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Kirkpatrick KV, Nocton JJ. Unusual Presentations of Systemic Lupus Erythematosus. Med Clin North Am 2024; 108:43-57. [PMID: 37951655 DOI: 10.1016/j.mcna.2023.05.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2023]
Abstract
Systemic lupus erythematosus (SLE) often develops during adolescence, may affect any organ system, and may present with a wide variety of signs and symptoms. It is critical to recognize the unusual manifestations of SLE in order to make a prompt diagnosis. Earlier diagnosis allows for appropriate treatment and ultimately decreases morbidity and mortality.
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Affiliation(s)
- Kaitlin V Kirkpatrick
- Pediatric Rheumatology, Medical College of Wisconsin, Children's Corporate Center, 999 North 92nd Street Suite C465, Milwaukee, WI 53226, USA
| | - James J Nocton
- Pediatric Rheumatology, Medical College of Wisconsin, Children's Corporate Center, 999 North 92nd Street Suite C465, Milwaukee, WI 53226, USA.
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2
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Bhandari SK, Gautam N, Pandeya A, Jha S. A case of bullous systemic lupus erythematosus: Diagnostic challenges and clinical implications. Clin Case Rep 2023; 11:e8167. [PMID: 37953897 PMCID: PMC10632556 DOI: 10.1002/ccr3.8167] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2023] [Revised: 10/20/2023] [Accepted: 10/21/2023] [Indexed: 11/14/2023] Open
Abstract
Skin involvement in systemic lupus erythematosus (SLE) is common. Bullous lesions in SLE patients are usually due to other autoimmune conditions or rarely, due to lupus itself. Bullous SLE is rare blistering disorder characterized by subepidermal blisters. We, hereby, present a case of bullous SLE in a 24-year-old female who responded well to systemic glucocorticoids, mycophenolate mofetil, and dapsone.
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Affiliation(s)
| | - Naveen Gautam
- Tribhuvan University Teaching HospitalKathmanduNepal
| | | | - Saket Jha
- Tribhuvan University Teaching Hospital, Internal Medicine, RheumatologyKathmanduNepal
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3
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Giri G, Bagheri S. Bullous Systemic Lupus Erythematosus: A Case Report. Cureus 2023; 15:e40002. [PMID: 37416004 PMCID: PMC10322164 DOI: 10.7759/cureus.40002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/05/2023] [Indexed: 07/08/2023] Open
Abstract
Bullous systemic lupus erythematous (BSLE) is a very rare autoimmune disease characterized by vesiculobullous lesions on mostly sun-exposed areas of skin. We present a case of a 36-year-old female who developed vesiculobullous lesions after previously having poorly controlled lupus. Dapsone was added to her treatment plan, and the lesions healed in a few weeks without scarring or pigmentation.
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Affiliation(s)
- Ganesh Giri
- Medicine, Charles E Schmidt College of Medicine, Florida Atlantic University, Boca Raton, USA
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4
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Ratanapokasatit Y, Seree-Aphinan C, Chanprapaph K. Refractory Bullous Systemic Lupus Erythematosus Successfully Treated with Rituximab: A Case Report and Literature Review. Clin Cosmet Investig Dermatol 2023; 16:883-890. [PMID: 37038449 PMCID: PMC10082637 DOI: 10.2147/ccid.s403866] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2023] [Accepted: 03/25/2023] [Indexed: 04/07/2023]
Abstract
Bullous systemic lupus erythematosus (BSLE) is a rare blistering skin manifestation of systemic lupus erythematosus (SLE). Dapsone is reported to be helpful in mild-to-moderate BSLE cases; however, its use may be limited or prohibited due to particular complications such as drug hypersensitivity, dose-dependent hemolytic anemia, and other significant hematologic abnormalities. Rituximab, an anti-CD20 monoclonal antibody, has been reported with off-label use in BSLE patients, but data are still limited. Hence, our objective is to explore the efficacy of rituximab among these patients. Herein, we report a 21-year-old Thai woman presented with blistering eruption on the oral cavity, scalp, trunk, and extremities for 1 month. The investigations revealed a positive direct Coomb's test, an elevated erythrocyte sedimentation rate (ESR), and a positive antinuclear antibody (ANA). Skin biopsy showed focal interface dermatitis. Direct immunofluorescence (DIF) illustrated mixed linear and granular deposition of immunoglobulin (Ig)G, IgM, IgA, and C3 along the dermo-epidermal junction (DEJ). Enzyme-linked immunosorbent assay (ELISA) showed circulating antibodies to type VII collagen. She was diagnosed with severe BSLE and autoimmune hemolytic anemia (AIHA) refractory to several oral immunosuppressants but was successfully treated with rituximab. The authors also performed a review of the literature on prior BSLE cases managed with rituximab.
