Histopathology and immunohistochemistry of depigmented lesions in lupus erythematosus

Treatments for disease damage in cutaneous lupus erythematosus: A narrative review

Cutaneous lupus erythematosus (CLE) is an autoimmune photosensitive disorder that affects the skin. CLE lesions can have signs of skin damage including dyspigmentation, scarring, atrophy and/or alopecia. Disease damage secondary to CLE can be cosmetically disfiguring and causes patients significant distress. While many current treatments for CLE focus primarily on reducing inflammation, there are few options for managing disease damage. Providers currently lack strong guidance on managing CLE damage due to the paucity of literature on this topic. Because of this knowledge gap, we aim to provide an overview of what is currently known about the pathogenesis and management of signs of disease damage in CLE. In this narrative review, Pubmed, Ovid Medline, and Google scholar were searched for relevant articles assessing pathogenesis and treatment of disease damage. Therapeutic options for CLE damage, including hyperpigmentation (laser and camouflage), hypopigmentation (melanocyte grafting and camouflage), scarring (laser, dermabrasion, and camouflage), atrophy (filler, fat transplantation, and flap procedures), and scarring alopecia (hair transplantation and camouflage) were identified. We found that investigations of therapeutics for CLE disease damage primarily consist of case reports and small case series. Reported adverse events due to treatment for CLE disease damage range from temporary erythema and discomfort to disease reactivation and pigmentary defects. There are various treatments for disease damage for each sign of disease damage. However, more robust investigations are needed to assess disease pathogenesis and improve treatments of disease damage due to CLE.

Subacute cutaneous lupus erythematosus leukoderma treated with melanocyte-keratinocyte transplantation procedure

Depigmented lesions may occur as postinflammatory sequelae of subacute cutaneous lupus erythematosus (SCLE), leading to great psychosocial impact. A 53-year-old male patient presented with post-SCLE depigmented facial lesions after five years of disease stability. We proposed surgical treatment with melanocyte-keratinocyte transplantation procedure (MKTP), and after five months the patient achieved 90% repigmentation, without Koebner phenomenon (KP). In theory, KP is a possible complication of MKTP procedure since the preparation of the receptor area involves the use of dermabrasion. In an attempt to avoid it, we suggest to maintain the treatment of the underlying disease and wait for a minimum period of disease stability before the procedure.

A rare case of male bullous lupus erythematosus complicated with subsequent annular hypopigmentation

A 57-year-old male had been suffering from an itchy map-shaped symmetrical erosive erythema with a crust that was attached to his upper arm and buttock, and occasionally he suffered from spiking fever. Laboratory examinations showed neither anti-desmoglein 1/3 antibodies nor anti-BP 180 antibodies, and he fulfilled the criteria for a diagnosis of systemic lupus erythematosus (SLE). Histologically, there was eosinophilic necrosis of keratinocytes, liquefaction and degradation with severe lymphocyte infiltration into the epidermis and subepidermal blister formation, suggestive of a variant of SLE, bullous lupus erythematosus (BLE). One month after remission of BLE, peculiar annular hypopigmentation appeared on the peripheral borders. An immunohistochemical analysis showed a decrease in Melan A-positive melanocytes and concomitant pigment incontinentia, with dense infiltration of CD8(+) T cells and IL-17A(+) Th17 cells. An ultrastructural analysis revealed a decrease, but not a complete disappearance, of both melanocytes and melanosomes, and no impairment in melanosomal transfer. In this case report, we would like to introduce the development of annular depigmentation complicated with BLE, and discuss the effects of lupus condition on melanocyte damage based on immunohistological and electromicroscopic findings of those vitiliginous lesions.

Differences in tumor thickness between hematoxylin and eosin and Melan-A immunohistochemically stained primary cutaneous melanomas

Tumor thickness (Breslow thickness) represents the main prognostic factor in primary melanoma. Potential differences in melanoma tumor thickness measurements between conventional hematoxylin and eosin (H&E) and Melan-A immunohistochemical staining were evaluated. Ninety-nine excisional biopsies were included in the study. From each sample, 2 consecutive histological sections were stained with H&E and Melan-A, respectively. Tumor thickness was measured from both sections by 2 independent observers. In 59 biopsy specimens (59.6%), higher tumor thickness measurements were recorded in Melan-A-stained than in H&E-stained sections. In 42.4% of such cases (25 biopsies), the observed differences were ≥0.2 mm. After Melan-A evaluation, 33% of in situ melanoma cases were reclassified as invasive melanoma, with thickness measurements ranging from 0.15 to 0.35 mm. In 23 biopsies, identical values were recorded with both techniques, whereas in 17 cases, measurements obtained with H&E staining were slightly higher (from 0.01 to 0.18 mm) than those obtained with Melan-A staining. A high rate of interobserver agreement was noted, and significant intertechnique measurement differences were detected. Significant discrepancies (≥0.2 mm) in thickness measurements between the 2 techniques were mainly attributed to the presence of individual or small clusters of melanocytic cells in the papillary dermis. These melanocytic cells could be easily overlooked in H&E-stained sections, especially in sections showing dense lymphohistiocytic inflammatory infiltrates, numerous melanin-containing histiocytic cells in the upper dermis, or extensive fibrotic changes or regression phenomena. This study confirms the practical interest of immunohistochemical staining with Melan-A in evaluating primary melanoma and, specifically, in situ melanoma cases.

Adult-onset dyschromatoses

The dyschromatoses are a group of pigmentary disorders characterized clinically by mixed and often guttate hypopigmentend and hyperpigmented lesions. There are many conditions that present with dyschromatosis, including genodermatoses, inflammatory skin diseases, infections, drug and chemical use, and nutritional disorders. Some conditions have extracutaneous features. In this article, we describe the dyschromatoses with typical onset in adulthood. Most diseases in this group are acquired conditions. To organize the various acquired dyschromatoses, we have categorized them into those with a history of chemical exposure, drug exposure or dermatological procedures, and those without a history of such exposure. In contrast to the genetic dyschromatoses, some acquired dyschromatoses are preventable and treatable. We hope this review will serve as a guide for dermatologists to the recognition and treatment of these conditions.