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Lupus band test: Anatomic regional variations in discoid lupus erythematosus
Lupus band test: Anatomic regional variations in discoid lupus erythematosus Dennis A. Weigand, M.D. Oklahoma City, OK Seventy-one patients with discoid lupus erythematosus were studied for anatomic regional variations in the lupus band test. The test was positive in 82% of biopsies from the scalp, face, neck, and upper extremity. Only three out of fourteen biopsies (21 %) from the trunk were positive. Discoid lupus erythematosus could be confirmed or strongly suspected in the light microscopic sections from all cases. Truncal lesions should not be selected for the lUpus band test in discoid lupus erythematosus if there are other choices. (J AM ACAD DERMATOL 14:426-428, 1986.)
The lupus band test1,2 is widely used in the diagnosis of discoid lupus erythematosus and systemic lupus erythematosus. The sensitivity of the test in the latter may be as high as 90%,3 and studies have shown that the likelihood of positive test results is related to anatomic region and/or sun exposure. 4 In contrast, there is little published information on the effect of anatomic region or sun exposure on the lupus band test in discoid lupus erythematosus. 5 In general, the lupus band test is a somewhat insensitive diagnostic test for discoid lUpus erythematosus, in our experience. About one third of histologically proved lesions, overall, are negative. 6 In this study, I analyze the sensitivity of the lupus band test in discoid lupus erythematosus by anatomic region to define further the sensitivity and potential usefulness of the test for diagnosis. MATERIALS AND METHODS The light microscopic and immunofluorescence findings in the lesions of seventy-one cases of discoid lupus erythematosus were studied. All specimens were examined in the Oklahoma Dermatopathology Laboratory From the Dermatology Service, Veterans Administration Medical Center, and the Department of Dermatology, University of Oklahoma Health Sciences Center. Accepted for publication Oct. 16, 1985. Reprint requests to: Dr. Dennis A. Weigand, 619 N.E. 13th St., Oklahoma City, OK 73104/405-271-6111.
426
during the past 5 years. Cases selected were those in which both light microscopy and direct immunofluorescence were performed in the initial diagnostic study and in which clinical and other laboratory data were sufficient to classify the disease as discoid lupus erythematosus. Specific technics and criteria employed have been previously published. 6 Fluorescence microscopy was performed with either an Olympus FLM transmission fluorescence microscope (with fluorescein isothiocyanate exciter filter and Y-52 barrier filter) or an Olympus BHTU epi-illumination fluorescence microscope (with IF-490 exciter filter and 0-531 barrier filter) with a mercury light source. The anatomic areas of the biopsies were classified into four groups: scalp, face and neck, upper extremity, and trunk. No biopsies from lower extremities were seen. No attempt was made to quantify sun exposure in these patients other than what was implied by anatomic areas. Patients with clinical and laboratory characteristics of subacute cutaneous lupus erythematosus7 were excluded from the study. RESULTS Marked variation occurred from area to area in the lupus band test (Table I). All nine biopsies from the scalp were positive. This finding supports Jordon's impression 5 that the lupus band test for discoid lUpus erythematosus is mainly helpful for detecting the disease in cases of scarring alopecia, where the band can be seen to extend down the outer root sheath of hair follicles. This finding was
Volume 14 Number 3 March, 1986
Lupus band test 427
Table I. Numbers of patients with discoid lupus erythematosus tested, by anatomic area Lupus band test
Scalp
Face and neck
Upper extremity
9
22
16
Positive Negative
o
Trunk
3
4
6
II
Table II. Microscopic findings in discoid lupus erythematosus lesions on the trunk Case No.
LBT
1
2
3 4 5 6 7
Hyperkeratosis
Atrophy
Liquefaction degeneration
Homogenization
++ ++ +
+ + +++
+ + +++
+ +
++
+++
++ +++ ++
+ +++ + + ++ + + ++
+ + + ++ ++ +++
8
9 10 11
12 13 14
+ + (IgG, C3) + (IgG) + + (IgG, IgM)
+ ++ +
+ + ++
Edema
+ + + ++ ++ +
Telangiectasis
Periappendageal infiltrate
Interface infiltrate
+
+
+
++
++ ++ + +
++
+ ++ +
-: Absent; +: mild; + +: moderate; + + +: severe; 0: could not evaluate; LBT: lupus band test.
