Discoid and systemic lupus erythematosus

Lupus erythematosus is a chronic autoimmune disease in which the immune system attacks healthy tissues, causing inflammation of the skin and multiple organs. The disease ranges from skin-limited discoid lupus erythematosus (DLE) to systemic lupus erythematosus (SLE) involving the kidneys, joints, heart, lungs, nervous system, and blood.

Women of child-bearing age are affected most frequently.

Pathophysiology (Brief)

The disease results from:

• Autoantibody production

• Immune complex deposition

• Chronic inflammation

• Tissue damage affecting multiple organs

Signs & Symptoms

Discoid lupus erythematosus

• Hypopigmented or depigmented plaques

• Follicular plugging

• Facial lesions

• Scarring alopecia when scalp is involved

Systemic lupus erythematosus

• Malar rash

• Discoid rash

• Photosensitivity

• Oral ulcers

• Arthritis

• Serositis

• Renal disease

• Fatigue

• Fever

Diagnostic Criteria

Diagnosis is based on:

• Typical clinical manifestations

• Positive autoimmune serology

• Organ involvement

Investigations

• Full blood picture

• ESR

• Liver function tests

• Renal function tests

• Urinalysis

• ANA

• Anti-dsDNA

• Anti-Sm antibodies

• Antiphospholipid antibodies

• Skin biopsy when indicated

Monitoring

• Blood count, liver and renal function every 3 months

• Random blood glucose every 3 months during prolonged corticosteroid therapy

Treatment

Non-pharmacological treatment

• Ophthalmology review before starting hydroxychloroquine and every 6 months thereafter

• Use sunscreen and protective clothing

• Monitor blood pressure

• Physiotherapy when needed

• Involve a physician

• Deworm with Albendazole 400 mg stat before prolonged immunosuppressive therapy where appropriate

Pharmacological Treatment

Discoid lupus erythematosus

• Clobetasol propionate cream/ointment (topical) 0.05% — apply every 12 hours

AND

• Hydroxychloroquine (PO) 200 mg once daily for not less than 3 months

Systemic lupus erythematosus

• Prednisolone (PO) 0.5–1 mg/kg once daily for 4 weeks, then taper gradually

AND

• Methotrexate (PO) 7.5–20 mg once weekly

AND

• Omeprazole (PO) 20 mg once daily when indicated for gastritis or peptic ulcer disease

Complications

• Lupus nephritis

• Cardiovascular disease

• Neuropsychiatric lupus

• Permanent skin scarring

• Increased infection risk

Patient counselling

• Avoid excessive sunlight.

• Use sunscreen daily.

• Attend regular eye examinations while taking hydroxychloroquine.

• Continue medications even when symptoms improve unless advised otherwise.