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Lu Q, Long H, Chow S, Hidayat S, Danarti R, Listiawan Y, Deng D, Guo Q, Fang H, Tao J, Zhao M, Xiang L, Che N, Li F, Zhao H, Lau CS, Ip FC, Ho KM, Paliza AC, Vicheth C, Godse K, Cho S, Seow CS, Miyachi Y, Khang TH, Ungpakorn R, Galadari H, Shah R, Yang K, Zhou Y, Selmi C, Sawalha AH, Zhang X, Chen Y, Lin CS. Guideline for the diagnosis, treatment and long-term management of cutaneous lupus erythematosus. J Autoimmun 2021; 123:102707. [PMID: 34364171 DOI: 10.1016/j.jaut.2021.102707] [Citation(s) in RCA: 29] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2021] [Accepted: 07/13/2021] [Indexed: 12/20/2022]
Abstract
Cutaneous lupus erythematosus (CLE) is an inflammatory, autoimmune disease encompassing a broad spectrum of subtypes including acute, subacute, chronic and intermittent CLE. Among these, chronic CLE can be further classified into several subclasses of lupus erythematosus (LE) such as discoid LE, verrucous LE, LE profundus, chilblain LE and Blaschko linear LE. To provide all dermatologists and rheumatologists with a practical guideline for the diagnosis, treatment and long-term management of CLE, this evidence- and consensus-based guideline was developed following the checklist established by the international Reporting Items for Practice Guidelines in Healthcare (RIGHT) Working Group and was registered at the International Practice Guideline Registry Platform. With the joint efforts of the Asian Dermatological Association (ADA), the Asian Academy of Dermatology and Venereology (AADV) and the Lupus Erythematosus Research Center of Chinese Society of Dermatology (CSD), a total of 25 dermatologists, 7 rheumatologists, one research scientist on lupus and 2 methodologists, from 16 countries/regions in Asia, America and Europe, participated in the development of this guideline. All recommendations were agreed on by at least 80% of the 32 voting physicians. As a consensus, diagnosis of CLE is mainly based on the evaluation of clinical and histopathological manifestations, with an exclusion of SLE by assessment of systemic involvement. For localized CLE lesions, topical corticosteroids and topical calcineurin inhibitors are first-line treatment. For widespread or severe CLE lesions and (or) cases resistant to topical treatment, systemic treatment including antimalarials and (or) short-term corticosteroids can be added. Notably, antimalarials are the first-line systemic treatment for all types of CLE, and can also be used in pregnant patients and pediatric patients. Second-line choices include thalidomide, retinoids, dapsone and MTX, whereas MMF is third-line treatment. Finally, pulsed-dye laser or surgery can be added as fourth-line treatment for localized, refractory lesions of CCLE in cosmetically unacceptable areas, whereas belimumab may be used as fourth-line treatment for widespread CLE lesions in patients with active SLE, or recurrence of ACLE during tapering of corticosteroids. As for management of the disease, patient education and a long-term follow-up are necessary. Disease activity, damage of skin and other organs, quality of life, comorbidities and possible adverse events are suggested to be assessed in every follow-up visit, when appropriate.
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Affiliation(s)
- Qianjin Lu
- Institute of Dermatology, Chinese Academy of Medical Sciences and Peking Union Medical College, Nanjing, China; Key Laboratory of Basic and Translational Research on Immune-Mediated Skin Diseases, Chinese Academy of Medical Sciences, Nanjing, China.
| | - Hai Long
- Department of Dermatology, The Second Xiangya Hospital, Central South University, Changsha, China.
