Alopecias in lupus erythematosus

Non-scarring alopecia in systemic lupus erythematosus patients at the Lagos State University Teaching Hospital: a cross-sectional study of prevalence, pattern, trichoscopy features and histopathological analysis

Introduction

trichoscopic and histopathological evaluation of non-scarring systemic lupus erythematosus (SLE) alopecia is uncommon. We aimed to document the prevalence, pattern of hair loss, trichoscopic and histopathologic differences between systemic lupus erythematosus patients with and without hair loss.

Methods

this was a cross-sectional comparative study of 75 systemic lupus erythematosus patients, 36 with hair loss from February to December 2020. Trichoscopic evaluation was conducted on all 75 patients. Twenty-three patients (12 with hair loss and 11 without) had scalp biopsies with mucin deposit evaluation. Disease activity was documented using the SLE disease activity index. Data was analyzed using SPSS 22.

Results

the mean age of the patients was 33.7 ± 12.4 years. Non-scarring alopecia was observed in 48%. The pattern of hair loss was <4 patches in 44.4%, mild diffuse in 25%, and severe diffuse in 30.6%. Disease activity was mild in 38.9%. Hair shaft changes included thin hair (97.2%), decreased number of hairs per follicular unit (97.2%), hypopigmented hair (85.7%), and follicular red dots (27.8%). Significant differences between the two groups were; a reduction in size and number of sebaceous glands on histopathology, hair shaft, and scalp pigmentary changes in the hair loss group.

Conclusion

the prevalence of non-scaring alopecia is high in SLE patients with patchy type as the commonest pattern. Trichoscopic and histopathologic differences exist in SLE patients with and without hair loss and the normal-appearing scalp in SLE patients is involved in the inflammatory process. Hair shaft thinning, hypopigmentation, and scalp pigmentary changes occur in SLE.

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.

Systemic lupus erythematosus and damage: What has changed over the past 20 years?

The young age of onset and chronic/relapsing nature of systemic lupus erythematosus (SLE) make SLE patients prone to develop and accrue organ damage as a result of long-standing disease activity and side effects of treatment. There is a growing interest in objectifying damage and identifying its risk factors. Still, the lack of therapeutic alternatives has led to difficulties in avoiding immunosuppressives particularly corticosteroids, which have been implicated in a large spectrum of organ damage in SLE patients. Moreover, it continues to be very challenging to determine what actually causes damage in different organ-systems. Cardiovascular disease continues to be one of the leading types of damage in patients with SLE, reported as early as 1976. Since then, many researchers have focused on identifying SLE or treatment-related and traditional risk factors. The same considerations are valid for other conditions, such as the occurrence of metabolic syndrome, osteoporosis, avascular necrosis, susceptibility to infections, etc. On the other hand, diverse risk factors contribute to the development of chronic kidney disease (CKD) in SLE. Most evidence suggests that high initial levels of serum creatinine, hypocomplementemia, nephrotic range proteinuria, concomitant uncontrolled hypertension, Black and Hispanic ancestry, non-adherence to treatment, and biopsy findings such as diffuse proliferative lupus nephritis (LN), a high chronicity index, tubular atrophy, and tubulointerstitial inflammation are risk factors for progression to end stage renal disease (ESRD) in LN. While cardiovascular disease, CKD and infections are leading causes of mortality in patients with SLE, hospitalizations are caused mostly by SLE disease flares and infections. Cognitive impairment and mood disorders are common in SLE but continue to impose a challenge on how to measure, manage and decipher the underlying pathogenesis. Nevertheless, they have a great impact on SLE patients' health-related quality of life (HRQoL) and social functioning. Also, skin manifestations, such as alopecia and scaring, cataracts, and sicca symptoms result in a significant decrease in HRQoL. In light of recent developments in SLE treatment, we can expect to enter a period of new-age targeted therapies that will enable us to reduce disease activity and glucocorticoid usage further and positively alter the trajectory of damage development and accrual in SLE.

Diagnosis and treatment of female alopecia: Focusing on the iron deficiency-related alopecia

Objectives

Alopecia is a soft but meaningful complaint affecting women's physical and psychological health. Female alopecia (FA) has diverse etiologies. Nonetheless, FA is stereotyped as female pattern hair loss, also known as female androgenetic alopecia, and has not been thoroughly investigated. This study aimed to identify the etiologies of FA at a tertiary medical center in Eastern Taiwan.

