Case and Research Letters
Comedonic Lupus: An Unusual Presentation of Cutaneous Lupus
Lupus comedónico: presentación inusual de lupus cutáneo
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Chessé, M.J. Fernández-Tapia, F. Borzotta" "autores" => array:3 [ 0 => array:4 [ "nombre" => "C." "apellidos" => "Chessé" "email" => array:1 [ 0 => "carlachesse@gmail.com" ] "referencia" => array:3 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] 2 => array:2 [ "etiqueta" => "*" "identificador" => "cor0005" ] ] ] 1 => array:3 [ "nombre" => "M.J." "apellidos" => "Fernández-Tapia" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] ] 2 => array:3 [ "nombre" => "F." "apellidos" => "Borzotta" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] ] ] "afiliaciones" => array:2 [ 0 => array:3 [ "entidad" => "Servicio de dermatología, Hospital Luis C Lagomaggiore, Ciudad de Mendoza, Argentina" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Consultorio particular Mendoza, Argentina" "etiqueta" => "b" "identificador" => "aff0010" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Lupus comedónico: presentación inusual de lupus cutáneo" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:8 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 655 "Ancho" => 755 "Tamanyo" => 98148 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0005" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Infiltrated erythematous plaque with edematous edges, and open comedones and milium cysts.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Skin manifestations of lupus erythematosus are varied. Some of them are atypical and may imitate benign skin diseases. Acneiform lesions are a rare, atypical form of presentation.</p><p id="par0010" class="elsevierStylePara elsevierViewall">A 48-year-old woman visited our department with a lesion on the chin that had appeared 2 months earlier. The patient had initially been diagnosed with lupus erythematosus discoides and a subacute cutaneous lupus erythematosus that had appeared 16 years earlier and had been treated with hydroxychloroquine. Treatment was suspended due to maculopathy. Four years after diagnosis of the cutaneous lupus, the patient was finally diagnosed with systemic lupus erythematosus (SLE), as she met clinical and laboratory criteria (lupus discoides, synovitis, lupus nephritis, positive antinuclear antibody titer).</p><p id="par0015" class="elsevierStylePara elsevierViewall">The physical examination revealed an infiltrated erythematous plaque with edematous edges, with some open comedones and milium cysts on the surface (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>). An incisional biopsy of the lesion was performed, and histology revealed a flattened epidermis with foci of vacuolization in the basement layer and thickening of the basement membrane, follicular dilations with keratotic plugs, and comedones. A perivascular and periadnexal inflammatory infiltrate was visible in the dermis (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>B).</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0020" class="elsevierStylePara elsevierViewall">Given these findings and the patient’s history, the lesion was diagnosed as comedonic lupus. The patient initially underwent treatment with hydrocortisone, 0.1%, with little response, followed by minocycline (100 mg/d for 3 months) in association with tretinoin cream, 0.005%, with good results, showing clear improvement of the lesion and residual scarring.</p><p id="par0025" class="elsevierStylePara elsevierViewall">Comedonic or comedonal lupus is a rare entity and a rare variant of chronic cutaneous lupus erythematosus. It is similar to other clinical entities such as acne, which can sometimes make diagnosis difficult.<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1,2</span></a> Very few cases have been reported in the medical literature and this disease is therefore thought to be underdiagnosed.<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1,3</span></a> Clinically, it is characterized by comedones on an erythematous plaque, mainly on seborrheic regions.<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> The etiology is unknown.<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1,2</span></a> It has been suggested that exposure to sunlight may be involved in the formation of comedones. The solar damage may produce changes in the collagen of the normal skin, altering its structure and promoting retention of sebum, concluding in the formation of comedones, as occurs in Favre-Racouchot syndrome. The other theory put forward is that follicular plugs act as a factor that promotes the formation of comedones.<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a></p><p id="par0030" class="elsevierStylePara elsevierViewall">Presentation typically occurs between the ages of 25 and 35 years, or even younger.<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1–3</span></a> The differential diagnosis should include inflammatory acne, Favre-Racouchot syndrome, milium cysts, inflammatory tinea, and nevus comedonicus.