Abstract:

A 32-year-old woman presented with a pruritic papulosquamous eruption that spread from the chest to the upper back, bilateral forearms, scalp, abdomen, and proximal lower extremities over a few weeks. Review of systems was negative for arthralgias, photosensitivity, oral ulcers, xerophthalmia, and xerostomia. She denied any infections or medication changes directly preceding the eruption. Of note, two months before the cutaneous eruption commenced, she had started oral terbinafine for onychomycosis. Personal and family history was negative for autoimmune disorders. Physical examination revealed coalescing scaly pink polycyclic plaques of the chest, scalp, forearms, proximal thighs, as well as dorsal hand targetoid plaques without scale. Tangential skin biopsies from the left volar forearm and left chest demonstrated interface dermatitis and at all levels of the epidermis showed scattered necrotic keratinocytes and exocytosis of lymphocytes, with subjacent moderately dense superficial perivascular lymphocytic inflammation. Absolute peripheral blood count was notable for mild lymphopenia (0.9 x10*9/L); serologies were remarkable for positive antinuclear antibody (1:160, speckled pattern) and Ro/SS-A antibody (>8 antibody index); anti-histone antibodies were negative. The constellation of clinicopathological and serological findings were supportive of drug-induced subacute cutaneous lupus erythematosus (DI-SCLE) secondary to oral terbinafine, which was discontinued. Systemic and topical corticosteroids (oral prednisone 0.5mg/kg/day tapered over three weeks and topical triamcinolone cream 0.1% and 0.025%) effected cutaneous improvement. Monitoring of residual disease activity is ongoing. This case highlights the potential for DI-SCLE to present with erythema multiforme-like features and serves as an opportunity to review other atypical clinicopathologic features of DI-SCLE including bullae and leukocytoclastic vasculitis.

Financial Disclosure:
No current or relevant financial relationships exist.

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Alexandra Leonard, MD