|Year : 2018 | Volume
| Issue : 3 | Page : 302-305
Discoid lupus erythematosus
Anilkumar L Bhoweer1, Sudarshan G Ranpise2
1 Ex-Professor, Oral Medicine and Radiology, Consultant Oral Diagnostician and Maxillofacial Radiologist and Dental Surgeon, Mumbai, Maharashtra, India
2 Professor and HOD, Department of Oral Medicine and Radiology, Bharati Vidyapeeth Dental College, CBD, Navi Mumbai, Maharashtra, India
|Date of Submission||26-Jun-2018|
|Date of Acceptance||10-Jul-2018|
|Date of Web Publication||18-Oct-2018|
Dr. Sudarshan G Ranpise
Professor & HOD, Department of Oral Medicine & Radiology, Bharati Vidyapeeth Dental College, CBD, Navi Mumbai, Maharashtra
Source of Support: None, Conflict of Interest: None
| Abstract|| |
Oral ulcerative lesions are very common and a proper diagnosis is required of the nonresponsive lesions to common antiseptic and analgesic creams which do not work on those ulcers. Specific local potent steroids work faster with given soft trays to apply, which holds the medicine for local action, as it does not get washed away with the mouth saliva. Lupus Erythematosus lesions respond slowly with medicine as this is an autoimmune disease. Systemic lupus erythematosus, it occurs, is a cutaneous autoimmune disease and can affect the skin and various internal organs. Thus, proper observation of oral ulcers is important and if there are any indications of such skin infections, then it requires a Dermatologist to handle for life-saving management as the disease is sometimes fatal. A general warning signal of recurrence can help the patient with history of oral lesion for the proper management even later in life by a Dermatologist. Oral lesions are very important in diagnosing systemic disease in many cases. Oral lesions are thus the mirror of general health.
Keywords: Autoimmune disease, discoid lupus erythematosus, potent local steroid, systemic lupus erythematosus
|How to cite this article:|
Bhoweer AL, Ranpise SG. Discoid lupus erythematosus. J Indian Acad Oral Med Radiol 2018;30:302-5
| Introduction|| |
Discoid lupus erythematosus (DLE) is A rare condition. It occurs as a reddish telangiectatic lesion in the oral cavity mucous membrane having white patches surrounding the lesion, and sometimes either thick or small white papillary radiating patterns around the lesion are seen as very delicate lines. Rarely, irregular red patches without white keratotic components or sometimes white keratotic patches are coincidentally seen, which makes it difficult to differentiate from Oral Lichen planus or even Leukoplakia.,,,, Hence, it is essential to confirm the clinical diagnosis with histopathologic findings. DLE it commonly occurs in buccal mucous membrane, gingiva, lips, or palatal mucosa.
| Case Report|| |
We came across a lady patient, aged 40–50 years, with one big palatal lesion extending into the edentulous gingival area and even crossing over the muccobuccal fold and cheek mucosa with ulcerations. The patient was wearing full dentures and could not use it because of unbearable pain.
The lesion on the palate showed whitish keratotic outline and also fungal greyish white patch over the larger surfaces [Figure 1]a and radiating keratotic papules. There was no skin lesion on the face anywhere.
|Figure 1: (a) Palatal large ulcerative lesion (Lt.) radiating and extending up to the cheek mucosa. (b) Small, circular lesion (Rt.) with radiating papules|
Click here to view
There was another small circular lesion of corn-size on the right side of the palatal lesion, a little away from the main left-side lesion. This small lesion had a reddish central area and was surrounded by a white-bordered patch [Figure 1]b.
The lesions did not respond to many local creams suggested by dental surgeons. The patient appeared worried and was in a stressful condition as having pain, eating difficulties, and inability to wear the upper denture. She was referred to us for diagnosis and management. The patient was also worried about cancer in the oral cavity and had cancer phobia. Although, cancer is seen in lesser number of patients, about 0.5–2%, leading to squamous cell carcinoma.
The patient did not have any habit of tobacco chewing or eating betel nut or paan masala of any type. Her general health was alright, with no diabetes or any other serious illness. We informed her (and her relative too) that a biopsy procedure will be required to confirm the condition. The patient did not have any skin lesion. The lesion clinically appeared to be DLE and ulcerative lichen planus as differential diagnosis.
The patient gave consent for the biopsy procedure and an incisional biopsy was done near the periphery of the large left-side lesion [Figure 2]. The biopsy confirmed the lesion was DLE.
Biopsy report [Figure 3], [Figure 4], [Figure 5], [Figure 6]: Serially sectioned large mucosa covered by ulcerated lesion is characterized by focal irregular acanthosis and dense diffuse inflammatory infiltrate, rather rich in plasma cells. The population of lymphocytes and histiocytes is small. The lesion is vascular with swollen capillary endothelium. There is no evidence of granuloma, fungal infection, or neoplasm. The findings are compatible with clinical diagnosis of DLE.
We decided to treat the lesions by local medications with most potent steroid cream base and advised the patient to initially apply with a finger three times daily with local anesthetic pain killer with antiseptic action. The local cream application should not be followed with eating or drinking any kind of fluid water, milk, cold drinks, etc. for about 20 min so that the local medicine does not get washed away.
The patient was advised not to use the upper denture till the muccobuccally ulcerative lesion does not heal. We decided to observe the response to the local steroid cream. The patient was initially asked to report after a gap of 4 days.
