Atypical Dyschromia in Skin of Color

Dyschromia is a concern for many patients, especially persons of color. Postinflammatory hypopigmentation and depigmentation can affect all skin types; however, it is more apparent in those with darker skin. Some members of the dermatology community may not comprehensively understand the mechanisms of these reactions and the extent of the psychosocial effect they have on persons of color. Skin of color patients experiencing a decrease or loss of pigmentation are left with few treatment options, with no available evidence-based treatment established from a sufficient sample size. Several diseases may present with hypopigmentation and/or depigmentation despite this not being a major criterion for these conditions, including atopic dermatitis, lichen planus, discoid lupus erythematosus, polymorphous light eruption, and scleroderma. Here, we present three cases of atypical dyschromia in skin of color to highlight the underlying hypo- and depigmentation that may present with active disease and persist despite appropriate treatment.  Practice Points: 1. These cases foreground the potential for a range of dermatologic conditions to result in atypical pigment changes in persons of color. 2. Postinflammatory hypopigmentation or depigmentation may persist in skin of color despite the regression of active disease.J Drugs Dermatol. 2024;23(2):100-102.     doi:10.36849/JDD.7683.

Atorvastatin-induced Lupus Erythematosus Tumidus: A Case Report and Literature Review

Lupus erythematosus tumidus (LET) is a rare photosensitive skin disease classified as a separate subtype of cutaneous lupus erythematosus. Clinically, it is characterized by erythematous plaques on sun-exposed areas. Typical histopathological findings are perivascular and periadnexal lymphohistiocytic infiltrates and prominent mucin deposition in the dermis. Treatment is based on photoprotection, topical corticosteroids, and antimalarial drugs. The exact pathogenesis of the disease is unknown. Drugs are considered a minor risk factor for the development of LET. We present a case of a 56-year-old woman who developed LET after starting treatment with atorvastatin. We describe her clinical course and review the literature concerning the cutaneous adverse reactions induced by statin drugs. To our knowledge, this is the first case of statin-induced LET. We conclude that statins can induce LET and that it is important for clinicians to be aware of this potential adverse effect associated with statins.

Intralesional Certolizumab for Refractory Lupus Pernio

This case report describes a patient with refractory lupus pernio that responded to treatment with a series of intralesional certolizumab injections.

Risk factors of progression from discoid lupus to severe systemic lupus erythematosus: a registry-based cohort study of 164 patients

BACKGROUND

No study has assessed the risk factors of progression from discoid lupus erythematosus (DLE) to severe systemic lupus erythematosus (sSLE) (defined as requiring hospitalization and specific treatment).

OBJECTIVE

To identify the risks factors of and generate a predicting score for progression to sSLE among patients with isolated DLE or associated with systemic lupus erythematosus with mild biological abnormalities.

METHODS

In this registry-based cohort study, multivariable analysis was performed using risk factors identified from literature and pruned by backward selection to identify relevant variables. The number of points was weighted proportionally to the odds ratio (OR).

RESULTS

We included 30 patients with DLE who developed sSLE and 134 patients who did not. In multivariable analysis, among 12 selected variables, an age of <25 years at the time of DLE diagnosis (OR, 2.8; 95% CI, 1.1-7.0; 1 point), phototype V to VI (OR, 2.7; 95% CI, 1.1-7.0; 1 point), and antinuclear antibody titers of ≥1:320 (OR, 15; 95% CI, 3.3-67.3; 5 points) were selected to generate the score. Among the 54 patients with a score of 0 at baseline, none progressed to sSLE, whereas a score of ≥6 was associated with a risk of approximately 40%.

LIMITATIONS

Retrospective design.

CONCLUSION

In our cohort, an age of <25 years at the time of DLE diagnosis, phototype V to VI, and antinuclear antibody titers of ≥1:320 were risk factors for developing sSLE.

