Brasileiro, A

Campos, S

Fidalgo, A

Anais Brasileiros de Dermatologia

PubMed

Repositório do Centro Hospitalar de Lisboa Central, EPE

lettersDo steroid hormones have an important role on cutaneous lupus physiopathology?*Ana	Brasileiro1 Sara Campos1 Ana	Fidalgo1 DOI: http://dx.doi.org/10.1590/abd1806-4841.20154387sReceived on 10.01.2015Approved	by	the	Advisory	Board	and	accepted	for	publication	on	19.02.2015*	 	Work		carried	out	at	the	Hospital	S.	António	dos	Capuchos	-	Centro	Hospitalar	Lisboa	Central	–	Lisbon,	Portugal. Financial Support: None.	 Conflict	of	Interest:	None.1	 Hospital	S.	António	dos	Capuchos	-	Centro	Hospitalar	Lisboa	Central	–	Lisbon,	Portugal.		 ©2015	by	Anais	Brasileiros	de	Dermatologia766Sir,An	 80-year-old-Caucasian-woman	 has	 been	followed during the last 25 years for cutaneous dis-coid	 lupus	 erythematosus	 (CDLE)	 without	 systemic	involvement.	The	lesions,	limited	to	the	face,	ears	and	scalp,	had	been	controlled	with	photoprotection,	top-ical	corticosteroids,	topical	calcineurin	inhibitors	and	hydroxychloroquine,	 combined	 intermittently	 with	intralesional and systemic steroids. Her medical histo-ry was otherwise not relevant and she had never been a smoker.Four years ago she underwent radical left mas-tectomy for carcinoma ductal in situ with positive oestrogen	 receptors,	 followed	 by	 hormonotherapy	with	 letrozole	 2,5mg/day.	 A	 month	 later	 there	 was	pronounced cutaneous worsening and the lesions became refractory to previously effective therapies (Figure	1).	There	were	no	other	recently	started	medi-cations or systemic complaints; routine blood labora-tory tests and autoimmunity antibodies were within normal	range.	Acitretin	25mg/day	was	attempted	but	An Bras Dermatol. 2015;90(5):766-8.Figure 1: A: Multiple	well-defined	erythematous	plaques	distributed	over	convex	areas	of	the	face;	B:	Marked	inflammatory	infiltration	of	the	scalp	with	follicular	plugging,	adherent	scale	and	alopeciaA BDo steroid hormones have an important role on cutaneous lupus physiopathology?  767An Bras Dermatol. 2015;90(5):766-8.Figure 2: Improvement of facial lesions with residual plaquesthere was further clinical worsening and immunosup-pressive therapies were contraindicated by the recent malignant neoplasia. Thalidomide 50mg/day was then	combined	with	previous	therapies,	with	marked	clinical	improvement	within	two	weeks,	allowing	the	discontinuation of systemic steroids and hydroxy-chloroquine	(Figure	2).	Sustained	therapeutic	efficacy	was observed over one-year follow-up despite main-tenance	of	letrozole	therapy.	No	significant	side	effects	have occurred.Lupus	erythematosus	(LE)	has	three	major	sub-types:	systemic	lupus	erythematosus	(SLE),	subacute	lupus	 erythematosus	 (SCLE)	 and	 cutaneous	 discoid	lupus	erythematosus	(CDLE).	The	pathogenesis	is	not	well	known	–	it	is	believed	to	stem	from	interplay	be-tween genetic and environmental factors. Ultraviolet radiation and immune dysregulation of innate and ac-quired	immune	responses	have	been	implicated.1 Hor-monal-influenced	mechanisms	might	also	play	a	role	in	LE.	The	skin	is	an	independent	steroidogenic	organ,	and cutaneous steroidogenesis has effects on local im-munologic activity. Oestrogen stimulates the produc-tion	of	interferon-y,	interleukin	1,	5,	6	and	10,	increas-es	B-cell	survival,	enhances	antibody	production	and	contributes to the persistence of autoreactive T-cells in SLE patients.2Additionally,	 epidemiological	 data	 supports	 a	role for sexual hormones in lupus susceptibility.1	An	esti-mated three-fold female predominance among patients with cutaneous lesions only has been observed.1 The female	preponderance	 is	even	higher	 in	SLE	patients,	occurring most commonly in reproductive-age women and being rare in prepubertal age.1 Furthermore,	report-ed cases of hormonal-induced SLE and anti-oestrogen drug-induced	 SCLE,	 namely	 anastrozole	 and	 tamoxi-fen,	also	suggest	a	role	for	hormonal	imbalance	in	LE	pathogenesis. 3-5	However,	no	case	of	CDLE	induced	or	aggravated by such therapies has been reported to date.Letrozole	is	a	third-generation	aromatase	inhib-itor indicated for hormone-sensitive breast cancer in postmenopausal women. Its anti-oestrogenic effects induce	 nearly	 complete	 suppression	 of	 aromatiza-tion	 in	all	 tissues.	Theoretically,	aromatase	 inhibitors	should	 be	 beneficial	 in	 lupus	patients,	 once	 they	 re-duce cutaneous estradiol production which stimulates inflammatory	 pathways.	 Conversely,	 in	 our	 patient,	letrozole	 paradoxically	 aggravated	 the	 disease,	 per-haps	 due	 to	 iatrogenic	 hormonal	 imbalance,	 which	points towards a pathogenic role for cutaneous hor-monal dysregulation in CLE.Considering	that	both	pathologies	are	not	rare,	probably more CLE women will undergo anti-oestro-gen therapy for breast cancer. Whether the cutaneous disease will have the same behaviour as in our patient remains unknown. Further studies are warranted to access the effect of aromatase inhibitors in CLE pa-tients.qAn Bras Dermatol. 2015;90(5):766-8.How	 to	 cite	 this	 article:	 Brasileiro	A,	Campos	 S,	 Fidalgo	A.	Do	 steroid	hormones	have	 an	 important	 role	 on	cutaneous	lupus	physiopathology?	An	Bras	Dermatol.		2015;	90(5):766-8.REFERENCES1. Bolognia JL, Jorizzo JL, Rapini RP. Dermatology. 3rd ed. Mosby: Elsevier; 2012. p. 615-629.2. Kim WU, Min SY, Hwang SH, Yoo SA, Kim KJ, Cho CS. Effect of oestrogen on T cell apoptosis in patients with systemic lupus erythematosus. Clin Exp Immunol. 2010;161:453-83. Chan KL, Mok CC. Development of systemic lupus erythematosus in a male-to-female transsexual: the role of sex hormones revisited. Lupus.  2013;22:1399-402.4. Trancart M, Cavailhes A, Balme B, Skowron F. Anastrozole-induced subacute cutaneous lupus erythematosus. Br J Dermatol.  2008;158:628-9. 5. Fumal I, Danchin A, Cosserat F, Barbaud A, Schmutz JL. Subacute cutaneous lupus erythematosus associated with tamoxifen therapy: two cases. Dermatology. 2005;210:251-2.Mailing  address:Ana BrasileiroAlameda Santo António dos Capuchos 1169-050 Lisbon, Portugal.E-mail: afmbrasileiro@gmail.com768 Brasileiro A, Campos S, Fidalgo A   

Do Steroid Hormones Have an Important Role on Cutaneous Lupus Physiopathology?

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http://dx.doi.org/10.1590/abd1806-4841.20154387

Do Steroid Hormones Have an Important Role on Cutaneous Lupus Physiopathology?

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