Lupus erythematosus and neutrophilic urticarial dermatosis: a retrospective study of 7 patients

Histopathologic Overlap Between Bullous Lupus Erythematosus and Linear IgA Bullous Dermatosis: A Comparative Study

ABSTRACT

Bullous lupus erythematosus (BLE) and linear IgA disease (LAD) are rare autoimmune subepidermal blistering diseases, with overlapping features despite different pathogenetic mechanisms. Diagnosis is based on immunofluorescence and serology. This retrospective study was undertaken to compare the histopathologic features of BLE and LAD (11 cases each). The mean age was 36 years in both groups, and female preponderance was noted in BLE. Clinically, all cases presented as tense, itchy blisters distributed over the trunk, face, and extremities. Subepidermal neutrophil-rich blisters were seen in 60% BLE and 54.54% LAD cases. Eosinophils in the blisters were noted in 4 cases (36.4%) of linear IgA bullous dermatosis, but not in any of the BLE cases. The adjacent epidermal changes noted include spongiosis (33%; 40%), papillary microabscesses (22%; 20%), and basal tagging by neutrophils (77%; 70%). Superficial perivascular inflammation was seen in all cases while deep perivascular inflammation was observed in 54% BLE and 36% LAD cases. Lymphocytes were the predominant infiltrate. Increased dermal mucin was seen in 60% BLE and 45% LAD cases. None of the histopathologic features showed a statistically significant difference between the 2 groups. Hence, histopathology alone is of limited value in distinguishing the 2 groups. Diagnosis rests on immunofluorescence and serologic findings, which should be used even in cases that seem to be classic LAD or patients without history of systemic lupus erythematosus.

Neutrophilic Urticarial Dermatosis

Neutrophilic urticarial dermatosis (NUD) is a rare form of dermatosis that is poorly understood. It was first described by Kieffer and colleagues as an urticarial eruption that is histopathologically characterized by a perivascular and interstitial neutrophilic infiltrate with intense leukocytoclasia and without vasculitis or dermal edema. NUD clinically presents as a chronic or recurrent eruption that consists of nonpruritic macules, papules, or plaques that are pink to reddish and that resolve within 24 hours without residual pigmentation. NUD is often associated with systemic diseases such as Schnitzler syndrome, lupus erythematosus, adult-onset Still's disease, and cryopyrin-associated periodic syndromes.

Role of neutrophils in cutaneous lupus erythematosus

There are various types of cutaneous lupus erythematosus (CLE), either with or without the association of systemic lupus erythematosus (SLE). In some of the subtypes of cutaneous lupus, histopathology reveals neutrophil infiltration in the lesional skin; however, the significance of neutrophils in CLE is not yet fully elucidated. Recent studies have shown that neutrophil extracellular traps (NETs) formation by activated neutrophils is observed in several types of CLE, including lupus panniculitis, subacute lupus erythematosus, and acute lupus erythematosus, although the number of reports is small. Excessive NETosis, due to either increased NETs formation or defective clearance of NETs, may play a role in the induction of autoimmunity and autoantibody production in SLE, as well as endothelial damage, thrombus formation, and vascular damage in the lesional skin. CLE is an excessive interferon-driven autoimmune disease. Plasmacytoid dendritic cells are located in lupus erythematosus skin and contribute to the etiology of skin lesions as a main producing cell of type I interferon. Neutrophils, monocytes, and keratinocytes also produce type I interferon via several triggers. Neutrophils play an important role in the innate immune response in SLE. In this review, several types of CLE with neutrophil infiltration, as well as the role of neutrophils are discussed.

Annular neutrophilic dermatoses

Neutrophilic dermatoses (NDs) constitute a group of diseases characterized by sterile neutrophilic infiltrations. Many NDs usually present with infiltrated erythematous plaques, nodules, urticarial plaques, or pustules. Lesions may show variability, and atypical presentations may develop among NDs. Annular lesions have been reported in many NDs and may lead to diagnostic problems. Clinical features and histopathologic findings such as localization of the neutrophilic infiltrate, existence of other cell types, and absence of true vasculitis may be helpful to distinguish NDs. Some of these NDs are associated with infections, inflammatory diseases, and malignancies. In most NDs, systemic steroids and dapsone are very effective and usually first choices. Colchicine, antimicrobials such as doxycycline, tetracycline, and sulfapyridine, and other immunosuppressants such as cyclosporin, methotrexate, and mycophenolate mofetil have been used successfully in treating many NDs. Tumor necrosis factor α inhibitors have also been used successfully in treating many NDs. Janus kinase inhibitors are effective in CANDLE (chronic atypical neutrophilic dermatosis with lipodystrophy and elevated temperature) syndrome, anakinra in neutrophilic urticarial dermatosis, and intravenous immunoglobulin in resistant pyoderma gangrenosum. We discuss the diagnosis and management of NDs that may present with annular lesions.

