Workup: Exam, biopsy
In addition to a routine history and physical examination, the workup for DLE should include a complete blood count, antinuclear antibody levels, anti-Ro, anti-La, hepatic and renal function tests, and urinalysis. Consider a diagnosis of SLE by using the American College of Rheumatology criteria. A biopsy for histopathology of a fresh lesion or a biopsy for immunofluorescence of an old lesion can confirm the diagnosis.
Therapeutic options are varied
Effective early therapies for DLE are available, but patients who do not respond appropriately may end up with deep scars, alopecia, and pigmentary changes that are considerably disfiguring, especially for dark-skinned people. Therefore, the goal of treatment is not only to improve the appearance of the skin by minimizing the scarring and preventing further lesions, but also to prevent future complications.
Avoiding sunlight. The primary therapeutic approach is to educate patients regarding exposure to sunlight. Sun-protective measures include the use of high-SPF sunscreen lotions and protective clothing, such as baseball caps without vent holes and wide-brimmed hats.7
Medication options. Current treatment options for DLE include antimalarial agents such as chloroquine, topical and intralesional glucocorticoids, and thalidomide. The use of potent topical steroids may prevent significant scarring and deformity, especially of the face. Common side effects include steroid withdrawal syndrome, perioral dermatitis, steroid acne, and rosacea. All of these side effects can be treated and result in less long-term deformity than untreated DLE (FIGURE 2).
Systemic agents. Widespread disease may require you use systemic agents, such as antimalarials. Chloroquine has long been considered the gold standard in the treatment of DLE.8 Due to the frequency of ocular side effects with chloroquine, hydroxychloroquine is by far the most widely used agent. Hydroxychloroquine at a dose of 6.5 mg/kg/d for 3 months may lead to resolution of lesions for many patients.7 In resistant cases, higher dosages (eg, 400 mg/d) or combinations (eg, hydroxychloroquine 200 mg/d plus quinacrine 50 to 100 mg/d) may be required for months or even years. An ophthalmological evaluation is advisable before starting antimalarial treatment, and you should repeat it at 4- to 6-month intervals during treatment.9 Systemic corticosteroids may be needed to obtain timely initial control, especially for widespread and disfiguring lesions.