Recent advances in cutaneous lupus

Cutaneous lupus erythematosus (CLE) is an inflammatory and autoimmune skin condition that affects patients with systemic lupus erythematosus (SLE) and exists as an isolated entity without associated SLE. Flares of CLE, often triggered by exposure to ultraviolet (UV) light result in lost productivity and poor quality of life for patients and can be associated with trigger of systemic inflammation. In the past 10 years, the knowledge of CLE etiopathogenesis has grown, leading to promising targets for better therapies. Development of lesions likely begins in a pro-inflammatory epidermis, conditioned by excess type I interferon (IFN) production to undergo increased cell death and inflammatory cytokine production after UV light exposure. The reasons for this inflammatory predisposition are not well-understood, but may be an early event, as ANA + patients without criteria for autoimmune disease exhibit similar (although less robust) findings. Non-lesional skin of SLE patients also exhibits increased innate immune cell infiltration, conditioned by excess IFNs to release pro-inflammatory cytokines, and potentially increase activation of the adaptive immune system. Plasmacytoid dendritic cells are also found in non-lesional skin and may contribute to type I IFN production, although this finding is now being questioned by new data. Once the inflammatory cycle begins, lesional infiltration by numerous other cell populations ensues, including IFN-educated T cells. The heterogeneity amongst lesional CLE subtypes isn't fully understood, but B cells appear to discriminate discoid lupus erythematosus from other subtypes. Continued discovery will provide novel targets for additional therapeutic pursuits. This review will comprehensively discuss the contributions of tissue-specific and immune cell populations to the initiation and propagation of disease.

Treatment of Hyperpigmented Discoid Lupus Erythematosus With Jessner's Peel: A Case Report

Discoid lupus erythematosus (DLE) is the most common type of chronic cutaneous lupus erythematosus and is categorized by well-demarcated, often hyper or hypopigmented macules or papules that gradually progress into discoid plaques. Lesions are most commonly found above the neck, particularly on the face, scalp, and ears.1.

LLDAS is an attainable treat-to-target goal in childhood-onset SLE

OBJECTIVES

To study whether clinical remission (CR) and Low Lupus Disease Activity State (LLDAS) are achievable goals in childhood-onset SLE.

METHODS

Data on medication use and disease activity were prospectively collected. LLDAS was defined as Safety of Estrogen in Lupus Erythematosus National Assesment-SLE disease Activity Index (SELENA-SLEDAI) ≤4 with zero scores for renal, Central Nervous System (CNS), serositis, vasculitis and constitutional components, no increase in any SLEDAI component since the previous visit, PGA ≤1, and prednisone dose ≤7.5 mg/day. CR on treatment (Tx) was defined as a Physician Global Assessment <0.5, SELENA-SLEDAI=0, with prednisone ≤5 mg/day and maintenance treatment with immunosuppressives. CR off Tx was the same but without prednisone or other immunosuppressive usage.

RESULTS

51 patients (700 visits) were included. Within 3 months after diagnosis, 94.1% of children were treated with hydroxychloroquine and 60.8% with prednisone. Prednisone dosage decreased from a median of 0.74 mg/kg/day at diagnosis to 0.44 mg/kg/day at 3 months and 0.16 mg/kg/day at 6 months after diagnosis. Use of mycophenolate mofetil increased from 25.5% to 56.9% within 6 months after diagnosis. All children achieved LLDAS (median 186 days) and 72.5% remained in LLDAS >50% of time. 52.9% children achieved CR on Tx, and only 21.6% children achieved CR off Tx.

CONCLUSIONS

LLDAS is an attainable treat-to-target goal in contrast to CR on and off Tx. Even more, LLDAS can be reached with limited use of corticosteroids with early introduction of immunosuppressives.

Pneumococcal Vaccination Among Lupus Patients: Who Are the Recipients?

PURPOSE

Pneumococcal vaccination (PV) is indicated for the elderly (age ≥65 years) and those with chronic disease or who are immunosuppressed. We aimed to study the rate and predictors of recommendation/receipt of 23 valent pneumococcal polysaccharide vaccine (PPSV23) in immunosuppressed systemic lupus erythematosus (SLE) patients.

METHODS

Data were obtained through self-report questionnaires and medical chart review of 150 SLE patients. Information on rheumatologist recommendation or receipt of PPSV23 in the preceding 5 years was collected if self-reported in a questionnaire or documented in the medical chart. Chart review was also done to collect data on patient demographics, physician characteristics (if patients had a primary care physician and rheumatologist's SLE patient volume), and the disease characteristics of SLE. Comparisons using χ2 or t tests and logistic regression analyses were conducted for predictors of recommendation/receipt of PV.

