Abstract

Mucocutaneous lesions are a common finding in systemic lupus erythematosus (SLE) characterized by a variety of findings from small, pink papules to diffuse plaques or ulcerations with crust. We present a case of a labial manifestation of SLE. A 63-year old woman with a history of SLE (ANA 1:640, positive anti-SSA and SSB antibodies) presented with a 7-year history of tender, burning lesions on the lip. Examination of the lower lip revealed erosions with impetiginized crust and white fine plaques. Shave biopsy revealed lichenoid interface dermatitis with neutrophils and serous crust. Histopathologic differential diagnosis included lichenoid actinic cheilitis or trauma with secondary impetiginization. The patient was treated with cryotherapy. A flare in her lupus was associated with worsening of lip rash. Bacterial culture showed Staphylococcus aureus superinfection. Given the clinical and histopathologic picture, the patient was diagnosed with lichenoid cheilitis as a manifestation of her chronic cutaneous lupus erythematosus. Treatment was initiated with fluocinonide and mupirocin ointment and patient reported improvement at follow up. Mucocutaneous manifestations are seen in up to 45% of SLE patients. While common, the varied presentation can make the diagnosis difficult. Histopathology and direct immunofluorescence can aid in the diagnosis. Histopathology often shows a lichenoid mucositis with variable epidermal atrophy and ulceration resulting from extensive basal vacuolar degeneration. Direct immunofluorescence shows deposition of multiple conjugates, most commonly IgM and C3 in continuous or granular patterns along the basement membrane zone, although this pattern is somewhat nonspecific especially in sun-exposed skin. Labial manifestations of cutaneous lupus should be considered by dermatologists and dermatopathologists in patients with cheilitis to prevent misdiagnosis and facilitate treatment.

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