Cutaneous Lupus Erythematosus in Patients with Darker Skin

00:01 Welcome to our lecture on cutaneous lupus erythematosus.

00:05 It's a diverse group of autoimmune connective tissue disorders which are localized to the skin. It can be associated with systemic lupus erythematosus.

00:16 4 in 100,000 people get this condition.

00:22 It's more common in women, particularly those between 20 and 50 years of age. It is multifactorial, but there is genetic susceptibility.

00:34 Environmental factors have been implicated smoking, sun exposure, medications, and innate and adaptive immune responses.

00:47 Clinically, cutaneous lupus erythematosus has multiple clinical variants as listed as acute, subacute, and chronic.

00:58 Now let's take a look at acute cutaneous lupus.

01:02 It can be localized or generalized.

01:04 Localized presents as malar or butterfly rash that lasts for hours, days, or weeks. In the butterfly area, the nasolabial folds are spared, which is unlike seborrheic dermatitis, which can be confused with.

01:21 The involved skin, feels warm and is slightly edematous.

01:27 Generalized acute cutaneous lupus usually presents as erythematous, maculopapular, or morbilliform eruption involving primarily sun exposed skin.

01:38 The differential diagnosis in general can be rosacea, seborrheic dermatitis, and contact dermatitis.

01:49 How about subacute cutaneous lupus erythematosus? This usually presents as psoriasis form papulosquamous rash or annular polycyclic plaques with central clearing.

02:02 The predilection sites use include the upper limbs and trunk, and they are triggered or aggravated by sun exposure.

02:12 Subacute differential involves psoriasis, tinea corporis, and discoid eczema, or nummular eczema.

02:22 Now let's take a look at chronic cutaneous lupus erythematosus.

02:27 This is the most common form of cutaneous lupus, has a few different forms from which discoid lupus erythematosus is the most common one.

02:37 Now let's look at discoid lupus erythematosus, or DLE. 25% of patients with SLE may develop typical discoid lesions at some point during the illness. 1 to 5% of patients with DLE will develop SLE.

02:54 It's more common in patients with black skin or skin of color patients.

02:59 The tendency to develop the disease at an earlier age is common in this group, and there's a higher mortality rate associated with it.

03:10 DLE or discoid lupus erythematosus can present as two distinct types.

03:15 The localized type, this is the most common type, that is, 80% of the cases they have lesions above the neck.

03:23 Generalized type, 20% of the cases it's less common, and the lesions are seen above and below the neck, and these patients with generalized lupus, a generalized DLE, have a higher chances of of developing systemic lupus erythematosus, and DLE usually presents as dry red patches that evolve to form red plaques with a adherent scale. There's usually follicular hyperkeratosis, which is quite common, and the scalp is involved and it may lead to cicatricial alopecia. So it's one of the causes of secondary scarring alopecia.

04:05 The differential diagnosis includes tinea fasciae, lupus vulgaris, and sarcoidosis.

04:12 One interesting fact about DLE if it involves the face, you also tend to commonly get involvement of the ear lobes inside the ear.

04:22 So always look at that area if you want to exclude DLE.

04:28 So we spoke about clinical manifestations.

04:30 Now we're going to talk about the complications.

04:32 The complications are for all the different types of cutaneous lupus.

04:37 It can progress to SLE but it depends on the type of cutaneous lupus erythematosus.

04:44 For example, more than 90% of patients with acute cutaneous lupus erythematosus eventually develop systemic lupus.

04:52 Patients with subacute cutaneous lupus erythematosus have around 50% chance to develop systemic lupus erythematosus.

05:01 Only 5 to 10% of patients with localized discoid lupus develop SLE during their lifetime. Around 15 to 30% of patients with generalized DLE will develop SLE.

05:16 Other complications include post-inflammatory hyperpigmentation, scarring, cicatricial hair loss, and cutaneous squamous cell carcinoma.

05:29 The diagnosis can be made and confirmed by doing a skin biopsy, and this is sent for histopathology and immunofluorescence.

05:39 The blood tests involve the following to ensure that there is no involvement of the systemic organs. Specific serology, which is ANA and ENA, is also essential when suspecting cutaneous lupus erythematosus.

05:55 The management involves sun protection and avoidance, use of broad spectrum sunscreen, avoiding smoking, or stopping smoking because smoking can actually even impair the effect of medication. Specific measures include local therapy, which includes topical steroids, and systemic therapy includes antimalarials, immune modulators, methotrexate, mycophenolate, and systemic corticosteroids.

06:30 It's important to note that it's been shown in the literature that patients who smoke and use chloroquine, it makes it difficult, it impairs the function of hydroxychloroquine, and there's less efficacy of the drug in smokers, that is, patients who have lupus and are smoking.