Hypopigmentation on face and arms
A 51-year-old black man went to see his physician because of the hypopigmentation around his ears, face, and arms. For the past 5 years, he had been taking medication for high blood pressure. The patient did not like the look of the white spots on his skin and was wondering if he had vitiligo like Michael Jackson.
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The family physician recognized the hypopigmentation and scarring of the pinna as classic and common findings in discoid lupus erythematosus (DLE). To confirm the diagnosis, a punch biopsy was done on an area of hypopigmentation of the arm. The antinuclear antibody (ANA) test was negative. Patients with DLE generally have negative or low ANA titers, and rarely have low titers of anti-Ro antibodies.
DLE lesions are characterized by discrete, erythematous, slightly infiltrated papules or plaques covered by a well-formed adherent scale. As the lesion progresses, the scale often thickens and becomes adherent. Hypopigmentation develops in the central area and hyperpigmentation develops at the active border. Resolution of the active lesion results in atrophy and scarring. When these lesions occur on the scalp, scarring alopecia often results.
DLE therapy includes corticosteroids (topical or intralesional) and oral antimalarials such as hydroxychloroquine. This patient chose to use topical steroids only. Patients who choose hydroxychloroquine will need eye exams by an ophthalmologist every 6 to 12 months to detect any retinal or visual field problems.
Photos and text for Photo Rounds Friday courtesy of Richard P. Usatine, MD. This case was adapted from: Mayeaux, EJ. Lupus erythematosus (systemic and cutaneous). In: Usatine R, Smith M, Mayeaux EJ, et al, eds. The Color Atlas of Family Medicine. New York, NY: McGraw-Hill; 2009:766-771.
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