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ARCHIVES THERE ARE 6 ARticles on the subject of cutaneous lupus erythematosus (CLE) that provide dermatologists
with new insights and offer us practical advice
about the manner in which we might care for
patients who present to our clinics and offices with cutaneous lesions of lupus erythematosus (LE). I reached
out to several of the authors for answers to some of the
questions that developed as I reviewed this group of articles systemically rather than individually. The answers that I received to some of my questions are within
this editorial. As part of the process of preparing this editorial, I have included some practical information about
how I evaluate and treat patients with CLE in my clinical practice and conclude with what I see are unanswered questions that remain for future study.
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Although none of the studies reported in this issue address the second part of the question posed, there is at
least 1 observation that suggests that the use of antimalarial therapy will possibly prevent the progression to SLE.
In a study of military recruits,8 it was demonstrated that
the development of SLE was preceded by a progressive
development of autoantibodies. As an extension of this
study, the same authors analyzed whether the time from
first symptom to development of SLE was altered by the
use of antimalarial therapy.9 One hundred thirty military recruits who eventually developed SLE were included in this analysis. There were 26 patients in whom
antimalarial drug therapy, primarily hydroxychloroquine, was started before classification of SLE, and they
were compared with those who did not have therapy prior
to classification. In addition, the authors9 compared these
patients with those treated with nonsteroidal antiinflammatory drugs (NSAIDs) and systemic corticosteroids. The use of corticosteroids or hydroxychloroquine was associated with a longer lag time from the first
symptom of SLE to the development of 4 criteria (only 1
patient was treated prior to any symptom). In addition,
the combination of hydroxychloroquine with corticosteroids was statistically associated with a longer lag time
than corticosteroids alone. There was no increase in the
lag time for NSAID therapy. Hydroxychloroquinetreated patients also had less frequent leukopenia, lymphopenia, and proteinuria. Although the symptom that
led to therapy in most patients was arthritis, there were
several patients in whom CLE (discoid rash) was the reason for therapy. Thus, it is possible that early use of antimalarial therapy might delay the development of SLE.
HOW DOES THE PRESENCE OF CLE HAVE
AN IMPACT ON A PATIENTS QUALITY OF LIFE,
AND DOES TREATMENT HAVE AN EFFECT
ON IMPROVING PATIENTS WHOSE DISEASE
HAS HAD AN IMPACT ON THEIR LIVES?
There are ample studies that document the impact of various skin diseases on the quality of life, but few have dealt
with the impact of CLE. The investigators5 at the University of Pennsylvania and University of Texas have clearly
shown that the presence of cutaneous disease is associated with an effect on patients quality of life and, further,
that the impact is greatest for patients with widespread DLE.5
In addition, their use of a validated scoring system will allow documentation of improvement in future studies of
therapies that might be developed for CLE. This was applied to the observation herein detailing the use of lenalidomide for the treatment of patients with recalcitrant LE10
and has also been used in several previous studies of newer
agents or new uses of existing agents.11,12
HOW OFTEN AND WHICH DRUGS ARE
INVOLVED IN EXACERBATION OF,
OR INDUCTION OF, CLE?
In 1985, Reed et al13 published the first case series of SCLE
that was linked to the administration of a drug. In their report, the onset of the cutaneous eruption occurred during
the administration of hydrochlorothiazide and resolved with
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seldorf, Germany, the second in Kyoto, Japan) will include this issue as they plan their meeting.
The development of systemic disease in patients with
what seems to be a strictly cutaneous disease at diagnosis has been highlighted in this issue of the Archives. What
is needed is a clear statement of how to monitor patients
for this possibility. Is there predictive value of obtaining
immunofluorescence microscopic findings on patients at
diagnosis? Should we be performing repeated serologic
testing in our patients, or should we only follow patients with a careful clinical history along with complete blood cell counts and urinalyses?
We need more information about whether the early onset of therapy, specifically with an antimalarial drug, might
delay the onset of systemic disease. We also need to prove
that smoking cessation is an effective adjunct to traditional therapy. Last, because there is a seemingly growing
body of patients with recalcitrant disease, we need to develop new therapies, particularly ones that are effective, safe,
and economical because many of the therapies we now consider (eg, mycophenolate mofetil, efalizumab, thalidomide, and lenalidomide) have potential toxic effects and
cost in the range of $1500 to $3000 per month. Bottom line:
although the work presented herein is clinically relevant,
and practical information for the care of our patients is available, there remain a number of unanswered questions.
Jeffrey P. Callen, MD
Correspondence: Dr Callen, Division of Dermatology,
University of Louisville School of Medicine, 310 E Broadway, Louisville, KY 40202 (jefca@aol.com).
Financial Disclosure: Dr Callen has received honoraria
from Amgen, Abbott Immunology, Genentech, Centocor, Electrical Optical Sciences, Medicis, and Steifel. He
serves on a safety monitoring committee for Genmab.
Additional Contributions: Carol Kulp-Shorten, MD, provided critical comments.
Disclaimer: Dr Callen is associate editor of the Archives
of Dermatology, but he was not involved in any of the decisions regarding review of the manuscript or its acceptance.
REFERENCES
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Hypothalamic-Pituitary-Adrenal Axis
Suppression in Systemic Glucocorticoid-Treated
Infantile Hemangiomas
Putting the Risk Into Context
Ulceration
Visual compromise
Infection
Pyschosocial stigmatization
Bleeding
Pain
Hypothyroidism
Coagulopathy
Laryngospasm
The recent serendipitous discovery of incidental IH improvement in infants treated with propranolol hydrochloride for cardiac concerns is very exciting.6 In their small cohort, Leaute-Labrze et al6 demonstrated that propranolol
not only appeared to stop hemangioma growth but to dramatically hasten involution. Propranolol is a relatively safe
agent that has a long track record. It is, however, typically
used in a very different patient population, who are often
observed in hospital during the initial dosing and followed
carefully. The idea that propranolol could be haphazardly
adopted as a first-line treatment for problematic IH on account of extraordinary but premature results gives pause and
redoubles the need for good safety data on the standard of
care and systemic GCs that propranolol might challenge.
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