Lupus erythematosus tumidus--a neglected subset of cutaneous Lupus erythematosus: report of 40 cases

Tumid Lupus Erythematosus (TLE): A Review of a Rare Variant of Chronic Cutaneous Lupus Erythematosus (cCLE) with Emphasis on Differential Diagnosis

Tumid lupus erythematosus (TLE) has been the subject of heated debate regarding its correct nosographic classification. The definition of TLE has changed over time, varying according to the different studies performed. In this review, we address the initial definition of TLE, the changes that have taken place in the understanding of TLE, and its placement within the classification of cutaneous lupus erythematosus (CLE), with a focus on clinical, histopathological, immunophenotypical, and differential diagnosis aspects.

Lupus Erythematosus Tumidus as a Distinct Uncommon Subtype of Cutaneous Lupus Erythematosus: A Case Report and Review

Lupus erythematosus tumidus (LET) is an uncommon but distinct photosensitive subtype of cutaneous lupus erythematosus (CLE). It differs from discoid and subacute cutaneous lupus erythematosus (SCLE) clinically and pathologically. LET is marked by extreme photosensitivity and carries a much lower risk of progression to systemic disease. The differential diagnosis of LET includes polymorphic light eruption (PMLE) and Jessner's lymphocytic infiltration of the skin (JLIS) because of subtle alterations in the histopathology and the paucity of immunopathologic markers in LET. We report herein a case of LET with positive immunoglobulin (Ig) deposits on direct immunofluorescence (DIF) testing. LET resolved completely with strict sun avoidance and treatment with topical corticosteroids, without the sequelae of atrophy, scarring, or dyspigmentation.

A case of lupus erythematosus tumidus misdiagnosed as erysipelas

A patient presented with erythema and oedema on the right eyelid, malar region and left thigh with pruritus and pain. She was diagnosed with erysipelas and had been treated with anti-inflammatory drugs, but the symptoms did not improve. Laboratory investigation and biopsy showed that she was consistent with lupus erythematosus tumidus. It's a typical and rare diease relatively.

Systemic lupus erythematosus presenting as lupus erythematosus tumidus and lupus nephritis: a case report

BACKGROUND

Lupus nephritis and lupus erythematosus tumidus (LET) are uncommon manifestations of systemic lupus erythematosus (SLE), and their coexistence as the initial presentation of SLE is exceedingly rare. Here, we report such a case, emphasizing the diagnostic challenges and therapeutic implications of this unusual association.

CASE REPORT

A 38-year-old North African woman presented in Nephrology department with a history of lower extremity edema, fatigue, and weight loss of 3 kg in 4 weeks. Physical examination revealed LET lesions on the chest and the Neck. Laboratory investigations showed lymphopenia, low C3 and C4 complement levels, positive antinuclear antibodies, anti-dsDNA antibodies, and anti-SSA/Ro antibodies. Renal function tests showed normal serum creatinine and nephrotic proteinuria. Renal biopsy revealed Class V lupus nephritis. Skin biopsy confirmed the diagnosis of LET, with the presence of lymphohistiocytic infiltrates and dermal mucin. The patient was diagnosed with SLE based on the 2019 EULAR/ACR criteria and treated with prednisone (1 mg/kg/day) and hydroxychloroquine. She showed significant improvement in her cutaneous and renal symptoms at 6 and 12 months follow-up.

CONCLUSION

The rarity of the coexistence of LET and lupus nephritis as the initial manifestation of SLE, especially in the North African population, underscores the need for further research to elucidate the immunopathogenic mechanisms and prognostic factors associated with this association.

Lupus Erythematosus Tumidus: Clinical and Pathological Features in a Series of 20 Patients

OBJECTIVE

We sought to assess the clinicopathologic/immunophenotypical features in patients with lupus erythematosus tumidus (LET).

METHODS

All skin biopsies diagnosed as LET in 16 years were retrieved from our pathology laboratory. Clinical charts were reviewed and immunohistochemical markers were performed. Subpopulations of cells in the infiltrates were studied, as well as the number/distribution of plasmacytoid dendritic cells (PDC), which were compared with two control groups: normal skin and discoid lupus erythematosus. Direct immunofluorescence was performed when available.

RESULTS

We found 20 patients (11 men and 9 women; mean age 43.5 years); the mean evolution previous to diagnosis was 20.3 months. They all had erythematous, nonscarring urticarial-like plaques: 8 in the head region only, 8 in trunk/limbs only; both segments were affected in 2 patients; topography was unknown in 2. Except for 1 patient, no one developed systemic lupus erythematosus. A dense perivascular/periadnexal superficial-to-deep lymphocytic infiltrate and stromal mucin deposition were characterized histopathologically; interphase changes were absent. Immunophenotype supported an inflammatory profile. The differential count of CD123 + PDC in 10/20 cases of LET (n = 1180) was notably higher than 5 cases of discoid lupus erythematosus (n = 419) and 5 cases of normal skin (n = 38). No immune deposits were found in 2 cases.

