2 February 2010 – Case of the Month #7

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We thank Dr. L. Katie Morrison, Wright State Dermatology, Dayton, Ohio (USA), for contributing this case.  We invite you to contribute a Case of the Month by sending an email to KHpathology@gmail.com with diagnostic images in JPG, GIF or TIFF format (or other diagnostic information), a relevant clinical history and a diagnosis, as well as your mailing address. If we use the case, we will list you as the contributor and send you $35 (US dollars) by check or PayPal for your assistance.

Dermatology Case of the Month #7

Clinical history

A 33 year old black woman presented with a four week history of a pruritic, non-scaling, facial rash.  She reported substantial exposure to sunlight.  She had applied hydrocortisone cream and BenadrylÒ without improvement.  She denied other systemic symptoms such as arthralgias, fever, headache or hematuria.

Physical exam revealed bilateral indurated, erythematous plaques on the cheeks perinasally, with sparing of the nasolabial folds.  No other areas of skin involvement were present.

Laboratory results were significant for an ANA titer of 1:40.  CBC was within normal limits.

Clinical images:

Micro images:

H&E, 10x                    20x                              40x

What is your diagnosis? 

(scroll down to continue)

Diagnosis:

Tumid lupus erythematosus

Discussion

Histologic sections show a superficial and deep dense lymphocytic perivascular and periadnexal infiltrate.  Superficial dermal edema is also present.  No interface changes are seen.  Colloidal iron staining (not shown) highlights dermal mucin that is not significantly increased.  No granulomas are identified.

Tumid lupus erythematosus (LE) is a rare form of chronic cutaneous lupus erythematosus, usually seen in young women, and characterized by indurated papules, plaques, and nodules.  There is no ulceration, atrophy or erythema.  It usually occurs on the trunk and is photosensitive.  Lesions are usually deeper and more nodular than classic lupus erythematosus, and there is usually no scaling (eMedicine).

Tumid LE does not respond well to topical corticosteroid treatment.  Hydroxychloroquine produces a better response (Skinmed 2006;5:92).  It usually resolves without residual scarring or discoloration.

The differential diagnosis includes classic lupus erythematosus with dermal involvement.  However, classic LE typically has follicular plugs, atrophy, scale, and scars (Arthritis Rheum 2003;49:494).  In addition, epidermal or interface involvement with lymphocytes is not seen in tumid LE (Cutis 2002;69:227).  Direct immunofluorescent tests are typically negative, and the ANA is usually 1:160 or less, as in the present case (Am J Dermatopathol 1999;21:356)

Additional references: Lever’s Histopathology of the Skin, Wikipedia

Nat Pernick, M.D., President

and Kara Hamilton, M.S., Associate Medical Editor
DermatologyOutlines.com

Telephone: 248/646-0325
Fax: 248/646-3119
Email: NatPernick@hotmail.com