Materials and Methods

This retrospective study enrolled female patients with hair loss who visited the dermatology department of (blinded information). A complete history taking was obtained, including the onset and duration of alopecia, menstruation, gynecologic diseases, psychological stress, underlying diseases, vaccination, and dietary habits, etc., Blood tests were performed, including hemoglobin (Hb), ferritin, Zn, autoimmune and thyroid profiles, etc., Iron deficiency (ID) was defined as serum ferritin level <60 ng/mL. The hair condition, ferritin, and Hb levels were monitored every 3 months after supplementation.

Results

A total of 155 patients were recruited. The etiologies of FA were diverse; the top five etiologies were nutrient deficiencies (83.9%), autoimmune (14.8%) and thyroid (7.7%) diseases, psychological stress (12.3%), and coronavirus disease 2019 (COVID-19) vaccination (6.5%). ID accounted for 70.3% of cases. The disease duration was an important prognostic factor for the improvement of serum ferritin. Patients with subjective improvement of hair regrowth also had more increase of ferritin levels after iron supplementation. The corresponding ferritin level for female anemia (Hb: 12.0 g/dL) was 5.1 ng/mL, lower than the adequate level for hair growth (40-60 ng/mL), the corresponding Hb level of which was 13.1-13.8 g/dL.

Conclusion

The causes of FA varied, including nutrient deficiencies, autoimmune diseases, psychological stress, thyroid diseases, and COVID-19 vaccination, etc., Therefore, a complete survey before treatment is essential. Seventy percentage of FA cases were ID-FA. We suggest to redefine the serum ferritin level ≥60 ng/mL, with the corresponding Hb ≥13.0 g/dL as the normal range for early diagnosis. Initiation of iron supplementation within 6 months would result in a better prognosis.

Tumid Lupus Erythematosus Presenting as Patchy Alopecia: A Discussion of Alopecia Associated With Lupus Erythematosus

Tumid lupus erythematosus (TLE), a subtype of chronic cutaneous lupus erythematosus (CCLE), presents with firm erythematous plaques that lack surface changes such as follicular plugging or scale. These lesions most commonly occur on the face and other photosensitive areas but may also present on the scalp as recurrent circumscribed patches of non-cicatricial alopecia. Including TLE as part of the differential for non-cicatricial alopecia can prove helpful in patients who fail to improve with empiric first-line treatments for more common causes of hair loss. We report a case of TLE that clinically mimicked alopecia areata and seek to highlight the relevant clinical and histological features to promote earlier diagnosis of this entity. A discussion of improved diagnostic and treatment modalities, as well as identifying the uncommon but possible association of TLE with underlying systemic disease, adds to the importance of maintaining clinical suspicion for TLE. Finally, we provide an overview to discriminate TLE from other forms of cutaneous lupus and their unique patterns of alopecia when presenting on the scalp.

Hair Disorders in Autoimmune Diseases

Alopecia is a common feature in several autoimmune diseases. With a wide spectrum of clinical presentations, it may manifest with a scarring or non-scarring nature, in a diffuse, patchy, or localized pattern. We as dermatologists have the opportunity of assessing patients with hair loss who may have an underlying undiagnosed autoimmune disorder. This review aimed to describe the main clinical, trichoscopic, and histopathological features of hair disorders associated with autoimmune diseases.

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.

Cutaneous Involvement in Systemic Lupus Erythematosus: A Review for the Rheumatologist

The majority of patients with systemic lupus erythematosus (SLE) have cutaneous manifestations at some point in their disease course. The skin findings in SLE are classified as SLE-specific or SLE-nonspecific based on histopathologic findings. SLE-specific skin diseases include chronic cutaneous lupus erythematosus (CLE), subacute CLE, and acute CLE. There are subsets of skin lesions within each group and the likelihood of associated SLE varies among them. SLE-nonspecific lesions are more common in patients with SLE and tend to coincide with active systemic disease. SLE-nonspecific lesions may be seen as a feature of another disease process, including other connective tissue diseases. It is important for the rheumatologist to be familiar with the spectrum of cutaneous diseases in SLE to help prognosticate the likelihood of systemic disease and to ensure patients receive timely dermatologic care with the goal of controlling disease activity to prevent damage.

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.

