Case Report Coexistence of lip‑tip vitiligo and disseminated discoid lupus erythematosus with hypothyroidism: Need for careful therapeutic approach Sudhanshu Sharma, Rashmi Sarkar, Vijay Kumar Garg, Suchi Bansal Department of ABSTRACT Dermatology and Venereology, Maulana There have been rare published cases of discoid lupus erythematosus (DLE) with other autoimmune cutaneous Azad Medical College and systemic disorders. We describe a 36 years old female patient with DLE lesions on the face and hands and L. N. J. P. Hospital, with coexistence of lip‑tip vitiligo and hypothyroidism. We discuss how the treatment has to be modified and New Delhi, India innovative in the presence of these three coexisting autoimmune disorders and how the dermatologist should do this to get a successful outcome. Key words: Association, autoimmune thyroiditis, discoid lupus erythematosus, vitiligo INTRODUCTION The central area of the plaque showed erythema and scaling and the plaque was surrounded by Coexistence of systemic lupus erythematosus a hyperpigmented border. It measured around and vitiligo has been infrequently reported.[1] 7 × 10 cm in size in its largest diameters. Atrophy However, cases of vitiligo coexisting with discoid was present over the central area of the plaque lupus erythematosus (DLE) have been much while induration was present over the peripheral rarer.[2] This is an important consideration as area [Figure 1]. Similar plaques were present the presence of one disorder may affect the over right eyelid, left ear, bilateral extensor therapy of the second and require detail clinical surface of forearm, which were variable in size as well as laboratory examination to rule out ranging from 1 × 2 cm to 3 × 6 cm in size in other autoimmune disorders. In the present their largest diameters. Depigmented macules Access this article online case, association of DLE with vitiligo and thyroid were present over bilateral proximal nail folds Website: www.idoj.in disease altered the therapeutic approach in the extending up to half of the lateral nail fold of the DOI: 10.4103/2229-5178.110636 Quick Response Code: affected patient. fingers and similar types of depigmented macules were observed over bilateral toe nails extending CASE REPORT from distal nail fold to lateral nail fold, upper perioral area and lips [Figure 2]. Although all the A 36‑year‑old female presented with complaints lesions were depigmented, a clinical diagnosis of a reddish, raised lesion on left cheek since of disseminated lupus erythematosus with lip‑tip 8 years. She also gave history of appearance of vitiligo was entertained. similar lesions on nose, malar area, and near the Address for ears since 2 years. There were also depigmented Histopathological examination of the lesion correspondence: asymptomatic lesions on tips of fingers, dorsa on the face showed follicular plugging, Dr. Rashmi Sarkar, of bilateral hands, perioral area and lips since basal cell degeneration, perivascular and Department of Dermatology and 2 months and appearance of similar lesions on periappendageal lymphocytic infiltrate, hence Venereology, Maulana tips of toes since 1 month. was consistent with the diagnosis of discoid Azad Medical College lupus erythematosus [Figure 3]. Histopathological and L. N. J. P. Hospital, On examination, a depigmented well defined examination from depigmented macule New Delhi, India. plaque was present over left side of the malar over finger showed decreased number of E‑mail: rashmisarkar@ area extending up to nasal bridge, external melanocytes in basal layer and was suggestive gmail.com auditory meatus and also the mandibular area. of vitiligo [Figure 4]. 112 Indian Dermatology Online Journal - September-December 2012 - Volume 3 - Issue 3 Sharma, et al.: Coexistence of lip‑tip vitiligo and disseminated discoid lupus erythematosus a b Figure 2: Depigmented maculeson upper and lower lip and bilateral a b proximal nail folds extending up to half of the lateral nail fold of the Figure 1: Depigmented well defined plaque with scaling on left side of fingers the malar area extending up to external auditory meatus, nasal bridge and the mandibular area Figure 4: Decreased number of melanocytes in basal layer of epidermis (H and E, ×45) DISCUSSION Figure 3: Epidermis shows presence of follicular plugging and basal cell degeneration while perivascular and periappendageal lymphocytic It has been observed that the autoimmune disorders are infiltrate is seen in the in the dermis (H and E, ×45) significantly elevated in vitiligo probands: Vitiligo itself, autoimmune Lupus band test from lesional exposed site was positive and thyroid disease, pernicious anemia, Addison’s disease, systemic [2] non‑lesional, non‑exposed skin was negative. Laboratory lupus erythematosus, and