Case Of Cutaneous Lupus Erythematosus Research Articles

Off-Label Use of Janus Kinase Inhibitors in Inflammatory Cutaneous Diseases.

Dysregulation of Janus kinase (JAK) pathways from uncontrolled cytokine signaling comprises the pathological basis for many complex inflammatory cutaneous disorders. Oral JAK inhibitors, upadacitinib, tofacitinib, and baricitinib targeting JAK 1 and JAK 1/3, respectively, are currently US Food and Drug Administration (FDA)-approved for several rheumatic conditions. However, studies have shown that JAK-mediated signaling pathways are involved in many immune-related dermatologic conditions. As a result, for recalcitrant diseases, JAK inhibitors are potential alternative therapies due to their broad targeted inhibitory mechanisms. In this case series, we present the successful off-label treatment of 6 cases across dermatomyositis, hidradenitis suppurativa, cutaneous lupus, and cutaneous Crohn’s disease, which failed conventional therapies with upadacitinib or tofacitinib. In the 3 dermatomyositis cases, use of upadacitinib or tofacitinib demonstrated positive clinical outcomes, with no recurrent symptoms in cases where upadacitinib was used. In treatment-resistant hidradenitis suppurativa, upadacitinib demonstrated reduced systemic flares and moderate cutaneous symptom improvement. In the case of cutaneous Crohn’s disease, upadacitinib resulted in reduced cutaneous symptoms without new flares. Tofacitinib resulted in completed resolution of cutaneous symptoms in our patient’s case of cutaneous lupus erythematosus. JAK inhibitors upadacitinib and tofacitinib may be potential drug candidates in patients with treatment-resistant disease, especially in cases of inflammatory cutaneous conditions such as dermatomyositis, hidradenitis suppurativa, cutaneous lupus, and cutaneous Crohn’s disease. Further studies with larger sample sizes among these conditions are warranted to assess potential broader applicability of the positive results demonstrated in our patient cases. J Drugs Dermatol. 2023;22(12):1183-1190. doi:10.36849/JDD.7500.

Changing Trends of Cutaneous Lupus Erythematosus (CLE) in a Tertiary Care Hospital in Northern Odisha, India.

Cutaneous lupus erythematosus (CLE) is a chronic autoimmune inflammatory skin disorder. Several studies have been published regarding its prevalence, demographic details, clinical spectrum, and various associated factors. In our out patient department (OPD), we noticed an increase in the number of cases of CLE in our area in the last few years. Therefore, the current cross-sectional study was conducted to assess the trends of CLE among patients who reported to a tertiary care hospital. The current study is a record-based cross-sectional study of 81 patients of CLE, who attended the dermatology OPD of a tertiary care hospital. Data were collected from 2017 to 2022 and were divided into three different periods of time (2017-2018, 2019-2020, and 2021-2022). Demographic details, clinical examination findings, and laboratory investigation reports were also collected. There was a rising trend in the cases of CLE. Females outnumbered males (2:1, 66.67%). The increase in cases from 2017-2018 to 2019-2020 was 157% and from 2019-2020 to 2021-2022 was 204%. In 2021-2022, 52% of cases of chronic CLE (CCLE) were males. Photosensitivity was the most common finding. The majority of patients were addicted to smoking. The current study noticed an increasing trend in all types of CLE. So, this rising trend should be investigated for possible triggering factors like climatic changes,infections, and drug factors with a larger sample size.

Epidemiology and demographics of cutaneous lupus erythematosus in Colombia between 2015 and 2019.

Cutaneous lupus erythematosus (CLE) is classified into three groups - acute, subacute, and chronic - based on clinical and histopathological characteristics. The risk of systemic manifestations varies among these groups. There are few studies on CLE epidemiology. For this reason, this paper aims to describe CLE prevalence and demographics in Colombia between 2015 and 2019. This descriptive, cross-sectional study used the international classification of diseases, tenth revision, for CLE subtypes, utilizing official data from the Colombian Ministry of Health. In people older than 19 years, 26,356 CLE cases were registered, yielding a prevalence of 76 cases per 100,000 population. CLE was more frequent in females, at a 5:1 ratio compared to males. The most common clinical presentation was discoid lupus erythematosus, in 45% of cases. The majority of cases occurred in people between 55 and 59 years old. This is the first study that describes CLE demographics in adults in Colombia. Findings regarding clinical subtypes and female predominance are consistent with those in the medical literature.