Adalimumab Biosimilar-Induced Autoimmunity-Related Sweet-Like Neutrophilic Dermatosis

ABSTRACT

Antitumor necrosis factor therapies have shown to produce a broad range of cutaneous eruptions. We report the case of a patient under adalimumab biosimilar treatment for a punctate inner choroidopathy who developed a cutaneous eruption on sun-exposed areas that showed a diffuse dermal neutrophilic infiltrate consistent with a Sweet-like neutrophilic dermatosis and some features of autoimmunity.

Current and future management of chronic spontaneous urticaria and chronic inducible urticaria

Background: Chronic urticaria (CU), characterized by ≥6 weeks of intense pruritus, remains a debilitating condition for patients. New and safe treatments are needed to manage CU recalcitrant to standard therapy. Objective: A review of the current literature of standard and novel therapeutics in the management of CU was conducted. Methods: A literature search via a medical literature data base and clinical trial data base was conducted to identify treatment options for CU and current clinical trials. Results: Second-generation antihistamines, omalizumab, and cyclosporine remain the most proven therapeutic options for CU. Dupilumab, mepolizumab, benralizumab, tezepelumab, and CDX-0159 are all undergoing clinical trials for CU. Although ligelizumab demonstrated initial promising results, a phase III study was discontinued due to a nonsuperior clinical impact compared with omalizumab. Conclusion: Novel therapies are needed for the treatment of recalcitrant CU. With a deeper understanding of the pathophysiology of CU, promising therapeutics are in clinical trials for CU.

Resistant Chronic Spontaneous Urticaria - A Case Series Narrative Review of Treatment Options

Background

Chronic spontaneous urticaria (CSU) can be extremely debilitating to the patient and challenging for the treating clinician. The National Institute of Health and Clinical Excellence (NICE) in the United Kingdom (UK) recommendation of omalizumab for patients who fail to respond to high-dose anti-histamines has improved treatment options and quality of life. However, there is still lack of clear guidelines for treatment of patients resistant to standard and anti-IgE therapies.

Methods

We discuss the therapeutic strategies employed among nine extremely resistant CSU cases and the heterogeneity between guidelines from different societies.

Results

Patients with anti-histamine-resistant urticaria either remained on omalizumab or started on immunosuppressive drugs (dapsone or ciclosporin) when they stopped responding to omalizumab. We used clinical assessment, skin biopsies (when available) and previous published reports to consider dapsone (for predominantly neutrophilic infiltration), or ciclosporin at doses between 2 and 4 mg/kg/day. One patient with ciclosporin-resistant urticaria responded to mycophenolate mofetil. Two patients remain on long-term omalizumab due to its relative safety and efficacy including 1 patient with underlying antibody deficiency where omalizumab was preferred over risks of using immunosuppressive medications.

Conclusions

These case studies bring to light the real-world difficulties in managing patients with resistant CSU and the need for generating the evidence base on alternative therapeutic options such as synergistic use of biologics and immunosuppressive drugs.

Cutaneous manifestations of lupus erythematosus: A practical clinicopathologic review for pathologists

Accurate diagnosis of connective tissue diseases is often challenging and relies on careful correlation between clinical and histopathologic features, direct immunofluorescence studies, and laboratory workup. Lupus erythematosus (LE) is a prototype of connective tissue disease with a variety of cutaneous and systemic manifestations. Microscopically, cutaneous LE is classically characterized by an interface dermatitis, although other histopathologic patterns also exist depending on the clinical presentation, location, and chronicity of the skin lesions. In this article, we review the clinical, serologic, histopathologic, and direct immunofluorescence findings in LE-specific and LE-nonspecific skin lesions, with an emphasis on lesser known variants, newly described features, and helpful ancillary studies. This review will guide general pathologists and dermatopathologists in accurately diagnosing and subclassifying cutaneous LE.

