Hypertrophic and ulcerated discoid lupus erythematosus

Hypertrophic lupus is an uncommon clinical variant of chronic cutaneous lupus that remains a challenge to treat. A 45-year-old female day-care worker with long-standing lupus presented with hypertrophic cutaneous involvement on the dorsal hand, elbow, and toe of 6 years' duration. Treatments included monotherapy with either hydroxychloroquine or chloroquine and potent topical and intralesional steroid injection. Systemic chemotherapy with R-CHOP chemotherapy for stage IIA diffuse large B-cell lymphoma did not clear the skin findings.

To review the clinical presentation and treatment of hypertrophic lupus. This report documents clinical improvement in refractory hypertrophic lupus with a regimen of acitretin and combination antimalarial therapy.

The available published literature on the treatment of hypertrophic lupus was reviewed. There is limited published experience combining retinoids and antimalarials for the treatment of refractory lupus. Combination therapy with two antimalarials (ie, quinacrine with either hydroxychloroquine or chloroquine) provides therapeutic benefit for resistant cutaneous disease. In this case, triple therapy with two antimalarials and an oral retinoid achieved clinical clearance relatively rapidly, and this effect was maintained over a year.

This article reports successful treatment of refractory hypertrophic discoid lupus with combination therapy that included chloroquine 250 mg/d, quinacrine 100 mg/d, and actitretin 25 mg/d.

This report suggests that combination therapy using two antimalarials and an oral retinoid is a consideration for refractory hypertrophic lupus, but further study is warranted.