Impact of smoking in cutaneous lupus erythematosus

Abstract

Objective: To investigate cigarette smoking in cutaneous lupus erythematosus (CLE).

Design: Prospective longitudinal cohort study.

Setting: Urban cutaneous autoimmune disease clinic.

Participants: A total of 218 individuals with CLE or systemic lupus erythematosus and lupus nonspecific skin disease seen between January 5, 2007, and July 30, 2010.

Main outcome measures: Cutaneous Lupus Erythematosus Disease Area and Severity Index (CLASI) scores to assess disease severity and response to treatment and Skindex 29+3 scores to assess patient quality of life.

Results: Current smokers with lupus erythematosus had higher median CLASI scores (9.5) than did never (7.0) and past (6.0) smokers with CLE (P = .02). Current smokers had higher median scores on all the Skindex 29+3 subsets. Current smokers taking hydroxychloroquine sulfate had higher quinacrine hydrochloride use than did nonsmokers (P = .04). Two to 7 months after enrollment, current smokers (median CLASI change, -3) treated with only antimalarial agents improved more than never (1) and past (0) smokers (P = .02). Eight months or more after enrollment, current smokers (CLASI change, 3.5) treated with antimalarial drugs plus at least 1 additional immunomodulator improved less than never (-1.5) and past (0) smokers (P = .04).

Conclusions: Current smokers with lupus erythematosus had worse disease, had worse quality of life, and were more often treated with a combination of hydroxychloroquine and quinacrine than were nonsmokers. Never and past smokers showed greater improvement when treated with antimalarial agents plus at least 1 additional immunomodulator. Current smokers had greater improvement when treated with antimalarial drugs only.

Figure 1

Differences in smoking status between lupus subjects with SLE + skin relative to subjects with CLE-only (p = 0.006).

Figure 2

Median CLASI scores for subjects in the lupus database at enrollment. Both never and past smokers differed significantly from current (p = 0.017, post-hoc Dunn’s test indicated *p < 0.05 for both never versus current and past versus current; bars represent interquartile range).

Figure 3

Median Skindex 29-3 scores compared by smoking status. Note that current smokers had higher scores in all subjects (*p < 0.05; **p < 0.01; bars represent interquartile range).