1
|
Becker SL, Kody S, Fett NM, Hines A, Alavi A, Ortega-Loayza AG. Approach to the Atypical Wound. Am J Clin Dermatol 2024:10.1007/s40257-024-00865-0. [PMID: 38744780 DOI: 10.1007/s40257-024-00865-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/17/2024] [Indexed: 05/16/2024]
Abstract
The heterogeneity of atypical wounds can present diagnostic and therapeutic challenges; however, as the prevalence of atypical wounds grows worldwide, prompt and accurate management is increasingly an essential skill for dermatologists. Addressing the underlying cause of an atypical wound is critical for successful outcomes. An integrated approach with a focus on pain management and patient engagement is recommended to facilitate enduring wound closure. Advances in treatment, in addition to further research and clinical training, are necessary to address the expanding burden of atypical wounds.
Collapse
Affiliation(s)
- Sarah L Becker
- Department of Dermatology, Oregon Health & Science University, 3303 S Bond Ave Building 1, 16th Floor, Portland, OR, 97239, USA
| | - Shannon Kody
- Department of Dermatology, Oregon Health & Science University, 3303 S Bond Ave Building 1, 16th Floor, Portland, OR, 97239, USA
| | - Nicole M Fett
- Department of Dermatology, Oregon Health & Science University, 3303 S Bond Ave Building 1, 16th Floor, Portland, OR, 97239, USA
| | | | - Afsaneh Alavi
- Department of Dermatology, Mayo Clinic, Rochester, MN, USA
| | - Alex G Ortega-Loayza
- Department of Dermatology, Oregon Health & Science University, 3303 S Bond Ave Building 1, 16th Floor, Portland, OR, 97239, USA.
| |
Collapse
|
2
|
Lim D, Kleitsch J, Werth VP. Emerging immunotherapeutic strategies for cutaneous lupus erythematosus: an overview of recent phase 2 and 3 clinical trials. Expert Opin Emerg Drugs 2023; 28:257-273. [PMID: 37860982 DOI: 10.1080/14728214.2023.2273536] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2023] [Accepted: 10/17/2023] [Indexed: 10/21/2023]
Abstract
INTRODUCTION Cutaneous lupus erythematosus (CLE) is an autoimmune disease that is clinically heterogenous and may occur with or without the presence of systemic lupus erythematosus (SLE). While existing on a spectrum, CLE and SLE present differences in their underlying pathogenesis and therapeutic responses. No new therapies have been approved in recent decades by the U.S. Food and Drug Administration for CLE, although frequently refractory to conventional therapies. There is an unmet need to develop effective drugs for CLE as it significantly impacts patients' quality of life and may leave irreversible disfiguring damage. AREAS COVERED This review provides an update on the latest phase 2 and 3 clinical trials performed in CLE or SLE using skin-specific outcome measures. Emergent therapies are presented alongside their mechanism of action as recent translational studies have permitted identification of critical targets among immune cells and/or pathways involved in CLE. EXPERT OPINION While the recent literature has few trials for CLE, drugs targeting type I interferon, its downstream signaling and plasmacytoid dendritic cells have shown promising results. Further research is required to develop long-awaited effective therapies, and this review highlights the importance of implementing trials dedicated to CLE to fill the current gap in CLE therapeutics.
Collapse
Affiliation(s)
- Darosa Lim
- Department of Dermatology, Corporal Michael J. Crescenz VAMC, Philadelphia, PA, USA
- Perelman School of Medicine, Department of Dermatology, University of Pennsylvania, Philadelphia, PA, USA
| | - Julianne Kleitsch
- Department of Dermatology, Corporal Michael J. Crescenz VAMC, Philadelphia, PA, USA
- Perelman School of Medicine, Department of Dermatology, University of Pennsylvania, Philadelphia, PA, USA
| | - Victoria P Werth
- Department of Dermatology, Corporal Michael J. Crescenz VAMC, Philadelphia, PA, USA
- Perelman School of Medicine, Department of Dermatology, University of Pennsylvania, Philadelphia, PA, USA
| |
Collapse
|
3
|
Current Knowledge of the Molecular Pathogenesis of Cutaneous Lupus Erythematosus. J Clin Med 2023; 12:jcm12030987. [PMID: 36769633 PMCID: PMC9918007 DOI: 10.3390/jcm12030987] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2023] [Revised: 01/23/2023] [Accepted: 01/24/2023] [Indexed: 02/01/2023] Open
Abstract
Cutaneous lupus erythematosus (CLE) is an autoimmune disease, which can be limited to the skin or associated with systemic lupus erythematosus (SLE). Gene expression analysis has revealed that both the innate and adaptive immune pathways are activated in CLE. Ultraviolet (UV) light, the predominant environmental factor associated with CLE, induces apoptosis in keratinocytes, and the endogenous nucleic acids released from the apoptotic cells are recognized via pattern recognition receptors, including Toll-like receptors. This leads to the production of type I interferon, a major contributor to the pathogenesis of CLE, by plasmacytoid dendritic cells. UV irradiation can also induce the externalization of autoantigens, such as SS-A/Ro, exposing them to circulating autoantibodies. T-helper 1 cells have been reported to play important roles in the adaptive immune response to CLE. Other environmental factors associated with CLE include drugs and cigarette smoke. Genetic factors also confer a predisposition to the development of CLE, and many susceptibility genes have been identified. Monogenetic forms of CLE also exist. This article aims to review current knowledge about the pathogenesis of CLE. A better understanding of the environmental, genetic, and immunoregulatory factors that drive CLE may provide important insights for the treatment of CLE.
Collapse
|
4
|
Stull C, Sprow G, Werth VP. Cutaneous Involvement in Systemic Lupus Erythematosus: A Review for the Rheumatologist. J Rheumatol 2023; 50:27-35. [PMID: 36109075 PMCID: PMC10152495 DOI: 10.3899/jrheum.220089] [Citation(s) in RCA: 13] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/25/2022] [Indexed: 02/08/2023]
Abstract
The majority of patients with systemic lupus erythematosus (SLE) have cutaneous manifestations at some point in their disease course. The skin findings in SLE are classified as SLE-specific or SLE-nonspecific based on histopathologic findings. SLE-specific skin diseases include chronic cutaneous lupus erythematosus (CLE), subacute CLE, and acute CLE. There are subsets of skin lesions within each group and the likelihood of associated SLE varies among them. SLE-nonspecific lesions are more common in patients with SLE and tend to coincide with active systemic disease. SLE-nonspecific lesions may be seen as a feature of another disease process, including other connective tissue diseases. It is important for the rheumatologist to be familiar with the spectrum of cutaneous diseases in SLE to help prognosticate the likelihood of systemic disease and to ensure patients receive timely dermatologic care with the goal of controlling disease activity to prevent damage.
Collapse
Affiliation(s)
- Courtney Stull
- C. Stull, MD, Corporal Michael J. Crescenz VAMC, and Department of Dermatology, University of Pennsylvania, Philadelphia, and Department of Rheumatology, University of Pittsburgh Medical Center, Pittsburgh
| | - Grant Sprow
- G. Sprow, BA, V.P. Werth, MD, Corporal Michael J. Crescenz VAMC, and Department of Dermatology, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Victoria P Werth
- G. Sprow, BA, V.P. Werth, MD, Corporal Michael J. Crescenz VAMC, and Department of Dermatology, University of Pennsylvania, Philadelphia, Pennsylvania, USA.
| |
Collapse
|
5
|
Goldman N, Han J, LaChance A. Diagnosis and Management of Cutaneous Manifestations of Autoimmune Connective Tissue Diseases. Clin Cosmet Investig Dermatol 2022; 15:2285-2312. [PMID: 36320926 PMCID: PMC9618245 DOI: 10.2147/ccid.s360801] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2022] [Accepted: 10/19/2022] [Indexed: 11/20/2022]
Abstract
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.
Collapse
Affiliation(s)
- Nathaniel Goldman
- Department of Dermatology, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, USA,New York Medical College, School of Medicine, Valhalla, NY, USA
| | - Joseph Han
- Department of Dermatology, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Avery LaChance
- Department of Dermatology, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, USA,Correspondence: Avery LaChance, Connective Tissue Diseases Clinic, Health Policy and Advocacy, Department of Dermatology, Brigham and Women’s Hospital, Harvard Medical School, 221 Longwood Avenue, Boston, MA, 02215, USA, Tel +1 617-582-6060, Fax +1 617-532-6060, Email
| |
Collapse
|
6
|
Histology of Skin Alterations in Lupus Erythematosus. ACTA MEDICA BULGARICA 2022. [DOI: 10.2478/amb-2022-0016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Abstract
Lupus erythematosus is an autoimmune connective tissue disorder showing a broad spectrum of clinical manifestations.
The aim of this study was to assess the correlation of skin histology and different types of lupus erythematosus.
Materials and methods: Fifty-one skin specimens were assessed from 39 female and 12 male patients with acute, subcutaneous and chronic lupus erythematosus, diagnosed and treated in the Department of Dermatology and Venereology, Alexandrovska University Hospital for a 4-year period.
Results: Follicular hyperkeratosis, epidermal atrophy, vacuolar degeneration and interface dermatitis were the most frequently observed lesions in chronic cutaneous lupus erythematosus while diffuse hyperkeratosis, epidermal atrophy and indistinct interface dermatitis in the dermis were predominant in subacute cutaneous lupus erythematosus. Lupus tumidus, a rare intermittent variant of cutaneous lupus erythematosus, showed almost no epidermal involvement and mucin deposition in the dermis. However, in one of our lupus tumidus patients the disease progressed to a systemic form with histological changes of acute cutaneous lupus erythematosus including atrophy, dermal-epidermal smoothing and lymphocytic infiltration in the dermis. Of note, a few patients showed histological changes of urticarial vasculitis-like and rheumatic-like patterns.
Conclusion: The correlation of clinical course, histopathological findings and immunological tests are of vital importance for the correct diagnosis and follow up of patients with lupus erythematodes, thus preventing complications and improving their quality of life.
