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Discoid lupus erythematosus

Medical Professionals

Professional Reference articles are designed for health professionals to use. They are written by UK doctors and based on research evidence, UK and European Guidelines. You may find the Lupus article more useful, or one of our other health articles.

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What is discoid lupus erythematosus?

Discoid lupus erythematosus (DLE) is a chronic photosensitive skin eruption which can be either localised or widespread. It is confined to the skin and does not cause any systemic symptoms. DLE can cause permanent scarring if treatment is inadequate.

How common is discoid lupus erythematosus? (Epidemiology)

  • The prevalence is between 17 and 48 per 100,000 people.

  • Women are much more often affected than men.

  • DLE usually presents in people aged between 20 and 40 years of age.

  • DLE is more common in smokers.1

  • DLE can be present in a small proportion of patients with systemic lupus erythematosus (SLE).2

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Discoid lupus erythematosus symptoms3

  • Localised DLE commonly involves the head and neck, and particularly the scalp and ears.

  • Generalised DLE, which occurs both above and below the neck, is less common and typically involves the extensor forearms and hands.

  • Occasionally, DLE can occur on mucosal surfaces, including lips, and oral, nasal, and genital mucosa.

  • DLE lesions appear as a well-demarcated, scaly, erythematous macule or papule, which gradually develops into an indurated discoid (coin-shaped) plaque with an adherent scale that is painful to remove.

  • Plaques tend to extend into the hair follicle, resulting in scarring alopecia.

  • These lesions typically become atrophic, with hyperpigmentation peripherally and depigmentation centrally.

  • Sun exposure or trauma (Koebner phenomenon) can exacerbate disease.

Differential diagnosis3

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  • The diagnosis of DLE is usually based on clinical features.

  • Biopsy for histology may be required.

  • Histopathological changes are characteristic but depend on the type and age of the lesion.

  • Most patients with DLE show a direct positive immunofluorescence in biopsies of lesions.4

  • Serology: approximately 20% of patients with DLE have a positive antinuclear antibody (ANA).

  • There may be a low white cell count and raised ESR.

  • Complement levels may be low.

  • Urinalysis may indicate renal involvement with albuminuria.

Blood tests should be repeated periodically, usually annually when the condition appears stable, to check for the onset of systemic disease.

Discoid lupus erythematosus treatment and management3 5

The mainstay of treatment includes sun protection, topical or intralesional steroids and antimalarial drugs.


  • Sun exposure must be minimised by avoiding going out in bright sun as much as possible and by wearing protective clothing and high-factor sunscreens.

  • The lesions are unsightly and usually in visible places, so cosmetic camouflage is required.


  • Topical therapies, including steroids and/or calcineurin inhibitors (eg, tacrolimus).

  • Corticosteroids may be used topically or intralesionally. Very potent forms are necessary for hypertrophic lesions.

  • Fluocinonide cream may be more effective than hydrocortisone in clearing DLE skin lesions.

  • When systemic treatment is required, antimalarial drugs, such as hydroxychloroquine, are the usually the first-line choice. Systemic steroids are generally avoided because of potential side effects.

  • Topical imiquimod cream is an alternative treatment for generalised DLE.6

  • Other possible treatments include topical retinoids and immunosuppressive agents (eg, azathioprine or mycophenolate).

  • Further options if needed include biologics (eg, rituximab), dapsone, or oral retinoids (eg, acitretin or isotretinoin).


  • Burned-out scarred lesions may be excised.

  • Photodynamic therapy can be effective for some cases.7

  • Laser therapy can be considered for lesions with prominent telangiectasias.


  • A minority of patients with DLE (fewer than 5%) progress to SLE.

  • In paediatric patients, however, DLE carries a significant risk of progression to SLE but may predict a milder phenotype of systemic disease.8

  • The presence of DLE in patients with SLE has not been shown to be associated with less severe disease.9

  • There are increased risks of photosensitivity and leukopenia and decreased risks of pleuritis and arthritis in patients with both SLE and DLE.2

  • Malignant degeneration (basal cell carcinoma or squamous cell carcinoma) may occur but is uncommon.10

  • Dark skin may lose its inherent protection with depigmentation.


  • DLE generally has a more benign disease course compared to other forms of cutaneous lupus, with only a reported 5-10% developing SLE throughout their disease course.

  • Generalised DLE is more likely to progress to systemic disease, compared to patients with localised DLE.

  • Pain in lesions may continue and disfiguration from scars and atrophy will be permanent.

  • DLE tends to heal with scarring, hair loss and pigmentary changes if treatment is not initiated in the early phase of the disease.

Further reading and references

  • Okon LG, Werth VP; Cutaneous lupus erythematosus: diagnosis and treatment. Best Pract Res Clin Rheumatol. 2013 Jun;27(3):391-404. doi: 10.1016/j.berh.2013.07.008.
  1. Bockle BC, Sepp NT; Smoking is highly associated with discoid lupus erythematosus and lupus erythematosus tumidus: analysis of 405 patients. Lupus. 2015 Jun;24(7):669-74. doi: 10.1177/0961203314559630. Epub 2014 Nov 19.
  2. Merola JF, Prystowsky SD, Iversen C, et al; Association of discoid lupus erythematosus with other clinical manifestations among patients with systemic lupus erythematosus. J Am Acad Dermatol. 2013 Jul;69(1):19-24. doi: 10.1016/j.jaad.2013.02.010. Epub 2013 Mar 28.
  3. Okon LG, Werth VP; Cutaneous lupus erythematosus: diagnosis and treatment. Best Pract Res Clin Rheumatol. 2013 Jun;27(3):391-404. doi: 10.1016/j.berh.2013.07.008.
  4. Bharti S, Dogra S, Saikia B, et al; Immunofluorescence profile of discoid lupus erythematosus. Indian J Pathol Microbiol. 2015 Oct-Dec;58(4):479-82. doi: 10.4103/0377-4929.168850.
  5. Jessop S, Whitelaw DA, Grainge MJ, et al; Drugs for discoid lupus erythematosus. Cochrane Database Syst Rev. 2017 May 5;5(5):CD002954. doi: 10.1002/14651858.CD002954.pub3.
  6. Turan E, Sinem Bagci I, Turgut Erdemir A, et al; Successful treatment of generalized discoid lupus erythematosus with imiquimod cream 5%: a case report and review of the literature. Acta Dermatovenerol Croat. 2014;22(2):150-9.
  7. Debu A, Girard C, Bessis D; Discoid lupus erythematosus successfully treated by photodynamic therapy. Br J Dermatol. 2015 Mar;172(3):821-2. doi: 10.1111/bjd.13407. Epub 2015 Jan 18.
  8. Arkin LM, Ansell L, Rademaker A, et al; The natural history of pediatric-onset discoid lupus erythematosus. J Am Acad Dermatol. 2015 Apr;72(4):628-33. doi: 10.1016/j.jaad.2014.12.028. Epub 2015 Jan 30.
  9. Saghafi M, Hashemzadeh K, Sedighi S, et al; Evaluation of the incidence of discoid lupus erythematosus in patients with systemic lupus erythematosus and its relationship to disease activity. J Cutan Med Surg. 2014 Oct;18(5):316-9.
  10. Fernandes MS, Girisha BS, Viswanathan N, et al; Discoid lupus erythematosus with squamous cell carcinoma: a case report and review of the literature in Indian patients. Lupus. 2015 Dec;24(14):1562-6. doi: 10.1177/0961203315599245. Epub 2015 Aug 6.

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The information on this page is written and peer reviewed by qualified clinicians.

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