Dermatologic Physical Exam

Proven Lupus Treatment By Dr Gary Levin

Proven Lupus Treatment

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Primary Lesions

Primary LP lesions are red to deep violet, flat-topped, angular geometric (polygonal) 1- to 3-mm papules. The papules may be separate or tightly grouped (see Photo 31).

Wickham's stria are a lacy network of white lines seen on the surface of the papules considered pathognomonic for LP (see Photo 32).

Early lesions tend to be red to dusky deep red. As the papules mature they acquire a deep violaceous hue, which is considered typical. As pigment is dropped from the basal cell layer some lesions may also have a brown cast.

Secondary Lesions

1. Scale is adherent and white, but not a prominent feature except in some hypertrophic variants (see Photo 33).

2. Large plaques form from coalescing papules, and the original papular morphology may be obscured. Satellite papules are frequently present at the periphery as a clue (see Photo 34).

3. Erosions are common with mucosal LP and occur on occasion in chronic hyper-trophic lesions (see Photos 32,35,36).

4. Scarring and atrophy are common with LP of the hair-bearing scalp, the nail matrix, and chronic hypertrophic lesions. Permanent hair and nail loss can occur, sometimes rapidly (see Photo 37).

5. Although victims complain bitterly of itching, excoriations are seldom seen in LP.

6. Dense purple or deep brown hyperpigmentation can occur as lesions resolve. This pigmentary change may last for years.

Distribution

Microdistribution: Follicular distribution is encountered on rare occasions. The disease may attack any hair bearing area. Follicular LP may be seen with other typical skin and mucous membrane lesions or may occur alone. It presents as pin-head-sized conical, rough red papules pierced by a hair. Permanent hair loss may occur.

Macrodistribution: The oral cavity shows a lacy white reticulated or arborizing pattern, most commonly on the posterior buccal mucosa opposite the molars. It will not rub off with a tongue blade. Oral lesions occur in 30 to 70% of cases depending on the series. Rare cases occur with oral, genital, and anal involvement only.

Classic papular lesions have a predilection for flexural surfaces of joints and forearms. Other frequent sites are the dorsal hands, extensor shins, lateral neck, buttocks, sacrum, glans penis, and ankles (see Fig. 9). The face, scalp, palms, and soles are only rarely involved.

In the exanthematic form, lesions can be distributed uniformly over much of the body surface and the characteristic distribution pattern is lost. The morphology of the primary lesions is usually diagnostic and oral lesions are found in a high proportion of cases as a supporting feature.

Configuration

1. Grouped papules are the most common pattern. If the grouping is follicular rather than random, the papules are small and evenly spaced following the anatomic spacing of the follicles.

2. Annular (ring) lesions with central clearing or central atrophy may occur but are uncommon. These are most often located on the glans penis.

3. Linear (long narrow band) lesions occur very rarely.

4. Reticulated (net-like or arborizing) configuration may occur with oral lesions.

Drawing Person Clothes
Figure 9: Macrodistribution of lichen planus.

Indicated Supporting Diagnostic Data

In many instances, oral and cutaneous lichen planus are clinically diagnostic and no specific laboratory testing is indicated.

Skin Biopsy

This test is indicated when the disease is strongly suspected but the diagnosis is clinically uncertain. Although LP and LP-like drug eruptions may show identical histology, subtle differences can sometimes point toward the latter diagnosis. Biopsy is particularly helpful for differentiating lichen planus and lupus erythematosus.

Direct Immunofluorescence

Although rarely needed, this test can be helpful in supporting a diagnosis of LP where other parameters are confusing. The pattern is quite different from that of lupus erythematosus; however, it is identical in an LP-like drug eruption.

General Laboratory Testing

The strong association of LP with chronic liver disease and hepatitis in some European series has led some authors to recommend routine screening. This association has not been confirmed in North America, and at present it would seem prudent to coordinate additional testing with information revealed in the review from the general history.

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