Collapse
|
7
|
O'Kane D, McCourt C, Meggitt S, D'Cruz DP, Orteu CH, Benton E, Wahie S, Utton S, Hashme M, Mohd Mustapa MF, Exton LS. British Association of Dermatologists guidelines for the management of people with cutaneous lupus erythematosus (CLE) 2021. Br J Dermatol 2021; 185:1112-1123. [PMID: 34170012 DOI: 10.1111/bjd.20597] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/17/2021] [Indexed: 11/28/2022]
Abstract
The overall objective of the guideline is to provide up-to-date, evidence-based recommendations for the management of cutaneous lupus erythematosus (CLE) in the presence or absence of systemic lupus erythematosus (SLE) in adults, young people and children. The document aims to: offer an appraisal of all relevant literature up to December 2020, focusing on any key developments address important, practical clinical questions relating to the primary guideline objective. provide guideline recommendations and if appropriate research recommendations.
Collapse
Affiliation(s)
- D O'Kane
- Department of Dermatology, Belfast Health & Social Care Trust, Belfast, BT9 7AB, U.K
| | - C McCourt
- Department of Dermatology, Belfast Health & Social Care Trust, Belfast, BT9 7AB, U.K
| | - S Meggitt
- Department of Dermatology, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle, NE1 4LP, U.K
| | - D P D'Cruz
- Louise Coote Lupus Unit, NHS Foundation Trust, Guys & St Thomas, London, SE1 9RT, U.K
| | - C H Orteu
- Department of Dermatology, Royal Free London NHS Foundation Trust, London, NW3 2QG, U.K
| | - E Benton
- St John's Institute of Dermatology, NHS Foundation Trust, Guy's & St Thomas, London, SE1 9RT, U.K
| | - S Wahie
- Department of Dermatology, County Durham and Darlington NHS Foundation Trust, DH1 5TW, U.K
| | | | - M Hashme
- Clinical Standards Unit, British Association of Dermatologists, London, W1T 5HQ, U.K
| | - M F Mohd Mustapa
- Clinical Standards Unit, British Association of Dermatologists, London, W1T 5HQ, U.K
| | - L S Exton
- Clinical Standards Unit, British Association of Dermatologists, London, W1T 5HQ, U.K
| | | |
Collapse
|
8
|
Hannon CW, McCourt C, Lima HC, Chen S, Bennett C. Interventions for cutaneous disease in systemic lupus erythematosus. Cochrane Database Syst Rev 2021; 3:CD007478. [PMID: 33687069 PMCID: PMC8092459 DOI: 10.1002/14651858.cd007478.pub2] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND Lupus erythematosus is an autoimmune disease with significant morbidity and mortality. Cutaneous disease in systemic lupus erythematosus (SLE) is common. Many interventions are used to treat SLE with varying efficacy, risks, and benefits. OBJECTIVES To assess the effects of interventions for cutaneous disease in SLE. SEARCH METHODS We searched the following databases up to June 2019: the Cochrane Skin Specialised Register, CENTRAL, MEDLINE, Embase, Wiley Interscience Online Library, and Biblioteca Virtual em Saude (Virtual Health Library). We updated our search in September 2020, but these results have not yet been fully incorporated. SELECTION CRITERIA We included randomised controlled trials (RCTs) of interventions for cutaneous disease in SLE compared with placebo, another intervention, no treatment, or different doses of the same intervention. We did not evaluate trials of cutaneous lupus in people without a diagnosis of SLE. DATA COLLECTION AND ANALYSIS We used standard methodological procedures expected by Cochrane. Primary outcomes were complete and partial clinical response. Secondary outcomes included reduction (or change) in number of clinical flares; and severe and minor adverse events. We used GRADE to assess the quality of evidence. MAIN RESULTS Sixty-one RCTs, involving 11,232 participants, reported 43 different interventions. Trials predominantly included women from outpatient clinics; the mean age range of participants was 20 to 40 years. Twenty-five studies reported baseline severity, and 22 studies included participants with moderate to severe cutaneous lupus erythematosus (CLE); duration of CLE was not well reported. Studies were conducted mainly in multi-centre settings. Most often treatment duration was 12 months. Risk of bias was highest for the domain of reporting bias, followed by performance/detection bias. We identified too few studies for meta-analysis for most comparisons. We limited this abstract to main comparisons (all administered orally) and outcomes. We did not identify clinical trials of other commonly used treatments, such as topical corticosteroids, that reported complete or partial clinical response or numbers of clinical flares. Complete clinical response Studies comparing oral hydroxychloroquine against placebo did not report complete clinical response. Chloroquine may increase complete clinical response at 12 months' follow-up compared with placebo (absence of skin lesions) (risk ratio (RR) 1.57, 95% confidence interval (CI) 0.95 to 2.61; 1 study, 24 participants; low-quality evidence). There may be little to no difference between methotrexate and chloroquine in complete clinical response (skin rash resolution) at 6 months' follow-up (RR 1.13, 95% CI 0.84 to 1.50; 1 study, 25 participants; low-quality evidence). Methotrexate may be superior to placebo with regard to complete clinical response (absence of malar/discoid rash) at 6 months' follow-up (RR 3.57, 95% CI 1.63 to 7.84; 1 study, 41 participants; low-quality evidence). At 12 months' follow-up, there may be little to no difference between azathioprine and ciclosporin in complete clinical response (malar rash resolution) (RR 0.83, 95% CI 0.46 to 1.52; 1 study, 89 participants; low-quality evidence). Partial clinical response Partial clinical response was reported for only one key comparison: hydroxychloroquine may increase partial clinical response at 12 months compared to placebo, but the 95% CI indicates that hydroxychloroquine may make no difference or may decrease response (RR 7.00, 95% CI 0.41 to 120.16; 20 pregnant participants, 1 trial; low-quality evidence). Clinical flares Clinical flares were reported for only two key comparisons: hydroxychloroquine is probably superior to placebo at 6 months' follow-up for reducing clinical flares (RR 0.49, 95% CI 0.28 to 0.89; 1 study, 47 participants; moderate-quality evidence). At 12 months' follow-up, there may be no difference between methotrexate and placebo, but the 95% CI indicates there may be more or fewer flares with methotrexate (RR 0.77, 95% CI 0.32 to 1.83; 1 study, 86 participants; moderate-quality evidence). Adverse events Data for adverse events were limited and were inconsistently reported, but hydroxychloroquine, chloroquine, and methotrexate have well-documented adverse effects including gastrointestinal symptoms, liver problems, and retinopathy for hydroxychloroquine and chloroquine and teratogenicity during pregnancy for methotrexate. AUTHORS' CONCLUSIONS Evidence supports the commonly-used treatment hydroxychloroquine, and there is also evidence supporting chloroquine and methotrexate for treating cutaneous disease in SLE. Evidence is limited due to the small number of studies reporting key outcomes. Evidence for most key outcomes was low or moderate quality, meaning findings should be interpreted with caution. Head-to-head intervention trials designed to detect differences in efficacy between treatments for specific CLE subtypes are needed. Thirteen further trials are awaiting classification and have not yet been incorporated in this review; they may alter the review conclusions.
Collapse
Affiliation(s)
- Cora W Hannon
- Dermatologist, Masters of Public Health Program, Harvard School of Public Health, Boston, Massachusetts, USA
| | | | - Hermenio C Lima
- Department of Dermatology, Clinical Unit for Research Trials and Outcomes in Skin (CURTIS), Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Suephy Chen
- Emory University Hospital, Emory Healthcare, Atlanta, Georgia, USA
| | - Cathy Bennett
- Office of Research and Innovation, Royal College of Surgeons in Ireland Coláiste Ríoga na Máinleá in Éirinn, Dublin, Ireland
| |
Collapse
|
9
|
Chakka S, Krain RL, Concha JSS, Chong BF, Merola JF, Werth VP. The CLASI, a validated tool for the evaluation of skin disease in lupus erythematosus: a narrative review. ANNALS OF TRANSLATIONAL MEDICINE 2021; 9:431. [PMID: 33842652 PMCID: PMC8033342 DOI: 10.21037/atm-20-5048] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
Cutaneous lupus erythematosus (CLE) can present with or without features of systemic lupus erythematosus (SLE), with estimates of the incidence of isolated skin disease almost equaling the incidence of those with systemic disease. However, despite the impact CLE has on a patient’s quality of life (QoL), there has been no US Food and Drug Administration (FDA) approved treatment for the disease in the past 50 years. In addition, patients with skin predominant LE are often excluded from clinical SLE trials. In the rare trials that include patients with skin predominant LE, disease activity and progression in the skin are often difficult to evaluate using multi-organ outcome measures. The need for new therapies for CLE and the lack of focus on skin outcomes has led to the development of the Cutaneous Lupus Disease Area and Severity Index (CLASI), a validated organ-specific outcome measure that is not only responsive to change in disease activity and damage but also correlated to changes in a patient’s QoL. This paper will emphasize the extensive validation studies performed in developing the CLASI, as well as the importance of clinical trials using the CLASI to address the need for improved therapies for patients with lupus skin manifestations.
