Initial management of discoid lupus and subacute cutaneous lupus

INTRODUCTION

Discoid lupus erythematosus (DLE) and subacute cutaneous lupus erythematosus (SCLE) are variants of cutaneous lupus that may occur independently or as manifestations of systemic lupus erythematosus. DLE most commonly occurs on the head and is characterized by well-defined inflammatory plaques that evolve into atrophic, disfiguring scars (picture 1A-B). SCLE typically presents with erythematous, scaly papules or annular plaques on the neck, upper trunk, and arms (picture 2A-B).

Concern over the appearance of skin lesions leads most patients with DLE or SCLE to desire treatment, and the majority will respond to photoprotection combined with topical antiinflammatory agents or systemic antimalarial drugs. In particular, early treatment of DLE is essential to minimize scarring.

The initial approach to the treatment of patients with DLE or SCLE will be discussed here. The clinical manifestations of DLE and SCLE and the management of patients with refractory disease are discussed separately. (See "Mucocutaneous manifestations of systemic lupus erythematosus", section on 'Discoid lupus' and "Mucocutaneous manifestations of systemic lupus erythematosus", section on 'Subacute cutaneous lupus erythematosus' and "Management of refractory discoid lupus and subacute cutaneous lupus".)

OVERVIEW OF TREATMENT

Although most individuals with DLE or SCLE require pharmacologic therapy to treat active skin lesions, the elimination of exacerbating factors is an important component of long term management. Strict photoprotection should be recommended, and photosensitizing medications should be discontinued if feasible. The possibility of drug-induced disease also needs to be considered in patients who present with SCLE, and should prompt discontinuation of any potential offending agents. (See 'Nonpharmacologic measures' below.)

For most patients with DLE or SCLE, topical corticosteroids are an appropriate first-line therapy (algorithm 1). Topical calcineurin inhibitors, which lack the atrophogenic effects of corticosteroids, have also been shown to be effective for the treatment of cutaneous lupus. However, topical calcineurin inhibitors are more expensive than many topical corticosteroids, and may have a slower onset of action. Intralesional corticosteroid injections can be used to treat patients with focal lesions that do not respond to topical treatment. (See 'Local therapy' below.)

                         

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Literature review current through: 20.6: May 2012
This topic last updated: Sep 3, 2011
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