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A 49-year-old woman presents with a complaint of hair loss on the scalp for 8 months. She states the area is itchy and painful. She denies any recent use of chemical or thermal hair relaxers. Medical history is positive for asthma. Examination reveals a 6cm scaly erythematous alopecic plaque on the left side of her scalp. A 4mm punch biopsy reveals hyperkeratosis, follicular plugging, and perivascular and periadnexal lymphoplasmacytic infiltrate with increased mucin. The basement membrane, highlighted by periodic acid-Schiff stain, is thickened.
Discoid lupus erythematosus (DLE) is a common cutaneous manifestation of systemic lupus erythematosus (SLE). Approximately 28% of patients with DLE develop SLE and a small percentage of patients with chronic DLE develop squamous cell carcinoma.1 It most commonly affects Black women...
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Discoid lupus erythematosus (DLE) is a common cutaneous manifestation of systemic lupus erythematosus (SLE). Approximately 28% of patients with DLE develop SLE and a small percentage of patients with chronic DLE develop squamous cell carcinoma.1 It most commonly affects Black women in the fourth or fifth decade of life.2 Discoid lupus erythematosus is an autoimmune condition that is multifactorial. Although most cases of DLE are localized, lesions below the neck can be indicative of more severe disease and possible SLE.
The primary lesion usually consists of a well-defined erythematous plaque with adherent scale, most commonly affecting the scalp, face, ears, and neck. Removal of the scale with tape often reveals keratin horn plugs, known clinically as the carpet-tack sign.3 The lesions are usually asymptomatic but can be tender and pruritic. The lesions can become larger over time and can progress to irreversible scarring alopecia with pigmentary changes, especially in people of color.4
The differential diagnosis of DLE presenting as an alopecic plaque on the scalp should include other papulosquamous entities, such as lichen planopilaris, tinea capitis, and central centrifugal cicatricial alopecia.5 Punch biopsy should be performed for a definitive diagnosis and will reveal hyperkeratosis, follicular plugging, and interface dermatitis with superficial and deep periadnexal and perivascular lymphoplasmacytic infiltrate.6,7
First-line treatment of DLE primarily consists of high-potency topical steroids.8 For patients refractory to topical corticosteroids, alternative therapy with intralesional corticosteroids or calcineurin inhibitors can be initiated.8,9 Patients should be advised of photoprotection and smoking cessation as UV exposure and tobacco use are major risk factors for DLE.8 Some patients may have complete resolution of lesions; however, treatment of DLE can be challenging and most patients heal with scarring and hyperpigmentation.4,10
Batul Momin is a third-year medical student at the Suwannee branch of Philadelphia College of Osteopathic Medicine; Joseph M. Dyer, DO, is a board-certified dermatologist with extensive experience in general and surgical dermatology.
References
1. Chong BF, Song J, Olsen NJ. Determining risk factors for developing systemic lupus erythematosus in patients with discoid lupus erythematosus. Br J Dermatol. 2012;166(1):29-35. doi:10.1111/j.1365-2133.2011.10610.x
2. Gaüzère L, Gerber A, Renou F, et al. (2019). Caractéristiques du lupus érythémateux systémique à La Réunion: étude rétrospective en population adulte au CHU de Saint-Denis [Epidemiology of systemic lupus erythematosus in Reunion Island, Indian Ocean: A case-series in adult patients from a University Hospital]. La Revue de Medecine Interne. 2019;40(4):214-219. https://doi.org/10.1016/j.revmed.2018.07.004
3. Inamadar AC. Perforation of paper with pen: Simple technique to explain the carpet tack sign in discoid lupus erythematosus. J Am Acad Dermatol. 2019;81(6):e159-e160. doi:10.1016/j.jaad.2019.03.039
4. Chen P, Broadbent E, Coomarasamy C, Jarrett P. Illness perception in association with psychological functioning in patients with discoid lupus erythematosus. Br J Dermatol. 2015;173(3):824-6. doi:10.1111/bjd.13709
5. Stefanato CM. Histopathology of alopecia: a clinicopathological approach to diagnosis. Histopathology. 2010;56(1):24-38. doi:10.1111/j.1365-2559.2009.03439.x
6. David Weedon. Weedon’s Skin Pathology, third edition. Elsevier Limited; 2010.
7. McKee PH, Calonje JE, Granter SR. McKee’s Pathology of the Skin, fifth edition. Elsevier; 2012.
8. 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’ Clinical Standards Unit. British Association of Dermatologists guidelines for the management of people with cutaneous lupus erythematosus 2021. Br J Dermatol. 2021;185(6):1112-1123. doi:10.1111/bjd.20597
9. Jessop S, Whitelaw DA, Grainge MJ, Jayasekera P. Drugs for discoid lupus erythematosus. Cochrane Database Syst Rev. 2017;5(5):CD002954. doi:10.1002/14651858.CD002954.pub3
10. Udompanich S, Chanprapaph K, Suchonwanit P. Hair and scalp changes in cutaneous and systemic lupus erythematosus. Am J Clin Dermatol. 2018;19(5):679-694. doi:10.1007/s40257-018-0363-8
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