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Fijałkowska A, Kądziela M, Żebrowska A. The Spectrum of Cutaneous Manifestations in Lupus Erythematosus: A Comprehensive Review. J Clin Med 2024; 13:2419. [PMID: 38673692 PMCID: PMC11050979 DOI: 10.3390/jcm13082419] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2024] [Revised: 04/13/2024] [Accepted: 04/18/2024] [Indexed: 04/28/2024] Open
Abstract
Lupus erythematosus (LE) is an autoimmune inflammatory disease with complex etiology. LE may present as a systemic disorder affecting multiple organs or be limited solely to the skin. Cutaneous LE (CLE) manifests with a wide range of skin lesions divided into acute, subacute and chronic subtypes. Despite classic forms of CLE, such as malar rash or discoid LE, little-known variants may occur, for instance hypertrophic LE, chilblain LE and lupus panniculitis. There are also numerous non-specific manifestations including vascular abnormalities, alopecia, pigmentation and nail abnormalities or rheumatoid nodules. Particular cutaneous manifestations correlate with disease activity and thus have great diagnostic value. However, diversity of the clinical picture and resemblance to certain entities delay making an accurate diagnosis The aim of this review is to discuss the variety of cutaneous manifestations and indicate the clinical features of particular CLE types which facilitate differential diagnosis with other dermatoses. Although in diagnostically difficult cases histopathological examination plays a key role in the differential diagnosis of LE, quick and accurate diagnosis ensures adequate therapy implementation and high quality of life for patients. Cooperation between physicians of various specialties is therefore crucial in the management of patients with uncommon and photosensitive skin lesions.
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Affiliation(s)
| | | | - Agnieszka Żebrowska
- Department of Dermatology and Venereology, Medical University of Lodz, Haller sq. 1, 90-647 Lodz, Poland; (A.F.); (M.K.)
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2
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Rao AG, M N, Ch S, Jhawar J. Bullous systemic lupus erythematosus in a pregnant woman with anaemia coexisting with asymptomatic hepatic haemangioma. Indian J Dermatol Venereol Leprol 2023; 89:585-588. [PMID: 37067137 DOI: 10.25259/ijdvl_1299_20] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2020] [Accepted: 11/01/2022] [Indexed: 02/05/2023]
Affiliation(s)
| | - Naresh M
- Department of Dermatology, SVS Medical College, Mahbubnagar, Telangana, India
| | - Sruthi Ch
- Department of Dermatology, SVS Medical College, Mahbubnagar, Telangana, India
| | - Jayshree Jhawar
- Department of Dermatology, SVS Medical College, Mahbubnagar, Telangana, India
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3
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Bitar C, Menge TD, Chan MP. Cutaneous manifestations of lupus erythematosus: A practical clinicopathologic review for pathologists. Histopathology 2021; 80:233-250. [PMID: 34197657 DOI: 10.1111/his.14440] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2021] [Accepted: 06/30/2021] [Indexed: 11/27/2022]
Abstract
Accurate diagnosis of connective tissue diseases is often challenging and relies on careful correlation between clinical and histopathologic features, direct immunofluorescence studies, and laboratory workup. Lupus erythematosus (LE) is a prototype of connective tissue disease with a variety of cutaneous and systemic manifestations. Microscopically, cutaneous LE is classically characterized by an interface dermatitis, although other histopathologic patterns also exist depending on the clinical presentation, location, and chronicity of the skin lesions. In this article, we review the clinical, serologic, histopathologic, and direct immunofluorescence findings in LE-specific and LE-nonspecific skin lesions, with an emphasis on lesser known variants, newly described features, and helpful ancillary studies. This review will guide general pathologists and dermatopathologists in accurately diagnosing and subclassifying cutaneous LE.