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Affiliation(s)
- Yanisa Ratanapokasatit
- Division of Dermatology, Department of Medicine, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Chutima Seree-Aphinan
- Division of Dermatology, Department of Medicine, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Kumutnart Chanprapaph
- Division of Dermatology, Department of Medicine, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
- Correspondence: Kumutnart Chanprapaph, Division of Dermatology, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, 270 Rama VI Road, Ratchathewi, Bangkok, 10400, Thailand, Tel +662-201-1141, Fax +662-201-1211, Email
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5
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Elmgren J, Nyberg F. Clinical aspects of cutaneous lupus erythematosus. Front Med (Lausanne) 2023; 9:984229. [PMID: 36698816 PMCID: PMC9868707 DOI: 10.3389/fmed.2022.984229] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2022] [Accepted: 12/16/2022] [Indexed: 01/11/2023] Open
Abstract
Lupus erythematosus (LE) is an autoimmune inflammatory disease with a wide clinical spectrum from life-threatening multi-organ inflammation in systemic lupus erythematosus (SLE) to limited skin disease in cutaneous LE (CLE). The etiology of CLE is still not fully understood but a multifactorial genesis with genetic predisposition and certain environmental factors as triggers for the development are generally accepted features. Lesions can be induced and aggravated by UV-irradiation and smoking is linked to more severe forms of skin disease and to co-morbidity. Drugs, including many common medicines like antihypertensives, are known to induce subacute CLE (SCLE). The mechanisms involved have recently been shown to be part of the IFN-I pathway and new, specific treatments are currently in clinical trials. CLE is currently classified in subtypes based on clinical presentation and duration into acute CLE (ACLE), SCLE, and chronic CLE (CCLE). Distinct subtypes can be seen in individual patients or coexist within the same patient. Because of the confluent and overlapping picture between these subsets, serology, and histopathology constitute an important role guiding towards correct diagnose and there is ongoing work to update the classification. The Cutaneous Lupus Area Severity Index (CLASI) is a validated tool to measure activity and damage both in clinical trials but also for the clinician to evaluate treatment and follow the course of the disease among patients. CLE is known to have substantial impact on the life of those affected. Several tools have been proposed to measure QoL in these patients, currently Skindex-29 is probably the most used. Patient education is an important part of prevention of flares, including UV-protection and smoking cessation. First-line treatment includes topical corticosteroids as well as topical calcineurin inhibitors with the addition of systemic treatment with antimalarials in more severe or therapy resistant cases. Treatment specifically targeting CLE has been lacking, however novel potential therapies are in later phase clinical trials. In this review we aim to describe the different subsets of the cutaneous form in LE with focus on clinical aspects.
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Affiliation(s)
- Julia Elmgren
- Department of Medicine, Karolinska Institutet, Stockholm, Sweden,Department of Dermatology, Karolinska University Hospital, Stockholm, Sweden,*Correspondence: Julia Elmgren,
| | - Filippa Nyberg
- Department of Medicine, Karolinska Institutet, Stockholm, Sweden,Department of Dermatology, Karolinska University Hospital, Stockholm, Sweden
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6
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Qiao L, Zhang B, Zheng W, Li M, Zhao Y, Zeng X, Zhang F, Wang L, Li L. Clusters of clinical and immunologic features in patients with bullous systemic lupus erythematosus: experience from a single-center cohort study in China. Orphanet J Rare Dis 2022; 17:290. [PMID: 35871005 PMCID: PMC9308262 DOI: 10.1186/s13023-022-02445-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2022] [Accepted: 07/14/2022] [Indexed: 11/29/2022] Open
Abstract
Background Bullous systemic lupus erythematosus (BSLE) is a rare subtype of systemic lupus erythematosus (SLE) that is clinically characterized by subepidermal tense vesicles or bullae. We aimed to investigate the clinical and laboratory features of patients with BSLE.
