A note on diagnosing CLE

The American College of Rheumatology (ACR) created an eleven-criteria tool for diagnosing lupus that includes clinical and lab. For a doctor to settle on a diagnosis of systemic lupus, at least 4 of the 11 criteria must be met.

Of the eleven criteria, four deal with symptoms of the skin. They are:

1. malar rash (butterfly rash)
2. discoid lesions
3. mucosal ulcers
4. photosensitivity

This overlap between the ACR systemic lupus guidelines and the cutaneous lupus symptoms have caused some researchers to question the prevalence of each disease.

The European Society of CLE analyzed their multi-center dataset in 2012 exploring the challenges of diagnosing these diseases. Of lupus patients with 4 or more ACR criteria, 48% of patients had CLE, but not systemic lupus.

It is not just researchers that are noticing the potential issues with the criteria. As a result, the Systemic Lupus International Collaborating Clinics Classification Criteria (SLICC) has been developed and is undergoing further comparative testing. For this guideline, there were 17 symptom criteria identified and a diagnosis of systemic lupus requires a clinical criterion and an immunologic one (or lupus nephritis).

Treatments for cutaneous lupus

When battling cutaneous lupus, a number of strategies and medications are used. Because the skin is impacted, there are often two goals of treatment:

1. Avoiding the development or progression of lesions
2. Improving the appearance of the skin

Along with preventative education (such as avoiding sunlight and UVA/UVB rays), a doctor may prescribe medications or topical treatments.

Here, we will focus on topical treatments. To learn more about the medication options, check out this 2014 review published in the journal Best Practice & Research: Clinical Rheumatology

Preventative cutaneous lupus topical treatments

It is crucial not to pick at, squeeze, or scratch cutaneous lupus lesions. This can make the current lesions worse, cause scarring, or even induce new lesions.

If you want to cover lesions or rashes, makeup products can be used. The 2014 review linked above mentions two by name: Dermablend and Covermark.

Additionally, it is important to consider skin health during day-to-day activities. Ultraviolet light can pass through glass and UV light is even present in some indoor fluorescent lights.

A study published in 2001 found that both UVA and UVB irradiation could cause new cutaneous lupus lesions. Because of this, the recommendation is to use a broad sunscreen with a high SPF (at least 50). Sunscreen should be applied 20-30 minutes before UV light exposure.

New research is beginning to explore alternative, non-medicinal treatments such as laser therapy, cryotherapy, and dermabrasion.

Cutaneous lupus topical treatments

Topical Corticosteroids

Examples: Fluocinonide cream; hydrocortisone cream

Effectiveness: Topical corticosteroids reduce inflammatory symptoms in cutaneous lupus. There has been a randomized study with 78 participants that had discoid lupus. The researchers found that higher-dose steroids were more effective in battling the symptoms of CLE. However, steroids are known for having many side effects. The authors of the 2014 CLE review concluded that: “the lowest potency [steroids] allowing for resolution should be used for the shortest duration possible”

Side effects: Atrophy; telangiectasia (spider veins); dermatitis caused by steroids

Calcineurin Inhibitors

Examples: Tacrolimus; pimecrolimus

Effectiveness: Studies suggest that calcineurin inhibitors are as effective as coritcosteroids but do not have the same potentially severe side effects. Some research suggests these topical treatments may be particularly useful for lesions on the face.

Interestingly, a study published in 2011 examined the effectiveness of tacrolimus 0.1% ointment on 30 men and women with cutaneous lupus. The ointment was applied twice per day. There was statistically significant improvement at both 28 and 56 days, but not at 84 days (when compared to placebo/vehicle).

Side effects: Some burning, erythema, irritation

R-salbutamol

Examples: Also known as albuterol

Effectiveness: While R-salbutamol did not improve the Localized Cutaneous Lupus Area and Severity Index (LCLASI) score in a clinical trial, the researchers did find statistically significant improvement in participants pain, itch, scaling, and ulceration.

Side effects: Shakiness; headaches; dizziness; increased feelings of anxiety

NOTE: As with all medications and prescription products, be sure to work with your lupus treatment team to ensure your treatment plan and dosing are suited for you.