NEWPORT BEACH, CALIF. – Thalidomide remains a good therapeutic choice to control cutaneous lupus when steroid creams and antimalarials fail to do the job, according to Dr. Ruth Ann Vleugels.
Dr. Vleugels said that she sometimes turns to systemic therapy for cutaneous lupus to prevent the severe and disfiguring scarring the condition can cause. The presence of erythematous, scaling lesions suggest active disease amenable to treatment.
Hydroxychloroquine or chloroquine are her first choices for systemic therapy, with the option of adding quinacrine in cases when response is inadequate.
But what do you do "when patients fail to respond to antimalarials alone?" asked Dr. Vleugels, who is director of the connective tissue disease clinic at the Brigham and Women’s Hospital in Boston.
In those cases, she said she sometimes adds methotrexate, but "I keep them on their [hydroxychloroquine] because it has some photoprotective benefits and may lower the risk of developing more significant [disease] down the road."
"Our other favorite is thalidomide. We have good luck with thalidomide. It’s a really good drug to consider for patients who are quite refractory; 7 out of 10 will clear their rash," while on thalidomide, Dr. Vleugels said at the SDEF Perspectives in Rheumatic Diseases meeting, held by Global Academy for Medical Education. GAME and this news organization are owned by Frontline Medical Communications.
As with isotretinoin, another teratogen, physicians have to enroll in a registry to prescribe thalidomide, and patients have to come back to the office every month for their next prescription because there are no refills.
In addition to being a teratogen, thalidomide is a sedative and so has to be dosed at night. The drug cannot be given to people at increased risk for clotting. About 30% of people on thalidomide develop peripheral neuropathies as well. Dr. Vleugels said that she tells her patients that "if they get bilateral pins and needles sensations, they need to let me know right away. Most the time, you just stop the medicine at that point," she said.
In general, the work-up for cutaneous lupus is like that for systemic lupus erythematosus, she said. "We do a full review of systems to hit all the [American College of Rheumatology] criteria but also ask about other things such as Reynaud’s, hair loss, miscarriages, history of clotting, etc. For labs, we get at least blood work, serology, and a urinalysis."
A medication and herbal review is also critical. "Probably at least 20% of SCLE [subacute cutaneous lupus erythematosus] patients have drug-induced disease. Hydrochlorothiazide is the classic cause, but also calcium channel blockers, and multiple other agents. We are seeing a lot of terbinafine-induced SCLE," she said.
St. John’s wort, ginkgo biloba, and Echinacea are photosensitizers. "If you have a patient with skin lupus, or SLE, who you are trying to photoprotect, you’re going to have a really hard time controlling their skin disease" if they are on any of these agents or supplements, Dr. Vleugels said.
Corticosteroid creams are an option for nonsystemic treatment. For body rashes, Dr. Vleugels said that she prefers a potent agent like clobetasol or a midpotency agent such as triamcinolone.
She said that she uses a low-potency agent such as desonide for the face "except when I really want to treat someone’s face aggressively. If patients have discoid lesions that I don’t want to scar or an impressive malar rash, I’ll give them a potent topical steroid for their face, but I make sure they use it one week on, one week off," she said.
"If you write for ‘one tube,’ a patient will get 15 g," which is insufficient for body rashes. "I’ll give most of my patients with body rashes a minimum of 120 g, but more likely 240 g. You really have to get away from writing for ‘one tube,’ " she said.
Up to 20% of patients with discoid lupus develop systemic disease, a higher proportion than once thought, and systemic disease can take almost a decade to manifest (Br. J. Dermatol. 2011;164:1335-41).
"[We used to think] that if we screened patients with skin-limited disease for the first few years, they’re over the hump. Now we realize we at least have to do careful reviews of systems and baseline labs for patients for longer than the first few years," Dr. Vleugels said.
SDEF and this news organization are owned by Frontline Medical Communications. Dr. Vleugels said she has no disclosures.