Lupus erythematosus of the scalp

Focal atrophic alopecia of the scalp (pseudopelade condition) can be caused by discoid lupus erythematosus (DLE) and disseminated lupus erythematosus of this localization. Rarely, foci of discoid lupus and disseminated lupus erythematosus on the scalp can be one of the manifestations of the systemic form of the disease. According to Mashkilleyson L.N. et al. (1931), who summarized observations of 1,500 patients with lupus erythematosus, lesions of the scalp were noted in 7.4%. Lelis I.I. (1970) constantized scalp lesions in 10% of patients. In general, the scalp is rarely affected by this dermatosis and mainly in women. In men, foci of discoid lupus erythematosus, in addition to typical areas, can also be localized on the auricles, in the area of the lower jaw, and on the scalp. In cases where scalp lesions are accompanied by rashes on the face, ears or exposed areas of the body, the disease is not diagnosed for a long time. Patients consult a doctor only when a persistent bald spot has already formed. Without treatment, the disease slowly progresses over many years and can lead to the formation of large foci of cicatricial alopecia. The frontal and temporal areas are often affected, where one, or more rarely, several foci are formed, which slowly increase in size.

Discoid lupus erythematosus of the scalp may manifest itself with typical and atypical lesions. In typical lupus erythematosus, the clinical manifestations depend on which of the main symptoms of this dermatosis (erythema, infiltration, hyperkeratosis, atrophy) prevail in the patient. At the onset of typical discoid lupus erythematosus of the scalp, the most characteristic feature is a clearly demarcated erythematous plaque (less often - plaques), weakly infiltrated and covered with hyperkeratotic scales tightly adhering to the surface with unevenly distributed follicular horny plugs. When scraping the lesion, which is accompanied by pain, the scales are difficult to separate from the surface. The peripheral erythematous crown is not always clearly expressed and may be absent. Gradually, hyperemia acquires a characteristic bluish tint and in the central part of the lesion, skin atrophy with alopecia develops relatively quickly. The skin becomes smooth, shiny, thinned without the mouths of hair follicles and hair, with telangiectasias. In some places within the center of the lesion, uncharacteristic thin, wafer-shaped lamellar scales remain. The lesion of discoid lupus erythematosus of the scalp has some clinical features. Thus, skin atrophy with hair loss develops relatively quickly, while the atrophic zone dominates, occupying most of the lesion. Often, dyschromia with a predominance of depigmentation, sometimes hyperpigmentation, develops within its limits at the same time. The progression of discoid lupus erythematosus can manifest itself not only by the characteristic erythematous peripheral border, but also by the appearance of foci of hyperemia and peeling within old atrophic areas of the skin.

In atypical discoid lupus erythematosus of the scalp, many characteristic clinical manifestations (hyperemia, infiltration, follicular keratosis) are weakly expressed or absent. The entire lesion is represented by atrophic alopecia and dyschromia, and only in the peripheral zone can a border of hyperemia with slight peeling and thinning of the hair sometimes be traced. O.N. Podvysotskaya described similar manifestations of the disease in 1948 in "Errors in the Diagnosis of Skin Diseases": "... sometimes the entire pathological process occurs deep in the skin and does not produce visible changes in its superficial layers, manifesting itself only in the final stage by skin atrophy and baldness. In such cases, the disease resembles the so-called false nesting alopecia (pseudopelade). There are patients who have foci of such atrophy with baldness on the head and simultaneously on the face - a typical form of lupus erythematosus." Thus, in case of atypical lesions of discoid lupus erythematosus on the scalp, the diagnosis of the dermatosis is significantly facilitated by the presence of typical lesions in a characteristic location (nose, cheeks, auricles, upper chest and back).

In disseminated lupus erythematosus of the scalp, round or oval lesions are usually also present on the face, auricles, sometimes on the neck, upper back and chest, and in some cases on the hands, feet and oral mucosa. Their diameter does not exceed 1.5-2.5 cm, infiltration and peripheral growth are weakly expressed. Hyperemia in the lesions is insignificant, the boundaries are unclear, small, thin scales are visible on the surface, which are difficult to separate when scraped, but without distinct follicular keratosis. Within the lesions, there is diffuse alopecia, expressed to varying degrees. In older lesions, especially in their central parts, alopecia and atrophy are more pronounced. The hair remaining within them is dry, thinner, breaks off when pulled. The skin in the affected areas is thinned, dyschromic, the follicular pattern is smoothed. At the same time, atrophy and baldness are usually not as pronounced as in discoid lupus erythematosus. Similar damage to the scalp also occurs in subacute cutaneous lupus erythematosus.

