Discoid Lupus: Response to Hydroxychloroquine (Plaquenil)

Regrowth of Scalp Discoid lupus (DLE) with Hydroxychloroquine

Discoid lupus erythematosus (DLE) is an inflammatory condition of the skin that can potentially cause scarring. When DLE affects the scalp, it may cause scarring alopecia. A variety of treatments are available, although topical steroids, steroids injections, calcineurin inhibitors, and hydroxychloroquine (HCQ) are first-line treatments in my practice.

Liang K R et al, 2024

I enjoyed reading a case report of a very nice response of a patient with DLE to treatment with HCQ. The study was conducted by Liang et al. in the journal Cureus. The patient presented was a 46-year-old female with isolated scalp DLE. A biopsy confirmed the diagnosis. The patient first underwent several therapy trials without help, including intralesional corticosteroids, topical tacrolimus and topical corticosteroids.

Here is a photo of the scalp before successful therapy:

Initial appearance of discoid lupus in a 46 year old patient. Source: Liang K R, Lee C, Hilts A, et al. (June 28, 2024) Resolution of Discoid Lupus Alopecia With Systemic Hydroxychloroquine and Topical Pimecrolimus Combination Therapy. Cureus 16(6): e63419. doi:10.7759/cureus.63419

Hydroxychloroquine and Pimecrolimus Stopped Disease and Regrew Hair

Treatment with hydroxychloroquine and topical pimecrolimus ultimately led to a halting of inflammation and some degree of regrowth. Improvement was noted within 8 weeks, and significant hair regrowth was noted at 12 months.

Here are “before and after” photos the authors present:

Source: Liang K R, Lee C, Hilts A, et al. (June 28, 2024) Resolution of Discoid Lupus Alopecia With Systemic Hydroxychloroquine and Topical Pimecrolimus Combination Therapy. Cureus 16(6): e63419. doi:10.7759/cureus.63419

After 1 year of treatment the authors report complete resolution

The authors report complete resolution after 1 year. Source: Liang K R, Lee C, Hilts A, et al. (June 28, 2024) Resolution of Discoid Lupus Alopecia With Systemic Hydroxychloroquine and Topical Pimecrolimus Combination Therapy. Cureus 16(6): e63419. doi:10.7759/cureus.63419

COMMENT

I liked this paper. My treatment ladder for DLE puts hdyroxychoroquine (Plaquenil) front and center as a key first-line agent along with topical steroids, steroid injections, and topical tacrolimus or pimecrolimus. This case report by Liang et al. highlights the benefits of evidence-based decision-making when selecting treatments.

The only concern I have with this paper is that 200 mg twice daily of hydroxychloroquine is rarely a good dose for women. I don’t know the patient’s weight, so I can’t comment on the dose and whether it’s appropriate. However, the dose is 5 mg/kg body weight or 6/6 mg /kg ideal body weight (lean body weight)—whichever is lower. For many women, a dose of 400 mg is just too high.

Options like methotrexate or acitretin are second line agents in my practice - the side effects are much greater than HCQ. The authors of this study remind us that methotrexate and retinoids are similarly effective to HCQ. With fewer side effects with HCQ, it just makes sense to keep this as a first line agent.

REFERENCE

Liang K R, Lee C, Hilts A, et al. (June 28, 2024) Resolution of Discoid Lupus Alopecia With Systemic Hydroxychloroquine and Topical Pimecrolimus Combination Therapy. Cureus 16(6): e63419. doi:10.7759/cureus.63419