Epidemiology of Cutaneous Lupus Erythematosus Among Adults Over Four Decades (1976-2018): A Lupus Midwest Network (LUMEN) Study

ObjectiveTo characterize the epidemiological trends and mortality of cutaneous lupus erythematosus (CLE) between 1976 and 2018 in Olmsted County, Minnesota. Patients and MethodsIn this retrospective population-based cohort study, all incident and prevalent CLE cases among adult residents in Olmsted County, Minnesota, between January 1, 1976, and December 31, 2018, were identified and categorized by subtype through medical record review using the resources of the Rochester Epidemiology Project. ResultsThe overall incidence rate of CLE between 1976 and 2018 was 3.9 (95% CI, 3.4 to 4.5) per 100,000. The incidence of CLE was relatively stable, with no major trend across sexes or age groups. The age- and sex-adjusted prevalence of CLE was 108.9 per 100,000 on January 1, 2015. Mortality in CLE patients was similar to that of the general population, with a standardized mortality ratio of 1.23 (95% CI, 0.88 to 1.66) with no observed trends in mortality over time. ConclusionIn the past 4 decades, the incidence of CLE remained stable. Patients with CLE have mortality comparable to that of the general population.

Association Between Drug Use and Subsequent Diagnosis of Lupus Erythematosus

It has been estimated that up to 30% of all subacute cutaneous lupus erythematosus (CLE) cases and up to 15% of systemic lupus erythematosus (SLE) cases are drug induced. Based on numerous case reports and several epidemiologic studies, more than 100 drugs from more than 10 drug classes are suspected to cause drug-induced lupus erythematosus. To examine the association between drug use and a subsequent diagnosis of CLE or SLE based on a systematic screening process of the drugs in the Anatomical Therapeutic Chemical classification system in a nationwide setting. A matched case-control study was conducted using all incident cases of CLE and SLE registered in the Danish National Patient Register between January 1, 2000, and December 31, 2017. Patients with CLE and patients with SLE were matched (1:10) on age and sex, with individuals from the general population serving as controls. To select which drugs to examine for an association with CLE or SLE, a screening process of all drugs was performed, including drugs filled at pharmacies and drugs administered in hospitals. Odds ratios (ORs) were calculated for the association between exposures to certain drugs and the subsequent diagnosis of CLE or SLE. In all, 3148 patients with CLE (n = 1298; 1022 women [78.7%]; median age at diagnosis, 50.5 years [interquartile range, 39.4-62.2 years]) or SLE (n = 1850; 1537 women [83.1%]; median age at diagnosis, 45.0 years [interquartile range, 33.6-56.4 years]) and 31 480 controls (25 590 women [81.3%]; median age, 47.5 years [interquartile range, 35.9-59.5 years]) were found. Many significant associations between drug use and a subsequent diagnosis of CLE and SLE were observed. Many associations were likely due to protopathic bias. However, new plausible causal associations were observed between CLE or SLE and some drugs, including fexofenadine hydrochloride (SLE: OR, 2.61 [95% CI, 1.80-3.80]; CLE: OR, 5.05 [95% CI, 3.51-7.26]), levothyroxine sodium (SLE: OR, 2.46 [95% CI, 1.97-3.07]; CLE: OR, 1.30 [95% CI, 0.96-1.75]), metoclopramide hydrochloride (SLE: OR, 3.38 [95% CI, 2.47-4.64]; CLE: OR, 1.47 [95% CI, 0.85-2.54]), and metronidazole hydrochloride (SLE: OR, 1.57 [95% CI, 1.09-2.27]; CLE: OR, 1.93 [95% CI, 1.25-2.97]). The study's findings suggest that physicians should be cognizant about whether a new case of CLE or SLE could be drug induced. Furthermore, the results highlight that the reported associations in the published literature may be due to publication or protopathic bias.

A Case of Cutaneous Lupus Erythematosus Showing Multiple Folliculitis-like Eruptions on the Scalp Successfully Treated with Hydroxychloroquine

A Case of Cutaneous Lupus Erythematosus Showing Multiple Folliculitis-like Eruptions on the Scalp Successfully Treated with Hydroxychloroquine

Periorbital erythema and swelling as a presenting sign of lupus erythematosus in tertiary referral centers and literature review.

