Nonscarring alopecia in systemic lupus erythematosus: A cross-sectional study with trichoscopic, histopathologic, and immunopathologic analyses

Systemic correlates of cutaneous manifestations of lupus erythematosus

BACKGROUND

We aimed to investigate the prevalence of skin disease among patients with systemic lupus erythematosus (SLE) and determine whether LE skin disease had clinical or serologic correlates with SLE.

METHODS

We reviewed records of 335 patients with SLE (seen at Mayo Clinic, Rochester, Minnesota, USA) and abstracted skin manifestations, fulfilled mucocutaneous SLE criteria, and clinical and serologic parameters.

RESULTS

Of the 231 patients with skin manifestations, 57 (24.7%) had LE-specific conditions, 102 (44.2%) had LE-nonspecific conditions, and 72 (31.2%) had both. LE skin disease was associated with photosensitivity, anti-Smith antibodies, and anti-U1RNP antibodies (all P < 0.001). Patients without LE skin disease more commonly had elevated C-reactive protein levels (P = 0.01). Patients meeting 2-4 mucocutaneous American College of Rheumatology criteria less commonly had cytopenia (P = 0.004) or anti-double-stranded DNA antibodies (P = 0.004). No significant associations were observed for systemic involvement (renal, hematologic, neurologic, and arthritis) when comparing patients with or without LE skin involvement. LE skin involvement was not significantly associated with internal SLE disease flare, number of medications, or overall survival.

CONCLUSIONS

LE skin disease commonly occurs in patients with SLE. The presence of LE skin disease had no mitigating impact on the severity of SLE sequelae, disease flares, number of medications, or overall survival.

Anti-MDA5 antibody-positive dermatomyositis: pathogenesis and clinical progress

Anti-melanoma differentiation-associated protein 5 (MDA5) antibody-positive dermatomyositis (MDA5-DM) is a subtype of dermatomyositis. Although the aetiology and pathology remain unclear, increasing evidence suggests that viral infection is a potential trigger of MDA5-DM. Multiple factors, including T cells, B cells, neutrophils and macrophages, are implicated in the pathophysiology of MDA5-DM. Distinctive skin rashes, rapidly progressive interstitial lung disease, peripheral lymphopenia and elevated serum ferritin levels are the most prominent clinical and laboratory features of MDA5-DM. Concomitant infection is a common complication of MDA5-DM. The proper evaluation of patients with MDA5-DM requires knowledge of the disease heterogeneity and clinical course variability. Several biomarkers, including serum levels of anti-MDA5 antibodies and biomarkers related to macrophage activation, have been identified as useful tools for monitoring disease activity and prognosis. MDA5-DM shows a poor response to conventional glucocorticoid and immunosuppressant therapy and has a poor overall prognosis. Therefore, there is an urgent need to explore the key pathogenic mechanisms of MDA5-DM and develop novel therapeutic options for patients. This Review discusses recent clinical progress and pathogenic findings of MDA5-DM.

Non-scarring alopecia of lupus erythematosus: A comprehensive review

BACKGROUND

Although non-scarring alopecia (NSA) is a frequent clinical finding in patients with systemic lupus erythematosus (SLE), it has been poorly described in the literature. It is considered a nonspecific sign in the current classification of skin lesions of LE. The aim of this study was to give an updated overview of the spectrum of NSA in LE patients, with emphasis on the clinical significance thereof.

METHOD

We conducted a review of the English literature using the PubMed-Medline database using the keywords "Alopecia" + "Lupus erythematosus". Publications describing LE patients with NSA were included.

RESULTS

Data for 237 patients from 27 publications were analyzed. Ninety-one patients had diffuse NSA, 43 had patchy NSA, 83 had lupus hair, 3 had alopecia of dermal cutaneous LE, and 17 had alopecia of linear and annular lupus panniculitis of the scalp. Patients with diffuse/patchy NSA and lupus hair shared the following features: strong association with systemic activity of LE, subtle clinical/trichoscopic signs of inflammation, histological aspect consistent with lesions specific to cutaneous LE, high likelihood of response to SLE therapy, and absence of progression to scarring alopecia. Association with SLE was rare in patients with dermal cutaneous LE or linear and annular lupus panniculitis of the scalp, and skin-directed therapies were most often effective. One patient of each subtype progressed to scarring alopecia.

