The major toxicity with thalidomide is a cumulative dose-dependent sensory neuropathy that is not always reversible upon drug discontinuation. Dr. Callen therefore keeps the dose as low as possible: Maintenance therapy might range from 50 mg/day to 25 mg every second or third day. He said he usually employs thalidomide in conjunction with an antimalarial agent unless the patient has antimalarial toxicity. A response to thalidomide becomes evident within a few weeks, although the full response takes about 3 months. Relapse is common with discontinuation of thalidomide; restarting the drug usually restores the clinical response, he said.
Other systemic options include dapsone (which in a controlled trial proved slightly less effective than chloroquine), methotrexate, azathioprine, and mycophenolate mofetil (CellCept).
The two major subtypes of cutaneous LE are discoid and subacute. Discoid lesions leave scarring and atrophy. Subacute cutaneous LE lesions do not, although there may be residual hypopigmentation. Discoid LE is subcategorized into localized to the head and neck or widespread. The distinction is clinically relevant because widespread discoid LE is more difficult to control, has a higher rate of associated serologic abnormalities, and probably is more likely to progress to SLE.
Dr. Callen disclosed serving as a consultant to Abbott, Amgen, Centocor, Electro-Optical Sciences, and Medicis.