Background The anti-BAFF monoclonal antibody, belimumab, was approved about five years ago by the US Food and Drug Administration for the treatment of adult SLE patients. The utility of belimumab for management of resistant systemic lupus erythematosus (SLE) has been demostrated but concerning skin manifestations only scarce evidences have been reported. We describe our experience of using this new drug for the successful management of recalcitrant cutaneous lupus.
Case report A 38-year-old man with a five year history of SLE presented, in May 2017, at our outpatient clinic for a disease flare with severe cutaneous involvement. On examination the patient presented malar rash and erythematous-infiltrated discoid lesions in the region of head and neck and erythematosus papules also on the extensor surface of the hands. Additional tests showed also systemic involvement by detecting low levels of C3 and C4, leukopenia (WBC 3000/µL) and positivity of ANA (1:1280 by IFI) and anti-dsDNA (42.8 UI/ml by ELISA, nv <30 UI/ml). SLE Disease Activity Index (SLEDAI) was 9, Cutaneous Lupus Disease Area and Severity index- activity and damage scores (CLASI) was 22 for activity and 1 for damage and Physician Global Assessment (PGA) was 8 cm. The patient failed previous treatment with HCQ, MTX, AZA, MMF and at time of our observation was taking, since December 2016, prednisone (12,5 mg daily) without improvement. Belimumab was added to concomitant steroid therapy at recommended dose (10 mg/kg). Early as 3 months after its initiation Belimumab therapy led to impressive clinical improvement in the lesions upper the hands and slighter in that in the region of head. Belimumab use also provided a significant steroid-sparing effect as well as facilitating the rapid improvement in skin symptoms and in systemic involvement.
Conclusion In this case report, the addition of belimumab to steroid monotherapy, in patient who failed previous immunosuppressive treatment improved the signs and symptoms of refractory cutaneous lupus. This report highlights the utility of belimumab for the treatment of severe skin involvement in SLE refractory to conventional therapies. Additional studies should be performed to assess the use of belimumab in the treatment of cutaneous lupus.
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