DISCUSSION

Diffuse/patchy NSA and lupus hair may represent a topographic variation of a single entity specific for LE. Prospective studies are warranted to further document the clinical significance of this manifestation.

Bioactive Compound-Loaded Nanocarriers for Hair Growth Promotion: Current Status and Future Perspectives

Hair loss (alopecia) has a multitude of causes, and the problem is still poorly defined. For curing alopecia, therapies are available in both natural and synthetic forms; however, natural remedies are gaining popularity due to the multiple effects of complex phytoconstituents on the scalp with fewer side effects. Evidence-based hair growth promotion by some plants has been reported for both traditional and advanced treatment approaches. Nanoarchitectonics may have the ability to evolve in the field of hair- and scalp-altering products and treatments, giving new qualities to hair that can be an effective protective layer or a technique to recover lost hair. This review will provide insights into several plant and herbal formulations that have been reported for the prevention of hair loss and stimulation of new hair growth. This review also focuses on the molecular mechanisms of hair growth/loss, several isolated phytoconstituents with hair growth-promoting properties, patents, in vivo evaluation of hair growth-promoting activity, and recent nanoarchitectonic technologies that have been explored for hair growth.

Sleep quality in men with androgenetic alopecia

PURPOSE

Sleep disturbances affect human health and contribute to several comorbidities. In men, androgenetic alopecia (AGA) is a common, non-scarring form of hair loss that affects a patient's self-esteem. There are limited data regarding the association between poor sleep quality and male AGA. We aimed to compare the prevalence of sleep abnormalities between male patients with AGA and controls to identify an association between the two conditions.

METHODS

A case-control study on patients with AGA and age-matched controls was conducted. Participants completed a standardized questionnaire that contained self-evaluated sleep measures, including Pittsburgh Sleep Quality Index (PSQI), Epworth Sleepiness Scale, and STOP-BANG questionnaire. Patients with AGA were classified into mild, moderate, and severe subgroups according to the Hamilton-Norwood classification for stratified analyses. Data between groups and among subgroups were compared.

RESULTS

Of 446 male participants, 223 (50%) were in the AGA group, and the remainder (50%) were in the control group. Multivariable logistic regression analysis revealed that hypertension (odds ratio [OR] = 1.90, 95% confidence interval [CI] = 1.16-3.11, p = 0.011) and STOP-BANG score ≥ 5 (OR = 2.05, 95%CI = 1.15-3.66, p = 0.015) were associated with AGA. For subgroup analyses, ordinal logistic regression model showed a significant association between severe AGA and three sleep profiles, namely total sleep time ≤ 6 h (OR = 2.16, 95%CI = 1.02-4.57, p = 0.044), PSQI > 5 (OR = 3.72, 95%CI = 1.42-9.72, p = 0.008), and STOP-BANG score ≥ 5 (OR = 3.01, 95%CI = 1.11-8.13, p = 0.030).

CONCLUSION

Our findings revealed an association between sleep disturbances and AGA, which may help guide appropriate management in these patients.

Comparative histopathological analyses of non-scarring alopecia in systemic lupus erythematosus patients in Lagos Nigeria

Background

Systemic lupus erythematosus (SLE) is known to cause non-scarring alopecia. However, histopathological evaluation is uncommon.

Aim

The objective of this study was to document the histopathology of non-scarring alopecia and to compare histopathology of alopecic and normal appearing scalp areas in SLE hair loss patients.

Patients and Methods

A cross-sectional comparative evaluation of scalp biopsies from 23 SLE patients; 12 with hair loss and 11 without was conducted over a 7-month period in 2020. A total of 58 scalp biopsies stained with H and E (23 vertical and 35 cross-sectional) were evaluated. Mucin deposit evaluation was done using Alcian blue (pH 2.5).

Results

There were no significant differences in the sociodemographic data between the patients. The SLE hair loss patients demonstrated mucin deposition (91.7%), reduced size/number of sebaceous glands (58.3%), epidermal atrophy (50.0%), naked arrector pili muscles (50.0%), lymphocytic infiltration (33.3%), pigment incontinence (16.7%), fibrous stellae (16.7%), increased telogen percentage, and increased terminal versus vellus hair ratios. On comparing the histopathology of those who had hair loss to those without hair loss, the only significant difference was in the number and size of sebaceous gland. There were no significant differences between scalp areas with and without hair loss in the SLE hair loss patients.

