Treatment of Hyperpigmented Discoid Lupus Erythematosus With Jessner’s Peel: A Case Report

Discoid lupus erythematosus (DLE) is the most common type of chronic cutaneous lupus erythematosus and is categorized by well-demarcated, often hyper or hypopigmented macules or papules that gradually progress into discoid plaques. Lesions are most commonly found above the neck, particularly on the face, scalp, and ears.¹ Twenty percent of patients with systemic lupus erythematosus (SLE) have a lifetime risk of developing DLE. Of this cohort, over 50% develop significant cutaneous scarring, and 33% develop cicatricial alopecia.^2,3 Standard treatment of DLE includes high potency topical corticosteroids and oral antimalarials. The hyperpigmentation noted in DLE is often most bothersome to patient due to cosmesis which can significantly impair quality of life. We present a case of DLE hyperpigmentation treated with chemical peels and a topical regimen that excludes hydroquinone and topical steroids.

A 51-year-old woman with history of DLE, deep vein thrombosis, and hypothyroidism presented with progressive facial hyperpigmentation of one-year duration that had not been treated. Physical examination revealed ill-defined hyperpigmented and erythematous patches on face in a periorbital/malar distribution with follicular plugging. Biopsy of the left cheek showed superficial and mid-perivascular and perifollicular infiltrate of lymphocytes and histiocytes, consistent with DLE. The patient was treated with monthly Jessner’s solution chemical peels for six months. A topical regimen of 1% Pimecrolimus cream and 15% azelaic acid was initiated for two months until mild erythema resolved. Subsequently, the regimen transitioned to 0.025% tretinoin cream, 15% azelaic acid, 7.5% dapsone gel, and 5.5% L-absorbic acid. Strict sun protection with physical sunscreen was also encouraged. After six months, a significant improvement in hyperpigmentation was noted by the patient and physician with near clearance of hyperpigmentation (Figure 1). The medical management of this patient’s DLE was performed by her rheumatologist who recommended hydroxychloroquine, however, patient declined.

The patient’s dyschromia was clinically and histopathologically consistent with DLE. Our report of monthly Jessner’s peel in conjunction with the topical regimen provided remarkable improvement.

Chemical peels are a common treatment in cosmetic dermatology for the treatment of numerous dermatologic disorders ranging from melasma to acne scarring. Peels generally consist of one or more chemically ablative agents that work to induce keratolysis or keratocoagulation of the skin.

This controlled destruction of all or part of the epidermis or dermis, followed by regeneration and remodeling results in an improved appearance and texture of the treated skin.⁴ Peeling agents can be further classified into the subtypes superficial, medium-depth, and deep types based on their depth of penetration. Superficial peeling agents, such as glycolic acid, salicylic acid, and Jessner’s solution (salicylic acid, lactic acid, resorcinol and ethanol) work to remove the stratum corneum without affecting the papillary and reticular dermis thus minimizing the risk of irritation.

Ethnic skin, specifically patients with Fitzpatrick skin phototypes IV to VI, is particularly susceptible to complications related to