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Case 390

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A 42-year-old female patient reports the appearance of persistent “red spots” for approximately 1 year. They started in the face, progressing to the chest, upper limbs, scalp and ears. She also mentions sporadic mild pruritus, photosensitivity, dry mouth and fatigue. Physical examination showed the presence of erythematous papules and plaques with irregular borders. Laboratory tests: ANF non-reagent, ESR = 4mm, anti-DNA non-reagent, anti-Sm non-reagent, anti-Ro non-reagent, and anti-La non-reagent.

Based on the case report and analysis of the images, what is the most likely diagnosis?

a) Tuberculoid leprosy

25%

b) Psoriasis

25%

c) Discoid Lupus Erythematosus

25%

d) Sarcoidosis

25%
   

Image Analysis

Image 1: Presence of an erythematous plaque of irregular contour on the scalp (red circle) in the parietal region.

Image 2: Presence of plaque (blue circle) and papule (green circle) in the patient's upper dorsal region. The papules are solid and circumscribed elevations, up to 1 cm, while the plaques are elevated lesions with a diameter greater than 1 cm, which may be due to the confluence of papules. Both erythematous, infiltrated and with irregular edges. Scales are adhered to the surface of the plate.

Image 3: Presence of diffuse erythematous papules (pink circles) in the retroauricular region, extending to the lateral and posterior region of the neck. The lesions are infiltrated and they have irregular contours.

Highlights

-       Lupus erythematosus most commonly affects the female and black population, aged 15 to 44 years;

-       It can appear in isolation on the skin or associated with manifestations in other organs, configuring SLE. The most prevalent chronic subtype of cutaneous lupus erythematosus is the discoid, the presence of which does not necessarily suggest the evolution of the disease to the systemic form;

-       The pathophysiology of lupus erythematosus involves the loss of immunological tolerance due to a genetic susceptibility, with the production of autoantibodies that are activated after interaction with environmental stimuli;

-       The diagnosis is clinical and biopsy may be requested in cases that raise doubts. ANF may or may not be present;

-       The standardization of preventive measures such as smoking cessation, use of sunscreen and physical barriers against light are important for a good prognosis, as well as early pharmacological treatment.

References

-       Clarke J. Initial management of discoid lupus and subacute cutaneous lupus. Uptodate [Internet] 2020. Available from: https://www.uptodate.com/contents/initial-management-of-discoid-lupus-and-subacute-cutaneous-lupus.

-       Merola J. Overview of cutaneous lupus erythematosus. Uptodate [Internet] 2020. Available from: https://www.uptodate.com/contents/overview-of-cutaneous-lupus-erythematosus.

-       Azulay R, Azulay D, Azulay-Abulafia L. Dermatologia. 6ª ed. 2013.

-       Goldman L, Ausiello D. Cecil Medicina Interna. 24ª ed. 2012.

Author

André Luiz Marzano de Assis, 5th year medical student at Universidade Federal de Minas Gerais (UFMG).

Mail: andre_marzano[at]hotmail.com

Supervisor

Débora Cerqueira Calderaro, adjunct professor at the Department of Locomotor Apparatus at UFMG and rheumatologist at Hospital das Clínicas of UFMG.

Mail: dccalderaro[at]gmail.com

Reviewers

Lara Hemerly De Mori, Melina Assunção Gomes de Araújo, Mateus da Costa Monteiro, Raphael Dias, Aristeu Fonseca and professor Júlio Guerra Domingues.

Translated by

Renata Aguiar Menezes Silva, 5th year medical student at UFMG.

Mail: renata.aguiar.16[at]gmail.com

Test question

[HDT-UFT 2015] Regarding lupus lesions, check the INCORRECT alternative.

a) Subacute cutaneous lupus is closely related to photosensitivity.

25%

b) Lupus discoid lesions on the scalp respond well to treatment with thalidomide.

25%

c) Bullous lupus is characterized by aggression against type 7 collagen.

25%

d) Tumid lupus is a rare subtype of chronic cutaneous lupus erythematosus.

25%

e) Discoid lupus lesions are the most associated with systemic lupus erythematosus.

25%
   

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