Collapse
Affiliation(s)
- Srita Chakka
- Corporal Michael J. Crescenz VAMC, Philadelphia, PA, USA.,Department of Dermatology, University of Pennsylvania, Philadelphia, PA, USA
| | - Rebecca L Krain
- Corporal Michael J. Crescenz VAMC, Philadelphia, PA, USA.,Department of Dermatology, University of Pennsylvania, Philadelphia, PA, USA
| | - Josef Symon S Concha
- Corporal Michael J. Crescenz VAMC, Philadelphia, PA, USA.,Department of Dermatology, University of Pennsylvania, Philadelphia, PA, USA
| | - Benjamin F Chong
- Department of Dermatology, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Joseph F Merola
- Department of Dermatology and Department of Medicine, Division of Rheumatology, Harvard Medical School, Brigham and Women's Hospital, Boston, MA, USA
| | - Victoria P Werth
- Corporal Michael J. Crescenz VAMC, Philadelphia, PA, USA.,Department of Dermatology, University of Pennsylvania, Philadelphia, PA, USA
| |
Collapse
|
10
|
Bolton C, Chen Y, Hawthorne R, Schepel IRM, Harriss E, Hofmann SC, Ellis S, Clarke A, Wace H, Martin B, Smith J. Systematic Review: Monoclonal Antibody-Induced Subacute Cutaneous Lupus Erythematosus. Drugs R D 2021; 20:319-330. [PMID: 32960413 PMCID: PMC7691410 DOI: 10.1007/s40268-020-00320-5] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
Background Subacute cutaneous lupus erythematosus (SCLE) lacks consensus diagnostic criteria and the pathogenesis is poorly understood. There are increasing reports of SCLE induced by monoclonal antibodies (mAbs), but there are limited data on the aetiology, clinical characteristics and natural course of this disease. Methods We devised a set of diagnostic criteria for SCLE in collaboration with a multinational, multispecialty panel. This systematic review employed a two-layered search strategy of five databases for cases of mAb-induced SCLE (PROSPERO registered protocol CRD42019116521). To explore the relationship between relative mAb use and the number of SCLE cases reported, the estimated number of mAb users was modelled from 2013 to 2018 global commercial data and estimated annual therapy costs. Results From 40 papers, we identified 52 cases of mAb-induced SCLE, occurring in a cohort that was 73% female and with a median age of 61 years. Fifty percent of cases were induced by anti-tumour necrosis factor (TNF)-ɑ agents. A median of three drug doses preceded SCLE onset and the lesions lasted a median of 7 weeks after drug cessation. Oral and topical corticosteroids were most frequently used. Of the licensed mAbs, adalimumab, denosumab, rituximab, etanercept and infliximab were calculated to have the highest relative number of yearly users based on global sales data. Comparing the number of mAb-induced SCLE cases with estimated yearly users, the checkpoint inhibitors pembrolizumab and nivolumab showed strikingly high rates of SCLE relative to their global use, but ipilimumab did not. Conclusion We present the first systematic review characterising mAb-induced SCLE with respect to triggers, clinical signs, laboratory findings, prognosis and treatment approaches. We identify elevated rates associated with the use of checkpoint inhibitors and anti-TNFɑ agents. Electronic supplementary material The online version of this article (10.1007/s40268-020-00320-5) contains supplementary material, which is available to authorized users.
Collapse
Affiliation(s)
- Chrissy Bolton
- University College London, University College London Hospitals NHS Foundation Trust, London, UK. .,Medical Sciences Division, University of Oxford, Oxford, UK. .,Translational Gastroenterology Unit, Experimental Medicine, University of Oxford, John Radcliffe Hospital, Oxford, OX3 9DU, UK.
| | - Yifan Chen
- Medical Sciences Division, University of Oxford, Oxford, UK
| | - Rachel Hawthorne
- John Radcliffe Hospital, Oxford University Hospitals NHS Trust, Oxford, UK
| | | | - Elinor Harriss
- Bodleian Health Care Libraries, The Knowledge Centre, Oxford University Old Road Campus Research Building, Oxford, UK
| | - Silke C Hofmann
- Department of Dermatology, Allergology and Dermatosurgery, HELIOS University Hospital Wuppertal, University of Witten/Herdecke, Wuppertal, Germany
| | - Spencer Ellis
- Lister Hospital, East and North Herts NHS Trust, Stevenage, UK
| | - Alexander Clarke
- The Kennedy Institute of Rheumatology, University of Oxford, Oxford, UK
| | - Helena Wace
- Addenbrookes Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Blanca Martin
- Department of Dermatopathology, St John's Institute of Dermatology, St Thomas' Hospital, London, UK
| | - Joel Smith
- Nuffield Department of Population Health, University of Oxford, Oxford, UK
| |
Collapse
|
11
|
Tsang V, Leung AKC, Lam JM. Cutaneous Lupus Erythematosus in Children. Curr Pediatr Rev 2021; 17:103-110. [PMID: 33655840 DOI: 10.2174/1573396317666210224144416] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/03/2020] [Revised: 12/22/2020] [Accepted: 01/01/2021] [Indexed: 11/22/2022]
Abstract
BACKGROUND The skin is commonly involved in autoimmune diseases, such as lupus erythematous. The cutaneous lupus erythematosus (CLE) can manifest with or without systemic symptoms. It is advantageous from a patient and healthcare system standpoint for early diagnosis and intervention. Prevention of complications is especially important in the pediatric population. OBJECTIVE To familiarize physicians with the clinical presentation, diagnosis, evaluation, and management of pediatric cutaneous lupus. METHODS The search term "cutaneous lupus" was entered into a Pubmed search. A narrow scope was applied to the categories of "epidemiology", "clinical diagnosis", "investigations", "comorbidities", and "treatment". Meta-analyses, randomized controlled trials, clinical trials, observational studies, and reviews were included. The search was restricted to English literature and children. A descriptive, narrative synthesis of the retrieved articles was provided. RESULTS A variety of innate and adaptive immune responses are being investigated to explain the pathogenesis of CLE. There are a number of variations of cutaneous manifestations varying from localized malar rash as in the case of ACLE lesions and papulosquamous psoriasiform lesions as in the case of SCLE to the multiple subtypes within chronic CLE. First-line pharmacological treatments include topicals, such as typical calcineurin inhibitors and corticosteroids, or oral agents, such as glucocorticoids, antimalarial drugs, and hydroxychloroquine. CONCLUSION CLE is inclusive of a number of subtypes that have varying dermatological manifestations in adult and pediatric populations. The current treatment modalities will change based on the newly understood molecular targets. Ongoing research on the mechanisms underlying CLE is necessary to derive new interventions for pediatric patients.
Collapse
Affiliation(s)
- Vivian Tsang
- Faculty of Medicine, University of British Columbia, Vancouver, British Columbia, BC, Canada
| | - Alexander K C Leung
- Department of Pediatrics, University of Calgary, The Alberta Children's Hospital, Calgary, Alberta, AB, Canada
| | - Joseph M Lam
- Department of Paediatrics, Associate Member, Department of Dermatology, University of British Columbia, Vancouver, British Columbia, AB, Canada
| |
Collapse
|
12
|
Chanprapaph K, Tankunakorn J, Suchonwanit P, Rutnin S. Dermatologic Manifestations, Histologic Features and Disease Progression among Cutaneous Lupus Erythematosus Subtypes: A Prospective Observational Study in Asians. Dermatol Ther (Heidelb) 2020; 11:131-147. [PMID: 33280074 PMCID: PMC7859020 DOI: 10.1007/s13555-020-00471-y] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2020] [Accepted: 11/21/2020] [Indexed: 01/19/2023] Open
Abstract
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.
Collapse
Affiliation(s)
- Kumutnart Chanprapaph
- Division of Dermatology, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Jutamas Tankunakorn
- Division of Dermatology, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Poonkiat Suchonwanit
- Division of Dermatology, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Suthinee Rutnin
- Division of Dermatology, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand.
| |
Collapse
|
13
|
Patel J, Borucki R, Werth VP. An Update on the Pathogenesis of Cutaneous Lupus Erythematosus and Its Role in Clinical Practice. Curr Rheumatol Rep 2020; 22:69. [PMID: 32845411 DOI: 10.1007/s11926-020-00946-z] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
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.
Collapse
Affiliation(s)
- Jay Patel
- Corporal Michael J. Crescenz VAMC, Philadelphia, PA, USA.,Department of Dermatology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Robert Borucki
- Corporal Michael J. Crescenz VAMC, Philadelphia, PA, USA.,Department of Dermatology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Victoria P Werth
- Corporal Michael J. Crescenz VAMC, Philadelphia, PA, USA. .,Department of Dermatology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA. .,Department of Dermatology, Perelman Center for Advanced Medicine, Suite 1-330A, 3400 Civic Center Boulevard, Philadelphia, PA, 19104, USA.
| |
Collapse
|
14
|
Zhou W, Wu H, Zhao M, Lu Q. New insights into the progression from cutaneous lupus to systemic lupus erythematosus. Expert Rev Clin Immunol 2020; 16:829-837. [PMID: 32746644 DOI: 10.1080/1744666x.2020.1805316] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
INTRODUCTION Between 5 and 25% of patients with cutaneous lupus erythematosus (CLE) can progress to systemic lupus erythematosus (SLE) during the course of the disease. There is no clear predictive guideline for the progression of CLE to SLE. AREAS COVERED Lupus erythematosus (LE), a chronic autoimmune disease, has a wide spectrum of manifestations. On one side of the spectrum is CLE, in which patients only display skin lesions. On the other side of the spectrum is SLE, which develops severe systemic involvement. CLE has even been considered as a separate entity from LE, while CLE is also proposed to be associated with SLE. In this review, the authors will describe the relationship between CLE and SLE; summarize the incidence, risk factors, systemic involvement, and management of patients who transition to SLE. The literature search was conducted mainly through PubMed from March to July 2020. EXPERT OPINION The identification of clinical characteristics and biomarkers in patients facing risk of developing SLE and monitoring the disease on a regular basis are essential to promptly manage and hopefully prevent transition to the systemic form.
