Conditions · Dermatology

Discoid lupus erythematosus !

Discoid lupus is a long-term autoimmune skin disease that causes scaly red patches on the face, ears and scalp that can leave scars and patchy hair loss.

Updated 2026-11-01

Structures involved

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• Skin
• Auricle
• Ear canal
• Nasal cartilages
• Orbicularis oris

Why it happens

• Basement membrane
• Hair follicles, sebaceous and sweat glands, nails

What it is

The most common form of chronic cutaneous lupus erythematosus: an autoimmune, photosensitive dermatosis with well-defined scaly plaques that heal with scarring, atrophy, pigment change and permanent (scarring) alopecia. Most patients have skin-limited disease, but some have or develop systemic lupus.

Who gets it

Usually starts between ages 20 and 40 and is more frequent in women and in people with darker skin, which includes many Colombian and Latin American patients. About 5% of patients with localised and 15–20% with generalised discoid lupus progress to systemic lupus erythematosus; about a quarter of people with SLE have discoid lesions at some point.

Causes

• Autoimmunity in genetically predisposed people, with an interferon-driven interface dermatitis
• Ultraviolet light as the main trigger of new lesions
• Smoking, which increases activity and reduces response to antimalarials
• Skin trauma (Koebner phenomenon)

Risk factors

• Female sex and age 20–40 years
• Darker skin types
• Smoking
• Sun exposure
• Family history of lupus or other autoimmune disease

Pathophysiology

Ultraviolet light injures keratinocytes, which release autoantigens and signals that recruit plasmacytoid dendritic cells and produce type I interferon. Cytotoxic T cells then attack the basal layer (interface dermatitis), causing vacuolar damage, a thickened basement membrane and follicular plugging. Deep inflammation around hair follicles destroys them, which explains permanent scarring alopecia.

Classification

• Localised discoid lupus: lesions above the neck (face, scalp, ears)
• Generalised discoid lupus: lesions above and below the neck, with higher risk of systemic lupus
• Other chronic cutaneous forms: hypertrophic lupus, lupus panniculitis (profundus), chilblain lupus and mucosal lupus

Symptoms and signs

• Red-violet, well-defined, coin-shaped (discoid) plaques with adherent scale
• Follicular plugging; the scale's undersurface shows spikes (carpet-tack sign)
• Central atrophic scarring with hypopigmentation and a hyperpigmented rim
• Typical sites: scalp, face, ears (conchal bowl and ear canal), lips
• Patchy permanent hair loss on the scalp
• Mild itch or burning, worse after sun

Diagnosis

Clinical

Typical scarring, scaly plaques on the face, scalp and ears; dermoscopy shows follicular keratotic plugs and, in late lesions, white scar areas.

Tests

Skin biopsy confirms interface dermatitis with follicular plugging, thickened basement membrane and deep perivascular and periadnexal inflammation; direct immunofluorescence shows a granular band at the dermo-epidermal junction (lupus band). Screening for systemic lupus: blood count, kidney function, urinalysis and antinuclear antibodies (often negative or low titre in pure DLE), with anti-dsDNA and complement if positive.

Imaging

Not needed for the skin disease. Baseline and periodic retinal examination with optical coherence tomography and visual field testing are required in patients on hydroxychloroquine.

Differential diagnosis

• Psoriasis and seborrheic dermatitis of the scalp and face
• Lichen planopilaris and other scarring alopecias
• Actinic keratosis and squamous cell carcinoma
• Sarcoidosis, tuberculosis of the skin (lupus vulgaris) and leishmaniasis in endemic areas
• Tinea faciei

Goal of treatment

Control inflammation early to prevent permanent scarring and hair loss, protect from ultraviolet light, stop smoking and screen periodically for systemic lupus.

Treatment

Lifestyle

Strict photoprotection with broad-spectrum sunscreen, hats and sun avoidance; stopping smoking.

Medical

First-line: potent topical or intralesional corticosteroids, with topical calcineurin inhibitors for the face. For widespread or resistant disease, oral antimalarials (hydroxychloroquine, sometimes adding quinacrine) are the systemic first choice; other options include methotrexate, mycophenolate, retinoids, dapsone and thalidomide under specialist care.

Follow-up

Regular retinal screening while on hydroxychloroquine; periodic clinical and laboratory review for signs of systemic lupus.

Procedure

Camouflage, and for stable burnt-out scarring alopecia, hair restoration in selected patients.

Complications

• Permanent scarring, atrophy and dyspigmentation
• Scarring (cicatricial) alopecia
• Squamous cell carcinoma in long-standing scars, especially on the lips
• Progression to systemic lupus in a minority
• Antimalarial retinopathy if not monitored

Prognosis

Chronic with flares, often worse in summer. Early treatment limits scarring; established scars and hair loss do not recover. Most patients never develop systemic lupus, but generalised disease carries a higher risk.

Prevention

• Photoprotection to reduce flares
• Smoking cessation
• Early treatment of new lesions to prevent scarring

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Related conditions

• Systemic lupus erythematosus
• Cutaneous squamous cell carcinoma
• Lichen planus
• Psoriasis
• Alopecia areata
• Rosacea

Educational information, not medical advice. For any symptom, see a health professional.

Sources: Discoid lupus erythematosus (DermNet, 2026).

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