Pulsed dye laser treatment of subacute cutaneous lupus erythematosus

S ir, We read with interest the report by Wolfe et al. on the induction of cutaneous lupus erythematosus following thermal injury with the argon laser1. The pulsed dye (PDL) argon and carbon dioxide lasers have been used to treat discoid lupus erythematosus and its variants (lupus erythematosus telangiectoides) with some succes.2–4 However, there are no reports of lasers being used to treat subacute cutaneous lupus erythematosus (SCLE). We report a patient with SCLE who responded to treatment with the PDL. A 39‐year‐old Caucasian woman, with a 14‐year history of systemic lupus erythematosus (SLE) diagnosed according to the American Rheumatism Association criteria, was seen in the Dermatology clinic. Her symptoms consisted of worsening photosensitivity, polyarthralgia and mouth ulcers. Examination revealed marked confluent erythema on the face, neck and arms (Fig. 1), which she was unable to cover up with cosmetic camouflage. She had received treatment with broad‐spectrum high‐factor sunscreens, oral steroids, hydroxychloroquine (200–400 mg daily), azathioprine (100 mg daily), intravenous pulsed methylprednisolone (l g) and immunoglobulin (IgG) with very little benefit. Investigations showed a normal full blood count. Erythrocyte sedimentation rate was raised at 40 mm Hg in the first hour and C3 and C4 were reduced. Antinuclear factor and antidouble stranded DNA antibodies were raised at 1 : 640 (homogenous) and 112 IU/mL (normal <100 IU/mL), respectively. Anti‐Ro, La and Sm antibodies were negative. Histology from lesional skin showed a lichenoid tissue reaction. Direct immunoflourescence showed the presence of IgG, IgM, IgA and C3 at the dermo‐epidermal junction. Chronic confluent erythema seen in a photosensitive distribution. The disfiguring facial erythema was treated with single pulses of the PDL (585 nm, 450 μsec pulse duration; Cynosure Inc., Chelmsford, Massachusetts) using the 5 mm spot size at 5.3 J/cm2. She was treated on four occasions, 1 month apart, resulting in marked improvement of the erythema (Fig. 2). Marked improvement following treatment with the pulsed dye laser. SCLE is a relatively benign subset of SLE with about half the patients fulfilling the criteria for SLE. The skin is affected with papulosquamous or annular polycyclic lesions seen in a photosensitive distribution. Twenty‐five per cent of patients with SLE demonstrate an abnormal response in the ultraviolet B and ultraviolet A spectrum, although exposure to UVA1 (340–400 nm) in a controlled trial reduced severity of disease.5 Therefore, longer wavelengths may be therapeutic if used cautiously. The PDL set at 585 nm selectively targets haemoglobin; it has been highly effective in the treatment of vascular lesions. Current treatment of chronic confluent erythema seen in SCLE is cosmetic camouflage. Our report demonstrates the efficacy of PDL in this condition.