| | | | - Syarief Hidayat
- League of ASEAN Dermatologic Societies, Kuala Lumpur, Malaysia
| | - Retno Danarti
- Department of Dermatology and Venereology, Gadjah Mada University, Yogyakarta, Indonesia
| | - Yulianto Listiawan
- Department of Dermatology and Venereology, Airlangga University, Surabaya, Indonesia
| | - Danqi Deng
- Department of Dermatology, The Second Affiliated Hospital of Kunming Medical University, Kunming, China
| | - Qing Guo
- Department of Dermatology, Sun Yat-Sen Memorial Hospital, Sun Yat-Sen University, Guangzhou, China
| | - Hong Fang
- Department of Dermatology, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Juan Tao
- Department of Dermatology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Ming Zhao
- Department of Dermatology, The Second Xiangya Hospital, Central South University, Changsha, China
| | - Leihong Xiang
- Department of Dermatology, Huashan Hospital, Fudan University, Shanghai, China
| | - Nan Che
- Department of Rheumatology and Immunology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Fen Li
- Department of Rheumatology and Immunology, The Second Xiangya Hospital, Central South University, Changsha, China
| | - Hongjun Zhao
- Department of Rheumatology and Immunology, Xiangya Hospital, Central South University, Changsha, China
| | - Chak Sing Lau
- Division of Rheumatology and Clinical Immunology, Department of Medicine, Queen Mary Hospital, Hong Kong, China
| | - Fong Cheng Ip
- Department of Dermatology, Yung Fung Shee Dermatological Clinic, Hong Kong, China
| | - King Man Ho
- Social Hygiene Service, Department of Health, Hong Kong Government, Hong Kong, China
| | - Arnelfa C Paliza
- Department of Dermatology, Faculty of Medicine and Surgery, University of Santo Tomas, Manila, Philippines
| | - Chan Vicheth
- Department of Dermatology, Khmer Soviet Friendship Hospital, Phnom Penh, Cambodia
| | - Kiran Godse
- D. Y. Patil University School of Medicine, Nerul, Navi Mumbai, India
| | - Soyun Cho
- Department of Dermatology, Seoul National University Boramae Medical Center, Seoul, South Korea
| | | | | | - Tran Hau Khang
- National Hospital of Dermatology, Vietnamese Society of Dermatology and Venereology, Hanoi, Viet Nam
| | - Rataporn Ungpakorn
- Skin and Aesthetic Lasers Clinic, Bumrungrad International Hospital, Bangkok, Thailand
| | - Hassan Galadari
- College of Medicine and Health Sciences, United Arab Emirates University, Al Ain, United Arab Emirates
| | | | - Kehu Yang
- Evidence-Based Medicine Center, School of Basic Medical Sciences, Lanzhou University, Lanzhou, China; Key Laboratory of Evidence Based Medicine and Knowledge Translation of Gansu Province, Lanzhou, China
| | - Youwen Zhou
- Department of Dermatology and Skin Science, University of British Columbia, Vancouver, BC, Canada
| | - Carlo Selmi
- Rheumatology and Clinical Immunology, Humanitas Clinical and Research Center- IRCCS, Rozzano, Milan, Italy; Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Milan, Italy
| | - Amr H Sawalha
- Divisions of Rheumatology, Departments of Pediatrics and Medicine & Lupus Center of Excellence, University of Pittsburgh, Pittsburgh, PA, USA
| | - Xuan Zhang
- Department of Rheumatology, Beijing Hospital, National Center of Gerontology, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China; Clinical Immunology Center, Medical Epigenetics Research Center, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Yaolong Chen
- Evidence-Based Medicine Center, School of Basic Medical Sciences, Lanzhou University, Lanzhou, China; Chinese GRADE Center, Lanzhou University, Lanzhou, China.
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Ogunsanya ME, Brown CM, Lin D, Imarhia F, Maxey C, Chong BF. Understanding the disease burden and unmet needs among patients with cutaneous lupus erythematosus: A qualitative study. Int J Womens Dermatol 2018; 4:152-158. [PMID: 30175217 PMCID: PMC6116830 DOI: 10.1016/j.ijwd.2018.01.002] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2017] [Revised: 01/30/2018] [Accepted: 01/31/2018] [Indexed: 11/24/2022] Open
Abstract
Background Cutaneous lupus erythematosus (CLE) is a rare dermatologic autoimmune disease marked by photosensitive lesions that can vary in appearance depending on the subtype. The extent to which CLE affects a patient’s quality of life (QoL) has not been fully characterized. Focus groups were conducted to explore patients’ perspectives of how CLE has affected their lives and to understand the unmet needs in regards to CLE treatment and care. Methods This qualitative study involved three focus groups with a total of 19 patients with CLE. A moderator guide containing open-ended questions was used to assess how CLE affects overall QoL. The focus groups were audio-recorded with notetaking. Data were content-analyzed to identify emergent themes. Results Four themes emerged as important to patients with CLE: disease sequelae, social interactions, functioning, and unmet needs. Most patients reported decreased QoL due to signs and symptoms such as dyspigmentation and scarring. Having CLE negatively affected patients’ mental health and personal relationships and led to negative coping strategies, such as recreational drug use. Issues related to body image were also elicited by patients. Patients cited unmet needs including lack of treatments to improve chronic skin lesions of CLE and inadequate patient education on living with CLE. Conclusions Providers can look for signs of QoL impairment in patients with CLE by asking questions related to body image, mental health, social isolation, and coping mechanisms. Future QoL measures can include the effect of CLE-specific attributes such as scarring and dyspigmentation to empower patients’ voices in determining therapeutic efficacy in future clinical trials. Findings from our study have added a new understanding of daily experiences that were elicited directly from patients with CLE.