<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a></p><p id="par0035" class="elsevierStylePara elsevierViewall">When comedones are absent, this disease may be called lupus with an acneiform scarring pattern. In this entity, the lesions are characterized by pitting, resulting from the destruction of the hair follicle and the sebaceous glands due to the inflammatory infiltrate.<a class="elsevierStyleCrossRefs" href="#bib0015"><span class="elsevierStyleSup">3,5–7</span></a></p><p id="par0040" class="elsevierStylePara elsevierViewall">The diagnosis is confirmed by means of the histopathology study, which shows a predominant interphase pattern with hydropic degeneration of the basement layer and thickening of the basement membrane, accompanied by keratotic plugs and comedones, as reported in our patient.<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1–3</span></a> When histology findings are not conclusive, immunofluorescence may contribute to the diagnosis, revealing a deposit of IgM, IgG, and C3 at the dermal-epidermal junction.<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1,6</span></a></p><p id="par0045" class="elsevierStylePara elsevierViewall">Several therapeutic options exist, although the treatment of choice is oral hydroxychloroquine (200 mg/12 h).<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1,7</span></a> In our case, hydroxychloroquine could not be administered due to the patient’s ophthalmologic history. Oral and topical retinoids may be used as an alternative and may be supplemented with topical or intralesional corticosteroids.<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> It should be noted that these treatments presented little therapeutic efficacy in our patient and minocycline (100 mg/d for 3 months) and topical tretinoin, together with strict photoprotection, was indicated, with good results; we therefore propose this regimen as another alternative treatment. The outcome of comedonic lupus is uncertain and, while few patients have been described in the literature, a risk of progression to SLE has been observed in half of cases.<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1–3</span></a> It should be noted that our patient already presented systemic lupus when the comedonic lupus lesion appeared.</p><p id="par0050" class="elsevierStylePara elsevierViewall">Comedonic lupus thus represents a rare presentation of chronic cutaneous lupus erythematous. Early diagnosis and long-term follow-up are very important due to the risk of systemic progression of the disease.</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Funding</span><p id="par0055" class="elsevierStylePara elsevierViewall">The authors state that they have received no external funding for this study.</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Conflicts of Interest</span><p id="par0060" class="elsevierStylePara elsevierViewall">The authors declares that they have no conflicts of interest.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:3 [ 0 => array:2 [ "identificador" => "sec0005" "titulo" => "Funding" ] 1 => array:2 [ "identificador" => "sec0010" "titulo" => "Conflicts of Interest" ] 2 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2019-05-02" "fechaAceptado" => "2019-07-14" "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Chessé C, Fernández-Tapia MJ, Borzotta F. Lupus comedónico: presentación inusual de lupus cutáneo. Actas Dermosifiliogr. 2021;112:370–371.</p>" ] ] "multimedia" => array:2 [ 0 => array:8 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 655 "Ancho" => 755 "Tamanyo" => 98148 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0005" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Infiltrated erythematous plaque with edematous edges, and open comedones and milium cysts.</p>" ] ] 1 => array:8 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 562 "Ancho" => 750 "Tamanyo" => 130102 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0010" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Hematoxylin–eosin staining. Note the flattened epidermis with foci of vacuolization in the basement layer and thickening of the basement membrane, follicular dilations with keratotic plugs, and comedones. Perivascular and periadnexal inflammatory infiltrate in the dermis. With kind permission of Dr. A.C. Innocenti.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:7 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Comedonic lupus: a rare presentation of discoid lupus erythematosus" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:5 [ 0 => "D.F. Farias" 1 => "R.M.F. Gondim" 2 => "I.P. Redighieri" 3 => "H. Muller" 4 => "V. 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| año/Mes | Html | Total | |
|---|---|---|---|
| 2024 Noviembre | 26 | 15 | 41 |
| 2024 Octubre | 164 | 65 | 229 |
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| 2022 Enero | 181 | 48 | 229 |
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