Lupus erythematosus: Significance of dermatologic findings

Herein, the different skin manifestations in patients with lupus erythematosus are reviewed, and their diagnostic, pathogenic and prognostic relevance are discussed, as well as their impact on therapeutic choices. The so-called specific lesions of LE result from an autoimmune pathomechanism and they allow diagnosis of LE by simple clinicopathological correlation since the findings are characteristic. They include the classic acute, subacute and chronic variants, characterised microscopically by interface dermatitis; the dermal variants of lupus, such as tumid lupus, displaying dermal perivascular lymphocytic infiltrate with mucin deposition under the microscope, and lupus profundus, in which lymphocytic lobular panniculitis progressing to hyaline fibrosis is found. Antimalarials are the treatment of choice for patients with specific LE lesions. The presence of some dermatological signs is the result of thrombotic vasculopathy. Their recognition allows the identification of lupus patients at increased cardiovascular risk and with a worse overall prognosis. Those signs include reticulated erythema on the tip of the toes, splinter hemorrhages, atrophie blanche, pseudo-Degos lesions, racemosa-type livedo, anetoderma, ulceration and necrosis. Those clinical manifestations, often subtle, must be recognised, and if present, patients should be treated with antiplatelet drugs. Finally, neutrophilic cutaneous lupus erythematosus includes a few entities that suggest that autoinflammatory mechanisms might play a key role in certain lupus manifestations. Among those entities, it is very important to diagnose neutrophilic urticarial dermatosis, which can mimic a classic lupus flare, because it is characterised by rash with joint pain, but immunosuppressants are not helpful. Dapsone is the treatment of choice.

Neutrophilic dermatoses with unusual and atypical presentations

Neutrophilic dermatoses (NDs) are a group of reactive, noninfectious autoinflammatory diseases characterized by (1) infiltration of the epidermis, dermis, and or/hypodermis by neutrophils; (2) their association with distinct diseases (eg, hematologic malignancy and chronic inflammatory diseases); (3) potential extracutaneous involvement; and (4) response to anti-inflammatory drugs, such as corticosteroids, dapsone, colchicine, and novel biologic therapies, such as the anti-interleukin-1 blockade. Although distinct NDs have been described, transitional forms with overlapping features are often identified. These justify a simplified classification of NDs with three major forms: superficial (epidermal or pustular) NDs, dermal (en plaques) NDs, and deep NDs. We review selected or novel variants of NDs, including subcorneal pustular dermatosis, the group of immunoglobulin A neutrophilic dermatoses, amicrobial pustular dermatosis of the folds, and neutrophilic urticarial dermatosis, as well as atypical forms of Sweet syndrome and pyoderma gangrenosum closely mimicking severe infectious diseases. Knowledge of these variants is essential for proper diagnosis, adequate management, and avoidance of a dangerous escalation of therapy, such as unnecessary immunosuppression or extensive surgery.

Neutrophilic Urticarial Dermatosis Without Underlying Systemic Disease

Neutrophilic urticarial dermatosis (NUD) is rare and poorly understood. First described in 2009, NUD has been reported in association with systemic and autoinflammatory disorders. Here, we describe an example of NUD occurring in the absence of underlying systemic findings that showed an excellent response to low-dose dapsone.

Neutrophilic urticarial dermatosis: A review

Neutrophilic urticarial dermatosis (NUD) is a rare form of dermatosis. In clinical terms, it consists of a chronic or recurrent eruption comprising slightly elevated, pink to reddish plaques or macules. The elementary lesion lasts 24 to 48hours and resolves without leaving any residual pigmentation. Extra-cutaneous signs are common, particularly fever or arthralgia. At histopathology, the dermis contains dense neutrophilic interstitial infiltrate with leukocytoclasis, but without fibrinoid necrosis of vessel walls. NUD often occurs in a setting of underlying systemic disease. The most commonly associated diseases are adult-onset Still's disease, Schnitzler syndrome, lupus erythematosus and cryopyrin-associated periodic syndromes. Treatment of NUD depends on the clinical context. Dapsone and colchicine are often effective.

Two case reports of pyoderma gangrenosum and systemic lupus erythematosus: A rare but nonfortuitous association?

RATIONALE

Pyoderma gangrenosum (PG), like other neutrophilic dermatosis, may be associated with a variety of systemic disorders including inflammatory bowel diseases, rheumatoid arthritis, and hematologic disorders. Conversely, the association between PG and systemic lupus erythematosus (SLE) has rarely been reported.

PATIENT CONCERNS

We report here 2 cases of this association.

DIAGNOSES

The first case involves a 32-year-old woman who developed, 1 year after SLE diagnosis, 3 painful nodular lesions of PG on her face, and cervical area. The second case was observed in a 37-year-old woman referred for ulcerative nodular papules of PG on her legs, whereas she had been diagnosed with SLE 10 years before. SLE was inactive in the first case, whereas PG occurred during a lupus flare up in the second one.