Dendritic cells may help differentiate discoid lupus erythematosus alopecia from lichen planopilaris

Introduction

Primary cicatricial alopecia (PCA) encompasses a heterogeneous group of inflammatory diseases characterized by the replacement of hair follicle structures by fibrous tissue. Discoid lupus erythematosus (DLE) and lichen planopilaris (LPP) are the most common causes of scarring alopecia. The distinction between both entities is often challenging because of significant clinical and histopathological overlap.

Aim

We hypothesized that dendritic cells which are implicated in PCA pathogenesis can provide a reliable histopathological clue to distinguish between these two entities.

Material and methods

In a retrospective cohort study including 51 patients diagnosed with LPP and DLE we mapped and quantified the distribution of dendritic cells. Cell count in lesional skin was performed on immunohistochemistry by using characteristic monoclonal antibodies to specific subpopulations of dendritic cells.

Results

We demonstrated that almost all subpopulations of dendritic cells were highly expressed in lesional skin of discoid lupus erythematosus patients in comparison with lichen planopilaris ones.

Conclusions

In the light of this observation, dendritic cells might be used as an additional clue in differential diagnosis of PCA.

Areata-Like Lupus as a Clinical Manifestation of Cutaneous Lupus Erythematosus

<b><i>Introduction:</i></b> Lupus erythematosus (LE) is a chronic autoimmune disease that frequently causes hair loss and scalp lesions. Hair loss can be scarring and nonscarring, diffuse, or patchy. The nonscarring patchy alopecia is usually related to systemic LE (SLE) and may simulate alopecia areata (AA), reason why it is named areata-like lupus. Our case was diagnosed with areata-like lupus but did not meet criteria for SLE. <b><i>Case Report:</i></b> A 63-year-old woman presented with irregular nonscarring patchy alopecia in the temporal and frontoparietal scalp. Trichoscopy showed exclamation mark hairs, vellus hairs, and sparse yellow dots. Histology revealed epidermal vacuolar interface dermatitis, lymphohistiocytic infiltrate around the bulbs of anagen follicles, and eccrine glands. Direct immunofluorescence showed deposits of C3, IgA, and IgG in the basement membrane zone. <b><i>Discussion:</i></b> Patients with cutaneous LE can also manifest as nonscarring patchy alopecia that is clinically similar to AA, despite the absence of systemic manifestations. Areata-like lupus is secondary to the lupus autoimmune infiltrate that affects the skin including the hair follicles. Trichoscopy, histology, and direct immunofluorescence are important to differentiate this form of alopecia from AA, which is believed to have a higher incidence in lupus patients.

A Case of Neuropsychiatric Systemic Lupus Erythematosus With Hair Loss as the First Diagnostic Symptom

Neuropsychiatric systemic lupus erythematosus is a serious complication of systemic lupus erythematosus. A 33-year-old female patient had repeated hair loss for more than 3 years. A dermatologic examination showed several pieces of irregularly shaped hair loss patterns in the center of the patient's scalp. The systemic treatment included oral hydroxychloroquine, aspirin enteric-coated tablets and prednisone, and intrathecal injection of dexamethasone and methotrexate. The local treatment included intralesional injection of triamcinolone acetonide and lidocaine in the lesion area, 0.1% tacrolimus ointment for external use. After 2-month treatment, hair regrew in a non-scarring patchy alopecia region with no further hair loss.

Discoid lupus erythematosus skin lesion distribution and characteristics in Black patients: a retrospective cohort study

OBJECTIVE

Epidemiological studies have shown that discoid lupus erythematosus (DLE) has a higher incidence and prevalence in racial/ethnic minority groups, particularly Black individuals. The objective of this retrospective cohort study was to identify the differences in DLE lesion distribution and characteristics in Black individuals compared with non-Black individuals.

METHODS

183 patients with DLE (112 Black patients and 71 non-Black patients) with a reported race/ethnicity and Cutaneous Lupus Erythematosus Disease Area and Severity Index (CLASI) scores were included in this retrospective cohort study. Univariate analysis was performed to determine significant differences in demographic data, clinical characteristics, DLE lesion distribution and DLE lesion characteristics in Black and non-Black patients with DLE. Multivariable logistic regression was preformed to determine significant predictors of DLE lesion location and characteristics.

