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6-42: Cutaneous Lupus Erythematosus

Nathan W. Rojek; Scott Worswick; Kanade Shinkai; Lindy P. Fox

ESSENTIALS OF DIAGNOSIS

ESSENTIALS OF DIAGNOSIS

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

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

  • Photosensitivity.

  • Distinctive histology.

GENERAL CONSIDERATIONS

Common forms of cutaneous lupus include chronic cutaneous lupus erythematosus (CCLE), of which discoid lupus erythematosus (DLE) is the most common subtype, and erythematous nonscarring red plaques of subacute cutaneous lupus erythematosus (SCLE). All occur most frequently in photoexposed areas (eFigure 6–82). Permanent hair loss and loss of pigmentation are common sequelae of discoid lesions.

eFigure 6–82.

Malar and facial erythema and scale in a 22-year-old woman with a flare of acute cutaneous lupus. This patient has had SLE since age 17 and the flare occurred after extended sun exposure. Note how the flare is not just on the malar area. (Reproduced with permission from Richard P. Usatine, MD, in Usatine RP, Smith MA, Mayeaux EJ Jr, Chumley HS. The Color Atlas and Synopsis of Family Medicine, 3rd ed. McGraw-Hill, 2019.)

A patient with malar and facial erythema exhibits red erythematous patches on the forehead, eyebrows, cheeks, nose, and lips. There are some open sores within the erythema.
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SLE is discussed in Part 22. Patients with SLE frequently have acute cutaneous lupus erythematosus (ACLE) lesions but may also have CCLE or SCLE lesions. Ten percent of patients with SLE have discoid skin lesions, and 5% of patients with discoid lesions have SLE.

CLINICAL FINDINGS

A. Symptoms and Signs

Symptoms are usually mild. In DLE, the lesions consist of violaceous-to-red, well-defined, single or multiple plaques, 5–20 mm in diameter, usually on the face, scalp, and external ears (conchal bowl) (eFigure 6–83) (eFigure 6–84). In discoid lesions, there is atrophy, telangiectasia, central depigmentation or scarring, a hyperpigmented rim, and follicular plugging. On the scalp, significant permanent hair loss may occur. In SCLE, the lesions are erythematous annular or psoriasiform plaques up to several centimeters in diameter and favor the upper chest and back (eFigure 6–85).

eFigure 6–83.

Discoid lupus erythematosus of the arm. (Used, with permission, from Lindy Fox, MD).

A patient with extensive plaques over the upper arm. The lesions are irregular in shape and size, depigmented to a pale pink at the center, and hyperpigmented to a dark brown along the borders.
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eFigure 6–84.

Discoid lupus of the face and ear in a darkly pigmented patient. (Used with permission, from Lindy Fox, MD.)

A patient with discoid lupus exhibits dark red lesions clustered over the ears and the side of the face.
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eFigure 6–85.

Subacute cutaneous lupus erythematosus: erythematous nonscarring red plaques on the back. (Used, with permission, from Lindy Fox, MD).

Three large, oval shaped lesions on a patient’s back are pale pink with red, demarcated borders.
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B. Laboratory Findings

In patients with DLE, SLE should be considered if the following findings are present: positive ANA, or other serologic studies (eg, anti-double-stranded DNA or anti-Smith antibody), high ESR, proteinuria, hypocomplementemia, widespread lesions (not localized to the head), nail ...

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