confirmed in some of our cases, in which extensive damage to the dermoepidermal junction had apparently obscured the deposition of immunoreactants, but the dermal-outer root sheath junction was better preserved. Results of the lupus band test on lesions from the face, neck, and upper extremities, composing the majority of cases, were positive in 79%. The percentage of positive lesions in the combined regions of the scalp, face, neck, and upper extremities was 82%. The most significant finding in this study was in discoid lupus erythematosus lesions on the trunk. Results of the lupus band test were positive in only three of fourteen patients. A review of the clinical information on these fourteen patients suggested that they may have had more widespread disease, on the average, than the other fifty-seven patients, but no other differences were apparent. The light microscopic sections from the same fourteen patients were all reviewed, and the findings are presented in Table II. Evaluation by eight mi-
croscopic criteria showed no trends or unusual features. All specimens except one (No.6) exhibited at least four of the eight criteria. The biopsy was shaHow, and no appendages were present for evaluation. There were also no clear differences between the three with positive results on the lupus band test (Nos. 12, 13, 14) and the remainder. In Case 10 the lupus band test showed negative results on the trunk but positive results on an upper extremity lesion. DISCUSSION
This study shows that anatomic regions must be taken into consideration when the lUpus band test is used in the diagnosis of discoid lupus erythematosus. The trunk is clearly not the site of choice for biopsy. Where no choice exists, one must question whether the test is worthwhile on truncal skin. Obviously, more useful information was obtained from light microscopic examination than from immunofluorescence in most of these fourteen patients.
428
Journal of the American Academy of Dermatology
Weigand
The subject of negative results on lupus band tests on non-sun-exposed (i.e., mainly truncal) skin has been examined mainly in reference to systemic lupus erythematosus. In a forum discussion,s Blaszczyk reported finding positive results on seven lupus band tests out of twenty-three tests (30%) on unexposed skin in disseminated discoid lupus erythematosus. The other details of this study were not reported. The incidence of positive results on lupus band tests in uninvolved skin in systemic lupus erythematosus is clearly influenced by anatomic region, and the correlation apparently is with degree of sun exposure. 8 Gilliam9 and ProvostS believe that ultraviolet light, among other things, may induce epidermal proliferation, with production of denatured deoxyribonucleic acid, which then can diffuse across the basement membrane and bind with autoantibodies in systemic lupus erythematosus. Whether this is true of discoid lupus erythematosus lesions is unknown. One must ask whether the negative lupus band test results in this study were related to a very short or very long duration of the lesions, as was previously shown in discoid lupus erythematosus. s Exact durations of lesions were mostly unknown in these cases, but they were certainly sufficient to have resulted in well-developed histologic changes in most cases and to have represented stillactive disease. In addition, the expected percentage of positive lupus band test results was seen in the biopsies from other anatomic regions. Therefore a chance occurrence of more' 'young" lesions from the trunk than from other areas is unlikely to account for the markedly lower rate of positive lesions from the trunk in this series.
In summary, this study further defines the proper use ofthe lupus band test in discoid lupus erythematosus by showing that the test usually shows negative results in truncal lesions, possibly because of little ultraviolet light exposure. Recognition of this difference should help to prevent misinterpretations and reduce the performance of unhelpful procedures. REFERENCES I. Burnham TK, Neblett TR, Fine G: The application of the fluorescence antibody technique to the investigation of lupus erythematosus and various dermatoses. J Invest Dermatol 41:451-456, 1963. 2. Connane RH: "Bound" globulin in the skin of patients with chronic discoid lupus erythematosus and systemic lupus erythematosus. Lancet 1:534-535, 1964. 3. Provost 'IT: Lupus band test, in Beutner EH, Chorzelski TP, Bean SF, editors: Immunopathology of the skin, ed. 2. New York, 1979, John Wiley & Sons, Inc., pp. 402403. 4. Ahmed AR, Provost TT: The incidence of a positive lupus band test using sun-exposed and non-sun-exposed skin. Arch DermatoI115:228-229, 1979. 5. Dahl MY, editor: Usefulness of direct immunofluorescence in patients with lupus erythematosus. (Forum discussion.) Arch DennatoI1l9:IOI0-1017, 1983. 6. Weigand DA: The lupus band test: Are-evaluation. J AM ACAD DERMATOL 11:230-234, 1984. 7. SontheimerRD, Maddison PJ, Reichlin M, et al: Serologic and HLA associations in subacute cutaneous lupus erythematosus, a clincial subset of lupus erythematosus. Ann Intern Med 97:664-671, 1982. 8. Provost TI: Lupus band test. Int J Dennatol 20:475-481, 1981. 9. Gilliam IN: The significance of cutaneous immunoglobulin deposits in lupus erythematosus and NZB/NZW FI hybrid mice. J Invest DennatoI65:154-161, 1975.
