CHRONIC DISCOID LUPUS ERYTHEMATOSUS
Presented by Henry Foong FRCP,
on July 1, 2002
Consultant Dermatologist, Foong Skin Specialist Clinic, Ipoh, Malaysia
Mr T F is a 46-year-old man who presented with a photosensitive skin eruption since 1987. He initially presented with oral lesions which was seen by a dental surgeon. The lesions were biopsied and was told to have lichen planus. He was then treated with topical kenalog in orabase. He didnt seem to improve and subsequently developed more lesions on the face, upper chest and exposed areas of the forearms and hands. He went on to consult other practitioners including dermatologists. He improved with oral prednisolone but flared up on reducing the dose. On one occasion, he was treated with oral plaquenil 200mg bd (hydroxychloroquine) but didnt seem to improve much. He then stopped taking the plaquenil.
Apart from photosensitivity, he did not have polyarthralgia or other constitutional symptoms. He had no Raynauds.
He works on a plantation and is chronically exposed to sun. He is also known to have a FDE (fixed drug eruption) to tetracyclines.
Examination showed multiple well defined raised thick hypertrophied erythematous plaques of irregular shape and sizes on the back of forearms and hands, upper back and neck. Those on the hands were markedly scarred and hypertrophied. There were also erosive changes on the lower lip. Streaks of whitish lacy-like pattern were noted on the inner buccal mucosa. Rest of examination was unremarkable.
Chronic Discoid Lupus Erythematosus
A biopsy of the lesion was done to confirm the diagnosis of lupus erythematosus. The histology of the lesion showed a vacuolar degeneration of basal layer, interface dermatitis with a sparse to moderately dense lymphocytic infiltrate surrounding the perivascular and periappendageal areas. It did not have the band-like dense lymphocytic infiltrate disrupting the derma-epidermal junction, irregular or saw tooth epidermal hyperplasia of lichen planus.
His antinuclear antibody (ANA) was negative.
Given his current histology changes, I feel this is more of cutaneous lupus erythematosus. Could this be a lichenoid variant of discoid lupus erythematosus or an overlap of lichen planus and lupus erythematosus? Review of the literature showed that LE and LP may occur as an overlap syndrome (LE/LP).
Ref: Inaloz HS et al. Lupus erythematosus/lichen planus overlap syndrome with scarring alopecia. J Eur Acad Dermatol Venereol 2000 Mar;15(2): 171-4.)
Andrew Carlson MD, FRCPC, Associate Professor, Divisions of Dermatopathology and Dermatology, Albany Medical College, Albany, NY, USA
Although the back of the hand and buccal lesions resemble lichen planus, the histology, the back lesions and history of photosensitivity all point to lupus erythematosus. Indeed, the histology is typical of lupus. If there was a band like infiltrate obscuring the de junction, than LP-overlap/lichenoid variant of LE would be a better sell.