UV hardening therapy: a novel intervention in patients with photosensitive cutaneous lupus erythematosus

Management of cutaneous manifestations of lupus erythematosus: A systematic review

BACKGROUND

Cutaneous lupus erythematosus (CLE), occurring with or without systemic lupus erythematosus (SLE), is a group of inflammatory skin diseases that can be very debilitating, causing significant psychological distress, and sometimes scarring.

OBJECTIVES

We sought to comprehensively present the evidence for different treatment modalities in patients with cutaneous manifestations of lupus erythematosus (LE).

METHODS

Medline, Embase, Scopus and Cochrane CENTRAL were searched electronically from 1990 to March 2019, using keywords related to cutaneous lupus and synonyms and treatment. Articles retrieved were screened for relevance, including reference lists of retrieved reviews. We included clinical trials, observational studies or case series with ≥5 patients focussing on treatment of CLE, with or without SLE.

RESULTS

The search identified 6637 studies, of which 107 were included. Each study commonly included a heterogeneous mixture of CLE subtypes, with or without SLE. The 107 included studies investigated 11 different categories of treatment in 7343 patients. Treatments included topical calcineurin inhibitors (13 studies), sun protection (5 studies), R-salbutamol cream (2 studies), antimalarials (22 studies), synthetic DMARDs (10 studies), retinoids (2 studies), thalidomide/lenalidomide (22 studies), biologic therapies (15 studies), intravenous immune globulin (3 studies), laser (6 studies) and other therapies (7 studies). General measures to be considered include smoking cessation, sun protection measures and optimisation of vitamin D levels. Moderate evidence exists for benefit with topical CNIs, particularly as a steroid sparing agent in areas at high risk of steroid complications (e.g. facial skin). There is moderate evidence for hydroxychloroquine, which is first-line in SLE patients, limited evidence to support other synthetic DMARDs, and moderate evidence supporting thalidomide but with significant risk of toxicity. Of biologic therapies, there are moderate data to support belimumab. Limited evidence exists for other therapies.

CONCLUSION

Many management options are available for CLE, including topical, systemic and biologic therapies, with a variable balance of efficacy and toxicity. There is a paucity of high-quality clinical trial data. Further trials are required to better understand optimal management of CLE, particularly in specific subgroups.

The effect of pre-phototest sun exposure on minimal erythema dose and minimal melanogenic dose among skin phototypes III, IV and V

BACKGROUND

Ethnicity, skin phototype and colour influenced minimal erythema dose (MED). Sun exposure has been postulated to increase MED. We determined immediate pigment darkening dose to UVA (IPDDA), MED and minimal melanogenic dose (MMD) for UVB and UVA, and investigated factors affecting these doses.

METHODS

Skin phototype was determined using Fitzpatrick phototype quiz, DSMII ColorMeter measured skin colours, sun exposure quantified using an index (SEI) and phototest performed with MEDlight-Multitester.

RESULTS

A total of 167 healthy volunteers participated. There were 110 (66%) females and 56 (34%) males; 124 (74.7%) were Malay, 27 (16.3%) Chinese and 14 (8.4%) Indians. One hundred and nine (65.7%) skin phototype IV, 30 (18.1%) phototype III and 27 (16.3%) phototype V. IPDDA ranges from 6 ± 1.5-5.7 ± 1.4 J/cm² . MED-UVB were 96.9 ± 17.6, 124 ± 29.3 and 118.6 ± 27.4 mJ/cm² for phototype III, IV and V, respectively. All MED-UVA were outside the tested dose range of 3.6-11 J/cm² . MMD-UVB were 106 ± 18.2, 134 ± 25.6 and 136 ± 31.1 mJ/cm² while MMD-UVA were 4.1 ± 4.1, 4.9 ± 3.8 and 5.7 ± 3.7 J/cm² respectively for phototypes III, IV and V. MED-UVB, MMD-UVB and MMD-UVA did not depend on skin phototype. Facultative skin whiteness (L*), erythema (E) and melanin content (M) correlated significantly with MED-UVB while constitutive skin colours were significant for L*, yellowness (b*), E and M. Sun exposure did not significantly correlate with MED-UVB and MMDs, however, an inverse relationship with MED-UVB was demonstrated.

CONCLUSION

Minimal erythema doses in our cohort were slightly different from other regional countries. Constitutive and facultative skin whiteness, erythema and melanin content correlated with MED. There was no association between skin phototype and sun exposure with MED or MMD.

