Thalidomide in SLE with Skin Damage Refractory to Other Treatment Options: Two Case Reports

Abstract

Background: Cutaneous manifestations of systemic lupus erythematosus (SLE) may persist despite antimalarials and conventional immunosuppressive therapy, causing substantial morbidity and prolonged corticosteroid exposure. Thalidomide has demonstrated activity in refractory cutaneous lupus erythematosus (CLE), but its use is limited by serious adverse effects, particularly teratogenicity and peripheral neuropathy. Case Presentations: We report two patients with SLE and refractory CLE. Case 1 was an adult woman with longstanding SLE and chronic, treatment-resistant cutaneous lesions despite multiple prior systemic therapies and prolonged corticosteroids, complicated by steroid-related adverse events. Thalidomide was introduced after failure or intolerance of standard options, leading to marked clinical improvement of cutaneous disease and steroid-sparing benefit; however, peripheral neuropathy developed during treatment and required discontinuation. Case 2 was a 16-year-old girl with SLE and active CLE confirmed by clinicopathologic assessment, insufficiently responsive to standard therapy. Thalidomide was initiated as a rescue option with rapid improvement in skin lesions, but neuropathic symptoms occurred early, prompting cessation and transition to alternative immunosuppression. Outcomes: In both cases, thalidomide was associated with clinically meaningful improvement of refractory cutaneous disease, but treatment-limiting neurotoxicity occurred, underscoring the narrow therapeutic window and the need for strict monitoring. Conclusion: Thalidomide may be an effective short-term rescue therapy for carefully selected patients with refractory CLE when conventional agents are ineffective or not tolerated. Its use requires rigorous risk–benefit assessment, comprehensive counseling, adherence to pregnancy-prevention requirements, and proactive surveillance for peripheral neuropathy with prompt discontinuation at the earliest signs of neurotoxicity. Future prospective studies incorporating standardized cutaneous activity indices and structured safety monitoring are required to clarify optimal dosing, treatment duration, relapse prevention strategies, and predictors of adverse events, especially in adolescents and other high-risk populations.