Background Cutaneous lupus erythematosus (CLE) includes a broad range of dermatologic manifestations. Periorbital involvement, however, is a relatively rare clinical presentation of CLE. Objectives This clinical study aimed to investigate the characteristics of this unique presentation of CLE in tertiary medical centers. Methods We enrolled patients with periorbital erythema and swelling as the presenting sign of lupus erythematosus, from January 2003 to November 2017, using the data of 553 pathologically proven CLE cases from the registration database of the Chang Gung Memorial Hospitals in Taiwan. Results We enrolled a total of 25 patients. The mean age was 46.7 years and 68% of the patients were female. Most of the patients (84.0%) presented with unilateral involvement, with the left orbit involved in 15 patients (60%); the upper eyelid was the most frequently involved (72%). Mean duration between the onset of clinical manifestations and the diagnosis of CLE was approximately 59 weeks. Nineteen patients had been previously misdiagnosed. All patients had features compatible with CLE on histopathological examination. In contrast, laboratory analysis of the autoimmune profile often revealed negative results, including those for antinuclear antibodies (25%). Notably, anti-SSA/SSB (45.5%) showed the highest positive rate. During follow-up, six patients developed systemic lupus erythematosus (SLE) and two patients developed Sjögren syndrome. Conclusions The diagnosis of CLE presenting as periorbital erythema and swelling is often delayed because of clinical mimicry and the high proportion of negative results on autoantibody tests. Increased clinical suspicion and prompt histopathological examination are crucial for early diagnosis. Moreover, one-fourth of the patients ultimately developed SLE, which highlights the importance of clinical awareness.

Risk of Cerebrovascular Accidents and Ischemic Heart Disease in Cutaneous Lupus Erythematosus: A Population-Based Cohort Study.

It is unclear whether isolated cutaneous lupus erythematosus (CLE) affects cardiovascular risk. We estimated the cumulative incidence and mortality of cardiovascular diseases in a population-based CLE cohort and compared the risk with a matched non-CLE cohort. All incident cases of CLE in Olmsted County, Minnesota, between 1965 and 2005 were followed until December 2013. The cumulative incidence of cerebrovascular accidents (CVAs [including stroke and transient ischemic attack]), ischemic heart disease (IHD [including coronary artery disease, myocardial infarction, and angina pectoris]), heart failure, and peripheral arterial disease (PAD) was derived and compared to an age-, sex-, and calendar year-matched non-CLE cohort using Cox models. There were 155 patients with CLE (mean ± SD age at diagnosis 48 ± 16 years, 65% female, mean ± SD BMI 26.3 ± 7.1 kg/m2 , 40% smokers, 9% with diabetes mellitus). During a median followup of 14.6 years, 41 CLE patients had cardiovascular events (15 patients with CVAs, 32 patients with IHD), with a 20-year cumulative incidence of 31.6%. As compared to non-CLE subjects, the risk of CVAs (smoking-adjusted hazard ratio [HR] 2.97 [95% confidence interval (95% CI) 1.13-7.78]) and PAD (HR 2.06 [95% CI 0.99-4.32]) was increased in patients with CLE, but the risk of IHD was not increased (HR 0.94 [95% CI 0.57-1.54]). There was no increase in cardiovascular mortality (HR 1.68 [95% CI 0.76-3.75]). The magnitude of risk for any cardiovascular outcome was not significantly influenced by the extent of cutaneous involvement. CLE may be associated with an increased risk of CVAs and PAD, but not IHD. Factors contributing to increased CVA risk in patients with CLE merit evaluation.

Cancer risk in cutaneous lupus erythematosus: a population-based cohort study.