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Affiliation(s)
- M E Ogunsanya
- College of Pharmacy, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma
| | - C M Brown
- College of Pharmacy, The University of Texas at Austin, Texas
| | - D Lin
- Department of Dermatology, University of Texas Southwestern Medical Center, Dallas, Texas
| | - F Imarhia
- College of Pharmacy, The University of Texas at Austin, Texas
| | - C Maxey
- College of Natural Sciences, The University of Texas at Austin, Austin, Texas
| | - B F Chong
- Department of Dermatology, University of Texas Southwestern Medical Center, Dallas, Texas
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Kuhn A, Aberer E, Bata-Csörgő Z, Caproni M, Dreher A, Frances C, Gläser R, Klötgen HW, Landmann A, Marinovic B, Nyberg F, Olteanu R, Ranki A, Szepietowski JC, Volc-Platzer B. S2k guideline for treatment of cutaneous lupus erythematosus - guided by the European Dermatology Forum (EDF) in cooperation with the European Academy of Dermatology and Venereology (EADV). J Eur Acad Dermatol Venereol 2016; 31:389-404. [PMID: 27859683 DOI: 10.1111/jdv.14053] [Citation(s) in RCA: 81] [Impact Index Per Article: 10.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2016] [Accepted: 10/26/2016] [Indexed: 12/31/2022]
Abstract
Cutaneous lupus erythematosus (CLE) is a rare inflammatory autoimmune disease with heterogeneous clinical manifestations. To date, no therapeutic agents have been licensed specifically for patients with this disease entity, and topical and systemic drugs are mostly used 'off-label'. The aim of the present guideline was to achieve a broad consensus on treatment strategies for patients with CLE by a European subcommittee, guided by the European Dermatology Forum (EDF) and supported by the European Academy of Dermatology and Venereology (EADV). In total, 16 European participants were included in this project and agreed on all recommendations. Topical corticosteroids remain the mainstay of treatment for localized CLE, and further topical agents, such as calcineurin inhibitors, are listed as alternative first-line or second-line topical therapeutic option. Antimalarials are recommended as first-line and long-term systemic treatment in all CLE patients with severe and/or widespread skin lesions, particularly in patients with a high risk of scarring and/or the development of systemic disease. In addition to antimalarials, systemic corticosteroids are recommended as first-line treatment in highly active and/or severe CLE. Second- and third-line systemic treatments include methotrexate, retinoids, dapsone and mycophenolate mofetil or mycophenolate acid, respectively. Thalidomide should only be used in selected therapy-refractory CLE patients, preferably in addition to antimalarials. Several new therapeutic options, such as B-cell- or interferon α-targeted agents, need to be further evaluated in clinical trials to assess their efficacy and safety in the treatment of patients with CLE.
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Affiliation(s)
- A Kuhn
- Interdisciplinary Center for Clinical Trials (IZKS), University Medical Center Mainz, Mainz, Germany.,Division of Immunogenetics, Tumor Immunology Program, German Cancer Research Center, Heidelberg, Germany
| | - E Aberer
- Department of Dermatology, Medical University of Graz, Graz, Austria
| | - Z Bata-Csörgő
- Department of Dermatology and Allergology, University of Szeged, Szeged, Hungary
| | - M Caproni
- Department of Medical and Surgical Critical Care Section of Dermatology, University of Florence, Florence, Italy
| | - A Dreher
- Evidence-Based Medicine Frankfurt, Institute for General Practice, Goethe-University Frankfurt, Frankfurt, Germany
| | - C Frances
- Department of Dermatology and Allergology, Hôpital Tenon, Paris, France
| | - R Gläser
- Department of Dermatology, Venerology and Allergology, University Hospital of Schleswig-Holstein, Campus Kiel, Kiel, Germany
| | - H-W Klötgen
- Department of Dermatology, Inselspital Bern - University Hospital, Bern, Switzerland
| | - A Landmann
- Division of Immunogenetics, Tumor Immunology Program, German Cancer Research Center, Heidelberg, Germany
| | - B Marinovic
- Department of Dermatology and Venereology, University Hospital Center Zagreb and School of Medicine University of Zagreb, Zagreb, Croatia
| | - F Nyberg
- Institution for Clinical Sciences, Unit for Dermatology, Karolinska Institutet at Danderyd Hospital (KIDS), Stockholm, Sweden
| | - R Olteanu
- Department of Dermatology, Colentina Clinical Hospital, Bucharest, Romania
| | - A Ranki
- Department of Skin and allergic diseases, Inflammation Center, Helsinki University Central Hospital, Helsinki, Finland
| | - J C Szepietowski
- Department of Dermatology, Venereology and Allergology, Wroclaw Medical University, Wroclaw, Poland
| | - B Volc-Platzer
- Department of Dermatology, Donauspital, University affiliated Hospital, Vienna, Austria
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