Introduction
Cutaneous lupus erythematosus (CLE) is an autoimmune disorder with variable skin manifestations
that can occur with or without systemic lupus erythematosus (SLE). While topical agents
such as corticosteroids and calcineurin inhibitors for single lesions and systemic
agents such as antimalarials, immunomodulators, and immunosuppressants for multiple
lesions have demonstrated effectiveness in the treatment of CLE, options are limited
when these modalities fail. The limited access to quinacrine in recent years has restricted
antimalarial combination use, emphasizing the need for alternative therapies. Recommended
second and third-line systemic treatments for CLE include methotrexate, mycophenolate
mofetil, dapsone, systemic retinoids, and thalidomide.
1
However, the use of thalidomide is limited by cost, the risk of thromboembolic events,
and the high incidence of peripheral neuropathy.
2
Lenalidomide is not often readily available for non-oncologic use. Therefore, there
is an unmet need for novel effective therapies in the treatment of CLE.
Janus kinases (JAKs) are receptor-bound tyrosine kinases that mediate the action of
various inflammatory cytokines through intracellular signaling via transducing signal
transducer and activator of transcription proteins. Many cytokines implicated in lupus
pathogenesis depend on JAK signaling to exert their intracellular action. In particular,
interferon-associated JAK activation is thought to play a key role in CLE lesions;
a recent study showed a significant upregulation of JAK signaling in cutaneous lesions
of lupus.
3
Therefore, JAK inhibitors represent a compelling option for the treatment of CLE.
Tofacitinib, a pan-JAK inhibitor with relative selectivity for JAK 1/3, has demonstrated
promising results in the treatment of cutaneous features of SLE in a recent study.
4
In another study, 67% of patients with SLE showed resolution of their arthritis or
rash while on baricitinib 4 mg daily, a JAK 1/2 inhibitor, although improvement was
not significant at a dose of 2 mg daily.
5
In both studies, the subtype of CLE was not defined, as improvement was measured using
the Systemic Lupus Erythematosus Disease Activity Index 2000 scale, which is not specific
to skin disease.
In this article, we describe the efficacy of tofacitinib in 3 patients with CLE, using
the Cutaneous Lupus Erythematosus Disease Area and Severity Index (CLASI), a scale
that has been validated for the assessment of CLE.
6
Methods
We identified all patients with CLE who were prescribed tofacitinib at the Skin Care
Center. Improvement was evaluated using the CLASI score and clinical information in
the patient's chart. Other endpoints included adverse events and the need for concurrent
therapies. The subtype of CLE was assessed using information available in the charts.
The cutaneous involvement in the first and second patients was evaluated using photographs
and teleconsultation due to restrictions associated with the COVID-19 pandemic. Although
in-person visits were offered, both patients declined. Patients were instructed to
have a third party take photographs of all skin-involved areas. We ensured that all
anatomical locations not included in the photographs were devoid of CLE involvement
by questioning the patient. If there was any doubt, the patient was asked to send
additional pictures. CLASI score items referring to mucous membrane involvement, dyspigmentation,
and alopecia were determined by verbal questioning. It should be noted that the use
of photographs to calculate CLASI scores has not yet been validated, thus caution
should be exercised when interpreting the results.
Results
The diagnosis of CLE was based on clinical, histopathologic, and laboratory evidence.
CLE subtype was assessed clinically, according to Gilliam's classification.