The lesion disappeared with a very good response in the first few days (3 weeks) and showed good healing, with reduction in size [Figure 7]a and with less discomfort and less pain. The cheek and muccobuccal fold lesion responded very well and disappeared in three weeks.
|Figure 7: (a) Good healing with reduction in size. (b) Reduction almost three-fourths|
Click here to view
Moreover, the small right-side palate lesion showed very good response and it healed almost three-fourths [Figure 7]b. In order to avoid fungal (Candida) superinfection, the patient was advised antifungal local cream twice daily and povidone-iodine mouthwash to rinse, to prevent the infection. The response was very good.
Later, the patient was asked to use the upper denture not for eating, but to put the local cream on the inner surface of the denture and wear the dentures for 20 min each time, three times daily, for better effect. Instructions were given, after removing denture, not to have liquids for half an hour and not to eat with the denture. A weekly follow-up was advised.
We noticed very good response to our local treatment and the lesions reduced in size fairly quickly. There was no discomfort to the patient. [Figure 8]a and b showing improvement in lesions].
The right-side palatal lesion totally disappeared in a very short period of time. The left lesion was very large initially but reduced in size within a small period of time and later healed completely in 3 months [Figure 9]a and [Figure 9]b. The patient was asked to wear the upper denture, maintain follow-ups, and also advised to keep the denture very clean. The patient was advised monthly observation later and to take nutritious food and vitamins.
|Figure 9: (a and b) Both lesions totally healed with normal palatal mucosa|
Click here to view
| Discussion|| |
Commonly, DLE is a connective tissue disease of unknown cause (immune deficiency). In systemic lupus erythematosus, many organs could be involved with the risk of array of signs and symptoms, whereas DLE only affects skin or mucous membrane. Oral mucosa is a benign disease, rarely undergoing malignant changes. Some cases have been reported to have squamous cell carcinoma by some authors, about 2% or a little more. DLE has a good prognosis. The skin lesions may appear accompanying systemic lupus. Sometimes skin lesion followed by oral lesions or oral lesions followed by skin lesion may occur in small quantity, and the oral lesion may be seen as systematic lupus erythematosus. It is more common in females and less in males. Although oral lesions in buccal mucosa, gingiva, labial mucosa, palatal mucosa is involved, sometimes, a histopathology report is insufficient to confirm the diagnosis of DLE. So, in addition, an immunofluorescence test can be done.
In our case the palatal mucosa was mainly involved, extending up to the upper gingival ridge on the left side and extending into the muccobuccal fold and buccal mucosa with ulceration. We treated this ulcerative lesion of DLE on the palate and alveolar gingiva and muccobuccal fold left check mucosa with a most potent steroid and found good results in a few days' time, also along with antifungal drugs to manage suprafungal infection and local anesthetic antiseptic to control pain and get relief.
In about 3 weeks, the right small palatal lesion healed completely, whereas the left palatal lesion took nearly 3 months to heal completely. The patient's own upper denture was used as a tray for local cream medication application, which showed wonderful results. The follow-up after 1 month showed no recurrence. The patient was using denture and eating regular food. Yet, a monthly follow-up was advised. To conclude, she was doing very well [Figure 9]a and [Figure 9]b, showing periodic improvement and curing of lesions using her dentures.
| Conclusion|| |
DLE can be treated by potent local steroid cream without any side effects. No systemic drugs were given. Local soft trays respond better for local cream medications as the medicine does not get washed away.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Schiødt M. Oral discoid lupus erythematosus. III. A histopathologic study of sixty-six patients. Oral Surg Oral Med Oral Pathol 1984;57:281-93.
Schiødt M, Pindborg JJ. Oral discoid lupus erythematosus. I. The validity of previous histopathologic diagnostic criteria. Oral Surg Oral Med Oral Pathol 1984;57:46-51.
Schiødt M, Holmstrup P, Dabelsteen E, Ullman S. Deposits of immunoglobulins, complement, and fibrinogen in oral lupus erythematosus, lichen planus, and leukoplakia. Oral Surg Oral Med Oral Pathol 1981;51:603-8.
Pramod John R. Immunological diseases; Essentials of Oral Medicine. Jaypee Brothers Medical Pub (P) Ltd.; 2000. p. 84-5.
Ranginwala AM, Chalishazar MM, Panja P, Buddhdev KP, Kale HM. Oral discoid lupus erythematosus: A study of twenty-one cases. J Oral Maxillofac Pathol 2012;16:368-73.
] [Full text]
Fernandes MS, Girisha BS, Viswanathan N, Sripathi H, Noronha TM. Discoid lupus erythematosus with squamous cell carcinoma: A case report and review of the literature in Indian patients. Lupus 2015;24:1562-6.
Schiødt M. Oral discoid lupus erythematosus. II. Skin lesions and systemic lupus erythematosus in sixty-six patients with 6-year follow-up. Oral Surg Oral Med Oral Pathol 1984;57:177-80.
Nisengard RJ, Jablonska S, Beutner EH, Shu S, Chorzelski TP, Jarzabek M, et al.
Diagnostic importance of immunofluorescence in oral bullous diseases and lupus erythematosus. Oral Surg Oral Med Oral Pathol 1975;40:365-75.
[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8], [Figure 9]