Collapse
Affiliation(s)
- Wenhui Zhou
- Department of Dermatology, The Second Xiangya Hospital of Central South University; Hunan Key Laboratory of Medical Epigenomics , Changsha, Hunan, China.,Research Unit of Key Technologies of Diagnosis and Treatment for Immune-related Skin Diseases, Chinese Academy of Medical Sciences , Changsha, Hunan, China
| | - Haijing Wu
- Department of Dermatology, The Second Xiangya Hospital of Central South University; Hunan Key Laboratory of Medical Epigenomics , Changsha, Hunan, China.,Research Unit of Key Technologies of Diagnosis and Treatment for Immune-related Skin Diseases, Chinese Academy of Medical Sciences , Changsha, Hunan, China
| | - Ming Zhao
- Department of Dermatology, The Second Xiangya Hospital of Central South University; Hunan Key Laboratory of Medical Epigenomics , Changsha, Hunan, China.,Research Unit of Key Technologies of Diagnosis and Treatment for Immune-related Skin Diseases, Chinese Academy of Medical Sciences , Changsha, Hunan, China
| | - Qianjin Lu
- Department of Dermatology, The Second Xiangya Hospital of Central South University; Hunan Key Laboratory of Medical Epigenomics , Changsha, Hunan, China.,Research Unit of Key Technologies of Diagnosis and Treatment for Immune-related Skin Diseases, Chinese Academy of Medical Sciences , Changsha, Hunan, China
| |
Collapse
|
15
|
Creadore A, Watchmaker J, Maymone MBC, Pappas L, Vashi NA, Lam C. Cosmetic treatment in patients with autoimmune connective tissue diseases: Best practices for patients with lupus erythematosus. J Am Acad Dermatol 2020; 83:343-363. [PMID: 32360722 DOI: 10.1016/j.jaad.2020.03.123] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/25/2019] [Revised: 03/06/2020] [Accepted: 03/10/2020] [Indexed: 11/29/2022]
Abstract
The cutaneous manifestations of lupus, especially chronic cutaneous lupus erythematosus, are a source of significant morbidity and can negatively impact patient quality of life. While the active inflammatory component of the disease may be adequately treated, patients are frequently left with residual skin damage and disfiguring aesthetic deficits. Dermatologists lack guidelines regarding the use and safety of various reconstructive and cosmetic interventions in this patient population. Laser treatments are largely avoided in the lupus population because of the possible photodamaging effects of ultraviolet and visible light. Similarly, given the autoimmune nature of this disease, some physicians avoid injectable treatment and grafts because of the concern for disease reactivation via antigenic stimulation. In the second article in this continuing medical education series we compile available data on this topic with the goal of providing evidence-based guidance on the cosmetic treatment of patients with lupus erythematosus with a focus on chronic cutaneous lupus erythematosus.
Collapse
Affiliation(s)
| | - Jacqueline Watchmaker
- Department of Dermatology, Boston University School of Medicine, Boston, Massachusetts
| | - Mayra B C Maymone
- Department of Dermatology, Boston University School of Medicine, Boston, Massachusetts
| | - Leontios Pappas
- Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts
| | - Neelam A Vashi
- Department of Dermatology, Boston University School of Medicine, Boston, Massachusetts
| | - Christina Lam
- Department of Dermatology, Boston University School of Medicine, Boston, Massachusetts.
| |
Collapse
|
16
|
Quelhas da Costa R, Aguirre-Alastuey ME, Isenberg DA, Saracino AM. Assessment of Response to B-Cell Depletion Using Rituximab in Cutaneous Lupus Erythematosus. JAMA Dermatol 2019; 154:1432-1440. [PMID: 30383114 DOI: 10.1001/jamadermatol.2018.3793] [Citation(s) in RCA: 40] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
Importance Cutaneous lupus erythematosus (CLE) can be severe and treatment resistant. B-cell depletion therapy (BCDT) with rituximab is well recognized in organ involvement in systemic lupus erythematosus (SLE), but its efficacy in cutaneous manifestations is less well established. Objective To evaluate the outcomes of BCDT in CLE and its clinical subtypes in the setting of associated SLE. Design, Setting, and Participants This single-center, retrospective, cohort study was performed at the adult tertiary referral Rheumatology Department of University College London Hospital, London, United Kingdom, from January 1, 2000, through March 31, 2016, with 12-month follow-up completed on March 31, 2017. Adult patients with carefully classified CLE and mucocutaneous British Isles Lupus Assessment Group (BILAG) grade A or B who were treated with rituximab BCDT were selected from a prospective database of 709 patients with SLE. Data were analyzed from April through December 2017. Main Outcomes and Measures Clinical response was examined at 6 and 12 months after treatment for CLE and its subtypes acute CLE (ACLE), subacute CLE (SCLE), chronic CLE (CCLE), and nonspecific LE (NSLE). A complete response was defined as achieving BILAG grade D; partial response, BILAG grade C; stable disease, no change; and disease flare, change from BILAG grade C or D to grade A or B. Results A total of 50 patients with SLE were eligible for inclusion; mean (SD) age at diagnosis was 26.9 (12.1) years, and 49 (98%) were women. Twenty-one patients had ACLE; 6, SCLE; 10, CCLE; and 11, NSLE (including 2 with concurrent ACLE and CCLE). Overall, at 6 months, 38 patients (76%) improved their mucocutaneous BILAG grade A or B status, including 20 (40%) with a complete response. At 12 months, 28 of 46 patients (61%) maintained this response, including 24 (52%) with a complete response. Two of 6 patients (33%) with SCLE showed a complete response at 6 and 12 months. Five of 12 patients (42%) with CCLE showed a complete response at 6 months, and 5 of 11 (45%), at 12 months. Fifteen patients (30%) required further rituximab therapy within 12 months for cutaneous involvement. Conclusions and Relevance B-cell depletion therapy using rituximab appears effective in patients with SLE and severe active CLE; however, outcomes are variable in those with SCLE and CCLE subtypes.
Collapse
Affiliation(s)
- Rita Quelhas da Costa
- Department of Rheumatology, University College London Hospital, University College London, London, United Kingdom.,Department of Internal Medicine, Centro Hospitalar do Porto, Porto, Portugal
| | - M Elena Aguirre-Alastuey
- Department of Rheumatology, University College London Hospital, University College London, London, United Kingdom.,Department of Internal Medicine, Compleio Asistencial Universitario de León, León, Spain
| | - David A Isenberg
- Department of Rheumatology, University College London Hospital, University College London, London, United Kingdom
| | - Amanda M Saracino
- Department of Rheumatology, University College London Hospital, University College London, London, United Kingdom
| |
Collapse
|
17
|
Padrão EMH, Teixeira LF, Maruta CW, Aoki V, Felipe da Silva AS, Kim EIM, Smelli LA. Bullous systemic lupus erythematosus - a case report. AUTOPSY AND CASE REPORTS 2019; 9:e2018069. [PMID: 30863736 PMCID: PMC6394362 DOI: 10.4322/acr.2018.069] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2018] [Accepted: 12/08/2018] [Indexed: 12/31/2022] Open
Abstract
Skin involvement in systemic lupus erythematosus (SLE) occurs in more than 75% of patients with this condition. Vesicles and blisters in lupus erythematosus (LE) may be present in SLE secondary to interface vacuolar changes in the epidermis, in discoid LE also secondary to vacuolar epidermal changes, and in bullous LE secondary to antibodies anti-collagen VII deposits with neutrophilic aggregates. In addition, blisters can occur due to the association of SLE with other autoimmune blistering diseases (e.g. bullous pemphigoid). BSLE is a rare blistering disease that mainly occurs in females (30–40 years old), and less frequently in children and adolescents. The most common presentation is rapid and widespread development of tense vesicles and bullae over erythematous macules or plaques. Preferential sites are: superior trunk, proximal superior limbs, and face (lips) with symmetrical distribution. Mucosal involvement is common on perioral, pharyngeal, laryngeal, and genital areas. The involvement of sun-exposed areas is not mandatory. The lesions usually progress with no scarring, but hypo or hyperchromia may be present. We report an 18-year-old female patient with blistering lesions at admission, who was diagnosed with BSLE. She was initially treated with systemic prednisone and hydroxychloroquine. Her condition evolved with relapsing lesions, which required the introduction of Dapsone. The authors emphasize the relevance of recognizing BSLE—a rare presentation of SLE—which may evolve with marked clinical presentation.
Collapse
Affiliation(s)
| | - Lucas Faria Teixeira
- Universidade de São Paulo, Medical School, Department of Internal Medicine. São Paulo, SP, Brazil
| | - Celina Wakisaka Maruta
- Universidade de São Paulo, Medical School, Department of Dermatology. São Paulo, SP, Brazil
| | - Valéria Aoki
- Universidade de São Paulo, Medical School, Department of Dermatology. São Paulo, SP, Brazil
| | - Aloisio Souza Felipe da Silva
- Universidade de São Paulo, University Hospital Pathology. São Paulo, SP, Brazil.,Universidade de São Paulo, Department of Pathology. São Paulo, SP, Brazil
| | - Elizabeth In Myung Kim
- Universidade de São Paulo, Hospital Universitário, Department of Internal Medcine. São Paulo, SP, Brazil
| | - Luciana Avena Smelli
- Universidade de São Paulo, Hospital Universitário, Department of Internal Medcine. São Paulo, SP, Brazil
| |
Collapse
|
18
|
Li Q, Wu H, Liao W, Zhao M, Chan V, Li L, Zheng M, Chen G, Zhang J, Lau CS, Lu Q. A comprehensive review of immune-mediated dermatopathology in systemic lupus erythematosus. J Autoimmun 2018; 93:1-15. [DOI: 10.1016/j.jaut.2018.07.007] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2018] [Accepted: 07/05/2018] [Indexed: 12/15/2022]
|
19
|
Wu MY, Wang CH, Ng CY, Kuo TT, Chang YC, Yang CH, Lin JY, Ho HC, Chung WH, Chen CB. Periorbital erythema and swelling as a presenting sign of lupus erythematosus in tertiary referral centers and literature review. Lupus 2018; 27:1828-1837. [PMID: 30134759 DOI: 10.1177/0961203318792358] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Background Cutaneous lupus erythematosus (CLE) includes a broad range of dermatologic manifestations. Periorbital involvement, however, is a relatively rare clinical presentation of CLE. Objectives This clinical study aimed to investigate the characteristics of this unique presentation of CLE in tertiary medical centers. Methods We enrolled patients with periorbital erythema and swelling as the presenting sign of lupus erythematosus, from January 2003 to November 2017, using the data of 553 pathologically proven CLE cases from the registration database of the Chang Gung Memorial Hospitals in Taiwan. Results We enrolled a total of 25 patients. The mean age was 46.7 years and 68% of the patients were female. Most of the patients (84.0%) presented with unilateral involvement, with the left orbit involved in 15 patients (60%); the upper eyelid was the most frequently involved (72%). Mean duration between the onset of clinical manifestations and the diagnosis of CLE was approximately 59 weeks. Nineteen patients had been previously misdiagnosed. All patients had features compatible with CLE on histopathological examination. In contrast, laboratory analysis of the autoimmune profile often revealed negative results, including those for antinuclear antibodies (25%). Notably, anti-SSA/SSB (45.5%) showed the highest positive rate. During follow-up, six patients developed systemic lupus erythematosus (SLE) and two patients developed Sjögren syndrome. Conclusions The diagnosis of CLE presenting as periorbital erythema and swelling is often delayed because of clinical mimicry and the high proportion of negative results on autoantibody tests. Increased clinical suspicion and prompt histopathological examination are crucial for early diagnosis. Moreover, one-fourth of the patients ultimately developed SLE, which highlights the importance of clinical awareness.