RESULTS

Black patients with DLE had worse baseline CLASI damage scores compared with non-Black patients with DLE (median (IQR): 10.0 (6.0-14.5) vs 6.0 (3.0-10.0), p<0.001) and had 48.9 greater odds of dyspigmentation in any anatomical location (p<0.001). Black patients had 2.54 greater odds of having scalp involvement (p=0.015) and 1.97 greater odds of having ear involvement (p=0.032) compared with non-Black patients. Black patients also had greater odds of scalp dyspigmentation (OR=5.85, p<0.001), ear dyspigmentation (OR=2.89, p=0.001) and scarring alopecia (OR=3.00, p=0.001) compared with non-Black patients.

CONCLUSIONS

Signs of disease damage, particularly ear dyspigmentation, scalp dyspigmentation and scarring alopecia, can more frequently affect Black patients with DLE. Recognising differences in clinical presentation of DLE among Black patients can assist future efforts with understanding biological, cultural, psychosocial and systemic factors that influence DLE presentation and outcomes in Black patients and may guide clinicians when counselling Black patients.

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.

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.

Chinese SLE Treatment and Research Group Registry (CSTAR) XIII: prevalence and risk factors for chronic scarring alopecia in patients with systemic lupus erythematosus

Background

Scarring alopecia in systemic lupus erythematosus (SLE) patients caused reduced life quality and prolonged disease course. This case-control study aims to survey the prevalence of scarring alopecia during the disease course of SLE and evaluate the risk factors for scarring alopecia in Chinese SLE patients.

Methods

SLE patients in Chinese SLE treatment and Research group (CSTAR) were recruited. Scarring alopecia was defined according to SLICC/ACR-DI which was collected during follow-up visits or via self-reported questionnaires. We collected demographic characteristics, common comorbidities, autoantibody profiles, disease activity status, major organ involvements, and treatment strategies of these patients at registry. Univariate and multivariate logistic regression analyses were used to investigate the risk factors for scarring alopecia.

Results

We recruited 4792 SLE patients, and 374 (7.80%) patients had scarring alopecia. Mucocutaneous lesions (OR 2.062, p < 0.001), high SLICC/ACR-DI (OR 1.409, p < 0.001), and positive anti-Sm (OR 1.374, p = 0.029) were risk factors for scarring alopecia, while renal (OR 0.714, p = 0.028) and cardio-respiratory involvements (OR 0.347, p = 0.044), and immunosuppressant treatment (OR 0.675, p < 0.001) were significantly negative associated with it.

Conclusions

The prevalence of scarring alopecia in SLE patients is 7.80%. Active treatment strategies should be adopted to prevent scarring alopecia occurring.

Expert Perspective: An Evidence-Based Approach to Refractory Cutaneous Lupus Erythematosus

Cutaneous lupus erythematosus (CLE) is a chronic autoimmune disease that can present with a variety of skin manifestations and have a dramatic effect on a patient's quality of life. Effective treatment options for this disease are limited, and the efficacy of these treatments is often supported by low levels of evidence. This makes the treatment of refractory disease especially challenging, as it is difficult to achieve a consensus on the appropriate progression of treatment beyond first- and second-line treatment options. The treatment of refractory CLE often involves some degree of immunosuppression, which carries some risk for patients and requires a thoughtful approach to the selection of medications. Some treatments that have proven to be effective in systemic disease may not be as effective in cutaneous disease, making it difficult to extrapolate from the available evidence on systemic lupus erythematosus (SLE). Ultimately, the increased use of objective skin measurements in SLE clinical trials is necessary to understand drug efficacy in CLE and develop new treatments for this challenging disease. Here, we provide clinical examples of the challenges involved in treating refractory CLE, examine the evidence currently available for treatment options, and provide an algorithmic approach to the treatment of refractory disease based on this evidence. Novel therapies under development for CLE are also discussed, as they may soon be part of the accepted treatment regimen for refractory CLE.

Evaluating change in disease activity needed to reflect meaningful improvement in quality of life for clinical trials in cutaneous lupus erythematosus

BACKGROUND

Outcome measures of clinical trials in cutaneous lupus erythematosus (CLE) should reflect clinically meaningful improvement in disease activity, as measured by the Cutaneous Lupus Disease Area and Severity Index activity score (CLASI-A).

OBJECTIVE

We aimed to define the degree of improvement in disease activity meaningful to a patient's quality of life.

METHODS

The change in the CLASI-A in 126 patients needed to predict meaningful change in QoL, as defined by the Emotions and Symptoms subscales of the Skindex-29, was evaluated by linear regression models.

