Subacute cutaneous lupus erythematosus in Adult
Acute cutaneous lupus erythematosus (ACLE)
- Transient cutaneous findings typified by malar erythema without scarring
- Strongly associated with systemic findings
- Inflammatory infiltrate seen in the superficial dermis on biopsy
- Photosensitive cutaneous eruption lasting longer than ACLE but without scarring
- 10%-15% of patients go on to have systemic findings
- Inflammatory infiltrate seen in the upper dermis on biopsy
- Also known as discoid lupus erythematosus (DLE)
- Chronic discoid lesions with permanent disfiguring scars
- 5%–10% of patients go on to develop systemic findings
- Significant inflammatory infiltrate seen in superficial and deep dermis as well as prominent involvement of the adnexa on biopsy
While the etiology remains poorly understood, there is a strong association with anti-Ro antibodies and SCLE. It is hypothesized that a complex interplay between genetic proclivity and environmental influences leads to a perpetuated autoimmune response. In addition, specific HLA types (HLA-B8, DR3, DRw52, DQ1) have been shown to be associated with lupus erythematosus. Risk factors for developing cutaneous lesions include sex (3:1 female-to-male ratio, especially during childbearing years) and ethnicity, with individuals of African descent demonstrating a higher incidence when compared to whites. Epidemiologic studies have shown that people of Hispanic, Asian, African American, and African Caribbean descent have an increased incidence of lupus in addition to excess morbidity.
Of note, certain drugs such as hydrochlorothiazide, terbinafine, and other antihypertensives, such as calcium channel blockers and angiotensin converting enzyme (ACE) inhibitors, and nonsteroidal anti-inflammatory drugs have been reported to trigger SCLE. These drug-induced SCLE lesions run an unpredictable course, and they may not clear after discontinuing the offending drug. Several different classes of chemotherapeutic agents have been reported as causing SCLE.
Photosensitivity is a prominent feature. Approximately 50% of patients meet American Rheumatism Association (ARA) criteria of SLE. About 10% of patients can develop acute cutaneous lupus or lesions of discoid lupus (chronic cutaneous lupus). In addition, anti-Ro antibodies are also seen in Sjögren syndrome, and some patients can have both SCLE and Sjögren syndrome.
L93.1 – Subacute cutaneous lupus erythematosus
239891002 – Subacute cutaneous lupus erythematosus
- Granuloma annulare – Mainly in children and young adults, biopsy will help differentiate granuloma annulare and SCLE; facial lesions are extremely rare.
- Tinea corporis – Usually has scale at the leading edge. Check potassium hydroxide (KOH).
- Erythema marginatum – Seen more commonly in children; cutaneous feature of acute rheumatic fever.
- Polymorphous light eruption – Most lesions resolve within several days.
- Erythema multiforme – Characteristic targetoid lesions; tends to involve the palms.
- Annular psoriasis – Biopsy will assist in differentiating psoriasis from SCLE.
- Annular urticaria – Wheals that are characteristically pruritic.
- Erythema annulare centrifugum (EAC) – Mostly seen on hips and thighs in patients in their 50s; biopsy can help differentiate EAC from SCLE. Usually has scale trailing the leading edge.
- Sarcoidosis – More infiltrative plaques.
- Lichen planus – Pruritic, scaly papules that involve the wrists, forearms, genitalia, and presacral area; biopsy will assist in differentiating lichen planus from SCLE.
- Syphilis – Check RPR.
- Drug-induced photosensitive reaction
- Drug-induced photoallergic reaction