Treatment of Discoid Skin Lesions With Azathioprine

To the Editor.—  Tsokos et al¹ recently described a case of a young woman with systemic lupus erythematosus whose mild systemic disease was controlled with prednisone, hydroxychloroquine sulfate (Plaquenil), and triamcinolone acetonide (Aristocort) 0.1% cream, but whose discoid skin lesions progressed despite these therapies. The next step in her therapy was azathioprine sodium (Imuran) administered orally, which resulted in improvement of her skin lesions.We would like to emphasize that there are less toxic therapies that should be used to treat resistant skin lesions before resorting to cytotoxic agents. Several articles on antimalarial therapy^2,3 suggest that if hydroxychloroquine alone does not control extensive skin lesions, quinacrine hydrochloride (Atabrine) can be added synergistically without any increase in eye toxicity. Improvement has been seen in as many as 95% of patients in several series.² In our experience in the Bellevue Hospital Lupus Clinic, New York, nearly all patients who