Dermatology pearls: Encourage sun protection, optimize steroids for cutaneous lupus
SAN DIEGO — While encouraging patients with cutaneous lupus erythematosus to use adequate sun protection, rheumatologists should be treating disease flares with more potent steroids then tapering off once other therapies are in progress, according to a presentation at the 2019 Congress of Clinical Rheumatology West.
“For patients with cutaneous lupus, sunscreen is only a small portion of the battle,” Ruth Ann Vleugels, MD, MPH, director of the Autoimmune Skin Disease Program at Brigham and Women’s Hospital, told attendees. “I want all my patients to wear a wide-brimmed hat and photoprotective clothes — like a long-sleeved shirt — and then apply their sunscreen.”
She noted, “Any time a patient comes to my office, I see what they wore and check to see if they brought their hat. They might say ‘oh I only walked from the car to the office’ and I take the moment to remind them, even if they walk from their house to the mailbox, they need their hat on. It is the small doses of sun that will flare their skin disease.”
Although smoking cessation is often recommended to all patients regardless of disease status, Vleugels said that patients with cutaneous lupus bear an exceptional benefit. “You may be less familiar with that fact that smoking is an independent risk factor for cutaneous lupus. If we can get our patients to stop smoking, it actually improves their disease to some degree based on that intervention alone.”
For most patients with cutaneous lupus, early treatment with topical steroids is essential to minimize scarring, Vleugels noted, but highlighted that rheumatologists should optimize their approach with these steroids.
“Rather than choosing a weak topical steroid, I want you to choose a potent or class 1 topical steroid, such as clobetasol or diprolene,” Vleugels said. “And I want you to pulse that in these patients – one week on, one week off – for the first two months while you are getting the other therapies started and then you can lower the strength of the topical steroid.”
Additionally, Vleugels noted that rheumatologists should keep measurements in mind when writing their prescriptions for topical steroids.
“If you don’t write a number of milligrams on your prescription, your patient gets a tube that is the size of a travel toothpaste,” she said. “This is really important because your patient will be drastically undertreated if that is the size of their tube. Keep in mind, we can also give patients triamcinolone, which comes in a pound jar of 454 grams and is the cheapest means of giving topical steroids.” —by Robert Stott
Vleugels RA. Cutaneous manifestations of rheumatic disease. Presented at: Congress of Clinical Rheumatology West; September 26-29, 2019; San Diego.
Disclosure: Vleugels reports a consulting relationship with Pfizer.