CONCLUSION

LET is a rare, peculiar form of cutaneous lupus erythematosus that only exceptionally evolves to systemic lupus erythematosus . Its clinical-pathologic/immunophenotypical features are very characteristic. The amount of CD123 + PDC is a very helpful feature among the criteria for its diagnosis and seems to be relevant in its pathogenesis.

Primary Cutaneous CD4-Positive Small/Medium T-Cell Lymphoproliferative Disorder Mimicking Jessner Lymphocytic Infiltrate and Tumid Lupus-A Report of Two Cases

ABSTRACT

Primary cutaneous CD4+ small/medium T-cell lymphoproliferative disorder is a benign lymphoproliferative disorder composed of small-sized to medium-sized pleomorphic cells expressing a follicular helper T-cell phenotype. Jessner lymphocytic infiltrate and tumid lupus are cutaneous conditions characterized by the presence of rich dermal lymphocytic infiltrates with a superficial, deep, perivascular and periadnexal distribution that include copious amounts of dermal mucin deposition. We report 2 cases of primary cutaneous CD4+ small/medium T-cell lymphoproliferative disorder presenting with markedly increased dermal mucin, mimicking both Jessner lymphocytic infiltrate and tumid lupus and provide a review of the differential diagnosis and highlight key distinguishing features.

Tumid lupus erythematosus and systemic lupus erythematosus: a rare coexistence

A patient diagnosed with tumid lupus erythematosus (TLE) was subsequently found to have systemic lupus erythematosus (SLE) after presenting to a tertiary care medical centre with shortness of breath and oedema. In this commentary, we discuss this patient's presentation and the association between TLE and SLE.

Development of Lupus Erythematosus Tumidus During the Course of Systemic Sclerosis

A man with systemic sclerosis (SS), manifested by characteristic skin lesions, gastro-esophageal reflux disease, and pulmonary fibrosis producing progressive respiratory failure, and a positive antinuclear antibody consistent with reactivity to fibrillarin, developed skin lesions with the clinical and histological characteristics of lupus erythematosus tumidus (LET) 10 years after the diagnosis of SS. His respiratory failure progressed and he expired from sepsis after tracheal intubation and mechanical ventilation two years after developing LET. The association of SS and LET, not described until now, raises questions about its pathogenesis and its prognostic significance.

Cutaneous Manifestations of "Lupus": Systemic Lupus Erythematosus and Beyond

Lupus, Latin for "wolf," is a term used to describe many dermatologic conditions, some of which are related to underlying systemic lupus erythematosus, while others are distinct disease processes. Cutaneous lupus erythematosus includes a wide array of visible skin manifestations and can progress to systemic lupus erythematosus in some cases. Cutaneous lupus can be subdivided into three main categories: acute cutaneous lupus erythematosus, subacute cutaneous lupus erythematosus, and chronic cutaneous lupus erythematosus. Physical exam, laboratory studies, and histopathology enable differentiation of cutaneous lupus subtypes. This differentiation is paramount as the subtype of cutaneous lupus informs upon treatment, disease monitoring, and prognostication. This review outlines the different cutaneous manifestations of lupus erythematosus and provides an update on both topical and systemic treatment options for these patients. Other conditions that utilize the term "lupus" but are not cutaneous lupus erythematosus are also discussed.

Lupus Erythematosus Tumidus with Pseudolymphomatous Infiltrates: A Case Report

A 39-year-old Japanese woman presented with a pruritic infiltrated erythematous plaque on the right cheek. Histopathologic analysis of the erythema showed dermal edema, separation of collagen bundles, and nodular perivascular and periadnexal infiltration of lymphocytes in the whole dermis, without epidermal changes. Alcian blue staining intensity was elevated between the collagen bundles, indicating dermal mucinosis. The nodular infiltrates consisted of CD3+ T cell clusters and CD20+ B cell clusters (ratio, approximately 3:1) and included numerous CD123+ cells, indicative of plasmacytoid dendritic cells. Blood analysis revealed serum antinuclear antibody at a titer of 1:160 (homogeneous, speckled pattern). Lupus erythematosus tumidus with pseudolymphomatous infiltrates was diagnosed. Hydroxychloroquine treatment partially improved symptoms; however, the addition of prednisolone was required for complete resolution. Lupus erythematosus tumidus is sometimes accompanied by pseudolymphomatous infiltrates. Dermal mucinosis and the presence of numerous plasmacytoid dendritic cells are useful in differentiating lupus erythematosus tumidus from pseudolymphoma.

