Vol 58: JulY • JuIllET 2012
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Canadian Family Physician•Le Médecin de famille canadien769
Dermacase
Answer to Dermacase
continued from page 7653. Tumid lupus erythematosus
First reported in the literature in 1930, tumid lupus ery- thematosus (LE) is an uncommon variant of chronic cutaneous LE; it is characterized by multiple smooth, indurated, erythematous to violaceous papules, plaques, or nodules, with no epidermal changes such as scal- ing or atrophy.1-5 The lesions are symmetrical and usu- ally appear on sun-exposed regions of the face, upper back, and chest.1-5 They often resolve without scarring.
Histopathology reveals mild to moderate perivascular and periadnexal lymphocytic infiltrate, both superficial and deep, with increased dermal mucin; interface changes at the dermoepidermal junction are usually absent. When performed, immunohistochemical analysis commonly reveals a predominance of CD3- and CD4-positive lym- phocytes, with a CD4 to CD8 cell ratio of roughly 3 to 1.5 Our patient had similar histopathologic findings.
Patients with tumid LE do not have cutaneous or sys- temic manifestations of systemic LE or other forms of cutaneous LE; rarely, however, coexistent systemic LE or discoid LE is reported. Serologic findings in tumid LE are mostly unremarkable, although antinuclear autoanti- bodies, such as anti–double-stranded DNA, anti-Ro/SSA, and anti-La/SSA antibodies, can be present in weak amounts.1-5 In our patient, antibody titres yielded nega- tive results, while complete blood count, liver function test results, complement levels, and results of urinalysis were all normal.
Differential diagnosis
Clinical differential diagnosis of tumid LE includes pity- riasis rosea, guttate psoriasis, and sarcoidosis.6-8 Pityriasis rosea is a self-limiting, pruritic, papulosquamous eruption that usually involves the trunk and proximal extremities of adolescents and young adults. Clinically, it is charac- terized by erythematous, scaly papules and plaques with long axes oriented along the skin-cleavage lines in those areas.6 Guttate psoriasis is a common form of psoriasis in children in whom there is evidence of a preceding upper respiratory tract infection. Small discrete, erythematous, and scaly papules and plaques usually develop on the trunk and extremities. In children, spontaneous remis- sion occurs within weeks to months, while adults might have a more chronic course.7 Sarcoidosis is a systemic, idiopathic, granulomatous disorder; common cutaneous
manifestations include erythema nodosum and red to violaceous papules and plaques on the face, trunk, and extremities.8 Results of histology show noncaseating epi- thelioid granulomas.8 In difficult cases, histologic exami- nation of affected skin might be required to make the distinction among possible diagnoses.
Management
Early diagnosis of tumid LE—and exclusion of other forms of LE—is the first step in optimal management. Use of topical corticosteroids, in conjunction with the avoidance of ultraviolet radiation, often results in complete resolu- tion of the lesions, as was the case with our patient. In difficult cases, antimalarial agents can also be used.2-5
Ms Abdullah was a registered nurse in the Department of Nursing at the American University of Beirut in Lebanon. Dr Abbas is Assistant Professor of Clinical Dermatology in the Department of Dermatology at the American University of Beirut.
Competing interests None declared References
1. Gougerot H, Burnier R. Lupus erythemateux “tumidus.” Bull Soc Fr Dermatol Syphiligr 1930;37:1291-2.
2. Kuhn A, Richter-Hintz D, Oslislo C, Ruzicka T, Megahed M, Lehmann P.
Lupus erythematosus tumidus—a neglected subset of cutaneous lupus ery- thematosus: report of 40 cases. Arch Dermatol 2000;136(8):1033-41.
3. Kuhn A, Sonntag M, Ruzicka T, Lehmann P, Megahed M. Histopathologic findings in lupus erythematosus tumidus: review of 80 patients. J Am Acad Dermatol 2003;48(6):901-8.
4. Vieira V, Del Pozo J, Yebra-Pimentel MT, Martínez W, Fonseca E. Lupus ery- thematosus tumidus: a series of 26 cases. Int J Dermatol 2006;45(5):512-7.
5. Stead J, Headley C, Ioffreda M, Kovarik C, Werth V. Coexistence of tumid lupus erythematosus with systemic lupus erythematosus and discoid lupus erythematosus: a report of two cases of tumid lupus. J Clin Rheumatol 2008;14(6):338-41.
6. Drago F, Broccolo F, Rebora A. Pityriasis rosea: an update with a criti- cal appraisal of its possible herpesviral etiology. J Am Acad Dermatol 2009;61(2):303-18.
7. Nestle FO, Kaplan DH, Barker J. Psoriasis. N Engl J Med 2009;361(5):496-509.
8. English JC 3rd, Patel PJ, Greer KE. Sarcoidosis. J Am Acad Dermatol 2001;44(5):725-43; quiz 744-6.