Conclusion

There are differences in size and number of sebaceous glands on histopathology between SLE patients who have hair loss and those who do not. Also, there are no histopathological differences between alopecic and non-alopecic scalp areas of SLE patient.

Epidemiological, Clinical, Trichoscopic, and Histopathological Features of Lupus Erythematous Mimicking Alopecia Areata: A Multicenter Retrospective Study

Introduction

All types of lupus erythematosus (LE) may cause hair loss. Nonscarring alopecia was correlated with systemic LE, based on its high specificity. Discoid LE can also appear as nonscarring patches in early stages. Patchy alopecia LE-specific may also mimic alopecia areata (AA) - which can co-occur with LE. The distinction is fundamental to early diagnosis and effective treatment. This study aims to analyze clinical, epidemiological, trichoscopic, and histopathological features of patients with patchy LE-specific alopecia, nonscarring type, mimicking AA.

Methods

This is a multicentric retrospective study. We reviewed the medical records of patients with a confirmed diagnosis of LE mimicking AA.

Results

Ten patients were included (90% female) with a mean age of 45.9 years. Clinically, 60% showed erythema and 70% presented incomplete hair loss. The most common trichoscopic findings were interfollicular arborizing vessels (90%) and scattered brown discoloration (80%). On histopathology, perivascular inflammation (85.7%), peribulbar lymphocytes (85.7%), and dermal pigment incontinence (71.4%) were present in most cases.

Discussion/Conclusion

Trichoscopy was found as an essential first step for the patchy alopecia diagnosis, enabling to differentiate LE from AA. Putting it mildly, trichoscopy raises the suspicion that leads to a biopsy, increasing the diagnostic accuracy with better outcome for patients.

Intramuscular Corticosteroid Therapy in the Treatment of Alopecia Areata: A Time-to-Event Analysis

Introduction

Intramuscular corticosteroids (IMC) have gained popularity for the treatment of severe alopecia areata (AA) in recent years; however, evidence on their efficacy and safety is still limited.

Objective

To evaluate the efficacy, relapse rate, and tolerability of IMC in the treatment of AA, as well as factors associated with treatment outcomes.

Methods

Time-to-event analysis was performed on patients with severe, extensive, or rapidly progressive AA receiving IMC. The IMC regimen comprised triamcinolone acetonide 20–40 mg/mL injected every 4–6 weeks. The evaluated outcomes included initial (25% regrowth), significant (75% regrowth), and complete hair regrowth (100% regrowth). Relapse and adverse events were also noted. Factors associated with treatment outcomes and relapse were analyzed using the Cox proportional hazards model.

Results

A total of 101 patients were eligible for analysis. Significant hair regrowth was obtained in 80.2% of the patients (n = 81), in a median time of 3.4 months (95% confidence interval [CI] = 2.9–4.4). Complete hair regrowth was achieved in 48.5% of the subjects (n = 49), and relapse was observed in 47.5% (n = 48). Acneiform eruption was the most common adverse effect. Multivariable analysis revealed that nail involvement was a negative predictor of significant hair regrowth (adjusted hazard ratio [HR] = 0.04, 95% CI = 0.01–0.55; P = 0.015), whereas duration of AA longer than 6 months was associated with disease recurrence (adjusted HR = 4.02, 95% CI = 1.52–4.66; P = 0.005).

Conclusion

This study demonstrated the efficacy and safety of IMC in the treatment of severe or active AA; however, the relapse rate remained relatively high after discontinuation of the therapy. Nail involvement was a negative predictor of significant hair regrowth, while disease duration longer than 6 months predicted AA relapse.

Variation of Hair Follicle Counts among Different Scalp Areas: A Quantitative Histopathological Study

INTRODUCTION

Scalp biopsy is a standard method for the definitive diagnosis of alopecia. The hair count parameters of each scalp area remain unclear. This study aimed to determine hair count values at different scalp locations from histopathology and to establish reference values for each part of the scalp.

METHODS

We obtained biopsy specimens from the frontal, vertex, temporoparietal, and occipital areas of the scalps of normal deceased subjects. All specimens were evaluated for the number of follicular units, hair counts, hair types, and stages of the hair cycle.

RESULTS

In total, 240 specimens were collected from 60 cadavers. Across all scalp sites, the temporoparietal area showed the lowest mean hair count, number of follicular units, terminal and vellus hairs, and terminal-to-vellus hair ratio. The average anagen-to-telogen hair ratio was comparable across all scalp sites. This study did not observe a significant association of hair parameters with gender differences or increasing age in all scalp areas.