Infiltración Linfocitaria de Jessner-Kanof. Reporte de un caso

Se presenta una paciente de raza blanca, de 48 años de edad, valorada en el servicio de Dermatología, refiriendo una mancha roja y escamosa en forma de línea en la frente de 1 año de evolución, que en ocasiones se acompañaba de ardor. Había utilizado varios tratamientos médicos sin mejoría, por lo que acude a nuestro servicio. Fue valorada y examinada detenidamente y se plantearon como diagnósticos probables: una Esclerodermia lineal, un Lupus Eritematoso Fijo Discoide Crónico y una Infiltración Linfocitaria de Jessner. Se realizó biopsia cutánea que confirmó que se trataba de una Infiltración Linfocitaria de Jessner-Kanof. Esta entidad es muy rara y controvertida. Se instauró tratamiento con antipalúdicos con mejoría total del cuadro cutáneo.

Tumid Lupus Erythematosus: A Rare and Distinctive Variant of Cutaneous Lupus Erythematosus Masquerading as Urticarial Vasculitis

Tumid lupus erythematosus (TLE) is a rare form of chronic cutaneous lupus that has triggered much debate regarding its clinical and histopathological features. It has been classically defined as annular erythematous, succulent, plaques involving the face and trunk that typically are devoid of any papulosquamous features such as scale and follicular plugging. These lesions are a clinical mimicker of other urticarial lesions such as urticarial vasculitis and lymphocytic infiltrate of Jessner. We report a case of TLE presenting in a 49-year-old Caucasian female whose initial clinical presentation was concerning for urticarial vasculitis due to presence of urticarial-like lesions present for approximately three months. Laboratory studies and histopathological correlations confirmed the diagnosis of TLE and the patient was successfully treated with topical corticosteroids.

Neue Klassifikationskriterien des SLE: was helfen sie für die klinische Diagnose des SLE?

Im September 2019 sind die gemeinsamen Klassifikationskriterien der European League Against Rheumatism (EULAR) und des American College of Rheumatology (ACR) für den systemischen Lupus erythematodes (SLE) erschienen. Die EULAR/ACR 2019 Klassifikationskriterien verwenden (jemals) positive antinukleäre Antikörper (ANA) als obligates Eingangskriterium und gewichtete Kriterien mit Werten von 2 bis 10 und einem Cut-off von 10. Die Kriterien sind in 10 Domänen geordnet, innerhalb derer Assoziationen zwischen verschiedenen Manifestationen bestehen, und nur der höchste Wert in einer Domäne wird verwendet. Kriterien werden nur gewertet, wenn es für sie keine andere Erklärung gibt, die wahrscheinlicher ist als der SLE. Die neuen Kriterien sind statistisch den älteren Kriteriensets überlegen. Sie gelten aber nur für die Klassifikation. Für die meisten Rheumatologinnen und Rheumatologen ist das Stellen der Diagnose eines SLE wesentlich relevanter als der Einschluss in SLE-Studien, für den die Klassifikationskriterien gedacht sind. Daher stellt sich die Frage, wie weit die Klassifikationskriterien für die Diagnose helfen können. Direkt dafür verwendet werden dürfen sie wirklich nicht. Erfahrene Ärztinnen und Ärzte sind besser und v. a. sensitiver als die besten Kriterien. Manche Detailinformationen helfen aber dennoch dabei, die individuelle Diagnose für konkret Patientinnen und Patienten zu stellen. Die vorliegende Arbeit erörtert die Neuigkeiten in den EULAR/ACR 2019-Kriterien, stellt den Unterschied zwischen Klassifikation und Diagnose dar und diskutiert, welche Informationen auch im klinischen Alltag Anwendung finden können.

Cosmetic treatment in patients with autoimmune connective tissue diseases: Best practices for patients with lupus erythematosus

The cutaneous manifestations of lupus, especially chronic cutaneous lupus erythematosus, are a source of significant morbidity and can negatively impact patient quality of life. While the active inflammatory component of the disease may be adequately treated, patients are frequently left with residual skin damage and disfiguring aesthetic deficits. Dermatologists lack guidelines regarding the use and safety of various reconstructive and cosmetic interventions in this patient population. Laser treatments are largely avoided in the lupus population because of the possible photodamaging effects of ultraviolet and visible light. Similarly, given the autoimmune nature of this disease, some physicians avoid injectable treatment and grafts because of the concern for disease reactivation via antigenic stimulation. In the second article in this continuing medical education series we compile available data on this topic with the goal of providing evidence-based guidance on the cosmetic treatment of patients with lupus erythematosus with a focus on chronic cutaneous lupus erythematosus.