Immune dysregulation associated with chronic autoimmune diseases, such as SLE, has been associated with increased cancer risk. It is unclear whether isolated cutaneous lupus erythematosus (CLE) modifies cancer risk. We estimated the cumulative incidence of cancer in a population-based CLE cohort and compared the risk with a matched non-CLE cohort. All incident cases of CLE in Olmsted County, MN, USA between 1965 and 2005 were identified and followed to December 2013. Estimates for the cumulative incidence of any cancer and skin cancer in patients with CLE were derived and compared with an age-, sex- and calendar-year-matched non-CLE cohort using Cox models. There were a total of 155 patients with CLE [age at diagnosis, 48 (sd 16) years; 65% females; BMI, 26.3 (sd 7.1) kg/m2; 40% smokers, 9% with diabetes]. During a median follow-up of 14.6 years, we observed 35 cases of incident cancer (including 10 cases of skin cancer). The cumulative 1-, 5- and 10-year incidence of any cancer after diagnosis of CLE was 1.4, 7.5 and 11.6%, respectively. Compared with matched non-CLE controls, the overall risk of malignancies was not increased in patients with CLE (smoking-adjusted hazard ratio = 1.29; 95% CI: 0.78, 2.13; P = 0.31). There was also no significant increase in risk of any skin cancer in patients with CLE (hazard ratio = 2.51; 95% CI: 0.91, 6.96; P = 0.16). CLE is not associated with an increased risk of any cancers, including skin cancers, compared with the general population. However, the number of events was small, limiting the power of the study.

Development and Pilot Testing of the Cutaneous Lupus Screening Tool.

Patients with cutaneous lupus erythematosus (CLE) experience significant morbidity and poor quality of life. In the absence of a dermatologist's examination, no reliable tool exists to confirm whether a patient has CLE for use in epidemiologic studies. To determine whether the Cutaneous Lupus Screening (CLUSE) tool can detect cases of CLE by measuring its performance in individuals with dermatologist-diagnosed CLE compared with individuals without CLE. The CLUSE tool is a novel, self-administered questionnaire with 15 closed-ended questions derived from the Delphi method. It includes features of disease validation for CLE as well as its most common phenotypes. This pilot study was administered during a 1-year period (July 1, 2011, to June 30, 2012) in outpatient dermatology clinics at an academic medical center. Data analysis was performed July 1, 2012, to November 30, 2013. Participants were individuals 18 years or older who had a definitive diagnosis of CLE or any other non-CLE dermatologic condition as established by a board-certified dermatologist. Eligible patients were recruited consecutively, and no individual approached declined to participate. Sensitivity and specificity of the individual questions from the CLUSE tool in predicting CLE, comparisons between summary scores for the dichotomous questions between the CLE cases and non-CLE controls, and 9 scoring algorithms that assign a diagnosis of CLE and its subtypes depending on an individual's response to each question. A total of 133 patients were given the CLUSE tool; 16 participants were excluded. Responses from 117 individuals were collected for analysis and included 24 CLE cases and 93 non-CLE cases. In the 117 questionnaires analyzed, mean (SD) and median (interquartile range) CLUSE scores differed in the CLE (5.6 [2.1] and 5.5 [3-10], respectively) vs non-CLE (0.96 [1.6] and 0 [0-7], respectively) groups (all P < .001). Of the 9 algorithms, algorithm 9, used for diagnosing CLE regardless of subtype, demonstrated the highest sensitivity (87.5%) and high specificity (96.8%). A combination of questions and representative photographs can ascertain cases of CLE with high sensitivity and specificity. The CLUSE tool is a brief, self-administered questionnaire with low respondent burden used for the identification of CLE. In the future, this questionnaire will be administered to large, established patient databases to gather epidemiologic data on this disease.

Genome-wide association study identifies new susceptibility loci for cutaneous lupus erythematosus.

Cutaneous lupus erythematosus (CLE) is a chronic autoimmune disease of the skin with typical clinical manifestations. Here, we genotyped 906600 single nucleotide polymorphisms (SNPs) in 183 CLE cases and 1288 controls of Central European ancestry. Replication was performed for 13 SNPs in 219 case subjects and 262 controls from Finland. Association was particularly pronounced at 4 loci, all with genomewide significance (P<5×10(-8) ): rs2187668 (PGWAS =1.4×10(-12) ), rs9267531 (PGWAS =4.7×10(-10) ), rs4410767 (PGWAS =1.0×10(-9) ) and rs3094084 (PGWAS =1.1×10(-9) ). All mentioned SNPs are located within the major histocompatibility complex (MHC) region of chromosome 6 and near genes of known immune functions or associations with other autoimmune diseases such as HLA-DQ alpha chain 1 (HLA-DQA1), MICA, MICB, MSH5, TRIM39 and RPP21. For example, TRIM39/RPP21 read through transcript is a known mediator of the interferon response, a central pathway involved in the pathogenesis of CLE and systemic lupus erythematosus (SLE). Taken together, this genomewide analysis of disease association of CLE identified candidate genes and genomic regions that may contribute to pathogenic mechanisms in CLE via dysregulated antigen presentation (HLA-DQA1), apoptosis regulation, RNA processing and interferon response (MICA, MICB, MSH5, TRIM39 and RPP21).