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Affiliation(s)
- Carole Bitar
- Department of Pathology, Michigan Medicine, University of Michigan, Ann Arbor, MI, USA.,Department of Dermatology, Michigan Medicine, University of Michigan, Ann Arbor, MI, USA
| | - Tyler D Menge
- Department of Pathology, Michigan Medicine, University of Michigan, Ann Arbor, MI, USA.,Department of Dermatology, Michigan Medicine, University of Michigan, Ann Arbor, MI, USA
| | - May P Chan
- Department of Pathology, Michigan Medicine, University of Michigan, Ann Arbor, MI, USA.,Department of Dermatology, Michigan Medicine, University of Michigan, Ann Arbor, MI, USA
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Clinical, histological, immunological presentations and outcomes of bullous systemic lupus erythematosus: 10 New cases and a literature review of 118 cases. Semin Arthritis Rheum 2018; 48:83-89. [DOI: 10.1016/j.semarthrit.2017.11.003] [Citation(s) in RCA: 38] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2017] [Revised: 10/15/2017] [Accepted: 11/03/2017] [Indexed: 11/22/2022]
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Momen T, Madihi Y. Bullous Systemic Lupus Erythematosus and Lupus Nephritis in a Young Girl. Oman Med J 2016; 31:453-455. [PMID: 27974963 DOI: 10.5001/omj.2016.91] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
Bullous systemic lupus erythematosus (BSLE) is an autoimmune blistering disease occurring in patients with systemic lupus erythematosus (SLE). It is a rare disease, especially in children. A 14-year-old girl initially presented with fatigue, generalized vesiculobullous skin lesions, and ulcers over the hard palate and oral mucosa. Clinical investigations revealed hematuria and proteinuria, a high erythrocyte sedimentation rate and titer of antinuclear antibody, and anti-double-stranded DNA. Skin biopsy findings were suggestive of BSLE. A renal biopsy confirmed the features of class V lupus nephritis. Based on the clinical features and investigations, a diagnosis of BSLE with nephritis was made. She received methylprednisolone pulse therapy and hydroxychloroquine; however, it did not alleviate the vesiculobullous eruption, so treatment with dapsone started and resulted in the dramatic disappearance of the lesions. Interruption of dapsone due to hemolysis did not aggravate the bullous disease. During follow-up, she had multiple flare-ups of disease and nephritis without rebound of bullous lesions. BSLE is a rare presentation of SLE in children. Differentiating it from other skin bullous diseases and SLE with blister is important for the correct management. The unusual presentation of this disease may delay the diagnosis and therefore requires a high index of clinical suspicion.
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Affiliation(s)
- Tooba Momen
- Division of Asthma, Allergy and Clinical Immunology, Child Growth and Development Research Center, Research Institute for Primordial Prevention of Non-Communicable Disease, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Yahya Madihi
- Division of Pediatric Nephrology, Child Growth and Development Research Center, Research Institute for Primordial Prevention of Non-Communicable Disease, Isfahan University of Medical Sciences Isfahan, Iran
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Fujimoto W, Hamada T, Yamada J, Matsuura H, Iwatsuki K. Bullous Systemic Lupus Erythematosus as an Initial Manifestation of SLE. J Dermatol 2014; 32:1021-7. [PMID: 16471470 DOI: 10.1111/j.1346-8138.2005.tb00894.x] [Citation(s) in RCA: 40] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2005] [Accepted: 06/27/2005] [Indexed: 11/29/2022]
Abstract
Bullous systemic lupus erythematosus (BSLE) is a rare subset of systemic lupus erythematosus that is often associated with autoimmunity to type VII collagen. We describe a 45-year-old woman with BSLE who presented with vesiculobullous lesions as an initial manifestation of SLE. The patient first noticed a widespread urticarial, erythematous eruption associated with tense blisters, erosions, and crusting. She was diagnosed with bullous pemphigoid and underwent a one-month course of treatment with betamethazone. Because of the appearance of marked proteinuria, a subsequent renal biopsy, and serological tests, the patient was diagnosed with rapidly progressive glomerulonephritis and systemic lupus erythematosus. The patient's IgG circulating antibodies labeled the dermal floor of salt-split skin and recognized type VII collagen in immunoblot studies. Although methylprednisolone pulse therapy for glomerulonephritis did not alleviate the vesicullobullous eruption, treatment with dapsone resulted in dramatic disappearance of the lesions. Cessation of dapsone therapy due to hemolysis with Heinz-body formation did not aggravate the bullous disease. Our case illustrates that a generalized vesiculobullous eruption can be the sole presenting manifestation of SLE. It also emphasizes the close temporal relationship between BSLE and lupus nephritis.
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MESH Headings
- Betamethasone/therapeutic use
- Biopsy, Needle
- Dapsone/therapeutic use
- Dermatologic Agents/therapeutic use
- Diagnosis, Differential
- Drug Therapy, Combination
- Female
- Fluorescent Antibody Technique, Direct
- Follow-Up Studies
- Humans
- Immunohistochemistry
- Lupus Erythematosus, Cutaneous/diagnosis
- Lupus Erythematosus, Cutaneous/drug therapy
- Lupus Erythematosus, Cutaneous/pathology
- Lupus Erythematosus, Systemic/diagnosis
- Lupus Erythematosus, Systemic/drug therapy
- Lupus Erythematosus, Systemic/pathology
- Middle Aged
- Severity of Illness Index
- Skin Diseases, Vesiculobullous/pathology
- Treatment Outcome
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Affiliation(s)
- Wataru Fujimoto
- Department of Dermatology, Kawasaki Medical School, Matsushima 577, Kurashiki-shi, Okayama 701-0192, Japan
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Iranzo P. Comments on "Bullous pemphigoid associated with chronic renal allograft rejection". J Am Acad Dermatol 2014; 71:194-5. [PMID: 24947691 DOI: 10.1016/j.jaad.2013.11.052] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2013] [Accepted: 11/10/2013] [Indexed: 10/25/2022]
Affiliation(s)
- Pilar Iranzo
- Dermatology Department, Hospital Clínic, Barcelona, Spain.
