Scaly chin lesion and previous patch of hair loss
Background
This 18-year-old girl has noted a scaly and slightly tender lesion on her chin; she has had a similar lesion on her scalp which has resulted in a patch of hair loss.
What is this likely condition?
The photograph shows a well-circumscribed scaly patch of erythema as well as early atrophy. Coupled with history of the patch of alopecia, discoid lupus erythematosus is the most likely diagnosis.
What will a skin biopsy most likely show?
Skin biopsy is required for diagnostic confirmation; it can be expected to show hyperkeratosis and follicular plugging. There may be epidermal atrophy, and patchy basal cell keratinocyte degeneration. PAS staining may show thickening of the basement membrane. In the dermis, there will be dense perivascular and periadnexal chronic lymphocytic inflammation.
Suggest three topical therapies
Topical treatments will include photoprotection with sunscreens. Super potent topical steroids, which are usually avoided on the face, can be accurately applied to the lesions. Additional benefit is sometimes shown by combining the use of topical steroids with topical tacrolimus. Intralesional steroids may be useful for recalcitrant disease.
Suggest two systemic therapies
Antimalarials, such as mepacrine (quinacrine) or hydroxychloroquine are indicated. If the condition is progressive despite the above, immunosuppression with either methotrexate or azathioprine may be offered as progressive disease will result in permanent scarring and hair loss.
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