Estrogen OCs May Speed Up Lupus Progression

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Estrogen OCs May Speed Up Lupus Progression

By: L. Goldman, New York Bureau

[skin & Allergy News 29(2):20, 1998. © 1998 International Medical News Group.]

NEW YORK -- Advise women with cutaneous lupus erythematosus not to take

estrogen-based oral contraceptives, Dr. G. s Jr. said at an annual

program on advances in dermatology sponsored by the New York University

Post-Graduate Medical School.

Estrogen-based OCs aggravate lupus, and it can promote the progression of

cutaneous lupus disease to systemic lupus, said Dr. s of the department of

dermatology at NYU.

This is primarily due to its effect in promoting B-cell

hyperresponsiveness and inducing or increasing autoimmunity, particularly in

women who are predisposed to autoimmune states.

He described the case of one of his own patients, a young woman who

presented with a single, small scalp lesion suggestive of a basal cell

carcinoma. It turned out to be cutaneous lupus erythematosus, which responded

well to a course of intralesional steroid injections. There was no evidence of

systemic disease.

The lesion remained healed, and the patient was symptom free for 6 months.

Shortly after going on an OC, she developed marked photosensitivity and

arthralgias that quickly progressed to frank arthritis with fever.

Within a few months of starting estrogen, she was diagnosed with

full-blown systemic lupus.

It is essential to inform patients with cutaneous lupus who wish to use

OCs that estrogen will likely exacerbate the condition, Dr. s said.

By the same logic, women with long-standing, treatment-refractory lupus

who are taking birth control pills may show significant symptom improvement and

greater treatment responsiveness if they stop the contraceptives.

The jury is still out on the effect of estrogen replacement regimens on

lupus, but there's ample reason to believe they, too, aggravate the disease.

Data from the ongoing National Institutes of Health-sponsored Safety of Estrogen

in Lupus Erythematosus National Assessment should provide more concrete answers.

Testosterone appears to have a protective effect in lupus. The relatively

few males who have systemic lupus tend to have lower-than-average testosterone

levels. This is possibly one reason that lupus is fairly common in patients with

Klinefelter's syndrome or other genetic anomalies characterized by low

testosterone production.

Further study is needed to support testosterone therapy for systemic

lupus, but Dr. s has found that some patients will benefit from addition of

50-200 mg/day of dehydroepiandrosterone to standard antilupus regimens. The main

side effect is mild acne. This regimen " is a good adjunct, but it is not

monotherapy. "

It is impossible to determine from the appearance of a cutaneous lesion

how likely it is that the patient will develop systemic disease. But this is

something patients invariably want to know.

A multivariate analysis based on data from five European lupus centers

indicated that the three most predictive factors for progression are

proteinuria-hematuria, chronic arthralgia, and elevated antinuclear antibody

titers.

The first two are much more common and much more readily testable. " You

must do a urinalysis on the first visit when you suspect lupus and regularly

thereafter, " said Dr. s.

Complement activation proteins tend to be highly elevated in the blood of

patients who progress from cutaneous to extracutaneous disease. New tests for

these molecules are on the horizon that could offer physicians much greater

prognostic power in the next few years.