Drugs for discoid lupus erythematosus

Discoid lupus erythematosus (DLE) is a severe form of skin inflammation which occurs particularly on sun-exposed skin. It can cause permanent scarring but this can be prevented by early treatment. All forms of cutaneous lupus erythematosus are most common in women of childbearing age: this is particularly important because some treatments, including thalidomide and retinoids, cause birth defects. This review found that fluocinonide cream is more effective than hydrocortisone. Hydroxychloroquine and acitretin appear to work equally well, although acitretin has more frequent and severe adverse effects. Participants taking acitretin showed a small increase in serum triglyceride, not sufficient to require withdrawal of the drug. The acitretin trial was flawed by the inclusion of people with subacute cutaneous lupus and by the lack of a placebo arm. The trial does not provide evidence that either hydroxychloroquine or acitretin will be effective in people not responding to the other agent as it did not use a cross-over design.

Authors' conclusions: 

Fluocinonide cream may be more effective than hydrocortisone in treating people with discoid lupus erythematosus. Hydroxychloroquine and acitretin appear to be of equal efficacy, although adverse effects are more frequent and more severe with acitretin. There is not enough reliable evidence about other drugs used to treat discoid lupus erythematosus.

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Background: 

Discoid lupus erythematosus is a chronic form of cutaneous (skin) lupus which can cause permanent scarring if treatment is inadequate. Many drugs have been used to treat this disease and some of these are potentially very toxic.

Objectives: 

To assess the effects of drugs for discoid lupus erythematosus.

Search strategy: 

In June 2009 we updated our searches of the Cochrane Skin Group Specialised Register, the Cochrane Central Register of Controlled Trials (CENTRAL) in The Cochrane Library (Issue 2, 2009), MEDLINE, EMBASE, LILACS, and online ongoing trials registers. The reference lists of relevant reviews were searched. Index Medicus (1956 to 1966) was handsearched and we approached authors for information about unpublished trials.

Selection criteria: 

We included all randomised trials of drugs to treat people with discoid lupus erythematosus. Drugs included in the search were azathioprine, chloroquine, clofazimine, corticosteroids, (oral and topical), dapsone, gold, interferon alpha-2a, methotrexate, phenytoin, retinoids, sulphasalazine, thalidomide, topical calcineurin blockers (pimecrolimus and tacrolimus), and biological agents (etanercept, efalizimab, infliximab, and rituximab).

Data collection and analysis: 

Two reviewers independently examined each retrieved study for eligibility.

Main results: 

Two trials involving 136 participants were included. No new trials were included in this update.

In a cross-over study of 12 weeks duration, fluocinonide 0.05% cream (a potent topical corticosteroid), appeared to be better than hydrocortisone 1% cream (a mild corticosteroid) when the first arm of the trial involving 78 participants was analysed at 6 weeks. Clearing or excellent improvement was seen in 27% of people using fluocinonide and in 10% of those using hydrocortisone, giving a 17% absolute benefit in favour of fluocinonide (95% CI 0.0 to 0.34, NNT (Number needed to treat) 6).

In the second trial, acitretin (50mg/day) was compared with hydroxychloroquine (400mg/day) in 58 people in a parallel trial of 8 weeks duration. There was marked improvement or clearing in 46% of people using acitretin and in 50% of those on hydroxychloroquine but there was no significant difference between the 2 interventions. The adverse effects were more frequent and more severe in the acitretin group. In this trial clearing of erythema was measured and found to be better in the hydroxychloroquine group (RR 0.61, 95% CI 0.36 to 1.06).