INTERVENTIONS

We found 23 previous cases of SLE and PG in the literature with most cases (12/20) occurring during a lupus flare.

OUTCOMES

Although rare, this association may be supported by common innate immunity dysregulation and abnormal neutrophil activation.

LESSONS

PG and other neutrophilic diseases reported in patients with SLE may be added to the large clinical spectrum of cutaneous lesions observed in SLE.

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.

Schnitzler Syndrome: a Review

PURPOSE OF REVIEW

We focus on recent advances in diagnosis and therapeutic strategies, as well as on pathogenesis of Schnitzler syndrome.

RECENT FINDINGS

New diagnostic criteria were established, and their external validity was assessed in a retrospective cohort study. The cytokine interleukin-1 (IL-1) plays a crucial role in the pathogenesis of the Schnitzler syndrome, and this explains the spectacular efficiency of IL-1 blocking therapies. The Schnitzler syndrome is now considered as a late-onset acquired autoinflammatory syndrome in which the cytokine IL-1 plays a crucial role. IL-1 blocking therapies are efficient on the inflammation-linked symptoms but not on the monoclonal component. Therefore, they probably don't reduce the risk of the development of lymphoproliferative disorders that remains the main prognostic issue. The link between autoinflammation and the monoclonal component needs to be further elucidated.

[Systemic lupus erythematosus : Unusual cutaneous manifestations]

BACKGROUND

Various different mucocutaneous symptoms may affect up to 80 % of systemic lupus erythematosus (SLE) patients.

OBJECTIVES

To investigate, various unspecific, but otherwise typical clinical symptoms of skin and mucous membranes that arise in SLE patients other than those defined as SLE criteria such as butterfly rash, chronic cutaneous lupus erythematosus, oral ulcers, and increased photosensitivity.

MATERIALS AND METHODS

Extensive search of peer-reviewed scientific articles was performed, medical histories of several SLE patients seen in our department were analyzed, and the rare disease courses in three SLE patients are presented.

RESULTS

Here we present a variety of unspecific but typical mucocutaneous manifestations in SLE patients: periungual erythema, periungual telangiectasia and periungual splinter hemorrhage, papules on the dorsum of the hands, scaling erythema, sometimes associated with necrosis, especially of the ears, along with complement deficiency, and the bizarre necroses of antiphospholipid syndrome. Furthermore, we show the typical clinico-histological features of neutrophilic urticarial dermatosis, as well as those of bullous SLE and finally a severe course of bacterial sepsis with Neisseria flavescens/macacae.

CONCLUSIONS

Here we show several unspecific but rather typical mucocutaneous symptoms in lupus patients that are indicative of SLE and thus may lead to an early diagnosis. Also, life-threatening bacterial sepsis may occur with microorganisms that are commonly considered "apathogenic", such as Neisseria flavescens/macacae, which exclusively affect immunosuppressed patients.

Blisters and Loss of Epidermis in Patients With Lupus Erythematosus: A Clinicopathological Study of 22 Patients

The nosology of bullous lesions or equivalents (vesicles, erosions, and crusts) in patients with lupus erythematosus (LE) is rarely addressed.The primary aim of this study was to draw up a precise phenotypic inventory of such skin lesions; the secondary objective was to assess a potential relationship between the different types of loss of epidermis and extracutaneous lupus manifestations.We conducted a retrospective multicenter study including 22 patients with definite LE and bullous lesions or equivalents. All biopsies were reviewed. Patients were recruited in the dermatology departments of 6 centers. Patients were included if they met the diagnosis of systemic LE according to American College of Rheumatology and/or Systemic Lupus International Collaborating Clinics criteria or diagnosis of cutaneous LE based on classic clinical criteria and/or histological ascertainment of LE. Patients were recruited through clinician's memory and photographic collections.Three clinico-pathological patterns could be individualized. First, toxic epidermal necrolysis (TEN)-like, sheet-like, skin detachment; sun-exposure, mild mucosal involvement, and dermal mucin deposition allow differential diagnosis with classical Lyell syndrome. Second, vesiculo-bullae and/or crusting occurring on typical lesions of subacute cutaneous lupus erythematosus or chronic cutaneous lupus erythematosus. Third, tense vesicles and/or blisters with an underlying neutrophilic dermatosis and a usual response to dapsone.A careful analysis of 22 LE patients with epidermal detachment reveals 2 main pathomechanisms: a classic LE interface dermatitis, which can be hyperacute and lead to TEN-like skin detachment; and a neutrophilic dermatosis, with tense vesicles and/or blisters, including classic bullous LE.