Coexistence of lip-tip vitiligo and disseminated discoid lupus erythematosus with hypothyroidism: Need for careful therapeutic approach
A 36-year-old female presented with complaints of a reddish, raised lesion on left cheek since 8 years. She also gave history of appearance of similar lesions on nose, malar area, and near the ears since 2 years. There were also depigmented asymptomatic lesions on tips of fingers, dorsa of bilateral hands, perioral area and lips since 2 months and appearance of similar lesions on tips of toes since 1 month.\nOn examination, a depigmented well defined plaque was present over left side of the malar area extending up to nasal bridge, external auditory meatus and also the mandibular area. The central area of the plaque showed erythema and scaling and the plaque was surrounded by a hyperpigmented border. It measured around 7 × 10 cm in size in its largest diameters. Atrophy was present over the central area of the plaque while induration was present over the peripheral area []. Similar plaques were present over right eyelid, left ear, bilateral extensor surface of forearm, which were variable in size ranging from 1 × 2 cm to 3 × 6 cm in size in their largest diameters. Depigmented macules were present over bilateral proximal nail folds extending up to half of the lateral nail fold of the fingers and similar types of depigmented macules were observed over bilateral toe nails extending from distal nail fold to lateral nail fold, upper perioral area and lips []. Although all the lesions were depigmented, a clinical diagnosis of disseminated lupus erythematosus with lip-tip vitiligo was entertained.\nHistopathological examination of the lesion on the face showed follicular plugging, basal cell degeneration, perivascular and periappendageal lymphocytic infiltrate, hence was consistent with the diagnosis of discoid lupus erythematosus []. Histopathological examination from depigmented macule over finger showed decreased number of melanocytes in basal layer and was suggestive of vitiligo [].\nLupus band test from lesional exposed site was positive and non-lesional, non-exposed skin was negative. Laboratory test revealed positive ANA, and anti SSA (Ro) Rheumatic factor, dS-DNA and other connective tissue disease markers were negative. We sent stool for occult blood, thyroid function test and serum cortisol examination to rule out possibility of other associated autoimmune disorders. Stool for occult blood was negative; serum cortisol level was normal but and thyroid function tests showed increased of TSH and decreased of T4.\nThe patient was advised photoprotection and started on oral hydroxychloroquine 200mg once a day for 1 week then 200 mg twice a day dosage for DLE and topical steroids for the vitiligo lesions keeping in mind that although the lip tip vitiligo lesions would have responded well to photochemotherapy, this therapy would have aggravated the lupus erythematosus lesions. Oral thyroxine hormone replacement therapy was started for low thyroid hormone. The patient was followed up after 6 weeks and 12 weeks when there was a partial resolution of facial lesions. Further patient was advised to apply 0.1% topical tacrolimus on facial lesions but follow up was not possible as the patient probably left the city.