A 30-year-old woman with a history of cutaneous lupus erythematosus (LE) developed lupus miliaris disseminatus faciei (LMDF) during her 32nd gestational week (Fig. 1). After the birth of a healthy daughter, the skin lesions improved without treatment. A worsening of LMDF 6 months later was treated with 20 mg isotretinoin (0.3 mg/kg body weight) in combination with an oral contraceptive. The skin lesions improved significantly after 1 month of systemic treatment; however, 4 months later, new lesions occurred on both cheeks, and were diagnosed as cutaneous LE (Fig. 2). Systemic isotretinoin therapy was discontinued and local application of a prednicarbate-containing ointment was initiated, leading to an improvement of the skin manifestations.
Histopathologic examination of an erythematous papule of the cheek revealed necrotic areas in the dermis surrounded by giant and epithelioid cells, as well as an inflammatory infiltrate around the hair follicles with lymphocytes, granulocytes, and histiocytes (Fig. 3). A skin biopsy taken from an erythematous plaque of the face revealed a thin epidermis with vacuolization of the dermo-epidermal junction, as well as necrotic keratinocytes, lymphocytic infiltrates, and the deposition of mucin, consistent with the diagnosis of LE (Fig. 4). Antinuclear antibodies (ANA) were positive (titer, 1 : 320), all routine laboratory parameters were within normal limits, and no anti-cardiolipin, -Ro/SSA, or -La/SSB antibodies were detectable.
The clinical course of this patient suggests that possible common pathogenetic pathways of LMDF and LE may involve a localized autoimmune-like process initially restricted to the site of the sebaceous glands, and in both diseases antigen expression may be provoked by UV radiation, hormonal, or viral factors.