title: Brief report: responses to rituximab suggest B cell-independent inflammation in cutaneous systemic lupus erythematosus.
abstract: OBJECTIVE
  The immunopathogenesis of systemic lupus erythematosus (SLE) is heterogeneous, and responses of skin to rituximab are variable. This study was undertaken to determine the phenotype of rituximab-responsive disease.
  
  
  METHODS
  Eighty-two patients with SLE who were receiving rituximab were prospectively studied. Of these patients, 32 had significant skin involvement before or after treatment. Disease activity was assessed using the British Isles Lupus Assessment Group (BILAG) index 2004. Cutaneous lupus subtype was classified by a dermatologist as acute cutaneous lupus erythematosus (ACLE), subacute cutaneous lupus erythematosus (SCLE), chronic cutaneous lupus erythematosus (CCLE), or other skin diseases, with supportive photographs or biopsies where necessary.
  
  
  RESULTS
  Of 26 patients with skin disease at baseline, 9 (35%) had a beneficial mucocutaneous response to rituximab at 6 months, with good responses in ACLE (6 of 14 patients [43%]), and poor responses in CCLE (0 of 8 patients) (P = 0.034). Clinical response was associated with anti-RNP negativity (P = 0.024) and anti-Ro negativity (P = 0.031). Flares of SCLE and CCLE occurred in 12 patients who either had no skin disease or had ACLE at baseline (i.e., a switch in subtype). Concomitant antimalarials or conventional immunosuppressants were not associated with response or flare rate. Posttreatment biopsies confirmed typical active SLE histology in lesions occurring during B cell depletion.
  
  
  CONCLUSIONS
  Our findings indicate that the clinical response to rituximab in cutaneous manifestations of SLE depends on subtype. None of the CCLE patients responded, and new CCLE lesions were observed during B cell depletion, suggesting that initiation and activity of these lesions is not B cell dependent. Flares of a range of skin diseases after B cell depletion may indicate a change in immune regulation following B cell-targeted therapy.
authors.affiliation: NIHR Leeds Biomedical Research Unit, Leeds Teaching Hospitals NHS Trust, and University of Leeds, Leeds, UK.
authors.forename: Edward M
authors.initials: EM
authors.lastname: Vital
authors.affiliation: NIHR Leeds Biomedical Research Unit, Leeds Teaching Hospitals NHS Trust, and University of Leeds, Leeds, UK, and Bradford Teaching Hospitals NHS Foundation Trust, Bradford, UK.
authors.forename: Miriam
authors.initials: M
authors.lastname: Wittmann
authors.affiliation: Leeds Teaching Hospitals NHS Trust, Leeds, UK.
authors.forename: Sara
authors.initials: S
authors.lastname: Edward
authors.affiliation: NIHR Leeds Biomedical Research Unit, Leeds Teaching Hospitals NHS Trust, and University of Leeds, Leeds, UK.
authors.forename: Md Yuzaiful
authors.initials: MY
authors.lastname: Md Yusof
authors.affiliation: Bradford Teaching Hospitals NHS Foundation Trust, Bradford, UK.
authors.forename: Helen
authors.initials: H
authors.lastname: MacIver
authors.affiliation: NIHR Leeds Biomedical Research Unit, Leeds Teaching Hospitals NHS Trust, and University of Leeds, Leeds, UK.
authors.forename: Colin T
authors.initials: CT
authors.lastname: Pease
authors.affiliation: NIHR Leeds Biomedical Research Unit, Leeds Teaching Hospitals NHS Trust, and University of Leeds, Leeds, UK.
authors.forename: M
authors.initials: M
authors.lastname: Goodfield
authors.affiliation: NIHR Leeds Biomedical Research Unit, Leeds Teaching Hospitals NHS Trust, and University of Leeds, Leeds, UK.
authors.forename: Paul
authors.initials: P
authors.lastname: Emery
mesh_terms: D058846:Antibodies, Monoclonal, Murine-Derived / Q000627:therapeutic use; D018501:Antirheumatic Agents / Q000627:therapeutic use; D001402:B-Lymphocytes / Q000276:immunology* / Q000473:pathology; D015331:Cohort Studies; D006801:Humans; D007166:Immunosuppressive Agents / Q000627:therapeutic use; D008178:Lupus Erythematosus, Cutaneous / Q000188:drug therapy / Q000276:immunology* / Q000473:pathology; D008180:Lupus Erythematosus, Systemic / Q000188:drug therapy / Q000276:immunology* / Q000473:pathology; D011446:Prospective Studies; D000069283:Rituximab; D012867:Skin / Q000276:immunology* / Q000473:pathology; D016896:Treatment Outcome
chemical_list: D058846:Antibodies, Monoclonal, Murine-Derived; D018501:Antirheumatic Agents; D007166:Immunosuppressive Agents; D000069283:Rituximab