Methods We retrospectively reviewed all patients who fulfilled the diagnostic criteria for BSLE in our institution from 2015 to 2021. Cutaneous lesions, systemic manifestations, treatment options, and outcomes were evaluated. For each case of BSLE, four controls were randomly selected from patients with single SLE. Major clinical and laboratory characteristics were compared between the two groups. Results Among 4221 patients with SLE, 12 developed BSLE. Vesiculobullous lesions were the first sign in five of the BSLE patients (5/12, 41.7%) and appeared after SLE diagnosis in the remaining seven patients (7/12, 58.3%), with a median duration from SLE onset of 36 months (4–115 months). The most common BSLE-affected sites were the head and neck (10/12, 83.3%), extremities (9/12, 75.0%), trunk (7/12, 58.3%), and mucosae (6/12, 50.0%). All patients with BSLE had extra-cutaneous involvement. The SLE disease activity index score exceeded 5 in 10/12 (83.3%) patients, which indicated high disease activity. Patients in the BSLE group had significantly higher incidences of proteinuria (83.3% vs. 47.9%, P = 0.027), hematuria (75% vs. 31.3%, P = 0.006), hemolytic anemia (33.3% vs. 0%, P = 0.000), and leukopenia (66.7% vs. 25.0%, P = 0.006) than those in the control group. The use of systemic corticosteroids, immunosuppressants, dapsone, and skin care was effective in controlling disease. Conclusions Vesiculobullous lesions may be the first manifestation and indicate a high disease activity in patients with BSLE. Early diagnosis using clinical, histopathological, and immunological evaluations can lead to appropriate treatment of this progressive disease and improve prognosis.
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Sprow G, Afarideh M, Dan J, Hedberg ML, Werth VP. Bullous systemic lupus erythematosus in females. Int J Womens Dermatol 2022; 8:e034. [PMID: 35923586 PMCID: PMC9324630 DOI: 10.1097/jw9.0000000000000034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2022] [Accepted: 06/06/2022] [Indexed: 11/30/2022] Open
Abstract
Bullous systemic lupus erythematosus (BSLE) is a rare blistering presentation of systemic lupus erythematosus, typically affecting women with the highest incidence in those of African descent. The key pathogenic insult includes the formation of autoantibodies against type VII collagen, which weaken the basement membrane zone and lead to the formation of subepidermal blisters. The acute vesiculobullous eruptions in BSLE generally tend to affect photo-distributed areas, although they can arise unrelated to sun exposure (eg, mucous membranes, axillae). The bullae can arise from erythematous macules, inflammatory plaques, or previously normal skin. Their appearance can range from small, grouped vesicles reminiscent of lesions in dermatitis herpetiformis to large, tense blisters, similar to bullous pemphigoid. Internal organ involvement occurs in up to 90% of those affected. This mostly includes lupus nephritis (classes III–V, lifetime prevalence of up to 90%), arthralgias/arthritis, and cytopenias, while serositis and neuropsychiatric involvement are rare. First-line management with dapsone should be considered in mild disease with stable underlying systemic lupus erythematosus. As discussed in this review, the off-label use of rituximab (an anti-CD20 B-cell depleting agent) has been shown to be safe and effective in several refractory cases of BSLE unresponsive to dapsone, glucocorticoids, or steroid-sparing immunosuppressants.