Collapse
Affiliation(s)
- M Y Wu
- 1 Department of Dermatology, Chang Gung Memorial Hospital, Taipei, Linkou, and Keelung, Taiwan.,2 College of Medicine, Chang Gung University, Kwei-Shan, Taoyuan, Taiwan
| | - C H Wang
- 1 Department of Dermatology, Chang Gung Memorial Hospital, Taipei, Linkou, and Keelung, Taiwan.,2 College of Medicine, Chang Gung University, Kwei-Shan, Taoyuan, Taiwan
| | - C Y Ng
- 1 Department of Dermatology, Chang Gung Memorial Hospital, Taipei, Linkou, and Keelung, Taiwan.,2 College of Medicine, Chang Gung University, Kwei-Shan, Taoyuan, Taiwan.,7 Department of Pathology, Chang Gung Memorial Hospital, Linkou, Taiwan
| | - T T Kuo
- 2 College of Medicine, Chang Gung University, Kwei-Shan, Taoyuan, Taiwan.,7 Department of Pathology, Chang Gung Memorial Hospital, Linkou, Taiwan
| | - Y C Chang
- 1 Department of Dermatology, Chang Gung Memorial Hospital, Taipei, Linkou, and Keelung, Taiwan.,2 College of Medicine, Chang Gung University, Kwei-Shan, Taoyuan, Taiwan
| | - C H Yang
- 1 Department of Dermatology, Chang Gung Memorial Hospital, Taipei, Linkou, and Keelung, Taiwan.,2 College of Medicine, Chang Gung University, Kwei-Shan, Taoyuan, Taiwan
| | - J Y Lin
- 1 Department of Dermatology, Chang Gung Memorial Hospital, Taipei, Linkou, and Keelung, Taiwan.,2 College of Medicine, Chang Gung University, Kwei-Shan, Taoyuan, Taiwan
| | - H C Ho
- 1 Department of Dermatology, Chang Gung Memorial Hospital, Taipei, Linkou, and Keelung, Taiwan.,2 College of Medicine, Chang Gung University, Kwei-Shan, Taoyuan, Taiwan
| | - W H Chung
- 1 Department of Dermatology, Chang Gung Memorial Hospital, Taipei, Linkou, and Keelung, Taiwan.,2 College of Medicine, Chang Gung University, Kwei-Shan, Taoyuan, Taiwan.,4 Whole-Genome Research Core Laboratory of Human Diseases, Chang Gung Memorial Hospital, Keelung, Taiwan.,5 Chang Gung Immunology Consortium, Chang Gung Memorial Hospital and Chang Gung University, Taoyuan, Taiwan.,6 Department of Dermatology, Chang Gung Memorial Hospital, Xiamen, China
| | - C B Chen
- 1 Department of Dermatology, Chang Gung Memorial Hospital, Taipei, Linkou, and Keelung, Taiwan.,2 College of Medicine, Chang Gung University, Kwei-Shan, Taoyuan, Taiwan.,3 Graduate Institute of Clinical Medical Sciences, College of Medicine, Chang Gung University, Taoyuan, Taiwan.,4 Whole-Genome Research Core Laboratory of Human Diseases, Chang Gung Memorial Hospital, Keelung, Taiwan.,5 Chang Gung Immunology Consortium, Chang Gung Memorial Hospital and Chang Gung University, Taoyuan, Taiwan.,6 Department of Dermatology, Chang Gung Memorial Hospital, Xiamen, China
| |
Collapse
|
20
|
Oh EH, Kim EJ, Ro YS, Ko JY. Ten-year retrospective clinicohistological study of cutaneous lupus erythematosus in Korea. J Dermatol 2018; 45:436-443. [PMID: 29423919 DOI: 10.1111/1346-8138.14233] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2017] [Accepted: 12/18/2017] [Indexed: 11/30/2022]
Abstract
An understanding of the differences in clinical manifestations and laboratory abnormalities between subtypes of cutaneous lupus erythematosus (CLE) is still lacking. The purpose of this study was to analyze demographic, clinical and histological features of CLE according to three main presentation subsets: acute (ACLE), subacute (SCLE) and chronic (CCLE). A 10-year retrospective analysis was performed on data from patients who were diagnosed with CLE between March 2005 and September 2015 in a Korean tertiary referral dermatology clinic. We compared demographic data and clinical and histological findings between three different CLE groups. An overall sample of 220 patients with CLE consisted of 67 patients with ACLE, 25 patients with SCLE and 135 patients with CCLE. Patients with CCLE regardless of systemic lupus erythematosus (SLE) presence had lower prevalence of anemia, urinary abnormalities and elevated erythrocyte sedimentation rate. Furthermore, CCLE patients who only had skin lesions showed lower female predominance, lower extracutaneous manifestation, fewer laboratory and immunological abnormalities including low antinuclear antibody titers and the lowest positivity for C3, C4 and anti-dsDNA, anti-Ro, anti-Sm and anti-RNP antibodies, and more prominent perieccrine inflammation and dermal fibrosis in histological findings. Considering distinct cutaneous manifestations of LE, a comprehensive awareness of each CLE subtype is important for achieving a favorable prognosis through appropriate diagnosis and management. This study provides comparative clinical and histological profiles of patients with different CLE subtypes in Korea.
Collapse
Affiliation(s)
- Eui Hyun Oh
- Department of Dermatology, College of Medicine, University of Hanyang, Seoul, Korea
| | - Eun Jin Kim
- Department of Dermatology, College of Medicine, University of Hanyang, Seoul, Korea
| | - Young Suck Ro
- Department of Dermatology, College of Medicine, University of Hanyang, Seoul, Korea
| | - Joo Yeon Ko
- Department of Dermatology, College of Medicine, University of Hanyang, Seoul, Korea
| |
Collapse
|
21
|
Abstract
The terms 'lichenoid' and 'interface' dermatitis are often used interchangeably to describe an inflammatory pattern characterized histologically by damage to the basal keratinocytes in the epidermis. The mechanism of cell damage of such cells is now best understood as apoptosis, or programmed cell death. This inflammatory pattern of dermatoses, is also accompanied frequently by a band of lymphocytes and histiocytes in the superficial dermis, that often obscures the dermal-epidermal junction, hence the term 'lichenoid'. A discussion of the more common lichenoid/interface dermatitides encountered in the routine clinical practice encompasses the following entities: lichen planus, lupus erythematosus, dermatomyositis, erythema multiforme, graft versus host disease, fixed drug reactions, and multiple others.
Collapse
Affiliation(s)
- Alejandro A Gru
- Department of Pathology & Dermatology, University of Virginia, Charlottesville, VA, Unitee States.
| | - Andrea L Salavaggione
- Department of Radiation Oncology, The Ohio State University, Columbus, OH, United States
| |
Collapse
|
22
|
Zanetti C, Aikawa N, Assad A, Goldenstein-Schainberg C, Pereira R. RELATO DE CASO: ASSOCIAÇÃO DE ABATACEPTE E MICOFENOLATO MOFETIL NO TRATAMENTO DE MANIFESTAÇÕES CUTÂNEAS REFRATÁRIAS EM PACIENTE COM LÚPUS ERITEMATOSO SISTÊMICO. REVISTA BRASILEIRA DE REUMATOLOGIA 2017. [DOI: 10.1016/j.rbr.2017.07.456] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022] Open
|
23
|
Pons-Estel GJ, Aspey LD, Bao G, Pons-Estel BA, Wojdyla D, Saurit V, Alvarellos A, Caeiro F, Haye Salinas MJ, Sato EI, Soriano ER, Costallat LTL, Neira O, Iglesias-Gamarra A, Reyes-Llerena G, Cardiel MH, Acevedo-Vásquez EM, Chacón-Díaz R, Drenkard C. Early discoid lupus erythematosus protects against renal disease in patients with systemic lupus erythematosus: longitudinal data from a large Latin American cohort. Lupus 2016; 26:73-83. [DOI: 10.1177/0961203316651740] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2015] [Accepted: 05/04/2016] [Indexed: 01/13/2023]
Abstract
Objectives The objective of this study was to examine whether early discoid lupus erythematosus (DLE) would be a protective factor for further lupus nephritis in patients with systemic lupus erythematosus (SLE). Methods We studied SLE patients from GLADEL, an inception longitudinal cohort from nine Latin American countries. The main predictor was DLE onset, which was defined as physician-documented DLE at SLE diagnosis. The outcome was time from the diagnosis of SLE to new lupus nephritis. Univariate and multivariate survival analyses were conducted to examine the association of DLE onset with time to lupus nephritis. Results Among 845 GLADEL patients, 204 (24.1%) developed lupus nephritis after SLE diagnosis. Of them, 10 (4.9%) had DLE onset, compared to 83 (12.9%) in the group of 641 patients that remained free of lupus nephritis (hazard ratio 0.39; P = 0.0033). The cumulative proportion of lupus nephritis at 1 and 5 years since SLE diagnosis was 6% and 14%, respectively, in the DLE onset group, compared to 14% and 29% in those without DLE ( P = 0.0023). DLE onset was independently associated with a lower risk of lupus nephritis, after controlling for sociodemographic factors and disease severity at diagnosis (hazard ratio 0.38; 95% confidence interval 0.20–0.71). Conclusions Our data indicate that DLE onset reduces the risk of further lupus nephritis in patients with SLE, independently of other factors such as age, ethnicity, disease activity, and organ damage. These findings have relevant prognosis implications for SLE patients and their clinicians. Further studies are warranted to unravel the biological and environmental pathways associated with the protective role of DLE against renal disease in patients with SLE.
