| Topical Therapy | | | | | | |
| Corticosteroids | CLN, generalized LN | Anti-inflammatory | For sensitive sites, 1%-2.5% hydrocortisone cream/ointment (or similar low-potency agent) 1-2 times daily; transition to TCI if ineffective after 2 wk. For nonsensitive sites, 0.1% triamcinolone cream/ointment (or similar mid-potency agent) 1-2 times daily; transition to TCI if ineffective after 2 wk | Epidermal atrophy, lightening of skin tone | None | III1 |
| Calcineurin inhibitors (tacrolimus/pimecrolimus) | CLN, generalized LN | Anti-inflammatory | Twice daily until symptom improvement or disease resolution | Minimal | None | III2,3 |
| Dinitrochlorobenzene immunotherapy | | Immunotherapy | 0.1% after, sensitivization with the 1% form every 2 wk | Symptomatic dermatitic eruptions, carcinogenicity | None | III4 |
| Systemic Therapy |
| Systemic corticosteroids | Refractory LN | Anti-inflammatory via activaiton of corticosteroid receptor | 0.3-1 mg/kg/d oral prednisone for 4-6 wk | Oral candidiasis, increased appetite, weight gain, peptic ulcers, hyperglycemia, psychological disturbances, muscle weakness, decreased bone mineral density, hypertension, bruising, striae, infections | Baseline risk assessment: Height, weight, BMI, blood pressure, CBC, serum glucose/A1c, signs/symptoms of recent or current infection; consider DEXA if chronic use is anticipated Routine monitoring: Repeat the above based on risk, dose, and duration at provider’s discretion | III1 |
| Acitretin | Palmoplantar LN | Activates retinoic acid receptors; anti-inflammatory and promotes epithelial turnover/maturation | 0.5-0.75 mg/kg/d | Mucocutaneous dryness/irritation (common), hyperlipidemia (common), teratogenesis, Staphylococcus aureus colonization, nail thinning, paronychia, increased intracranial pressure, transaminitis | Consider lipids, CBC, and transaminases | III5 |
| Isotretinoin | CLN, generalized LN | shrinkage of sebaceous glands, decrease in sebum secretion | 0.5-1 mg/kg daily | cheilitis, xerosis, myalgia, and arthralgia | Monthly pregnancy tests, serum lipid levels, and liver function tests | III |
| Cyclosporine | Refractory LN | Anti-inflammatory via cyclophilin inhibition and reduction of IL-2 | 1.0-2.5 mg/kg/d | Hypertension, edema, headache, paraesthesias, hypertrhichosis, hypertriglyceridemia, GI upset, gingival hyperplasia, renal dysfunction, infections | Before starting, screen for skin cancer and occult infection Obtain blood pressure, CBC, RFT, lipids, serum K, Mg, and uric acid at baseline. Repeat every 2 wk for at least the 1st 3 mo, then reduce monthly if stable. Increase monitoring frequency during periods of dose adjustment or starting new medication | III6 |
| Procedural Therapy |
| Narrow UVB | Generalized LN | Suppression of T-cell responses; induces T-cell apoptosis | 50%-80% minimal erythema dose, 3 times per week until remission, then taper over 3-6 wk | Skin: transient erythema and pruritis | None | III7-9 |
| Local PUVA | CLN | Lymphocytotoxic effect | Dosing variable ... |