Dear Editor,

Subacute cutaneous lupus erythematosus erythematosus is a variant of cutaneous lupus erythematosus that can occur in photosensitive patients with anti-Ro anti-bodies ^1,2.

This cutaneous complication of lupus is treated primarily with photoprotection and antimalarials. In more than half of the cases this therapeutic approach is usually sufficient. However, 25% of patients present refractory subacute cutaneous lupus that requires systemic immunosuppressive medication such as cyclophosphamide with variable efficacy and not free of side effects, so its indication is not routine^2-4. We present the case of a patient with subacute lupus resistant to conventional therapy and requiring systemic immuno-suppressive therapy.

An 18-year male presented to outpatient clinic with papulosquamous rash over face hands and feet of three weeks duration and on examination and evaluation was diagnosed as systemic lupus erythematosus as patient was fulfilling 7 out of 11 ACR criteria⁵ (oral ulcers, cutaneous lupus/ malar rash, Alopecia, photosensitivity, leucopenia, ANA hep 2 Positive, DsDNA Positive) for SLE and had moderate disease flare with SLEDAI 136. Patient was put on 0.5mg/kg prednisolone, azathioprine and hydroxychloroquine, however the cutaneous lupus progressed and leucopenia persisted despite the immunosuppressants and deterioration of skin lesions (Figure1) .

The patient was started on IV antibiotic Piperacillin ta- zobactam in view of raw skin lesions of subacute cutaneous lupus which seemed infected and in addition had positive CRP and leukopenia suggestive of infection. After 72 hrs. of IV antibiotics high dose steroid equivalent to 1mg/kg of prednisolone was started and Cyclophosphamide 15mg/KG was given as infusion. The patient showed excellent results within 3 weeks of starting treatment with corticosteroids and cyclophos- phamide as shown in Figures 1, Figures 2 and Figure 3. This improvement was observed from the cutaneous and hematological point of view.

Figure 1 Day of admission. 

Figure 2 One week after cyclophosphamide. 

Figure 3 Two weeks after cyclophosphamide.