Photoprotection awareness and practices among patients with systemic lupus erythematosus and its association with disease activity and severity

Objective The objective of this paper is to determine photoprotection awareness, knowledge, practices, and its relationship with disease activity and damage in patients with systemic lupus erythematosus (SLE). Methods A cross-sectional study was performed. Data were acquired from in-person interviews and medical records. Results A total of 199 (89.6%) females and 23 (10.4%) males were recruited. Median age was 39.00 (interquartile range (IQR) 18) years, disease duration 12.12 (IQR 8) years, Fitzpatrick skin phototype III 119 (53.6%) and IV 81 (36.5%). Systemic Lupus Erythematosus Disease Activity Index 2000 (SLEDAI-2 K) was 2.95 (IQR 4) while Systemic Lupus International Collaborating Clinics/American College of Rheumatology Damage Index (SLICC-ACR DI) was 1.20 (IQR 2). The majority 205 (92.3%) were aware of sun exposure effects on SLE. Photoprotection methods were shade seeking 209 (94.1%), sun avoidance 212 (95.5%), long pants 168 (75.7%), long sleeves 155 (69.8%), sunscreen 116 (52.3%), sunglasses 114 (51.4%) and head cover 103 (46.4%). Significantly higher photoprotection practice scores (PPS) were observed in females, Malays, and individuals with higher education level and internet accessibility. PPS were not significantly correlated with SLICC-ACR DI and SLEDAI-2 K. Independent predictors for good photoprotection practice (GPP) were ethnicity (OR = 3.66, 95% CI 1.78-7.53), awareness (OR = 3.77, 95% CI 1.09-13.08) and cutaneous involvement (OR = 2.43, 95% CI 1.11-5.28). Photoprotection methods and GPP were not predictors for disease activity or damage. Conclusion Photoprotection awareness and knowledge was good. Shade seeking and sun avoidance were the common photoprotection methods practised. The use of sunscreen requires improvement. Photoprotection awareness and cutaneous manifestation were predictors for GPP. Neither photoprotection methods nor GPP were associated with disease activity or damage.

A review of UVA-mediated photosensitivity disorders

A number of skin conditions are characterised by photosensitivity to UVA. Some of these are exclusively UVA-mediated conditions, while others include UVA in the action spectrum which also include UVB and/or visible light. This review aims to describe this diverse range of conditions for non-dermatologist scientists with an interest in this topic. As such, clinical details, including treatments, are brief and succinct. Recent advances in understanding the pathogenesis of these conditions is highlighted.

Treatment of cutaneous lupus erythematosus

In patients with cutaneous lupus erythematosus (CLE) and mild skin involvement, local therapy consisting of topically applied pharmacological agents, e.g., topical/intralesional steroids, may be sufficient. Recent reports have also shown efficacy of topical calcineurin inhibitors in patients with CLE, particularly on the face. Special attention receives consistent sun protection through photoresistant clothing and application of light-shielding substances with highly potent chemical or physical UVA- and UVB-protective filters. These substances should be applied in sufficient amount (ca. 2 mg/cm(2)) at least 20-30 minutes before sun exposure in order to avoid induction and exacerbation of cutaneous lesions. The mainstay of treatment for disfiguring and widespread skin manifestations in patients with CLE, irrespective of the subtype of the disease, is antimalarial agents. Our understanding of the use of combinations of antimalarials and proper dosing according to the ideal bodyweight limits problems with toxicity. Further therapies, such as methotrexate, or retinoids, dapsone, mycophenolate mofetil, and thalidomide in selected cases, can be helpful for patients with resistant disease; however, side effects need to be taken into consideration. Recent advances in biotechnology resulted in the development of novel systemic agents, but randomized controlled trials are necessary for the approval of new therapeutic strategies in CLE.

Cutaneous lupus erythematosus: update of therapeutic options part I

In patients with cutaneous lupus erythematosus (CLE), it is important to provide instructions concerning methods of protection from sunlight and artificial sources of ultraviolet radiation. Topical corticosteroids are the mainstay of treatment for patients with CLE; however, they are of limited value because of their well-known side effects. Recently, calcineurin inhibitors have been shown to be efficient as topical therapy in various CLE subtypes. The first-line treatment for severe and widespread skin manifestations is antimalarials; hydroxychloroquine or chloroquine can each be combined with quinacrine in refractory CLE. Systemic steroids can be used additionally in exacerbations of the disease. In the first part of this review, recent information on topical and first-line systemic treatment is described in detail while providing the reader with up-to-date information on efficacy, side effects, and dosage for the various agents. In the second part, additional systemic agents for the treatment of CLE will be discussed.