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A Rare Manifestation of Bullous Systemic Lupus Erythematosus in Children: A 10-year Retrospective Study in a Tertiary Care Hospital. Autoimmune Dis 2022; 2022:9388745. [PMID: 35911475 PMCID: PMC9325629 DOI: 10.1155/2022/9388745] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2022] [Accepted: 07/02/2022] [Indexed: 11/17/2022] Open
Abstract
Bullous systemic lupus erythematosus (BSLE) is an uncommon cutaneous presentation that occurs even less frequent in the pediatric population. A retrospective review was performed from January 2012 to December 2021 in all pediatric patients (aged <18 years) who fulfilled the diagnostic criteria for BSLE to evaluate the clinical characteristics, extracutaneous involvement, histopathologic features, immunofluorescence patterns, serological abnormalities, internal organ involvement, treatments, and outcomes. Among 1,415 patients with SLE, five patients were validated for the diagnosis of BSLE, accounting for 0.35%. The mean age at diagnosis was 12.2 years (standard deviation, 1.92). The clinical features of BSLE in the study population were generalized tense bullae and large extensive vesicles on the lips and perioral and mucosal areas. Pediatric BSLE in the study population revealed high SLE disease activity with multiple organ involvement. Hematologic abnormalities, serositis, and renal involvement were found in all patients, while polyarthritis (40%) and neurological abnormalities (40%) were less frequently observed. Systemic corticosteroids, intravenous immunoglobulin, immunosuppressants, antimalarials, and dapsone were prescribed in the study population. The cutaneous lesions subsided in all patients with a median clearance duration of 14 days (range, 5–56 days). BSLE in the pediatric population has auxiliary manifestations with high disease activity. Multiple organ involvement, especially hematologic abnormalities, serositis, and renal involvement, was frequently found in the study population. Although cutaneous lesions in BSLE subsided in all patients, involvement of other organs, especially renal impairment, required aggressive treatment, and long-term follow-up.
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Cooper EE, Pisano CE, Shapiro SC. Cutaneous Manifestations of "Lupus": Systemic Lupus Erythematosus and Beyond. Int J Rheumatol 2021; 2021:6610509. [PMID: 34113383 PMCID: PMC8154312 DOI: 10.1155/2021/6610509] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/01/2021] [Accepted: 05/11/2021] [Indexed: 11/18/2022] Open
Abstract
Lupus, Latin for "wolf," is a term used to describe many dermatologic conditions, some of which are related to underlying systemic lupus erythematosus, while others are distinct disease processes. Cutaneous lupus erythematosus includes a wide array of visible skin manifestations and can progress to systemic lupus erythematosus in some cases. Cutaneous lupus can be subdivided into three main categories: acute cutaneous lupus erythematosus, subacute cutaneous lupus erythematosus, and chronic cutaneous lupus erythematosus. Physical exam, laboratory studies, and histopathology enable differentiation of cutaneous lupus subtypes. This differentiation is paramount as the subtype of cutaneous lupus informs upon treatment, disease monitoring, and prognostication. This review outlines the different cutaneous manifestations of lupus erythematosus and provides an update on both topical and systemic treatment options for these patients. Other conditions that utilize the term "lupus" but are not cutaneous lupus erythematosus are also discussed.
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Affiliation(s)
- Elizabeth E. Cooper
- Department of Dermatology, Dell Medical School at the University of Texas, Austin 78701, USA
| | - Catherine E. Pisano
- Department of Dermatology, Dell Medical School at the University of Texas, Austin 78701, USA
| | - Samantha C. Shapiro
- Department of Medicine, Division of Rheumatology, Dell Medical School at the University of Texas, Austin 78701, USA
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10
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Vishwajeet V, Chatterjee D, Saikia UN, Mahajan R, Radotra B, Handa S, De D. Bullous lesions in patients with cutaneous lupus erythematosus: A clinicopathologic study. J Am Acad Dermatol 2021; 85:1641-1643. [PMID: 33421476 DOI: 10.1016/j.jaad.2020.12.060] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2020] [Revised: 12/19/2020] [Accepted: 12/25/2020] [Indexed: 11/19/2022]
Affiliation(s)
- Vikarn Vishwajeet
- Department of Histopathology, Post Graduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - Debajyoti Chatterjee
- Department of Histopathology, Post Graduate Institute of Medical Education and Research (PGIMER), Chandigarh, India.
