Discoid lupus erythematosus presenting with cysts, comedones, and cicatricial alopecia on the scalp

Abstract

To the Editor: Discoid lupus erythematosus (DLE) of the scalp usually starts with red-purple macules, papules, or small plaques that then develop into erythematous hairless patches. In early lesions, ostia may still be present, and in the course of the disease, hair follicles are irreversibly destroyed and the lesions become atrophic.1Olsen E.A. Bergfeld W.F. Cotsarelis G. Price V.H. Shapiro J. Sinclair R. et al.Summary of North American Hair Research Society (NAHRS)-sponsored Workshop on Cicatricial Alopecia, Duke University Medical Center, February 10 and 11, 2001.J Am Acad Dermatol. 2003; 48: 103-110Abstract Full Text Full Text PDF PubMed Scopus (291) Google Scholar, 2Whiting D.A. Cicatricial alopecia: clinico-pathological findings and treatment.Clin Dermatol. 2001; 19: 211-215Abstract Full Text Full Text PDF PubMed Scopus (150) Google Scholar, 3Headington J.T. Cicatricial alopecia.Dermatol Clin. 1996; 14: 773-782Abstract Full Text Full Text PDF PubMed Scopus (98) Google Scholar A 33-year-old female patient of East Indian descent was referred to the University of British Columbia hair clinic with a complaint of patchy hair loss. The patient had developed DLE lesions on the lateral aspect of the upper nose, cheeks, and on her left ear, and small areas of hair loss on the scalp 1 and a half years before her visit at our clinic. Her previous dermatologist treated her with hydroxychloroquine 200 mg twice daily, intralesional triamcinolone acetate 5 mg/cc on five occasions, and topical betamethasone dipropionate 0.05% lotion twice daily for 1 year and strongly emphasized sun protection. Over the past year, her facial lesion had considerably improved. However, her scalp lesions progressed in spite of the treatment. On her first visit, the patient showed several skin colored plaques and nodules on her scalp, displaying cicatricial alopecia. Four lesions presented with cribriform openings, releasing yellow-brown horn-like material similar to fistulated comedones (Fig 1). The scalp biopsy showed classic pathologic features of the DLE and epidermal inclusion cysts (Fig 2).Fig 2A, A 2-mm punch biopsy showing a deep lymphocytic, perivascular infiltrate and an interface dermatitis in the follicular epithelium. B, Prominent interface dermatitis. (Original magnification: A, ×40; B, ×100.)View Large Image Figure ViewerDownload Hi-res image Download (PPT) We continued oral treatment with hydroxychloroquine and treated the lesions topically with tretinoin 0.025% cream (Retisol-A 0.025% cream; Stiefel Canada Inc, Montréal, Quebec, Canada) for 2 and a half months. The scalp lesions did not improve, and we decided to discontinue both hydroxychloroquine and topical tretinoin. Oral isotretinoin was suggested as a treatment option, but the patient refused. Four weeks later, the patient developed a new DLE lesion on her face and three new firm subcutaneous nodules without associated comedones on her scalp. Moreover, two of the scalp lesions showed a marked progression in size and an increase of comedone-like openings within the lesions. We treated the remaining lesions with intralesional triamcinolone acetate injections 10 mg/cc every 6 weeks and clobetasol 0.05% lotion twice daily and restarted oral treatment with hydroxychloroquine. On subsequent visits, we added mechanical extraction of the comedones to our treatment plan. Under this combination therapy, the lesions flattened and stabilized. We decided to refer the patient for an excisional biopsy of one large stable lesion on her vertex area. The lesion measured 2 cm in diameter and was reconstructed with a bilateral rotation flap. The histologic findings showed benign epithelial inclusion cysts and comedones with surrounding scarring; however, there were no features of active lupus erythematosus. Excision of the remaining cystic lesion was refused by the patient. DLE has been described with acneiform lesions and comedones.4Chang Y.H. Wang S.H. Chi C.C. Discoid lupus erythematosus presenting as acneiform pitting scars.Int J Dermatol. 2006; 45: 944-945Crossref PubMed Scopus (13) Google Scholar, 5Deruelle-Khazaal R. Ségard M. Cottencin-Charrière A.C. Carotte-Lefebvre I. Thomas P. Chronic lupus erythematosus presenting as acneiform lesions.Ann Dermatol Venereol. 2002; 129 ([French]): 883-885PubMed Google Scholar, 6El Sayed F. Dhaybi R. Ammoury A. Bazex J. Lupus comedonicus (in French).Ann Dermatol Venereol. 2007; 134: 897-898Crossref PubMed Scopus (5) Google Scholar, 7Pramatarov K.D. Chronic cutaneous lupus erythematosus—clinical spectrum.Clin Dermatol. 2004; 22: 113-120Abstract Full Text Full Text PDF PubMed Scopus (26) Google Scholar Whether the nodules and comedones in our case are primary or a secondary change is not clear. The site of our first punch biopsy, which was taken 1 and a half years after the patient developed her first lesions, showed comedone-like structures and histologically cysts and features of DLE. These findings suggest that the cysts and comedones are part of the primary DLE lesion. The excised lesion on the vertex area showed no histopathologic features of DLE but still showed epidermal inclusion cysts. This can be possibly regarded as the secondary change of the scarring process.