Collapse
Affiliation(s)
- G J Pons-Estel
- Department of Autoimmune Diseases, Institut Clínic de Medicina i Dermatologia, Barcelona, Spain
| | - L D Aspey
- Department of Dermatology, Emory School of Medicine, Atlanta, USA
| | - G Bao
- Division of Rheumatology, Emory School of Medicine, Atlanta, USA
| | - B A Pons-Estel
- Servicio de Reumatología, Hospital Provincial de Rosario, Rosario, Argentina
| | - D Wojdyla
- GLADEL Consultant, Universidad Nacional de Rosario, Rosario, Argentina
| | - V Saurit
- Servicio de Reumatología, Hospital Privado, Córdoba, Argentina
| | - A Alvarellos
- Servicio de Reumatología, Hospital Privado, Córdoba, Argentina
| | - F Caeiro
- Servicio de Reumatología, Hospital Privado, Córdoba, Argentina
| | | | - E I Sato
- Departamento de Medicina, Universidade Federal da São Paulo (UNIFESP), São Paulo, Brazil
| | - E R Soriano
- Sección de Reumatología, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
- Fundación Dr Pedro M Catoggio para el Progreso de la Reumatología, Buenos Aires, Argentina
| | - L T L Costallat
- Divisao de Reumatologia, Universidade Estadual de Campinas, Campinas, Brazil
| | - O Neira
- Sección de Reumatología, Hospital del Salvador, Facultad de Medicina, Universidad de Chile, Santiago, Chile
| | - A Iglesias-Gamarra
- Facultad de Medicina, Universidad Nacional de Colombia, Bogota, Colombia
| | - G Reyes-Llerena
- Servicio Nacional de Reumatología, Centro de Investigaciones Médico Quirúrgicas (CIMEQ), La Habana, Cuba
| | - M H Cardiel
- Centro de Investigación Clínica de Morelia, Morelia, México
| | - E M Acevedo-Vásquez
- Servicio de Reumatología, Hospital Nacional ‘Guillermo Almenara Irigoyen’, School of Medicine, Universidad Nacional Mayor de San Marcos, Lima, Perú
| | - R Chacón-Díaz
- Servicio de Reumatología, Hospital Universitario, Caracas, Venezuela
| | - C Drenkard
- Division of Rheumatology, Emory School of Medicine, Atlanta, USA
| |
Collapse
|
24
|
Neema S, Chatterjee M, Basu A. Erythroderma: A unique presentation of acute lupus. INDIAN JOURNAL OF RHEUMATOLOGY 2015. [DOI: 10.1016/j.injr.2015.05.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
|
25
|
Itoi S, Tanemura A, Tani M, Kitaba S, Terao M, Murota H, Oiso N, Katayama I. Immunohistochemical Analysis of Interleukin-17 Producing T Helper Cells and Regulatory T Cells Infiltration in Annular Erythema Associated with Sjögren's Syndrome. Ann Dermatol 2014; 26:203-8. [PMID: 24882975 PMCID: PMC4037673 DOI: 10.5021/ad.2014.26.2.203] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2012] [Revised: 03/11/2013] [Accepted: 04/22/2013] [Indexed: 11/22/2022] Open
Abstract
Background Peculiar erythema known as annular erythema associated with Sjögren's syndrome (AESS) can be differentiated from autoimmune annular erythema and subacute cutaneous lupus erythematosus, both clinically and histologically. However, there are no detailed investigations on immune competent cells infiltration. Objective Preferential infiltration of interleukin-17-producing T helper (Th17) cells and regulatory T (Treg) cells into the labial salivary gland is reported to play a role in maintaining mucoepithelitis in patients with Sjögren's syndrome. In this study, we evaluated Th17 and Treg cell infiltration into the lesional skin of AESS. Methods We analyzed the numbers and infiltration patterns of Th17 and FoxP3 (+) Treg cells in seven cases of AESS using immunohistochemistry. Seven patients with systemic lupus erythematosus (SLE), atopic dermatitis (AD) and psoriasis vulgaris (PV), which are representatives of Th17 cell-involved skin disorders, were enrolled as disease controls. Results Periappendageal and epidermal changes, such as follicular plugging and liquefaction, were evident in the annular erythema of SLE, not AESS, tissue samples. In AESS tissue samples, dense perivascular and periappendageal infiltration of lymph cells was observed in the middle-to-deep dermis, as previously described, in contrast to the superficial infiltration pattern observed in both AD and PV samples. While the total number of infiltrated lymphocytes was similar between AESS and SLE tissue samples, Th17 cells were found to be preferentially infiltrated in the middle-to-deep dermis in AESS samples. Conclusion These results suggest that an increased number and distribution of infiltration of Th17 cells is a preferential feature of AESS, rather than a characteristic feature of annular erythema of SLE.
Collapse
Affiliation(s)
- Saori Itoi
- Department of Dermatology Integrated Medicine, Graduate School of Medicine, Osaka University, Osaka, Japan
| | - Atsushi Tanemura
- Department of Dermatology Integrated Medicine, Graduate School of Medicine, Osaka University, Osaka, Japan
| | - Mamori Tani
- Department of Dermatology Integrated Medicine, Graduate School of Medicine, Osaka University, Osaka, Japan
| | - Shun Kitaba
- Department of Dermatology Integrated Medicine, Graduate School of Medicine, Osaka University, Osaka, Japan
| | - Mika Terao
- Department of Dermatology Integrated Medicine, Graduate School of Medicine, Osaka University, Osaka, Japan
| | - Hiroyuki Murota
- Department of Dermatology Integrated Medicine, Graduate School of Medicine, Osaka University, Osaka, Japan
| | - Naoki Oiso
- Department of Dermatology, Kinki University Faculty of Medicine, Osaka, Japan
| | - Ichiro Katayama
- Department of Dermatology Integrated Medicine, Graduate School of Medicine, Osaka University, Osaka, Japan
| |
Collapse
|
26
|
Dickey BZ, Holland KE, Drolet BA, Galbraith SS, Lyon VB, Siegel DH, Chiu YE. Demographic and clinical characteristics of cutaneous lupus erythematosus at a paediatric dermatology referral centre. Br J Dermatol 2014; 169:428-33. [PMID: 23601021 DOI: 10.1111/bjd.12383] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/09/2013] [Indexed: 12/17/2022]
Abstract
BACKGROUND Paediatric cutaneous lupus erythematosus (CLE) is uncommon and inadequately described in the literature. Similar to adults, children with CLE develop LE-specific and/or LE-nonspecific skin findings. Similarities and differences in demographics and clinical course between paediatric and adult CLE have not been sufficiently described. OBJECTIVES To detail the demographic and clinical features of paediatric CLE and compare these findings with those reported in the adult literature. METHODS A retrospective chart review was performed of 53 children seen in a paediatric dermatology clinic with cutaneous manifestations of LE. RESULTS Patients presented with all five major subtypes of CLE, with some notable differences from adult CLE and previously published reports of paediatric CLE. Progression from discoid LE to systemic LE (SLE) did not occur in our cohort. Patients with subacute CLE were more likely than adults to have lesions below the waist as well as concomitant SLE. Sex distribution for CLE in our study was equal prior to puberty and female predominant in post-pubertal patients. CONCLUSIONS Children with CLE have variable clinical presentations and progression to SLE that may be different from adult disease. Specifically, children with acute and subacute CLE may be more likely than adults to have systemic disease; therefore, patients with these subtypes should be monitored closely for evidence of SLE. Study limitations included small patient numbers that may limit the ability to generalize these data and relatively short follow-up intervals.
Collapse
Affiliation(s)
- B Z Dickey
- Medical College of Wisconsin, Milwaukee, WI, USA
| | | | | | | | | | | | | |
Collapse
|
27
|
Sidhu HK, Dukes GD, Goldenberg G. Dermatopathology of rheumatologic diseases. ACTA ACUST UNITED AC 2014. [DOI: 10.1586/edm.12.10] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
|
28
|
Lee ES. Skin and Rheumatic Disease. JOURNAL OF RHEUMATIC DISEASES 2013. [DOI: 10.4078/jrd.2013.20.4.209] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Affiliation(s)
- Eun-So Lee
- Department of Dermatology, Ajou University School of Medicine, Suwon, Korea
| |
Collapse
|
29
|
Yoon J, Kim HM, Kim TH, Kim CW, Sun YW, Yoon TJ. Autologous fat transfer in a patient with lupus erythematosus profundus. Case Rep Dermatol 2012; 4:207-10. [PMID: 23139658 PMCID: PMC3493019 DOI: 10.1159/000343469] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
Lupus erythematosus profundus, a form of chronic cutaneous lupus erythematosus, is a rare inflammatory disease involving in the lower dermis and subcutaneous tissues. It primarily affects the head, proximal upper arms, trunk, thighs, and presents as firm nodules, 1 to 3 cm in diameter. The overlying skin often becomes attached to the subcutaneous nodules and is drawn inward to produce deep, saucerized depressions. We present a rare case of lupus erythematosus profundus treated with autologous fat transfer.
Collapse
Affiliation(s)
- Jimi Yoon
- Department of Dermatology and Institute of Health Sciences, School of Medicine, Gyeongsang National University, Jinju, Korea
| | | | | | | | | | | |
Collapse
|
30
|
Huang CF, Wang WM, Chiang CP. Scaly ear rash as the herald of a young girl with juvenile systemic lupus erythematosus. Ann Dermatol 2012; 23:S333-7. [PMID: 22346271 PMCID: PMC3276790 DOI: 10.5021/ad.2011.23.s3.s333] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2010] [Revised: 04/08/2011] [Accepted: 04/11/2011] [Indexed: 11/15/2022] Open
Abstract
Juvenile systemic lupus erythematosus (JSLE) is an autoimmune-mediated multiorgan disease. The cutaneous manifestation is one of the most common initial presentations in JSLE. A typical lesion is a facial malar rash, but a patient may sometimes present with nonclassical lesions. Herein, we report two cases of JSLE with similar persistent scaly ear rashes as the heralding cutaneous symptom preceding systemic symptoms. Identifying this atypical and underestimated cutaneous rash in juvenile patients might help the clinician make the correct diagnosis and provide earlier intervention, which may help prevent disease progression.
