Cutaneous Lupus Considerations with Joseph Merola, MD, MMSc

Joseph Merola, MD, MMSc, dermatologist and rheumatologist at UT Southwestern Medical Center in Dallas, shed light on crucial lupus considerations for dermatologists, marking an exciting era in connective tissue disease management. His insights at the 2024 Masterclasses in Dermatology conference emphasized the dynamic landscape of lupus treatment and the evolving opportunities for patients.¹

Merola emphasized the importance of considering vitamin D levels and drug-induced lupus while addressing localized or disseminated disease. He also discussed the role of systemic activity and advocated for the use of integrated antimalarials, particularly hydroxychloroquine.The talk touched upon established guidelines and algorithms for lupus management, showcasing a comprehensive approach. Merola shared his perspective on the dosing of hydroxychloroquine, emphasizing the need for therapeutic levels early on in treatment. Emerging therapies he’s keeping an eye on include novel agents targeting type 1 interferon and plasmacytoid dendritic cells, such as CAR-T cell therapy.²

Merola shared some of the hurdles in lupus research, including heterogeneity in classification and outcome measures in an interview with Dermatology Times. He presented efforts to address these challenges, such as classification criteria and core outcome sets, stressing the need for standardized measures in clinical trials.

Dermatology Times: How have clinical data and treatment landscape evolved for cutaneous lupus?

Merola: I had the opportunity to talk a little bit about cutaneous lupus, and lupus for the dermatologist. I think some of the big takeaway messages were number one, it'sa very exciting time for us to be treating lupus. I think it’s a hopeful time for patients because the field hasn't had new therapies for decades, really. And all of a sudden,we have a whole pipeline of drugs facing systemic lupus. And if we get through some regulatory hurdles for skin lupus, we believe there'll be a number of new therapies facing skin lupus.

We talked about a few in particular:Anifrolumab(Saphnel), which we've had some really great experience with; and skin lupus type I interferon inhibitor and some new drugs, a BDCA-2 inhibitor that blocks plasmacytoid dendritic cells in lupus and cutaneous lupus showing great promise; and also deucravacitinib (Sotyktu), now household name in dermatology, approved for psoriasis undergoing trials for a number of different indications. But one of those being cutaneous lupus, which again, we're quite excited about as an oral agent. That's got very good safety and tolerability for skin lupus, particularly when we consider how many potentially toxic and pregnancy-incompatible therapies we currently have for skin lupus.

Dermatology Times: What are the challenges of managing cutaneous lupus and opportunities for enhanced options?

Merola: There's a number of challenges to getting therapies currently to skin lupus patients. One of them is that current systemic lupus trials really don't include appropriate outcome measures for us to tell her so who those patients are with skin lupus in the study, but then how they respond to therapy meaningfully. You know, in recent times that has gotten a little bit better in for example, the inclusion of classy as well as cutaneous lupus, IGA instruments, and such. Sowe're making progress. I think the regulatory hurdles are not insurmountable, they're still present and we're trying to break those barriers. Presently, there area number of ongoing phase 3 and phase 2/3 studies in skin lupus that I really hope will helpopen up the field wide from a regulatory standpoint because we certainly have a pipeline of interesting and potential therapies sitting behind the floodgates right now.

References

1. Merola J. What’s new in lupus. Presented at: Masterclasses in Dermatology February 16-19, 2024; Puerto Rico.
2. Shi H, Gudjonsson JE, Kahlenberg JM. Treatment of cutaneous lupus erythematosus: current approaches and future strategies. Curr OpinRheumatol. 2020;32(3):208-214. doi:10.1097/BOR.0000000000000704