Epidemiology of systemic lupus erythematosus and cutaneous lupus erythematosus in a predominantly white population in the United States.

Epidemiologic studies comparing the incidence and prevalence of systemic lupus erythematosus (SLE) and isolated cutaneous lupus erythematosus (CLE) are few. Olmsted County, Minnesota provides a unique setting for such a study owing to resources of the Rochester Epidemiology Project. We sought to describe and compare the incidence and prevalence of SLE and CLE from 1993-2005. SLE cases were identified from review of medical records and fulfilled the 1982 American College of Rheumatology classification criteria. CLE cases included patients with classic discoid lupus erythematosus, subacute CLE, lupus panniculitis, and bullous lupus erythematosus. Age- and sex-adjusted incidence and prevalence were standardized to the 2000 US white population. The age- and sex-adjusted incidence of SLE (2.9 per 100,000; 95% confidence interval [95% CI] 2.0-3.7) was similar to that of CLE (4.2 per 100,000; 95% CI 3.1-5.2, P = 0.10). However, the incidence of CLE was 3 times higher than SLE in men (2.4 versus 0.8 per 100,000; P = 0.009). The age- and sex-adjusted prevalence of CLE on January 1, 2006 was higher than that of SLE (70.4 versus 30.5 per 100,000; P < 0.001). The prevalences of CLE and SLE in women were similar, but the prevalence of CLE was higher in men than in women (56.9 versus 1.6 per 100,000; P < 0.001). The incidence of CLE rose steadily with age and peaked at 60-69 years. The incidences of CLE and SLE are similar, but CLE is more common than SLE in men and in older adults. These findings may reflect differences in genetic or environmental etiology of CLE.

Pediatric Cutaneous Lupus Erythematosus Treated with Pulsed Dye Laser

Pulsed dye laser (PDL) has been used in adults to treat refractory cutaneous lupus erythematosus (CLE). We report the first case of CLE in a child successfully treated with PDL.

TNF Blockade and Cutaneous Lupus Erythematosus: Where do We Stand and Where are We Going?

Anti-TNF - a agents are used as a reserve treatment for cases of severe psoriasis and psoriatic arthritis that do not respond to conventional therapies. The current use of anti-TNF -a for systemic lupus erythematosus (SLE) and cutaneous lupus erythematosus (CLE) is limited by the clinical observations of the induction of a SLE syndrome. Despite the great number of SLE-like syndromes reported as a side effect of anti-TNF - a blockers, only very few cases of CLE are believed to be a consequence of these drugs. Moreover, on the basis of clinical and laboratory data, anti-TNF -a blockers could be considered as an option for CLE refractory to conventional

Prominent CD56 expression by damaged and regenerating muscle fibers in the skin

Antibodies to CD56 label natural killer cells as well as tissues with neural and neuroendocrine differentiation. Despite its apparently limited distribution, other conditions may unexpectedly show strong CD56 expression. We report three cases to document another setting with strong expression of CD56 in the skin: damaged and/or regenerating muscle fibers. One case of cutaneous lupus erythematosus, one case of lymphomatoid granulomatosis, and one case of a dermal scar adjacent to cutaneous muscle fibers were evaluated with a panel of antibodies, including CD56. All cases showed histopathologic evidence of muscle fiber damage in the setting of lymphocytic infiltration or trauma. All cases showed prominent expression of CD56 by damaged and/or regenerating muscle fibers. The degree of CD56 expression was directly proportional to the proximity to the injury site and inversely proportional to fiber diameter. Even though CD56 is a useful marker for certain cytotoxic lymphomas and neural/neuroendocrine neoplasms, its expression is not limited to these conditions. Our cases highlight another unexpected example of strong CD56 expression in the skin: damaged and/or regenerating muscle fibers. The growing list of CD56-positive conditions suggests that this marker may not be as specific as initially assumed.