Collapse
Affiliation(s)
- Ching-Fu Huang
- Department of Dermatology, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan
| | | | | |
Collapse
|
31
|
Grönhagen C, Fored C, Granath F, Nyberg F. Cutaneous lupus erythematosus and the association with systemic lupus erythematosus: a population-based cohort of 1088 patients in Sweden. Br J Dermatol 2011; 164:1335-41. [DOI: 10.1111/j.1365-2133.2011.10272.x] [Citation(s) in RCA: 156] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
|
32
|
Matsui S, Kitaba S, Itoi S, Kijima A, Murota H, Tani M, Katayama I. A case of disseminated DLE complicated by atopic dermatitis and Sjögren's syndrome: link between hypohidrosis and skin manifestations. Mod Rheumatol 2010; 21:101-5. [PMID: 20824298 DOI: 10.1007/s10165-010-0352-0] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2010] [Accepted: 08/11/2010] [Indexed: 11/24/2022]
Abstract
We report an unusual case of disseminated discoid lupus erythematosus (DLE) complicated by pre-existing atopic dermatitis (AD) and late-onset Sjögren's syndrome (SS). Disseminated DLE lesions were sparse on the expected sites for AD, such as the medial region of the extremities or v-neck area. The patient fulfilled the diagnostic criteria for AD and SS but not for systemic lupus erythematosus. Histopathological analysis of the crusted erythematous lesions revealed typical DLE with few FoxP3(+) cells and a moderate number of IL-17(+) cells. A quantitative sweating test showed impaired sweating of both lesional and non-lesional skin due to underlying hypohidrosis that was related to AD and SS. This finding suggests that dissemination of DLE was triggered by scratching and a Köbner phenomenon-like effect related to hypohidrotic and xerotic skin. To the best of our knowledge, this is the first reported case of disseminated DLE complicated by AD and SS.
Collapse
Affiliation(s)
- Saki Matsui
- Department of Dermatology Integrated Medicine, Graduate School of Medicine Osaka University, 2-2 Yamada-Oka, Suita, Osaka, 565-0871, Japan
| | | | | | | | | | | | | |
Collapse
|
33
|
Sepehr A, Wenson S, Tahan SR. Histopathologic manifestations of systemic diseases: the example of cutaneous lupus erythematosus. J Cutan Pathol 2010; 37 Suppl 1:112-24. [PMID: 20482683 DOI: 10.1111/j.1600-0560.2010.01510.x] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Affiliation(s)
- Alireza Sepehr
- Department of Pathology, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA, USA.
| | | | | |
Collapse
|
34
|
Klein RS, Morganroth PA, Werth VP. Cutaneous lupus and the Cutaneous Lupus Erythematosus Disease Area and Severity Index instrument. Rheum Dis Clin North Am 2010; 36:33-51, vii. [PMID: 20202590 DOI: 10.1016/j.rdc.2009.12.001] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
This article provides an overview of cutaneous lupus erythematosus, including classification schemes, disease subtypes, and therapy. It also describes the Cutaneous Lupus Erythematosus Disease Area and Severity Index, a novel clinical outcome instrument that quantifies cutaneous activity and damage in cutaneous lupus erythematosus.
Collapse
|
35
|
Bae YI, Yun SJ, Lee JB, Kim SJ, Won YH, Lee SC. A clinical and epidemiological study of lupus erythematosus at a tertiary referral dermatology clinic in Korea. Lupus 2009; 18:1320-6. [PMID: 19884217 DOI: 10.1177/0961203309345769] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Dermatological examination is critical for the evaluation of lupus erythematosus. However, little is known about the epidemiology and clinical characteristics of the lupus erythematosus patients that visit dermatology clinics with the chief complaint of skin lesions, especially among Asian populations. We performed this study to determine the epidemiology of cutaneous lupus erythematosus for three subtypes: acute cutaneous lupus erythematosus, subacute cutaneous lupus erythematosus, and chronic cutaneous lupus erythematosus, and for lupus erythematosus non-specific skin disease. Also, we sought to determine the relationship between each type of lupus erythematosus, by the skin manifestations and systemic lupus erythematosus. The medical records of lupus erythematosus patients that were diagnosed by their clinical manifestations, skin biopsy results, and laboratory findings from January 1998 through December 2007 were reviewed. A total of 117 patients were diagnosed with lupus erythematosus; 62 cases had chronic cutaneous lupus erythematosus, 11 had subacute cutaneous lupus erythematosus, and 41 had acute cutaneous lupus erythematosus. The remaining three had systemic lupus erythematosus features with lupus erythematosus non-specific skin lesions such as Raynaud phenomenon, livedo reticularis/vasculitis, non-scarring alopecia, and periungual telangiectasia. The acute cutaneous lupus erythematosus subgroup showed extreme female predominance (9.2:1) whereas subacute and chronic cutaneous lupus erythematosus subgroups did not. Patients with chronic cutaneous lupus erythematosus tended to be older than other groups (peak incidence in the fifth decade). Incidence of laboratory abnormalities, including positive connective tissue markers such as antinuclear, double-strand DNA, and Ro/SS-A antibodies, were present in the order acute, subacute, and chronic cutaneous lupus erythematosus. Acute cutaneous lupus erythematosus almost always indicated systemic involvement of lupus erythematosus, whereas chronic cutaneous lupus erythematosus did not predict the development or existence of systemic lupus erythematosus and had a benign clinical course. Careful consideration of lupus erythematosus non-specific skin lesions may help detect systemic lupus erythematosus regardless of the diagnosis of cutaneous lupus erythematosus.
Collapse
Affiliation(s)
- Y I Bae
- Department of Dermatology, Chonnam National University Medical School, Gwangju, Korea
| | | | | | | | | | | |
Collapse
|
36
|
|
37
|
|
38
|
|
39
|
WATANABE T, TSUCHIDA T. Lupus erythematosus profundus: a cutaneous marker for a distinct clinical subset? Br J Dermatol 2008. [DOI: 10.1046/j.1365-2133.1996.d01-735.x] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
|
40
|
|
41
|
Choffray A, Pinquier L, Bachelez H. Exacerbation of Lupus Panniculitis following Anti-Hepatitis-B Vaccination. Dermatology 2007; 215:152-4. [PMID: 17684379 DOI: 10.1159/000104268] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2007] [Accepted: 02/06/2007] [Indexed: 11/19/2022] Open
Abstract
Even though benefits of vaccination policies have been widely demonstrated, vaccine injections might be associated with rare side effects. In this setting, the potential role of vaccines, mostly against hepatitis B virus, in the induction of autoimmunity has been a matter of controversy. We report the case of a woman followed for a lupus panniculitis which had been in remission for 3 years, who developed a lupus flare following an anti-hepatitis-B vaccine injection. The topography of recurring lupus lesions, the chronology of the flare and the increase in the antinuclear autoantibody serum level all supported a causal role for vaccination in the relapse of the lupus lesions. We believe that the present case might provide a first observation of lupus panniculitis possibly induced by hepatitis B vaccination, and this should be added to the range of dysimmune manifestations caused by vaccinations.
Collapse
Affiliation(s)
- A Choffray
- Department of Dermatology, Centre Hospitalier Universitaire, Liège, Belgium
| | | | | |
Collapse
|
42
|
Werth VP. Clinical manifestations of cutaneous lupus erythematosus. Autoimmun Rev 2005; 4:296-302. [PMID: 15990077 DOI: 10.1016/j.autrev.2005.01.003] [Citation(s) in RCA: 109] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/01/2005] [Accepted: 01/04/2005] [Indexed: 11/30/2022]
Abstract
The skin findings seen in lupus erythematosus can present with either lupus-specific or lupus-nonspecific findings, with lupus-specific skin disease showing findings histopathologically distinct for cutaneous lupus erythematosus. Lupus-specific skin diseases include chronic cutaneous, subacute cutaneous, and acute cutaneous lupus erythematosus. The types of skin lesions in each group are clinically distinct and recognizing the specific subsets helps in prognosticating the likelihood of underlying systemic lupus. A number of medications are associated with cutaneous lupus, in particular with subacute cutaneous lupus erythematosus. Lupus nonspecific skin lesions are not histopathologically distinct for cutaneous lupus and/or may be seen as a feature of another disease process. Nonspecific disease-related skin lesions are frequently seen in patients with SLE, usually in the active phase of the disease. The current ACR classification criteria for SLE include four somewhat overlapping dermatologic criteria, butterfly rash, discoid lupus, photosensitivity, and oral ulcers and thus patients can be classified as having SLE with only skin manifestations.