| | - Uma Nahar Saikia
- Department of Histopathology, Post Graduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - Rahul Mahajan
- Department of Dermatology, Post Graduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - Bishan Radotra
- Department of Histopathology, Post Graduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - Sanjeev Handa
- Department of Dermatology, Post Graduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - Dipankar De
- Department of Dermatology, Post Graduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
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Konstantinov NK, Pearson DR. Systemic Lupus Erythematosus: Considerations in Diagnosis and Management for the Inpatient Dermatologist. CURRENT DERMATOLOGY REPORTS 2020. [DOI: 10.1007/s13671-020-00312-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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12
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Torres Saavedra FA, Campo LR, Mendez MV, Barreneche NM, Suaza GAV, Restrepo JDR, Martinez-Gomez M. Bullous lupus as the first manifestation of systemic lupus erythematosus in the pediatric population: A diagnostic challenge in daily practice. Lupus 2020; 29:1937-1942. [PMID: 32842868 DOI: 10.1177/0961203320950814] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
INTRODUCTION In the GLADEL cohort, the bullous lupus (BSLE) prevalence was 0.41%. However, literature on pediatric BSLE is scarce. This study described the clinical, histological, and immunological characteristics and the treatment response in a series of children with BSLE as the first clinical manifestation of pediatric SLE. METHODS The clinical, histological, and immunological characteristics of a series of 5 cases of BSLE between 2010-2019 from two reference centers in Colombia were analyzed. RESULTS All cases had bullous lesions that resolved with residual hypopigmentation. One had a focal seizure, and another arthritis with thrombocytopenia. Two had transient proteinuria with normal urinalysis. Anti-nuclear antibody titers ranged from 1:160 to 1:2560, and four were anti-dsDNA (+). Five patients had anti-RNP antibodies, and four anti-Sm antibodies. All had low C3, and 80% low C4 counts; 80% had erythrocyte sedimentation rate (ESR) ≥20 mm/hour and 60% had C-reactive protein (CRP) ≥0.5 mg/dL. All patients responded to glucocorticoids and dapsone. Histology reports and direct immunofluorescence (DIF) test showed subepidermal blisters with neutrophils in the papillary dermis and linear deposits of Igs/complement proteins in 80% of the skin biopsies. IgG/IgM was present in 5 samples. IgA was positive in 60% and C3 in 80%. CONCLUSIONS In this pediatric series, BSLE tends to have a monophasic behavior associated with neuropsychiatric, skeletal, and hematological involvement in 40% of the patients, and with good prognosis.
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Affiliation(s)
- Fabio Andrés Torres Saavedra
- Rheumatology Group GRUA, Department of Internal Medicine, Facultad de Medicina, Universidad de Antioquia, Medellín, Colombia.,Hospital Universitario San Vicente Fundación, Medellín, Colombia
| | - Lyna Ramirez Campo
- Rheumatology Group GRUA, Department of Internal Medicine, Facultad de Medicina, Universidad de Antioquia, Medellín, Colombia.,Hospital Universitario Fundación Valle del Lili, Cali, Colombia
| | - Monica Velasquez Mendez
- Rheumatology Group GRUA, Department of Internal Medicine, Facultad de Medicina, Universidad de Antioquia, Medellín, Colombia.,Hospital Universitario San Vicente Fundación, Medellín, Colombia
| | - Natalia Mejia Barreneche
- Hospital Universitario San Vicente Fundación, Medellín, Colombia.,Dermatological Research Center CIDERM, Service of Dermatology, Facultad de Medicina, Universidad de Antioquia, Medellín, Colombia
| | - Gloria Andrea Vargas Suaza
- Hospital Universitario San Vicente Fundación, Medellín, Colombia.,Dermatological Research Center CIDERM, Service of Dermatology, Facultad de Medicina, Universidad de Antioquia, Medellín, Colombia
| | - Juan David Ruiz Restrepo
- Hospital Universitario San Vicente Fundación, Medellín, Colombia.,Dermatological Research Center CIDERM, Service of Dermatology, Facultad de Medicina, Universidad de Antioquia, Medellín, Colombia
| | - Manuel Martinez-Gomez
- Hospital Universitario San Vicente Fundación, Medellín, Colombia.,Dermatological Research Center CIDERM, Service of Dermatology, Facultad de Medicina, Universidad de Antioquia, Medellín, Colombia
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Bullous Lupus: An Atypical Case of Refractory Disease in a Patient with Sulfa Allergy. Case Rep Rheumatol 2020; 2020:8873337. [PMID: 32802547 PMCID: PMC7403923 DOI: 10.1155/2020/8873337] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2020] [Revised: 07/14/2020] [Accepted: 07/14/2020] [Indexed: 11/30/2022] Open
Abstract
Bullous systemic lupus erythematosus (BSLE) is a rare cutaneous autoimmune disorder characterized by rapid, widespread vesiculobullous lesions in patients with Systemic Lupus Erythematosus (SLE). BSLE can present as the initial manifestation of SLE and may be a marker of severe disease. In this case report, we present a case of a 22-year-old African American woman with BSLE and impaired renal function with subsequent nephrotic range proteinuria concerning for lupus nephritis and autoimmune hemolytic anemia, refractory to systemic corticosteroids, immunoglobulin, and mycophenolate mofetil, requiring dapsone after careful desensitization due to prior history of angioedema with sulfa drugs. This case highlights the importance of the prompt recognition of BSLE as the initial manifestations of SLE and illustrates the association of BSLE with severe disease and the benefit of concomitant use of dapsone with corticosteroids and other immunosuppressant drugs, even in patients with a history of sulfa allergy.
