What is the diagnosis and treatment for skin plaques with atrophic centers and telangiectasia?

Diagnosis: Chronic Discoid Lupus Erythematosus (DLE)

Skin plaques with atrophic centers and telangiectasia are pathognomonic for chronic discoid lupus erythematosus (DLE), which presents as well-demarcated erythematous plaques with central atrophy, scarring, pigmentary changes, and telangiectasia. 1

Clinical Presentation

The characteristic lesions appear as:

• Round or oval erythematous plaques with adherent scales or crusts 2
• Central porcelain-white atrophy with surrounding telangiectatic rim 1
• Follicular plugging and peripheral spread 1
• Hypopigmentation, hyperpigmentation, and telangiectasia in long-standing lesions 1
• Butterfly-like distribution on face involving cheeks and nose in many cases 1
• Disseminated DLE (DDLE) when lesions extend beyond head/neck to trunk and limbs 2

Diagnostic Workup

Obtain a deep punch or incisional biopsy to confirm diagnosis and rule out malignancy, as chronic non-healing plaques with atrophy can represent cutaneous squamous cell carcinoma or other malignant processes. 3

Histopathological Features to Confirm:

• Hyperkeratosis with follicular plugging 2
• Focal epidermal thinning and vacuolar alteration at dermo-epidermal junction 2
• Thickened epidermal basement membrane 2
• Superficial and deep perivascular/periadnexal lymphocytic infiltrate 2
• Interstitial mucin deposition 2

Direct Immunofluorescence (DIF):

• Deposits of immunoglobulins and complement at dermo-epidermal junction 2
• Granular IgM pattern may be present (though this overlaps with lupus features) 4

Treatment Algorithm

First-Line Topical Therapy:

Apply high-potency topical corticosteroid ointment (clobetasol propionate 0.05% or betamethasone dipropionate 0.05%) twice daily to affected plaques for 2-4 weeks. 5

• Use mid-to-high potency preparations under occlusion for localized lesions 6
• Apply sparingly to avoid skin atrophy, striae, and worsening telangiectasia 5
• Critical pitfall: Avoid high-potency steroids on facial lesions—use only hydrocortisone 2.5% or Class V/VI steroids on the face to prevent atrophy. 5

Adjunctive Measures:

• Liberal application of fragrance-free, hypoallergenic emollients at least once daily 5
• Strict sun protection with high-SPF sunscreen and protective clothing 7
• Avoid fragranced products and irritants 5

Second-Line Options for Refractory Lesions:

If no response after 4 weeks of optimized high-potency topical therapy, switch to topical tacrolimus 0.1% ointment twice daily as a steroid-sparing alternative. 5

• Intralesional triamcinolone acetonide (5-10 mg/cc) for persistent localized plaques 6
• Topical vitamin D analogs combined with topical steroids for resistant lesions 6

Phototherapy for Widespread Disease:

Narrowband UVB (TL-01) phototherapy is first-line treatment for disseminated DLE due to superior long-term safety profile. 6

Systemic Therapy Considerations:

• Hydroxychloroquine or chloroquine for extensive or refractory disease 8
• Methotrexate for cases unresponsive to antimalarials 6, 8

Monitoring and Safety

• Regular clinical review when using high-potency topical corticosteroids 5
• Do not exceed 100g per month of moderately potent preparations without dermatology supervision 5
• Plan steroid-free periods annually when using alternative treatments 5
• Monitor for corticosteroid-induced skin atrophy and telangiectasia, which correlate with prolonged use 9

When to Refer to Dermatology

Refer urgently if:

• No response to optimized high-potency topical therapy within 4-6 weeks despite documented adherence 5
• Rapidly growing or non-healing wound lasting longer than 4 weeks (to rule out malignant transformation) 3
• Need for systemic immunosuppressive therapy 8
• Scarring alopecia develops on scalp 2

Critical Pitfalls to Avoid

• Never assume treatment failure without first confirming adequate application technique and duration (twice daily to all affected areas for minimum 2-4 weeks). 5
• Do not continue ineffective corticosteroids indefinitely—this risks both disease progression and steroid-related adverse effects including worsening atrophy and telangiectasia. 5, 9
• Always biopsy chronic non-healing plaques to exclude malignancy, as DLE can transform to squamous cell carcinoma in long-standing lesions. 3
• Avoid using high-potency steroids on facial skin—use only low-potency hydrocortisone on the face. 5