Tumid Lupus Erythematosus and Systemic Lupus Erythematosus: A Report on Their Rare Coexistence

Tumid lupus erythematosus (TLE) is a rare variant of cutaneous lupus erythematosus. Clinically, it lacks typical changes found in discoid lupus and antinuclear antibodies (ANA) levels are elevated in only 10% of the patients. Coexistent systemic lupus erythematosus (SLE) has been reported to be rare, and literature shows only a few case reports. We present a case of coexistent tumid lupus and SLE. We present a case of a 48-year-old Caucasian female who presented with chronic facial rash, photosensitivity, intermittent oral ulcers, joint pain with morning stiffness, and unintentional weight loss. Laboratory studies showed positive ANA at 1:640, elevated erythrocyte sedimentation rate, positive anticardiolipin immunoglobulin (Ig) G, anticardiolipin IgM, and anti-beta-2 glycoprotein IgM. Skin biopsy of the rash showed a superficial and deep dense lymphocytic infiltrate with mucin deposition, histopathology favoring tumid lupus. The patient was diagnosed with TLE with SLE and was started on hydroxychloroquine with improvement in her rash. Ultraviolet light and certain medications have been proven to play a role in the pathogenesis of tumid lupus. It usually responds to photoprotection, topical treatment, or oral antimalarial therapy.

A 23-Year-Old Man with Hyper-IgM Syndrome Presenting with Asymptomatic Violaceous Facial Plaques

Tumid lupus is a rare subtype of chronic cutaneous lupus that is characterized by urticaria-like photosensitive plaques. Unlike discoid lupus, it has minimal to no surface change and resolves without scarring. On pathological examination, it may be distinguished from other types of lupus by abundant interstitial mucin deposits. Herein, we describe a case of tumid lupus in a 23-year-old Kuwaiti male with hyper-IgM syndrome. To our best knowledge, this is the first report of tumid lupus in a patient with a primary immunodeficiency.

Lupus erythematosus tumidus: clinical perspectives

Lupus erythematosus tumidus (LET) is an uncommon and photosensitive inflammatory skin disorder which is characterised by erythematous urticarial plaques. In the last 20 years, extensive research on clinical and histological aspects of the disease have led to a better characterization of this nosological entity and to differentiate it from other similar or related diseases. Today, LET is considered as a separate subtype of cutaneous lupus erythematosus (CLE) with a benign, intermittent clinical course (intermittent CLE, ICLE) and only rarely associated with systemic lupus erythematosus (SLE).

Suspected inflammatory rheumatic diseases in patients presenting with skin rashes

Skin lesions occur, often at very early stages, in many of the most frequent inflammatory rheumatic diseases such as in systemic lupus erythematosus (SLE), dermatomyositis (DM), systemic sclerosis (SSc), Sjögren's syndrome, rheumatoid arthritis (RA), and psoriatic arthritis. It is important to recognize the different specific cutaneous lesions in SLE (e.g., "butterfly" rash in acute, annular or psoriasiform photosensitive lesions in the subacute form, and discoid lesions in the chronic form) for an early diagnosis and to estimate the associated risks of internal disease, whereas nonspecific lesions (exanthema, vasculitis, and alopecia) can be part of SLE flares. Cutaneous lesions in DM (Gottron's papules and sign, heliotrope rash, dystrophic cuticles, and nailfold capillary abnormalities) may occur before any clinically evident muscular or systemic organ involvement and are of utmost importance for early diagnosis. The pattern of cutaneous lesions and associated autoantibodies also allow the distinction of different phenotypes, either more prone to life-threatening interstitial lung disease (MDA-5) or with higher risk for neoplasia (TIF1-γ). Many other skin lesions, although not specific, require further investigation to look for a possible underlying inflammatory rheumatic disease: non-pruritic urticarial lesions in anti-C1q-associated urticarial vasculitis, Still's disease or hereditary auto-inflammatory syndromes, transient macular purpura of vasculitis in Sjögren's syndrome, Behçet's disease, or RA, Raynaud's phenomenon in SSc and mixed connective tissue disease, erythema nodosum or other panniculitis in RA, Behçet's disease and SLE, pustular eruptions in Behçet's disease, psoriasis, and hereditary auto-inflammatory syndromes. After reviewing in detail the cutaneous manifestations of the most frequent inflammatory rheumatic diseases, we describe a topographic and morphological approach to skin rashes, calling attention to facial rashes, hand involvement, scalp, nail, or leg lesions or to some morphological aspects of skin lesions (annular, pustular, urticarial, or exanthematous) that may be the initial manifestations of inflammatory rheumatic diseases. The importance of skin lesions is confirmed by their presence as part of the classification criteria of many inflammatory rheumatic diseases. They also contribute to early diagnosis, to characterize disease phenotypes, to aid in effective patient management, and, ultimately, to impact on disease prognosis.

