Ten-year retrospective clinicohistological study of cutaneous lupus erythematosus in Korea

Skin and beyond: Demographics, clinical features and systemic involvement of cutaneous lupus erythematosus in Pakistani population

BackgroundLupus erythematosus (LE) is an autoimmune disease with skin being the most important organ involved and presents as LE specific and LE nonspecific lesions.ObjectiveTo determine the clinical demographics, systemic involvement and disease impact on daily lives of patients of cutaneous lupus erythematosus (CLE).MethodologyA cross sectional study of a total of 135 patients who presented with cutaneous symptoms were enrolled. Informed consent was taken. Detailed History, examination, clinical features, laboratory and radiograph investigations were conducted to assess the systemic involvement of internal organs.ResultsOf the 135 patients, 73.3% patients were female and 26.7% were male. Mean age was 28.1 years and duration of CLE was 8.4 months. 56.3% of patients belonged to the rural area. Isolated Chronic CLE (CCLE) was observed in 35.5%, CCLE with overlap Acute CLE (ACLE) in 30.3% and Isolated ACLE in 33.3%. Only two patients had Sub acute CLE (SCLE). In LE specific lesions, limited and generalized discoid rash was noted in 33.3% and 17.7% respectively. 46.6% patients had Malar rash. Oral and nasal ulcers were observed in 51.1 %. Non scarring alopecia was seen in 53.3% of patients. Scarring alopecia was observed in 35.5%. 34% patients had Raynaud's phenomenon, 23.7% had Periungual telangiectasia, and 14.8% had Vasculitis. In systemic involvement, joint involvement was observed in 49 patients (36.3%), renal in 48 patients (35.6%), haematological in 42 patients (31.1%), serositis, 23 patients (17%) and neurological in 14 patients (10.4%). No difference in sexes was observed. ANA positivity was seen in 61 patients, (45.1%), most of whom were females. (56.5%) Anti DSDNA was positive in 42 patients (31.1%) of which 40 were women. Mean DLQI was 11.01 ± 8.2. 45 patients had no or slight effect on their lives. 22.9%, 27.4% and 16.3% had moderate, large and very large effects of CLE on their lifestyle.ConclusionThe clinical characteristics of cutaneous lupus is similar to other studies, but the renal involvement is higher with cutaneous involvement in this study, while Serositis is less prevalent. Localized discoid lupus did not show extra cutaneous involvement, but showed significant impact on daily life.

Ultraviolet Radiation-Induced Tolerogenic Dendritic Cells in Skin: Insights and Mechanisms

Ultraviolet (UV) radiation has profound effects on the immune system, including the induction of tolerogenic dendritic cells (DCs), which contribute to immune suppression and tolerance. This review explores the roles of conventional CD11c⁺ DCs, as well as cutaneous Langerhans cells and CD11b⁺ myeloid cells, in UV-induced immune modulation. Two key mechanisms underlying the immunosuppressive relationship between UV and DCs are discussed: the inactivation of DCs and the induction of tolerogenic DCs. DCs serve as a critical link between the innate and adaptive immune systems, serving as professional antigen-presenting cells. In this context, we explore how UV-induced DCs influence the activity of specific T cell subsets, including regulatory T lymphocytes and T helper cells, and shape immune outcomes. Finally, we highlight the implications of UV-induced tolerogenic DCs in select dermatologic pathologies, including cutaneous lupus, polymorphic light eruption, and skin cancer. Understanding the mechanisms by which UV radiation alters DC function offers insights into the complex interplay between environmental factors and immune regulation, providing potential avenues for preventive and therapeutic intervention in UV-induced skin diseases.

