Psoriasis – SCLE overlap-deciding role of dermatopathology.

DR. SHILPA SONI.

SKIN & VD, MGMCH.

IntroductionSCLE [1,2,3]

Comprises 10% of patients with LE

two-thirds - non-scarring papulosquamous lesions

One third - annular polycyclic lesions.

Reported associations include Sjögren’s syndrome [5],

rheumatoid arthritis, Sweet’s syndrome[6], Crohn’s

disease [7]

Rare reported associations include lichen planus and

psoriasis

SCLE

Homogeneous ANA are found in approximately

60% of patients

Anti-Ro/SS-A antibodies are seen in approximately

80% of patients [1]

Higher titres seen in females [10]

Psoriasis

Most common systemic auto-inflammatory

disorder

5-8% develop arthritis

Prevalence increases with age

Higher prevalence of arthritis is seen in patients

with more severe psoriasis and those with nail

involvement.

Psoriasis-SCLE overlapRare association1.1% 0f psoriasis associated with LE (15%

SCLE)

Important role of histopathology and

immunological markers in reaching the

diagnosis

Case reportA 65 year old female presenting to us with

erythroderma

Associated with joint pain affecting wrists,

elbows, knees and ankles

No other systemic symptoms, previous similar

episode, other chronic illness.

No other family member affected.

Medications over past 6 months

Methotrexate (Previously inj 25mg / week, on tab 15

mg/wk over past 1 month)

Azathioprine 50 mg OD over previous 1 month

Dermatological examination,

Multiple erythematous polymorphic annular lesions

covered with psoriasiform scaling affecting large area

of the body

Psoriasiform scaling of scalp

Joint examination,

Bilateral knee joints – mild swelling with tenderness

Admitted in skin ward

Continued on oral methotrexate 15mg/week

Ciclosporin 100 mg/d added

Investigations

low haemoglobin (9.8gm%)

raised ESR (50)

RF negative; CBC, LFT, RFT, sugar normal

Skin biopsy forearm – SCLE

Further course

Considering presence of annular psoriasiform

lesions with histopathology showing SCLE

ANA – positive

Anti – Ro – positive 158.11 (negative <20)

Developed methotrexate induced myelotoxicity

Improved with withdrawl of methotrexate and

administration of G-CSF

Follow up after 15 daysContinues to improve on low dose methotrexate. Azathioprine addedLesions became localized and look more on psoriasiform pattern.Further biopsy taken from back

Psoriasis

ImpressionPsoriasis – SCLE overlap

Discussion The interesting point about this patient: the association of the two diseases

Psoriasis has been said to associate with other autoimmune dermatological diseases in 0.74% of cases

Its coexistence with lupus erythematosus (LE) is, however, rare (6–8), accounting for 1.1% in patients with LE (4).

Different LE forms have been found

associated with psoriasis: Millens & Muller

(6) studied 27 patients in whom LE and

psoriasis were associated and found that

48% of them had discoid lesions, 37% systemic LE

15% SCLE.

Psoriatic lesions antedated LE in 50% of

cases, while they developed simultaneously in

38% and followed LE in 12% of cases.

One study [9] showed that The patients with

psorasis, demonstrated elevated antinuclear

antibody (ANA) titer; dilution titer varied from

1:80-640 with a homogeneous or a speckled

pattern.

1.7% of total psoriatic patients demonstrate

anti-Ro antibodies and 47% shows positive ANA.

Thus, the incidence of psoriasis and lupus

erythematosus coexistence is low and a baseline

immunological screening test for psoriasis might

not prove worthwhile.

Therefore histopathology is must.

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cutaneous lupus erythematosus: a cutaneous marker for

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4 ] Provost TT, Watson RM. Anti-Ro (SSA), HLA DR3-positive

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