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For further information, see CMDT PART 6-15: CUTANEOUS LUPUS ERYTHEMATOSUS

Key Features

Essentials of Diagnosis

  • Localized violaceous red plaques, usually on the head (discoid lupus erythematosus) or the trunk (chronic cutaneous lupus erythematosus)

  • Scaling, follicular plugging, atrophy, dyspigmentation, and telangiectasia of involved areas

  • Photosensitivity

  • Distinctive histology

General Considerations

  • Two most common forms of chronic cutaneous lupus erythematosus (CCLE)

    • Chronic scarring lesions (discoid lupus erythematosus [DLE])

    • Erythematous non-scarring red plaques (subacute cutaneous lupus erythematosus [SCLE])

  • Ten percent of patients with systemic lupus erythematosus (SLE) have discoid skin lesions, and 5% of patients with discoid lesions have SLE

  • The disease is persistent but not life endangering unless systemic lupus supervenes, which is uncommon

  • Treatment with antimalarials is effective in perhaps 60% of cases

  • Some medications may induce SCLE with a positive Ro/SSA, most commonly

    • Hydrochlorothiazide

    • Calcium channel blockers

    • Angiotensin-converting enzyme (ACE) inhibitors

    • Tumor necrosis factor inhibitors

    • Terbinafine

Clinical Findings

Symptoms and Signs

  • Usually mild

  • DLE lesions

    • Consist of violaceous red, well-localized, single or multiple plaques

    • Measure 5–20 mm in diameter

    • Usually appear on the face, scalp, and external ears (conchal bowl)

    • Significant permanent hair loss may occur on scalp

    • Other characteristics

      • Atrophy

      • Telangiectasia

      • Central depigmentation or scarring

      • A hyperpigmented rim

      • Follicular plugging

  • SCLE lesions

    • Are erythematous annular or psoriasiform plaques

    • Measure up to several centimeters in diameter

    • Favor the upper chest and back

Differential Diagnosis

  • Psoriasis

  • Seborrheic dermatitis

  • Acne rosacea

  • Lupus vulgaris (cutaneous tuberculosis)

  • Sarcoidosis

  • Bowen disease (squamous cell carcinoma in situ)

  • Polymorphous light eruption

  • Lichen planopilaris

Diagnosis

Laboratory Tests

  • In patients with DLE, the possibility of SLE should be considered if the following findings are present:

    • Positive antinuclear antibody (ANA)

    • Other positive serologic studies (eg, anti-double stranded DNA or anti-Smith antibody)

    • High erythrocyte sedimentation rate

    • Proteinuria

    • Hypocomplementemia

    • Widespread lesions (not localized to the head)

    • Nailfold changes (dilated or thrombosed nailfold capillary loops)

    • Arthralgia with or without arthritis

  • Patients with marked photosensitivity and symptoms otherwise suggestive of lupus may have negative ANA tests but are positive for antibodies against Ro/SSA or La/SSB (SCLE)

Diagnostic Procedures

  • Skin biopsy used to confirm diagnosis

Treatment

Medications

General measures

  • Use photoprotective clothing and broad-spectrum sunblock with SP 30 or more

  • UVA coverage is essential in photosensitive patients

  • Avoid using drugs that are potentially photosensitizing (eg, doxycycline) when possible

  • Caution: Do not use any form of radiation therapy

Local treatment

  • High-potency corticosteroid creams applied each night and covered with airtight plastic film (eg, Saran Wrap) or Cordran tape; or ...

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