CONCLUSIONS

The present study revealed the diversity of the hair index among different scalp areas and suggested that normal hair count values should be separately standardized on each scalp region. Our findings may provide useful reference values for the histopathological evaluation of hair disorders in Asians.

Circle Hairs in a Patient with Multiple Myeloma

Circle hair is a rare body-hair disorder of unknown etiology, typically characterized by perfectly or nearly perfectly coiled hair located below the cornified layer of the skin. Its main histopathological features are dilated hair-follicle infundibula and entrapped hair shafts. After its first description in 1963, there have only been a small number of reported cases, and its pathophysiology remains unclear. Herein, we report a case of an 80-year-old woman with skin lesions and abnormal hairs on both legs. We also propose a possible mechanism of her circle hairs: it may have occurred as an effect of her acquired ichthyosis secondary to her underlying multiple myeloma. There is no specific treatment for circle hairs, and reassurance that it is a harmless condition is sufficient. We prescribed a topical humectant and keratolytic agent to moisten the skin and lessen the hair entrapment, which resulted in clinical improvement. As the pathogenesis of the disease is unknown, further studies are warranted.

Histopathological Evidence of Occipital Involvement in Male Androgenetic Alopecia

Background: The occipital region of the scalp is generally accepted as an unaffected area of androgenetic alopecia (AGA) for both genders. However, evidence of AGA involving the occipital scalp has been demonstrated in women; meanwhile, it is unclear whether occipital involvement also occurs in men. Objective: We aimed to determine if there is occipital involvement in men with AGA. Methods: This case-control study compared hair counts of scalp biopsy specimens from the occipital region of 82 men with Hamilton-Norwood III-VII and 82 unaffected men. Results: The mean ages of men with AGA and controls were 40.1 ± 8.9 and 38.6 ± 10.5 years, respectively (P = 0.291). A significant decrease in total hair follicles, terminal hair follicles, follicular units and terminal to vellus (T:V) ratio, along with a significant increase in follicular stelae was indicated in the AGA group compared to controls (all P < 0.05). Subgroup analyses revealed that average counts of total hair follicles, terminal hair follicles and T:V ratios were also significantly lower in males with Hamilton-Norwood VI and VII than in controls (all P < 0.05). There were no correlations between increasing age and hair count parameters, but a significant negative association was found between total follicle numbers and disease duration (r = -0.23, P = 0.02). Conclusions: AGA can involve the occipital area of male patients with advanced disease. Therefore, the occiput of particular cases should not be used to determine reference data for normal scalp hair, and preoperative measurements of miniaturized hairs in the donor site are strongly recommended in all persons undergoing hair transplantation.

Current controversies in trichology: a European expert consensus statement

INTRODUCTION

Hair disorders are one of the most common conditions within dermatology practice but, although new diagnostic tools and therapeutic options have arisen, the management of these patients still represents a major clinical challenge.

OBJECTIVE

This study aimed at gathering information and achieving consensus on relevant recommendations on the latest advances in alopecia, trichoscopy and hair dermocosmetics.

METHODS

Experts of the steering committee consulted the available evidence on trichology-related areas from the past 5 years and formulated recommendations based on the evidence and their experience. A modified two-round Delphi procedure was performed among 45 European dermatologists experts in trichology to consult their degree of agreement on twenty recommendations, using a 4-point Likert scale. Consensus was defined as >80% of participants scoring either 1 (totally agree) or 2 (agree).

RESULTS

In the first round of the Delphi questionnaire, 75% of the recommendations reached consensus. Those that were not agreed upon were reformulated by the steering committee and voted again after an online meeting, where consensus was achieved in all recommendations.

CONCLUSIONS

All recommendations reached consensus after the two-round Delphi questionnaire and may be useful in clinical practice for dermatologists. The participants agreed that besides this consensus, further clinical studies are needed to assess the benefits of the emerging tools and treatments and to clarify the controversies that still exist in the field, aiming at improving patients' quality of life.

Prevalence and Risk Factors Associated with the Occurrence of Autoimmune Diseases in Patients with Alopecia Areata

BACKGROUND

Increased rates of autoimmune diseases (ADs) have been reported in association with alopecia areata (AA); however, the risk factors for coexisting ADs in AA patients have been poorly investigated.

OBJECTIVE

To evaluate the prevalence and factors associated with AD comorbidities in patients with AA.

