Lupus erythematosus of the scalp

To the focal atrophic alopecia of the scalp (pseudopelada condition) discoid (DCV) and disseminated red lupus of this localization can lead. Rarely, the foci of discoid lupus and disseminated lupus erythematosus on the scalp may be one of the manifestations of the systemic form of the disease. According to the data of Mashkileyson L.N. Et al. (1931) generalized observations of 1500 patients with lupus erythematosus, lesion of the scalp was noted in 7.4%. Lelis II (1970) constituted a scalp injury in 10% of patients. In general, the scalp is affected by this dermatosis rarely and mostly in women. In men, foci of discoid lupus erythematosus in addition to typical areas can also be localized on the auricles, in the region of the lower jaw, and in the hairy scalp. In cases where scalp damage is accompanied by eruptions on the face, the auricles or on open areas of the trunk, the disease is not diagnosed for a long time. Patients consult a doctor only when a foci of persistent baldness has already formed. Without treatment, the disease for many years slowly progresses and can lead to the formation of large foci of scarring alopecia. Often the frontal and temporal areas are affected, where one is formed, more rarely - several foci that slowly increase in size.

Discoid lupus erythematosus on the scalp may appear typical and atypical lesions. In typical lupus erythematosus, clinical manifestations depend on which of the main symptoms of this dermatosis (erythema, infiltration, hyperkeratosis, atrophy) prevail in the patient. In the debut of the typical discoid lupus erythematosus, the most distinctive is the clearly delineated erythematous plaque (less often - plaques), slightly infiltrated and covered with hyperkeratotic scales adhering to the surface with unevenly distributed follicular corneous cork. When scraping the focus, which is accompanied by soreness, the scales are difficult to separate from the surface. Peripheral erythematous corolla is not always pronounced and may be absent. Gradually, hyperemia acquires a characteristic cyanotic shade and in the central part of the focus relatively quickly develops skin atrophy with alopecia. The skin becomes smooth, shiny, thinned without the mouths of the hair follicles and hair, with telangiectasias. In places within the center of the hearth are uncharacteristic thin, oblate-like lamellar scales. The focus of discoid lupus erythematosus of the scalp has some clinical features. Thus, atrophy of the skin with hair loss develops comparatively quickly, while the atrophic zone dominates, occupying most of the focus. Often within its limits, dyschromia develops with the predominance of depigmentation, and sometimes - hyperpigmentation. Progression of discoid lupus erythematosus can be manifested not only by the characteristic erythematous peripheral rim, but also by the appearance of foci of hyperemia and peeling within the old atrophied areas of the skin.

With atypical discoid lupus erythematosus of the scalp, many characteristic clinical manifestations (hyperemia, infiltration, follicular keratosis) are weak or absent. The entire focus is represented by atrophic alopecia and dyschromia, and only in the peripheral zone is sometimes observed a rim of hyperemia with a slight peeling and thinning of the hair. ON Podvysotskaya, in 1948, described such manifestations of the disease in the "Errors in the Diagnosis of Skin Diseases": "... Sometimes the whole pathological process proceeds deep in the skin and does not give visible changes to its superficial layers, manifesting itself only in the final stage of skin atrophy and baldness. In such cases, the disease resembles the so-called false nesting alopecia (pseudo-peloid). There are patients who have pockets of such atrophy with baldness on their heads and at the same time on their face a typical form of lupus erythematosus. " Thus, with atypical foci of discoid lupus erythematosus on the scalp, the diagnosis of dermatosis is significantly facilitated by the presence of typical foci in the characteristic localization (nose, cheeks, auricles, upper parts of the chest and back).

With disseminated lupus erythematosus, round or oval lesions are usually also present on the face, the auricles, sometimes on the neck, upper back and chest, and in some cases - on the hands, feet and mucous membrane of the mouth. Their diameter does not exceed 1.5-2.5 cm, infiltration and peripheral growth are poorly expressed. Hyperemia in the foci is insignificant, the borders are indistinct, small, thin scales are visible on the surface, hardly separating when scraping, but without distinct follicular keratosis. Within the foci of defeat there is a diffuse alopecia, expressed in different degrees. In older foci, especially in their central parts, baldness and atrophy are more pronounced. The remaining hair in their hair is dry, thinner, breaking off when sipping. The skin in the affected areas is thinned, dyschromic, the follicular pattern is smoothed. At the same time, atrophy and alopecia are usually not as pronounced as in discoid lupus erythematosus. A similar lesion of the scalp can also occur with a subacute cutaneous form of lupus erythematosus.