Cutaneous manifestations of pediatric lupus

PURPOSE OF REVIEW

To review recent evidence on cutaneous manifestations of lupus, with a focus on evidence for pediatric patients.

RECENT FINDINGS

Cutaneous manifestations of SLE are common and may precede signs or symptoms of systemic disease. Early recognition and initiation of therapy improves quality of life by reducing cutaneous disease activity. Antimalarials are first line for moderate-to-severe disease. Photo protection is a critical component of therapy and perhaps the only modifiable risk factor for SLE. Recognition of cutaneous vasculopathy may reduce mortality from vascular occlusion.

SUMMARY

There is a critical need for better understanding of pathogenesis, risk factors and outcomes in cutaneous lupus to determine optimal treatment and surveillance strategies. Correlation of clinical phenotypes with biomarkers may help to stratify patients, optimize targeted interventions, and influence prognosis.

The Cutaneous Spectrum of Lupus Erythematosus

Systemic lupus erythematosus is a complex autoimmune disease with a wide spectrum of clinical and immunopathological features. Cutaneous and articular manifestations are the most common signs in patients with systemic lupus erythematosus. We here review the pathogenesis and the new classification of cutaneous lupus erythemathosus with a discussion of the significance of the various cutaneous signs. The lesions are classified according to the level of the cellular infiltrate and tissue damage in the epidermis, dermis, and/or subcutis. Furthermore, cutaneous lesions pointing to the presence of a thrombotic vasculopathy and those due to a distinct inflammatory, neutrophilic-mediated reaction pattern are highlighted. Particular attention will be given in describing the histology of skin manifestation. Treatment options for cutaneous lupus erythemathosus have increased with the introduction of new biological therapies. However, the majority of the patients still benefit from antimalarials, which remain the cornerstone of treatment. The evaluation and management of cutaneous lupus erythemathosus patients depend on the clinical findings and associated symptoms.

A case report of lupus erythematosus tumidus converted from discoid lupus erythematosus

RATIONALE

Lupus erythematosus tumidus (LET) is an uncommon type of cutaneous lupus erythematosus (CLE) that is rarely associated with other forms of lupus erythematosus.

PATIENT CONCERNS

We report a 62-year-old Chinese man presented with recurrent erythematous facial plaques for 1 year and a low-grade fever for 1 week. He had been diagnosed as discoid lupus erythematosus (DLE) 1 year before. Physical examination showed diverse lesions, including prominent swelling of the eyelids, a few erythematous, edematous plaques on the left forehead, face, and neck, and 2 hairless macules. The histopathologic findings reveal liquefaction degeneration of the basal cells, perivascular, and periadnexal infiltration of lymphocytes, and interstitial mucin deposition in the superficial, and deep dermis.

DIAGNOSES

A diagnosis of LET was made on clinical and histological features.

INTERVENTIONS

The patient started treatment with prednisolone (1 mg/kg. d), combined with hydroxychloroquine (200 mg twice daily), and topical tacrolimus.

OUTCOMES

The cutaneous lesions completely cleared after a period of 3 months. No adverse effects or clinical evidence of recurrence had been found during the 6-month follow-up period.

LESSONS

We report a case of LET converted from DLE with diverse lesions, unusual pathologic findings and slow response to the treatment of corticosteroids combined with hydroxychloroquine. We speculate that a continuous spectrum may include DLE, LET, and systemic lupus erythematosus (SLE), these 3 entities could potentially, convert between each other.

Changing antimalarial agents after inefficacy or intolerance in patients with cutaneous lupus erythematosus: A multicenter observational study

BACKGROUND

Changing from one antimalarial (AM) agent to another is often recommended in cutaneous lupus erythematosus (CLE) when the first AM agent is ineffective or poorly tolerated.

OBJECTIVE

To evaluate the effect on cutaneous response of a switch from hydroxychloroquine to chloroquine, or the reverse, after failure of the first AM agent.

METHODS

We conducted a retrospective observational study between 1997 and September 2015. The overall cutaneous response rate and reasons for failure of the switch were assessed for up to 48 months. Kaplan-Meier survival curves were used to assess the risk for failure of the second AM agent.

