A suggested algorithm for the management of cutaneous manifestations of SLE has highlighted the wide range of potential therapies available.

The algorithm was developed from evidence from a systematic review resulting in 107 studies examining 11 different categories of treatment in 7,343 patients.

Led by Australian researchers, the review found topical therapy with calcineurin inhibitors may be a good first-line, steroid-sparing approach in mild CLE disease.

“In practice, topical corticosteroids are routinely used either as first line monotherapy in mild localized CLE, or in combination with systemic agents in more severe and widespread disease. However, despite anecdotal evidence and expert opinion supporting this, there is limited formal evidence and no studies to report in this review,” the study said.

It said calcineurin inhibitors, when used in sensitive areas such as facial skin, carry a lower risk of complications including telangiectasia and striae compared with topical corticosteroids.

The review found limited evidence of benefit for R-salbutamol cream.

There was moderate evidence for hydroxychloroquine in mild-moderate disease requiring systemic therapy however much less evidence for any other antimalarials.

“Trials of second line agents or combination therapy may avoid escalation to more immunosuppressive therapies,” it said.

The review found limited evidence supporting the use of synthetic dMARDs such as methotrexate in moderate-severe disease although anecdotal evidence suggested they might be worth trialling.

Cyclophosphamide and thalidomide were likely beneficial but had a high risk of toxicity and notably, thalidomide was of limited use in many lupus patients who were women of childbearing age.

Lenalidomide had slightly less evidence for benefit than thalidomide but also had fewer adverse effects.

The review found some evidence for belimumab, conflicting data for rituximab and limited data for other biologics.

“Other possible options for treatment of CLE include laser therapy, with low-moderate evidence for pulsed dye laser; however, caution must be taken in light of the theoretical risk of disease flare on exposure to laser light wavelengths.”

There was conflicting data on the use of IVIG.

General measures to be considered in all patients with cutaneous SLE included smoking cessation, sun protection measures and optimisation of vitamin D levels.

“Although based on the results of this literature review, we have described a potential management approach for CLE, this review highlights the need for further high-quality RCTs with clearly defined outcome measures to assist in refining the treatment approach to CLE,” it concluded.