Several conditions mimic DLE
The differential diagnosis for DLE includes the following:
Lichen plano pilaris. This condition has a predilection to the crown of the head and the frontal central region of the scalp; it is also associated with bilateral eyebrow hair loss. Patients may complain of pruritus, localized tenderness, and a burning sensation. The etiology is unknown; it is most often seen in middle-aged women with a chronic, progressive clinical course.4
Alopecia areata. Patients suddenly lose hair in patches. The hair grows back, and then falls out again. This asymptomatic condition is a tissue-restricted autoimmune disease of the hair follicle that most commonly occurs among children and young adults.5
Dissecting scalp cellulitis. This is a suppurating and cicatrizing disease of the scalp of unknown etiology. It typically affects the scalp vertex and occipital region, and is most common among young black men. The erythematous papules eventually discharge seropurulent material and form underlying intercommunicating sinuses with eventual scarring.6 Patients are likely to complain of pain and pruritus.
Tinea capitis. As noted earlier, this is commonly referred to as “ringworm” and is of a fungal, infectious etiology that typically affects children. Permanent scarring and alopecia are common in affected areas, and patients complain of itching and burning.
Diagnosis can be made on clinical grounds
While a clinical diagnosis of DLE can be made, a tissue biopsy of a new inflamed site is confirmatory. Histopathologic findings show hyperkeratosis, follicular plugging, thickening of the basement membrane, atrophic epidermis, and dermal perifollicular and periappendageal lymphocytic inflammatory infiltrate.
Direct immunofluorescence of lesions shows granular immunoglobulin and complement deposition at the dermal-epidermal junction.7,8
Early treatment is key
Early treatment may be helpful in preventing permanent scarring. Therapeutic options commonly used are oral antimalarials (strength of recommendation [SOR]: A) and topical (SOR: A) or intralesional (SOR: B) corticosteroids.9 Other topical agents, such as calcineurin inhibitors, retinoids, and imiquimod, have been found to be helpful in some cases.
Alternative systemic agents that appear to be useful include methotrexate, azathioprine, thalidomide, dapsone, and mycophenolate mofetil. Patients should be advised to avoid the sun and wear broad-spectrum sunscreen.7,10