A 35-year-old woman comes to the physician for a follow-up visit. She was recently diagnosed with systemic lupus erythematosus after a 2-month history of fatigue and a skin rash. She was advised to use over-the-counter hydrocortisone cream for the facial rash but it did not help. Her previous medical history is insignificant. The patient has never been pregnant. She does not use tobacco and drinks only 1 or 2 alcoholic beverages a week. She currently takes no prescription medications.
Her vital signs are normal. Skin findings are shown in the image below.

Which of the following is the best therapy for this patient's rash?

Question

A 35-year-old woman comes to the physician for a follow-up visit.  She was recently diagnosed with systemic lupus erythematosus after a 2-month history of fatigue and a skin rash.  She was advised to use over-the-counter hydrocortisone cream for the facial rash but it did not help.  Her previous medical history is insignificant.  The patient has never been pregnant.  She does not use tobacco and drinks only 1 or 2 alcoholic beverages a week.  She currently takes no prescription medications.
Her vital signs are normal.  Skin findings are shown in the image below.

Which of the following is the best therapy for this patient's rash?

Quizplus · Accepted Answer

11ec193a_993c_5c11_853d_19a07231ba62_MD0002_00 This patient has a malar rash that is characteristic of systemic lupus erythematosus (SLE). The rash in SLE usually involves-sun exposed areas of the face, including the nasal bridge, but spares the nasolabial folds. In patients with acute cutaneous SLE who have typical systemic symptoms (eg, fatigue, inflammatory arthritis, pleuritis/pericarditis), the characteristic "butterfly" pattern across the nose and cheeks strongly suggests the diagnosis. However, in many cases, the cutaneous manifestations of SLE may precede the onset of systemic features, and the rash may be mistaken for more common conditions such as rosacea or drug photosensitivity. Definitive diagnosis may require biopsy. systemic lupus erythematosus (SLE) nasolabial folds Mild cases of acute cutaneous SLE may be managed with simple measures such as sun protection and topical corticosteroids. For patients who have moderate disease or have failed initial management, especially those with associated systemic or joint symptoms, antimalarial drugs such as hydroxychloroquine are effective and well tolerated. Systemic glucocorticoids and immunosuppressive agents such as methotrexate or azathioprine are rarely needed to clear skin lesions except for severe or bullous lesions (Choice E). (Choice A) Dapsone, an antibiotic drug, is available in oral and topical forms. The topical form is used primarily for acne vulgaris. Oral dapsone may be used in severe autoimmune skin disease, such as bullous SLE dermatitis, but its toxicity limits use in mild-to-moderate disease. (Choice C) Isotretinoin is an oral retinoid that is most often used for severe nodular acne and can also be used in severe SLE dermatitis. Its use is also limited by significant toxicity, including teratogenicity. (Choice D) Lenalidomide is a thalidomide analog that has been studied for use in chronic cutaneous LE (discoid lupus). It is generally used only in severe cases and is associated with an increased risk for systemic disease flares. (discoid lupus) Educational objective: Dermatitis associated with systemic lupus erythematosus can be managed with sun protection and topical glucocorticoids in most mild cases. Antimalarial drugs such as hydroxychloroquine are used in moderate cases. Immunosuppressive drugs are considered for severe and refractory cases. __________ References: Management of "refractory" skin disease in patients with lupus erythematosus. (http://www.ncbi.nlm.nih.gov/pubmed/16150402)

A 35-Year-Old Woman Comes to the Physician for a Follow-Up