Recognition and Management of Cutaneous Connective Tissue Diseases

Connective tissue diseases (CTDs) encompass a broad spectrum of clinical presentations that involve multidisciplinary management. Cutaneous findings are common in CTD and careful examination of these features aids in appropriate diagnosis and subsequent evaluation. Thorough work-up of CTD is crucial to properly identify disease subtypes and systemic involvement. Management plans can be developed based on diagnosis and systemic manifestations of disease. Disease management often requires treatment with pharmacotherapies with potential for toxicities, further underscoring the importance of diagnostic accuracy in this patient population. Evolving research strives to better elucidate the pathogenic mechanisms of CTDs allowing for more targeted treatment modalities.

The Koebner phenomenon on tattoos and piercings in a patient with cutaneous lupus: a case report and review of the literature

The Koebner phenomenon is associated with cutaneous lupus erythematosus (CLE). A 20-year-old woman with a 10-year history of systemic lupus, treated with hydroxychloroquine and methotrexate, presented with features of chronic discoid lupus erythematosus (DLE) on the scalp, at the site of ear piercings, and on the temporal bone at the site of trauma from her jewelry. She also had subacute CLE (SCLE) lesions on old black tattoos. Histology and direct immunofluorescence confirmed CLE. We reviewed 13 cases of Koebner phenomenon on tattoos in patients with CLE (seven men, median age: 31.5 years) and none after piercings. Lesions developed within 1 week to 16 years after tattooing. Lesions may be isolated, precede, or be associated with other CLE lesions. They can appear secondarily on the tattoo. There is no specific color affinity, but cases have shifted from red to black, possibly when mercury was withdrawn from red inks. CLE on tattoos is a rare phenomenon that more often presents with DLE features than SCLE. Patients should be warned of the potential risk of developing lesions on tattoos. Immunosuppressive treatment needs to be taken into account if a patient wishes to get a tattoo. However, tattooing is not associated with severe complications.

Generalized Discoid Lupus Erythematosus as the Presenting Sign of Small Cell Lung Carcinoma

A 46-year-old woman with a 30 pack-year smoking history presented with a worsening eruption on the left cheek that failed to improve with metronidazole gel. The cutaneous eruption spread to most of her face and did not respond to a brief tapering course of prednisone. During the initial evaluation at our institution, approximately 6 weeks after the onset of the cutaneous eruption, the patient had erythematous, crusted plaques on her face and scalp (Figure 1A); they were also present on the V-area of the anterior aspect of the neck and upper region of the chest, the shoulders, and the arms, with isolated lesions on the trunk and legs. Her oral mucosa had erythematous erosions on the hard palate and gingivae. A review of systems revealed pain and burning of her skin lesions, but no muscle weakness or other systemic clinical manifestations. The differential diagnosis included autoimmune connective tissue disease, pemphigus foliaceous, sarcoidosis, lichen planus, phototoxic drug eruption, and eczema herpeticum.

Drug-induced lupus erythematosus

Drug-induced lupus erythematosus (DI-LE) is defined as an entity characterized by clinical manifestations and immunopathological serum findings similar to those of idiopathic lupus but which is temporally related to drug exposure and resolves after withdrawal of the implicated drug. Similarly to idiopathic lupus, DI-LE can be divided into systemic LE, subacute cutaneous LE (SCLE), chronic cutaneous LE (CCLE) and cutaneous LE tumidus. DI-SCLE is the most frequent variant of drug-induced cutaneous LE and presents mainly with annular-polycyclic lesions; the clinical picture is often widespread, with involvement of the lower legs that are usually spared in idiopathic SCLE. ANA and anti-Ro/SSA antibodies are typically present, whereas antihistone antibodies are uncommonly found. We have recently addressed the question whether DI-SCLE differs significantly from its idiopathic counterpart by virtue of clinical features and, based on our findings, we have suggested that the frequent occurrence of malar rash and bullous, erythema multiforme-like and vasculitic manifestations can be regarded as the hallmark of DI-SCLE. In contrast, the histology is not a useful diagnostic criterion for DI-SCLE, considering that the typical pattern of lichenoid interface dermatitis is seen only in the early stage of disease and tissue eosinophilia does not represent a differentiating histopathological feature. DI-CCLE and DI-LE tumidus, albeit possibly misdiagnosed, are rarely observed and are characterized by classic discoid lesions and erythematous-oedematous plaques on sun exposed areas, respectively. Management of DI-LE is based on the discontinuation of the offending drug; topical and/or systemic corticosteroids and other immunomodulating/immunosuppressive agents should be reserved for resistant cases.

