A 55-year-old woman comes to the physician with a rash on her face for the past 4 weeks. The rash seems to get worse when she spends time outdoors, but it does not flare with food intake. She has no flushing or itching. The patient denies fever, weight loss, or muscle weakness. She was recently diagnosed with hypertension and type 2 diabetes mellitus and started on lisinopril, metformin, and sitagliptin.
Physical examination reveals a 1-cm ulcer in the roof of the hard palate. A photograph of the rash is shown below.

Which of the following conditions is the most likely diagnosis?

Question

A 55-year-old woman comes to the physician with a rash on her face for the past 4 weeks.  The rash seems to get worse when she spends time outdoors, but it does not flare with food intake.  She has no flushing or itching.  The patient denies fever, weight loss, or muscle weakness.  She was recently diagnosed with hypertension and type 2 diabetes mellitus and started on lisinopril, metformin, and sitagliptin.
Physical examination reveals a 1-cm ulcer in the roof of the hard palate.  A photograph of the rash is shown below.

Which of the following conditions is the most likely diagnosis?

Quizplus · Accepted Answer

This patient presents with an acute photosensitive rash, oral ulcer, and new-onset hypertension, features suggestive of systemic lupus erythematosus (SLE). Patients with SLE may present with rash months to years before development of other symptoms. The classic butterfly rash appears as erythema and scaling over the cheeks and bridge of nose with sparing of the nasolabial folds. It usually worsens with ultraviolet light exposure and can be mistaken for sunburn. Some patients may also have oral or nasopharyngeal ulcers, alopecia, or cutaneous bullae. Patients should be advised to avoid ultraviolet light exposure and use sun protection. Lupus rash can be treated initially with topical glucocorticoids, but patients with persistent rash should be treated with oral hydroxychloroquine (antimalarials). Systemic glucocorticoids and immunosuppressive agents are not used frequently except in patients with bullous lesions. (Choice A) Typical lesions of erythema multiforme appear as target lesions with central erosions or bullae. Erythema multiforme occurs most commonly in the setting of an infection (eg, herpes simplex), and the lesions usually resolve within 2 weeks. erythema multiforme (Choice B) Patients with erythematotelangiectatic rosacea usually present with persistent facial erythema, telangiectasias, and episodes of facial flushing. They do not have the classic malar rash with abrupt cutoff (butterfly wing) that is seen in patients with lupus. (Choice C) Drug eruptions usually begin within days to weeks of starting a new medication. They occur in dependent areas with subsequent generalization and are almost always pruritic. Drug eruptions (Choice D) Seborrheic dermatitis is characterized by scaling and erythema, usually on the scalp, face, and upper trunk (areas rich in sebaceous glands). When present on the face, it affects the lateral sides of the nose and nasolabial folds (unlike lupus), eyebrows, and forehead. Seborrheic dermatitis Educational objectives: Patients with undiagnosed systemic lupus erythematosus may initially present with a photosensitive classic butterfly rash, oral ulcers, or alopecia. Treatment of lupus rash includes avoidance of sun exposure, topical steroids, and antimalarials for persistent rash. __________ References: Cutaneous lupus erythematosus: issues in diagnosis and treatment. (http://www.ncbi.nlm.nih.gov/pubmed/19824738) Diagnosis and treatment of rosacea: state of the art. (http://www.ncbi.nlm.nih.gov/pubmed/22648219)

A 55-Year-Old Woman Comes to the Physician with a Rash