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Tintle SJ, Cruse AR, Brodell RT, Duong B. Classic Findings, Mimickers, and Distinguishing Features in Primary Blistering Skin Disease. Arch Pathol Lab Med 2019; 144:136-147. [DOI: 10.5858/arpa.2019-0175-ra] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Context.—
Blistering diseases comprise a large group of clinically polymorphic and sometimes devastating diseases. During the past few decades, we have developed an elegant understanding of the broad variety of blistering diseases and the specific histopathologic mechanism of each.
Objective.—
To review examples of the classic findings of specific blistering diseases and emphasize the importance of considering unrelated conditions that can mimic the classic finding.
Data Sources.—
This article combines data from expert review, the medical literature, and dermatology and pathology texts.
Conclusions.—
We have chosen several common examples of classic blistering diseases that are mimicked by other cutaneous conditions to highlight the basic findings in blistering conditions and the importance of clinician-to-pathologist communication.
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Affiliation(s)
- Suzanne J. Tintle
- From the Departments of Dermatology (Drs Cruse and Brodell) and Pathology (Drs Tintle, Cruse, and Brodell), and Affiliate Faculty, Dermatopathology Associates (Dr Duong), University of Mississippi Medical Center, Jackson; and the Department of Dermatology, University of Rochester Medical Center, Rochester, New York (Dr Brodell)
| | - Allison R. Cruse
- From the Departments of Dermatology (Drs Cruse and Brodell) and Pathology (Drs Tintle, Cruse, and Brodell), and Affiliate Faculty, Dermatopathology Associates (Dr Duong), University of Mississippi Medical Center, Jackson; and the Department of Dermatology, University of Rochester Medical Center, Rochester, New York (Dr Brodell)
| | - Robert T. Brodell
- From the Departments of Dermatology (Drs Cruse and Brodell) and Pathology (Drs Tintle, Cruse, and Brodell), and Affiliate Faculty, Dermatopathology Associates (Dr Duong), University of Mississippi Medical Center, Jackson; and the Department of Dermatology, University of Rochester Medical Center, Rochester, New York (Dr Brodell)
| | - Buu Duong
- From the Departments of Dermatology (Drs Cruse and Brodell) and Pathology (Drs Tintle, Cruse, and Brodell), and Affiliate Faculty, Dermatopathology Associates (Dr Duong), University of Mississippi Medical Center, Jackson; and the Department of Dermatology, University of Rochester Medical Center, Rochester, New York (Dr Brodell)
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Alves F, Gonçalo M. Suspected inflammatory rheumatic diseases in patients presenting with skin rashes. Best Pract Res Clin Rheumatol 2019; 33:101440. [PMID: 31585842 DOI: 10.1016/j.berh.2019.101440] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
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.
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Affiliation(s)
- Francisca Alves
- Clinic of Dermatology, University Hospital of Coimbra, Portugal
| | - Margarida Gonçalo
- Clinic of Dermatology, University Hospital of Coimbra, Portugal; Faculty of Medicine, University of Coimbra, Coimbra, Portugal.
