Discoid Lupus Erythematosus

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1 S023 Hair and Scalp Dermoscopy Discoid Lupus Erythematosus Bruna Duque Estrada, M.D. Instituto de Dermatologia Prof. Rubem David Azulay Rio de Janeiro, Brazil.

2 Disclosure of Relationship with Industry Bruna Duque- Estrada, MD S023 Hair and Scalp Dermoscopy Disclosures I have no conflicts to disclosure

3 Discoid Lupus Erythematosus (DLE) Primary Cicatricial Alopecia Although the hair follicle is not the primary target of inflammatory process Onset 20-40s Scalp involvement is often the presenting symptom 50-80% of patients with Chronic Cutaneous Lupus

4 Discoid Lupus Erythematosus Well- demarcated alopecic patch Follicular plugging, adherent scale and erythema Hypo- or hyperpigmentation Symptoms: itching, pain, burning and ternderness Early diagnosis may avoid scarring and atrophy

5 Trichoscopy of DLE - Objectives Diagnosis: present trichoscopic features of DLE Avoid scarring: call attention for early diagnosis Indicate biopsy sites Follow- up: differentiate active from non- active lesions Make differential diagnosis with scarring and non- scarring alopecias

6 Discoid Lupus Erythematosus Diagnostic features Keratotic plugs Thick arborizing vessels Blue- grey dots Red dots Scattered brown discoloration White patches Ref Trabalho Ross, nosso, Lidia e Tosti

7 Discoid Lupus Erythematosus Keratotic plugs Large yellow dots Use dry dermoscopy Dark yellow to yellow brown

8 Hyperkeratosis and plugging of the follicular ostia with keratotic material Acute and periphery of chronic lesions

9 Discoid Lupus Erythematosus Thick arborizing vessels Deep plexus + Epidermal atrophy + 90% of DLE lesions May last in late- stage disease A. Rakowska et al. J Drugs Dermatol 2012

10 Discoid Lupus Erythematosus Red spider in a yellow dot Yellow dots + thin arborizing vessels Epidermal atrophy Late stage DLE A. Rakowska et al. J Drugs Dermatol 2012

11 Discoid Lupus Erythematosus Blue- grey dots Speckled pattern Melanin and melanophages in the dermis Interfollicular interface dermatitis African descendents Duque- Estrada B et al. An Bras Dermatol. 2010

12 Discoid Lupus Erythematosus Scattered brown discoloration Pigment incontinence African descendents and Caucasians A. Rakowska et al. J Drugs Dermatol 2012

13 Discoid Lupus Erythematosus Blue- white veil Pigment incontinence + hyperkeratosis Use immersion fluid African descendents

14 Discoid Lupus Erythematosus Blue- white veil Pigment incontinence + hyperkeratosis Use immersion fluid African descendents

15 Discoid Lupus Erythematosus Red dots Early Diagnosis, active disease Follicular opening surrounded by dilated vessels Good prognostic factor for hair regrowth Tosti A. et al. Arch Dermatol 2009

16 Rosettes Shiny white Four oval- shaped points Optical effect between of crossed polarization in the follicular and perifollicular structures Narrowing of infundibula or blockage by keratin Early disease follicle preserved

17 Discoid Lupus Erythematosus Perifollicular scaling Dry Dermoscopy V sign - Compound structures Lichenoid infiltrate and perifollicular fibrosis Differential diagnosis: LPP Miteva M., Tosti A. JEADV 2013

18 Discoid Lupus Erythematosus Interfollicular scaling Hyperkeratosis Differential: psoriasis, seb dermatitis

19 Discoid Lupus Erythematosus Milky red/pink areas White patches

20 Trichoscopy ofdle Active features Inactive (end- stage) features Keratotic plugs Loss of follicular openings Red dots Pink areas Thick arborizing vessels White patches Blue- gray dots Thin Arborizing vessels Scattered brown discoloration Yellow dots with spider vessels Blue- white veil Perifollicular scale Fine interfollicular scaling Rosettes

21 DLE & Frontal Fibrosing Alopecia DLE may coexist with FFA 1: Trüeb RM, El Shabrawi- Caelen L, Kempf W. Cutaneous Lupus ErythematosusPresenting as Frontal Fibrosing Alopecia: Report of 2 Patients. Skin Appendage Disord Oct;3(4): : Contin LA, Martins da Costa Marques ER, Noriega L. Frontal Fibrosing Alopecia Coexisting with Lupus Erythematosus: Poor Response to Hydroxychloroquine. SkinAppendage Disord Jan;2(3-4): : del Rei M, Pirmez R, Sodré CT, Tosti A. Coexistence of frontal fibrosingalopecia and discoid lupus erythematosus of the scalp in 7 patients: just a coincidence? J Eur Acad Dermatol Venereol Jan;30(1): : Khan S, Fenton DA, Stefanato CM. Frontal fibrosing alopecia and lupus overlap in a man: guilt by association? Int J Trichology Oct;5(4): : Gaffney DC, Sinclair RD, Yong- Gee S. Discoid lupus alopecia complicated byf rontal fibrosing alopecia on a background of androgenetic alopecia. Br J Dermatol Jul;169(1): : Duque- Estrada B, Tamler C, Sodré CT, Barcaui CB, Pereira FB. Dermoscopy patterns of cicatricial alopecia resulting from discoid lupus erythematosus and lichen planopilaris. An Bras Dermatol Mar- Apr;85(2):

22 Take home message 1. Early Lesions Trichoscopy helps you to be suspicious of DLE Keratotic plugs, Red dots, Rosettes prefibrotic stage

23 Take home message 2. Clinically evident DLE Trichoscopy confirms diagnosis, helps recognizing active/late stage areas and choosing biopsy sites

24 Take home message 3. Diffuse scaling may be a sign of DLE Remove the scales before perfoming trichoscopy

25 Take home message 4. Try not miss late stage DLE Cicatricial alopecia Trichoscopy will suggest DLE, and helps choosing biopsy sites

26 Thank you!

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