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Étude de trois cas de lupus érythémateux bulleux. Ann Dermatol Venereol 2013; 140:778-83. [DOI: 10.1016/j.annder.2013.04.087] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2012] [Revised: 02/13/2013] [Accepted: 04/08/2013] [Indexed: 11/19/2022]
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dos Santos CE, Isaacsson Velho PH, Marques FM, Werner B, Aragão SC, Filho AR. Lúpus eritematoso sistêmico bolhoso em gestante: relato de caso*. REVISTA BRASILEIRA DE REUMATOLOGIA 2013. [DOI: 10.1590/s0482-50042013000500011] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
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Luijten RK, Fritsch-Stork RD, Bijlsma JW, Derksen RH. The use of glucocorticoids in Systemic Lupus Erythematosus. After 60years still more an art than science. Autoimmun Rev 2013; 12:617-28. [DOI: 10.1016/j.autrev.2012.12.001] [Citation(s) in RCA: 48] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2012] [Accepted: 12/02/2012] [Indexed: 01/18/2023]
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11
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Sáez-de-Ocariz M, Espinosa-Rosales F, López-Corella E, de León-Bojorge B. Bullous lesions as a manifestation of systemic lupus erythematosus in two Mexican teenagers. Pediatr Rheumatol Online J 2010; 8:19. [PMID: 20615233 PMCID: PMC2909230 DOI: 10.1186/1546-0096-8-19] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/17/2009] [Accepted: 07/08/2010] [Indexed: 11/10/2022] Open
Abstract
Rarely, systemic lupus erythematosus (SLE) presents with bullous lesions due to severe edema and hydropic degeneration of the basal layer, or as a subepidermal blistering disease. Here, we describe two Mexican teenagers, one with SLE with blisters and another with bullous SLE. We also discuss the mechanisms and clinical implications of lesion formation in patients with SLE and bullae.
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Affiliation(s)
| | - Francisco Espinosa-Rosales
- Department of Primary Immunodeficiencies Research, National Institute of Pediatrics, Mexico City, Mexico
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Kole AK, Ghosh A. Cutaneous manifestations of systemic lupus erythematosus in a tertiary referral center. Indian J Dermatol 2009; 54:132-6. [PMID: 20101308 PMCID: PMC2807152 DOI: 10.4103/0019-5154.53189] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023] Open
Abstract
BACKGROUND Systemic lupus erythematosus (SLE) is an autoimmune disease with multiorgan involvement. The skin is the second most commonly affected organ. SLE with skin lesions can produce considerable morbidity resulting from painful skin lesions, alopecia, disfigurement, etc. Skin lesions in patients with lupus may be specific (LE specific) or may be non specific (LE non specific). Acute cutaneous LE (Lupus specific) has a strong association with systemic disease and non-specific skin lesions always indicate disease activity for which patients present to rheumatologists and internists. Therefore, a thorough understanding of the cutaneous manifestations of SLE is essential for most efficient management. AIMS The aims of this study were to evaluate the patterns and prevalence of skin lesions in patients with SLE and to assess the relationship between skin lesions and other systemic involvement. MATERIALS AND METHODS At the Department of Rheumatology and Clinical Immunology, IPGME&R in Kolkata, 150 patients with SLE fulfilling the clinical and laboratory criteria of the American Rheumatology Association (updated 1982) were examined and followed-up for cutaneous manifestations between January 2002 and January 2007. RESULTS Skin lesions were important clinical features. About 45 patients (30%) presented with skin lesions although all patients had skin lesions during the follow-up period. Skin changes noted were as follows: Lupus specific lesions: malar rash in 120 patients (80%), photosensitive dermatitis in 75 patients (50%), generalized maculopapular rash in 40 patients (26.67%), discoid rash in 30 patients (20%), subacute cutaneous lupus erythematosus (SCLE) in 5 patients (3.34%), lupus profundus in 5 patients (3.34%). The lupus non-specific lesions were non-scarring alopecia in 130 patients (86.67%), oral ulcers in 85 patients (56.67%), vasculitic lesions in 50 patients (33.34%), bullous lesions in 15 patients (10%), Raynaud's phenomenon in 10 patients (6.67%), pyoderma gangrenosum in 2 patients (1.34%), erythema multiforme in 10 patients (6.67%), and nail fold infarcts in 2 patients (1.34%); however, mucosal discoid lupus, lichenoid discoid lupus, livedo reticularis, sclerodactyly, etc. were not detected. Patients having lupus-specific skin lesions e.g., malar rash were associated with systemic involvement, whereas those having lupus non-specific skin lesions were associated with disease flare. CONCLUSIONS Skin lesions in patients with SLE are important disease manifestations and proper understanding is essential for diagnosis and efficient management.
