Distinguishing Cutaneous Manifestations of Lupus from Panniculitis-like T-Cell Lymphoma

Abstract

Distinguishing cutaneous manifestations of lupus, such as lupus profundus and discoid lupus, from a variant of T-cell lymphoma known as subcutaneous panniculitis-like T-cell lymphoma. These disease states are characterized by tender and hard nodules that are localized on the face, arms, shoulders, breast, and buttocks. In this case we describe a 69 year-old female with a previous history of systemic lupus erythematosus and discoid lupus who presented with worsening alopecia and frontal scarring despite being previously well controlled on Hydroxychloroquine alone. She was evaluated by dermatology and was receiving intralesional steroid injections, but ultimately did not have any improvement. She had a skin biopsy to evaluate further that was consistent with subcutaneous panniculitis-like T-cell lymphoma and she was started on Methotrexate and Prednisone 1 mg/kg, resulting in improvement of her symptoms. As demonstrated by Arps & Patel and the above case presentation, the importance of a biopsy and inflammatory markers for distinguishing between a cutaneous manifestation of lupus (i.e. discoid lupus vs panniculitis vs discoid lupus with features of panniculitis) from panniculitis-like T-cell lymphoma becomes essential and should be a consideration when a patient is having worsening lesions despite already being on appropriate medical therapy.