Long lasting DLE lesions are dominated by atrophy, scarring, and depigmentation.
Atrophic scars may be indistinguishable from burnt-out DLE, lacking any signs of inflammation, particularly depigmented scars after superficial third-degree burns. Atrophic acne scars differ by their multiplicity and characteristic distribution. They are not accompanied by pigmentary changes in white skin. The characteristically depressed scars after cutaneous leishmaniosis, in contrast, are hyperpigmented. In all instances, the borders of the scars must be carefully inspected to detect residual rims of scaling erythemas, which would be a clue for DLE.
Lesions of vitiligo may closely resemble burnt-out DLE, with regular and only mildly altered surface texture because of its round shape and circular outlines. Lesions must be carefully examined for minimal signs of scarring. At the clinical overview, vitiligo is characterized by its larger lesions and its predilection for periori-ficial location.
Fig. 11.1. A Actinic keratoses: irregular, firm, hyperkeratotic masses ("limestonelike") on erythematous ground. Note the photodamaged skin at the periphery. B M. Bowen: a flat, irregularly hyperkera-totic, partially erosive lesion with polycyclic borders and little inflammation. C Discoid lupus erythematosus: lesions of intermediate age with central atrophy and raised ery-thematous borders
Hypopigmented lesions of tuberculous leprosy differ by their ill-defined borders; the presence of residual pigmentation, scaling, and faint erythema; and loss of sensory function.
Lupus vulgaris in advanced stages may show similarity with scarring lesions of DLE. Whereas fresh lesions of lupus vulgaris are characterized by reddish brown macules and patches of soft and friable consistency that display a typical "apple-jelly" color on diascopy, more advanced lesions may exhibit considerable atrophy and scarring. As a distinguishing mark, remnants of tuberculous granulation tissue are often found at the periphery and in the centers; if probed, the instrument tends to break through the overlying skin. Moreover, lupus vulgaris has a tendency to ulcerate, which is very uncommon in DLE, and depigmentation is absent. A common feature of lupus vulgaris and DLE is mutilation of acral sites, for example, ear lobes or nose, which was the historical reason to apply the term "lupus" to both.
Coral reef keratoakanthomas may imitate old DLE lesions, with pronounced scarring and irregular, "moth-eaten" change of the surface texture. These low-grade malignancies are characterized by their large and round size, their location in sun-exposed skin areas, and their elevated borders. In their early stage, they display multiple keratotic plugs that are larger than the follicular plugs of DLE.
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