What medical treatments are available for lupus?

The diagnosis of lupus marks the beginning of medical management that does not necessarily aim for a complete cure, but rather for remission, meaning the control of inflammation to prevent irreversible damage. Management of lupus must be personalized and adjusted according to the severity of organ involvement and the patient’s profile (age, pregnancy, other existing diseases, etc.). It ranges from basic monitoring combined with the prescription of antimalarial drugs for mild cases, to intensive treatment protocols that include immunosuppressive or biologic therapies for severe situations. Each strategy seeks to maintain the balance of the immune system, prevent flares, and reduce the development of complications.

The current range of medical treatments now makes it possible to offer an almost normal life to most patients with lupus, provided they adhere strictly to their therapy.

Once the diagnosis has been established, the main objective becomes clear: to immediately calm the inflammation and restore a certain balance within the immune system. This is the stage at which the first level of lupus treatment is introduced, generally effective for managing mild to moderate forms. These treatments also play an essential long-term role: they help reduce the frequency of flares, as well as limit their severity when they occur.

Synthetic antimalarial drugs as first-line treatment in lupus.

In practice, hydroxychloroquine is almost always recommended. It forms the cornerstone of long-term treatment for most patients. It offers multiple benefits, including reducing the frequency of flares and providing long-term organ protection. Its mechanism is based on modulation of the immune system: it inhibits certain enzymes in lysosomes, limits lymphocyte activation, and reduces the production of autoantibodies and the stimulation of Toll-like receptors, which are responsible for inflammation. This treatment is generally well tolerated, even during pregnancy, but a few contraindications exist, particularly in the presence of severe kidney disease, significant liver impairment, preexisting cardiac disorders, or hypersensitivity to the drug.

According to a meta-analysis, prolonged use of hydroxychloroquine could reduce the risk of mortality in lupus patients by approximately 50%. In addition, beyond its ability to enhance immunity, it also has a beneficial effect on the lipid profile and reduces the risk of thrombosis.

However, prolonged use requires regular monitoring. Hydroxychloroquine tends to slowly accumulate in certain cells of the eye, particularly in the retina. Over time, this buildup can disrupt the function of the cells responsible for capturing light (photoreceptors), as well as the supporting cells, leading to a rare but serious retinopathy. An electrocardiogram may also be recommended for patients with cardiac rhythm disorders, because hydroxychloroquine can, in rare cases, slow the electrical conduction in the ventricles, promoting arrhythmias that are sometimes benign but can be more serious. Precautions are also necessary to avoid drug interactions, particularly with certain antiarrhythmic agents, digoxin, or medications that alter heart rhythm. The usual dosage in adults is 200 to 400 mg per day, adjusted according to the patient’s weight and tolerance.

Non-steroidal anti-inflammatory drugs (NSAIDs) for mild forms of lupus.

For less severe manifestations, such as joint pain or a low-grade fever, nonsteroidal anti-inflammatory drugs (NSAIDs), such as ibuprofen or naproxen, may be prescribed. These medications act rapidly by inhibiting cyclooxygenase enzymes (COX-1 and COX-2), which reduces the production of prostaglandins responsible for inflammation, pain, and fever, without hormonal effects or direct action on the immune system. However, they must be used with caution. The main contraindications include renal insufficiency, gastritis or an active ulcer, a history of bleeding disorders, certain cardiovascular and neurological conditions, as well as hypersensitivity to NSAIDs.

During the third trimester of pregnancy, certain NSAIDs are also not recommended.

Precautions for use are necessary: monitor kidney and liver function, avoid combining them with anticoagulants or high-dose corticosteroids, and limit their use to short, intermittent treatment periods. The usual dosage for ibuprofen is 200 to 400 mg every six to eight hours, while naproxen is generally prescribed at 250 to 500 mg twice a day, always adjusted according to the patient’s tolerance and body weight. Adverse effects may include gastrointestinal disorders (stomach pain, ulcers, bleeding), long-term kidney toxicity, increased blood pressure, skin reactions, or coagulation disorders.

Clinical research has shown that prolonged use of NSAIDs in patients with lupus can also mask the early onset of nephritis, which requires careful medical monitoring.

Corticosteroid therapy for lupus.