Ethnic and geographical differences in systemic lupus erythematosus: an overview

Systemic lupus erythematosus (SLE) is one of the most heterogeneous autoimmune disorders known. There is production of a variety of autoantibodies and patients present with a wide range of symptoms due to multiple organ involvement by the disease process. The underlying cause is not fully understood but it may involve genetic and environmental factors. It is interesting to note that while SLE is found worldwide, it is more commonly found in some countries, and within a country certain ethnic groups appear to be more susceptible to develop this condition than others. Additionally, the presentation and course of SLE appear highly variable between patients of different ethnic origins. For example, African-Americans and Orientals are believed to have a more severe disease than Caucasian whites. But are these ethnic and geographical differences real? If yes, they may provide investigators insight into the underlying pathoaetiology of this condition and pave the way to future research directions in lupus.

Role of apoptosis stimulus factor and its ligand in the induction of apoptosis in some ultraviolet induced diseases

BACKGROUND

Fas (factor of apoptosis stimulus) is one of the death receptors belonging to the tumor necrosis factor superfamily of receptors. When bound to its ligand, Fas-ligand (Fas-L), it triggers apoptosis. Ultraviolet (UV) rays can induce keratinocyte apoptosis by Fas/Fas-L interaction.

AIM

The aim of the study was to evaluate the role of Fas and Fas-L in basal cell carcinoma (BCC) as an example of malignant neoplasm and discoid lupus erythematosus (DLE) as a benign skin disease, which are both induced by UV.

SUBJECTS AND METHODS

The study included 20 cases of BCC, 20 cases of DLE and ten control cases. All biopsies of BCC and DLE were examined histopathologically. They were also examined for Fas and Fas-L by PCR.

RESULTS

In BCC, apoptosis was detected in 60 percent of cases. Fas was found to be positive in only one case and it was found to be negative in the other 19 cases (95 %). Fas-L was found to be positive in 100 percent of cases. In DLE, apoptosis was detected in 90 percent of cases. Fas was positive in 80 percent of cases, Fas-L was positive in 90% of cases.

CONCLUSION

Over-expression of Fas-L and lack of expression of Fas by tumor cells together with other factors act in favor of BCC by helping its survival and progression. Also, it seems that Fas/Fas-L interaction plays a critical role in the apoptosis seen in cases of DLE and hence in the pathogenesis of DLE.

Kutaner Lupus erythematodes

Cutaneous lupus erythematosus (CLE) is a heterogenous disorder with a wide range of skin manifestations. Therefore, it has been difficult to develop a unifying concept for classifying CLE from the dermatologic perspective in the past. In 2004, the classification system was updated and includes now acute CLE (ACLE), subacute CLE (SCLE), chronic CLE (CCLE), and intermittent CLE (ICLE). Additional rarely described variants are not listed as separate entities but are included in the classical forms. Diagnosis of the different subtypes of CLE is made by considering genetic, clinical, histopathologic, and immunoserologic findings, with a systematic analysis of individual criteria. In the past years, the etiology and pathogenesis of CLE has been subject of intensive research and it has been shown by several groups that exogenous factors, such as ultraviolet light and drugs, can induce CLE. The first part of this review will enable the reader to identify the various clinical manifestations of CLE and to employ characteristic criteria to assess differential diagnostic considerations.

Association between Discoid Lupus erythematosus and Cigarette Smoking

BACKGROUND

Discoid lupus erythematosus (DLE) is a chronic cutaneous disease affecting photoexposed areas and has also been associated with cigarette smoking.

OBJECTIVE

To evaluate the association between smoking and DLE.

METHODS

A case-control study was performed involving 57 cases diagnosed with DLE and 215 healthy controls.

RESULTS

A higher smoking prevalence was noted in DLE cases (84.2%) than controls (33.5%), and the odds ratio adjusted for gender, age and ultraviolet index in the city of origin was 14.4 (95% confidence interval 6.2-33.8; multiple logistic regression, p < 0.01). The cumulative smoking exposure was not related to premature DLE development. At the beginning of the disease, smokers had more extensive involvement than nonsmokers; compromise of the upper arms was statistically related to smoking.

CONCLUSION

Cigarette smoking was statistically associated with DLE development. Other studies are needed in order to evaluate the effects of smoking cessation on the course of disease.