Drug-induced hypersensitivity syndrome/drug reaction with eosinophilia and systemic symptoms. Part II diagnosis and management

Drug-induced hypersensitivity syndrome, also known as drug reaction with eosinophilia and systemic symptoms, is a severe cutaneous adverse reaction characterized by an exanthem, fever, and hematologic and visceral organ involvement. The differential diagnosis includes other cutaneous adverse reactions, infections, inflammatory and autoimmune diseases, and neoplastic disorders. Three sets of diagnostic criteria have been proposed; however, consensus is lacking. The cornerstone of management is immediate discontinuation of the suspected drug culprit. Systemic corticosteroids remain first-line therapy, but the literature on steroid-sparing agents is expanding. Longitudinal evaluation for sequelae is recommended. Adjunctive tests for risk stratification and drug culprit identification remain under investigation. Part II of this continuing medical education activity begins by exploring the differential diagnosis and diagnosis of drug-induced hypersensitivity syndrome/drug reaction with eosinophilia and systemic symptoms and concludes with an evidence-based overview of evaluation and treatment.

Diagnosis and Management of Cutaneous Manifestations of Autoimmune Connective Tissue Diseases

The cutaneous features of autoimmune connective tissue disease pose a unique challenge to patients and clinicians managing these conditions. In this review, we outline the key elements of diagnosis and treatment of cutaneous lupus erythematosus, dermatomyositis, systemic sclerosis, and morphea. This article also aims to present an update on gold standard as well as new and emerging therapies for these conditions. Overall, dermatologists can play a key role in diagnosing and treating autoimmune connective tissue diseases and this review intends to provide an up-to-date toolkit to guide clinical dermatologists in this endeavor.

Clinico-histological and Immunopathological Features of Patients with Cutaneous Lupus Erythematosus at Tertiary Dermatology Centre in Malaysia

BACKGROUND

Cutaneous lupus erythematosus (CLE) is a chronic, autoimmune skin disease with a wide spectrum of clinical presentations in different populations.

OBJECTIVE

To study the clinico-histological and immunological features of CLE in a multi-ethnic population and to identify the predictive factors of disease severity based on CLE disease area and severity index (CLASI) scores.

METHODS

This is a cross-sectional study of CLE conducted from March 2019 till February 2020.

RESULTS

A total of 111 patients were recruited with female to male ratio of 4.9:1. Acute CLE contributed 47.7%, followed by chronic CLE, 46.9% and subacute CLE, 5.4%. Eighty-four percent of patients had systemic lupus erythematosus. About 67.3% with chronic CLE developed systemic involvement. Anti-nuclear antibody (ANA) was detected in 90.0%. Skin biopsy(n=42) showed perivascular lymphocytic infiltration (95.2%), epidermal atrophy (47.6%) and hydropic degeneration of basal layer (47.6%). More than 40% had immunoglobulin deposition at dermo-epidermal junction, predominantly granular pattern. Mean CLASI-total was 6.44±7.70, CLASI-activity 2.75±4.10 and CLASI-damage 3.71±4.76. Body surface area (BSA) involved was found to be an independent predictive factor for CLASI-activity (OR:1.34, p=0.018). For CLASI-damage, BSA (OR:4.14, p<0.0001), discoid lupus erythematosus (DLE) subtype (OR:13.10, p=0.001), cutaneous vascular disease (OR:26.59, p=0.014), scalp involvement (OR:8.7, p=0.008) and hypocomplementemia (OR:5.71, p=0.046) were the positive predictive factors. Mean DLQI was 5.91 ± 5.34 and it correlated significantly with disease severity.

CONCLUSIONS

We observed a high percentage of patients with CLE with systemic manifestations and positive ANA. More aggressive treatment of those with positive predictive factors for severe disease combined with significant clinical activity may be warranted.

Cutaneous manifestations of lupus erythematosus: A practical clinicopathologic review for pathologists

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.