Histopathology

In the epidermis, follicular hyperkeratosis (horny plugs in the mouth of the hair follicles) and also vacuolar dystrophy of the basal layer cells, considered pathognomonic for discoid lupus erythematosus, are also found. The thickness of the epidermis may be different: the areas of acanthosis are replaced by a thin malpighian layer and smoothed outgrowths of the epidermis in the old foci clearly expressed atrophy of the epidermis. The cells of the spiny layer are swollen, edematous, with pale-colored nuclei or, opposite the nucleus, brightly colored and homogeneous. A similar type of change is present in the epithelium, the outer root vagina of the hair follicles, which leads to the formation of horny plugs, cysts and hair loss; hair follicles completely disappear. In the dermis there are enlarged 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. It is often possible to see the penetration of infiltrate cells into a capsule of epithelial follicles, as well as sebaceous glands. In the field of infiltrates collagen and elastic fibers are destroyed, in the remaining areas of the dermis loosened due to edema. There is an extended PAS-positive band in the region of the basal membrane. With the direct immunofluorescence in the lesions in 90-95% of patients with discoid lupus erythematosus, a strip-like deposition of immunoglobulins G and C-3 complement in the basal membrane of the epidermis is observed.

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 the follicular form of red flat lichen, scleroderma, sarcoidosis of the skin, plaque skin lymphoma, follicular mucinosis, darya follicular dysarthosis, keratosis follicular prickly decalvic and actinic elastosis of the scalp in men who developed early pronounced androgenic alopecia of the frontal and parietal areas. In addition, one should also consider the rare possibility of metastasis in the scalp of the scalp of the primary cancer of the internal organs. Inflammatory changes that occur in the foci of metastasis in the scalp may in some cases lead to a lesion resembling discoid lupus erythematosus, which also develops atrophy of hair follicles and hair loss. This should be especially remembered in patients who have foci of lesions on the scalp resembling discoid lupus erythematosus and who have previously undergone operative treatment of breast or bronchial cancer, kidney, mucous membrane of the mouth, stomach or intestine, etc.

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

First of all, the patient must exclude the systemic form of lupus erythematosus. With disseminated lupus erythematosus, one should remember the existence of a special form - superficial, chronic disseminated lupus erythematosus (the so-called subacute skin type KB). It is characterized by widespread ring-shaped foci on the skin, which, when merged, form polycyclic scaly regions along the chest, back, face, limbs with hypopigmentation and telangiectasia in the central part. With this form of dermatosis, occupying, as it were, an intermediate position between the dermal and systemic forms of KV, there are manifestations characteristic of systemic lupus erythematosus, but they are expressed in an easy degree (arthralgia, renal changes, 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 aggravate it. These include hydralazine, procainamide, isoniazid, ftivazid, 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 location.

Treatment of lupus erythematosus of the scalp

Patients are treated with 4-hydroxyquinoline derivatives; contraindications to their use, drugs and treatment schemes are basically the same as those used to treat patients with red planar lichens. It is considered appropriate combination of these drugs with nicotinic acid or its derivatives (xantinol nicotinate), vitamins C and group B. With insufficient effectiveness or poor tolerance of oxyquinoline derivatives, combined treatment with small doses of chloroquine diphosphate and prednisolone in amounts equal to their content in 3-6 Presocil tablets, i.e. 1 / 2-1 tablet / day of chloroquine diphosphate and the same amount of prednisolone after meals. In the arsenal of drugs used in the treatment of patients with discoid lupus erythematosus and disseminated lupus erythematosus, retinoids and avlosulfone (dapsone), which also lead to remission, are located. With active manifestations of discoid or disseminated lupus erythematosus, ointments and creams with glucocorticosteroids having a high and high activity and not having a pronounced atrophogenic effect (methylprednisolone aceponate, mometasone furoate, etc.) are applied externally. In the future, protection from UVL is required (limitation of sun exposure or reflection of the water surface, use of headdresses, sunglasses, photoprotective creams, etc.).

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

[1], [2], [3], [4], [5], [6]