Risk Factors for Cutaneous-to-Systemic Lupus Progression Identified

February 3, 2014

A retrospective review establishes that progression from cutaneous lupus to SLE is infrequent, and identifies factors common among those in whom the disease does progress. Also, a study from Scotland questions whether dermatologists are too busy to follow guidelines for management of psoriatic arthritis.

Wieczorek IT, Propert KJ; Okawa J, et al.Systemic Symptoms in the Progression of Cutaneous to Systemic Lupus Erythematosus. (2014) JAMA Dermatol,. Jan 29; doi:10.1001/jamadermatol.2013.9026

Chong BF. Invited Commentary: Understanding How Cutaneous Lupus Erythematosus Progresses to Systemic Lupus Erythematosus. (2014) JAMA Dermatol. Jan 29; doi:10.1001/jamadermatol.2013.9030

Parkins GJ, Leman JA. Psoriasis guidelines. Psoriasis: are clinicians too busy to assess disease severity? (2014).BMJ; 31 Jan; 348:g1081 doi: dx.doi.org/10.1136/bmj.g1081

Only a small percentage of patients with cutaneous lupus erythematosus (CLE) will eventually develop systemic lupus erythematosus (SLE), and of those, most will have mild systemic disease, according to this retrospective review. However, the article observes a practice gap: This insidious progression is easy to overlook, and clinicians should conduct a complete review of symptoms at each visit.

Unlike previous studies, this one reports specific systemic symptoms experienced by patients that converted to SLE. The article observes that while American College of Rheumatology (ACR) criteria use the term "rash," dermatologists prefer more specific descriptors.

Of 77 patients with CLE, 13 (17%) developed SLE over a mean of eight years, and only four met the ACR criteria for mucocutaneous disease. Only five developed moderate to severe systemic disease.

The commentary by Chong notes that the article identifies specific risk factors for progression, such as positive antinuclear antibodies, widespread discoid lesions, female gender, and increased numbers of SLE criteria. It suggests that with vigilance for progression, dermatologists need not refer most cases to specialists, even those who appear to be progressing.

More accurate prognosis based on results of studies now under way could “revolutionize” treatment, writes Chong, because treatment could be started promptly for those at high risk for progression to SLE.

Another article published last week also relates to the interface between dermatology and rheumatology: In scotland, at least, general dermatologists appear rarely to follow guidelines about assessing and managing psoriasis and psoriatic arthritis.

The Scottish guideline on diagnosing and managing psoriasis and psoriatic arthritis in adults recommends recording the Psoriasis Area and Severity Index and Dermatology Life Quality Index in dermatology secondary care at baseline, and serially, to assess efficacy of interventions.

However, in general dermatology clinics, those indexes were recorded in only 6% of 103 patients. In contrast, in a dedicated psoriasis clinic, those indexes were recorded in 68% of 116 patients. Because of this failure, 75 patients continued an ineffective drug for six months or longer.

Clinicians cite time pressures as the main barrier to regular use of the guidelines.