Treating and Evaluating Cutaneous Lupus Erythematosus

During her session, “Cutaneous Lupus: Pathogenesis, Evaluation, and Treatment,” presented at Dermatology Week 2022, Victoria Werth, MD, went over the evaluation and treatment of cutaneous lupus erythematosus (CLE).

First, she covered what exactly goes into evaluating CLE noting that patient history–including their medication—and physical examinations are part of the most important steps in evaluating CLE. She also added that skin biopsy and laboratory tests play a huge part as well.

On skin biopsies she stated, “Sometimes, years later, a patient will say, ‘Well, I had a history of lupus,’ and you just don’t know how well documented it was and it makes it very hard, sometimes, for the context later to know what’s going on.” She added, “A skin biopsy is important, especially because very often we’re going to be giving them systemic medications for a period of time, and we’ll want to make sure we have the right diagnosis.”

She referenced a few highly important laboratory tests, such as antinuclear antibody, complete blood cell count, comprehensive metabolic panel, and urinalysis. If results showed evidence of systemic disease, the next steps would be to get C3, C4, anti-dsDNA, anti-Smith, anti-SSA, and anti-SSB. She added that, in addition to the urinalysis, urine proteins and creatinine ratio would get checked.

Regarding the treatment of CLE, Dr Werth listed the following:

• Sun avoidance utilizing sunscreens and sun clothing
• No smoking
• Topicals, such as steroids, pimecrolimus, and tacrolimus
• Antimalarials, such as hydroxychloroquine (HCQ) and chloroquine
• Immunosuppressives
• Thalidomide and derivatives such as lenalidomide
• Other treatment options, such as steroids, dapsone, retinoids, rituximab, and belimumab

She noted that the evidence for the use of HCQ was presented by a single-center cohort study where patients were treated with antimalarials. Of those patients, 55% responded to HCQs, and 66% of patients treated with HCQ-refractory responded to HCQ in addition to quinacrine.

For immunosuppressives, Dr Werth presented an open-label prospective study of 13 patients who didn’t respond or tolerate antimalarials. In this study, 50% of patients responded to immunosuppressives, with methotrexate and mycophenolate mofetil more effective compared with azathioprine.

She continued to thalidomide, with a study conducted in Barcelona, Spain, showing that its effectiveness was 80% to 90% where improvement started in 2 weeks and reached full effects in 4 to 8 weeks. She also introduced iberdomide, which is a novel high-affinity ligand of cereblon (CRBN) and part of the CRL4CRBN E3 ubiquitin ligase complex. It was screened to be more potent than thalidomide or lenalidomide.

Finally, Dr Werth discussed rituximab and belimumab. She noted that rituximab has been reported to help patients with refractory bullous lupus. Additionally, she presented a trial consisting of 82 patients with systemic lupus erythematosus (SLE) who had received rituximab, of which 39% with baseline skin disease had showcased a beneficial skin response at 6 months. For belimumab, she shared that it stimulates B lymphocytes to develop into mature B-cells. It was studied in SLE and had no measure of skin disease.

She concluded this discussion by listing the other following new treatments for CLE:

• Anti-IFN receptor monoclonal antibody such as anifrolumab
• Anti-BDCA2
• Anti-pDC

“There are many, many more approaches in the pipeline,” Dr Werth stated.

Reference
Werth V. Cutaneous lupus: pathogenesis, evaluation, and treatment. Presented at: Dermatology Week 2022; May 11-14, 2022; Virtual.