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Therapeutic Approach

Lupus panniculitis (LEP) is an uncommon subtype of chronic cutaneous lupus characterized by painful, indurated subcutaneous nodules, and/or depressed plaques distributed on the proximal extremities, breasts, buttocks, and face. Discoid lesions commonly overlie the area of panniculitis. Some reserve the term “lupus profundus” for cases of LEP with overlying discoid lupus1 while others consider the two synonymous. LEP can occur in isolation or in association with systemic lupus erythematosus. Clinicians diagnosing and managing LEP must be familiar with and rule out subcutaneous panniculitis-like T-cell lymphoma (SPTCL), which is a key clinical and pathologic mimicker. LEP has a chronic, relapsing course, with prominent atrophy in the later stages. Initiation of treatment early in the inflammatory phase is preferable. Topical agents and intralesional steroids have a limited role in mild and localized disease, however systemic agents are generally required for control of this condition. In most cases, the authors consider antimalarials (either alone or in combination) as first-line, methotrexate or mycophenolate mofetil as second-line, and thalidomide or lenalidomide as third-line, with the ultimate choice in therapy(ies) guided by individual patient risk factors, comorbidities, and preferences. Other alternative agents included below are considered on a case-by-case basis if the aforementioned are unavailable or ineffective. See Table 62-1.

Table 62-1Lupus Panniculitis Treatment Table

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