Case description
A 57-year-old male presented with a 2-year history of a recurrent pruritic rash. He reported multiple rounds of intralesional triamcinolone acetonide injections which resolved existing lesions, but new ones recurred. Two years of treatment with hydroxychloroquine at a dose of 200 mg twice daily provided no improvement. The patient was a former smoker with a 70-pack-year smoking history (quit in 2024). Physical examination revealed annular erythematosus plaques on the shoulders, trunk, back, and limbs (Fig 1). Antinuclear antibody was negative. A punch biopsy of one of the lesions revealed perivascular and interstitial lymphohistiocytic infiltrate in the dermis and interstitial mucin (Fig 2).
Fig 1.
Clinical images of tumid lupus erythematosus showing multiple erythematous annular plaques on the (A) back, (B) trunk and (C-F) extremities.
Fig 2.
Histopathologic images revealing (A) dense perivascular and (B) interstitial lymphohistiocytic infiltrates without epidermal involvement.
Question: What is the diagnosis?
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A.
Granuloma annulare
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B.
Erythema annulare centrifugum
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C.
Tumid lupus erythematosus (TLE)
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D.
Deep morphea
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E.
Subacute cutaneous lupus erythematosus (SCLE)
Answer
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C.
Tumid lupus erythematosus – Correct. TLE diagnosis is confirmed by its classic histopathologic triad, including a perivascular and periadnexal lymphocytic infiltrate, abundant interstitial mucin, and epidermal sparing (Fig 2).
Discussion
TLE is a chronic form of lupus that primarily affects the skin while sparing internal organs. A key distinguishing feature histologically is the minimal epidermal involvement along with perivascular and periadnexal lymphocytic infiltrate, which differentiates TLE from other cutaneous lupus variants such as discoid lupus erythematosus and SCLE, both of which typically demonstrate significant interface dermatitis.1 Despite its clinical overlap with other lupus subtypes, TLE is frequently seronegative; a negative ANA result should not dissuade clinicians from considering this diagnosis. Foundational studies have consistently reported low rates of ANA positivity and a minimal risk of progression to systemic lupus erythematosus-estimated at below 5%-affirming TLE as a primarily cutaneous condition.2
Antimalarials remain the first-line treatment, though treatment failure is relatively common, and does not exclude the diagnosis when clinicopathologic correlation is strong. Epidemiologically, it occurs predominantly in middle-aged women, with a mean age of onset of 56.3 years.3 For management, intralesional corticosteroids may be used for localized lesions, while counseling on lifestyle modification is essential. Given TLE’s marked photosensitivity, strict photoprotection is critical, and due to its strong association with smoking, clinicians should emphasize smoking cessation as a key part of comprehensive management.3
Conflicts of interest
None disclosed.
Footnotes
Funding sources: None.
Patient consent: The authors obtained written consent from the patient for the publication of the case details. The consent forms were not included with submission but can be provided upon request.
IRB approval status: Not required for this case report.
References
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