RESULTS

The mean (SD) age was 47.4 (15.9) years; 90% were women. Sixty-five of 94 eligible patients for PV (based on immunosuppressive medications use or age) had been either recommended or administered PPSV23. On univariate logistic regression analysis, age, duration of disease, current use of hydroxychloroquine or mycophenolate, and rheumatologist's SLE patient volume were significant correlates of recommendation/receipt of PPSV23. However, on multivariate analysis, the only significant predictor was rheumatologist's SLE patient volume after adjusting for the above correlates such that with every 50 patients increase in SLE patient clinic volume, the odds of recommendation/receipt of PPSV23 increased by 2.37 times.

CONCLUSIONS

The volume of lupus patients that rheumatologists see is strongly associated with the likelihood that their SLE patients will have PPSV23 recommended and delivered, suggesting a volume outcome relationship.

Tumid lupus erythematosus and systemic lupus erythematosus: a rare coexistence

A patient diagnosed with tumid lupus erythematosus (TLE) was subsequently found to have systemic lupus erythematosus (SLE) after presenting to a tertiary care medical centre with shortness of breath and oedema. In this commentary, we discuss this patient's presentation and the association between TLE and SLE.

What's wrong with neutrophils in lupus?

Polymorphonuclear neutrophils (PMNs) act by promoting phagocytosis, and are regarded as the first line of defense against pathogen invasion. However, recent investigations have revealed that they have many previously unknown functions. These functions include mitogen-induced cell-mediated cytotoxicity, production of cytokines/chemokines/growth factors, and release of neutrophil extracellular traps (NETs) and ectosomes/exosomes. Membrane exchange (trogocytosis) is also noted following direct cell-cell contact with other immune cells for modulating innate and adaptive immune responses. These observations strongly suggest that neutrophils may play an important role in the immune network. Systemic lupus erythematosus (SLE) is a prototype of systemic autoimmune diseases characterised by the production of diverse antigen-driven autoantibodies against intra- and extracellular molecules. Multiple immune dysfunctions have been reported in SLE patients. These include excessive interferon alpha (IFN-α) expression, aberrant cytokine/chemokine/growth factor production, skewing of T cell immune responses toward Th2 and Th17 pathways, polyclonal B cell activation, increased apoptosis and NET formation, defective clearance of cell debris and NET-related molecules, and abnormal ectosome/exosome release in the plasma. We have demonstrated that SLE-PMNs per se exhibit aberrant cytokine/chemokine expression, defective glucose metabolism, and increased mitochondrial DNA D310 heteroplasmy with reduced redox capacity. Our data also indicate that autoantibodies purified from SLE sera disrupt PMN functions. In the present review, we discuss these abnormalities in detail and attempt to elucidate the potential roles of disrupted PMN functions in lupus pathogenesis.

Antibodies to periodontogenic bacteria are associated with higher disease activity in lupus patients

OBJECTIVES

Microbial infections and mucosal dysbiosis influence morbidity in patients with systemic lupus erythematosus (SLE). In the oral cavity, periodontal bacteria and subgingival plaque dysbiosis provide persistent inflammatory stimuli at the mucosal surface. This study was undertaken to evaluate whether exposure to periodontal bacteria influences disease parameters in SLE patients.

METHODS

Circulating antibodies to specific periodontal bacteria have been used as surrogate markers to determine an ongoing bacterial burden, or as indicators of past exposure to the bacteria. Banked serum samples from SLE patients in the Oklahoma Lupus Cohort were used to measure antibody titres against periodontal pathogens (Aggregatibacter actinomycetemcomitans, Porphyromonas gingivalis, and Treponema denticola) and commensals (Capnocytophaga ochracea, and Streptococcus gordonii) by ELISA. Correlations between anti-bacterial antibodies and different clinicalparameters of SLE including, autoantibodies (anti-dsDNA, anti-SmRNP, anti-SSA/Ro and anti-SSB/La), complement, and disease activity (SLEDAI and BILAG) were studied.

