Clinico-histological and Immunopathological Features of Patients with Cutaneous Lupus Erythematosus at Tertiary Dermatology Centre in Malaysia

BACKGROUND

Cutaneous lupus erythematosus (CLE) is a chronic, autoimmune skin disease with a wide spectrum of clinical presentations in different populations.

OBJECTIVE

To study the clinico-histological and immunological features of CLE in a multi-ethnic population and to identify the predictive factors of disease severity based on CLE disease area and severity index (CLASI) scores.

METHODS

This is a cross-sectional study of CLE conducted from March 2019 till February 2020.

RESULTS

A total of 111 patients were recruited with female to male ratio of 4.9:1. Acute CLE contributed 47.7%, followed by chronic CLE, 46.9% and subacute CLE, 5.4%. Eighty-four percent of patients had systemic lupus erythematosus. About 67.3% with chronic CLE developed systemic involvement. Anti-nuclear antibody (ANA) was detected in 90.0%. Skin biopsy(n=42) showed perivascular lymphocytic infiltration (95.2%), epidermal atrophy (47.6%) and hydropic degeneration of basal layer (47.6%). More than 40% had immunoglobulin deposition at dermo-epidermal junction, predominantly granular pattern. Mean CLASI-total was 6.44±7.70, CLASI-activity 2.75±4.10 and CLASI-damage 3.71±4.76. Body surface area (BSA) involved was found to be an independent predictive factor for CLASI-activity (OR:1.34, p=0.018). For CLASI-damage, BSA (OR:4.14, p<0.0001), discoid lupus erythematosus (DLE) subtype (OR:13.10, p=0.001), cutaneous vascular disease (OR:26.59, p=0.014), scalp involvement (OR:8.7, p=0.008) and hypocomplementemia (OR:5.71, p=0.046) were the positive predictive factors. Mean DLQI was 5.91 ± 5.34 and it correlated significantly with disease severity.

CONCLUSIONS

We observed a high percentage of patients with CLE with systemic manifestations and positive ANA. More aggressive treatment of those with positive predictive factors for severe disease combined with significant clinical activity may be warranted.

Cutaneous Lupus Erythematosus: An Update on Pathogenesis, Diagnosis and Treatment

Cutaneous lupus erythematosus (CLE) includes a broad range of dermatologic manifestations, which may or may not be associated with systemic disease. Recent studies in this area continue to shape our understanding of this disease and treatment options. Epidemiologic studies have found an incidence of CLE of 4.30 per 100,000, which approaches similar analysis for systemic lupus erythematosus (SLE). Although there have been extensive efforts to define SLE, the classification of CLE and its subgroups remains a challenge. Currently, diagnosis relies on clinical and laboratory findings as well as skin histology. The Cutaneous Lupus Area and Severity Index™ (CLASI™) is a validated measure of disease activity and damage. CLE pathogenesis is multifactorial and includes genetic contributions as well as effects of ultraviolet (UV) light. Immune dysregulation and aberrant cell signaling pathways through cytokine cascades are also implicated. Patient education and avoidance of triggers are key to disease prevention. Antimalarials and topical steroids continue to be the standard of care; however, immunosuppressants, thalidomide analogs and monoclonal antibodies are possible systemic therapies for the treatment of recalcitrant disease.

Efficacy of Intravenous Immunoglobulin Monotherapy in Patients with Cutaneous Lupus Erythematosus: Results of Proof-of-Concept Study

Cutaneous lupus erythematosus (CLE) is a chronic inflammatory autoimmune skin disease. Evidence-based therapy for CLE is lacking in the most part. Intravenous immunoglobulin (IVIg) is being increasingly utilized as off-label therapy for a variety of autoimmune and inflammatory conditions, especially in dermatology. The usefulness of IVIg in CLE is not well established. The goal of the present study was to obtain the proof-of-concept evidence that IVIg can control acute CLE and thus replace current systemic immunosuppressive therapy that causes severe side effects and adverse reactions. Sixteen patients who tried and failed various systemic treatments for CLE were screened and consented to use IVIg as a monotherapy. The IVIg was administered at 500 mg/kg/day on 4 consecutive days up to a total of 2 g/kg/month for 3 months, and the subjects were monitored for additional 6 months off any drug for a possible relapse. The cumulative results revealed an overall improvement, as evinced by a decrease of both objective and subjective measures of disease activity. The most sensitive and specific objective and subjective instruments for assessment of the therapeutic effect of IVIg were CLASI-A (Cutaneous Lupus Erythematosus Disease Area and Severity Index) measuring disease activity and Skindex-29 scores, respectively. The CLASI-A score dropped down from the initial value taken as 100%, and remained in the range of approximately 70% until the last visit. Three patients (18.8%) had a temporary flare of CLE symptoms but recovered within a month from the relapse. No serious side effects and adverse reactions occurred. Thus, IVIg monotherapy in CLE allowed to achieve: i) rapid and persistent decreased in disease activity; ii) steady improvement of patients’ quality of life assessed by Skindex-29; iii) low relapse rate; and iv) mild nature and short duration of relapses. Since healing was maintained for months after IVIg treatment, it is possible that the IVIgtriggered molecular events mediating the therapeutic action of IVIg that continued to unfold after the end of therapy.

Evaluation of the quality of life of lupus erythematosus patients with cutaneous lesions in Japan

The quality of life (QOL) of lupus erythematosus (LE) patients with skin manifestations is impaired, but little is known about Japanese patients. We assessed whether the skin symptoms in LE are associated with the QOL using the Japanese versions of the Skindex-29 and Cutaneous Lupus Erythematosus Disease Area and Severity Index (CLASI). In all, 54 LE patients with cutaneous lesions completed the Japanese version of the Skindex-29, and physicians assessed the severity of their eruptions using the CLASI before and after treatment. The QOL of the LE patients was better after the therapeutic intervention using the Skindex-29 questionnaire. We tested several factors for an independent association with the QOL. A significant risk factor for a poor QOL was a female gender in “Functioning” before treatment. In addition, a poor QOL tended to be correlated with a female gender in “Emotions” and older current age in “Symptoms” before treatment, and with a longer duration of SLE in “Functioning” after treatment. In the CLASI analysis, skin manifestation activity in the acute phase correlated with a poor emotional and functional QOL rather than a symptomatic QOL. To the best of our knowledge, this is the first report evaluating the QOL of Japanese LE patients, despite the small cohort.