Diffuse Facial Hyperpigmentation as a Presenting Sign of Lup
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Lupus erythematosus (LE) is an autoimmune disorder commonly affecting the skin; cutaneous lesions may indicate systemic involvement, warranting further evaluation. Photosensitivity, which may result in hyperpigmentation, is a well-known feature of the disease. In contrast, the prevalence of primary hyperpigmentation as a presenting sign of LE is not well established. A 56-year-old man of Indian origin presented with an 8-month history of hyperpigmented, slightly pruritic facial lesions, previously treated as postinflammatory hyperpigmentation with Kligman formulation and topical steroids without improvement. He had no systemic symptoms. The patient's past medical history was unremarkable, and he did not receive any chronic medications. He had been using facial cosmetic products for several years prior to rash appearance.

On physical examination, the patient had skin type IV according to Fitzpatrick classification and presented with hyperpigmented scaly thin plaques over the forehead, temples, and cheeks. A punch biopsy obtained from the patient's forehead showed superficial and deep perivascular, vacuolar/lichenoid interface dermatitis with thin epidermis. Alcian blue stain was weakly positive, and CD-123 stain, a marker for plasmacytoid monocytes often detected in LE, was positive. Further evaluation revealed positive antinuclear antibodies (ANA) at titers of 1:640 with a speckled pattern and positive anti-Ro antibodies. The patient had slightly abnormal coagulation studies with negative Coombs' test. Urine analysis showed small amounts of protein (11–50 mg/dL) without casts. Other laboratory tests were unremarkable.

Patch tests using the European standard and cosmetics series were positive for thiuram mix, a finding that was deemed insignificant in the absence of relevant exposure. Based on the histologic findings and autoimmune serology, the patient was diagnosed with a hyperpigmented variant of CLE. Systemic treatment with hydroxychloroquine (200 mg, twice daily) was initiated with slight improvement following 6 months of treatment.