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Rutnin S, Chanprapaph K. Vesiculobullous diseases in relation to lupus erythematosus. Clin Cosmet Investig Dermatol 2019; 12:653-667. [PMID: 31564947 PMCID: PMC6732903 DOI: 10.2147/ccid.s220906] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2019] [Accepted: 08/13/2019] [Indexed: 12/13/2022]
Abstract
Vesiculobullous lesions in lupus erythematosus (LE) are a rare cutaneous manifestation of cutaneous and/or systemic LE with variable presentation. While the minor forms of LE-associated vesiculobullous disease may cause disfigurement and discomfort, the severe forms can present with hyperacute reaction and life-threatening consequences. Specific LE and aspecific cutaneous LE are defined by the presence or absence of interface change on histopathology that can be applied to vesiculobullous diseases in relation to LE. However, the diagnosis of LE-associated vesiculobullous diseases remains difficult, due to the poorly defined nosology and the similarities in clinical and immunohistopathological features among them. Herein, we thoroughly review the topic of vesiculobullous skin disorders that can be encountered in LE patients and organize them into four groups: LE-specific and aspecific vesiculobullous diseases, LE-related autoimmune bullous diseases, and LE in association to non-autoimmune conditions. We sought to provide an updated overview highlighting the pathogenesis, clinical, histological, and immunopathological features, laboratory findings, and treatments and prognosis among vesiculobullous conditions in LE.
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Affiliation(s)
- Suthinee Rutnin
- Division of Dermatology, Department of Medicine, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Kumutnart Chanprapaph
- Division of Dermatology, Department of Medicine, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
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17
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Ribero S, Sciascia S, Borradori L, Lipsker D. The Cutaneous Spectrum of Lupus Erythematosus. Clin Rev Allergy Immunol 2018; 53:291-305. [PMID: 28752372 DOI: 10.1007/s12016-017-8627-2] [Citation(s) in RCA: 67] [Impact Index Per Article: 11.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
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.
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Affiliation(s)
- Simone Ribero
- Department of Medical Sciences, Section of Dermatology, University of Turin, Turin, Italy.
| | - Savino Sciascia
- Center of Research of Immunopathology and Rare Diseases- Department of Clinical and Biological Sciences, University of Turin, San Giovanni Hospital, Turin, Italy
| | - Luca Borradori
- Department of Dermatology, University of Bern, Inselspital, Berne, Switzerland
| | - Dan Lipsker
- Dermatologic Clinic, Faculty of Medicine, University of Strasbourg, Strasbourg, France
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18
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Pons-Estel GJ, Quintana R, Alarcón GS, Sacnún M, Ugarte-Gil MF, Pons-Estel BA. A 12-year retrospective review of bullous systemic lupus erythematosus in cutaneous and systemic lupus erythematosus patients. Lupus 2018; 27:1753-1754. [DOI: 10.1177/0961203318776104] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Affiliation(s)
- G J Pons-Estel
- Hospital Provincial de Rosario, Rosario, Santa Fe, Argentina
- Centro Regional de Enfermedades Autoinmunes y Reumáticas (CREAR), Grupo Oroño. Rosario, Santa Fe, Argentina
| | - R Quintana
- Hospital Provincial de Rosario, Rosario, Santa Fe, Argentina
- Centro Regional de Enfermedades Autoinmunes y Reumáticas (CREAR), Grupo Oroño. Rosario, Santa Fe, Argentina
| | - G S Alarcón
- Department of Medicine, Division of Clinical Immunology and Rheumatology, School of Medicine, The University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - M Sacnún
- Hospital Provincial de Rosario, Rosario, Santa Fe, Argentina
| | - M F Ugarte-Gil
- Department of Rheumatology, Hospital Guillermo Almenara Irigoyen. EsSalud, Lima, Perú
- Universidad Científica del Sur, Lima, Perú
| | - B A Pons-Estel
- Hospital Provincial de Rosario, Rosario, Santa Fe, Argentina
- Centro Regional de Enfermedades Autoinmunes y Reumáticas (CREAR), Grupo Oroño. Rosario, Santa Fe, Argentina
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