The Ears Have It (and She Doesn’t Want It)

ANSWER
The correct answer is to obtain a biopsy (choice “d”), the results of which would likely dictate rational and effective treatment. The other choices are largely empirical and not based on available evidence.

DISCUSSION
In this case, the biopsy (with samples from the arm rash as well as from the ears) showed unequivocal evidence of connective tissue disease—almost certainly lupus.

Systemic lupus erythematosus (SLE) has protean manifestations because it can affect so many different organs in so many different ways. Reduced to its simplest elements, lupus is an autoimmune process that results in a form of vasculitis that can affect any perfused tissue.

In terms of the skin, the visible manifestations of lupus are numerous and not always obvious. Sun is a known exacerbating factor, as this case demonstrated quite well: The patient’s rash was pronounced on sun-exposed skin but spared covered skin. When this was brought to her attention, the patient recalled a baby-sitting job earlier in the year (summer) that had required her to spend time outdoors. She also acknowledged that her smoking habit often took her into the backyard, where she would stand in the sun.

That being said, neither the arm rash nor the ear changes are “typical” of lupus (although the latter did include patulous follicular orifices, enlarged pores often seen focally with lupus). The effect is simply the result of the patient’s normal dark skin color; on a white person, the discoloration would have been pink or red.

Although these changes were suspicious for lupus, it was necessary to establish the diagnosis by biopsy—especially since the patient was already being treated for the disease. With that accomplished, the patient was sent back to her rheumatologist, who indicated he would probably treat her with a biologic, plus or minus methotrexate.