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Lupus Erythematosus, Subacute Cutaneous: Differential Diagnoses & Workup

Author: Jeffrey P Callen, MD, Professor of Medicine, Chief, Division of Dermatology, University of Louisville School of Medicine
Contributor Information and Disclosures

Updated: Apr 13, 2009

Differential Diagnoses

Dermatomyositis
Lupus Erythematosus, Acute
Erythema Annulare Centrifugum
Lupus Erythematosus, Discoid
Erythema Gyratum Repens
Polymorphous Light Eruption
Erythema Multiforme
Psoriasis, Plaque
Granuloma Annulare
Sarcoidosis
Henoch-Schönlein Purpura (Anaphylactoid Purpura)
Tinea Corporis
Hypersensitivity Vasculitis (Leukocytoclastic Vasculitis)
Lichen Planus

Workup

Laboratory Studies

  • Serologic testing
    • Most patients with subacute cutaneous lupus erythematosus (SCLE) manifest a positive antinuclear antibody (ANA) reaction when tested with human substrates. HEp-2 cells are the substrate used most commonly in commercial laboratories.
    • Anti-Ro (SS-A) autoantibodies are present in a high proportion of patients as follows:
      • Annular SCLE - 90%
      • Papulosquamous SCLE - 80-85%
      • SCLE with vasculitis, Sjögren syndrome, or C2d deficiency - Greater than 95%
      • Mothers of neonates with LE - Greater than 90%
    • Anti-La (SS-B) autoantibodies often are present in a lesser percentage.
    • Usually, laboratories perform the anti-Ro and anti-La autoantibody assays as a pair. Occasionally, patients have only anti-La (SS-B) autoantibodies.
    • Anti-native DNA (double-stranded or nDNA) antibodies usually reflect SLE, but they may occur in some patients with SCLE.
  • Other laboratory tests
    • Anemia, leukopenia, and/or thrombocytopenia may be present.
    • Elevated sedimentation rate may occur in some patients.
    • Rheumatoid factor may be positive.
    • Complement levels may be depressed.
    • Urinalysis should be performed initially and periodically throughout the patient's course.

Other Tests

  • Deposition of immunoglobulin and/or complement at the dermal-epidermal junction is a characteristic feature of LE. Examination of tissue may be performed on skin lesions (lesional) or normal skin (nonlesional). Nonlesional biopsies may be performed on sun-exposed or nonexposed surfaces. Testing of nonlesional nonexposed skin is termed the lupus band test (LBT).
    • Use and interpretation of these tests vary according to the site of biopsy. Only 60% of patients with subacute cutaneous lupus erythematosus (SCLE) test positive on lesional skin. Some, usually those with SLE, have a positive LBT.
    • Older lesions may be more likely to be negative on immunofluorescence microscopy. Lesions of TLE frequently are negative. The frequency of positive tests also is affected by tissue handling techniques. Snap frozen tissue is less likely to be falsely positive than tissue sent to the laboratory in Michel transport media.

Histologic Findings

Characteristic histopathologic alterations observed in subacute cutaneous lupus erythematosus (SCLE) include (1) vacuolar alteration of the basal cell layer and (2) an inflammatory cell infiltrate (usually lymphocytic) around vessels (perivascular), around appendiceal structures (periappendiceal), and in a subepidermal location. Epidermal changes, such as atrophy, are common, but follicular plugging is less frequent than in patients with DLE. An abundance of mucin often is seen within the dermis.

Histopathologic features differ depending upon the type and age of the lesion. For example, papulosquamous lesions of SCLE are much more likely to manifest diagnostic findings than annular lesions of SCLE. TLE lacks epidermal involvement.

More on Lupus Erythematosus, Subacute Cutaneous

Overview: Lupus Erythematosus, Subacute Cutaneous
Differential Diagnoses & Workup: Lupus Erythematosus, Subacute Cutaneous
Treatment & Medication: Lupus Erythematosus, Subacute Cutaneous
Follow-up: Lupus Erythematosus, Subacute Cutaneous
Multimedia: Lupus Erythematosus, Subacute Cutaneous
References
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References

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Further Reading

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Keywords

subacute cutaneous lupus erythematosus, SCLE, systemic lupus erythematosus, SLE, lupus, autoimmune disease, discoid lupus erythematosus, Sjogren syndrome

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Contributor Information and Disclosures

Author

Jeffrey P Callen, MD, Professor of Medicine, Chief, Division of Dermatology, University of Louisville School of Medicine
Jeffrey P Callen, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Dermatology, American College of Physicians, and American College of Rheumatology
Disclosure: Amgen Honoraria Consulting; Abbott Honoraria Consulting; Electrical Optical Sciences Honoraria Consulting; Centocor Honoraria Consulting; Genetech Honoraria Consulting; Celgene Honoraria Consulting

Medical Editor

Kathleen David-Bajar, MD, Former Consultant to the Army Surgeon General, Department of Dermatology, Brooke Army Medical Center
Kathleen David-Bajar, MD is a member of the following medical societies: Alpha Omega Alpha and American Academy of Dermatology
Disclosure: Nothing to disclose.

Pharmacy Editor

Michael J Wells, MD, Associate Professor, Department of Dermatology, Texas Tech University Health Sciences Center
Michael J Wells, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Dermatology, American Medical Association, and Texas Medical Association
Disclosure: Nothing to disclose.

Managing Editor

Lester F Libow, MD, Dermatopathologist, South Texas Dermatopathology Laboratory
Lester F Libow, MD is a member of the following medical societies: American Academy of Dermatology, American Society of Dermatopathology, and Texas Medical Association
Disclosure: Nothing to disclose.

CME Editor

Joel M Gelfand, MD, MSCE, Medical Director, Clinical Studies Unit, Assistant Professor, Department of Dermatology, Associate Scholar, Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania
Joel M Gelfand, MD, MSCE is a member of the following medical societies: Society for Investigative Dermatology
Disclosure: AMGEN Consulting fee Consulting; AMGEN Grant/research funds None; Genentech Consulting fee Consulting; Centocor Consulting fee Consulting; Centocor Grant/research funds None; Covance Consulting fee Consulting; Shire  Consulting

Chief Editor

William D James, MD, Paul R Gross Professor of Dermatology, University of Pennsylvania School of Medicine; Vice-Chair, Program Director, Department of Dermatology, University of Pennsylvania Health System
William D James, MD is a member of the following medical societies: American Academy of Dermatology and Society for Investigative Dermatology
Disclosure: elsevier Royalty Other; american college of physicians Honoraria Other

 
 
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