Do skin lesions in the young sound an alarm.

Sir,

Systemic lupus erythematosus (SLE) is predominantly a disorder of females. Males including adolescents are rarely affected. Juvenile SLE is usually a more aggressive disease than adult SLE. One such juvenile was seen by the author who had few atypical manifestations.

A 16-year-old male presented with a history of intermittent scattered skin lesions over scalp, ears, back, and lateral part of arm over preceding 2 years. He had not taken any treatment for these lesions. For the last 1 month, he started having intermittent episodes of fever along with painful oral ulcers and flare of the skin lesions over extremities and trunk. After that, he sought medical attention. There was no abnormal bleeding, cough, headache, or weight loss. He also complained of intermittent pain in both knees. Clinical examination showed blood pressure of 109/64 mmHg, and absence of pallor, icterus, lymphadenopathy, or clubbing. Skin examination revealed scattered discoid lesions (pigmented raised border with central atrophy and depigmentation) [Figures 1 and 2]. There was diffuse hair fall with atrophic scars [Figure 3]. Earlobes had atrophic scars. Hard palate showed erosions [Figure 4] and the lower lip had single erosion. Systemic examination did not reveal any abnormal findings in the chest, cardiovascular, abdomen, and nervous system. Hemoglobin was 8.8 gm%, total leukocyte count 3900, and platelets were 2.87 lakhs. Liver and kidney function tests were normal. Antinuclear antibody and dsDNA were positive. Urine did not show any casts or albumin. The patient was treated as a case of SLE with steroids.

Figure 1

Scattered discoid lesions (pigmented raised border with central atrophy and depigmentation) over the upper limb

Figure 2

Discoid lesions over the back

Figure 3

Diffuse hair fall with atrophic scars over the scalp

Figure 4

Erosions over the hard palate

SLE is a multisystem disorder of autoimmune etiology characterized by the presence of autoantibodies against self-proteins. It is more common in females of childbearing age with reported female: male ratio of 8–15:1.[1] Male lupus is a rare phenomenon. Predominance in females may be the effect of endogenous sex hormones exerting their effects on the immune system; however, the exact cause is not known.[2] There are studies comparing the differences in clinical features in males versus females. It has been reported that male patients had more renal involvement, neurological involvement, thrombotic episodes, arthritis, and cardiovascular involvement.[3] Male SLE patients are usually older at disease onset as compared to females.[4] The mean age range to experience first SLE-related symptoms in males has been reported to be 26–38.4 years.[5] Males were found to have significantly less photosensitivity, oral ulcers, thrombocytopenia, or increased erythrocyte sedimentation rate in comparison with women in one study.[6] Thus, this is one of the rare instances where SLE has affected a juvenile male and led to the relatively uncommon involvement of skin and oral cavity without other significant systemic involvement. Early diagnosis could have prevented progression of lesions. Hence, we must be careful about atypical manifestations of SLE.

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