Collapse
Affiliation(s)
- Victoria P Werth
- Department of Dermatology, University of Pennsylvania, Philadelphia V.A. Hospital, 2 Rhoads Pavilion, 36th and Spruce Sts, Philadelphia, PA 19104, United States.
| |
Collapse
|
43
|
Wouters CHP, Diegenant C, Ceuppens JL, Degreef H, Stevens EAM. The circulating lymphocyte profiles in patients with discoid lupus erythematosus and systemic lupus erythematosus suggest a pathogenetic relationship. Br J Dermatol 2004; 150:693-700. [PMID: 15099365 DOI: 10.1111/j.0007-0963.2004.05883.x] [Citation(s) in RCA: 40] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
BACKGROUND Discoid lupus erythematosus (DLE) and systemic lupus erythematosus (SLE) are chronic inflammatory diseases of unknown aetiology; the relationship of DLE with SLE has been a subject of debate for many years. OBJECTIVES; To find evidence for systemic immune activation in DLE by analysis of the immunophenotypic profiles of circulating lymphocytes, and to compare these changes with those in patients with SLE. METHODS The immunophenotypic profile of peripheral blood lymphocyte subsets from 23 DLE patients without clinical or laboratory evidence of systemic disease, 25 SLE patients and 38 healthy donors was characterized by two-colour immunofluorescence flow cytometry analysis. None of the patients was receiving corticosteroid or immunosuppressive treatment. RESULTS Patients with DLE had increased numbers of circulating HLA-DR+ CD3+ T cells and HLA-DR+ CD4+ T cells, indicating systemic T-cell activation, and an expansion of CD5+ CD19+ B cells. Decreased numbers of T-cell subsets expressing the differentiation markers CD11b and CD16/56, and of CD16/56+ natural killer cells were also found. In SLE, the changes were similar but more pronounced. In addition, a profound CD4+ T-cell lymphopenia and an increase of HLA-DR+ CD8+ T cells were found only in SLE. CONCLUSIONS Our data provide evidence for systemic activation of the cellular immune system in patients with purely cutaneous DLE. Similarities in the lymphocyte immunophenotypic profiles in patients with DLE compared with SLE suggest that there are common immunopathological processes in these two conditions.
Collapse
Affiliation(s)
- C H P Wouters
- Department of Dermatology, University Hospital Gasthuisberg, Herestraat 49, 3000 Leuven, Belgium.
| | | | | | | | | |
Collapse
|
44
|
Abstract
Cutaneous lupus erythematosus (CLE) includes a variety of lupus erythematosus (LE)-specific skin lesions that are subdivided into three categories - chronic CLE (CCLE), subacute CLE (SCLE) and acute CLE (ACLE) - based on clinical morphology, average duration of skin lesions and routine histopathologic examination. This paper describes our personal experience in the management of CLE over the last 30 years, with details on preferential therapeutic options related to clinical, histologic and immunopathologic aspects of each clinical subset of the disease. Effective sunscreening and sun protection are considered the first rule in the management of CLE because of the high degree of photosensitivity of the disease. Antimalarial agents are crucial in the treatment of CLE and are the first-line systemic agents, particularly in discoid LE (DLE) and SCLE. Dapsone is the drug of choice for bullous systemic LE (BSLE) as well as for LE in small dermal vessels (e.g. leukocytoclastic vasculitis). Retinoids, known as second-line drugs for systemic therapy, are sometimes used to treat chronic forms of CLE and are particularly successful in treating hypertrophic LE. Systemic immunosuppressive agents are required to manage the underlying systemic LE disease activity in patients with ACLE. These drugs, especially azathioprine, methotrexate, cyclophosphamide and cyclosporine, together with corticosteroids, constitute third-line systemic therapy of CLE. In our experience, oral prednisone or parenteral 'pulsed' methylprednisolone are useful in exacerbations of disease activity. Thalidomide provides one of the most useful therapeutic alternatives for chronic refractory DLE, although its distribution is limited to a few countries because of the risk of teratogenicity and polyneuropathy. However, medical treatment with local corticosteroids remains the mainstay of CLE treatment, especially for DLE. Patient education regarding the disease is also important in the management of CLE, because it helps relieve undue anxiety and to recruit the patient as an active participant in the treatment regimen.
Collapse
Affiliation(s)
- Paolo Fabbri
- Department of Dermatological Sciences, University of Florence, Florence, Italy.
| | | | | | | |
Collapse
|
45
|
Morihara K, Kishimoto S, Shibagaki R, Takenaka H, Yasuno H. Follicular lupus erythematosus: a new cutaneous manifestation of systemic lupus erythematosus. Br J Dermatol 2002; 147:157-9. [PMID: 12100201 DOI: 10.1046/j.1365-2133.2002.04728.x] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
We report the clinical, histopathological and immunological features of follicular erythema and petechiae in a 30-year-old Japanese woman with systemic lupus erythematosus (SLE). Histology showed this eruption to constitute a cutaneous manifestation of SLE. To our knowledge, this is the first reported case of follicular erythema and petechiae in association with SLE. Accordingly, we propose that this rare eruption be termed 'follicular lupus erythematosus'.
Collapse
Affiliation(s)
- K Morihara
- Department of Dermatology, Kyoto Prefectural University of Medicine, 465 Kajii-cho, Kawaramachi Hirokoji, Kamigyo-ku, Japan.
| | | | | | | | | |
Collapse
|
46
|
Zecević RD, Vojvodić D, Ristić B, Pavlović MD, Stefanović D, Karadaglić D. Skin lesions--an indicator of disease activity in systemic lupus erythematosus? Lupus 2001; 10:364-7. [PMID: 11403268 DOI: 10.1191/096120301675962535] [Citation(s) in RCA: 50] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Cutaneous manifestations have great diagnostic value for systemic lupus erythematosus (SLE). In this study we tried to establish a correlation between lupus erythematosus LE-specific and LE-nonspecific cutaneous lesions and disease activity measured by the Systemic Lupus Erythematosus Disease Activity Index (SLEDAI). Sixty-six patients with SLE were evaluated. They were divided into three groups having: (1) only LE-specific lesions (38 or 58.46%); (2) only LE-nonspecific lesions (4 or 6.15%); and (3) both types of lesions (23 or 35.38%). Results were analyzed using the Student t-test. Patients with LE-nonspecific skin manifestations had significantly increased disease activity compared to those with only LE-specific lesions. The number of different skin lesion types also correlated with disease activity. It was significantly increased in a group with three different types of lesion, either specific or nonspecific. Patients with only one type of lesion had mild disease. An intermediate disease activity was found in the group with two different lesion types. Lupus-specific skin manifestations serve primarily as an important diagnostic clue. In conclusion, patients with LE-nonspecific lesions have significantly more active SLE than those with LE-specific lesions and may therefore require more intensive therapy and disease monitoring.
Collapse
Affiliation(s)
- R D Zecević
- Department of Dermatology, Military Medical Academy, Belgrade, Yugoslavia.
| | | | | | | | | | | |
Collapse
|
47
|
Abstract
The presentation of lupus erythematosus (LE) ranges from a skin rash unaccompanied by extracutaneous stigmata to a rapidly progressive lethal multiorgan disease. The diagnosis and subclassification is traditionally based on the correlation of serological and clinical findings. The latter include a photoinduced skin rash, arthralgia, arthritis, fever, Raynaud's phenomenon, anemia, leukopenia, serositis, nephritis and central nervous sysdtem disease. The conventional classification scheme includes systemic, subacute cutaneous and discoid LE. Recent advances in our understanding of the cutaneous histopathology which correlates with the traditional forms of LE, along with certain novel LE subtypes, are the focus of this review. In addition to the main subtypes of LE, we will discuss associated vasculopathic lesions and the contribution of immunofluorescence microscopy to the diagnosis of LE and related connective tissue disease syndromes. Consideration will be given to unusual variants of LE such as anti-Ro/SSA-positive systemic lupus erythematosus (SLE), bullous SLE, lymphomatoid LE, lupus erythematosus profundus, drug induced LE, linear cutaneous LE, chiblains LE and parvovirus B19-associated LE.
Collapse
Affiliation(s)
- A N Crowson
- Central Medical Laboratories, Winnipeg, MB, Canada.
| | | |
Collapse
|
48
|
Abstract
Photosensitivity and induction of skin lesions following UV radiation is a common problem of patients with cutaneous and systemic forms of lupus erythematosus. The detrimental effect of UV radiation to patients with lupus erythematosus was already recognized in the last century. Skin lesions can now be provoked under standardized conditions allowing the diagnosis and classification of patients with photosensitive disorders. The aim of this review is to give an overview on the history, test procedure and test results in patients with lupus erythematosus.
Collapse
Affiliation(s)
- M Walchner
- Department of Dermatology, Ludwig-Maximilians-University of Munich, Germany
| | | | | |
Collapse
|
49
|
Sontheimer RD. The lexicon of cutaneous lupus erythematosus--a review and personal perspective on the nomenclature and classification of the cutaneous manifestations of lupus erythematosus. Lupus 1997; 6:84-95. [PMID: 9061656 DOI: 10.1177/096120339700600203] [Citation(s) in RCA: 125] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Affiliation(s)
- R D Sontheimer
- Department of Dermatology, University of Texas Southwestern Medical Center, Dallas, USA
| |
Collapse
|
50
|
Abstract
The prevalence rates of systemic lupus erythematosus (SLE) may vary within 17-48/100,000 population worldwide. Although population-based epidemiological studies are still missing, the cutaneous variants of lupus erythematosus (LE) are 2-3 times more frequent than SLE itself. The most common age of onset is 20-40 y. Overall, cutaneous LE is regarded as a variant with less severe course and better prognosis. However, CDLE and SCLE last for many years and may lead, like SLE, to severe disability for work and limited life quality; also, a small proportion of patients with cutaneous LE develops SLE during the course of their disease. This implies considerable amount of medical management and costs for the community. Early recognition of cutaneous LE patients at risk to develop SLE and preventive measures against disease triggering factors are important tasks for physicians attending with cutaneous LE patients. It seems that signs of nephropathy, elevated ANA-titers and arthralgias may serve as prognostic predictors for transition into SLE. Characteristic features of cutaneous LE are photosensitivity and female predominance. UV light is a major environmental triggering factor in cutaneous LE. Skin lesions may be induced or preexistent lesions may exacerbate due to UV light in up to 80-90% of all patients. Therefore, socioeconomic counseling of the young patients, for example choice of occupation and sun protection, are essentials in compliant patients. Also, since females are 3-6 times more frequently affected than males, the possibility of hormonal influences including pregnancy and estrogen-containing drugs should be discussed. Risk considerations for females wishing to become pregnant are required, and avoidance of estrogen-containing contraceptives should be recommended.
Collapse
Affiliation(s)
- B Tebbe
- Department of Dermatology, University Medical Benjamin Franklin, Free University of Berlin, Germany
| | | |
Collapse
|