What Pharmacists Need to Know About Topical Treatments for Subacute and Discoid Cutaneous Lupus
It’s summertime and you know what that means—patients who love their time outdoors are barraging pharmacists with questions about rashes and bug bites. As you interact with these patients, be on the lookout for any rashes that are indicative of cutaneous lupus. All types of cutaneous lupus, including subacute and discoid, are exacerbated by sunlight and they’re most likely to occur in spring and summer. Whether patients know they have lupus or not, your intervention can make a significant difference. Early treatment—sun protection and topical creams—improves outcomes for subacute and discoid cutaneous lupus.
Autoimmune Diseases Declared Major Women’s Health Concern
When it comes to autoimmune diseases, one word comes to mind: diversity—such great diversity that it translates into a diagnostic challenge. Autoimmunity causes about 100 serious chronic conditions, affecting 5 to 8 percent of the population. Most of the patients—an estimated 74 to 90 percent—are women. The Office of Research on Women’s Health at the National Institutes of Health declared autoimmune disease to be a major women’s health concern—and not just because it disproportionately affects women. Autoimmune diseases one of the 10 leading causes of death in women younger than 65 and the fourth largest cause of disability.1
More than 80 health conditions are associated with autoimmunity, but these occur most frequently:
- Rheumatoid arthritis
- Crohn’s disease
- Type 1 diabetes
- Multiple sclerosis
- Systemic lupus erythematosus
Systemic lupus erythematosus is a leading cause of kidney disease, stroke and heart disease in women of childbearing age. Classic lupus symptoms include a triad of fever, joint pain and rash, but it presents with nine different types of manifestations, each with their own treatment protocols:
Subacute and Discoid Cutaneous Lupus
After isolating dermatologic manifestations, you’re left with three categories of cutaneous lupus: chronic, subacute and acute. As you encounter patients with questions about rashes, keep these symptoms in mind:
- Acute malar rash – Butterfly rash presenting as erythema over the cheeks and nasal bridge that lasts from days to weeks and may be painful or pruritic. This rash can appear in other conditions but is strongly associated with systemic lupus.
- Subacute rash – Non-scarring annular or psoriasiform patches with crusted margins. It often occurs in sun-exposed areas, especially the limbs and torso, but often not the face. About half of patients with this rash will have lupus.
- Chronic discoid lesions – Presents as erythematous to purple, scaly plaques that cause follicular plugging and often result in scarring. About 25 percent of patients with systemic lupus have discoid lesions, but they may have discoid lupus without organ involvement.
Chronic cutaneous lupus has three primary types—discoid, tumid and lupus panniculitis—but discoid is the most common. Tumid lupus presents as papules and plaques, while painful subcutaneous nodules are symptomatic of lupus panniculitis. The malar rash is a well-known symptom, but you may not be as familiar with subacute and discoid lupus. Here are a few key points:
Subacute cutaneous lupus – While spontaneous remission is possible, most patients must manage chronic skin problems with exacerbations common in spring and summer. Healed skin lesions can leave dyspigmentation. Arthralgia and myalgia are the most common symptoms when systemic lupus occurs. Subacute rash usually occurs following exposure to ultraviolet light, but the following drugs also trigger the rash in up to 30 percent of patients:2
- Hydrochlorothiazide – Other antihypertensive agents may be involved but hydrochlorothiazide is the most frequent.
- Calcium channel blockers
- Angiotensin-converting enzyme inhibitors
- Nonsteroidal anti-inflammatory drugs
- Antifungal agent
- Chemotherapy agents
- Proton pump inhibitors
- Tumor necrosis factor antagonists
Discoid cutaneous lupus – Discoid lupus is more likely to occur in genetically predisposed patients, but experts haven’t identified the exact mechanism. The discoid form represents 50 to 85 percent of all cases of cutaneous lupus. Although it seldom progresses to systemic lupus, it has considerable morbidity. Lesions are often painful and tend to cause disfigurement from scars or atrophy, including scarring alopecia. Early treatment may prevent or lessen scarring. Like subacute cutaneous lupus, sun exposure triggers lesions, especially in spring and summer.3
Topical Treatment Options
Patients with cutaneous lupus often express concern about their appearance, how to heal outbreaks and ways to prevent future lesions—all of which reflect the primary treatment goals. While there are no FDA-approved therapies for cutaneous lupus, medications are often prescribed, including antimalarials, leprostatic agents and immunomodulators. Otherwise, first line treatment relies on sunscreens and topical treatments.
Sun protection – One of the biggest challenges may be encouraging compliance with sun protection, which is the first line treatment for subacute and discoid rashes. Patients with the subacute form are so sensitive to UV light they may need to avoid sun exposure. Here are the basics of sun protection for these patients:
- Sunscreen – Patients should use a broad spectrum product with a minimum SPF of 30. They should apply it at least 20 minutes before going outside and then reapply every two to three hours.
- Time of day – Advise patients to avoid sunlight between 10:00 AM and 4:00 PM.
- Protective clothing – Any type of clothing – long sleeves, pants, hats – helps protect from UV light, but patients may consider specialized clothes that offer 100 percent protection such as Solumbra.
- All types of sun exposure – Remind patients that they should avoid artificial sunlight in tanning salons.
Topical treatment – Following sun protection, standard medical therapy for cutaneous lupus consists of the following topical treatments:
- Corticosteroids – Topical corticosteroids are the mainstay of cutaneous treatment. They’re used in 81.5 percent of patients with reported efficacy of 88 percent, according to Autoimmunity Reviews in 2013.4 Fluocinonide cream has proven to be an effective choice. Intermittent treatment with steroid-free intervals may prevent adverse effects such as skin atrophy and steroid-induced rosacea.5
- Calcineurin inhibitors – Topical tacrolimus or pimecrolimus are used to treat discoid and subacute cutaneous lupus. They may cause pruritus, burning or increased erythema, but they don’t have to be discontinued if the patient can tolerate the adverse effects.
- Immunomodulators – Several case reports found improvement in discoid lupus following treatment with topical imiquimod.
Assessment of Skin Rashes Promotes Better Outcomes
Pharmacist outreach significantly improves the quality of life for patients with cutaneous lupus. You may be the first professional to alert patients that their rash may be a sign of lupus, leading to a critical diagnosis.6 You’re also in the position to remind them about the vital role of sun protection. Finally, you have the chance to recommend topical treatments that improve their rash and appearance. In the end, you’ll build a base of customers who keep coming back because they know they can rely on your expertise.
Pharmaceutica North America provides diverse pharmaceuticals to meet the needs of your patients with cutaneous lupus, including prescription drugs such as fluocinonide cream and diclofenac sodium. Contact us today to talk about how we can support your pharmacy.
- “Trends in Selected Autoimmune Diseases,” June 2016, https://www.uspharmacist.com/article/trends-in-selected-autoimmune-diseases ↩
- “Subacute Cutaneous Lupus Erythematosus,” March 2016, http://emedicine.medscape.com/article/1065657-overview ↩
- “Discoid Lupus Erythematosus,” February 2016, http://emedicine.medscape.com/article/1065529-overview ↩
- “Therapeutic Strategies Evaluated by the European Society of Cutaneous Lupus Erythematosus (EUSCLE) Core Set Questionnaire in More Than 1000 Patients with Cutaneous Lupus Erythematosus,” May 2013, http://www.ncbi.nlm.nih.gov/pubmed/23220353 ↩
- “Treatment of Cutaneous Lupus,” August 2011, http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3245840/ ↩
- “Lupus: Help and Resources,” 2016, http://www.lupus.org/resources/tools-for-your-patients ↩