METHODS

This case-control study included patients diagnosed with AA between January 2000 and March 2020. Individuals with AA, both with and without concomitant ADs, were statistically compared. Variables significantly associated with coexisting ADs were identified using univariate and multivariate logistic regression analyses. Multinomial logistic regression analysis was performed to identify the specific risk factors for each concomitant AD.

RESULTS

Among the 615 patients with AA, comorbid ADs were found in 76 (12.4%). Autoimmune thyroid disease (AITD) exhibited the highest frequency (n = 42, 6.8%), followed by vitiligo (n = 15, 2.4%), and systemic lupus erythematosus (SLE) (n = 12, 2.0%). Logistic regression analyses revealed that female sex (odds ratio [OR] = 2.45, 95% confidence interval [CI] = 1.24-4.82; P = 0.011), nail abnormalities (OR = 2.49, 95% CI = 1.14-5.46; P = 0.023), and atopic diseases (OR = 1.98, 95% CI = 1.09-2.43; P < 0.001) were significantly associated with coexisting ADs. Regarding each concomitant AD, nail abnormalities were an associated factor for AITD (OR = 4.65, 95% CI = 1.96-7.24; P = 0.01), whereas coexisting atopic diseases were demonstrated as a predictor of vitiligo (OR = 2.48, 95% CI = 1.43-4.58; P = 0.02). Female sex (OR = 1.61, 95% CI = 1.18-4.27; P = 0.04) and family history of AD (OR = 1.85, 95% CI = 1.26-4.19; P = 0.03) were predictors of SLE.

CONCLUSION

This study suggests that female AA patients with nail abnormalities and atopic diseases have increased rates of AD comorbidities. A thorough review of systems for associated factors can help physicians screen for concomitant ADs.

Nailfold Capillaroscopy With USB Digital Microscopy in Connective Tissue Diseases: A Comparative Study of 245 Patients and Healthy Controls

Background: Nailfold capillaroscopy (NFC) is a valuable tool to detect microcirculation abnormalities in connective tissue diseases (CTDs). However, whether the universal serial bus (USB) digital microscopy used as onychoscopy is as effective as the videocapillaroscopy in determining the diagnostic and prognostic values of CTDs remains to be determined. Objective: This study aims to investigate NFC features of systemic lupus erythematosus (SLE), dermatomyositis (DM), and systemic sclerosis (SSc) patients and compare with normal controls as well as examine which feature could differentiate among CTDs. Furthermore, we aim to explore different capillaroscopic abnormalities and their association with disease activity. Methods: Nailfold images were taken from patients and healthy controls using a USB digital microscopy. Patterns on the capillary morphology, diameter, architecture, and density were recorded and compared. We further determined the NFC findings in SLE, DM, and SSc and corresponded to their respective disease activity scoring system. Results: A total of 245 participants, consisting of 54 SLE, 32 DM, and 51 SSc patients, as well as 108 controls, were enrolled. All capillaroscopic features, except for tortuous capillaries, were significantly more common in CTDs than healthy control (all p < 0.05). A multinomial logistic regression analysis revealed that bushy capillaries had significantly higher odds for both SLE and DM than SSc (OR: 4.10, 95% confidence interval (CI): 1.71-9.81, p = 0.002 and OR: 7.82, 95% CI, 2.86-21.38, p < 0.001, respectively). Elongated capillaries demonstrated significant odds for SLE compared with SSc (OR: 3.35, 95% CI: 1.005-11.20, p = 0.049), while prominent subpapillary plexus showed greater odds for SLE compared with both DM and SSc (OR: 2.75, 95% CI: 1.07-7.02, p = 0.03 and OR: 5.78, 95% CI: 2.29-14.58, p < 0.001, respectively). The presence of hemorrhage, enlarged capillaries, and the low-density index had significantly higher odds in favor of SSc than SLE. Bushy capillaries were the only pattern with a strong association for DM over SSc. The presence of enlarged capillaries indicated higher SLE severity, but no specific finding was related to DM or SSc skin scores. Conclusions: Nailfold capillaroscopic examination using a digital microscope is a valuable method for the diagnosis of SLE, DM, and SSc. Several morphologic patterns can help differentiate among CTDs; however, the prognostic significance of this method requires further investigations.

