[Refractory subacute cutaneous lupus erythematosus treated with rituximab].

Subacute cutaneous lupus erythematosus (SCLE) is a variant of photosensitive cutaneous lupus erythematosus that is often associated with anti-Ro antibodies. We present 3 cases of treatment-refractory SCLE that resolved satisfactorily with rituximab. Patient 1 was a 54-year-old woman (smoker) diagnosed with SCLE. She had annular lesions on her back (Fig. 1 A), upper chest, and arms. Testing for antinuclear antibody (ANA) was positive (titer, 1/640), with a homogeneous pattern; the results for other antibodies were negative. The patient received high-dose prednisone (50 mg/d), antimalarial agents (chloroquine 250 mg/d and hydroxychloroquine 400 mg/d) for 3 years, thalidomide 50-150 mg/d for 16 months, cyclophosphamide 100 mg/d, mycophenolate 500 mg/d, etanercept (50 mg, 2 doses per week), and intravenous immunoglobulins (2 g/kg). Improvement was partial, and the patient experienced the following side effects: blurred vision (antimalarial agents), sensory axonal polyneuropathy (thalidomide), and leukopenia (cyclophosphamide). In view of the lack of response, rituximab was started at a weekly dose of 375 mg/m (4 doses) combined with prednisone 5-10 mg/d. Remission was complete after 2 months. The same regimen was repeated annually (1 g/15 d, 2 doses) for 4 years because of the appearance of new outbreaks, and control of the cutaneous lesions was excellent (Fig. 1 B). Patient 2 was a 37-year-old woman (smoker) with epilepsy, for which she was receiving carbamazepine but later switched to valproic acid. She had been diagnosed with SCLE at age 34 years and had annular lesions on her upper chest, back, and arms. Her ANA pattern was homogeneous (titer, 1/640), anti-La was positive, and testing for the remaining antibodies, including antihistone antibodies, was negative. She had responded well to prednisone 50 mg/d, hydroxychloroquine 400 mg/d (18 months), and azathioprine 100 mg/d, which was discontinued because of drug-induced leukopenia. Her skin lesions worsened considerably when azathioprine was stopped (Fig. 2 A); therefore, rituximab was started at a weekly dose of 375 mg/m (4 doses) combined with low-dose prednisone (10 mg/d) and antimalarial agents. The patient progressed favorably, with no active lesions after 3 months. The regimen was repeated 1 year later (1 g/15 d, 2 doses), and the patient remained free of active lesions during the 8 months following the last infusion of rituximab (Fig. 2 B). Control of the disease was maintained with hydroxychloroquine 200-400 mg/d.