Chronic cutaneous lupus erythematosus--clinical spectrum

Melanotic lupus erythematosus: A review of a newly described clinical form of chronic cutaneous lupus erythematosus

Melanotic lupus erythematosus (LE) is a rare and newly described form of chronic cutaneous LE. In this review, we have synthesized existing data on the epidemiologic, clinical, histologic, and immunologic features of melanotic LE. We performed a systematic review using PubMed to identify eligible publications. Eight contributions fulfilled the eligibility criteria and were included in the qualitative synthesis. Twenty-eight patients with a mean age of 57.7 years were included. All patients had medium to dark skin phototypes. The lesions presented either as solitary and localized, poorly limited, round, or oval patches (50%) or as a more diffuse or generalized, sometimes reticulated, hyperpigmentation (50%). Patients diagnosed with systemic LE accounted for 14% of included cases. Antinuclear antibodies were positive in 10.7% of cases. Hydroxychloroquine and topical steroids were the most commonly used treatments. Complete resolution of the lesions was noted in 27.27% of cases. No patient experienced atrophy, destruction, or deformity of the skin. Melanotic LE appears to affect mainly patients with dark phototypes. It is characterized by late age at the onset of disease and an overall good prognosis.

Diffuse Facial Hyperpigmentation as a Presenting Sign of Lupus Erythematosus: Three Cases and Review of the Literature

Lupus erythematosus (LE) is an autoimmune disorder commonly affecting the skin; cutaneous lesions may indicate systemic involvement, warranting further evaluation. Photosensitivity, which may result in hyperpigmentation, is a well-known feature of the disease. In contrast, the prevalence of primary hyperpigmentation as a presenting sign of LE is not well established. Here, we compare 3 unique cases of diffuse facial hyperpigmentation as the primary manifestation of LE (cutaneous or systemic) and review previously reported cases. Our data highlight the need for considering LE in the differential diagnosis of facial hyperpigmentation and substantiate the importance of this unique lupus variant in early diagnosis and patient evaluation.

Probable systemic lupus erythematosus with cell-bound complement activation products (CB-CAPS)

Complement activation is a key feature of systemic lupus erythematosus (SLE). Detection of cell-bound complement activation products (CB-CAPS) occurs more frequently than serum hypocomplementemia in definite lupus. We describe a patient with normocomplementemic probable SLE who did not fulfill ACR classification criteria for lupus, but the diagnosis was supported by the presence of CB-CAPS.

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.

Overview of common, rare and atypical manifestations of cutaneous lupus erythematosus and histopathological correlates

The skin is the second most frequently affected organ system in lupus erythematosus. Although only very rarely life threatening--an example is lupus erythematosus-associated toxic epidermal necrolysis--skin disease contributes disproportionally to disease burden in terms of personal and psychosocial wellbeing, vocational disability, and hence in medical and social costs. Since several manifestations are closely associated with the presence and activity of systemic lupus erythematosus, prompt and accurate diagnosis of cutaneous lupus erythematosus is essential. This review aims to cover common, rare, and atypical manifestations of lupus erythematosus-associated skin disease with a detailed discussion of histopathological correlates. Cutaneous lupus erythematosus covers a wide morphological spectrum well beyond acute, subacute and chronic cutaneous lupus erythematosus, which are commonly classified as lupus-specific skin disease. Other uncommon or less well-known manifestations include lupus erythematosus tumidus, lupus profundus, chilblain lupus, mucosal lupus erythematosus, and bullous lupus erythematosus. Vascular manifestations include leukocytoclastic and urticarial vasculitis, livedoid vasculopathy and livedo reticularis/ racemosa. Finally, we discuss rare presentations such as lupus erythematosus-related erythema exsudativum multiforme (Rowell syndrome), Kikuchi-Fujimoto disease, extravascular necrotizing palisaded granulomatous dermatitis (Winkelmann granuloma), and neutrophilic urticarial dermatosis.

Grupos sanguíneos e lúpus eritematoso crônico discoide

FUNDAMENTOS: Lesão discoide é a manifestação cutânea mais comum do lúpus eritematoso, e formas cutâneas crônicas apresentam características imunológicas próprias, direcionadas ao polo Th1. Diversas doenças possuem associação com grupos sanguíneos, o que não foi ainda estudado no lúpus discoide. OBJETIVO: Investigar a associação entre tipos sanguíneos (ABO e Rh) e lúpus eritematoso discoide. MÉTODOS: Estudo prospectivo tipo transversal envolvendo tipagem sanguínea ABO e Rh, inquérito de dados clínicos e dosagem de FAN e C4 de portadores de lúpus discoide sem critérios de doença sistêmica, atendidos em hospital universitário. RESULTADOS: Foram incluídos no estudo 69 pacientes, sendo 71,0% do sexo feminino (p 1:160, em 31,9%; e níveis baixos de C4, em 8,7%. Não houve diferença significativa entre as frequências dos grupos sanguíneos dos pacientes e da população local; entretanto, o grupo A foi associado às formas disseminadas da doença (OR 4,1 e p < 0,05). CONCLUSÕES: Grupos sanguíneos de pacientes com lúpus discoide apresentam frequência semelhante à da população; porém, formas clínicas disseminadas foram mais prevalentes entre portadores do grupo A.

