Drug-induced lupus erythematosus with emphasis on skin manifestations and the role of anti-TNFα agents

Abstract

Drug-induced lupus erythematosus (DILE) is a lupus-like syndrome temporally related to continuous drug exposure which resolves upon drug discontinuation. There are currently no standard diagnostic criteria for DILE. Findings include skin manifestations, arthritis, serositis, anti-nuclear and anti-histone antibodies positivity. Similarly to idiopathic lupus erythematosus, DILE can be divided into systemic (SLE), subacute cutaneous (SCLE) and chronic cutaneous lupus (CCLE). Systemic DILE presents as a milder version of idiopathic SLE, and the drugs most frequently implicated are hydralazine, procainamide and quinidine. Anti-TNFα therapies are the latest class of medications found to be associated, although rarely, with a "lupus-like" syndrome, which is however clinically distinct from classical DILE. Drug-induced SCLE is the most common form of DILE. It is very similar to idiopathic SCLE in terms of clinical and serologic characteristics. The most commonly implicated drugs are antihypertensive drugs and terbinafine, but in recent years also proton pump inhibitors and chemotherapeutic agents have been associated. Drug-induced CCLE is very rare and usually caused by fluorouracil agents and NSAIDS, but some cases have induced by pantoprazole and anti-TNFα agents.

Figure 1

(a–c) A 70-year-old women presented with a photosensitive malar erythema since one month, and with macular erythematous lesions on the upper arms and trunk. She also complained of arthralgia, myalgia and low grade fever. Laboratory findings included a moderately elevated erythrocyte sedimentation rate and the presence of ANA with a homogenous pattern. Anti-dsDNA antibodies were absent; anti-histone antibodies were positive. The patients had been taking hydrochlorothiazide for hypertension for two years. (d–f) After drug discontinuation and one month of very low dose systemic steroids (prednisone 0.2 mg/kg), her skin lesions, and systemic symptoms progressively disappeared.

Figure 2

A 56-year-old man with chronic hepatitis C virus had annular-polycyclic lesions on his trunk, face and right knee with a chronic relapsing course for four years. The findings had appeared a few months after starting IFN-α therapy. He had no systemic symptoms.

Figure 3

(a) A 28-year-old woman presented with pruritic, erythematous, scaling plaques on her nose and cheeks since 2 months. She had used ibuprofen daily for headache and dysmenorrhea for one year. She had no systemic symptoms. (b) Two months after drug discontinuation, her skin lesions disappeared without any treatment.