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Description
A 44-year-old man presented with a 9-month history of desquamative hand injuries with recent worsening. He reported no related trauma.
The patient reported recent self-limiting arthralgias in the ankles and knees, with oedema of the hands and feet. He also mentioned generalised rosacea after heat exposure and self-limited episodes of dry mouth.
Physical examination of the affected hands revealed dehydration of soft tissues, with erythema and heat in the palms of the hands, with central scaling lesions, bilaterally (figure 1).
Hands at admission.
Subsequent laboratory tests were positive for antinuclear antibodies with AC-4 pattern (antibody titre 320 by indirect immunofluorescence (normal, <160); antibody value 2.40 U/mL by fluorescence enzyme immunoassay (normal, <0.7)) and lupus anticoagulant, confirming the diagnosis.1 2
In the full-body CT scan, there was no evidence of major organ system involvement.
This patient received treatment with oral prednisone (20 mg/day), hydroxychloroquine (400 mg/day) and methotrexate (20 mg/week), with resolution of clinical reports.3 Residual skin lesions in the palms of the hands (figure 2) after 2 months of treatment, reducing the doses of hydroxychloroquine (200 mg/ day) and methotrexate (10 mg/week).
Hands after therapeutics.
Patient’s perspective
When these lesions started to appear, there was just a small area of flaking on one hand, especially on the right. I initially blamed my job because I am a firefighter and I have to transport heavy materials and sick persons. Also, the fact that I was always wearing gloves because of the pandemic made my hands sweatier, and that I thought would aggravate the situation. However, I started to notice that, even when for a few months, I worked very little and wore no gloves, this was worsening. I had my wounds treated, but there was no way to resolve it. In the meantime, the pains in my knees and elbows started, my tongue was dry, but I did not even care, what really worried me was my hands, because they did not hurt, but they looked worse and worse. I was told later that it was lupus. I had heard of it. A month later, the injuries were practically resolved.
Learning points
Systemic lupus erythematosus is a multifaceted disease that impacts individuals at relatively young ages, especially woman. Despite therapeutic advances, the rate of mortality is unchanged; treatment goals should be remission or the greatest possible reduction in disease activity.
Cutaneous manifestations are common and may occur in more than 75% of patients. Acute cutaneous lupus consists of indurated, flat erythematous, rash or papulosquamous lesions. Panniculitis or hypertrophic lesions are infrequent.
For cutaneous involvement, hydroxychloroquine and topical drugs are often sufficient, although further systemic immunosuppression could be necessary. The need to try to reduce the intake of medication whenever possible is imperative, thus, minimising damage attributable to medication side effects.
Ethics statements
Footnotes
Contributors Study design: HA and RF. Data collection: HA and RF. Data analysis: HA, IA and BR-A. Writing: HA, IA, BR-A and RF.
Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.
Competing interests None declared.
Provenance and peer review Not commissioned; externally peer reviewed.