Dermatologic overview of lupus erythematosus and its subsets

Cross-sectional analysis of a collaborative Web-based database for lupus erythematosus-associated skin lesions: prospective enrollment of 114 patients

OBJECTIVES

To assess disease severity in subsets of patients with cutaneous lupus erythematosus (CLE) by using outcome and quality-of-life measures, and to determine treatment responsiveness by establishing a Web-based database of patients with skin manifestations of lupus.

DESIGN

Prospective, cross-sectional study.

SETTING

University hospital cutaneous autoimmunity outpatient clinic.

PATIENTS

One hundred fourteen patients who presented from January 15, 2007, to November 8, 2007, and met the criteria for having CLE or lupus-nonspecific skin disease.

MAIN OUTCOME MEASURES

Scores on the CLE Disease Activity and Severity Index and the modified Skindex-29 (a quality-of-life measure) completed at each visit.

RESULTS

Seven patients (6.1%) presented with acute CLE, 21 (18.4%) with subacute CLE, 77 (67.5%) with chronic CLE, 7 (6.1%) with systemic lupus erythematosus and LE-nonspecific skin lesions, and 1 (0.9%) with LE-nonspecific skin disease only. The mean baseline CLE Disease Activity and Severity Index activity/damage scores in patients with acute, subacute, and chronic CLE were 6.4/5.1, 11.1/1.6, and 7.5/10.2, respectively. The mean baseline modified Skindex-29 scores were 76.3, 79.4, and 82.7, respectively (P = .80). The disease in 11 of the patients (9.6%) was considered refractory to conventional therapies. Significantly more patients in the refractory group than the nonrefractory group were current smokers (P = .006).

CONCLUSION

This Web-based database should allow collection of data related to disease activity, quality of life, and response to therapy at multiple centers.

Chronic cutaneous lupus erythematosus--clinical spectrum

The typical clinical manifestation of chronic cutaneous lupus erythematosus (CCLE) is the chronic discoid lupus erythematosus. This form is characterized by inflammatory, scarring lesions mainly involving the head or neck, but also elsewhere, mostly on the photoexposed areas. The typical lesions in chronic discoid lupus erythematosus appear as round or oval erythematous plaques with scales and follicular plugging. These plaques are well demarcated and spread peripherally. On the face, they can form a butterfly-like rash involving the cheeks and nose. The long-standing lesions are atrophic and scarring, sometimes with hypo-, and hyperpigmentation and teleangiectasias. In 50% of the patients, there is a widespread skin involvement. This form is considered to be the typical clinical picture of CCLE.

Clinical course and prognosis of cutaneous lupus erythematosus

Classical variants of specific cutaneous LE lesions are chronic discoid LE (CDLE) and subacute cutaneous LE (SCLE). CDLE and SCLE may appear at any age; however, the most common age of onset is between 20 and 40 years, with a female predominance of 3:1 in CDLE and 3-6:1 in SCLE. Nonspecific LE skin lesions such as generalized or acrolocalized vasculitis (4-30%), livedo reticularis (22-35%), and alopecia (38-78%) are frequently seen in patients with cutaneous LE. Other typical cutaneous LE subsets such as LE profundus/panniculitis, LE tumidus, urticaria vasculitis, hypertrophic LE, and bullous LE are rather rare variants. Butterfly rash and/or macular exanthema are characteristic skin lesions of systemic lupus erythematosus (SLE) rarely found in patients with cutaneous LE.

Epidemiology and socioeconomic impact of skin disease in lupus erythematosus

The prevalence rates of systemic lupus erythematosus (SLE) may vary within 17-48/100,000 population worldwide. Although population-based epidemiological studies are still missing, the cutaneous variants of lupus erythematosus (LE) are 2-3 times more frequent than SLE itself. The most common age of onset is 20-40 y. Overall, cutaneous LE is regarded as a variant with less severe course and better prognosis. However, CDLE and SCLE last for many years and may lead, like SLE, to severe disability for work and limited life quality; also, a small proportion of patients with cutaneous LE develops SLE during the course of their disease. This implies considerable amount of medical management and costs for the community. Early recognition of cutaneous LE patients at risk to develop SLE and preventive measures against disease triggering factors are important tasks for physicians attending with cutaneous LE patients. It seems that signs of nephropathy, elevated ANA-titers and arthralgias may serve as prognostic predictors for transition into SLE. Characteristic features of cutaneous LE are photosensitivity and female predominance. UV light is a major environmental triggering factor in cutaneous LE. Skin lesions may be induced or preexistent lesions may exacerbate due to UV light in up to 80-90% of all patients. Therefore, socioeconomic counseling of the young patients, for example choice of occupation and sun protection, are essentials in compliant patients. Also, since females are 3-6 times more frequently affected than males, the possibility of hormonal influences including pregnancy and estrogen-containing drugs should be discussed. Risk considerations for females wishing to become pregnant are required, and avoidance of estrogen-containing contraceptives should be recommended.

Subacute cutaneous lupus erythematosus--the annular variant. A histological and ultrastructural study of five cases

Subacute cutaneous lupus erythematosus is an uncommon, non-scarring variant of lupus erythematosus which has received scant attention in the pathology literature. Its recognition as a distinct entity is important, as, although mild systemic features may be associated, there is characteristically a relative absence of life-threatening renal or central nervous systemic involvement. Subacute cutaneous lupus erythematosus may be clinically sub-divided into the more common annular and the rarer papulosquamous (psoriasiform) variants. A clinicopathological study of five cases of the annular variant is presented with a review of the literature. We highlight the histological and ultrastructural appearances. Discriminatory features from the other variants of lupus erythematosus and additional conditions with which it may be confused, including lichen planus and acute graft-versus-host disease, are discussed.