Subacute Cutaneous Lupus Erythematosus (SCLE) Workup

  • Author: Jeffrey P Callen, MD; Chief Editor: William D James, MD   more...
 
Updated: May 15, 2012
 

Approach Considerations

Most patients with subacute cutaneous lupus erythematosus (SCLE) manifest a positive antinuclear antibody (ANA) reaction when tested with human substrates.

Anemia, leukopenia, and/or thrombocytopenia may be present, elevated sedimentation rate may occur in some patients, rheumatoid factor may be positive, and complement levels may be depressed. Urinalysis should be performed initially and also carried out periodically throughout the patient's course.

Next

Serologic Testing

As mentioned, most patients with subacute cutaneous lupus erythematosus (SCLE) manifest a positive 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%
  • Drug-induced SCLE - 70-80%

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.

Previous
Next

Biopsy

Deposition of immunoglobulin and/or complement at the dermoepidermal 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).

The 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.

Previous
Next

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

Previous
Proceed to Treatment & Management
 
 
Contributor Information and Disclosures
Author

Jeffrey P Callen, MD  Professor of Medicine (Dermatology), 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; Celgene Honoraria Safety Monitoring Committee

Specialty Editor Board

Michael J Wells, MD  Associate Professor, Department of Dermatology, Texas Tech University Health Sciences Center, Paul L Foster School of Medicine

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.

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.

Chief Editor

William D James, MD  Paul R Gross Professor of Dermatology, Vice-Chairman, Residency Program Director, Department of Dermatology, University of Pennsylvania School of Medicine

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

References

  1. Braunstein I, Klein R, Okawa J, Werth VP. The interferon-regulated gene signature is elevated in subacute cutaneous lupus erythematosus and discoid lupus erythematosus and correlates with the cutaneous lupus area and severity index score. Br J Dermatol. May 2012;166(5):971-5. [Medline]. [Full Text].

  2. Klein LR, Elmets CA, Callen JP. Photoexacerbation of cutaneous lupus erythematosus due to ultraviolet A emissions from a photocopier. Arthritis Rheum. Aug 1995;38(8):1152-6. [Medline].

  3. Reed BR, Huff JC, Jones SK, Orton PW, Lee LA, Norris DA. Subacute cutaneous lupus erythematosus associated with hydrochlorothiazide therapy. Ann Intern Med. Jul 1985;103(1):49-51. [Medline].

  4. Bentley DD, Graves JE, Smith DI, Heffernan MP. Efalizumab-induced subacute cutaneous lupus erythematosus. J Am Acad Dermatol. May 2006;54(5 Suppl):S242-3. [Medline].

  5. Bezerra EL, Vilar MJ, da Trindade Neto PB, Sato EI. Double-blind, randomized, controlled clinical trial of clofazimine compared with chloroquine in patients with systemic lupus erythematosus. Arthritis Rheum. Oct 2005;52(10):3073-8. [Medline].

  6. Cassis TB, Callen JP. Bupropion-induced subacute cutaneous lupus erythematosus. Australas J Dermatol. Nov 2005;46(4):266-9. [Medline].

  7. Farhi D, Viguier M, Cosnes A, Reygagne P, et al. Terbinafine-induced subacute cutaneous lupus erythematosus. Dermatology. 2006;212(1):59-65. [Medline].

  8. Lowe G, Henderson CL, Grau RH, Hansen CB, Sontheimer RD. A systematic review of drug-induced subacute cutaneous lupus erythematosus. Br J Dermatol. Mar 2011;164(3):465-72. [Medline].

  9. Durosaro O, Davis MD, Reed KB, Rohlinger AL. Incidence of cutaneous lupus erythematosus, 1965-2005: a population-based study. Arch Dermatol. Mar 2009;145(3):249-53. [Medline].

  10. Schmitt V, Meuth AM, Amler S, Kuehn E, Haust M, Messer G, et al. Lupus erythematosus tumidus is a separate subtype of cutaneous lupus erythematosus. Br J Dermatol. Jul 7 2009;[Medline].

  11. Cohen MR, Crosby D. Systemic disease in subacute cutaneous lupus erythematosus: a controlled comparison with systemic lupus erythematosus. J Rheumatol. Sep 1994;21(9):1665-9. [Medline].

  12. Black DR, Hornung CA, Schneider PD, Callen JP. Frequency and severity of systemic disease in patients with subacute cutaneous lupus erythematosus. Arch Dermatol. Sep 2002;138(9):1175-8. [Medline].

  13. Herzinger T, Plewig G, Rocken M. Use of sunscreens to protect against ultraviolet-induced lupus erythematosus. Arthritis Rheum. Sep 2004;50(9):3045-6. [Medline].

  14. Stege H, Budde MA, Grether-Beck S, Richard A, Rougier A, Krutmann J. Evaluation of the capacity of sunscreens to photoprotect lupus erythematosus patients by employing the photoprovocation test. Eur J Dermatol. Jul-Aug 2002;12(4):VII-IX. [Medline].

