LAUSR

Reversibility of alopecia caused by chronic cutaneous lupus erythematosus Dear Editor, Chronic cutaneous lupus erythematosus (CCLE) is a common cause of cicatricial alopecia (CA) which represents almost 2% of presentations to specialist hair clinics. CA from CCLE is seven times more common in women. CA is generally permanent and irreversible, although hair regrowth has been noted in some patients with CA secondary to CCLE. We present three cases of CCLE where prompt treatment led to significant hair regrowth. A 29-year-old female presented with a 2-month history of multiple circular patches of CA. She had a past history of Raynaud’s syndrome. Dermoscopy revealed loss of follicular ostia, telangiectasia, and significant postinflammatory hyperpigmentation consistent with a cicatricial alopecia. Histology showed CA with loss of terminal follicles, mid-dermal fibrosis, perifollicular, perivascular, and interface lymphocytic infiltrate, necrotic keratinocytes, pigment incontinence, and epidermal atrophy. Indirect immunofluorescence was positive for IgM in the basement membrane. Antinuclear antibody (ANA) and anti-double-stranded-DNA (dsDNA) were negative, however anti-PM/SCL was positive. The clinical and histological findings supported a diagnosis of discoid lupus erythematosus (DLE). Treatment was started with prednisolone 20 mg daily and minoxidil 0.45 mg daily. Hair regrowth was apparent at 2 weeks. Hydroxychloroquine 200 mg twice daily was introduced, and the patches of cicatricial alopecia were injected with triamcinolone acetonide 5 mg/ml. On review at 6 weeks, there was marked hair regrowth in all patches (Fig. 1). A 29-year-old male with no significant past medical history presented with a 2-month history of a solitary patch of CA with central atrophy and hyperpigmentation. Histology revealed a CA with prominent perifollicular lymphocytic inflammation and increased stromal mucin. There were 24 vellus follicles, but no terminal follicles were present. A weakly positive ANA (1/80) was present, with negative anti-dsDNA and extractable nuclear antigens (ENA). Clinical and histological features were consistent with DLE. He was treated with intralesional triamcinolone acetonide 5 mg/ml. Review at 4 weeks confirmed marked hair regrowth and reduced erythema. Hydroxychloroquine 200 mg daily was commenced, and the lesion was reinjected with triamcinolone 5 mg/ ml. Five months later, he had near-complete remission (Fig. 1). A 38-year-old female presented with a 3-year history of a solitary, 10 9 10 cm, slowly enlarging patch of CA. Past medical history included iron deficiency anemia. Dermoscopy revealed areas of loss of follicular ostia and yellow dots. Histology showed a CA with associated basal vacuolar changes in the epidermis, thickening in the basement membrane, a marked increase in dermal mucin, and a deep and superficial perivascular chronic inflammatory infiltrate with interface changes. Indirect immunofluoresence was nonspecific with perivascular staining for fibrinogen, C3, and C1q. ANA and anti-dsDNA were negative, and anti-PM/SCL was low positive. Clinical and histological features were consistent with lupus profundus. She was treated with intralesional triamcinolone acetonide 5 mg/ml. At week 6, hair regrowth was evident and the size of the alopecic patch had reduced to 7 9 6 cm (Fig. 1). CA associated with CCLE is generally considered irreversible. This case series highlights the potential reversibility of CA with prompt treatment.