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Bizarre appearance of chronic cutaneous lupus erythematosus of face mimicking factitial dermatitis

Old dermatological wisdom says that syphilis and lupus are great imitators. Cutaneous manifestations of lupus erythematosus (LE) are usually characteristic ; however, some patients may present with a less typical clinical picture. Correct diagnosis of cutaneous lupus erythematosus (CLE) requires a high level of clinical suspicion and understanding of broad differential diagnosis. Early lesions of CLE are sometimes difficult to diagnose, both clinically and histopathologically. A 41-year-old woman presented to our department with a history of symmetrical, sharply demarcated, scaly erythematous annular lesions situated above the eyebrows and below the lower eyelids. Biopsy revealed thinned epidermis with flattening of the dermoepidermal junction, vacuolar degeneration of the basal layer and apoptotic keratinocytes. The patient has been followed closely for 2 years since now, and there are no signs of systemic disease. The immunologic tests, performed every 6 months, are within normal limits (ANA/ENA, C3, C4 and CH50). However, the skin lesions never disappeared completely either there were no newly formed ones. On clinical examination, residual atrophy is observed. Cutaneous LE is present in 75% of patients at some point during the course of systemic LE. Skin affection is the second most frequent presentation after joint involvement, and CLE can precede the clinical symptoms for weeks to months in about 25% of patients. Clinical picture, along with laboratory tests, biopsy and histology should be considered in unusual cases, knowing that CLE can present in various ways. Chronic cutaneous LE commonly involves the face. Eyelid involvement can be solitary and present either with swelling due to periorbital oedema and erythema or with discoid lesions. Histopathological examination of skin biopsies is considered to be the gold standard in diagnosing cutaneous lupus. Although histology was confirmative in our case, and none of the literature data were found about factitial dermatitis with the lupus-like histological presentation, we are still closely observing the patient. It is quite uncommon to see classical dermatosis in such a symmetric and geometric pattern without further progression. Some lupus variants like hypertrophic, verrucous, and lupus profundus variant can be exogenously induced along with some cases of DLE (isomorphic response, Koebner phenomenon). Linear lupus following Blaschko lines should be considered in a paediatric population. According to our knowledge, this is a quite atypical clinical presentation of lupus lesions. Histology was confirmative in our case for CLE, but in our opinion, mechanical trauma as a provocative agent cannot be fully excluded.

chronic cutaneous lupus erythematosus of face ; atypical clinical presentation of lupus lesions

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