How do you manage a patient with severe RA or SLE that worsens after stopping immunosuppressants due to having chronic foot ulceration?

Fear the foot ulcer! These portals of entry for microorganisms can wreak havoc in immune-compromised patients. Rheumatologists must ensure that these lesions are being properly managed. Since healing can often be prolonged in some of our patients, the decision of whether and when to resume immune suppressive therapy must be addressed.

In general, open wounds that have not shown signs of healing preclude the use of immune-suppressive therapies. If antimicrobial therapy has been initiated, and there are signs of wound stability (e.g., no growth in size, reduction in surrounding erythema, and reduced pain levels), it may be safe to slowly reinstitute immune suppressive therapy. I generally add these back sequentially if the patient is taking m...

I agree with not using any steroids. IVIG has been used as an adjunct and off-label drug option in SLE when standard immunosuppressives are contraindicated and there's an active infection or SLE is refractory (Sakthiswary and D'Cruz, PMID 25310743). I may opt to use IVIG until the ulcer is resolved. Benefits of IVIG in SLE are well described in this article.