When health status worsens, corticosteroids are used to rapidly control inflammatory flares, often with a dramatic impact on symptoms. The prescribed doses vary according to the type and severity of the condition, and once symptoms are controlled, the dose is gradually reduced to limit side effects. In the case of a severe flare or the need for a very rapid effect, corticosteroids can be administered by intravenous infusion. However, this effectiveness is accompanied by significant side effects. Prolonged use can lead to weight gain in about 30 to 50% of patients, a risk of diabetes in 10 to 20%, and high blood pressure in up to 20 to 30%. The immunosuppressive effect also increases the risk of infections, and comorbidities may accumulate, such as cataracts or metabolic disorders.

In children, caution is even more important in order not to interfere with growth. Cortisone is also a frequent cause of osteoporosis. It is estimated thatabout 30 to 50% of patients exposed over the long term develop bone fragility, with a real risk of fractures. The therapeutic goal remains to find the minimum effective dose (often < 7.5 mg/day) and to progressively taper it down as soon as this is possible. Clinical studies show that continuous administration of high-dose corticosteroids, generally more than 20 mg/day of prednisone or equivalent for several months to several years, is the main factor in cumulative organ damage over a decade. Current protocols therefore favor large doses over a short period (bolus therapy), followed by a rapid taper in order to preserve the patient’s metabolism.

When the disease worsens or affects vital organs (kidneys, heart, and brain), it becomes necessary to use drugs that can further suppress the immune system.

Immunosuppressive drugs in cases of severe or treatment‑resistant organ involvement in lupus.

For moderate to severe forms of lupus, immunosuppressants such as azathioprine, methotrexate, or mycophenolate mofetil may be prescribed. Their role is to calm the immune system by reducing the activity of the cells responsible for inflammation: they slow the proliferation of T and B lymphocytes, decrease the production of pro-inflammatory substances, and disrupt immune activation mechanisms.

Their main advantage is that they make it possible to reduce, or even discontinue, cortisone, which helps limit its side effects. However, they require close medical monitoring, particularly through regular blood tests, because in approximately 10 to 30% of cases, they can lower the blood level of white blood cells. Some of them, such as methotrexate, mycophenolate mofetil, and cyclophosphamide, are strictly contraindicated during pregnancy because of the risk of congenital malformations.

In contrast, the use of mycophenolate mofetil has revolutionized the prognosis of lupus nephritis. A comparative study assessed the effectiveness of immunosuppressive agents in lupus, particularly in lupus nephritis. Several randomized trials and meta-analyses show that mycophenolate mofetil is at least as effective as cyclophosphamide for inducing renal remission, with sometimes a tendency toward better outcomes.

Biotherapies in the treatment of lupus.

Biologic therapies (monoclonal antibodies) have represented a significant advance in the management of lupus in recent years. Unlike conventional drugs, they specifically target certain mechanisms of the immune system. Belimumab, administered subcutaneously (usually as a weekly injection), works by blocking a key protein, BAFF (B-cell Activating Factor), which is required for the survival of B lymphocytes involved in the disease. By preventing this protein from binding to its receptors, it deprives these cells of survival signals, leading to a gradual reduction in the most abnormal B lymphocytes. Newer agents, such as anifrolumab, administered as a monthly infusion, target even more specific pathways, particularly type I interferons, which play a major role in lupus-related inflammation.

The results of the phase III clinical trials (TULIP) are particularly promising. They show that biotherapies are not limited to reducing the overall disease activity, assessed in particular by the SLEDAI index, but also provide tangible improvements in everyday life. In a large number of patients, there is a significant decrease in persistent skin damage and a relief of chronic joint pain. In a very large Italian observational study including 443 patients with lupus treated with belimumab, a significant reduction in the activity of joint and cutaneous manifestations was observed, as well as high remission rates in certain clinical forms—for example, up to approximately 76% cutaneous remission in some subgroups at 18 months.

These treatments are generally proposed when the disease remains active despite conventional therapies. They help reduce the overall activity of lupus, improve persistent symptoms, and decrease dependence on corticosteroids. However, their use requires certain precautions: they are contraindicated in cases of active infection and must be used with caution in immunocompromised patients. Updating vaccination status is often recommended before starting these treatments, and regular monitoring is essential. The most common adverse effects include reactions at the injection site or during infusions, headaches, fatigue, and an increased risk of infections, particularly viral infections (such as shingles with anifrolumab). More rarely, hypersensitivity reactions may occur.

