1. A 47 year-old woman is seen in clinic for a 2 month history of fatigue and a rash which is non-pruritic on the arms and upper torso. She reports that the rash worsens with sun exposure. On further inquiry she denies any sicca symptoms, no joint pain nor has she noticed any Raynaud phenomenon. On examination, she appears in no distress with normal vitals. Examination of the skin revealed no inflamed joints nor effusions. There are no other rashes on exam. Laboratory studies, including metabolic panel, complete blood count, and urinalysis, are normal. ANA is negative, ENA is positive (anti-Ro/SSA antibody) . Her rash appears as follows:
What is the most likely diagnosis?
A. Systemic lupus erythematosus
B. Erythema multiforme
C. Subacute cutaneous lupus erythematosus
D.Psoriasis
(NEW!) 2. A 28-year old woman is evaluated for an 8-month history of a non-pruritic, painless indurated plaques on her back and lower abdomen. On further inquiry about this rash she denies any association with sun-exposure or other environmental triggers nor she has identified any palliative or provocative factors. There is no history of reflux disease, no shortness of breath with exertion nor any history of Raynaud phenomenon. Her past medical history is unremarkable and she only takes oral contraceptive medications. On physical examination her vitals are stable and normal. On her back there is a 4× 5-cm and on lower abdomen 3 x 8-cm areas of induration where the skin is quite smooth with some associated blanchable-erythema. Examination of her nail beds show no evidence of capillary loop dropout nor any other skin lesions are noted. Her laboratory tests including an ANA was negative. A skin biopsy was done on the first visit and the results return two weeks later showing an increased number of lymphocytes in the dermis with a perivascular predominance in keeping with sclerodema.
What is the most likely diagnosis?
A. Limited Cutaneous Systemic Sclerosis
B. Limited Morphea
C. Diffuse Morphea
D. Diffuse Cutaneous Systemic Sclerosis
ANSWERS
1. C –This patient has a diagnosis of subacute cutaneous lupus erythematosus. There are two major forms, an annular and papulosquamous variant, the latter being less common. The papulosquamous form can resemble psoriasis whereas the annular form typically manifest as scaly erythematous circular plaques with central hypopigmentation. Subacute cutaneous lupus erythematosus can be caused by medications thiazide diuretics and calcium channel blockers. These rashes tend to involve the upper torso and extensor surfaces of the arms. About 1 in 10 patients with SLE will develop such manifestations and it is typically associated with anti-Ro/SSA and anti-La/SSB antibodies. In this case, this patient has no other findings that satisfy diagnostic criteria for SLE. Read more about SLE here on Medscape
2. B- This is a case of limited morphea. Morphea is a type of sclerosis that involves the skin without other extra-cutaneous or systemic manifestations which is different from the cases of systemic sclerosis. Additionally, as this patient’s biopsy confirmed, morphea has the same histologic appearance with systemic sclerosis. Additionally, morphea can be divided into two (2) distinct categories: a limited variant and a diffuse variant. This is a case of a limited variant, in cases of diffuse morphea there tends to be involvement of the torso and limbs. Read more about systemic sclerosis here on Medscape.