RESULTS

A total of 64 patients with CLE (78% were women) were included; for 48 patients, the switch was for inefficacy, and for 16, it was for adverse events. Median follow-up was 42 months (range, 3-171). Of the patients changed because of inefficacy, 56% were responders at month 3; however, the response decreased over time, with a median duration before failure of the second AM agent of 9 months (95% confidence interval, 6-24). For patients switched because of adverse events, the second AM agent was well tolerated in 69% of cases.

LIMITATIONS

Retrospective design and subjective evaluation of cutaneous response.

CONCLUSION

A change of AM agent should be considered in patients with CLE when the first AM agent is ineffective or poorly tolerated.

Cutaneous lupus erythematosus: updates on pathogenesis and associations with systemic lupus

PURPOSE OF REVIEW

Cutaneous lupus erythematosus (CLE) is a common manifestation among systemic lupus patients. There are no U.S. Food and Drug Administration approved therapies for CLE, and these lesions are frequently disfiguring and refractory to treatment. The present review will cover the recent inroads made into understanding the mechanisms behind CLE lesions and discuss promising therapeutic developments.

RECENT FINDINGS

The definition of cutaneous lupus is being refined to facilitate diagnostic and research protocols. Research into the pathogenesis of CLE is accelerating, and discoveries are now identifying genetic and epigenetic changes which may predispose to particular disease manifestations. Furthermore, unique features of disease subtypes are being defined. Murine work supports a connection between cutaneous inflammation and systemic lupus disease activity. Importantly, human trials of type I interferon blockade hold promise for improving our treatment armamentarium for refractory CLE lesions.

SUMMARY

Continued research to understand the mechanisms driving CLE will provide new methods for prevention and treatment of cutaneous lesions. These improvements may also have important effects on systemic disease activity, and thus, efforts to understand this link should be supported.

Efficacy and comparison of antimalarials in cutaneous lupus erythematosus subtypes: a systematic review and meta-analysis

BACKGROUND

The antimalarials (AMs) hydroxychloroquine (HCQ) and chloroquine (CQ) have demonstrated variable cutaneous response rates in cutaneous lupus erythematosus (CLE).

OBJECTIVES

We sought to assess the global cutaneous response rates to HCQ and CQ, with respect to CLE subtypes, based on previously published studies.

METHODS

We performed a systematic review and meta-analysis of studies published in MEDLINE, Embase and the Cochrane Library between 1965 and December 2015. The proportions of responders to AMs according to CLE subtypes were extracted from individual studies and pooled using random-effects or fixed models. The odds ratio (OR) was used as the measure of association to compare the response rates between CLE subtypes and AMs.

RESULTS

Among 1990 courses of treatment with AMs from 31 included studies, the overall response rate to AMs was 63% [95% confidence interval (CI) 55-70], with important statistical heterogeneity across the included studies. HCQ had a higher overall efficacy than CQ, but this was not significant (OR 1·48, 95% CI 0·98-2·23). The response rate to AMs was different between CLE subtypes, ranging from 31% (95% CI 20-44) for chilblain lupus to 91% (95% CI 87-93) for acute CLE. The response was significantly higher for acute CLE than for subacute CLE and intermittent CLE. In case of failure of monotherapy with AM, the combination of quinacrine with HCQ or CQ seemed effective, whereas too little data were available to assess the efficacy of the switch to another AM agent.

CONCLUSIONS

Wide discrepancies in cutaneous response to AMs are observed between CLE subtypes. A specific therapeutic approach considering CLE subtypes may improve CLE management.

Lupus tumidus: a report of two cases

Lupus tumidus is considered a rare subtype of chronic cutaneous lupus erythematosus, characterized by erythema and bright urticarial erythematous-violaceous lesions that leave no scars after regression. Histopathology reveals perivascular and periannexal lymphohistiocytic infiltrates in the papillary and reticular dermis and interstitial mucin deposition. Treatment is based on photoprotection, topical corticosteroids and antimalarials. We report two cases of lupus tumidus, which deserve attention for their low frequency in the literature, in addition to their relevance as a differential diagnosis among dermatologic disorders.

Comorbidity and pathogenic links of chronic spontaneous urticaria and systemic lupus erythematosus--a systematic review

