51-year-old woman with Follicular L.E.

presented by

David Elpern M.D., Williamstown, MA, USA

on October 17, 2004

Dermatologist, The Skin Clinic, Williamstown, MA, USA

R.D., 51-year-old office manager
6 months
Trunk, extremities, face and scalp

RD is a 51-year-old office manager who presented in April 2004 with a four month history of pruritic lesions on back. This began a few months after starting hydrochlorthiazide. There was a history of “lichen planus” 20 - 30 years back after the birth of a child. This time, she was preparing for a daughter's wedding and was under some stress. Since April, she has developed more wide-spread lesions mostly on the extremities and scarring alopecia. Potent topical corticosteroids were not of value, neither was tacrolimus ointment. Plaquenil was started in mid May at a dose of 200 mg. per day, but shortly after it was increased to 200 mg b.i.d. the patient developed a pruritic eruption different from her other lesions. This cleared after stopping the Plaquenil. Other than mild myalgias, she has no constitutional symptoms. She has just restarted the Plaquenil.

Physical Examination

Initially, the only cutaneous findings were hyperkeratotic, flesh-colored to slightly hyperpigmented papules located on the mid-upper back. By mid May she had developed similar lesions: discrete and confluent hyperpigmented folicular papules cheeks and forehead and some flat-topped papules on both legs. At around this time, she started to develop an inflammatory alopecia. The scalp showed mild erythema and some scarring.
This has progressed and at present she has impressive diffuse alopecia. After Plaquenil was increased to 400 mg/day she developed erythematous papules and small plaques on the hips and upper chest. These disappeared two weeks after stopping Plaquenil. The eruption on the back and face is slowly improving, but the alopecia is progressing


Laboratory Data

CBC normal, Blood Chemistries normal, Urinalysis normal. ESR 25
ANA +ve 1:640 speckled
RNP Antibody 157.6 U (nl <20 U)
Anti DS-DNA (-ve), Anti-Histone (-ve). All other ANAs negative including Ro and La
C-4 borderline low. G6PD normal.


Interface dermatitis with pigment incontinence, superficial and mid perivascular and periappendageal lymphocytic infiltrate, with marked dermal mucin deposition and extravasated erythrocytes


Follicular Lupus Erythematosus

Reasons Presented

For diagnostic and therapeutic suggestions. Follicular L.E. is unusual. Please comment on this entity. The patient has not responded well to therapy. Your suggestions regarding treatment will also be appreciated.

Questions and Discussions  
References Reference:
1. Morihara K, Kishimoto S, Shibagaki R, Takenaka H, Yasuno H. Follicular lupus erythematosus: a new cutaneous manifestation of systemic lupus erythematosus. Br J Dermatol. 2002 Jul;147(1):157-9.
We report the clinical, histopathological and immunological features of follicular erythema and petechiae in a 30-year-old Japanese woman with systemic lupus erythematosus (SLE). Histology showed this eruption to constitute a cutaneous manifestation of SLE. To our knowledge, this is the first reported case of follicular erythema and petechiae in association with SLE. Accordingly, we propose that this rare eruption be termed 'follicular lupus erythematosus'.

Comments from Faculty and Members

Robert I. Rudolph, M.D., FACP, Clinical Professor of Dermatology, University of Pennsylvania, Philadelphia. PA, USA on Oct 18, 2004

Photos and case presentation are excellent. Based on the photos I'd vote for lichen planopilaris, the Graham-Little syndrome, or perhaps an LE/LP overlap. Sure doesn't look like "a pure LE" to me. Good luck with therapy.

Diane Thaler M.D., Madison, WI, USA on Oct 18, 2004

kudos to david for not referring to "race"....

Massone Cesare MD, Department of Dermatology, Medical University of Graz, Graz, Austria on Oct 19. 2004

Lichen planopilaris would be also my first impression. It could fit both clinically (follicular keratotic lesions and Brocq's pseudopelade) and histologically, and it would explain also the worsening with Plaquenil therapy and the clinical improvement after stopping Plaquenil. Pruritus is common in lichen. ANA have been described in LP in 40% of cases of lichen planus using rat oesophagus has substrate (Carrizosa et al, Exp Dermatol. 1997: 54). thiazides may induce lichenoid drug reactions and could have been the Koebner in this case. Has the patient also mucosal lesion? Is she HCV+? Has she variable alopecia of the axillae and groins? CsA could be a therapeutic option.

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