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Abstract
Background Cutaneous lupus erythematosus (CLE) is the most common manifestation of SLE and may occur without systemic features. Skin disease is particularly heterogeneous, rendering assessment of activity difficult. Laser Doppler imaging (LDI) is a non-invasive imaging tool that monitors blood perfusion in dermal tissue. It has been shown to correlate with inflammation in psoriasis but no study has been undertaken in CLE.
Objectives To evaluate validity of LDI against the gold standard of histology from skin biopsy as well as other clinical tools including the Revised Cutaneous Lupus Erythematosus Disease Area and Severity Index (RCLASI) and Visual Analogue Scale (VAS) scoring of photographs.
Methods A prospective observational study was conducted in consecutive patients with CLE flare at a single centre. Disease activity was assessed using RCLASI and measured using a high resolution LDI system (Moor Instruments) by JB and YY, both blinded to clinical assessment. Relative difference to the non-lesion area was calculated and expressed in perfusion unit (PU). Skin biopsy was obtained in those who consented and scored as 0=non-active, 1=mild activity and 2=active. Photographs were taken on the same day and were later assessed by a dermatologist and a rheumatologist who were blinded to LDI results using a 100mm VAS. The agreement of VAS between both clinicians was analysed using Bland-Altman limits of agreement (LOA) and the correlation between histology and LDI, RCLASI and VAS were analysed using Kendall's Tau-a.
Results 20 patients were studied (19 female, median age 47.2 (range 21–62) years, 6 smokers, 2 CLE only, 14 (70%) ANA positive at the time of the scan). The distribution of CLE type were: acute CLE=7, subacute CLE=6 and chronic CLE=7. The agreement between the VAS scores of the two clinicians was fair; mean difference 7.8 (95% CI LOA -26 to 42) mm versus average. In 10 patients with skin biopsy, the correlation with histology was better for LDI (tau-a=0.56) than RCLASI [-0.09; difference (90% CI) 0.64 (0.10, 1.19)] or VAS [-0.16; 0.71 (0.13, 1.29)] (figure 1). One patient who was deemed to have a subacute CLE flare based on clinical assessment indeed had a negative histology and a low PU.
Conclusions In this preliminary analysis, assessment of blood perfusion to dermal tissue using LDI provides a valid quantitative and objective measure of inflammation in cutaneous lupus. The findings from LDI also had a better correlation with histology from skin biopsy compared to currently used clinical tools. Further validation and longitudinal analysis including assessment of responsiveness to therapy will provide further evidence on the usefulness of LDI in clinical practice and trials.
Acknowledgements The authors would like to acknowledge Lorraine Green for substantial contribution in the acquisition of data and NIHR for funding the Laser Doppler Imaging.
Disclosure of Interest None declared