Childhood lupus requires particular attention. In this age group, the disease is often more active, which makes management more complex. This higher intensity is explained by a combination of factors. Children’s immune systems often react more strongly, and kidney and neurological involvement tends to appear earlier and in a more severe form. The goal is to control inflammation without impairing growth or disrupting puberty. Thus, the treatment of juvenile lupus aims to limit long-term cortisone use as much as possible, favoring so-called “steroid-sparing” therapies. This strategy helps to control the disease while reducing long-term side effects. Among these treatments, hydroxychloroquine is often prescribed to reduce the frequency of flares, with regular ophthalmologic monitoring, while certain immunosuppressants, such as azathioprine or mycophenolate, may be used in cases of severe manifestations, with strict adherence to dosing and avoiding certain drugs such as methotrexate during the first trimester of any future pregnancy. For treatment-resistant forms, certain biologic therapies, such as belimumab starting at age 5, may be considered under close medical supervision.

However, treatment is not limited to medication. Preventive measures are also essential: strict sun protection, up-to-date vaccination, and psychological support. This last aspect is often underestimated, yet it is critically important. It helps the child cope better with the disease, particularly with physical changes related to treatment, such as facial swelling. Several clinical studies indicate that the early use of immunosuppressants, such as azathioprine, can reduce exposure to corticosteroids by about 40%. In the long term, this helps preserve metabolic health in adulthood and bone mineral density during the critical period of growth.

In addition to first- and second-line treatments, the management of lupus also involves another essential dimension: supportive care. Although these approaches are not intended to directly halt the immune system attack, they nonetheless fulfill several roles, including protecting organs from collateral damage, reducing the side effects of intensive treatments, and maintaining a stable level of daily comfort.

Lupus and topical use of botanical extracts.

Topical treatments most often represent the first line of defense against the cutaneous symptoms of the discoid form of lupus. Topical corticosteroids act by binding to specific nuclear receptors in order to inhibit the production of pro‑inflammatory mediators, which helps reduce tissue damage without entering the systemic circulation. One study suggests that the use of high‑potency topical corticosteroids leads to a complete healing of skin lesions in approximately 50% of patients with discoid lupus erythematosus. However, prolonged use can cause skin atrophy.

The intake of evening primrose or borage seed oils, which are rich in gamma-linolenic acid (GLA), can help restore the often-altered lipid barrier. In addition,true lavender essential oil or Boswellia carterii has soothing properties and inhibits the enzyme 5-lipoxygenase, which converts arachidonic acid into leukotrienes. These molecules act as powerful alarm signals, causing swelling, redness, and an influx of immune cells into the skin. This helps to calm skin irritation and reduce tissue damage around lupus lesions. Moreover, studies on Boswellia extracts support their noteworthy anti-inflammatory potential, suggesting that these botanical preparations could help limit the excessive use of topical steroids.

Although these treatments improve the skin’s aesthetic appearance and comfort, they do not address the underlying immune cause. They can be used as a supplement, without replacing medical treatments.

Dietary supplements for lupus.

In the management of lupus, certain dietary supplements can provide beneficial support. They are always taken in addition to medical treatment, and their effectiveness depends largely on taking them consistently. Vitamin D plays a central role. Its functions go beyond its ability to protect bones, which are weakened in patients receiving corticosteroid therapy. It also helps modulate the immune system. This is why a daily supplementation of 800 to 2000 IU, depending on individual needs, is recommended. Omega-3 fatty acids, which are mainly found in fish oils, are also of interest. They act both on inflammation and on the health of the heart and blood vessels, which is an important aspect in lupus. When consumed at about 2 to 3 g per day, they may help reduce joint pain and improve blood vessel function.

Certain plants are sometimes mentioned for their anti-inflammatory properties. For example, turmeric (Curcuma longa) contains curcumin, a compound that acts on mechanisms similar to those targeted by certain medications. However, its effect remains moderate and more preventive in nature. One study points out that while some plants can provide long-term support and may help reduce corticosteroid use, they are not sufficient to manage an acute flare.

Although some supplements can more or less support lupus management, certain plant species should be avoided. Alfalfa, for example, contains a substance that can overstimulate the immune system and trigger or worsen a flare.

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