Photo Quiz

Annular Skin Lesions on the Chest

 

Am Fam Physician. 2019 Apr 15;99(8):517-518.

A woman presented with a one-year history of mildly pruritic, annular lesions on her neck, ears, and chest. She had no history of drug or medication use prior to the onset of the plaques. The patient reported hair loss on the scalp. Results of routine blood tests and urine examination were unremarkable.

On examination, there were multiple scaly plaques of varying size on the anterior aspect of her neck and chest. The larger plaques had central atrophic scarring and hyperpigmentation, with a prominent peripheral rim of erythema (Figure 1). There were horseshoe and figure eight morphologies where plaques had coalesced. The rest of the skin, mucosae, and nails were normal. A punch biopsy was obtained from the skin lesions and submitted for histopathologic examination.

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FIGURE 1


FIGURE 1

Question

Based on the patient's history and physical examination findings, which one of the following is the most likely diagnosis?

A. Annular atrophic lichen planus.

B. Annular psoriasis.

C. Discoid lupus erythematosus.

D. Fixed drug eruption.

Discussion

The answer is C: discoid lupus erythematosus. Histopathologic examination from the punch skin biopsy revealed epidermal hyperkeratosis, parakeratosis and atrophy, follicular plugging, few apoptotic keratinocytes, and basal cell vacuolization. Dense lymphomononuclear infiltrate was present at the junction of epidermis and dermis (interface dermatitis) and in the perifollicular and perivascular distribution, suggesting discoid lupus erythematosus. Findings on direct immunofluorescence were positive for speckled antinuclear antibody. A 24-hour urine protein test was normal. The patient was treated with daily hydroxychloroquine (Plaquenil).

Discoid lupus erythematosus is the most common subtype of cutaneous lupus, with lesions mostly localized above the neck. However, 20% to 40% of patients with discoid lupus erythematosus present with a generalized form, in which

Address correspondence to Davinder Parsad, MD, at parsad@me.com. Reprints are not available from the authors.

Author disclosure: No relevant financial affiliations.

References

show all references

1. Cardinali C, Caproni M, Bernacchi E, Amato L, Fabbri P. The spectrum of cutaneous manifestations in lupus erythematosus—the Italian experience. Lupus. 2000;9(6):417–423....

2. Lee HJ, Sinha AA. Cutaneous lupus erythematosus: understanding of clinical features, genetic basis, and pathobiology of disease guides therapeutic strategies. Autoimmunity. 2006;39(6):433–444.

3. Eyler JT, Garib G, Thompson KR, Dahiya M, Swan JW. Annular atrophic lichen planus responds to hydroxychloroquine and acitretin. Cutis. 2017;100(2):119–122.

4. Guill CL, Hoang MP, Carder KR. Primary annular plaque-type psoriasis. Pediatr Dermatol. 2005;22(1):15–18.

5. Flowers H, Brodell R, Brents M, Wyatt JP. Fixed drug eruptions: presentation, diagnosis, and management. South Med J. 2014;107(11):724–727.

This series is coordinated by John E. Delzell Jr., MD, MSPH, Associate Medical Editor.

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