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

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A presentation by Andrew G. Franks, Jr, MD …

A presentation by Andrew G. Franks, Jr, MD
Director, Connective Tissue Disease Service
Clinical Professor of Dermatology and Medicine (Rheumatology)
One of New York Magazine’s Best Doctors 2008
at the Manhattan stop on New York City Hospital Tour

NYU Langone Medical Center
October 14, 2008

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  • Nice presentation & well explained facts..Loved it..Thanks a lot for sharing..:)

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  • Andrew G Franks. Jr. M.D.,FACP
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  • I have DSLE and maybe Subacute Discoid Lupus.
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  • 1. Lupus & Your Skin Andrew G. Franks, Jr., M.D., FACP Director, Skin Lupus Center Professor of Clinical Dermatology & Medicine (Rheumatology) NYU School of Medicine
  • 2. Brain Salivary, Parotid glands Thyroid Heart, Lungs GI tract Kidneys Special complications of pregnancy Joints Blood vessels Skin Heterogeneity of SLE
  • 3. 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 ?
  • 4. 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
  • 5. 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)
  • 6.  
  • 7.  
  • 8.  
  • 9. 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
  • 10.  
  • 11.  
  • 12. 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)
  • 13. 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
  • 14.  
  • 15. Chronic Cutaneous Lupus
    • 6:5 Female
    • Is disk-shaped (discoid)
    • Also known as Discoid Lupus (DLE)
    • Seen commonly by dermatologists
  • 16. 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
  • 17.  
  • 18.  
  • 19.  
  • 20.  
  • 21.  
  • 22. 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
  • 23. 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
  • 24. 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)
  • 25. 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
  • 26. 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
  • 27. Moving from Lab to Patient
  • 28. 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.
  • 29. 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
  • 30. 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
  • 31. 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
  • 32. 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
  • 33.
    • 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
  • 34. Topical Therapy
    • Topical corticosteroids
    • Corticosteroid injections
    • Elidel (pimecrolimus) or Protopic (tacrolimus)—can be helpful
  • 35. 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
  • 36. 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
  • 37. Using Antimalarials
    • Usually start with hydroxychloroquine
    • May need initial blood tests
    • Eye exam within the first month of treatment and annually
  • 38. 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
  • 39. 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
  • 40. 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
  • 41. Anti-TNF 
    • Effective in treating skin disease
    • Increases autoantibody production
    • Patients need to be selected carefully
    Remicade, Enbrel, Humira
  • 42. Repair of Damaged Skin
    • Reduction of Scars
    • Removal of Blood Vessels
    • Elimination of Dark Stains
  • 43. 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
  • 44. 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
  • 45.  
  • 46.  
  • 47.  
  • 48.  
  • 49.  
  • 50.  
  • 51. 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!