Alopecia Areata: An Autoimmune Disease of Multiple Players

Alopecia areata (AA) is an autoimmune disease of the hair follicles. It is characterized by a well-defined non-scarring alopecic patch or patches that may extend to the entire scalp or lead to total body hair loss. Due to its unpredictable clinical course, AA causes substantial psychological harm. Despite the high prevalence of this disease and extensive research, its exact pathomechanism is unclear, and current treatments have a high relapse rate that has deemed AA incurable. Over the past few decades, researchers have investigated multiple potential factors that may help alleviate its pathogenesis and provide effective treatment. Given its complex immunopathogenesis, AA is considered an autoimmune disease with multiple factors. This review gathers current evidence that emphasizes molecular mechanisms, possible causative etiologies, and targeted immunotherapies for AA. Understanding its underlying mechanisms may shed light on new strategies to effectively manage AA in the future.

Measuring Patient Quality of Life Following Treatment for Alopecia

Alopecia is a challenging problem for both physicians and patients in terms of diagnosis and treatment. Alopecia usually has negative effects on patients' emotional and psychological well-being. Several studies have examined the effect of alopecia on patients' health-related quality of life (HRQoL) and have consistently reported poor scores. However, deeper insight into the impact of alopecia on affected individuals and its measurement using HRQoL questionnaires is lacking in the literature. In this article, the methods for measuring the HRQoL of patients with alopecia were comprehensively reviewed. Their applications and limitations were also discussed.

Central Centrifugal Cicatricial Alopecia: Challenges and Treatments

Central centrifugal cicatricial alopecia (CCCA) is the most common form of primary scarring alopecia diagnosed in women of African descent. Although the etiology was originally attributed exclusively to hairstyling practices common among women of African descent, more recent research on CCCA supports the concept that there are several contributing factors, including variants in gene expression, hair grooming practices that increase fragility on the hair follicle, and associations with other systemic conditions. Treatment of CCCA involves a combination of patient counseling and education on alternative hairstyles, medical therapies, and procedural methods when necessary.

Case Report: Reversal of Long-Standing Refractory Diffuse Non-Scarring Alopecia Due to Systemic Lupus Erythematosus Following Treatment With Tofacitinib

The Janus kinases (JAKs) are intracellular tyrosine kinases involved in a broad variety of inflammatory cascades participating in the pathogenesis of systemic lupus erythematosus (SLE). Diffuse non-scarring alopecia is one of the most frequent cutaneous manifestations in SLE, resulting in devastating psychosocial consequences. Although recent studies have shown promising outcomes of the JAK inhibitors in SLE treatment, the efficacy of tofacitinib in diffuse non-scarring alopecia due to SLE has never been reported. Here we present a 29-year-old SLE patient with a 10-year history of refractory severe diffuse non-scarring alopecia who experienced dramatic hair regrowth with tofacitinib. Furthermore, we have made a systematic review regarding the potential effectiveness of tofacitinib in systemic and cutaneous lupus erythematosus. To the best of our knowledge, this is the first case study depicting an SLE patient with refractory alopecia who experienced impressive hair regrowth with the JAK1/3 inhibitor tofacitinib therapy, which contributes to expanding the field of possible uses of tofacitinib in SLE patients with difficult-to-treat cutaneous involvement, including severe alopecia.

Recent Insight on the Management of Lupus Erythematosus Alopecia

Lupus erythematosus (LE) is a chronic autoimmune condition with a wide spectrum of clinical presentations. Alopecias, both non-scarring and scarring, frequently occur in the context of LE and can assume several different patterns. Furthermore, alopecia occurring with LE may be considered LE-specific if LE-specific features are present on histology; otherwise, alopecia is considered non-LE-specific. Non-scarring alopecia is highly specific to systemic LE (SLE), and therefore has been regarded as a criterion for the diagnosis of SLE. Variants of cutaneous LE (CLE), including acute, subacute, and chronic forms, are also capable of causing hair loss, and chronic CLE is an important cause of primary cicatricial alopecia. Other types of hair loss not specific to LE, including telogen effluvium, alopecia areata, and anagen effluvium, may also occur in a patient with lupus. Lupus alopecia may be difficult to treat, particularly in cases that have progressed to scarring. The article summarizes the types of lupus alopecia and recent insight regarding their management. Data regarding the management of lupus alopecia are sparse and limited to case reports, and therefore, many studies including in this review report the efficacy of treatments on CLE as a broader entity. In general, for patients with non-scarring alopecia in SLE, management is aimed at controlling SLE activity with subsequent hair regrowth. Topical medications can be used to expedite recovery. Prompt treatment is crucial in the case of chronic CLE due to potential for scarring and irreversible damage. First-line therapies for CLE include topical corticosteroids and oral antimalarials, with or without oral corticosteroids as bridging therapy. Second and third-line systemic treatments for CLE include methotrexate, retinoids, dapsone, mycophenolate mofetil, and mycophenolate acid. Additional topical and systemic medications as well as physical modalities used for the treatment of lupus alopecia and CLE are discussed herein.

