Management of discoid lupus erythematosus and subacute cutaneous lupus erythematosus in adults

SLE: systemic lupus erythematosus; HCQ: hydroxychloroquine; DLE: discoid lupus erythematosus; SCLE: subacute cutaneous lupus erythematosus.

* Sun-protective measures (sunscreen, protective clothing, etc) and the removal of photosensitizing or disease-exacerbating drugs are important components of management.

¶ Disease that is rapidly progressing or associated with worsening of scarring or cosmetically significant pigmentary alteration.

Δ Limited disease may be considered disease that is unlikely to cause disfigurement and for which daily topical therapy is manageable (ie, involves a limited body surface area in sites the patient can easily reach).

◊ Prednisone (0.5 to 1 mg/kg per day) is given for 2 to 4 weeks to attain disease control while awaiting the onset of action of HCQ. Prednisone is subsequently tapered and discontinued.

§ Topical corticosteroids are our preferred initial treatment for most patients. DLE is treated with super high-potency or high-potency topical corticosteroids. SCLE is treated with super high-potency to medium-potency topical corticosteroids. A comparison table of topical corticosteroid preparations is available in UpToDate. Topical calcineurin inhibitors (eg, pimecrolimus 1% cream, tacrolimus 0.1% ointment) are more expensive than some topical corticosteroids but are useful for long-term topical treatment in sites prone to corticosteroid-induced skin atrophy (eg, face, neck, intertriginous skin). Intralesional corticosteroid therapy requires multiple injections and is generally most feasible for treatment of a few small lesions. Patients with disease resistant to one of these local therapies may try an alternative local therapy or proceed to HCQ treatment.

¥ HCQ is continued at a reduced dose. Refer to additional UpToDate content on the initial management of DLE and SCLE for details.

‡ Local therapy may be stopped when all signs of active disease (eg, scale, erythema, edema) resolve. If continued treatment is necessary to maintain the response, a topical corticosteroid of reduced potency or a topical calcineurin inhibitor can be used for maintenance treatment.

† For details on HCQ dosing and administration, refer to additional UpToDate content on initial management of DLE and SCLE.

** Topical corticosteroids and/or intralesional corticosteroid injections may be beneficial as adjunctive therapy or as a bridge therapy while awaiting the onset of action of HCQ.

¶¶ A small subset of patients respond better to chloroquine than HCQ; refer to additional UpToDate content on initial management of DLE and SCLE for details. For options for refractory disease, refer to additional UpToDate content on the management of refractory DLE and SCLE.