Rapid Improvement of Subacute Cutaneous Lupus erythematosus with Low-Dose Methotrexate

Subacute cutaneous lupus erythematosus Low-dose methotrexate Interleukin-1 blocking I. Böhm, MD, Department of Dermatology, University of Bonn, Sigmund-Freud-Strasse 25, D-53105 Bonn (Germany) When standard regimens fail in controlling cutaneous lupus erythematosus (LE), a variety of other therapeutics including azathio-prine, isotretinoin, interferon α2a, cyclophosphamide, dapsone, cyclo-sporin A or thalidomide have been used. Recently it has been shown that methrotrexate (MTX) is able to control rheumatoid arthritis with a low rate of adverse effects [1, 2]. Therefore, we treated with low-dose MTX once a week a female patient with subacute cutaneous LE who was refractory to systemic glucocorticosteroids; we could document an excellent clinical outcome without any side-effects. A 36-year-old female patient presented with a 10-year history of cutaneous LE with arthralgias. Erythematosquamous and papulosqua-mous lesions were seen mainly on the trunk, the arms and upper legs (fig. i). Skin biopsy revealed hyperkeratosis, focal thinning of the epidermis and some scattered colloid bodies. The basal cells showed minimal hydropic degeneration and the basement membrane was slightly thickened. Lymphocytic infiltration was seen in the upper dermis with a perivascular pattern and showed particular invasion into the epidermis. Focal extravasation of erythrocytes was present. Direct immunofluorescence showed only perivascular deposits of the complement component C3. Routine laboratory findings were normal except for the erythrocyte sedimentation rate (62/72 mm), dsDNA antibodies (ELISA) 534.0 U/ml (normal 9-40) and antinuclear antibodies (Hep2 cells) 1:2,560 (normal < l :80) with a homogeneous fluorescence pattern. Antibodies against Ro (SSA), La (SSB), Ul-snRNP and RNP-SM complex were detected. Anticardiolipin antibodies were 34.8 U/ml (normal 0-12.0). Other systemic LE symptoms could be excluded. Based on these findings, the diagnosis of subacute cutaneous LE with systemic involvement was made. Before admission she had been treated for 10 years with systemic glucocorticosteroids with a daily dose of up to 20 mg. Initially, she noticed improvement, but later the skin lesions were refractory to steroid therapy and she had developed Cushing’s symptoms. We started MTX therapy with 25 mg/week i.v. (first injection with 12.5 mg/week). Two weeks after starting