Non-bullous neutrophilic lupus erythematosus-Muted bullous disease?

Non-bullous neutrophilic lupus erythematosus is a rare form of cutaneous lupus erythematosus (LE). We hereby present a case of 24-year-old female, known case of discoid LE (DLE) with negative ANA stabilized on hydroxychloroquine for 2 years. She reported new occurrence of erythematous, mildly pruritic, papular lesions and painful mucosal ulceration. The ANA became strongly positive by ELISA and urine showed proteinuria. A provisional diagnosis of Rowell syndrome was made, skin biopsy was taken, and patient started on steroids. Histopathology showed interface vacuolar change and many neutrophils in the dermis with leukocytoclasia without any bulla formation. The skin lesions responded promptly to addition of dapsone following biopsy report. We conclude that the presence of neutrophils associated with interface pathology on biopsy represents a muted form of bullous LE, especially in patients on immunosuppression. This case highlights the importance of histopathologic examination in the evaluation of any new skin lesions in a patient of lupus on therapy.