Treatment of discoid lupus erythematosus scarring alopecia with deucravacitinib: A case report

Abstract

Discoid lupus erythematosus is a chronic, recurring, autoimmune skin disease causing annular, scarring plaques on the head and neck. Deucravacitinib, a tyrosine kinase 2 inhibitor in the Janus kinase inhibitor family, represents an emerging treatment option in systemic lupus erythematosus with potential applicability to discoid lupus erythematosus. We describe a 48-year-old woman with multiple treatment-refractory scalp plaques and associated alopecia treated with deucravacitinib. She demonstrated resolution of symptoms and 1–2 cm hair regrowth at a 3-month follow-up, with significant hair regrowth and reduction in plaque size at a 6-month follow-up. The patient tolerated the medication well with no side effects. This case highlights the potential of deucravacitinib as an effective therapy for refractory discoid lupus erythematosus.

Introduction

Discoid lupus erythematosus (DLE) is a chronic manifestation of cutaneous lupus erythematosus (CLE) characterized by scaly, annular plaques often occurring above the neck. Lesions can cause permanent scarring, pigmentary changes, and alopecia. First-line treatment consists of photoprotection, topical corticosteroids, and topical calcineurin inhibitors, with systemic therapies reserved for unresponsive cases or widespread disease. Deucravacitinib is an oral tyrosine kinase 2 (TYK2) inhibitor with U.S. Food and Drug Administration approval for plaque psoriasis and evidence for the treatment of psoriatic arthritis and inflammatory bowel disease. ¹ Emerging literature on Janus kinase (JAK) inhibitors, including deucravacitinib, suggests favorable results for treating systemic lupus erythematosus (SLE).^2,3 A limited number of case reports have assessed JAK inhibitors, including ruxolitinib and tofacitinib, in DLE, with promising results. ² In addition, two phase II trials demonstrated the potential efficacy of topical delgocitinib and R333 in treating DLE; however, these trials did not achieve their outcomes. ² Herein, we describe the second published case to date of DLE successfully treated with deucravacitinib. ⁴

Case report

A 48-year-old, otherwise healthy, Caucasian female was referred to our clinic with non-healing recurring scalp plaques and associated hair loss. Skin biopsy found inflammatory, scarring alopecia consistent with lupus erythematosus. The patient reported focal scalp pruritus, pain, swelling, and skin peeling, but denied features of SLE including arthralgias, fatigue, fevers, or ulcers. Autoantibodies, including antinuclear antibodies, extractable nuclear antigens, and anti-double stranded DNA, were negative. Physical examination revealed three distinct areas of scarring alopecia on her left frontal (Figure 1(a)), right frontal (Figure 1(c)), and left posterior scalp (Figure 1(e)) with erythema and scale. Having previously attempted topical potent corticosteroids, calcineurin inhibitors, and crisaborole without success, she later underwent treatments with intralesional triamcinolone acetonide (March 2021 to May 2023), isotretinoin (April to July 2023), and hydroxychloroquine (started June 2021), all of which also failed to yield improvement.

Figure 1.

Scalp plaques before initiation of deucravacitinib and 6 months after initiation of deucravacitinib. (a) Left frontal scalp plaque pre-deucravacitinib. (b) Left frontal scalp plaque post-deucravacitinib. (c) Right frontal scalp plaque pre-deucravacitinib. (d) Right frontal scalp plaque post-deucravacitinib. (e) Left posterior scalp plaque pre-deucravacitinib. (f) Left posterior scalp plaque post-deucravacitinib.

Given her treatment-refractory disease, she was started on off-label 6 mg daily deucravacitinib in July 2023, while continuing hydroxychloroquine at 200 mg daily Monday to Friday and 200 mg twice daily Saturday to Sunday. This dose of hydroxychloroquine was based on her weight of 65 kg and targeted a total dose of 5 mg/kg/day of actual body weight, averaged over the 7 days of the week. At 3-month follow-up, she reported complete relief of pruritus and pain, with 1–2 cm hairs regrowing on physical examination. She tolerated the medication well with no side effects. Six months post-deucravacitinib initiation, the patient demonstrated significant hair regrowth and a reduction in plaque size (Figure 1(b), (d), (f)). The apparent erythema in Figure 1(f) was not noticed clinically, and we feel that this was an artifact of the photograph.

Discussion

Various inflammatory cytokines involved in CLE and SLE, including interferons, interleukin (IL)-6, IL-12, and IL-23, signal through the JAK/STAT pathway.^1,2 Unlike other JAK inhibitors which bind to the catalytic domain, deucravacitinib inhibits TYK2 by selectively binding to the pseudokinase regulatory domain, potentially resulting in greater selectivity. ¹

Ezeh et al. describe a 65-year-old female who similarly had multiple treatment-refractory plaques of DLE alopecia. This patient had a longer history of DLE and achieved improvement in her DLE and palmoplantar pustular psoriasis after only 1 month on deucravacitinib. ⁴ Side effects were minimal, with only mild acneiform eruption in the Ezeh et al. case. This current case report provides additional support for the therapeutic utility of deucravacitinib in patients with DLE scarring alopecia.

Ongoing clinical trials are being conducted to evaluate the safety and efficacy of deucravacitinib in DLE and subacute CLE with pending results. ⁵ In the interim, this case supports deucravacitinib as a promising addition to the therapeutic toolbox for refractory DLE.