Chronic spontaneous urticaria (CSU) is a common mast cell-driven disease characterized by the development of wheals (hives), angioedema (AE), or both for > 6 weeks. It is thought that autoimmunity is a common cause of CSU, which is often associated with autoimmune thyroiditis, whereas the link to other autoimmune disorders such as systemic lupus erythematosus (SLE) has not been carefully explored. Here, we systematically reviewed the existing literature for information on the prevalence of CSU in SLE (and vice versa) and we examined the possible clinical and pathogenetic relationship between CSU and SLE. The prevalence of CSU and CSU-like rash in SLE was investigated by 42 independent studies and comorbidity in adult patients reportedly ranged from 0% to 21.9% and 0.4% to 27.5%, respectively (urticarial vasculitis: 0-20%). In children with SLE, CSU was reported in 0-1.2% and CSU-like rash in 4.5-12% (urticarial vasculitis: 0-2.2%). In contrast, little information is available on the prevalence of SLE in patients with CSU, and more studies are needed to determine the rate of comorbidity. Recent insights on IgG- and IgE-mediated autoreactivity suggest similarities in the pathogenesis of CSU and SLE linking inflammation and autoimmunity with the activation of the complement and coagulation system. Future studies of patients with either or both conditions could help to better define common pathomechanisms in CSU and SLE and to develop novel targeted treatment options for patients with CSU and SLE.

Lupus erythematosus tumidus in systemic lupus erythematosus: novel association and possible role of early treatment in prevention of discoid lupus erythematosus

Skin involvement in systemic lupus erythematosus (SLE) occurs in varied forms. Lupus erythematosus tumidus (LET) is not known to occur with SLE. In our patient presented below, LET occurred in a patient with SLE. Some of the lesions progressedto scarring discoid lesions, while others responded very well to hydoxychloroquine treatment. We, as rheumatologists, are not very aware of this entity, which is so amenable to prevention and treatment if recognized correctly.

Lupus erythematosus tumidus: an underestimated entity

There have been few reports of lupus erythematosus tumidus (LET) in the literature. Most of textbooks of dermatology or dermatopathology mention this entity only briefly, if at all. The authors describe an additional case of this underdiagnosed disorder that further supports its existence as a separate entity in the spectrum of the variants of chronic cutaneous lupus erythematosus. Although most cases are reported in the European countries, to our knowledge, this is the first case documented in Portugal. The clinical, photobiological and histological features as well as differential diagnosis, treatment and prognosis are also discussed.

Lupus erythematosus revisited

Lupus erythematosus (LE) is a multifactorial autoimmune disease with clinical manifestations of differing severity. The exact pathomechanisms and interactions resulting in the inflammatory and immunological processes of this heterogeneous disease remain elusive. Approaches in the understanding of the pathomechanisms revealed that the clinical expression of LE is predisposed by susceptibility genes and that various environmental factors are responsible for an abnormal immune response. Several studies demonstrated that ultraviolet (UV) light is one of the major factors in the pathogenesis of the disease. Standardized photoprovocation in patients with LE has been shown to be a safe and efficient model for evaluating the underlying pathomechanisms which lead to the production of autoantibodies and immune complexes. In particular, interferons were defined as important players in the early activation of the immune system and were observed to play a specific role in the immunological interface between the innate and the adaptive immune system. Abnormalities or disturbances in the different processes of cell death, such as apoptosis or necrosis, have also been recognized as crucial in the pathogenesis of LE. Although each process is different and characterized by unique features, the processes are interrelated and result in a complex disease.

An experience of using methylprednisolone aceponate in the therapy of lupus erythematosus tumidus

Lupus erythematosus tumidus is a rare skin form of lupus erythematosus. About 250 cases of lupus erythematosus tumidus have been described in the world by now. A specific clinical sign of this dermatosis is the appearance of annular or arcuate urticaria-like rash. As a rule, the appearance of the rash is preceded by ultraviolet irradiation. The administration of glucocorticosteroid drugs of local action belonging to classes of potent and very potent steroids is the first-line therapy for lupus erythematosus tumidus. The authors describe a case of the successful treatment of lupus erythematosus tumidus with methylprednisolone aceponate (Advantan ointment) in a female patient aged 56.

Mucocutaneous manifestations in juvenile-onset systemic lupus erythematosus: a review of literature

Patients diagnosed with juvenile-onset systemic lupus erythematosus (JSLE) often have skin and oral lesions as part of their presentation. These mucocutaneous lesions, as defined by the American College of Rheumatology (ACR) in 1997, include malar rash, discoid rash, photosensitivity and oral ulcers. It is therefore essential to recognize mucocutaneous lesions to accurately diagnose JSLE. The mucocutaneous lesions can be divided into those with classical histological features (LE specific) and those strongly associated with and forming part of the diagnostic spectrum, but without the classical histological changes of lupus (LE nonspecific). A malar rash is the most commonly associated LE specific dermatological presentation. This skin manifestation is an acute form and also correlates with disease activity. Subacute (polycyclic or papulosquamous lesions) and chronic (discoid lesions) forms, whilst showing classical histological changes supportive of lupus, are less commonly associated with systemic lupus and do not correlate with disease activity. The most commonly associated skin lesions without classical lupus changes are cutaneous vasculitis, oral ulcers and diffuse non-scarring alopecia. These signs frequently relate to disease activity. An understanding of cutaneous signs and symptoms of lupus in children is important to avoid delay in diagnosis. They will often improve as lupus is adequately controlled and their reappearance is often the first indicator of a disease flare.

