Severe or Widespread Discoid Lupus When Retinoid or Dapsone Therapy Has Failed: What to Do Next
Clinical Scenario
This protocol addresses patients with severe or widespread skin lesions of discoid lupus erythematosus, or those at risk of scarring or progression to systemic disease, who are not pregnant and not breastfeeding.
Previous Treatment — Failure Condition
This is a next-line protocol. The preceding regimen consisted of retinoids (acitretin or isotretinoin) or dapsone, given alongside antimalarials. Escalation to this line is indicated when response to retinoid therapy is not achieved within 2 to 6 weeks of treatment.
Treatment Approach (Overview)
The next step involves a mycophenolate-based regimen used in combination with antimalarials, recommended as a third-line option for refractory disease. The full dosing algorithm, sequencing, and alternative options are detailed in the complete protocol.
References
- We recommend antimalarials as first-line and long-term systemic treatment in all CLE patients with severe or widespread skin lesions, in particular in patients with the risk of scarring and development of systemic disease.
- In severe or widespread active CLE lesions, systemic corticosteroids are recommended as first-line treatment in addition to antimalarials.
- We recommend MMF as third-line treatment in refractory CLE patients, preferably in addition to antimalarials.
- We recommend 2 x 500 mg MMF per day as starting dose that can be increased up to 3 g per day depending on the clinical response.
- We suggest MPA as an alternative treatment to MMF.
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