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Affiliation(s)
- Alakes Kumar Kole
- From the Institute of Post Graduate Medical Education and Research, Department of Rheumatology and Clinical Immunology
| | - Alakendu Ghosh
- From the Institute of Post Graduate Medical Education and Research, Department of Rheumatology and Clinical Immunology
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Cato EE, Lima ADS, Pontes ALL, Vannucci AB, Levites J. Lúpus eritematoso sistêmico bolhoso associado à nefrite lúpica: relato de dois casos. An Bras Dermatol 2007. [DOI: 10.1590/s0365-05962007000100008] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
O lúpus eritematoso sistêmico bolhoso é reconhecido como entidade distinta relacionada à auto-imunidade contra colágeno VII. Em alguns casos, a presença de doença bolhosa coincide com a exacerbação do lúpus eritematoso sistêmico, especialmente da nefrite lúpica. São descritos dois casos de mulheres jovens com erupção vésico-bolhosa em áreas expostas e não expostas ao sol associada à nefrite lúpica. O diagnóstico foi comprovado pela histopatologia e imunofluorescência direta características. O tratamento com corticosteróide e dapsona costuma ser eficiente.
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Affiliation(s)
| | | | | | | | - Jacob Levites
- Unifesp, Brasil; Complexo Hospitalar Heliópolis, Brasil
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Abstract
Blistering eruptions are rare cutaneous manifestations of lupus erythematosus (LE) that may be caused by different mechanisms. Subepidermal clefting with frank vesiculation may occur in early lesions of chronic-, subacute-, and acute-cutaneous LE due to a severe vacuolar alteration of the dermoepidermal junction (DEJ), dermal edema, and lekocytoclastic vasculitis. An exaggerated example of such changes is rarely seen at the advancing edge of the annular plaques of subacute cutaneous LE with erythema-multiforme (EM)-like appearance, a condition formerly described as Rowell's syndrome. In a recently reported novel variant of LE-associated toxic epidermal necrolysis, dysregulated keratinocyte apoptosis has been proposed as an underlying mechanism. These vesiculobullous lesions are considered to be LE-specific. Blistering may also occur in LE in the context of a coexisting immunobullous disease. Pemphigus, bullous pemphigoid (BP), epidermolysis bullosa acquisita (EBA), dermatitis herpetiformis, and linear IgA bullous dermatosis have been all reported in association with LE. Their differentiation relies upon characteristic clinical, histologic, and immunopathologic features (Table 1). These blistering eruptions are rather non-specific for LE.
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Affiliation(s)
- Snejina Vassileva
- Department of Dermatology and Venereology, Sofia Faculty of Medicine, Sofia, Bulgaria.
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Malcangi G, Brandozzi G, Giangiacomi M, Zampetti M, Danieli MG. Bullous SLE: response to methotrexate and relationship with disease activity. Lupus 2003; 12:63-6. [PMID: 12587829 DOI: 10.1191/0961203303lu241cr] [Citation(s) in RCA: 40] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
We report on a case of 40-year-old female with systemic lupus erythematosus (SLE) who developed a severe bullous eruption on sun-exposed areas. The bullous manifestation was associated with a flare of lupus serologies, whereas the previous manifestations of the disease were quiescent. Due to prior intolerance to many drugs, she was given oral methotrexate (10 mg/week). The drug administration was followed by a rapid and full resolution of cutaneous lesions. Five months later she developed a class III lupus nephritis. Our case is the first report of efficacy of methotrexate in bullous SLE and rises the question of the relationship between bullous eruption and SLE activity.
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Affiliation(s)
- G Malcangi
- Istituto di Clinica Medica Generale, Ematologia ed Inmunologia Clinica, Torrette di Ancona, Italy
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