Hyperkeratotic nail discoid lupus erythematosus evolving towards systemic lupus erythematosus: therapeutic difficulties

Nail changes occur in about 25% of systemic lupus erythematosus (SLE) cases. Onycholysis has been reported as the most frequent abnormality in SLE. Nailbed hyperkeratosis may be observed in both SLE and discoid lupus erythematosus (DLE). Involvement of the nail apparatus in DLE is extremely uncommon and never restricted to it. We report on a patient in whom the clinical features on the proximal nailfold were similar to those observed on the skin of a patient with typical DLE. This has, to the best of our knowledge, not yet been reported. The patient also exhibited a very distinctive prominent subungual hyperkeratosis. Interestingly, the patient developed biological alterations suggesting a systematization of the disease. Only a combination of systemic corticoids, retinoids and antimalarials was able to achieve nail improvement and this partial resistance to therapy may be explained by the very unusual subungual hyperkeratosis.

Thalidomide for treatment of severe generalized discoid lupus lesions in two patients with systemic lupus erythematosus

We describe 2 patients with systemic lupus erythematous whose widespread discoid lupus erythematosus was unresponsive to systemic steroids and antimalarial agents. They showed dramatic improvement to thalidomide at a dose of 300 mg/d, with maximum benefit achieved within 15 weeks of therapy. Dosages of 50 to 100 mg/d were effective in maintaining remission for 1 year. However, thalidomide-induced neuropathy was observed in both cases.

Systemic lupus erythematosus in childhood

Systemic lupus erythematosus is a disease of immune dysregulation that strikes approximately 1 in 2000 individuals. The usual patient is a young woman of child-bearing age; however, this illness affects patients of all ages, ethnic backgrounds, and both sexes. Twenty percent of all cases of lupus are diagnosed during the first two decades of life. Perhaps the most essential point in treating a child with lupus is to be aware and concerned about how to deliver treatment to a patient in the middle of their physical, intellectual, and emotional development.

Comparison of anti 60 and 52 kDa SS-A/Ro antibodies in the pathogenesis of cutaneous lupus erythematosus

Anti SS-A/Ro antibodies are involved in the pathogenesis of cutaneous lupus erythematosus (CLE) in a part through antibody dependent cellular cytotoxicity (ADCC). However, it is still obscure which and how anti 60 and anti 52 kDa Ro antibodies are involved. To address the issue, we examined both types of anti Ro antibodies of sera from patients with systemic LE (SLE) or discoid LE (LE). The titer of anti 60 kDa antibody in SLE was significantly much higher than that of DLE or control. The positive ratio of DLE showed more higher tendency than control, but it was not statistically significant. The similar tendency was observed in the titer of anti 52 kDa antibody. An association between the anti 60 kDa antibody and the anti 52 kDa antibody was statistically significant in SLE patients. Although the relative index (RI) was statistically significant in DLE, they included many negative sera, which biased the statistics. Both anti 60 kDa antibody and anti 52 kDa antibody could induce significant ADCC of ultraviolet B (UVB) light-irradiated keratinocytes from neonatal foreskins and/or normal adults, in which anti 60 kDa antibody showed higher cytotoxicity than anti 52 kDa antibody. The autologous combination studies (keratinocytes and monospecific anti 60 or anti 52 kDa antibody from patients) suggested anti 60 kDa antibody was more potent to induce ADCC activity than anti 52 kDa antibody. Taken together, it is likely that anti 60 kDa antibody dependent keratinocyte damage plays more significant role in the pathogenesis of SLE skin lesions than anti 52 kDa dependent damage. However, both type antibodies seemed to have little contribution to the pathogenesis of DLE skin lesion.

Discoid lupus erythematosus developing in areas where fragments of windshield glass had become embedded in the skin

We observed a 26-year-old female patient with discoid lupus erythematosus on her left cheek skin, where fine fragments of windshield glass had been embedded in an automobile accident 8 years previously. She gradually developed general fatigue, morning stiffness of fingers and anti-nuclear antibody. As an etio-pathogenesis of this patient, we speculate that a long exposure to quartz (silica) could give rise to discoid lupus erythematosus in only local damaged areas and at the same time induce systemic immunological changes in some genetically restricted persons; such as production of anti-nuclear antibody. Silica has multi-potential biological effects, especially on immunological functions.