Hydroxychloroquine administration for Japanese lupus erythematosus in Wakayama: A pilot study

Hydroxychloroquine (HCQ) is used as the first-line systemic treatment for severe, widespread or refractory cutaneous lupus erythematosus (CLE) in many countries. However HCQ is not an approved drug in Japan. For the establishment of HCQ therapy as the alternative treatment for CLE in Japan, we conducted a pilot study in Japanese patients with refractory CLE by administrating HCQ, and evaluated the improvements in the skin lesions using the Cutaneous Lupus Erythematosus Disease Area and Severity Index (CLASI). We administrated HCQ to seven CLE cases, including four systemic lupus erythematosus (SLE) cases. The skin lesions of the four cases improved dramatically, and their mean CLASI activity index decreased significantly following HCQ treatment. Arthralgia improved in all three cases with arthralgia and general malaise also improved in two of the three cases who had complained. In three cases who discontinued HCQ therapy after 16 weeks of treatment, their skin lesions and general malaise worsened soon, and after the resumption of HCQ therapy these symptoms improved again. The mean serum triglyceride and total cholesterol levels also decreased significantly at the end of this study. Our results suggest that HCQ might be effective for Japanese SLE skin lesions and CLE, and support the studies which reported that HCQ prevented clinical flare ups of SLE. An additional effect to improve lipid profiles was also observed in our Japanese cases. It is necessary to confirm that these effects are reproducible when Japanese lupus erythematosus cases are given HCQ.

Cutaneous lupus erythematosus on the elbows: a peculiar localization

The presence of lesions limited to the elbows as expression of a cutaneous lupus erythematosus (CLE) is very unusual. To describe the clinical and microscopic characteristics of these lesions, as well as their relationship with the different cutaneous lupus erythematosus subsets. Seven cases of CLE with lesions on the elbows, collected from 1998 to 2009, were retrospectively analysed. All patients had a previous or concomitant diagnosis of lupus erythematosus based on other typical skin lesions for each subtype of lupus erythematosus, and they all met clinical and microscopic criteria. Six patients were women with a mean age of 33.8 years. Five cases had been previously diagnosed with CLE (three lupus erythematosus [LE] tumidus, one subacute CLE and one acute CLE). In the other two cases, these lesions were the first manifestation of the disease. The lesions consisted of pruriginous, erythematous papules and plaques with a slightly scaly surface, located on both elbows. Microscopically, in addition to the typical features of CLE, other changes were observed, including alterations in the texture and the staining properties of collagen fibres (five cases), an interstitial histiocytic infiltrate (four cases), eosinophils (one case) and a Churg-Strauss granuloma (one case). These peculiar lesions located on the elbows should be included in the spectrum of cutaneous manifestations of LE. Their histopathology combines changes of both LE and interstitial granulomatous dermatitis.

Microphthalmia-Associated Transcription Factor-Positive Pseudonests in Cutaneous Lupus Erythematosus