  15. Kuhn A, Gensch K, Haust M, Meuth AM, Boyer F, Dupuy P, et al. Photoprotective effects of a broad-spectrum sunscreen in ultraviolet-induced cutaneous lupus erythematosus: a randomized, vehicle-controlled, double-blind study. J Am Acad Dermatol. Jan 2011;64(1):37-48. [Medline].

  16. Francès C, Cosnes A, Duhaut P, Zahr N, Soutou B, Ingen-Housz-Oro S, et al. Low blood concentration of hydroxychloroquine in patients with refractory cutaneous lupus erythematosus: a French multicenter prospective study. Arch Dermatol. Apr 2012;148(4):479-84. [Medline].

  17. Housman TS, Jorizzo JL, McCarty MA, Grummer SE, Fleischer AB Jr, Sutej PG. Low-dose thalidomide therapy for refractory cutaneous lesions of lupus erythematosus. Arch Dermatol. Jan 2003;139(1):50-4. [Medline].

  18. Sticherling M, Bonsmann G, Kuhn A. Diagnostic approach and treatment of cutaneous lupus erythematosus. J Dtsch Dermatol Ges. Jan 2008;6(1):48-59. [Medline].

  19. Usmani N, Goodfield M. Efalizumab in the treatment of discoid lupus erythematosus. Arch Dermatol. Jul 2007;143(7):873-7. [Medline].

  20. Cusack C, Danby C, Fallon JC, et al. Photoprotective behaviour and sunscreen use: impact on vitamin D levels in cutaneous lupus erythematosus. Photodermatol Photoimmunol Photomed. Oct 2008;24(5):260-7. [Medline].

  21. James JA, Kim-Howard XR, Bruner BF, Jonsson MK, McClain MT, Arbuckle MR, et al. Hydroxychloroquine sulfate treatment is associated with later onset of systemic lupus erythematosus. Lupus. 2007;16(6):401-9. [Medline].

  22. Jung H, Bobba R, Su J, Shariati-Sarabi Z, Gladman DD, Urowitz M, et al. The protective effect of antimalarial drugs on thrombovascular events in systemic lupus erythematosus. Arthritis Rheum. Mar 2010;62(3):863-8. [Medline].

  23. Callen JP, Klein J. Subacute cutaneous lupus erythematosus. Clinical, serologic, immunogenetic, and therapeutic considerations in seventy-two patients. Arthritis Rheum. Aug 1988;31(8):1007-13. [Medline].

  24. Callen JP. Management of "refractory" skin disease in patients with lupus erythematosus. Best Pract Res Clin Rheumatol. Oct 2005;19(5):767-84. [Medline].

  25. Callen JP. Cutaneous lupus erythematosus: a personal approach to management. Australas J Dermatol. Feb 2006;47(1):13-27. [Medline].

  26. Huber A, Tuting T, Bauer R, Bieber T, Wenzel J. Methotrexate treatment in cutaneous lupus erythematosus: subcutaneous application is as effective as intravenous administration. Br J Dermatol. Oct 2006;155(4):861-2. [Medline].

  27. Kreuter A, Hyun J, Altmeyer P, Gambichler T. Intravenous immunoglobulin for recalcitrant subacute cutaneous lupus erythematosus. Acta Derm Venereol. 2005;85(6):545-7. [Medline].

  28. Wenzel J, Brahler S, Bauer R, Bieber T, Tuting T. Efficacy and safety of methotrexate in recalcitrant cutaneous lupus erythematosus: results of a retrospective study in 43 patients. Br J Dermatol. Jul 2005;153(1):157-62. [Medline].

  29. Kreuter A, Tomi NS, Weiner SM, Huger M, Altmeyer P, Gambichler T. Mycophenolate sodium for subacute cutaneous lupus erythematosus resistant to standard therapy. Br J Dermatol. Jun 2007;156(6):1321-7. [Medline].

  30. Chang AY, Piette EW, Foering KP, Tenhave TR, Okawa J, Werth VP. Response to Antimalarial Agents in Cutaneous Lupus Erythematosus: A Prospective Analysis. Arch Dermatol. Jul 18 2011;[Medline].

 
Previous
Next
 
Early lesions of subacute cutaneous lupus erythematosus may simulate polymorphous light eruption.
Papulosquamous lesions of subacute cutaneous lupus erythematosus may simulate psoriasis.
Annular lesions of subacute cutaneous lupus erythematosus.
Tumid lupus erythematosus.
Neonatal lupus erythematosus.
 
 
 
All material on this website is protected by copyright, Copyright © 1994-2012 by WebMD LLC.
This website also contains material copyrighted by 3rd parties.

DISCLAIMER: The content of this Website is not influenced by sponsors. The site is designed primarily for use by qualified physicians and other medical professionals. The information contained herein should NOT be used as a substitute for the advice of an appropriately qualified and licensed physician or other health care provider. The information provided here is for educational and informational purposes only. In no way should it be considered as offering medical advice. Please check with a physician if you suspect you are ill.