Question:

A 37-year old lady complained of increasing scalp hair loss and scaly rash over the body, face, hands and neck in the past one year. Increase in dandruff and scalp pruritus was also noted. The hair loss was patchy and she denied self plucking of the scalp hair. The skin rash was found to be more severe after sun exposure and there were some morning stiffness of the small joints of the hands. No abnormality was noted in the mucous membranes.

The patient had been diagnosed to have systemic lupus erythematosus (SLE) after thorough clinical review and confirmation with blood tests for immune markers. She had been on systemic steroid and azathioprine but the skin rash seemed to persist. Skin biopsy confirmed the diagnosis of discoid lupus erythematosus. There are numerous cutaneous manifestations for SLE. Discoid lupus erythematosus (DLE) most frequently involves the face and scalp. It is characterized by erythematous, well-defined, scaly patches which tend to heal with atrophy, scarring and hypo or hyperpigmentation. DLE lesions can be localized or disseminated. Localized DLE may have cutaneous lesions only and the risk of developing to SLE is about 5%. However, DLE lesions are not uncommon in patients with an established diagnosis of SLE. About 25% of SLE patients will develop lesions of DLE at some time in the course of SLE. Avoidance of sunlight, anti-malarial drugs and potent topical steroids are the mainstay of treatment for DLE lesions.

Tinea capitis should be considered in prepubertal children with scaly erythematous rash with patchy hair loss on the scalp. Broken hairs and loss of shininess of the hair (making the hairs looks dull-grey and loss of glooming), or a folliculitis like picture on the scalp (kerion) are clinical hints that indicate the need of mycology examination of the hair though tinea capitis is uncommon in adult. Seborrhoeic dermatitis or eczema is common in elderly. Excessive dandruff with yellowish erythematous greasy scaly rash with ill defined border on the scalp and nasolabial fold, eyebrows, pre-sternal region and flexures are characteristics of seborrhoeic dermatitis. There has not been enough evidence to confirm that seborrhoeic dermatitis will lead to hair loss even in severe form though it may accelerate the onset of male pattern baldness. Lichen planus on the scalp may closely mimic discoid lupus erythematosus and can lead to scarring patchy hair loss. Other associated clinical features (e.g. whitish streaks in buccal mucosa for lichen planus and other features of lupus erythematosus) can differentiate the two conditions. Skin biopsy is necessary to document the diagnosis in scarring alopecia.