Histopathology

In the epidermis, diffuse and follicular hyperkeratosis (horny plugs in the mouths of hair follicles) are found, as well as vacuolar degeneration of the cells of the basal layer, which is considered pathognomonic for discoid lupus erythematosus. The thickness of the epidermis may vary: areas of acanthosis are replaced by a thinned Malpighian layer and smoothed outgrowths of the epidermis; in old foci, epidermal atrophy is clearly expressed. The cells of the spinous layer are swollen, edematous, with palely stained nuclei or, on the contrary, the nuclei are brightly stained and homogeneous. Similar changes are present in the epithelium of the outer root sheath of hair follicles, which leads to the formation of horny plugs, cysts and hair loss; hair follicles disappear completely. The dermis contains dilated blood and lymphatic vessels. Around the hair follicles, sebaceous glands and vessels there are infiltrates consisting mainly of lymphocytes and a small number of plasma cells, histiocytes and macrophages. Penetration of infiltrate cells into the capsule of epithelial follicles and sebaceous glands can often be seen. In the area of infiltrates, collagen and elastic fibers are destroyed, in other areas the dermis is loosened due to edema. There is an extended PAS-positive band in the basement membrane zone. Using direct immunofluorescence, strip-like deposition of immunoglobulins G and C-3 complement in the basement membrane zone of the epidermis is detected in the lesions in 90-95% of patients with discoid lupus erythematosus.

Diagnosis of lupus erythematosus of the scalp

Discoid lupus erythematosus of the scalp should be distinguished from other dermatoses of this localization, leading to focal atrophic alopecia. Discoid lupus erythematosus is differentiated from follicular lichen planus, scleroderma, cutaneous sarcoidosis, cutaneous plaque lymphoma, follicular mucinosis, follicular dyskeratosis Darier, keratosis follicularis spinosus decalvans and actinic elastosis of the scalp in men who have developed early pronounced androgenetic alopecia of the frontal and parietal regions. In addition, the rare possibility of metastasis to the scalp of primary cancer of the internal organs should also be taken into account. Inflammatory changes occurring in the foci of metastasis in the scalp may in some cases lead to lesions resembling discoid lupus erythematosus, where atrophy of the hair follicles and hair loss also develop. This should be especially remembered in patients with lesions on the scalp resembling discoid lupus erythematosus and who have previously undergone surgical treatment for breast cancer or cancer of the bronchi, kidneys, oral mucosa, stomach or intestines, etc.

Histological examination of the affected skin helps to exclude metastasis of cancer to the scalp and establish a diagnosis of dermatosis that has led to atrophic alopecia.

First of all, it is necessary to exclude systemic lupus erythematosus in the patient. In case of disseminated lupus erythematosus, it is necessary to remember the existence of a special form - superficial chronic disseminated lupus erythematosus (the so-called subacute cutaneous form of LE). It is characterized by widespread ring-shaped lesions on the skin, which, when merging, form polycyclic flaky areas on the chest, back, face, limbs with hypopigmentation and telangiectasias in the central part. In this form of dermatosis, which occupies an intermediate position between the cutaneous and systemic forms of LE, there are manifestations characteristic of systemic lupus erythematosus, but expressed to a mild degree (arthralgia, changes in the kidneys, polyserositis, anemia, leukopenia, thrombocytopenia, etc.), including immunological changes (LE cells, antinuclear factor, antibodies to DNA, etc.). At the same time, unlike systemic lupus erythematosus, the prognosis of the disease is favorable. It is necessary to exclude medications that can provoke the development of lupus erythematosus or exacerbate it. These include hydralazine, procainamide, isoniazid, phthivazid, chlorpromazine, sulfonamides, streptomycin, tetracycline, penicillin, penicillamine, griseofulvin, oral contraceptives, piroxicam, etc. It is important to identify and sanitize foci of chronic infection regardless of their localization.

Treatment of lupus erythematosus of the scalp

Treatment of patients is carried out with 4-oxyquinoline derivatives; contraindications to their use, drugs and treatment regimens are essentially the same as those used in the treatment of patients with lichen planus. A combination of these drugs with nicotinic acid or its derivatives (xanthinol nicotinate), vitamins C and B is considered advisable. In case of insufficient effectiveness or poor tolerance of oxyquinoline derivatives, combined treatment with small doses of chloroquine diphosphate and prednisolone in quantities equal to their content in 3-6 Presocil tablets is indicated, i.e. 1/2-1 tablet per day of chloroquine diphosphate and the same amount of prednisolone after meals. The arsenal of drugs used in the treatment of patients with discoid lupus erythematosus and disseminated lupus erythematosus include retinoids and avlosulfone (dapsone), which also bring the disease to remission. In active manifestations of discoid or disseminated lupus erythematosus, ointments and creams with glucocorticosteroids of medium and high activity and without pronounced atrophogenic effect (methylprednisolone aceponate, mometasone furoate, etc.) are applied externally. In the future, protection from UV radiation is necessary (limiting exposure to the sun or water surfaces that reflect rays, using hats, sunglasses, sunscreen creams, etc.).

An important method of preventing relapses and stopping the growth of atrophic alopecia is the clinical examination of patients with discoid and disseminated lupus erythematosus. It includes examination of such patients for the purpose of early detection of possible signs of systemicity, as well as conducting preventive courses of treatment in early spring and autumn.

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