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Experts create algorithm for management of cutaneous manifestations in lupus

Researchers compiled a treatment algorithm for cutaneous manifestations of lupus erythematosus based on data from 104 studies, according to a study presented at the American College of Rheumatology/Association of Rheumatology Professionals annual meeting.

A literature search was employed to compare evidence for various treatment modalities in patients with cutaneous manifestations of lupus. The search identified 6,637 studies, of which 104 were included, covering 11 categories of treatment in 6,811 patients.

The treatments evaluated included topical calcineurin inhibitors in 13 studies, sun protection in five studies, R-salbutamol cream in two studies, antimalarials in 23 studies, synthetic disease-modifying antirheumatic drugs (DMARDs) in 10 studies, retinoids in two studies, Thalomid (thalidomide, Celgene)/Revlimid (lenalidomide, Celgene) in 22 studies, biologic therapies in 12 studies, IV immune globulin in three studies, laser in six studies and other therapies in six studies.

In all patients, researchers recommend sunscreen smoking cessation and vitamin D supplementation when a patient is deficient.

In those with mild disease, topical corticosteroids are recommended as a first-line therapy or as an adjuvant in more severe disease. There is moderate evidence for the steroid-sparing effect in topical calcineurin inhibitors, according to researchers.

For patients with mild to moderate disease that requires systemic therapy, hydroxychloroquine showed moderate evidence for benefit, in other antimalarials the researchers found a lower level of evidence. If hydroxychloroquine fails, they suggest combination therapy or rotation to another antimalarial.

In moderate to severe disease, data on thalidomide showed a moderate benefit; however, it also showed a significant risk for adverse events. Researchers found limited evidence to support methotrexate, mycophenolate mofetil and azathioprine. Cyclophosphamide is beneficial but comes with a high risk for toxicity.

As for biologic therapies, Benlysta (belimumab, GlaxoSmithKline) had moderate data to support its benefit. Rituxan (rituximab, Genentech) had conflicting data to support benefit when combined with cyclophosphamide, and there is limited data available in other biologics, according to researchers.

In other available therapies, there is limited data favoring the benefit in retinoids and conflicting data in IV immune globulin. In laser therapy, researchers found low to moderate evidence for pulsed dye laser — which may assist with scarring — but researchers recommend caution in active cutaneous lupus. – by Abigail Sutton

Reference:

Fairley J, et al. Abstract #2584. Presented at: ACR/ARP Annual Meeting; Nov. 8-13, 2019; Atlanta.

Disclosures: Fairley reports no relevant financial disclosures. Please see the study for all other authors’ relevant financial disclosures.