10.5826/dpc.1301a44
text/xml
2160-9381
2478
en
Pavithra Ayyanar
https://creativecommons.org/licenses/by-nc/4.0
Dermatology Practical & Conceptual
Pigmented Macular Variant of Chronic Cutaneous Lupus Erythematosus: Clinico-dermoscopic Features of Three Patients With Skin of Color
Text.Serial.Journal
https://dpcj.org/index.php/dpc
Letter to the Editor
2023-01-31
2022-03-20
2023-01-31
2023-03-01
e2023044
Dermatol Pract Concept
Pavithra Ayyanar
2023/01/31
10.5826/dpc.1301a44
e2023044
Department of Pathology, AIIMS, Bhubaneswar, India
2160-9381
en
e2023044
Chatterjee M, Neema S. Dermoscopy of Pigmentary Disorders in Brown Skin. Dermatol Clin. 2018;36(4):473-485. DOI: 10.1016/j.det.2018.05.014. PMID: 30201156.
Pigmented Macular Variant of Chronic Cutaneous Lupus Erythematosus: Clinico-dermoscopic Features of Three Patients With Skin of Color
https://dpcj.org/index.php/dpc/article/download/2478/1921
 Pigmented Macular Variant of Chronic Cutaneous
Lupus Erythematosus: Clinico-dermoscopic Features
        of Three Patients With Skin of Color
             Biswanath Behera1, Rashmi Kumari2, Debasis Gochhait3, Pavithra Ayyanar4


1 Department of Dermatology, and Venereology, AIIMS, Bhubaneswar, India
2 Department of Dermatology, Venereology and Leprology, JIPMER, Puducherry, India
3 Department of Pathology, JIPMER, Puducherry, India
4 Department of Pathology, AIIMS, Bhubaneswar, India



Key words: macular pigment, lupus erythematosus, discoid, dermoscopy
Citation: Behera B, Kumari R, Gochhait D, Ayyanar P. Pigmented macular variant of chronic cutaneous lupus erythematosus:
Clinico-dermoscopic features of three patients with skin of color. Dermatol Pract Concept. 2023;13(1):e2023044. DOI: https://doi.
org/10.5826/dpc.1301a44
Accepted: September 16, 2022; Published: January 2023
Copyright: ©2023 Behera et al. This is an open-access article distributed under the terms of the Creative Commons Attribution-
NonCommercial License (BY-NC-4.0), https://creativecommons.org/licenses/by-nc/4.0/, which permits unrestricted noncommercial use,
distribution, and reproduction in any medium, provided the original authors and source are credited.
Funding: None.
Competing Interests: None.
Authorship: All authors have contributed significantly to this publication.
Corresponding Author: Rashmi Kumari, M.D., Associate Professor, Dept. of Dermatology, Venereology and Leprology, JIPMER,
Puducherry, Pin-605006. Phone no- 09489692199, E-mail: rashmi.sreerag@gmail.com




To the Editor,                                                           in target-like structures (central white clod/eccrine opening
                                                                         surrounded by brown structureless area) and perifollicu-
    Chronic cutaneous lupus erythematosus (CCLE) is char-                lar gray ring. Case-1 showed also concentric structures as
acterized by the presence of well-defined erythematous scaly             dark brown clod within a light brown clod (Figure 1 and 2).
plaques with associated atrophy, scarring, telangiectasia, and           The clinico-dermoscopic details of the 3 cases are given
pigmentary alteration. The pigmented macular variant is a                in Table 1. Two 4 mm punch biopsies were done: one for
less recognized morphological variant [1].                               histopathological examination and the other for direct im-
    All 3 cases in our series were female with Fitzpatrick               munofluorescence from hyperpigmented macules. The histo-
skin phototype V. They presented with multiple, ill-defined,             pathology of all the cases was diagnostic of CCLE. On direct
light-to-dark brown macules of variable size, predominantly              immunofluorescence, linear deposition of immunoreactant
on the face and head. Associated scarring was noticed only               IgG and, or IgM were noted along the basement membrane
in Case #1. The dermoscopic feature was dominated by fol-                zone in all three cases.
licular plugging and pigment structures like brown dots,                      George et al in 1992 reported a hyperpigmented vari-
globules, homogenous areas, brown to blue-gray peppering,                ant of discoid lupus erythematosus and advocated that as-
and brown pigment network. The brown to blue-gray pep-                   ymptomatic chronic hyperpigmented macules should alert
pering showed a peri-appendageal accentuation and resulted               the clinicians to suspect the diagnosis [1]. Boyd delineated




Letter to Editor | Dermatol Pract Concept. 2023;13(1):e2023044                                                                      1
    Figure 1. (A) Multiple ill-defined brown macules. (B) Dermoscopy under nonpolarized mode shows follicular plugging (blue arrow),
    brown dots, globules, and fine peppering (purple arrow), and concentric structures (red arrow), (C) Perifollicular gray ring (blue
    arrows), follicular plugging (red arrow), and perifollicular accentuated peppering (circle). (D) Brown globule (blue arrow), follicular
    plugging (red arrows), and perifollicular accentuated peppering (black arrow). (E) Peri-eccrine accentuation of peppering (blue ar-
    rows), and target-like structures (white clod surrounded by brown ring (red arrows). (F) Histology shows epidermal atrophy, melanin
    in stratum corneum, basal vacuolar degeneration, and pigment incontinence (H & E, x100).


