Cutaneous lesions of the digits in systemic lupus ...



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Oral Manifestations of Lupus

Dorinda Thomas

Riverside Community College

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Abstract

The importance to understand the correlation between lupus erythematosus and oral lesions should not be minimized. There are many people that suffer from lupus erythematosus and present with signs of oral lesions. The research collected and described herein helps explain the importance to identify oral lesions and through biopsy determine weather they are lupus erythematosus derived.

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Oral Manifestations of Lupus

Lupus erythematosus is an autoimmune disease that a clinician may encounter. The purpose of this paper is to review the current research in the topic of lupus and oral manifestations and to help in determining what form of lupus manifestations a patient may present with and then determine and implement proper treatment.

Etiology

Lupus erythematosus is an acute and chronic inflammatory autoimmune disease of an unknown cause and is progressive with periods of remission (Ibsen & Phelan, 2004). Lupus erythematosus is eight times more likely to be found in women than men and is three times more likely found in black women then white women (Ibsen, 2004). Lupus erythematosus is subdivided into systemic and cutaneous forms (Lourenco, de Carvalho, Boggio, Sotto, Vilela, Rivitti, & Nico, 2007). Systemic lupus erythematosus is a syndrome not a specific disease. The syndrome ranges from mild cutaneous lupus erythematosus lesions and/or arthritis to renal failure or intense nervous, cardiac and hematological disturbances (Labady, Dorrego, Gonza, Perez, & de Henning, 2007). Cutaneous lupus erythematosus is more of a benign condition – limited to skin and/or mucosal surfaces (Lourenco et al., 2007). Some researchers suggest that oral lupus erythematosus lesions are present in 9-45% of patients with the systemic form of lupus and 3-20% with the cutaneous form of the disease (Lourenco et al., 2007).

Clinical Manifestations

Patients with systemic lupus erythematosus can present with both cutaneous and oral manifestations. Manifestations may include a malar rash; also known as a butterfly

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rash (see Figure 2) and discoid rashes which are round-like rashes usually found on the neck, face, chest, scalp, or orally (see Figure 1) (Labady et al., 2007). Extraoral findings may also include fingernail adnormalities that have been observed as being similar to lichen planus and show signs of pitting and hyperkeratosis (Bouaziz, Barete, Le Pelletier, Amoura, Piette, & Frances, 2007). A patient can also have photosensitivity; a sun allergy and oral ulcers (Labady et al., 2007).

According to a research study conducted in a Venezuelan population consisting of 90 patients, oral mucosal ulcerations occured in more than 40% of the patients having systemic lupus erythematosus (Labady et al., 2007). The findings in these patients with oral lupus erythematosus lesions consisted of a range from a red macula or plaque ulceration that may or may not have been surrounded by a white irradating striae border to a white plaque on a pigmented mucosa (Labady et al., 2007). Clinical features varied according to anatomical location; hard palate lesions were a red maculae or plaque, and lesions on the buccal mucosa where white lesions that were plaque and lichen-like striae where as lesions located on the lips were either red plaques or ulcers (Labady et al., 2007). In more than 75% of lupus erythematosus patients observed in a study, the patients complained about oral soreness, dryness and periodontal problems as well as oral lesions occurring in more than one site (Lourenco, Sotto, Vilela, de Carvalho, Rivitti, & Nico, 2006).

Differential Diagnosis

A biopsy is very important when diagnosing a lupus erythematosus lesion. Although a patient may present with lupus and the lupus erythematosus lesions may

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correspond with the systemic disease, a biopsy for histopathological evaluation and direct immunofluorescence examination is necessary because the lupus erythematosus lesions that correspond with the disease can vary and can be a differential diagnosis of lichen planus, leukoplakia and squamous cell carcinoma (Lourenco et al., 2006). Some of the histopathological features that differentiate lupus erythematosus from the noted differential diagnosis is that the specimens contained hyperkeratosis, atrophy of rete process, superficial and deep inflammatory infiltrate, edema in the lamina propria and thick continuous or patchy PAS-positive deposits (Lourenco et al., 2006)

Treatment

There is no specific treatment for oral lesions of lupus erythematosus however, treatment is necessary. Oral manifestations of lupus erythematosus can be given systemic treatment; however, systemic treatment does not always resolve the issue so topical treatment can be a recommendation (European Association of Oral Medicine, 2005). Often oral lupus erythematosus lesions can be frequently infected by Candida and antimycotic treatment needs to be given for this (European Association of Oral Medicine, 2005). There is no cure for lupus erythematosus and since the etiology of the syndrome is unknown the prevention is questionable (European Association of Oral Medicine, 2005).

Conclusion

Research continues to be conducted regarding lupus erythematosus and oral lesions and the correlation between the two is relevant and important. There are many people that have the autoimmune disease that have signs and symptoms of oral lesions. A

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biopsy is important so that the proper diagnosis and treatment can be determined for each unique case.

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References

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immunological manifestations in 151 SLE patients living in Dubai. SAGE Journal, 17, 62-66.

Bouaziz, J. D., Barete, S., Le Pelletier, F., Amoura, Z., Piette, J. C., & Frances, C. (2007).

Cutaneous lesions of the digits in systemic lupus erythematosus: 50 cases. SAGE Journal, 16, 163-167.

European Association of Oral Medicine. (2005, March). Oral lupus erythamtosus.

Retrieved April 13, 2008, from

Ibsen, O. A. C., Phelan, J. A. (2004). Immunity. Elsevier, Oral Pathology for the Dental

Hygienist (4th ed.) (pp109-111). St. Louis, MO: Saunders An Imprint of Elsevier.

Labady, J. L., Dorrego, M. V., Gonzalez, N., Perez, R., de Henning, M. M. (2007). Oral

manifestations of systemic and cutaneous lupus erythematosus in a Venzuelan population. Journal of Oral Pathology & Medicine, 36, 524-527.

Lourenco, S. V., Sotto, M. N., Vilela, M. A. C., de Carvalho, F. R. G.,

Rivitti, E. A., & Nico, M. M. S. (2006). Lupus erythematosus: Clinical and histopathological study of oral manifestations and immunohistochemical profilupus erythematosus of epithelial maturation. Journal of Cutaneous Pathology, 33, 657-662.

Lourenco, S. V., de Carvalho, F. R.G., Boggio, P., Sotto, M. N., Vilela, M. A. C., Rivitti,

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E. A., & Nico, M. M. S. (2007). Lupus erythematosus: Clinical and histopathological study of oral manifestations and immunohistochemical

profilupus erythematosus of the inflammatory infiltration. Journal of Cutaneous Pathology, 34, 558-564.

University of Padova, Italy. (1996). Systemic Lupus Erythematosus in Younger Women.

Retrieved April 28, 2008, from the Medscape Web site: viewarticle/408846_6

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Appendix

Figure 1. Lupus erythematosus discoid lesion on the right buccal mucosa area.

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From “Oral lupus erythamtosus,” by European Association of Oral Medicine, 2005. Retrieved April 13, 2008 from

Figure 2. A 30 year old female patient, presents with a lupus erythematosus butterfly rash also called a malar rash.

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From “Systemic Lupus Erythematosus in Younger Women,” by University of Padova, Italy. Retrieved April 28, 2008 from viewarticle/408846_6

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