Tumid Lupus Erythematosus Presenting as Patchy Alopecia: A Discussion of Alopecia Associated With Lupus Erythematosus

Abstract

Tumid lupus erythematosus (TLE), a subtype of chronic cutaneous lupus erythematosus (CCLE), presents with firm erythematous plaques that lack surface changes such as follicular plugging or scale. These lesions most commonly occur on the face and other photosensitive areas but may also present on the scalp as recurrent circumscribed patches of non-cicatricial alopecia. Including TLE as part of the differential for non-cicatricial alopecia can prove helpful in patients who fail to improve with empiric first-line treatments for more common causes of hair loss. We report a case of TLE that clinically mimicked alopecia areata and seek to highlight the relevant clinical and histological features to promote earlier diagnosis of this entity. A discussion of improved diagnostic and treatment modalities, as well as identifying the uncommon but possible association of TLE with underlying systemic disease, adds to the importance of maintaining clinical suspicion for TLE. Finally, we provide an overview to discriminate TLE from other forms of cutaneous lupus and their unique patterns of alopecia when presenting on the scalp.

Keywords: derm-rheum; hair loss treatment; non-scarring alopecia; scalp lesions; tumid lupus.

Figure 1. Patient at the time of presentation with a few circumscribed patches of alopecia, some with new hair growth. Mild dermal atrophy was noted overlying the left temporal scalp.

Figure 2. Patient presents eight months later with complaints of recurrent patchy alopecia. A firm, tender nodule with surrounding bogginess was appreciated on palpation.

Figure 3. A: Hematoxylin and eosin (2.5× magnification) staining showing lymphocyte-predominant inflammation mainly surrounding periadnexal structures. Some superficial perivascular inflammation is also present but without significant interface changes at the basement membrane (arrow). B: Hematoxylin and eosin (4× magnification) demonstrating periadnexal lymphocytic infiltrate (arrow). C: Alcian blue staining (4× magnification) revealing increased dermal mucin (arrows). D: CD3 staining (2.5× magnification) confirming that the periadnexal inflammation is predominantly composed of T-cells. CD20 staining (not pictured) was also performed and was nearly negative. No significant lymphocytic epidermotropism was identified.

CD20: cluster of differentiation 20

Figure 4. Patient three months after the final diagnosis, now with one residual patch of alopecia. At this time, the patient had been on hydroxychloroquine for two months.