Table 1. Summarises the case histories illustrating the protean of periorbital DLE presentations.

	Demographic (age is at onset of symptoms)	Interval to diagnosis (months)	Presentation	Examination findings	Investigations	Treatment and outcome
Patient 1	50 F Caucasian	6	Painless, progressive periorbital swelling Treated as infective cellulites Concern regarding possible necrotising fasciitis	Significant oedema, violaceous erythema, and eczematous changes (Figure 1a)	CT orbits: enlarged lacrimal gland and extraocular muscles (Figure 1b) Lacrimal gland biopsy: lymphocytic infiltration Punch biopsy right upper lid: perivascular lymphocytic infiltration throughout dermis, lichenoid changes, vacuolar degeneration ANA: positive; dsDNA negative	No improvement with systemic antibiotics or corticosteroids. Spontaneous resolution after discontinuing all treatment
Patient 2	48 F Afro-Caribbean	10	Bilateral sore, itchy lower eyelids	Well-demarcated lid margin depigmentation (Figure 1d) Subtle tarsoconjunctival hypertrophy	Shave biopsy: histological abnormalities consistent with DLE ANA: negative	Significant improvement with hydroxychloroquine (200 mg OD)
Patient 3	47 F Afro-Caribbean	38	Intermittent left upper lid swelling	Atrophic anterior lamella (Figure 1e) Lid margin destruction, complete loss of lashes, patchy depigmentation Scarred meibomian orifices	Punch biopsy: direct immunofluorescence consistent with DLE ANA: negative	Significant improvement with hydroxychloroquine (200 mg OD) and oral corticosteroids Reduced sun exposure Mild residual hypopigmentation
Patient 4	43 F Asian	57	Left lower-lid lesion. Intermittent bleeding	Scaly erythematous plaque (Figure 1f) Shallow ulceration of lid margin, focal madarosis, tarsoconjunctival hyperaemia	Two biopsies: nonspecific inflammation Repeat full thickness biopsy: histological abnormalities consistent with DLE	No improvement with oral corticosteroids Intralesional corticosteroid—partially effective Significant improvement with hydroxychloroquine (200 mg OD)
Patient 5	23 M Afro-Caribbean	86	Recurrent right lower-lid swelling. Treated as atypical chalazion Previous surgical excision—recurrence after 6 months	Disorganised anterior lamella Areas of erosion, erythematous nodules and pigmentation	Full thickness biopsy: hyperkeratosis, perivascular and periadnexal chronic inflammatory cell infiltrate, in keeping with DLE ANA: negative	Improvement on hydroxychloroquine (200 mg OD) Poor compliance led to worsening of the lesion
Patient 6	46 F Caucasian	48	Itching, redness and thickening all four eyelids Previously diagnosed as blepharo-conjunctivitis treated with lid hygiene	Irregular, thickened, fissured lid margins Focal lash loss and conjunctival thickening	Biopsy: cutaneous lymphoid hyperplasia ANA: negative	Spontaneous resolution after discontinuing all treatment
Patient 7	71 F Caucasian	18	Right lower-lid itching and excoriation Treated as blepharitis and allergic dermatitis	Irregular, thickening and madarosis	Full thickness biopsy: lichenoid infiltrate consistent with DLE	Improvement on hydroxychloroquine (200 mg OD)