RESULTS

SLE patients had varying amounts of antibodies to different oral bacteria. The antibody titres against A. actinomycetemcomitans, P. gingivalis, T. denticola, and C. ochracea were higher in patients positive for anti-dsDNA antibodies, and they showed significant correlations with anti-dsDNA titres and reduced levels of complement. Among the periodontal pathogens, only antibodies to A. actinomycetemcomitans were associated with higher disease activity.

CONCLUSIONS

Our results suggest that exposure to specific pathogenic periodontal bacteria influences disease activity in SLE patients. These findings provide a rationale for assessing and improving periodontal health in SLE patients, as an adjunct to lupus therapies.

Systemic Lupus Erythmatosus is Associated with Disturbed Cytokine Milieu and Increased TNF-Related Apoptosis-Induced Ligand Levels

Systemic lupus erythematosus (SLE) is a prototypic systemic autoimmune disease. Tumor necrosis factor (TNF)-related apoptosis-inducing ligand (TRAIL) is cytotoxic to a wide variety of transformed cells, but not to most normal cells. This study measures serum levels of tumor necrosis factor (TNF)-α, interleukin (IL)-6 and 10 and soluble TRAIL (sTRAIL) in patients with SLE and assesses their relation to severity of the disease. The study included 70 SLE patients and 20 healthy controls. Patients were diagnosed according to criteria proposed by the American Rheumatism Association for classification of SLE and disease activity was scored using the British Isles Lupus Assessment Group (BILAG-2004). All study participants were subjected to estimation of TNF-α, IL-6, IL-10 and sTRAIL using ELISA. Results revealed that mean disease duration was 6.5±1.5 years, mean BILAG score was 18.2±12.1, while 15 patients (21.4%) had quiescent disease. Blood levels of C3 and C4 and leucocytic count showed progressive decrease, while serum C-reactive protein and anti-double strand DNA antibodies levels showed marked increase with increased disease activity. Five patients (7.1%) were neutropenic. Serum levels of sTRAIL and IL-6 were significantly (P>0.05) higher in patients (1113.5±294 ng/ml and 60±21.5 ng/ml, respectively) than controls (354.7±47.2 ng/ml and 15.6±3.3 ng/ml, respectively) and in patients had active (1157±317 ng/ml and 64.3±20.7 ng/ml, respectively) versus patients had quiescent disease (965.4±115 ng/ml and 45.4±18 ng/ml, respectively). Serum levels of TNF-α were significantly (P>0.05) higher in patients (2.4±0.7 ng/ml) especially those with active (2.8±2 ng/ml) disease compared to controls (1.45±0.9 ng/ml). Patients with quiescent disease showed non-significantly higher TNF-α level (1.52±0.5 ng/ml) as compared to control, but significantly lower than patients with active disease. Serum levels of IL-10 were significantly lower in total patients (2.4±0.7 ng/ml) and patients with active disease (2.33±0.7) as compared to control (2.61±0.6 ng/ml) with a non-significantly (P>0.05) higher levels in patients with quiescent disease (2.61±0.6 ng/ml) than patients with active disease. Estimated serum sTRAIL, TNF-α and IL-6 levels showed positive significant correlation with calculated BILAG activity score, while estimated serum IL-10 levels showed negative significant correlation with activity score. In conclusion, SLE is associated with disturbed levels of serum cytokines and sTRAIL. These disturbances may underlie pathogenesis and/or activation of SLE as BILAG-2004 numeric scoring system significantly correlated with estimated levels of serum cytokines and sTRAIL.

[Topical thalidomide having good effect on refractory chronic discoid lupus erythematosus: a case report]

Systemic thalidomide has good effect on refractory chronic discoid lupus erythematosus (CDLE) whereas topical regimen of it has not been reported previously. In this paper, a case of refractory CDLE cured with topical thalidomide in clinic was reported and the feasibility of topical therapy was reviewed.

SEROMUCOID IN LUPUS ERYTHRMATOSUS AND SCLERODERMA

Seromucoid levels in blood of 50 normal men and in 63 cases of cutaneous collagen diseases were studied. There was a marked rise in the seromucoid level in cases of systemic lupus erythematosus and also a significant rise in scleroderma. This rise in seromucoid level may be a reflection of the degenerative connective tissue.