The lupus band test1,2 is widely used in the diagnosis of discoid lupus erythematosus and systemic lupus erythematosus. The sensitivity of the test in the latter may be as high as 90%,3 and studies have shown that the likelihood of positive test results is related to anatomic region and/or sun exposure. 4 In contrast, there is little published information on the effect of anatomic region or sun exposure on the lupus band test in discoid lupus erythematosus. 5 In general, the lupus band test is a somewhat insensitive diagnostic test for discoid lUpus erythematosus, in our experience. About one third of histologically proved lesions, overall, are negative. 6 In this study, I analyze the sensitivity of the lupus band test in discoid lupus erythematosus by anatomic region to define further the sensitivity and potential usefulness of the test for diagnosis. MATERIALS AND METHODS The light microscopic and immunofluorescence findings in the lesions of seventy-one cases of discoid lupus erythematosus were studied. All specimens were examined in the Oklahoma Dermatopathology Laboratory From the Dermatology Service, Veterans Administration Medical Center, and the Department of Dermatology, University of Oklahoma Health Sciences Center. Accepted for publication Oct. 16, 1985. Reprint requests to: Dr. Dennis A. Weigand, 619 N.E. 13th St., Oklahoma City, OK 73104/405-271-6111.
426
during the past 5 years. Cases selected were those in which both light microscopy and direct immunofluorescence were performed in the initial diagnostic study and in which clinical and other laboratory data were sufficient to classify the disease as discoid lupus erythematosus. Specific technics and criteria employed have been previously published. 6 Fluorescence microscopy was performed with either an Olympus FLM transmission fluorescence microscope (with fluorescein isothiocyanate exciter filter and Y-52 barrier filter) or an Olympus BHTU epi-illumination fluorescence microscope (with IF-490 exciter filter and 0-531 barrier filter) with a mercury light source. The anatomic areas of the biopsies were classified into four groups: scalp, face and neck, upper extremity, and trunk. No biopsies from lower extremities were seen. No attempt was made to quantify sun exposure in these patients other than what was implied by anatomic areas. Patients with clinical and laboratory characteristics of subacute cutaneous lupus erythematosus7 were excluded from the study. RESULTS Marked variation occurred from area to area in the lupus band test (Table I). All nine biopsies from the scalp were positive. This finding supports Jordon's impression 5 that the lupus band test for discoid lUpus erythematosus is mainly helpful for detecting the disease in cases of scarring alopecia, where the band can be seen to extend down the outer root sheath of hair follicles. This finding was
Volume 14 Number 3 March, 1986
Lupus band test 427
Table I. Numbers of patients with discoid lupus erythematosus tested, by anatomic area Lupus band test
Scalp
Face and neck
Upper extremity
9
22
16
Positive Negative
o
Trunk
3
4
6
II
Table II. Microscopic findings in discoid lupus erythematosus lesions on the trunk Case No.
LBT
1
2
3 4 5 6 7
Hyperkeratosis
Atrophy
Liquefaction degeneration
Homogenization
++ ++ +
+ + +++
+ + +++
+ +
++
+++
++ +++ ++
+ +++ + + ++ + + ++
+ + + ++ ++ +++
8
9 10 11
12 13 14
+ + (IgG, C3) + (IgG) + + (IgG, IgM)
+ ++ +
+ + ++
Edema
+ + + ++ ++ +
Telangiectasis
Periappendageal infiltrate
Interface infiltrate
+
+
+
++
++ ++ + +
++
+ ++ +
-: Absent; +: mild; + +: moderate; + + +: severe; 0: could not evaluate; LBT: lupus band test.
