Dermatology: Practical and Conceptual Image Letter | Dermatol Pract Concept. 2023;13(1):e2023048 1 Cutaneous Lupus Erythematosus Mimicking Acne Vulgaris Tugba Kevser Uzuncakmak1, Elif Cansel Özcakir2 1 Sisli Memorial Hospital, Department of Dermatology, Istanbul, Turkey 2 Istanbul University-Cerrahpasa, Cerrahpasa medical Faculty, Department of Dermatology, Istanbul, Turkey Citation: Uzuncakmak TK, Özcakir EC. Cutaneous Lupus Erythematosus Mimicking Acne Vulgaris. Dermatol Pract Concept. 2023;13(1):e2023048. DOI: https://doi.org/10.5826/dpc.1301a48 Accepted: August 26, 2022; Published: January 2023 Copyright: ©2023 Uzuncakmak et al. This is an open-access article distributed under the terms of the Creative Commons Attribution- NonCommercial License (BY-NC-4.0), https://creativecommons.org/licenses/by-nc/4.0/, which permits unrestricted noncommercial use, distribution, and reproduction in any medium, provided the original authors and source are credited. Funding: None. Competing Interests: None. Authorship: All authors have contributed significantly to this publication. Corresponding Author: Tugba Kevser Uzuncakmak, MD, Sisli Memorial Hospital, Department of Dermatology, Istanbul, Turkey. Telephone: 0 +90- (530) 6640226 E-mail: drtugbakevserustunbas@gmail.com Case Presentation A 19-year-old female presented with cicatricial acneiform le- sions bilaterally on cheeks and subcutaneous nodular lesions on the bilaterally proximal aspect of the upper and lower extremities (Figure 1, A-E). She was previously diagnosed with acne vulgaris and treated with topical 2% erythromy- cin and isotretinoin 0.05 % gel for one year. Dermoscopic examination of the facial lesions revealed multiple linear and branching vessels over translucent yellowish-orange globular structures on scar-like areas (Figure 1, A and B). An inci- sional biopsy was performed from the atrophic plaque on the right arm. The histologic specimen shown lobular panniculi- tis accompanied by core crumbs, focal fibrin thrombi, focal hyaline necrosis, and lipomembranous changes (Figure 1G). An additional punch biopsy from the facial lesion reported a granuloma formation, perivascular and perifollicular in- flammation accompanied by calcification (Figure 1H). Lab- oratory tests revealed positivity for double stranded DNA and antinuclear antibodies (ANA) homogeneously positive with a titer of 1:320. Anti-SS-A, anti-SS-B and anti-CCP were negative. Serum complement C3 and C4 levels were within normal limits. Based on the clinical, histopathologi- cal and laboratory findings, a diagnosis of cutaneous lupus erythematosus was made. The patient was referred to the Rheumatology department and treated with a daily regimen of azathioprine 100 mg, hydroxychloroquine 400 mg, pred- nisolone 5 mg and indomethacin 25 mg. Topical tacrolimus 0.03% ointment and tretinoin 0.025 % cream were also administered for the treatment of the cutaneous lesions on her face. Teaching Point Lupus erythematosus is one of the major imitators in der- matology and may present with various cutaneous manifes- tations such as symmetrical confluent erythema and edema overlying the malar cheeks, erythema and edema of the hands, symmetric erythematous eruption of non-indurated mac- ules and papules, scaly annular lesions or papulo-squamous plaques, exfoliative erythroderma, discoid scaly purplish mac- ule or papules, hyperkeratotic/verrucous, bullous, urticarial or 2 Image Letter | Dermatol Pract Concept. 2023;13(1):e2023048 mucosal lesions [1]. To date, acneiform presentation and gran- ulomatous formation as seen in our patient have been rarely reported both in cutaneous and systemic lupus erythema- tous [2-7] Hence, lupus erythematous should be definitely in- cluded in the differential diagnosis of refractory acne lesions, and in these cases dermoscopy should be considered manda- tory for the diagnosis of difficult-to-treat acneiform eruptions. References 1. Walling HW, Sontheimer RD. Cutaneous lupus erythemato- sus: issues in diagnosis and treatment. Am J Clin Dermatol. 2009;10(6):365-381. DOI: 10.2165/11310780-000000000 -00000. PMID: 19824738. 2. Sitohang IBS, Rheza AM, Sirait SP, Fitri EM, Suseno LS. Acne Vulgaris Mimicking Cutaneous Lupus Erythematosus in an Adolescent: Report of a Rare Case. Case Rep Dermatol. 2021;13(1):69-74. DOI: 10.1159/000511530. PMID: 33708086. PMCID: PMC7923721. 3. Mohanty B, Kumar B. Systemic lupus erythematosus camouflag- ing: As refractory acne in a young girl. J Family Med Prim Care. 2019;8(1):276-279. DOI: 10.4103/jfmpc.jfmpc_376_18. PMID: 30911520. PMCID: PMC6396584. 4. Deruelle-Khazaal R, Ségard M, Cottencin-Charrière AC, Carotte-Lefebvre I, Thomas P. Lésions acnéiformes révélatrices d’un lupus érythémateux chronique [Chronic lupus erythema- tosus presenting as acneiform lesions]. Ann Dermatol Venereol. 2002;129(6-7):883-885. PMID: 12218916. 5. Vieira ML, Marques ERMC, Leda YLA, Noriega LF, Bet DL, Pereira GAAM. Chronic cutaneous lupus erythematosus pre- senting as atypical acneiform and comedonal plaque: case re- port and literature review. Lupus. 2018;27(5):853-857. DOI: 10.1177/0961203317726377. PMID: 28857716. 6. Farias DF, Gondim RM, Redighieri IP, Muller H, Petri V. Come- donic lupus: a rare presentation of discoid lupus erythematosus. An Bras Dermatol. 2011;86(4 Suppl 1):S89-S91. DOI: 10.1590 /s0365-05962011000700023. PMID: 22068781. 7. Henostroza-Inga K, Torres-Ibérico R, Atamari-Anahui N, Lipa-Chancolla R. Dermatitis granulomatosa neutrofílica en empalizada como presentación inicial de lupus eritematoso sistémico [Palisaded neutrophilic granulomatous dermatitis as the initial presentation of systemic lupus erythematosus]. Bol Med Hosp Infant Mex. 2021;78(6):652-656. DOI: 10.24875 /BMHIM.21000035. PMID: 34934217. Figure 1. (A,B) Multiple bizarre cicatricial acneiform lesions on cheeks with multiple linear and branching vessels over translucent yellowish-orange globular structure on scar-like areas, dermoscopically. (C) Multiple subcutaneous atrophic nodular lesions on the right arm. (D) Subcutaneous atrophic nodular lesion on the left arm. (E) Multiple subcutaneous nodular lesions on the lower proximal extremity. (F) Septal thickening and lobular inflammation rich in histiocytes (H&E, x200). (G,H) Periadnexial inflammation with focal granulomatous reaction (H&E, x40, x200).