Letter to the Editor

Lupus
0(0) 1–2
! The Author(s) 2021
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DOI: 10.1177/09612033211033989
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Belimumab in subacute cutaneous lupus We present a case of a 64-years old male suffering
erythematosus biopsy proven chronic facial discoid CLE for 14 years
and mild scarring alopecia areas that did not respond
to hydroxychloroquine nor azathioprine. Topical ste-
Sir, roids were the main treatment for his CLE for years.
We read with interest the article published in Lupus Patient also suffered from idiopathic high blood pres-
by Vashisht et al.1 describing a series of patients with sure and autoimmune hepatitis (anti-LKM positive
recalcitrant cutaneous lupus erythematosus (CLE). In
this prospective observation of 5 recalcitrant CLE
patients with systemic lupus erythematosus (SLE) sat-
isfactory treated with belimumab in whom previous
medium-high steroid dose, immunosupressants and
anti-malarials were insufficient. This series included
acute CLE, subacute CLE and chronic CLE patients
with median CLE duration of 4 months, in whom a
rapid (<2 months) and clinically significant improve-
ment with belimumab treatment was observed.
Moreover, CLE Disease Area and Severity Index
(CLASI) score decreased and no changes on damage
score were observed, leading to an important steroids
sparing effect.
Belimumab has shown overt efficacy in both muco-
cutaneous and musculoskeletal domains of SLE and
also improving SLE activity markers, as observed in
clinical trials. This data enhances the possibility to con-
sider belimumab as an effective long-term disease mod-
ifying drug in SLE patients with mucocutaneous
activity (rash, mucosal ulcers and alopecia), although
limited data is available on its efficacy on each specific
CLE involvement.2 Salle et al. described a CLASI-50
response in 8/16 intravenously belimumab treated CLE
patients (including 3 patients with isolated CLE) who
failed to a median of 6.5 systemic therapies, at 6-month
follow-up.3 As response predictors, the presence of a
Fitzpatrick phototype IV-VI and lower baseline
CLASI score were suggested. Fruchter et al. found sub-
stantial response in 6 out of 16 CLE patients
treated with intravenous belimumab in whom anti-
malarials were inneffective, mainly in those who
showed isolated CLE, with no SLE diagnosis.4
Husein-ElAhmed et al. presented a case of subacute
CLE with SLE who responded well to belimumab
Figure 1. Facial subacute cutaneous lupus erythematosus
after failure of multiple systemic treatments, including (SCLE) pictures before belimumab (a, b) and after
rituximab.5 belimumab (c, d).
2 Lupus 0(0)
antibodies). Eventually, on October 2020 patient
suffered a flare of psoriasiform subacute CLE in
sun-exposed areas (maculo-papular erythema with
papulosquamous lesions and spread pustules on the
face, especially on the malar and frontal areas, chin,
nose, ears and scalp) with CLASI score of 21/1
(Figure 1(a) and (b)). No symptoms or signs of SLE
a part from the presence of high titers of ANA (1/640)
were observed. The use of methotrexate and thalido-
mide were ruled out for safety issues (history of herpet-
ic encephalitis in 2019). Therefore, subcutaneous
belimumab was initiated after the lack of improvement
with several topical treatments (steroids, tacrolimus,
pimecrolimus) and oral steroids on December 2020,
after local authorities approval. Within 2 months, a sig-
nificant improvement in his generalized facial erythem-
atous desquamating rash was observed, with no new
flare of pustular lesions nor side-effects (Figure 1(c)
and (d)). CLASI score improved to 7/1 within 2 months
after initiation.
In conclusion, we suggest the efficacy of belimumab
in recalcitrant SCLE patients, irrespective of the pres-
ence of SLE, in whom the improvement is expected
within 2–6 months. Larger studies are needed to con-
firm this hypothesis.
Declaration of conflicting interests
The author(s) declared no potential conflicts of interest with
respect to the research, authorship, and/or publication of this
article.
Funding
The author(s) received no financial support for the research,
authorship, and/or publication of this article.
Patient consent
The patient signed an informed consent to give permission for
publication.
ORCID iD
Vicenç Torrente-Segarra https://orcid.org/0000-0001-
6597-3565
References
1. Vashisht P, Borghoff K, O’Dell JR and Hearth-Holmes
M. Belimumab for the treatment of recalcitrant cutaneous
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2. Presto JK, Hejazi EZ and Werth VP. Biological therapies
in the treatment of cutaneous lupus erythematosus. Lupus
2017; 26: 115–118.
3. Salle R, Chasset F, Kottler D, et al. Belimumab for refrac-
tory manifestations of cutaneous lupus: a multicenter, ret-
rospective observational study of 16 patients. J Am Acad
Dermatol 2020; 83: 1816–1819.
4. Fruchter R, Kurtzman DJB, Patel M, et al. Characteristics
and alternative treatment outcomes of antimalarial-
refractory cutaneous lupus erythematosus. JAMA
Dermatol 2017; 153: 937–939.
5. Husein-ElAhmed H, Callejas-Rubio JL, Rios-Fernandez
R and Ortego-Centeno N. Refractory subacute cutaneous
lupus erythematous responding to a single course of beli-
mumab: a new anti-BLyS human monoclonal antibody.
Indian J Dermatol Venereol Leprol 2014; 80: 477–478.
Vicenç Torrente-Segarra1 , Laura Peramiquel2 and
Maria Bonet1
1
Rheumatology Department, Hospital Consorci Sanitari
Alt Pened
es Garraf (CSAPG), Vilafranca del
Penedes, Spain
2
Dermatology Department, Hospital Consorci Sanitari
Alt Pened
es Garraf (CSAPG), Vilafranca del
Penedes, Spain
Corresponding author:
Vicenç Torrente-Segarra, Rheumatology Department,
Hospital Consorci Sanitari Alt Pened es Garraf
(CSAPG), Vilafranca del Pened es, Espirall s/n 08720,
Spain. Email: vtorrente@hsjdbcn.org