confirmed in some of our cases, in which extensive damage to the dermoepidermal junction had apparently obscured the deposition of immunoreactants, but the dermal-outer root sheath junction was better preserved. Results of the lupus band test on lesions from the face, neck, and upper extremities, composing the majority of cases, were positive in 79%. The percentage of positive lesions in the combined regions of the scalp, face, neck, and upper extremities was 82%. The most significant finding in this study was in discoid lupus erythematosus lesions on the trunk. Results of the lupus band test were positive in only three of fourteen patients. A review of the clinical information on these fourteen patients suggested that they may have had more widespread disease, on the average, than the other fifty-seven patients, but no other differences were apparent. The light microscopic sections from the same fourteen patients were all reviewed, and the findings are presented in Table II. Evaluation by eight mi-
croscopic criteria showed no trends or unusual features. All specimens except one (No.6) exhibited at least four of the eight criteria. The biopsy was shaHow, and no appendages were present for evaluation. There were also no clear differences between the three with positive results on the lupus band test (Nos. 12, 13, 14) and the remainder. In Case 10 the lupus band test showed negative results on the trunk but positive results on an upper extremity lesion. DISCUSSION
This study shows that anatomic regions must be taken into consideration when the lUpus band test is used in the diagnosis of discoid lupus erythematosus. The trunk is clearly not the site of choice for biopsy. Where no choice exists, one must question whether the test is worthwhile on truncal skin. Obviously, more useful information was obtained from light microscopic examination than from immunofluorescence in most of these fourteen patients.
428
Journal of the American Academy of Dermatology
Weigand
The subject of negative results on lupus band tests on non-sun-exposed (i.e., mainly truncal) skin has been examined mainly in reference to systemic lupus erythematosus. In a forum discussion,s Blaszczyk reported finding positive results on seven lupus band tests out of twenty-three tests (30%) on unexposed skin in disseminated discoid lupus erythematosus. The other details of this study were not reported. The incidence of positive results on lupus band tests in uninvolved skin in systemic lupus erythematosus is clearly influenced by anatomic region, and the correlation apparently is with degree of sun exposure. 8 Gilliam9 and ProvostS believe that ultraviolet light, among other things, may induce epidermal proliferation, with production of denatured deoxyribonucleic acid, which then can diffuse across the basement membrane and bind with autoantibodies in systemic lupus erythematosus. Whether this is true of discoid lupus erythematosus lesions is unknown. One must ask whether the negative lupus band test results in this study were related to a very short or very long duration of the lesions, as was previously shown in discoid lupus erythematosus. s Exact durations of lesions were mostly unknown in these cases, but they were certainly sufficient to have resulted in well-developed histologic changes in most cases and to have represented stillactive disease. In addition, the expected percentage of positive lupus band test results was seen in the biopsies from other anatomic regions. Therefore a chance occurrence of more' 'young" lesions from the trunk than from other areas is unlikely to account for the markedly lower rate of positive lesions from the trunk in this series.
In summary, this study further defines the proper use ofthe lupus band test in discoid lupus erythematosus by showing that the test usually shows negative results in truncal lesions, possibly because of little ultraviolet light exposure. Recognition of this difference should help to prevent misinterpretations and reduce the performance of unhelpful procedures. REFERENCES I. Burnham TK, Neblett TR, Fine G: The application of the fluorescence antibody technique to the investigation of lupus erythematosus and various dermatoses. J Invest Dermatol 41:451-456, 1963. 2. Connane RH: "Bound" globulin in the skin of patients with chronic discoid lupus erythematosus and systemic lupus erythematosus. Lancet 1:534-535, 1964. 3. Provost 'IT: Lupus band test, in Beutner EH, Chorzelski TP, Bean SF, editors: Immunopathology of the skin, ed. 2. New York, 1979, John Wiley & Sons, Inc., pp. 402403. 4. Ahmed AR, Provost TT: The incidence of a positive lupus band test using sun-exposed and non-sun-exposed skin. Arch DermatoI115:228-229, 1979. 5. Dahl MY, editor: Usefulness of direct immunofluorescence in patients with lupus erythematosus. (Forum discussion.) Arch DennatoI1l9:IOI0-1017, 1983. 6. Weigand DA: The lupus band test: Are-evaluation. J AM ACAD DERMATOL 11:230-234, 1984. 7. SontheimerRD, Maddison PJ, Reichlin M, et al: Serologic and HLA associations in subacute cutaneous lupus erythematosus, a clincial subset of lupus erythematosus. Ann Intern Med 97:664-671, 1982. 8. Provost TI: Lupus band test. Int J Dennatol 20:475-481, 1981. 9. Gilliam IN: The significance of cutaneous immunoglobulin deposits in lupus erythematosus and NZB/NZW FI hybrid mice. J Invest DennatoI65:154-161, 1975.