Lip lupus erythematosus

CLINICAL RECORD A 40-year-old Indigenous Australian woman was referred to an outreach dermatology clinic in the Top End of the Northern Territory for assessment of painful lip ulceration of 2 years’ duration. She had been reviewed 16 months earlier in a distant regional centre, and a diagnosis of squamous cell carcinoma of the lip had been proposed. Skin biopsy had not been performed and the patient had refused a planned extensive surgical excision of the lip lesion at that assessment. Her general health was good. Examination at the outreach clinic showed extensive and bilateral lower lip exophytic ulceration and crusting (Box 1). The upper lip and other cutaneous and oral surfaces were normal. Lower lip skin biopsy samples were taken from the ulcer and adjacent lower lip mucosa to confirm a clinical diagnosis of lupus erythematosus and to exclude malignancy (Box 2). The hyperkeratotic squamous epithelium ranged from atrophic to acanthotic, with foci of lichenoid basal vacuolar damage resulting in squamous cell apoptosis and colloid bodies. The submucosa contained a dense mixed inflammatory cell infiltrate of lymphocytes, histiocytes, plasma cells and melanophages. Direct immunofluorescence investigation showed weak (1+) granular IgM and complement component 3 positivity along the junctional region. No squamous dysplasia or malignancy was identified. The results of blood testing, including antinuclear antibody testing, extractable nuclear antigen and DNA-antibody studies, were negative. Serum complement levels were normal. The patient was instructed to reduce lip sun exposure, apply broad-spectrum sunscreen twice daily and apply betamethasone dipropionate cream (0.5 mg/g) daily. On review 3 months later, there was a dramatic resolution of pain and ulceration. In the absence of any clinical or histological suggestion of malignancy, surgical treatment was not indicated or anticipated.Johanna M Warren, Peter F Bourke, Lachlan J Warre