Lupus and Your Skin: Spot It, Stop It, Stay Healthy

Lupus & Your Skin Andrew G. Franks, Jr., M.D., FACP Director, Skin Lupus Center Professor of Clinical Dermatology & Medicine (Rheumatology) NYU School of Medicine

Brain Salivary, Parotid glands Thyroid Heart, Lungs GI tract Kidneys Special complications of pregnancy Joints Blood vessels Skin Heterogeneity of SLE

Skin Disease Overview
How is lupus of the skin identified ?
Can skin lupus be prevented ?
What is the treatment of skin lupus?
Can damaged lupus skin be repaired ?

Identification of Skin Disease
Characteristic and unique features
Skin biopsy may be needed
Patients may have only skin lupus or the disease may be present throughout the body (ie, systemic)
Classifications help doctors to categorize patients and choose therapy

Acute Cutaneous Lupus
Present mostly in patients with systemic disease (SLE)
10:1 Female
Characteristic features:
Butterfly rash (malar rash, not scarring)
Photosensitivity
Blisters & /or erosions
Diffuse hair loss (not permanent)

Subacute Cutaneous Lupus
Mimics common diseases such as psoriasis or fungal infections
Scaly red patches with clearing in center
Very Photosensitive, both UVB & UVA
Often drug-aggravated, but hard to prove
Anti-Ro Ab frequently present

Neonatal Lupus
Anti-Ro antibodies can transfer from mother to child through the placenta
Babies do not actually have lupus. They improve after several weeks as the mother’s antibodies no longer are in the baby’s blood stream
UV light brings out the signs of the disease
(rash around the eyes)

Neonatal Lupus (Cont’d)
No treatment of the skin required other than avoidance of UV light
Can cause heart problems, liver problems, or low platelets in the baby
Recommend high-risk pregnancy OB/GYN

Chronic Cutaneous Lupus
6:5 Female
Is disk-shaped (discoid)
Also known as Discoid Lupus (DLE)
Seen commonly by dermatologists

Chronic Cutaneous Lupus (Cont’d)
Discoid “plaque” (DLE)
P lugged hair follicles
A trophy or thinning of the top layer of skin
S cale or hardness of the skin
T elangiectasias or “spider veins”
E rythema or reddening
Scarring & permanent hair loss can develop

If I Have Cutaneous Lupus, What are the Chances That I Will Develop Systemic Lupus?
Your doctor will keep watch for the following:
Rash below the neck
Related skin lesions
High levels of ANA
Protein in the urine
Blood in the urine
Generalized Joint pain

Prevention of Cutaneous Lupus
Sunscreen & Sun Precautions
Fluorescent Light
Smoking (including secondary)
Hormone changes
Injury to skin, including personal care products & heat
Infection
Diet & Nutrition
Alternative Medicines

UV Protection
UVB (sunburn range) and UVA (non-sunburn range)
UVB blocked by glass
UVA blocked by plastic
UVA can go through car or office windows
Exposure can occur with artificial lights (compact fluorescent) and older computer screens ( not flat panel)

UV Protection (Cont’d)
Suncreens marked with SPF numbers only block UVB which is helpful but not complete protection
Important sunscreen reminders:
UVA and UVB protection
High SPF
Mexoryl & Helioplex are new agents in sunscreen that offer good UVA protection
“ Star Rating” for UVA soon
Sun Protective clothing

Treatment
1 st Line
Antimalarials
Dapsone
Steroids
2 nd Line
Retinoids
Thalidomide
Azathioprine
Methotrexate
Cyclophosphamide
Cyclosporine
Leflunamide
3 rd Line
Rituxin
Remicade, Enbrel, Humira
Raptiva

Moving from Lab to Patient

Clinical Trials
Every clinical trial is carefully designed & then approved by an IRB to answer certain research questions.
A trial plan called a " protocol " indicates which study procedures will be done, when they’ll be done, by whom, and why.
Initially drugs are tested for safety .
Subsequently, drugs are tested for efficacy and compared to standard treatments or to placebo.

Types of Trials
Phase 1 Trials
Usually conducted in 20-80 healthy young adults
Determine safe and well-tolerated doses
Test “escalating” single doses & repeat doses
Provide an initial evaluation of how a drug is absorbed, metabolized and excreted

Types of Trials
Phase 2 Trials
Conducted in 100-300 individuals with the disease or condition
Determine safety in patients
Determine if drug is efficacious vs. placebo or active comparator
Determine optimal doses for efficacy and safety

Types of Trials
Phase 3 (Pivotal) Trials
Conducted in 1000-3000 individuals with the disease condition
Test the drug’s efficacy & compare to placebo &/or standard treatment
Monitor & reveal less common side effects

Types of Trials
Phase 4 Trials
Conducted after a drug is approved and on the market
Find out more about the drug’s long-term benefits, risks, and optimal use
Possibly test the drug in different populations e.g. children

Inclusion Criteria :
Diagnosis of cutaneous discoid lupus by clinical and histopathological exam, 18 – 65 yrs
Exclusion Criteria :
Systemic lupus involving the internal organs
Systemic vasculitis
History of other clinically significant disease process
History of HIV, hepatitis B or C.
Concurrent use of immune modulating therapy
Evidence of incompletely treated tuberculosis
Pregnant or lactating female
PDE-4 Inhibitor in Cutaneous Lupus [email_address] www.ClinicalTrials.gov

Topical Therapy
Topical corticosteroids
Corticosteroid injections
Elidel (pimecrolimus) or Protopic (tacrolimus)—can be helpful

Oral Medications
First choice : antimalarials- Plaquenil (hydroxychloroquine, alone or combined)
Second choice : dapsone , retinoids (Accutane or Soriatane), thalidomide
Third choice : methotrexate, Imuran (azathioprine), CellCept (mycophenolate mofetil), Neoral (cyclosporine)
Chloroquine Quinacrine

What Determines Which Drug I Will Receive?
Known drug allergies
Other disease present (eg, diabetes)
Age, gender
Drug side effects
Severity of disease
Skin only or SLE

Using Antimalarials
Usually start with hydroxychloroquine
May need initial blood tests
Eye exam within the first month of treatment and annually

Using Antimalarials (Cont’d)
Wait 6-8 weeks to see if it’s working
If necessary, add quinacrine
May switch to chloroquine
Drug dose is dependent on body weight

Thalidomide
“ Fast” response
Starts to work within 2 weeks, maximum effect by 2 to 3 months
Effective in many patients who do not respond to antimalarials

Thalidomide Concerns
Can cause nervous system problems (eg, numbness and tingling)
Cannot be used in pregnant women
Premature ovarian failure
Increased risk of blood clots

Anti-TNF 
Effective in treating skin disease
Increases autoantibody production
Patients need to be selected carefully
Remicade, Enbrel, Humira

Repair of Damaged Skin
Reduction of Scars
Removal of Blood Vessels
Elimination of Dark Stains

Laser Surgery
Can be helpful for treating scars, discoloration and blood vessels
Patient MUST be in remission with no active lesions
Does not affect the disease itself

Laser Surgery (Cont’d)
Patients may be required to be on an antimalarial drug
Dark-skinned patients can experience skin discoloration
Patients need to have realistic expectations

Summary
Classifications of lupus help physicians make appropriate drug choices
A majority of patients respond well to antimalarials and topical steroids
Most patients who do not respond to antimalarials will respond to thalidomide or third or fourth line agents.
More treatments on the horizon!

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Lupus and Your Skin: Spot It, Stop It, Stay Healthy

by LupusNY on Oct 17, 2008

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