Role of biomarkers in the diagnosis and prognosis of patients with cutaneous lupus erythematosus

Cutaneous lupus erythematosus (CLE) is a connective tissue disease with varying presentations, and clinical sequelae including itching, dyspigmentation, and scarring. CLE can occur as its own entity or in conjunction with systemic disease, known as systemic lupus erythematosus (SLE). Because CLE is clinically diverse, identification of a biomarker may help not only facilitate early diagnosis and management but also identify individuals at risk for poor prognosis and development of SLE. While potential biomarkers in SLE have been extensively studied, few biomarkers for CLE have been identified and incorporated into clinical practice. Anti-SS-A antibody is a commonly used biomarker for diagnosis of subacute CLE patients. Type I interferon-related proteins such as MxA and guanylate binding protein‐1 (GBP-1) and chemokines such as CXCR3, CXCL9, and CXCL10 have been identified as biomarkers that may support diagnosis and track disease activity. First-line oral treatment for CLE currently consists of anti-malarials such as hydroxychloroquine (HCQ), chloroquine (CQ), and quinacrine (QC). Studies have found that an increased myeloid dendritic cell population with higher TNF-α expression may be predictive of poor treatment response to HCQ in CLE patients. Autoantibodies against nuclear antigens (e.g., anti-double-stranded DNA and anti-Smith antibodies) and elevated erythrocyte sedimentation rate have been more commonly found in CLE patients progressing to SLE than those who have not. This review aims to summarize previous and emerging biomarkers for CLE patients.

Dermatologic Manifestations, Histologic Features and Disease Progression among Cutaneous Lupus Erythematosus Subtypes: A Prospective Observational Study in Asians

Introduction

Cutaneous manifestations are central to the primary diagnosis of systemic lupus erythematosus (SLE). However, information on the clinical, histopathologic, and direct immunofluorescence (DIF) features among subtypes of cutaneous lupus erythematosus (CLE), as well as longitudinal prospective observational study to evaluate the natural history and the progression to SLE, is lacking among Asians. Our objectives are to summarize the differences in the clinical, histopathologic, and DIF characteristics and serological profiles between various subtypes of CLE, and to provide its natural history and the association with disease activity in our Asian population.

Methods

A prospective observational study on CLE patients was performed between May 2016 and May 2020. Patients underwent full physical/dermatologic examination, skin biopsy for histology, and DIF. Systemic Lupus Erythematosus Disease Activity Index 2000 (SLEDAI-2K) scores and laboratory data were evaluated. Time schedule and characteristics for resolution and/or the disease progression to SLE were recorded in subsequent follow-ups.

Results

Of 101 biopsy-proven CLE patients, 25 had acute CLE (ACLE), 8 had subacute CLE (SCLE), 39 had chronic CLE (CCLE) only, 22 had CCLE with SLE, and 7 had LE-nonspecific cutaneous lesions only. Patients with exclusive CLE showed lower female preponderance, serological abnormalities, and correlation to systemic disease. However, when CLE was accompanied with any LE-nonspecific cutaneous manifestations, they were associated with high antinuclear antibody (ANA) titer, renal, hematologic, joint involvement, and greater SLEDAI score. Of 207 biopsy sections, SCLE/CCLE regardless of systemic involvement showed significantly higher percentage of superficial/deep perivascular and perieccrine infiltration than ACLE. On DIF, deposition of multiple immunoreactants was associated with higher systemic disease. Approximately 10% of CLE-only patients later developed SLE but had mild systemic involvement.

Conclusion

Our findings support that each CLE subtype has a diverse and unique character. Comprehensive understanding of the differences among CLE subtypes is important for achieving the correct diagnosis and providing appropriate disease monitoring and management.

Supplementary Information

The online version contains supplementary material available at 10.1007/s13555-020-00471-y.

An Update on the Pathogenesis of Cutaneous Lupus Erythematosus and Its Role in Clinical Practice

PURPOSE OF REVIEW

Understanding the pathogenesis of cutaneous lupus erythematosus (CLE) is an important step in developing new medications and providing effective treatment to patients. This review focuses on novel research within CLE pathogenesis, as well as some of the medications being developed based on this knowledge.

