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subacute cutaneous lupus erythematosus

Etiology: - precipitating factors: a) sunlight b) drug eruption (15%) [2] - hydrochlorothiazide - calcium channel blocker - ACE inhibitor - terbinafine - TNF-alpha inhibitors Epidemiology: 1) 10% of patients with lupus erythematosus 2) young & middle aged individuals 3) uncommon in black & hispanics 4) females > males Pathology: (dermatopathology) 1) liquefaction degeneration of the epidermal basal layer 2) edema of the upper dermis 3) vesicles may be present 4) colloid bodies in the epidermis 5) 40% have immune deposits in the dermal-epidermal junction Clinical manifestations: 1) sudden onset of annular or psoriasiform lesions - crusted margins & central hypopigmentation with annular lesions 2) confluent malar erythema (no subacute cutaneous lupus [2]) 3) generalized erythematous papules or urticaria 4) no follicular plugging 5) no scarring, little atrophy 6) distribution: light exposed areas: shoulders, arms, dorsal aspect of hands, upper trunk 7) non-scarring alopecia 8) periungual telangiectasias 9) tends to burn more than itch 10) patients may have a few of the criteria of SLE a) photosensitivity b) arthralgias c) serositis d) renal disease 11) serious manifestations of SLE are uncommon a) severe vasculitis b) severe CNS disease c) progressive renal disease 12) 50% of patients do not have systemic manifestations of SLE 13) fatigue, malaise 14) arthralgias 15) fever * images [4,5] Laboratory: 1) serology a) anti-Ro (SSA) antibodies (80%) b) anti-La (SSB) antibodies c) low titers of antinuclear antibodies (ANA) d) antibodies against EEA1 (not specific) e) circulating immune complexes 2) skin biopsy Differential diagnosis: 1) dermatomyositis 2) secondary syphilis 3) psoriasis tends to improve with sunlight [2] 4) seborrheic dermatitis 5) tinea corporis Management: 1) sunscreen, protective clothing 2) topical corticosteroids are sometimes helpful 3) systemic therapy a) thalidomide 100-300 mg PO QD - very effective for skin lesions b) hydroxychloroquine 400 mg PO QD, plus (if needed) quinacrine hydrochloride 100 mg PO QD

Related

anti-nuclear antibody (ANA) in serum dermatomyositis hydroxychloroquine (Plaquenil) psoriasis quinacrine; mepacrine (Atrabine) seborrheic dermatitis; seborrhea; cradle cap (infants) SSA/Ro Ab in serum SSB/La Ab in serum syphilis thalidomide (Thalamid, Corronarobetin) Tinea corporis

General

cutaneous lupus erythematosus

References

  1. Color Atlas & Synopsis of Clinical Dermatology, Common & Serious Diseases, 3rd ed, Fitzpatrick et al, McGraw Hill, NY, 1997, pg 350-51
  2. Medical Knowledge Self Assessment Program (MKSAP) 15, 16, 17, 18, 19. American College of Physicians, Philadelphia 2009, 2012, 2015, 2018, 2022.
  3. Walling HW, Sontheimer RD. Cutaneous lupus erythematosus: issues in diagnosis and treatment. Am J Clin Dermatol. 2009;10(6):365-81 PMID: 19824738
  4. Lin J, James WD (images) Medscape: Subacute Cutaneous Lupus Erythematosus (SCLE) http://emedicine.medscape.com/article/1065657-overview
  5. DermNet NZ. Cutaneous lupus erythematosus (images) http://www.dermnetnz.org/immune/cutaneous-lupus.html
  6. Lowe GC, Henderson CL, Grau RH, Hansen CB, Sontheimer RD. A systematic review of drug-induced subacute cutaneous lupus erythematosus. Br J Dermatol. 2011 Mar;164(3):465-72 PMID: 21039412
  7. Grunhagen CM, Fored CM, Linder M, Granath F, Nyberg F. Subacute cutaneous lupus erythematosus and its association with drugs: a population-based matched case-control study of 234 patients in Sweden. Br J Dermatol. 2012 Aug;167(2):296-305. Epub 2012 Jul 5. PMID: 22458771