Cutaneous, systemic features and laboratory characteristics of late- versus adult-onset systemic lupus erythematosus in 1006 Thai patients

BACKGROUND

Age at disease onset may modulate systemic lupus erythematosus (SLE), but its relation to cutaneous/extracutaneous manifestation remains understudied.

OBJECTIVE

To compare the cutaneous, systemic features, laboratory characteristics, and disease severity between late- and adult-onset SLE patients.

METHODS

Analyses of the cutaneous, systemic involvement, laboratory investigations, SLE disease activity index 2000 (SLEDAI-2K), and disease damage were performed to compare between groups.

RESULTS

Of 1006 SLE patients, 740 and 226 had adult- (15-50 years) and late-onset (>50 years), respectively. Among 782 with cutaneous lupus erythematosus (CLE), acute CLE (ACLE) and chronic CLE (CCLE) were more common in the adult- and late-onset SLE, respectively (p = 0.001). Multivariable logistic regression analysis demonstrated that male patients and skin signs, including papulosquamous subacute CLE, discoid lupus erythematosus, and lupus profundus, were associated with late-onset SLE (all p < 0.05). Late-onset SLE had lower lupus-associated autoantibodies, and systemic involvement (all p < 0.05). ACLE, CCLE, mucosal lupus, alopecia, and non-specific lupus were related to higher disease activity in adult-onset SLE (all p < 0.001). There was no difference in the damage index between the two groups.

CONCLUSIONS

Late-onset SLE had a distinct disease expression with male predominance, milder disease activity, and lower systemic involvement. Cutaneous manifestations may hold prognostic values for SLE.

Dermatologic Manifestations, Histologic Features and Disease Progression among Cutaneous Lupus Erythematosus Subtypes: A Prospective Observational Study in Asians

Introduction

Cutaneous manifestations are central to the primary diagnosis of systemic lupus erythematosus (SLE). However, information on the clinical, histopathologic, and direct immunofluorescence (DIF) features among subtypes of cutaneous lupus erythematosus (CLE), as well as longitudinal prospective observational study to evaluate the natural history and the progression to SLE, is lacking among Asians. Our objectives are to summarize the differences in the clinical, histopathologic, and DIF characteristics and serological profiles between various subtypes of CLE, and to provide its natural history and the association with disease activity in our Asian population.

Methods

A prospective observational study on CLE patients was performed between May 2016 and May 2020. Patients underwent full physical/dermatologic examination, skin biopsy for histology, and DIF. Systemic Lupus Erythematosus Disease Activity Index 2000 (SLEDAI-2K) scores and laboratory data were evaluated. Time schedule and characteristics for resolution and/or the disease progression to SLE were recorded in subsequent follow-ups.

Results

Of 101 biopsy-proven CLE patients, 25 had acute CLE (ACLE), 8 had subacute CLE (SCLE), 39 had chronic CLE (CCLE) only, 22 had CCLE with SLE, and 7 had LE-nonspecific cutaneous lesions only. Patients with exclusive CLE showed lower female preponderance, serological abnormalities, and correlation to systemic disease. However, when CLE was accompanied with any LE-nonspecific cutaneous manifestations, they were associated with high antinuclear antibody (ANA) titer, renal, hematologic, joint involvement, and greater SLEDAI score. Of 207 biopsy sections, SCLE/CCLE regardless of systemic involvement showed significantly higher percentage of superficial/deep perivascular and perieccrine infiltration than ACLE. On DIF, deposition of multiple immunoreactants was associated with higher systemic disease. Approximately 10% of CLE-only patients later developed SLE but had mild systemic involvement.

Conclusion

Our findings support that each CLE subtype has a diverse and unique character. Comprehensive understanding of the differences among CLE subtypes is important for achieving the correct diagnosis and providing appropriate disease monitoring and management.

Supplementary Information

The online version contains supplementary material available at 10.1007/s13555-020-00471-y.