RECENT FINDINGS

The subtle differences between systemic lupus erythematosus (SLE) and CLE pathogenesis are highlighted by differences in the circulating immune cells found in each disease, as well as the specific pathways activated by ultraviolet light. Plasmacytoid dendritic cells and the related type I interferon pathway are major components of CLE pathogenesis, and as such, therapies targeting components of this pathway have been successful in recent clinical trials. B cell-depleting therapies have shown success in SLE; however, their role in CLE is less clear. Understanding the differences between these manifestations of lupus allows for the development of therapies that are more effective in skin-specific disease. Discovering key pathways in CLE pathogenesis is critical for understanding the clinical features of the disease and ultimately developing new and effective therapies.

Chronic Cutaneous Lupus Erythematosus: Depression Burden and Associated Factors

OBJECTIVES

Depression may occur in up to 30% of individuals with cutaneous lupus erythematosus (CLE), many of whom may also have systemic manifestations. Chronic cutaneous lupus erythematosus (CCLE) conditions are less likely to present systemic involvement than acute and subacute conditions but more often cause permanent scarring and dyspigmentation. However, little is known about depression in those who have CCLE confined to the skin (primary CCLE). As African Americans are at high risk for primary CCLE and depression, we aimed to investigate the prevalence of and explore the risk factors for depression in a population-based cohort of predominantly Black patients with primary CCLE.

METHODS

This was a cross-sectional analysis of a cohort of individuals with a documented diagnosis of primary CCLE, established in metropolitan Atlanta, GA, USA. Participants were recruited from the Centers for Disease Control and Prevention (CDC) population-based Georgia Lupus Registry, multicenter dermatology clinics, community practices, and self-referrals. The Patient-Reported Outcomes Measurement Information System (PROMIS) was used to measure the primary outcome: depressive symptoms. Stand-alone questions were used to assess sociodemographics and healthcare utilization. Emotional, informational, and instrumental support were measured with PROMIS short forms, interpersonal processes of care with the IPC-29 survey, and skin-related quality of life with the Skindex-29+ tool.

RESULTS

Of 106 patients, 92 (86.8%) were female, 91 (85.8%) were Black, 45 (42.9%) were unemployed or disabled, and 28 (26.4%) reported moderate to severe depressive symptoms. Depression severity was lower in patients who were aged ≥ 60 years, were married, or had graduated from college. Univariate analysis showed that being employed (odds ratio [OR] 0.24; 95% confidence interval [CI] 0.10-0.61), insured (OR 0.23; 95% CI 0.09-0.60), reporting higher instrumental, informational, and emotional support (OR 0.75; 95% CI 0.60-0.94; OR 0.62; 95% CI 0.49-0.78; and OR 0.48; 95% CI 0.35-0.65, respectively), visiting a primary care physician in the last year (OR 0.16; 95% CI 0.04-0.61) and reporting better physician-patient interactions (OR 0.56; 95% CI 0.37-0.87) were negatively associated with depression. Patient's perception of staff disrespect (OR 2.30; 95% CI 1.19-4.47) and worse skin-related quality of life (OR 1.04; 95% CI 1.02-1.06) rendered higher risk. In multivariate analysis, only perception of staff disrespect (OR 2.35; 95% CI 1.06-5.17) and lower emotional support (OR 0.48; 95% CI 0.35-0.66) remained associated with depression.

CONCLUSION

Over one-quarter of a predominantly Black population-based cohort of individuals with primary CCLE reported moderate to severe depression, a rate three to five times higher than described previously in the general population from the same metropolitan Atlanta area. Our findings suggest that, while patient's perception of discrimination in the healthcare setting may play a role as a determinant of depression, social support may be protective. In addition to routine mental health screening and depression treatment, interventions directed at providing emotional support and improving office staff interpersonal interactions may contribute to reduce the risk of depression in patients with CCLE.