Using her insights as a dual rheumatologist-dermatologist, Ruth Ann Vleugels, MD, MPH, MBA, shared the latest information regarding diagnosis and management of cutaneous lupus1 and dermatomyositis.2
In her first presentation, Dr Vleugels focused on therapies for cutaneous lupus, including systemic lupus erythematosus, discoid lupus, lupus panniculitis, and subacute cutaneous lupus. Therapy for cutaneous lupus is in a ladder fashion, starting with photoprotective measures. Patients should be counseled on behavioral practices as well as proper sunscreen use and appropriate photoprotective clothing options. “I always tell my patients that none of my medicines are as strong as the sun, so we need to protect your skin to help you get better,” shared Dr Vleugels.
Vitamin D status should also be considered in this patient population. Next, smoking cessation should be initiated. Therapies include topical corticosteroids or topical tacrolimus, and systemic agents include:
- Antimalarials
- Methotrexate
- Mycophenolate mofetil
- Thalidomide
- Azathioprine
- Dapsone
- Acitretin/isotretinoin
- Intravenous immunoglobulin (IVIG)
- Belimumab
- Apremilast
- Lenalidomide
Dermatomyositis is often mistaken for lupus, and it is crucial to diagnose early because of its associations with lung disease and malignancy. These patients also greatly benefit from photoprotection, but pruritus should not be ignored by the dermatologist. In patients with moderate to severe cutaneous dermatomyositis, antimalarials should be used in combination with methotrexate, mycophenolate mofetil, or IVIG from the start. But which one should be used for what patient?
“In any patient that has a high-risk lung phenotype, we really want to reach for mycophenolate mofetil,” explained Dr Vleugels. If results are extrapolated from the systemic sclerosis literature, mycophenolate mofetil has shown improvement in interstitial lung disease in the setting of connective tissue disease. In patients who have active malignancy, or in whom cancer workup is still awaiting results, methotrexate is the best option to use in conjunction with the antimalarials. IVIG, on the other hand, is the most effective but the most expensive option of the three.
References
- Vleugels RA. Cutaneous lupus. Presented at: Symposium for Inflammatory Skin Disease; April 9-11, 2021; virtual.
- Vleugels RA. Dermatomyositis. Presented at: Symposium for Inflammatory Skin Disease; April 9-11, 2021; virtual.
