A 35-year-old woman comes to the office due to a rash. For the past year, she has had progressive development of multiple lesions on her face, neck, and central chest associated with mild pruritus. The patient otherwise feels well and has no chronic medical conditions. Vital signs are normal. Skin examination reveals numerous scaly lesions with pigment changes and shallow ulceration, as shown in the exhibit. Which of the following is the most likely diagnosis for this patient's skin disorder?

Question

A 35-year-old woman comes to the office due to a rash.  For the past year, she has had progressive development of multiple lesions on her face, neck, and central chest associated with mild pruritus.  The patient otherwise feels well and has no chronic medical conditions.  Vital signs are normal.  Skin examination reveals numerous scaly lesions with pigment changes and shallow ulceration, as shown in the exhibit. Which of the following is the most likely diagnosis for this patient's skin disorder?

Quizplus · Accepted Answer

This patient has chronic, scaly, irregular, erythematous plaques with ulceration and central hypopigmentation surrounded by hyperpigmentation. This presentation is consistent with discoid lupus erythematosus (DLE), the most common form of chronic cutaneous lupus erythematosus. DLE can occur independently, although systemic lupus erythematosus (SLE) eventually develops in up to 30% of patients. Risk factors for progression to SLE include widespread lesions, concurrent arthralgias/arthritis, and high antinuclear antibody titers. DLE most commonly affects sun-exposed regions of the head and neck but may also involve the chest and upper extremities. The lesions tend to slowly expand over a period of months to years, eventually leading to dermal atrophy and scarring. The rash often extends into the hair follicles, resulting in scarring alopecia. (Choice B) Necrobiosis lipoidica is characterized by confluent annular lesions with a yellowish-brown hue, dilated blood vessels, and epidermal atrophy. It typically affects pretibial skin and is most common in patients with diabetes mellitus. Necrobiosis lipoidica (Choice C) Like DLE, porphyria cutanea tarda affects sun-exposed areas (mainly the face and dorsum of the hands). However, the lesions characteristically form fragile blisters and erosions rather than scaly plaques. Also, although the disorder can lead to chronic scarring, individual lesions are often triggered acutely by minor trauma. blisters (Choice D) Systemic sclerosis (scleroderma) causes induration and hardening of the skin, most commonly at the hands/fingers and face. Ulcerations are typically located at the fingertips. Ulcerations Educational objective: Discoid lupus erythematosus presents with scaly, erythematous plaques, leading to atrophy, hypopigmentation, and scarring. It most commonly affects sun-exposed areas of the head and neck. References: Cutaneous lupus erythematosus: diagnosis and treatment. (http://www.ncbi.nlm.nih.gov/pubmed/24238695)

A 35-Year-Old Woman Comes to the Office Due to a Rash