Lupus erythematosus tumidus: a clinical and histological study of 25 cases

Background

Lupus erythematosus tumidus (LET) is a subtype of cutaneous lupus erythematosus (CLE) that has been well characterized in recent years. However, some controversy still remains concerning the histological features of epidermal involvement.

Objectives

The objective of this report is to describe the clinical and microscopic features of LET in patients diagnosed at Hospital Universitari Germans Trias i Pujol, Spain.

Methods

We conducted a retrospective study of 25 patients with a diagnosis of LET.

Results

All patients presented with typical LET lesions (smooth, erythematous plaques without macroscopic epidermal changes, such as follicular plugs or scale, that resolved without residual scarring or hypopigmentation). None of the patients fulfilled the criteria for systemic lupus erythematosus during follow-up. Test results for antinuclear antibodies were positive in five patients (20%), with titres below one of 320 in all cases. Twenty-two patients (88%) required antimalarial therapy; response was good in 70% and moderate response in 30%. Minor epidermal alterations were observed in 52% of biopsy specimens, with focal basal vacuolization being the most frequent.

Conclusions

LET is a variant of CLE that has distinctive clinical, histologic and prognostic features. Unlike the patients in the case series previously described in the literature, most of our patients required treatment with antimalarials. Histology revealed mild epidermal alterations in a significant percentage of patients. Thus, in our opinion, the absence of microscopic epidermal alterations is not constant in LET.

Reticular erythematous mucinosis: histopathological and immunohistochemical features of 25 patients compared with 25 cases of lupus erythematosus tumidus

BACKGROUND AND OBJECTIVES

Reticular erythematous mucinosis (REM) and lupus erythematosus tumidus (LET) share similarities. However, to our knowledge no study extensively compared the histological features of these two conditions. The aim of this study is to compare the histological and immunohistochemical features of REM and LET.

METHODS

We evaluated epidermal thickness, hyperkeratosis, dermo-epidermal junction changes, interstitial mucin deposition, vessel dilatation and pattern, type and density of the inflammatory infiltrate in 25 cases of REM and LET. Anti-CD3, anti-CD20, anti-CD68, anti-CD4, anti-CD8, anti-CD123, anti-CD2AP, anti-IgG and anti-C3 antibodies were tested in a subset of patients.

RESULTS

Both diseases are characterized by perivascular dermal infiltrates of lymphocytes mainly CD4+ positive and increased dermal mucin. However, REM tended to show more scattered and more superficial lymphocytes with more superficial mucin and to have less frequent immunoglobulin and complement depositions along the dermo-epidermal junction. Plasmacytoid dendritic cells (PDCs) were less represented in REM, and were mainly found as single cells differently from LET.

CONCLUSIONS

REM and LET present some differences in the infiltrate, including PDCs, the mucin deposition and the immunoreactant deposition at the dermo-epidermal junction that justify the distinction of the two diseases and suggest different pathogenetic mechanisms.

The classification and diagnosis of cutaneous lupus erythematosus

Lupus erythematosus (LE) is an inflammatory connective tissue disease of generalized autoimmunity characterized by pathogenic autoantibodies and immune complexes, attributed to loss of immune tolerance. Cutaneous involvement, which appears in the majority of patients with the disease, can present as LE-specific or LE-nonspecific manifestations. The LE-nonspecific manifestations include e.g. vascular skin changes and may be associated with systemic organ manifestations or other autoimmune diseases. In contrast, the LE-specific manifestations encompass the various subtypes of cutaneous lupus erythematosus (CLE), which are classified as separate entities without or with less severe systemic organ involvement. In the "Duesseldorf Classification", CLE is subdivided into four different categories: acute CLE (ACLE), subacute CLE (SCLE), chronic CLE (CCLE), and intermittent CLE (ICLE). Differentiation between these subtypes is based on clinical features and average duration of the cutaneous lesions, but can also consider histological changes of skin biopsy specimens and laboratory abnormalities. In addition, direct immunofluorescence and photoprovocation may be applied to confirm the diagnosis in specific cases. Further investigations should be considered dependent on the clinical symptoms of the CLE patient and the results of the laboratory tests. A revised scoring system, the Cutaneous Lupus Erythematosus Disease Area and Severity Index (RCLASI) has recently been validated to assess disease activity and damage in CLE. In this review, we focus on the classification of CLE and the diagnostic procedures to identify and confirm the different subtypes of the disease.