Cutaneous Lupus Erythematosus and Vitiligo

Lupus erythematosus and vitiligo are diseases of autoimmune origin. Reports in the literature suggest patients are more likely to suffer more than 1 autoimmune disease (30% of patients with generalized vitiligo have another autoimmune disease).1 However, there are few reports of cutaneous lupus erythematosus in association with vitiligo. We describe a 42-year-old woman with no family history of autoimmune disease. In August 2008 she consulted for the appearance of erythematous papules on the arms, face, and upper trunk. The papules were slightly infiltrated, of variable size, and coalesced into larger plaques on hypopigmented skin; there was no desquamation (Figure 1). On suspicion of cutaneous lupus, a biopsy was performed, which showed vacuolar degeneration of the basal layer with a lymphocytic infiltrate in the dermis, dense perivascular lymphocytic cuffing, and focal deposits of mucin (Figure 2). Autoimmunity tests for antinuclear and anti-DNA antibodies were negative. Topical corticotherapy and sun protection measures were prescribed, and the patient improved. The lupus lesions improved considerably within 3 months. However, the patient continued to present large hypopigmented plaques on the forearms, face, and upper trunk where the lupus lesions had been. Achromotrichia, not present at the first visit, was also observed in the eyebrows, scalp hair, and eyelashes (Figure 3). The lesions were suggestive of vitiligo, even though most were in areas that had previously presented lupus lesions. The differential diagnosis was with postinflammatory lesions secondary to lupus. The patient came to follow-up visits every 6 months; no new lupus lesions were observed, but the achromotrichia continued to spread. Our patient was therefore diagnosed with subacute cutaneous lupus with no systemic involvement (in remission at the time of writing) and vitiligo. Reports of the coexistence of 2 autoimmune pathologies such as lupus erythematosus and vitiligo are rare in the literature. The earliest articles usually mention the differential diagnosis between the residual hypopigmented lesions of cutaneous lupus and vitiligo.2 In 1981, Forestier et al described 2 patients, 1 with discoid lupus who developed vitiligo-like lesions and 1 with vitiligo whose clinical course was complicated by the appearance of lesions of discoid lupus. Both patients presented elevated antinuclear antibodies, while all other autoantibodies were negative. Postinflammatory lesions were also considered in our patient, but the course of the lesions and, in particular, the achromotrichia supported the diagnosis of vitiligo. Other authors have subsequently reported further, isolated cases of patients with lupus who developed vitiligo over the course of their disease.2,4,5 A genetic explanation for the association between lupus erythematosus and vitiligo has recently been attempted. In a study of 16 European families, Nath et al6 found that the SLVe1 gene on chromosome 17 may explain the relationship between systemic lupus erythematosus and vitiligo. Rahner et al7 related various mutS homolog 6 gene mutations (present in hereditary nonpolyposis colorectal cancer) with the presence of both autoimmune processes. However, both authors base their findings on a small number of patients. More studies are needed in patients with systemic lupus erythematosus and in patients with cutaneous lupus with no systemic involvement. Based on the greater predisposition to the association of autoimmune conditions, isolated cases of patients with more than 1 autoimmune disease have been reported by several authors, such as Johnson et al,1 who reported a case of vitiligo associated with type 1 diabetes mellitus and Callen,8 who described a patient with discoid lupus erythematosus and autoimmune thyroiditis with high References