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Lupus Pernio
1. G R A N D R O U N D S
U S C D E R M A T O L O G Y
M A Y 3 , 2 0 1 1
J E N N I F E R A R M S T R O N G
Lupus Pernio
2. Overview
๏ Sarcoidosis is a
multisystem
granulomatous
inflammatory
disease that can
affect any organ.
๏ Cutaneous lesions
present in 20%-
35% of patients
3. Lupus Pernio
Lupus pernio, first
described by Besnier in
1889, is a manifestation
of sarcoidal skin lesions.
4. Lupus Pernio
๏ Its name comes from Latin perniล = chilblain on the
foot.
๏ Inflammation of the skin of the hands or feet, resulting
from exposure to cold
๏ Thought to resemble a mild frostbite
Lupus Pernio Frostbite
5. Epidemiology
๏ More common in
African Americanโs and
Puerto Rican
populations
๏ Female> Male
๏ Usually with long-
standing systemic,
usually pulmonary
disease
6. Etiology
๏ The etiology of this disease is still unknown.
๏ The serum concentration of angiotensin-
converting enzyme (ACE) is increased, and
measurements have been used as an index
of disease activity.
7. Cutaneous Findings: violaceous, indurated plaques and
nodules
โฆโฆโฆโฆโฆโฆโฆโฆโฆโฆโฆโฆโฆโฆโฆโฆโฆโฆโฆโฆโฆEars
โฆ..โฆโฆโฆโฆโฆโฆโฆโฆโฆโฆโฆโฆโฆโฆโฆโฆโฆโฆโฆโฆโฆโฆโฆโฆโฆโฆ.Nose
โฆโฆโฆโฆโฆโฆโฆโฆโฆโฆ Dorsum of hand, fingers
โฆโฆโฆโฆโฆโฆโฆโฆโฆโฆโฆโฆ.โฆโฆโฆโฆ Toes
โฆโฆโฆโฆโฆโฆโฆโฆโฆโฆโฆโฆโฆCheeks and Lips
9. Key Findings
๏ Cutaneous involvement is
either specific or nonspecific.
๏ก Specific lesions manifest as
noncaseatinggranulomas
๏ท that consist of mononuclear
phagocytes, epithelioid
macrophages and multinucleate
giant cells
๏ก Whereas nonspecific lesions (EN)
do not reveal granulomas on
histopathologic examination.
10. Standard Treatment
๏ A stepwise approach to patient care is appropriate
๏ First Line: mild skin-limited disease.
๏ก Potent topical corticosteroids
๏ท clobetasol
๏ก Intralesionalinjections
๏ท triamcinolone(3-10 mg/mL)
๏ First Line: deforming skin lesions or for widespread
disease
๏ก Systemic therapy: prednisone 40-80 mg/day tapered used
alone or in combination with antimalarials or methotrexate
11. Standard Treatment
๏ Second Line
๏ก Antimalarials and methotrexate may be used as monotherapy
for steroid-resistant sarcoidosis or in patients unable to
tolerate steroids.
๏ท Given the concern regarding ocular toxicity, the maximum dosages
of chloroquine and hydroxychloroquine should not exceed 3.5 and
6.5 mg/kg/day, respectively.
๏ท Methotrexate is given in weekly doses of 10-30 mg
12. Treatment โ Chronic/Refractory
๏ TNF-ฮฑantagonists
๏ก Infliximab ( IV 3-10 mg/kg at 0, 2 and 6 weeks)
๏ก Etanercept (injected subcutaneously at doses of 40 mg either
weekly or every 2 weeks)
๏ก Thalidomide may have a role in cutaneoussarcoidosis,
especially in refractory and chronic cases that are resistant to
the standard regimens.
๏ท 50 to >400 mg/day (average 100mg/day) has limited, but
promising supporting data
13. Other
๏ Isotretinoin, 0.5-2 mg/kg/day, has been used
successfully in a handful of reported cases.
๏ Ablative: Pulsed dye or CO2 laser is available for the
debulking of granulomatous lesions
๏ก However, there are no evidence-based recommendations
because of the limited number of patients treated
๏ Melatonin (20 mg/day) and allopurinol (100-300
mg/day) are not well studied in
cutaneoussarcoidosis, and the clinical experience
with tetracycline derivatives has been mixed.
14. Prognosis
๏ The course is usually
chronic, and severe
cosmetic disfigurement may
result.
๏ Lupus pernio, especially
involving the nasal rim, has
pulmonary involvement
๏ก upper respiratory tract (50%)
๏ก lungs (75%).
15. Differential Diagnosis
โขLupus vulgaris
โขDeep Fungal
โขLupus erythematosus
โขRhinophyma when localized to the nose
โขMalignant pleomorphic lymphoma
โขProtracted superficial Wegener's granulomatosis
โขTertiary syphilis
โขDiscoid Lupus
16. References
โข Chensue SW, Warmington K, Ruth J, Lincoln P, Kuo MC, Kunkel SL: Cytokine
responses during mycobacterial and schistosomal antigen-induced pulmonary
granuloma formation. Production of Th1 and Th2 cytokines and relative
contribution of tumor necrosis factor.Am J Path 1994, 145:1105-1113
โข Badgwell C, Rosen T: Cutaneoussarcoidosis therapy updated.J Am
AcadDermatol 2007, 56:69-83
โข Shakoory B, Chathman W. Recognizing and managing the musculoskeletal
manifestations of Sarcoidosis. The Journal of Musculoskeletal Medicine 2008,
25: 12
โข Baughman RP, Lower EE. Newer therapies for cutaneoussarcoidosis: the role
of thalidomide and other agents. Am J ClinDermatol. 2004;5(6):385-94.
โข Yayoi NAGAI, Naoya IGARASHI, Osamu ISHIKAWA. Lupus pernio with
multiple bone cysts in the fingers. The Journal of Dermatology Volume 37,
Issue 9, pages 812โ814, September 201
17. References cont.
๏ James DG. Lupus pernio. Lupus. 1992 May;1(3):129-31
๏ Fernandez-Faith E, McDonnell Cutaneoussarcoidosis: differential diagnosis.
J.ClinDermatol. 2007 May-Jun;25(3):276-87.
๏ Takashi Koyama, MD, Hiroyuki Ueda, MD, Kaori Togashi, MD, ShigeakiUmeoka,
MD, Masako Kataoka, MD and Sonoko Nagai, MD. Radiologic Manifestations of
Sarcoidosis in Various Organs. RadioGraphics. March-April 2011, 31 (2)
๏ Marchell, Richard M; Judson, Marc. A CutaneousSarcoidosisSeminRespirCrit Care
Med 2010; 31: 442-451
๏ Doherty CB, Rosen T. Evidence-based therapy for cutaneoussarcoidosis. Drugs.
2008;68(10):1361-83.
๏ PICS: TheAltitudeExperience.com, Dermis.net, dermatlas, Journal of Head and
Neck Medicine, Lexic, emedicine, Access Medicine
Editor's Notes
Lupus pernio is usually more common in black women with long-standing systemic, usually pulmonary, sarcoidosis than in other people. It is also commonly seen with chronic uveitis and bone cysts.
Red-to-purple or violaceous, indurated plaques and nodules that usually affect the nose, the cheeks, the ears, and the lips, but it can appear on the dorsa of the hands, the fingers, the toes, and the forehead.
pulmonary, sarcoidosis than in other people. It is also commonly seen with chronic uveitis and bone cysts. bone cysts in 43% and ocular lesions in 37%.