probably inflammatory bowel disease. test revealed positive ANA, and anti SSA (Ro) Rheumatic Autoimmune thyroid disease association with systemic lupus factor, dS‑DNA and other connective tissue disease markers erythematosus is commonly reported (prevalence = 3.9‑24%) were negative. We sent stool for occult blood, thyroid function and hypothyroidism is much more common as compare to [3] test and serum cortisol examination to rule out possibility hyperthyroidism (5.7%/1.7%). Data regarding autoimmune of other associated autoimmune disorders. Stool for occult thyroid disease association with DLE are not available in the blood was negative; serum cortisol level was normal but literature. In two case reported by Forestier et al., DLE occurred and thyroid function tests showed increased of TSH and within the vitiliginous skin on both exposed and non‑exposed [4] decreased of T4. surfaces. A similar occurrence was reported by Jeffrey Callen, Temine and Tramier, Chowdhury and Banerjee, Forestier et al. The patient was advised photoprotection and started on oral and Johnson et al.[1,4‑7] DLE coexisting with vitiligo has also been hydroxychloroquine 200mg once a day for 1 week then 200 mg reported with alopecia universalis, dermatophyte nail infection, twice a day dosage for DLE and topical steroids for the vitiligo malignant melanoma and urticaria.[8‑10] lesions keeping in mind that although the lip tip vitiligo lesions would have responded well to photochemotherapy, this therapy Table 1 shows a few case reports in the Indian setup and the would have aggravated the lupus erythematosus lesions. Oral west where patients had coexisting vitiligo and DLE and their thyroxine hormone replacement therapy was started for low treatment. The majority of patients with concurrent DLE and thyroid hormone. The patient was followed up after 6 weeks and vitiligo resided in regions with potential chronic sun exposure, 12 weeks when there was a partial resolution of facial lesions. such as India and Southern Europe.[1,4,9] Further patient was advised to apply 0.1% topical tacrolimus on facial lesions but follow up was not possible as the patient Ying Jin et al. identified several chromosomal regions that probably left the city. appear to contribute to this epidemiologic association, including Indian Dermatology Online Journal - April-June 2013 - Volume 4 - Issue 2 113 Sharma, et al.: Coexistence of lip‑tip vitiligo and disseminated discoid lupus erythematosus Table 1: Case reports of discoid lupus erythematosus with vitiligo and other diseases Author Year Association Treatment Temine and Tramier[5] 1961 DLE+vitiligo None Chowdhury and Banerjee[6] 1968 DLE+vitiligo None Forestier, et al.[4] 1981 DLE+vitiligo None Jeffrey and Callen[1] 1984 DLE+vitiligo+autoimmune thyroiditis Oral hydroxychloroquine+topical steroids+thyroid hormone Pavithran[8] 1986 DLE+vitiligo+alopecia areata None Nath, et al.[12] 1988 Vitiligo+drug induced DLE PUVA Khosravi, et al.[9] 2003 DLE+vitiligo+chronic dermatophyte Oralchloroquine+oral steroids+topical steroids infection Ulker, et al.[10] 2005 DLE+vitiligo+malignant melanoma+urticaria None Johnson, et al.[7] 2008 DLE+vitiligo Oral hydroxychloroquine+Topical steroids Present case 2011 DLE+vitiligo+autoimmune thyroiditis Oral hydroxychloroquine+topical steroids+thyroid hormone+topical 0.1% tacrolimus DLE: Discoid lupus erythematosus one on chromosome 17p13.[11,12] Treatment of DLE includes of vitiligo and associated autoimmune diseases in Caucasian probands photoprotection, topical or intralesional glucocorticoids, and their families. Pigment Cell Res 2003;16:208‑14. 3. Pyne D, Isenberg DA. Autoimmune thyroid disease in systemic lupus or antimalarial medication. Alternative therapies include erythematosus. Ann Rheum Dis 2002;61:70‑2. retinoids or immunosuppressive agents, such as thalidomide, 4. Forestier JY, Ortonne JP, Thivolet J, Souteyrand P. Association of lupus methotrexate, mycophenolate mofetil, or azathioprine.[6,10] erythematosus and vitiligo. Ann Dermatol Venereol 1981;108:33‑8. Treatment of vitiligo in the presence of DLE is mainly local 5. Temime P, Tramier G. Symmetrical lupus erythematosus on vitiligo of and systemic corticosteroid.[8] However, it is known that lip the hands. Bull Soc Fr Dermatol Syphiligr 1961;68:91‑2. 6. Chowdhury DS, Berjee AK. Development of discoid lupus erythematosus tip vitiligo would not respond much to topical and systemic in vitiligo. Bull Calcutta Sch Trop Med 1968;16:111‑2. corticosteroids. The presence of one disorder may affect the 7. Johnson H, Bossenbroek NM, Rosenman K, Meehan SA, Robles M, therapy of the other, as photochemotherapy which would be Pomeranz MK. Chronic cutaneous lupus erythematosus in vitiligo. a good alternative for lip tip vitiligo can not be given