RESULTS

In patients with an initial CLASI-A of ≥8, a 42.1% or ≥7-point and a 31.0% or ≥5-point decrease in CLASI-A predicts meaningful improvement in the Emotions and the Symptoms subscales, respectively.

LIMITATIONS

This is a retrospective study of prospectively collected data at a single site.

CONCLUSIONS

A CLASI-A score of ≥8 for trial entry allows for inclusion of patients with milder disease where CLASI-A improvement by ≥50% is clinically significant and meaningful.

Systemic Lupus Erythematosus Presenting as Alopecia Areata

Alopecia areata is an inflammatory, non-scarring hair loss associated with autoimmune conditions. It is more commonly seen with thyroid disorders and vitiligo, but alopecia areata has also been linked to diabetes, psoriasis, rheumatoid arthritis, and systemic lupus erythematosus. Indeed, individuals with alopecia areata have an increased risk of developing systemic lupus erythematosus. A 36-year-old woman presented with hair loss characteristic of alopecia areata. After intralesional injections with triamcinolone acetonide, the areas of hair loss exhibited near complete hair regrowth. Laboratory examination and additional history were suggestive of systemic lupus erythematosus. She was referred to a rheumatologist who confirmed the diagnosis. Awareness of the comorbidities associated with alopecia areata can uncover other autoimmune conditions, such as thyroid disorders and systemic lupus erythematosus. The diagnosis of a new-onset alopecia areata may prompt a deeper investigation of potentially associated conditions.

Alopecia areata in patients with systemic lupus erythematosus treated with belimumab: a plausible association

Belimumab, an anti-B-lymphocyte stimulator monoclonal antibody, was recently approved for the treatment of systemic lupus erythematosus. Alopecia areata is characterized by an acute immune-mediated hair loss. Herein, we report on three adult systemic lupus erythematosus patients who developed alopecia areata in association with belimumab treatment. Alopecia areata was resolved in all three patients and belimumab was discontinued in two of them. Thus, in the current report, we explore the plausible link between alopecia areata and belimumab.

Suspected inflammatory rheumatic diseases in patients presenting with skin rashes

Skin lesions occur, often at very early stages, in many of the most frequent inflammatory rheumatic diseases such as in systemic lupus erythematosus (SLE), dermatomyositis (DM), systemic sclerosis (SSc), Sjögren's syndrome, rheumatoid arthritis (RA), and psoriatic arthritis. It is important to recognize the different specific cutaneous lesions in SLE (e.g., "butterfly" rash in acute, annular or psoriasiform photosensitive lesions in the subacute form, and discoid lesions in the chronic form) for an early diagnosis and to estimate the associated risks of internal disease, whereas nonspecific lesions (exanthema, vasculitis, and alopecia) can be part of SLE flares. Cutaneous lesions in DM (Gottron's papules and sign, heliotrope rash, dystrophic cuticles, and nailfold capillary abnormalities) may occur before any clinically evident muscular or systemic organ involvement and are of utmost importance for early diagnosis. The pattern of cutaneous lesions and associated autoantibodies also allow the distinction of different phenotypes, either more prone to life-threatening interstitial lung disease (MDA-5) or with higher risk for neoplasia (TIF1-γ). Many other skin lesions, although not specific, require further investigation to look for a possible underlying inflammatory rheumatic disease: non-pruritic urticarial lesions in anti-C1q-associated urticarial vasculitis, Still's disease or hereditary auto-inflammatory syndromes, transient macular purpura of vasculitis in Sjögren's syndrome, Behçet's disease, or RA, Raynaud's phenomenon in SSc and mixed connective tissue disease, erythema nodosum or other panniculitis in RA, Behçet's disease and SLE, pustular eruptions in Behçet's disease, psoriasis, and hereditary auto-inflammatory syndromes. After reviewing in detail the cutaneous manifestations of the most frequent inflammatory rheumatic diseases, we describe a topographic and morphological approach to skin rashes, calling attention to facial rashes, hand involvement, scalp, nail, or leg lesions or to some morphological aspects of skin lesions (annular, pustular, urticarial, or exanthematous) that may be the initial manifestations of inflammatory rheumatic diseases. The importance of skin lesions is confirmed by their presence as part of the classification criteria of many inflammatory rheumatic diseases. They also contribute to early diagnosis, to characterize disease phenotypes, to aid in effective patient management, and, ultimately, to impact on disease prognosis.