Khalifa Shaquie MD, PhD, Professor of Dermatology,
College of Medicine, University of Baghdad, Baghdad, Iraq
on Sept 20, 2005
This is an interesting case of lupus profundus. We have similar
experience with this condition comparable to Dr Foong report.
This patient should be treated urgently to prevent or minimise
the deformity in the right cheek. Regarding the the left deformity,the
best solution is to inject with fat taken from buttock or abdominal
wall. I have personal experience of injecting fat to a similar
deformity and gave very nice cosmetic appearance for 3 years
follow up. Although fat can resorb but could be repeated and
reach a permanent status without any side effects that could
be seen with other fillers.
Mohsin Ali MBBS, MRCP, Amersham, United Kingdom on
Sept 20, 2005
Good work. Keep it up!
David Elpern M.D. Williamstown, MA, USA on
Sept 20, 2005
I saw a similar patient a few months back.
She is a 64 yo woman who presented for a wart on a finger.
Around 30 years ago, after a pregnancy, she developed facial
lesions which drained pus for many years. It was called DLE
and eventually healed with impressive facial lipoatrophy. She
has some scarring alopecia, too. In addition, she has calcinosis
cutis on arms and thighs (none have ulcerated recently). Her
"lupus" has burned out and she has had not meds for
> 20 years.
Thought these pictures might interest VGRD members.
Shahbaz A Janjua MD, Ayza Skin & Research Centre,
Lalamusa, Pakistan on Sept 20, 2005
An excellent case presentation of lupus profundus. It reminds
me of the case we (Dr.Ian McColl, Dr.Jayakar Thomas, and I)
reported two years earlier. It was in fact second case report
in the literature involving the periparotid and parotid regions
in addition to the typical areas. I treated that patient with
oral hydroxychloroquine and topical steroids. The disease progression
halted after a few months of treatment but the facial disfigurement
remained a challenging task to deal with. I referred the patient
to a plastic surgeon to take care of the facial atrophic scars.
In my opinion collagen fillers are worth trying in such cases.
You may access the case here. http://www.ayubmed.edu.pk/JAMC/PAST/16-4/Shahbaz%20CR.htm
Khaled El-hoshy M.D., Troy, Michigan, USA on
Sept 20, 2005
Once diagnosis established, autologous fat transfer may be
an option after disease control. Repeated sessions every 3-9
months may be needed.
Rick Sontheimer MD, Professor and Vice-Chairman, Dept.
of Dermatology University of Oklahoma Health Sciences Center,
Oklahama City,OK, USA on Sept 20, 2005
I would normally obtain histopathologic confirmation of a presumed
diagnosis of lupus panniculitis/lupus profundus, even knowing
that a biopsy site in a lupus panniculitis lesion can at times
be quite slow to heal. However, if the scarring alopecia of
her scalp was found to be due to histopathologically-confirmed
discoid LE then I think that it could be safe to assume that
the swelling of her right cheek represented active lupus panniculitis
while the depressed area on her left cheek represented localized
lipoatrophy resulting from previous lupus panniculitis activity.
I personally have had good luck was single agent or combined
antimalarial therapy for active lupus panniculitis (especially
in non-smokers). However, appropriate time intervals (6 wks-3
mos) must be given to allow these drugs to work maximally. Thalidomide
can also be useful in rapidly calming lupus panniculitis inflammation.
Because of the depth of the lipoatrophy on her left cheek one
might initially consider autologous fat transfer rather than
artificial fillers.
However, caution should be taken with any type of cosmetic
manipulation in lupus panniculitis for the fear of surgical
trauma-induced ulceration and/or Koebnerizatin. It would be
best to have all evidence of lupus panniculitis/discoid LE activity
suppressed medically before cosmetic revision is considered.
When weighing the cost benefit of cosmetic manipulation of lupus
panniculitis,
It should be kept in mind that even therapeutic intralesional
corticosteroid injections have been associated with ulcerative
breakdown of lupus panniculitis lesions.
Julian Manzur M.D., Havana, Cuba on Sept 23,
2005
I have seen significant atrophy after high concentration administration
of intralesional triamcinolone on plaques in patients with discoid
lupus erythematosus.
Of course, this is not related with this patient.
Robert I. Rudolph, M.D., FACP, Clinical Professor of
Dermatology, University of Pennsylvania, Philadelphia. PA, USA
on Sept 25, 2005
My impression is that this patient has "Parry Romberg
disease". While I guess LE could cause this, I would be
skeptical.
Abir Saraswat MD, Lucknow, India on Sepy 26,
2005
I have treated a woman recently whose case exemplifies the
problem of plastic surgical correction of these deformities.
She had recurrent nodules on both her cheeks for the last
3 to 4 years which were subsiding in several months with lipoatrophy.
Dissatisfied with medical treatment, she went for excision of
one of the nodules which was done by a plastic surgeon and repaired
with a rotation flap. Within 2 months, a new nodule developed
right on the incision line and was followed over the next few
months by more nodules on other points on the margin.
She was subsequently treated with low dose oral steroids and
Azathioprine. Therapy was stopped after 6 months and she has
been asymptomatic for 6 months now.
In light of this, I feel that any surgical correction of lipoatrophy
should only be done well after complete cessation of activity
of the disease. Prof. Sontheimer's reminder of caution with
any intralesional manipulation is especially apt in the spirit
of primum non nocere.
Henry Foong's additional note on Sept 26,
2005 :
The serology of the patient's ANA was 1:160 (nucleolar pattern).
Her dsDNA Antibody was negative. This makes the clinical diagnosis
of lupus profundus / panniculitis most likely. I would agree
that the disease activity must be quiscent before contemplating
on any surgical procedure. Autologous fat transfer would be
more favourable in view of the depth of the lipoatrophy.
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