Montelukast as a treatment for refractory cutaneous lupus: A case series

There are no drugs specifically approved to treat cutaneous lupus. Inflammatory cells in lupus skin lesions can produce leukotrienes (LT), which promote tissue damage. In addition to hypersensitivity reactions, LT are also associated with cardiovascular diseases and elevated serum LT levels have been linked to worse atherosclerotic disease in lupus. Targeting LT could thus be an alternative to treat lupus. We present 4 cases of cutaneous lupus successfully treated with montelukast (MLK), a Cys-LT antagonist.

Four consecutive female systemic lupus erythematosus (SLE) patients with refractory skin lesions were treated with MLK (10 mg/d) in the Hospital Universitário Walter Cantídio of the Universidade Federal do Ceará. Skin lesions were scored using Revised Cutaneous LE Disease Area and Severity Index (RCLASI). Relative expression of the 5-lipoxigenase (ALOX5) and 15-lipoxigenase (ALOX15) genes was determined in peripheral blood cells (PBC) from lupus patients and 4 age-matched female controls.

All patients experienced improvement of skin lesions measured using RCLASI scores within 2-12 weeks following initiation of MLK. The response was sustained for at least 3 months follow-up and no adverse events were recorded. ALOX5 but not ALOX15 gene expression was significantly (P = 0.0425) increased in PBC from SLE patients vs controls.

This is the first report of a fast and sustained successful response of cutaneous lupus to MLK. Given its acceptable safety profile, our data encourage development of a randomized trial as an attempt to reposition MLK as a safe, affordable alternative to treat cutaneous lupus.