Discoid Lupus Erythematosus – Treatment
Since DLE can cause irreversible scarring alopecia, the goal of therapy is to prevent the formation of new lesions and to treat early existing lesions before scarring occurs. DLE responds better to therapy than LPP. Patients with DLE should be counseled on sun protection and avoidance. Midpotent and superpotent topical steroids can be used to treat existing lesions.
Intralesional triamcinolone, at doses of 5 to 10 mg/cc, are often effective at treating existing scalp lesions (lower concentrations should be used for facial lesions). I recommend against initial concomitant use of superpotent topical steroids and intralesional triamcinolone, as this combination can result in significant atrophy. If the patient is not developing new lesions, topical and intralesional steroids can be the mainstays of treatment. However, these treatment modalities do not prevent development of new plaques; this requires systemic therapy.
Hydroxychloroquine, or Plaquenil, is the most effective systemic therapy with the least amount of toxicity for DLE patients. After obtaining a baseline complete blood count (CBC), liver function tests (LFTs), a G6-P-D, and an eye exam by an ophthalmologist, start hydroxychloroquine at a dose of 400 mg a day. Repeat the CBC and LFTs about one month after initiating therapy, and then every 4 to 6 months. An eye exam should be performed by an ophthalmologist every 6 to 12 months while on hydroxychloroquine to screen for early retinopathy. Once the patient has responded, the hydroxychloroquine dose can be dropped to 200 mg/day and maintained for months to a few years to prevent recurrence of the disease. If hydroxychloroquine is not effective after 2 months of therapy, quinacrine (Atabrine) can be added. This medication is only available in the United States through compounding pharmacies.
Other systemic medications which have proven beneficial for patients with DLE include thalidomide, dapsone, isotretinoin, and methotrexate.