To the Editor: Nicholson and Gerami1 recently reported 2 cases where microphthalmia-associated transcription factor (MITF) aided in distinguishing Mart-1-positive pseudomelanocytic nests from true melanocytic nests in the setting of lichenoid dermatitis. We have been interested in the pseudomelanocytic nest phenomenon since it was first reported by Maize et al2 in 2003. The difficulty of differentiating true Mart-1/Melan-A-positive melanocytic nests from pseudonests is a practical dilemma, as both may occur in the setting of lichenoid tissue reactions, and there is a potential for misdiagnosis if pathologists rely on a single immunostain.1-5 We have found that even combinations of stains like Mart-1 plus MITF have the potential to result in misdiagnosis and wish to alert the pathologists to this potential pitfall. Most of the reports of pseudomelanocytic nests have been described in pigmented actinic keratosis, cutaneous lupus erythematosus (CLE), or lichenoid inflammatory lesions from the head and neck suggesting some relationship to chronically sun-damaged skin.2,4-5 We previously determined that the Mart-1-positive pseudonest phenomenon is uncommon in cases of lichen planus, suggesting that it may be uncommon in sun-protected skin.6 Our current study sought to establish the frequency of pseudonests in the setting of CLE on sun-damaged skin. A search was preformed for cases of CLE from the files of Brooke Army Medical Center and Wilford Hall Medical Center from 1999 to 2009. Each of the cases was initially reviewed by one pathologist to make sure that the biopsies demonstrated marked solar elastosis within the dermis. Cases without significant solar elastosis were excluded from the study. Fresh sections from 53 cases of CLE on sun-damaged skin were stained with hematoxylin and eosin (H&E), Mart-1, and MITF. Three dermatopathologists reviewed the (H&E) slides to determine whether a vacuolar interface or lichenoid interface reaction pattern was present and if collections of cells were present at the dermal-epidermal junction suspicious for pseudonests. Both the Mart-1 and MITF stains were then reviewed in each case. Of the 53 cases of CLE, 30 showed lichenoid interface dermatitis, whereas the other 23 showed a vacuolar interface dermatitis. A total of 6 cases demonstrated areas suspicious with pseudonests on H&E stain (Table 1). Each of these cases demonstrated a lichenoid interface dermatitis. One case (case 30) was remarkable for nested cells that were strongly positive for both Mart-1 and MITF but negative for S100 (Fig. 1A-D). The MITF stain demonstrated at least 2 nonlabeling nuclei (Fig. 1C, inset), which could have alerted the pathologist to the possibility of an aberrant staining pattern. S100 is highly sensitive for melanocytes, and S100-negative melanocytic lesions are rare.7-9 The patient has been followed since 2004 for cutaneous lupus and has developed additional morphologically similar lesions that responded to topical fluocinonide and oral plaquenil but has not demonstrated any evidence of a melanocytic lesion at the biopsy site. In the clinical context of CLE, there is little chance that the solitary aggregate represented an incidental melanocytic nest. Failure to stain with S100 and clinical follow-up support our contention.FIGURE 1: A, Case of CLE with a small nest of cells at the dermal-epidermal junction (H&E: ×20; inset ×60). B, Avid cytoplasmic staining for Mart-1 (×20; inset ×60). C, MITF positive, note that 2 nuclei in the aggregate lack staining (×20; inset ×60). D, Negative staining with S100 (×20; inset ×60).TABLE 1: Cases With Pseudonests Present in H&E or Immunostained SectionsThe pathogenesis of the pseudonest phenomenon remains speculative.2,5 A combination of melanocytes, degenerated keratinocytes, and macrophages has been proposed. Ultimately, studies of the ultrastructural characteristics of pseudonests may help to determine their composition. Our results suggest that MITF may stain pseudonests in a manner similar to Mart-1/Melan-A and cannot be relied upon to distinguish pseudonests from true melanocytic nests. A recent poster at a national dermatopathology conference also described the presence of MITF-positive pseudonests in a case of lichen planus pigmentosus, suggesting our experience is not unique.10 We caution pathologists about overreliance on MITF. We believe that clinical correlation is essential, and when Mart-1/Melan-A-positive and MITF-positive aggregates are noted in the setting of lichenoid dermatitis, S100 staining should be performed. CPT Margaret Abuzeid, MD* LTC Scott R. Dalton, DO† Tammie Ferringer, MD†‡ Richard Bernert, MD§ Dirk M. Elston, MD†‡ Department of *Pathology, Brooke Army Medical Center and Wilford Hall Medical Center, San Antonio, TX Department of †Dermatology; and ‡Pathology, Geisinger Medical Center, Danville, PA §Arizona Dermatopathology, Scottsdale, AZ

Subacute Cutaneous Lupus Erythematosus Induced or Exacerbated by Proton Pump Inhibitors

, treating peptic ulcer and gastroesophageal reflux disease. They are generally well tolerated, but side-effects occur in up to 5% of patients, mainly as headache, diarrhoea and nausea (1). Fewer than 15 articles reporting cutaneous side-effects have been published, including 2 cases of cutaneous lupus erythematosus (CLE) (2, 3). We report here 5 ad-ditional cases of subacute cutaneous lupus erythematosus (SCLE) induced or exacerbated by PPIs, with a detailed summary of 2 cases. CASE REPORTS

Cutaneous lupus erythematosus induced by infliximab

To the Editor: Infliximab is a monoclonal antibody to tumor necrosis factor alpha (TNF-α) used to treat rheumatoid arthritis, inflammatory bowel disease, pyoderma gangrenosum, sarcoidosis, Sjogren' s syndrome, and psoriasis.1-7 We report a case of cutaneous lupus erythematosus as a reaction to infliximab, which occurred during treatment of rheumatoid arthritis.