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Proton pump inhibitor-induced subacute cutaneous lupus erythematosus — SCE Rheumatology MCQ

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ModerateDermatologyProton pump inhibitor-induced subacute cutaneous lupus erythematosusSCE Rheumatology

A 52-year-old woman with systemic lupus erythematosus has been clinically stable for 3 years on hydroxychloroquine 300 mg daily. Seven weeks after starting omeprazole for uncomplicated dyspepsia, she develops a minimally symptomatic photosensitive eruption. Examination shows widespread non-scarring annular and polycyclic erythematous scaly plaques over the upper trunk and extensor arms, without blistering or ulceration. Skin biopsy demonstrates an interface dermatitis compatible with subacute cutaneous lupus erythematosus. Anti-Ro/SSA antibodies are positive. Complement concentrations, anti-double-stranded DNA antibody titre, full blood count and urinalysis are unchanged, and there are no other clinical features of active systemic lupus erythematosus. Which is the most appropriate immediate management?

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Correct answer: D — Stop omeprazole, avoid another proton pump inhibitor, continue hydroxychloroquine, and reinforce photoprotection

Explanation lettering: B = shown as A · D = shown as B · E = shown as D · A = shown as E

The morphology and distribution are characteristic of subacute cutaneous lupus erythematosus (SCLE), but the decisive features are its onset seven weeks after omeprazole initiation and the absence of accompanying systemic lupus activity. Proton pump inhibitors can induce SCLE after weeks, months or even years of exposure. The first intervention is withdrawal of the suspected trigger, with photoprotection and observation for improvement. Hydroxychloroquine should be continued because it was controlling her underlying disease. Another proton pump inhibitor should not simply be substituted, as recurrence has occurred across the drug class. A suspected adverse reaction should also be reported through the Yellow Card scheme. A is inadequate because topical treatment does not remove the likely trigger. B represents escalation for persistent idiopathic cutaneous lupus and would become appropriate only after trigger withdrawal and reassessment if clinically significant disease persisted. C is attractive because lansoprazole provides equivalent acid suppression, but cross-reactivity between proton pump inhibitors is recognised. D removes the trigger but exposes a patient with mild, non-ulcerative skin disease and no systemic flare to unnecessary immediate systemic glucocorticoids. Topical or systemic corticosteroids may be considered if there is no remission after withdrawal or if the eruption is sufficiently severe, but they are not the preferred initial response in this case.

Reference: Proton pump inhibitors: very low risk of subacute cutaneous lupus erythematosus (September 2015) — https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/459148/Drug_Safety_Update_-_September_2015_pdf.pdf Omeprazole 20 mg Capsules — Summary of Product Characteristics (28 June 2024) — https://www.medicines.org.uk/emc/product/4895/smpc