| Comments from Faculty and Members |
Thomas Jayakar MD, PhD , Professor of Dermatology,
Chennai, India on Feb 28, 2005
I had seen this picture earlier from Dr. Janjua.
I was favoring a diagnosis of actinic lichen planus as well
as an LE/LP overlap. The side view picture shows telangiectasia
over the malar region. We should probably keep in mind photo-induced
poikiloderma.
A biopsy with immunofluorescence study will be the final court
of appeal. I wish Dr. Janjua could coax the patient to agree
for a biopsy. Best wishes to VGR-D
Raafa Hayani MD, Baghdad, Iraq on Feb 28,
2005
The hyperpigmented lesions are looking violaceous so the exclusion
of actinic lichen planus via biopsy is mandatory.The hypopigmented
skin are looking otherwise completely normal with involvement
of area near orifices which support the diagnosis of vitiligo
whether due to external cause like phenolic compound or internal
causes. We see many cases of DLE with postinflamatory vitiligo
like leukoderma but the skin is not looking normal like this
and if the photos are not so clear the possibility of LP DLE
overlap is good and still biopsy is important.
Walter and Dorinda Shelley, M.D., Professors of Dermatology,
Medical College of Ohio, Toledo, OH, USA on Feb 28,
2005.
Here is our take on this patient:
1) Looks like DLE - but if nothing is palpable, it is probably
vitiligo.
2) The distribution is striking and suggests underlying peridontal
or tooth disease of lower jaw. She needs comprehensive dental
exam and
x-rays.
3) Where did the lesions start? Lips? (consider HSV) Below ears?
(chronic ear infection) Scalp line, anterior or posterior? (look
at throat).
4) Follow the trail of infection and TREAT - suggest 4 week
trials with Augmentin, doxycycline, Flagyl, and Zovirax.
Richard Sontheimer M.D., Professor and Vice-Chairman,
Department of Dermatology, Fleischaker Endowed
Chair in Dermatology, University of Oklahoma
Health Sciences Center, Oklahoma City, Oklahoma,
USA on Feb 28, 2005
I would be interested in knowing more about the duration of
this eruption. If it has been present for a long period of time
I would more strongly consider a burned out case of cutaneous
LE or LE/lichen planus overlap. Some forms of cutaneous LE can
resolve with non-atrophic vitiligo-like depigmentation (eg,
SCLE and superficial forms of discoid LE). In addition, I think
that the association between the hyperpigmentation and hypopigmentation
also suggest cutaneous LE. On the forhead and scalp, several
areas of hypopigmentation appear to be immediately bordered
by hyperpigmentation. This arrangement of pigmentary changes
is very characteristic of cutaneous LE (i.e., peripheral postinflammatory
hyperpigmentation surrounding central postinflammatory hypopigmentation).
I would also be interested in knowing whether she might have
any of the follicular changes in her external auditory canals
that are often seen in cutaneous LE patients having involvement
of the face and scalp (perifollicular hyperpigmentation, patulous
follicules, keratin plugged follicles). I would consider a skin
biopsy mandatory in this case.
Khaled El-Hoshy MD, Troy, Michigan, USA on
Feb 28, 2005
Consider actinic lichen planus, topical steroids and sunscreen
usage may be of help.
Abir Saraswat MD, Lucknow, India on Mar 1,
2005
The predominantly periorificial distribution is reminiscent
of vitiligo, as is the sharply demarcated depigmented patch
on the chin, which does not have any hyperpigmented border or
scarring. the involvement of scalp and hairline and sparing
of the most convex parts of the face makes a primary photosensitive
eruption unlikely. Keeping in mind the violaceous macules (?papules),
coexisting vitiligo / Lichen planus is my first possibility.
A biopsy from the lesions at the hairline should be not too
disfiguring.
Additional image posted on March 2, 2005
Omid Zargari MD, Assistant Professor
of Dermatology, Razi Hospital, Guilan University of Medical
Sciences, Rasht, Iran on Mar 2, 2005
To me it looks like DLE (or LE/LP overlap). Pigmentary changes
are not uncommon in DLE, especially in dark skin people.
Khalifa Shaquie MD, PhD, Professor of Dermatology,
College of Medicine, University of Baghdad, Baghdad, Iraq
on Mar 3, 2005
On careful examination of the rash, we can notice both lichenoid
eruption and leucoderma on the face of outdoor worker. So both
problems could be triggered by sunlight. Regarding lichenoid
rash is strongly suggestive lichen planus actinicus after excluding
the thiazides intake that can cause lichenoid solar rash. Lichen
planus actinicus is a common problem in Middle East and India
and no problem to establish right clinical diagnosis. Post-inflammatory
leucoderma can happen at the lesions of LP actinicus but in
the present case the leucodermas are unrelated and go beyond
the LP rash. So accordingly the white milky spots are ordinary
vitiligo which accidently occured in combination with LP actinicus
and both are induced by autoimmune reaction. Psoralen drugs
should not be used in treatment of vitiligo otherwise will exacerbate
LP actinicus. So the management needs avoidance of sunlight
exposure with sunsreen and corticosteroid, both topical and
systemic for both vitiligo and LP. In addition we can use topical
5% iodine tincture or 5% lactic solution 3 times weekly for
vitiligo as additional remedy.
Sunil Dogra MD, Dept. of Dermatology, Postgraduate
Institute of Medical Education and Research, Chandigarh, India
on Mar 7, 2005
Lesions particularly over the forehead are violaceous and depigmented
macules and patches over lips and ear are characteristic of
vitiligo. No scarring and lack of hyperpigmentation at borders
or center of these dipigmented patches or any other epidermal
change make DLE to be very unlikely. I wil consider the possibility
of LP(actinic?) and vitiligo overlap. Biopsy from forehead papule
should resolve issue.
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