine, and is not associated with ophthalmologic toxicity. This agent is not readily available, but several compounding pharmacies in the USA have it.

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Aug 7, 2016 | Posted by in Dermatology | Comments Off on Subacute cutaneous lupus erythematosus

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