Coexistence of tumid lupus erythematosus with systemic lupus erythematosus and discoid lupus erythematosus: a report of two cases of tumid lupus

Tumid lupus erythematosus (LE) is a rare variant of chronic cutaneous LE that is characterized clinically by smooth, nonscarring, pink to violaceous papules or plaques without evidence of surface change. Histopathologic features include superficial and deep lymphocytic infiltration in a perivascular and periadnexal distribution, with dermal interstitial mucin deposition and focal or absent dermoepidermal junction involvement. These clinical and histopathologic features can be challenging to differentiate from other cutaneous diseases. This is particularly true because patients with tumid LE usually do not have other manifestations of systemic LE or cutaneous LE. We present 2 cases of tumid LE, one associated with concomitant systemic LE and the other occurring concurrently with discoid LE. Furthermore, we demonstrate the rare occurrence of a patient with tumid LE occurring below the waist at a photo-protected site.

Association of HLA-DRB1*16 with chronic discoid lupus erythematosus in Mexican mestizo patients

BACKGROUND

Chronic discoid lupus erythematosus (CDLE) is present in 15-30% of patients with systemic lupus erythematosus (SLE). Approximately 5% of CDLE cases can evolve to SLE at some stage of the disease.

AIM

The aim of this study was to determine gene frequencies of HLA-DRB1 alleles in Mexican mestizo patients with CDLE, irrespective of the presence of systemic disease.

METHODS

The study comprised 28 Mexican mestizo patients with CDLE who were attending the Passover Dermatology Centre, in Mexico City. HLA-DRB1 and DQ allele typing was performed by sequence-specific oligotyping after DNA amplification using PCR. The study also included 99 ethnically matched healthy individuals as controls.

RESULTS

In the patient group, a significantly increased gene frequency was found for the HLA-DR4 (P = 0.016, OR = 2.24, 95% CI 1.14-4.38) and HLA-DR16 alleles (P = 0.005, OR = 5.51, 95% CI 1.49-21.08).

CONCLUSION

HLA-DRB1 alleles seem to be involved in the genetic susceptibility to CDLE in the Mexican mestizo population.

Preliminary evaluation of in vivo reflectance confocal microscopy features of discoid lupus erythematosus

BACKGROUND

Discoid lupus erythematosus (DLE) can simulate other inflammatory diseases both clinically and histologically. In vivo reflectance confocal microscopy (RCM) is a noninvasive, reproducible imaging technique already reported to be useful in the evaluation of several inflammatory skin conditions such as contact dermatitis, psoriasis and Darier disease.

OBJECTIVES

The aims of our study were to define RCM features of DLE and to evaluate its feasibility in biopsy site selection.

METHODS

Discoid lesions were selected for RCM evaluation from 10 patients with an established diagnosis of DLE. Subsequently, a 4-mm punch biopsy of the same areas evaluated with RCM was rendered for histopathological examination.

RESULTS

A series of RCM features of DLE was identified and shown to correlate well with histopathological evaluation. Interface changes, as well as epidermal, dermal and adnexal inflammatory cell infiltration, were identified with RCM in a high percentage of the lesions. A limitation of RCM examination besides imaging depth was the inability to distinguish lymphocytes from other white blood cells.

CONCLUSIONS

The utility of RCM as a diagnostic tool for DLE awaits further evaluation, although it appears to be promising for biopsy site selection.

Cutaneous lupus erythematosus: understanding of clinical features, genetic basis, and pathobiology of disease guides therapeutic strategies

Cutaneous features of the protean disease lupus erythematous (LE) constitute 4 of 11 diagnostic criteria for systemic lupus erythematosus (SLE) and are exhibited by approximately 3/4 of patients during the course of their disease. Because the pathogenesis of LE is multifactorial and polygenic, many of the details of the pathogenesis remain unclear. We review here the clinical features of cutaneous lupus and recent genetic data that elucidate potential candidate genes for both cutaneous lupus erythematosus (CLE) and SLE. We discuss advances in elucidating the autoimmune pathogenesis of CLE and SLE. Furthermore, promising experimental therapies based on these advances are reviewed in the context of B cell directed therapies, T cell directed therapies, disruption of B and T cell interactions, cytokine directed therapies and finally, end-effector targeted therapies.

Dermatologic signs

BACKGROUND

Dermatology signs serve as important clues to primary skin disorders and internal conditions.

OBJECTIVE AND METHODS

To highlight major cutaneous signs based on a MEDLINE literature search from 1966 to March 2006.

RESULTS AND CONCLUSIONS

A multitude of signs exist in dermatology. Appreciation and knowledge of cutaneous signs will enhance the care of patients with dermatologic manifestations.

Kutaner Lupus erythematodes

Cutaneous lupus erythematosus (CLE) is a heterogenous disorder with a wide range of skin manifestations. Therefore, it has been difficult to develop a unifying concept for classifying CLE from the dermatologic perspective in the past. In 2004, the classification system was updated and includes now acute CLE (ACLE), subacute CLE (SCLE), chronic CLE (CCLE), and intermittent CLE (ICLE). Additional rarely described variants are not listed as separate entities but are included in the classical forms. Diagnosis of the different subtypes of CLE is made by considering genetic, clinical, histopathologic, and immunoserologic findings, with a systematic analysis of individual criteria. In the past years, the etiology and pathogenesis of CLE has been subject of intensive research and it has been shown by several groups that exogenous factors, such as ultraviolet light and drugs, can induce CLE. The first part of this review will enable the reader to identify the various clinical manifestations of CLE and to employ characteristic criteria to assess differential diagnostic considerations.