Thalidomide Helpful in Lupus Skin Lesions

Laurie Barclay, MD

January 24, 2003

Jan. 24, 2003 — Thalidomide may be an effective approach to treating cutaneous manifestations of systemic lupus erythematosus (LE), according to the results of a retrospective medical record review reported in the January issue of the Archives of Dermatology.

"Thalidomide is an anti-inflammatory agent and an immunomodulator that inhibits the production of tumor necrosis factor alpha," write Tamara S. Housman, MD, from the Wake Forest University School of Medicine in Winston-Salem, North Carolina, and colleagues. "It has shown promise as a treatment option for the cutaneous manifestations of LE."

Between 1998 and 2000, 29 patients started treatment at Wake Forest for refractory cutaneous manifestations of LE unresponsive to conventional agents, and 23 who took thalidomide, 100 mg daily, for one month or more were included in the analysis.

Of the 23 patients, 17 (74%) had complete resolution of the cutaneous manifestations of LE, three patients (13%) had at least 75% partial improvement, and three patients (13%) had less than 75% partial clinical improvement. Of 23 patients who had a complete or partial response, 21 (91%) did so within eight weeks of starting thalidomide.

"Based on this case series, we believe that low-dose thalidomide should be given prime consideration in the treatment of antimalarial drug–resistant interface lesions of LE and has earned a niche on the therapeutic ladder in the management of these lesions," the authors write.

They recommend prospective, randomized, double-blind, placebo-controlled trials, and note that thalidomide is reserved as a second-line therapy because of its cost to the patient (approximately $567 for a 28-day course at 100 mg/day); the degree of monitoring by the STEPS protocol; its teratogenicity and adverse effects including peripheral neuropathy; and the availability of antimalarial therapy.

"New developments in dermatology including the introduction of the System to Manage Accutane-Related Teratogenicity (SMART) Program monitoring requirements for isotretinoin and the acceptance of newer, most costly biologic tumor necrosis factor-alpha inhibitors into dermatologic practice should obviate those limitations to thalidomide use," the authors write. "Using thalidomide in a seasonal fashion (from spring to fall) increases the likelihood of compliance and usage by both physicians and patients."

Arch Dermatol. 2003;139:50-54

Reviewed by Gary D. Vogin, MD

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