Lupus eritematoso túmido, una entidad en proceso de definición

An Uncommon Presentation of Tumid Lupus Erythematosus Manifesting As Annular, Non-scarring Alopecia on the Scalp

Tumid lupus erythematosus (TLE) is a rare subtype of cutaneous lupus, which can present diagnostic challenges due to its overlapping features with other skin disorders. Understanding the clinical and histopathological characteristics of TLE is essential for accurate diagnosis and management. In this article, we describe a case of TLE in a 45-year-old man who presented with annular, urticarial, non-scarring plaques on the scalp associated with non-scarring alopecia in the affected area. The patient had a long history of scalp lesions with intermittent resolution and no associated systemic symptoms. On examination, the patient had erythematous, edematous, non-scaly plaques on the occipital and temporal scalp regions, and hair loss was observed in these areas, consistent with non-scarring alopecia. Dermoscopy revealed arborizing blood vessels on a background of erythema, with no scaling, atrophy, or follicular plugging. A skin biopsy confirmed the diagnosis, revealing the characteristic periadnexal and perivascular lymphocytic infiltrates with dermal mucin and edema. Laboratory tests showed a decreased C4 complement level, though other autoimmune markers were within normal limits. The patient showed no systemic symptoms or other signs of systemic lupus erythematosus (SLE). The patient was treated with topical clobetasol dipropionate 0.05% ointment, which resulted in rapid improvement of the lesions. This case underscores the need to include TLE in the differential diagnosis when evaluating annular scalp lesions with associated non-scarring alopecia and emphasizes the critical role of histopathological examination in confirming the diagnosis.

Lupus Erythematosus Tumidus: Clinical and Pathological Features in a Series of 20 Patients

OBJECTIVE

We sought to assess the clinicopathologic/immunophenotypical features in patients with lupus erythematosus tumidus (LET).

METHODS

All skin biopsies diagnosed as LET in 16 years were retrieved from our pathology laboratory. Clinical charts were reviewed and immunohistochemical markers were performed. Subpopulations of cells in the infiltrates were studied, as well as the number/distribution of plasmacytoid dendritic cells (PDC), which were compared with two control groups: normal skin and discoid lupus erythematosus. Direct immunofluorescence was performed when available.

RESULTS

We found 20 patients (11 men and 9 women; mean age 43.5 years); the mean evolution previous to diagnosis was 20.3 months. They all had erythematous, nonscarring urticarial-like plaques: 8 in the head region only, 8 in trunk/limbs only; both segments were affected in 2 patients; topography was unknown in 2. Except for 1 patient, no one developed systemic lupus erythematosus. A dense perivascular/periadnexal superficial-to-deep lymphocytic infiltrate and stromal mucin deposition were characterized histopathologically; interphase changes were absent. Immunophenotype supported an inflammatory profile. The differential count of CD123 + PDC in 10/20 cases of LET (n = 1180) was notably higher than 5 cases of discoid lupus erythematosus (n = 419) and 5 cases of normal skin (n = 38). No immune deposits were found in 2 cases.

CONCLUSION

LET is a rare, peculiar form of cutaneous lupus erythematosus that only exceptionally evolves to systemic lupus erythematosus . Its clinical-pathologic/immunophenotypical features are very characteristic. The amount of CD123 + PDC is a very helpful feature among the criteria for its diagnosis and seems to be relevant in its pathogenesis.

Mepacrine as successful monotherapy for refractory Jessner-Kanof disease: still an important drug in the dermatologic armamentarium

INTRODUCTION

Jessner-Kanof disease (JKD), a lymphocytic infiltration of the skin, can be difficult to treat. Mepacrine (quinacrine), an anti-malarial less available in Belgium, may be beneficial.

PATIENTS AND METHODS

Two female patients with biopsy-proven and therapy-resistant JKD, not responding to topical and systemic corticosteroids, (hydroxy-)chloroquine and/or dapsone, were treated with mepacrine 100 mg daily.

RESULTS

In both patients an amelioration was observed during the first month of treatment, and clinical remission was obtained by the fourth month, without any side-effects. In both cases, the dose could be tapered to three times weekly.

DISCUSSION

JKD is strongly related to lupus erythematosus (tumidus), and although spontaneous remissions may occur, it is notoriously difficult to treat. Mepacrine may be initiated as an add-on therapy to (hydroxy-)chloroquine, but also as monotherapy. A dose of 100 mg a day, tapered to weekly doses once remission is obtained, seems feasible. Except for (mild) yellow skin discoloration, the drug has few side-effects, and offers the advantage of not displaying retinal toxicity.

CONCLUSION

Mepacrine is still a useful and safe drug for treating cutaneous lupus erythematosus and related skin conditions, such as refractory JKD in particular. Its future availability, also in Belgium, is therefore important.

Lupus erythematosus tumidus: a clinical and histological study of 25 cases

Background

Lupus erythematosus tumidus (LET) is a subtype of cutaneous lupus erythematosus (CLE) that has been well characterized in recent years. However, some controversy still remains concerning the histological features of epidermal involvement.

Objectives

The objective of this report is to describe the clinical and microscopic features of LET in patients diagnosed at Hospital Universitari Germans Trias i Pujol, Spain.

Methods

We conducted a retrospective study of 25 patients with a diagnosis of LET.

Results

All patients presented with typical LET lesions (smooth, erythematous plaques without macroscopic epidermal changes, such as follicular plugs or scale, that resolved without residual scarring or hypopigmentation). None of the patients fulfilled the criteria for systemic lupus erythematosus during follow-up. Test results for antinuclear antibodies were positive in five patients (20%), with titres below one of 320 in all cases. Twenty-two patients (88%) required antimalarial therapy; response was good in 70% and moderate response in 30%. Minor epidermal alterations were observed in 52% of biopsy specimens, with focal basal vacuolization being the most frequent.

Conclusions

LET is a variant of CLE that has distinctive clinical, histologic and prognostic features. Unlike the patients in the case series previously described in the literature, most of our patients required treatment with antimalarials. Histology revealed mild epidermal alterations in a significant percentage of patients. Thus, in our opinion, the absence of microscopic epidermal alterations is not constant in LET.

Reticular erythematous mucinosis: histopathological and immunohistochemical features of 25 patients compared with 25 cases of lupus erythematosus tumidus

BACKGROUND AND OBJECTIVES

Reticular erythematous mucinosis (REM) and lupus erythematosus tumidus (LET) share similarities. However, to our knowledge no study extensively compared the histological features of these two conditions. The aim of this study is to compare the histological and immunohistochemical features of REM and LET.

METHODS

We evaluated epidermal thickness, hyperkeratosis, dermo-epidermal junction changes, interstitial mucin deposition, vessel dilatation and pattern, type and density of the inflammatory infiltrate in 25 cases of REM and LET. Anti-CD3, anti-CD20, anti-CD68, anti-CD4, anti-CD8, anti-CD123, anti-CD2AP, anti-IgG and anti-C3 antibodies were tested in a subset of patients.

RESULTS

Both diseases are characterized by perivascular dermal infiltrates of lymphocytes mainly CD4+ positive and increased dermal mucin. However, REM tended to show more scattered and more superficial lymphocytes with more superficial mucin and to have less frequent immunoglobulin and complement depositions along the dermo-epidermal junction. Plasmacytoid dendritic cells (PDCs) were less represented in REM, and were mainly found as single cells differently from LET.

CONCLUSIONS

REM and LET present some differences in the infiltrate, including PDCs, the mucin deposition and the immunoreactant deposition at the dermo-epidermal junction that justify the distinction of the two diseases and suggest different pathogenetic mechanisms.