a distinct profile of patients with solitary hyperpigmented              of inflammation and were distributed primarily on the face
macules over the face and neck without any scaling, at-                  and around the ear.
rophy, scarring, or telangiectasia [2]. These lesions had a                  The dermoscopic features, follicular plugging, brown to
late-­onset, short disease duration, lower incidence of photo-           blue-gray dots, globules, or peppering in our series reflect
sensitivity, and overall better prognosis. They could clinically         the basic pathology of CCLE. The former corresponds to
be mistaken for seborrheic keratosis, solar lentigo or lentigo           the dilated follicular infundibulum keratotic plugging, and
maligna, but the histopathology was consistent with CCLE.                the latter to the melanin in stratum corneum and to the der-
The three cases in our series had multiple asymptomatic                  mal pigment incontinence. Besides, we observed perifollic-
light-to-dark brown macules without any previous history                 ular gray ring and peri-eccrine target-like structures, which



2                                                                             Letter to Editor | Dermatol Pract Concept. 2023;13(1):e2023044
 Figure 2. (A) Multiple ill-defined light brown macules on the ear. (B) Dermoscopy under nonpolarized mode shows blue-gray peppering
 (arrow) over a light brown background. (C) Histology shows epidermal atrophy, follicular plugging, interface dermatitis, and perifollicu-
 lar lymphocytes and macrophages infiltration (H & E, x100). (D) Multiple ill-defined dark-brown macules over the retro auricular area.
 (E) ­Dermoscopy under nonpolarized mode shows follicular plugging (purple arrows), pigment network (red arrow), and peppering (blue
 arrows). (F) Brown pigment network, follicular plugging (red arrows), and periappendageal accentuated peppering (blue arrows). (G) Focal
 white homogenous area with overlying peppering (arrow). (H) Histology shows atrophic epidermis along with interface dermatitis (H &
 E, x100). Inset shows Periodic acid–Schiff positive thick basement membrane (PAS, x400).




possibly reflected the predominance of peri-appendageal                    Diagnosing the pigmented macular variant of CCLE in
interface dermatitis and the resulting pigment incontinence            skin of color, as in our patients, is challenging. It can mimic
[3,4]. The pigmented macular variant of CCLE will have                 various acquired hyperpigmentation disorders such as li-
more prominent pigment incontinence in skin of color. This             chen planus pigmentosus (LPP), pigment contact derma-
feature may not be striking in Fitzpatrick skin phototype I-II.        titis (PCD), and melasma. Besides, it can also be confused



Letter to Editor | Dermatol Pract Concept. 2023;13(1):e2023044                                                                           3
                Table 1. Clinical and dermoscopic details of the pigmented macular variant
                                 of chronic cutaneous lupus erythematosus.
             Gender/Age                              Duration      Associated
    Cases      in years               Location      in months       features                    Dermoscopic features
 Case-1     Female/35        Face, upper trunk     Two            Nil                Brown dots, globules, and peppering
                                                                                     Blue-gray peppering
                                                                                     Follicular plugging
                                                                                     Peri-appendageal accentuation of
                                                                                     peppering
                                                                                     Perifollicular gray ring
                                                                                     Target-like structures
                                                                                     Pseudo-pigment (brown) network
                                                                                     Concentric structures
 Case-2     Female/30        Bilateral ear and     Three          SLE                Brown homogenous area
                             infra-auricular                      Non-scarring       Blue-gray peppering
                             area                                 alopecia           Follicular plugging
                                                                  ISM                Perifollicular gray ring
 Case-3     Female/30        Bilateral ear, pre-   Two            SLE             Brown and white homogenous area
                             and-post-auricular                   Lupus nephritis Brown and blue-gray peppering
                             area                                 ISM             Peri-appendageal accentuation of
                                                                                  peppering
                                                                                  Follicular plugging
                                                                                  Perifollicular gray ring
                                                                                  Brown pigment network

SLE = Systemic lupus erythematosus.



with both benign and malignant pigment tumors such as             similarity to various facial pigmentary lesions. We describe
flat seborrheic keratosis, large cell acanthoma, solar lentigo    the clinico-dermoscopic features in three patients with skin
and lentigo maligna. Clinically, it may not always be possi-      of color. Future studies will determine the role of dermos-
ble to diagnose and differentiate pigmented macular CCLE          copy in diagnosing and differentiating this rare entity from
from other causes of acquired hyperpigmentation, includ-          its clinical mimics.
ing post-inflammatory hyperpigmentation. Dermoscopy
may help in solving this problem. Dermoscopic features
                                                                  References
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in skin of color are as follows: melasma and PCD show a            1. George R, Mathai R, Kurian S. Cutaneous lupus erythema-
brown pigmentation, pseudo-pigment network, brown                     tosus in India: immunofluorescence profile. Int J Derma-
                                                                      tol. 1992;31(4):265-269. DOI: 10.1111/j.1365-4362.1992.
to gray dots and globules, and characteristically spare the
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                                                                   2. Boyd AS. Localized chronic cutaneous lupus erythematosus mas-
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                                                                      Dermatol. 2022;61(1):7-19.DOI: 10.1111/ijd.15741. PMID:
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eye in the diagnosis of CCLE.                                      4. Chatterjee M, Neema S. Dermoscopy of Pigmentary Disorders
     In conclusion, the clinical diagnosis of the pigmented           in Brown Skin. Dermatol Clin. 2018;36(4):473-485. DOI:
macular variant of CCLE can be challenging due to its                 10.1016/j.det.2018.05.014. PMID: 30201156.




4                                                                       Letter to Editor | Dermatol Pract Concept. 2023;13(1):e2023044