7
Three patients with CLE treated with tofacitinib were identified (Table I). All of
them had biopsy-confirmed CLE. They had multiple skin lesions and had failed at least
2 second or third-line systemic agents, in combination with antimalarial therapy and
topical therapy, including potent corticosteroids and/or calcineurin inhibitors. The
dose of tofacitinib was 5 mg twice daily for all patients. The first patient, a 51-year-old
man with rheumatoid arthritis, had severe discoid lupus (Fig 1, upper panel), Raynaud
syndrome, and fingertip ulcerations. He had been on hydroxychloroquine 400 mg daily
for one year, and mycophenolate mofetil 1 g twice daily and prednisone 5 mg daily
for 6 months for the treatment of his arthritis. Because his cutaneous lupus remained
active, tofacitinib was added to the existing treatment. After 4 months, his CLASI
score had decreased from 28 to 8, although he had ongoing digital involvement. The
second patient was a 75-year-old woman with subacute CLE and Sjögren syndrome. She
had failed multiple prior systemic treatments, had been maintained on hydroxychloroquine
200 mg daily for 2 years, and tofacitinib was added. She improved from a CLASI 21
to CLASI 0 in 5 months. It should be noted that the first and second patients were
both assessed via telemedicine. The third patient was a 50-year-old woman with SLE,
discoid lupus, and tumid lupus. Antimalarial therapy had been discontinued due to
retinal toxicity. She had been on prednisone 10 mg daily for 3 months prior to addition
of tofacitinib. Her CLASI improved from 23 to 16 in 1 month, but because of ongoing
facial involvement (Fig 1, lower panel), the patient wished to switch therapy. Tofacitinib
was well tolerated in all 3 patients. Laboratory parameters were evaluated monthly
for 2 months after the initiation of tofacitinib, then every 2 months. Only the first
patient had changes in his baseline parameters, his white blood cell count dropping
from 4 × 109/L to 2.6 × 109/L, remaining stable afterward.
Table I
Clinical summaries of patients treated with tofacitinib
Patient No./Age/sex
Disease duration
Clinical presentation
Previous treatments
Concurrent treatments
Duration of tofacitinib treatment
CLASI activity
Clinical outcome
Before
After
1/50s/M
2 years
Discoid lupus Raynaud syndrome and fingertip ulcerations
HCQMTXMMFPrednisone
MMF 2 g/dHCQ 400 mg/d 5/7 days and 200 mg/d 2/7 daysPrednisone 5 mg/d
4 months
28∗
8∗
Improvement in discoid lupusOngoing Raynaud syndrome despite treatment
2/70s/F
8 years
SCLESjögren syndrome
HCQCQQuinacrineCsAMMFAcitretin
HCQ 200 mg/d
7 months
21∗
0∗
Resolution of all cutaneous lesions of lupus
3/50s/F
11 years
Discoid lupusTumid lupusACLESLE
HCQCQQuinacrineMTXAZAMMFPrednisone
Prednisone 10 mg/d
1 month
23
16
Effectiveness on limbs but ongoing facial involvement, tofacitinib switched to MMF
and prednisone 20 mg/d after 1 month
ACLE, Acute cutaneous lupus erythematosus; AZA, azathioprine; CLASI, cutaneous lupus
erythematosus disease area and severity index; CsA, cyclosporine; CQ, chloroquine;
HCQ, hydroxychloroquine; MTX, methotrexate; MMF, mycophenolate mofetil; SCLE, subacute
cutaneous lupus erythematosus; SLE, systemic lupus erythematosus.
∗
CLASI scores from patients 1 and 2 were calculated using patient-supplied pictures.
Fig 1
Clinical images of patients 1 and 3 before and after tofacitinib treatment for cutaneous
lupus erythematosus.
Discussion
Two studies have described the use of JAK inhibitors in the treatment of CLE, using
the SLE Disease Activity Index 2000 as the main end point.
4
,
5
JAK inhibitors have not specifically been studied for the treatment of skin involvement.
In this study, we measured CLASI scores, which monitor skin disease activity on a
more continuous scale than the SLE Disease Activity Index 2000. In the 3 patients
studied, CLASI improvement was more than 4 points, which is the number required for
clinically significant improvement.
8
Reported side effects from tofacitinib include infections, cytopenia, thrombocytosis,
and elevated liver enzymes, none of which were observed in the patients presented.
Potentially increased rates of venous thromboembolic disease and malignancy are additional
concerns. The main limitation of this study is the use of photographs and telemedicine
to derive CLASI scores in 2 of the patients, a method that has not been validated
and could lead to potential bias. Other limitations include the retrospective design,
the small number of patients, the short follow-up, and the concurrent use of other
treatments. Although our results are encouraging, larger studies are needed to assess
the effectiveness of JAK inhibitors in CLE.
Conflicts of interest
None disclosed.