What is your approach for severe SCLE in patients unable to tolerate HCQ?

1. 30% of subacute cutaneous lupus erythematosus (SCLE) is worsened by or caused by drugs, especially PPIs, calcium channel blockers (CCBs), thiazides, minocycline, and anti-fungal meds. Very different from other drug-induced disorders, the culprit drug could have been started months to years (as long as 11 years in the literature) before the onset or worsening of SCLE (especially to CCBs). PPI-induced SCLE is often resistant to immunosuppressants (one clue for this association). So, I stop or change possible culprit drugs.
   
   N.B. It often takes as long for the SCLE to resolve as per the length of time it took to appear/worsen after first taking the offending drug.
2. SCLE can be due to cancer (paraneoplastic), so ensure the patient is up to date ...

I would make sure they are not taking a drug that could cause SCLE, like omeprazole or another PPI. You could try methotrexate or mycophenolate mofetil. Anifrolumab would probably work but is hard to get unless the patient has SLE. Lenalidomide is a thalidomide derivative that works well for very refractory diseases. There are a number of studies of CLE, including SCLE, that are evaluating new treatments that worked well in phase 1 and 2 trials. We need new effective and safe therapies for cutaneous lupus and so if near a center doing these trials could be an option if the therapies mentioned above don't work.

I have found that adding 15-25 mg/week sc Methotrexate works very well for SCLE that is insufficiently responsive to HCQ or for patients unable to take HCQ. Failing that, anifrolumab provided the patient has sufficient SLE criteria to access it.

With regard to HCQ intolerance, whether it be GI intolerance, pruritus, or dysesthesias, more often than not I have found this to be very preparation-dependent, with patients often tolerating an alternative manufacturer's product. In the past two decades, much of the HCQ dispensed in the U.S. has been manufactured by entities overseas, a number of whom that have had difficulty adhering to FDA-required manufacturing standards for importation (a major reason we lost access to quinacrine for several ye...