Topical calcineurin inhibitors in cutaneous lupus erythematosus In the management of cutaneous lupus erythematosus (CLE), topical calcineurin inhibitors have recently been established as the first-line treatment according to the S2k guidelines for the treatment of CLE.^{1 2} This recommendation is further supported by the 2019 European League Against Rheumatism (EULAR) recommendations, which state that topical calcineurin inhibitors should be considered as a primary choice for treating cutaneous lesions in patients with systemic lupus erythematosus (SLE).³ A randomized, controlled trial demonstrated tacrolimus 0.1% ointment to be significantly more effective than placebo in treating CLE.⁴ Additionally, facial lesions showed a better response to tacrolimus ointment 0.1% compared to lesions on the body, particularly when the lesions had been present for less than 6 months. In summary, tacrolimus ointment 0.1% is recommended primarily for treating facial lesions in CLE and can serve as an alternative to topical glucocorticoids. In cases where the disease is widespread and/or there is a risk of scarring, concurrent treatment with antimalarials is recommended.

Case: A 34-year-old female with SLE A 34-year-old female patient diagnosed with SLE presented with confluent erythematous, edematous papules and plaques, known as ’malar rash’, on the left side of her face. She received treatment with antimalarial agents and mycophenolate mofetil; however, over the past month, she had developed skin lesions after sun exposure. After 28 days of treatment with tacrolimus ointment 0.1%, her skin lesions had completely resolved. No recurrence of skin lesions was observed after 84 days of treatment with 0.1% tacrolimus ointment.⁴

References

1. Kuhn A, et al. S2k guideline for treatment of cutaneous lupus erythematosus - guided by the European Dermatology Forum (EDF) in cooperation with the European Academy of Dermatology and Venereology (EADV). J Eur Acad Dermatol Venereol. 2017 Mar;31(3):389–404. doi: 10.1111/jdv.14053.

2. Worm M, et al. S2k guideline: Diagnosis and management of cutaneous lupus erythematosus - Part 2: Therapy, risk factors and other special topics. J Dtsch Dermatol Ges. 2021 Sep;19(9):1371–1395. doi: 10.1111/ddg.14491.

3. Fanouriakis A, et al. 2019 update of the EULAR recommendations for the management of systemic lupus erythematosus. Ann Rheum Dis. 2019 Jun;78(6):736–745. doi: 10.1136/annrheumdis-2019-215089.

4. Kuhn A, et al. Efficacy of tacrolimus 0.1% ointment in cutaneous lupus erythematosus: a multicenter, randomized, double-blind, vehicle-controlled trial. J Am Acad Dermatol. 2011 Jul;65(1):54–64, 64.e1-2. doi: 10.1016/j.jaad.2010.03.037.

Learning Objectives

• Discuss the topical and systemic treatment options in CLE

• Describe the preventive strategies in CLE

• Discuss the therapeutic guidelines of CLE

• Describe the RCLASI as validated activity and damage score of CLE