Report of an association between discoid lupus erythematosus and smoking

Smoking has been shown to be associated with many medical disorders, including many involving the skin. While preliminary studies suggest a modest association between smoking and systemic lupus erythematosus, epidemiologic data on discoid lupus erythematosus (DLE) and smoking are lacking. To study this relationship, we examined current smoking habits in two unique patient populations with DLE. One group was compared with matched dermatology patients while the second group was compared with the corresponding statewide population. For both groups, the current smoking prevalence was much higher than that of the comparison population. For the control-matched group of DLE patients, smoking prevalence was found to be significantly greater than that of controls (odds ratio 12.2; p = 0.001). We therefore propose that smoking is a risk factor for development of DLE.

Cutaneous lupus erythematosus during the neonatal and childhood periods

Cutaneous lupus erythematosus may be related to maternal autoantibody production in the neonatal lupus syndrome, or may occur later in childhood, with or without findings of systemic lupus erythematosus (SLE). In the first section, we will discuss the transient, passively transferred neonatal disease, and in the second, we will discuss the persistent, actively acquired forms of lupus erythematosus in childhood.

Discoid lupus erythematosus

Discoid lupus erythematosus is a manifestation of chronic cutaneous lupus erythematosus with a small risk of systemic involvement. In this review article, the role of predisposing factors such as haplotype, hormones, antibodies and sunlight are discussed. The clinical features, including variants and associations, and management options are presented.

The sequelae of chronic cutaneous lupus erythematosus

Eighty-six patients with chronic cutaneous lupus erythematosus were examined. Twelve of these also suffered from systemic lupus erythematosus. The mean duration of the disease was 15.1 years. Fifty-seven percent of patients (49/86) had scarring of some kind producing destruction and deformity; 47% (41/86) had scarring of glabrous surfaces and 35% (30/86) had scarring alopecia; 35% (30/86) were also suffering from pigmentary disturbance. The details and treatment of these and other non-scarring sequelae are discussed.

Experimental reproduction of skin lesions in lupus erythematosus by UVA and UVB radiation

Sunlight is a well-established factor in the induction and exacerbation of lupus erythematosus. Although experimental reproduction of lupus erythematosus lesions with wavelengths shorter than 320 nm was demonstrated previously, the effect of wavelengths longer than 320 nm was not investigated adequately. In this study we show that the action spectrum of lupus erythematosus reaches into the UVA region. A total of 128 patients with lupus erythematosus underwent phototesting with the use of polychromatic UVB and long-wave UVA. Subsets of the disease consisted of discoid lupus erythematosus (n = 86), subacute cutaneous lupus erythematosus (n = 22), and systemic lupus erythematosus (n = 20). Skin lesions clinically and histologically compatible with lupus erythematosus were induced in 64% of patients with subacute cutaneous lupus erythematosus, 42% of patients with discoid lupus erythematosus, and 25% of patients with systemic lupus erythematosus. The action spectrum of the induced lesions was within the UVB range in 33% of patients, in the UVA range in 14%, and in the UVB and UVA range in 53%. In positive test reactions patchy dark erythema and urticarial plaques developed within a few days. In some patients typical discoid lesions persisted for months.

[Photobiology of lupus erythematosus]

Photosensitivity is one of the criteria of the American Rheumatism Association for the diagnosis of systemic lupus erythematosus. Although UV irradiation is a major factor in the pathogenesis of photosensitive cutaneous lupus erythematosus, so far the exact pathomechanism is unknown. The following review presents historical, clinical and experimental data on the photobiology of cutaneous lupus erythematosus.

Chronic cutaneous lupus erythematosus

Chronic cutaneous LE is a diverse disease, characterized by predominantly cutaneous disease with few systemic complications. Discoid lesions are commonly seen, but they are not specific for chronic cutaneous LE. These scarring and disfiguring changes are also present in neonatal LE, SLE, and complement deficiency LE. Because definitive diagnosis cannot be made by cutaneous examination alone, all patients should initially be evaluated for systemic disease. A small percentage of patients with chronic cutaneous LE will ultimately develop SLE, and therefore, patients should be re-evaluated periodically. The pathogenesis of the cutaneous lesions is not definitively known. There is suggestive evidence implicating T-cell mediated injury, especially in discoid LE. Antibody-dependent cellular cytotoxicity may also play a significant role in cellular damage in subacute cutaneous LE and neonatal LE, especially in the presence of anti-Ro antibody. Immunoglobulin deposition in association with membrane attack complex, has been associated with epidermal injury in some cases. Treatment of chronic cutaneous LE is largely symptomatic and nonspecific, focusing on reduction of inflammation. Further knowledge of pathogenesis will, hopefully, provide for specific immunologic therapy.

