Letter

Efalizumab-induced subacute cutaneous lupus erythematosus

The drugs that usually trigger the subacute cutaneous form of lupus are antihypertensives such as thiazides,68,69 angiotensin converting enzyme inhibitors,70 β-blockers,71 and calcium channel blockers (Table 2). DISCLE has recently been described in patients taking terbinafine,72–74 bupropion,75 antineoplastic agents,76–78 leflunomide,65,66 efalizumab,79 proton pump inhibitors,80 tamoxifen,81 neuroleptics (phenytoin,82 oxcarbazepine83), benzodiazepines (tetrazepam, lormetazepam),84 procainamide,84 and etanercept.85 The chronic cutaneous form of lupus, which is very rare, has usually been caused by fluorouracil (especially tegafur and tegafur-uracil) or one of its more modern derivatives, such as capecitabine.30,86

Efalizumab has been reported to increase the rate of acne compared with placebo (4% vs 1%) in a large double-blind study comprising 1928 patients.180 In addition to the adverse effects reported in larger studies, there have been specific reports of efalizumab-induced subacute cutaneous lupus erythematosus,181 DRESS (Drug Reaction with Eosinophilia and Systemic Symptoms) syndrome,182,183 dermatitis/lichen simplex chronicus,184 exacerbation of pityriasis rubra pilaris,185 eruptive seborrheic keratoses,186 eruptive dermatofibromas,187 and guttate psoriasis.188 Efalizumab is approved for the treatment of psoriasis, so it has been a point of special interest among clinicians and researchers that subsets of patients using the agent develop de novo psoriatic lesions or experience worsening of preexisting psoriasis (ie, rebound psoriasis).

Efalizumab had been presented as an alternative therapy for discoid lupus erythematosus. However, some studies indicated successful results while others demonstrated induction of the disease.80–82 Etanercept is a dimeric fusion protein of the p75 component of human TNF receptor fused to human IgG Fc.

Obviously, this patient had mild SLE before therapy with efalizumab. Furthermore, a 65-year-old woman, who was treated for oral and cutaneous lichen planus with efalizumab, developed photodistributed SCLE 8 weeks after the initial injection.177 Aside from antinuclear antibodies (titer 1:160) with speckled pattern and anti-Ro/SSA antibodies, anti-dsDNA antibodies were positive without clinical symptoms of SLE; however, the test for anti-dsDNA antibodies was not specified (in case of positive anti-dsDNA antibodies the antinuclear antibodies usually show a homogenous pattern; possibly, the anti-dsDNA antibodies in this patient were not of the pathogenic IgG-isotype).