Tumid Lupus Erythematosus: An Intriguing Dermatopathological Connotation Treated Successfully with Topical Tacrolimus and Hydroxyxhloroquine Combination
A 27-year-old married woman, mother of two, accessed our dermatology outpatient department with an asymptomatic pink-red plaque over the right cheek for the last 5 months. She denied photosensitivity, oral ulcerations, fever, and joint pains. Rest of the systemic examination was insignificant. Physical examination revealed single erythematous, indurated, 3 cm-sized plaque over the right cheek []. Regional lymph nodes were not enlarged. Rest of the muco-cutaneous and systemic examination was normal. A clinical differential diagnosis of tumid lupus erythematosus (tumid LE), Jessner's lymphocytic infiltrate, and pseudolymphoma was made. Microscopic examination of the sections from the lesion revealed slightly thinned epidermis, subepidermal edema, superficial and deep, largely perivascular and some periappendageal lymphocytic infiltrate []. Dermo-epidermal junction was normal. Increased amounts of mucin were identified on staining with Alcian blue. The biopsy specimen from the lesion was subjected to direct immunofluorescence, which showed moderate IgG, and weak IgA, IgM, C3, and fibrin deposits along the basement membrane zone in a linear fashion []. Facility for CD4 and CD8 staining was not available in our institution. Further instrumental investigations including anti-nuclear antibody (ANA) titers (by indirect immunofluorescence on Hep-2 cell line), complete blood counts, liver and renal functions, and blood sugar levels were normal. LE cell test was not done. Urine routine microscopy and 24-hour urine protein were normal too. In addition, imaging studies including X-ray chest and an ultrasound of abdomen were unremarkable. Accordingly, a diagnosis of tumid lupus erythematosus was entertained. After obtaining an ophthalmology clearance, the patient was administered hydroxychloroquine sulphate in a dose of 200 mg daily and was asked to take adequate photoprotection including broad-spectrum sunscreen. The lesion had regressed after a period of 4 months. However, a month later, she had a flare up in the lesion while on hydroxychloroquine and despite adequate photoprotection. Considering the potential side effects of potent topical corticosteroids on face and the very fact that topical tacrolimus has been shown to be effective in non-hyperkeratotic LE lesions, it was decided to add topical tacrolimus 0.1% ointment to HCQS. The lesion resolved completely over a period of 3 weeks []. Subsequently, HCQS was stopped, and she is now on oral antioxidants and photoprotection. The patient is on follow-up for 4 months post-treatment and has not shown recurrence.