Discoid lupus erythematosus-like lesions in an autosomal form of chronic granulomatous disease

Chronic granulomatous disease (CGD) is characterized by a bactericidal defect involving the oxidative metabolism of polymorphonuclear leukocytes (PML) and is most often transmitted as an X-linked trait. The cutaneous features of this disorder include infections and lupus-like rashes. These have been described in female carriers as well as in males with the disease. Two cases of siblings presenting an autosomal form of CGD syndrome, with lupus-like cutaneous manifestations, are reported here.

Lupus erythematosus in childhood

Lupus erythematosus in childhood comprises the following distinctive lupus subsets: neonatal lupus erythematosus, systemic lupus erythematosus, discoid lupus erythematosus, subacute cutaneous lupus erythematosus, complement deficiency syndromes with subacute cutaneous lupus lesions, and lupus panniculitis. The clinical features and pathogeneses of each of these lupus syndromes is discussed in this review.

Systemic lupus erythematosus in patients with chronic cutaneous (discoid) lupus erythematosus. Clinical and laboratory findings in seventeen patients

The presence of the discoid lupus erythematosus (DLE) skin lesion in a patient with systemic lupus erythematosus (SLE) has been suggested to be a marker of less frequent and less severe renal disease. The clinical and laboratory features of seventeen patients who were seen in a dermatology practice and who had DLE as a manifestation of SLE (DLE-SLE) are reported. DLE preceded the diagnosis of SLE in eight patients. In six patients, the onset was concurrent, whereas in three the SLE was present prior to the discoid skin lesions. Five of the patients had lesions of subacute cutaneous lupus erythematosus (SCLE), and Raynaud's phenomenon occurred in eight patients. Clinical evidence of a renal abnormality was present in six patients (hematuria in three, proteinuria in five, and abnormal renal function in two). Antibodies to nuclear and/or cytoplasmic components were abnormal in all patients. Antibody subsets did not correlate well with clinical findings; only half of those with Raynaud's phenomenon demonstrated a positive ribonucleoprotein; only one patient with SCLE demonstrated anti-Ro (SSA) antibody, but four of the six patients with a renal abnormality had an elevated anti-native deoxyribonucleic acid antibody titer. The cutaneous lesions were eventually widespread in all patients, although two had initial disease that was localized to the head and neck. Although renal disease occurs in this group, it is less common and usually milder than in previous groups of unselected SLE patients.

Discoid lupus erythematosus-like lesions and stomatitis in female carriers of X-linked chronic granulomatous disease

The skin and oral mucosa were studied in an unselected series of carriers of x-linked chronic granulomatous disease, a hereditary condition in which phagocytic cells display a pronounced functional defect. Three carriers had discoid lupus erythematosus (DLE)-like skin lesions which histopathologically were consistent with DLE of the hypertrophic and profundus type. Four patients had experienced photosensitivity in childhood. Seven patients had recurrent aphthous-like stomatitis which should be distinguished from the recurrent aphthous stomatitis seen in otherwise healthy individuals. The remarkably high incidence of DLE-like symptoms in heterozygous carriers might be related to the presence of mixed populations of defective and normal phagocytes. The variable expression of skin symptoms may be related to uneven distribution of abnormal and normal phagocytes. Female patients with these clinical symptoms, especially the combination of DLE-like skin lesions and aphthous-like stomatitis, should be suspected of being carriers of chronic granulomatous disease and studies of phagocyte function in vitro should be performed, since the diagnosis of the carrier state is of utmost importance for genetic counselling before pregnancy.

Lupus erythematosus

Lupus erythematosus (LE) is a multisystem disease. Genetic predisposition, altered immunity, hormones, drugs, viruses, and ultraviolet light all may play a role in etiology. A wide range of cutaneous lesions occur, and variants such as subacute cutaneous LE, complement-deficient LE, and neonatal LE have recently been emphasized. Management of the LE patient, including appropriate diagnostic studies and therapy relevant to the dermatologist, is discussed in the review.

Hypercalcemia and discoid lupus erythematosus-like syndrome associated with renal cell carcinoma

Multiple systemic manifestations of renal cell carcinoma have been reported. The first case of a discoid lupus erythematosus-like syndrome and the third reported case of hypercalcemia associated with an elevated serum prostaglandin E2 level in a patient with renal cell carcinoma is presented herein.