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Lupus erythematosus, discoid II
PATHOLOGICAL FINDINGS: • Hyperkeratosis
• Epidermal atrophy
• Liquefactive degeneration of basal cell layer
• Edema, mucin, and inflammation of dermis
• Follicular plugging
• Basement zone thickened with strong periodic acid-Schiff reaction staining
SPECIAL TESTS: Immunofluorescent staining of skin biopsies (lupus band test)
IMAGING: N/A
DIAGNOSTIC PROCEDURES: Skin biopsy
TREATMENT APPROPRIATE HEALTH CARE: Outpatient
GENERAL MEASURES: Avoid sun exposure, avoid excessive heat, cold, or trauma
SURGICAL MEASURES: N/A
ACTIVITY: Full activity
DIET: Regular
PATIENT EDUCATION: • Teach patients proper use of sunscreens and other measures to prevent sun exposure (e.g., wide-brimmed hats, long sleeves, etc.)
• Advise patient about symptoms of systemic lupus erythematosus (SLE) that should be watched for
• Griffiths: Instructions for Patients, Philadelphia, W.B. Saunders Co.
MEDICATIONS DRUG(S) OF CHOICE: • Localized DLE:
• Low to medium potency topical corticosteroid (eg, triamcinolone 0.1% bid to all active lesions
• If no response in 2-3 weeks, move to higher potency topical corticosteroid applied tid (eg, betamethasone) with or without occlusion
• Intralesional corticosteroid (eg, triamcinolone 2.5-5 mg/mL for the face or 5-10 mg/mL elsewhere) for resistant lesions. Use 0.5 mL per 1 cm plaque.
• Widespread DLE:
• Hydroxychloroquine 200 mg or chloroquine 250 mg qd or bid and/or quinacrine 100 mg daily
• Short-term (1-2 weeks) of topical corticosteroids is helpful at the same time antimalarials are being started
Contraindications: Antimalarials such as hydroxychloroquine may have to be avoided in patients with preexisting retinal or hepatic disease. Do not give to individuals with G6PD deficiency. Quinacrine rarely causes hematologic cytopenia.
Precautions:
• Observe for skin atrophy with topical steroids especially with use on the face
• Patients on antimalarials should have an eye examination by an ophthalmologist at start of treatment and at 6 month intervals to monitor signs of retinal damage
Significant possible interactions: N/A
ALTERNATIVE DRUGS: • Localized DLE: Intralesional triamcinolone 2.5 mg/cc injected at monthly intervals. Prednisone 15 mg bid, then tapered after response.
• Widespread DLE: Quinacrine 100 mg qd, dapsone 100 mg qd, azathioprine 100 mg qd. Systemic retinoid, eg, etretinate 1 mg/kg; thalidomide is also effective
FOLLOW UP PATIENT MONITORING: • Recheck patients once or twice per month
• Ophthalmology followup at 6 month intervals if patient on antimalarial
• If lesions subside, reduce dosage of antimalarials over 2-3 months, then discontinue
PREVENTION/AVOIDANCE: Avoid sun exposure or excessive heat, cold, or skin trauma
POSSIBLE COMPLICATIONS: Hypertrophic scarring, hypopigmentation (especially in blacks)
EXPECTED COURSE AND PROGNOSIS: • 40% remit completely; 1-5% may develop systemic lupus (these patients usually have widespread DLE)
• Not life-threatening unless it turns into systemic type
MISCELLANEOUS ASSOCIATED CONDITIONS: • Systemic lupus erythematosus
• Mixed connective tissue disease (MCTD)
• Antiphospholipid syndrome
AGE-RELATED FACTORS:
Pediatric: Neonatal lupus erythematosus is a syndrome of cutaneous lupus and/or congenital heart block. It is caused by transplacental passage of one of several maternal antibodies.
Geriatric: N/A
Others: N/A
PREGNANCY: N/A
SYNONYMS: • Chronic cutaneous lupus erythematosus
ICD-9-CM: 695.4 Lupus erythematosus (local, discoid)
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