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CORRESPONDENCE
Year : 2022  |  Volume : 67  |  Issue : 4  |  Page : 421-423
Reticular erythematous mucinosis successfully treated with laser in a male patient with systemic lupus erythematosus


From the Department of Dermatology, Fukushima Medical University, Fukushima, Japan

Date of Web Publication2-Nov-2022

Correspondence Address:
Takako Miura
From the Department of Dermatology, Fukushima Medical University, Fukushima
Japan
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijd.ijd_863_21

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How to cite this article:
Miura T, Yamamoto T. Reticular erythematous mucinosis successfully treated with laser in a male patient with systemic lupus erythematosus. Indian J Dermatol 2022;67:421-3

How to cite this URL:
Miura T, Yamamoto T. Reticular erythematous mucinosis successfully treated with laser in a male patient with systemic lupus erythematosus. Indian J Dermatol [serial online] 2022 [cited 2022 Dec 8];67:421-3. Available from: https://www.e-ijd.org/text.asp?2022/67/4/421/360360




Sir,

A 65-year-old man was referred to our department complaining of persistent erythema on the back for 4 years' duration. He was diagnosed as having systemic lupus erythematosus (SLE) when he was 48 years old, based on the findings of a positive anti-nuclear antibody (1:320), anti-DNA antibody, rheumatoid factor and lupus nephritis. He had been treated with oral prednisolone (PSL), and was taking 10 mg/day PSL when he visited us. Physical examination revealed reticular erythema with partial infiltration on the back [Figure 1]a, whereas neither his face nor chest was involved. Histopathological examination showed perivascular mononuclear cell infiltration in the upper dermis and myxomatous upper to mid-dermis [Figure 1]b. Alcian blue and colloidal iron stains revealed mucin deposition [Figure 1]c. Deposition of immunoglobulin M (IgM) was detected at the dermo-epidermal junction by direct immunofluorescence. Neither topical corticosteroid nor oral PSL (up to 10 mg/day) resulted in satisfactory effects after 5 years, and hydroxychloroquine was not available in Japan at the time. Therefore, we started therapy with a pulsed dye laser between 5.0 and 5.75 J/cm2. In total, nine laser sessions (5 J/cm2 × 1, 5.25 J/cm2 × 4 and 5.75 J/cm2 × 4) were performed with an interval of 1 month. After a long-term follow-up period, the clinical signs of reticular erythematous mucinosis (REM) had almost completely disappeared [Figure 1]d, and thereafter the patient was followed 10 years without worsening.
Figure 1: (a) Infiltrative erythematous patches on the back. (b) Histopathology showing subepidermal and perivascular lymphocytic infiltration and dermal oedema (H&E stain, ×200). (c) Alcian blue stain revealed mucin deposition between collagen bundles in the dermis (×200). (d) Improvement after nine sessions with a pulsed dye laser

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REM clinically presents with erythematous macules and papules that coalesce into reticulated patterns on the midline of the chest and back, and is histopathologically characterized by dermal mucinosis.[1],[2] Although REM is sometimes considered to be the same entity of plaque-type mucinosis, plaque-type mucinosis does not always have a reticular appearance. The differentiation from lupus erythematosus tumidus (LET) is sometimes difficult, and previous studies have suggested that REM showed overlapping aspects with LET, both of which share common features, including a plaque-like clinical appearance, histopathological findings of perivascular and perifollicular lymphocytic infiltration with dermal mucin deposition, favourable response to anti-malarial drugs and association with SLE.[1],[2],[3] Rongioletti et al.[1] suggested that compared with LET, REM has unique features such as a reticular pattern with typical involvement of the midlines of the chest and back with a predilection for middle-aged women, and a possible association with malignancies and thyroid dysfunction; however, a relationship with photosensitivity is controversial. By contrast, in LET, strong photosensitivity, higher rate of immune deposition in the skin and association with other clinical manifestations of lupus erythematosus (LE) are frequently observed. We diagnosed our patient as having REM because the clinical features were reticular erythema, and the involved site was the middle of the back, as opposed to sun-exposed areas. Therapy for REM is challenging, and recent studies have shown favourable effects of anti-malarial agents. After several treatments failed, we started laser therapy. Although very few cases of REM successfully treated with dye laser have been reported,[4] we carefully started laser because our patient had SLE. Pulsed dye laser treatment has been used for cutaneous LE lesions with low evidence levels.[5] The treatment outcome in the present case was successful, suggesting that dye laser treatment is one of the selective therapies for REM, even if patients have SLE.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
   References Top

1.
Rongioletti F, Merlo V, Riva S, Cozzani E, Cinotti E, Ghigliotti G, et al. Reticular erythematous mucinosis: A review of patients' characteristics, associated conditions, therapy and outcome in 25 cases. Br J Dermatol 2013;169:1207-11.  Back to cited text no. 1
    
2.
Cinotti E, Merlo V, Kempf W, Carli C, Kanitakis J, Parodi A, et al. Reticular erythematous mucinosis: Histopathological and immunohistochemical features of 25 patients compared with 25 cases of lupus erythematosus tumidus. J Eur Acad Dermatol Venereol 2015;29:689-97.  Back to cited text no. 2
    
3.
Kuhn A, Richter-Hintz D, Oslislo C, Ruzicka T, Megahed M, Lehmann P. Lupus erythematosus tumidus--A neglected subset of cutaneous Lupus erythematosus: Report of 40 cases Arch Dermatol 2000;136:1033-41.  Back to cited text no. 3
    
4.
Greve B, Raulin C. Treating REM syndrome with the pulsed dye laser. Lasers Surg Med 2001;29:248-51.  Back to cited text no. 4
    
5.
Erceg A, de Jong EM, van de Kerkhof PC, Seyger MM. The efficacy of pulsed dye laser treatment for inflammatory skin diseases: A systematic review. J Am Acad Dermatol 2013;69:609-15.  Back to cited text no. 5
    


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