Updated Review of Discoid Lupus Erythematosus Treatments
An update to the Cochrane Review of discoid lupus erythematosus (DLE) treatment has found that fluocinonide cream 0.05% may be more effective than hydrocortisone cream 1% in clearing skin lesions, however evidence for for the efficacy – or lack thereof – of current DLE treatments as a whole, is lacking.
Many therapies have been considered for use in the treatment of DLE, some of which carry potentially toxic side effects. As the last Cochrane Review on DLE was published in 2009, the authors wanted to see what new treatment information was available. A search of all randomized controlled trials (RCTs) that included treatment comparisons up to September 2016 was conducted; laser treatment, phototherapy and other physical therapies were not considered.
In total, five trials were analyzed that included 197 individuals. For each of the five studies, researchers found a potential for bias through conducting a ‘Risk of bias' assessment; none of the trials were deemed ‘high quality'. Additionally the primary outcome measures (percentage with complete resolution of skin lesions, percentage with clearing of erythema in at least 50% of lesions, and improvement in patient quality of life) were poorly addressed in the trials that were reviewed, with some trials measuring none of these outcomes.
Fluocinonide cream 0.05% was shown in one study to have a greater therapeutic effect than hydrocortisone cream 1%, with 27% (10/37) in the fluocinonide group compared to 10% (4/41) in the hydrocortisone group reporting compete resolution of skin lesions (RR 2.77, 95% CI 0.95 to 8.08). Three individuals in the hydrocortisone group reported skin irritation, and two in the fluocinonide reported burning, but no one discontinued use due to adverse events.
A separate trial of 58 individuals with DLE compared acitretin (50mg daily) to hydroxychloroquine (400mg daily). Results showed that complete resolution was seen in 46% of the acitretin group and in 50% in the hydroxychloroquine group (RR 0.93, 95% CI 0.54 to 1.59). In addition, 42% and 68% of patients reported clearing of erythema in at least 50% of lesions in the acitretin and hydroxychloroquine groups, respectively. Four individuals in the acitretin arm withdrew due to gastrointestinal events or dry lips (moderate-quality evidence).
Of the other trials none reported on the reviews pre-defined primary outcomes. In one trial assessing tacrolimus, five individuals complained of burning and itching and one individual had a herpes simplex infection reactivated (moderate-quality evidence). Another trial comparing Topical R-salbutamol 0.5% cream to placebo found that those in the treatment arm had significant improvements in pain and itch however no changes in erythema were found between salbutamol and placebo.
Due to the low level of reliable evidence the authors called for further studies concluding that, “Overall, the quality of the trials and levels of uncertainty were such that there is a need for further trials of sufficient duration comparing, in particular, topical steroids with other agents.”
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