Sir,

Lupus erythematosus (LE) is an autoimmune disease that may rarely affect the oral mucosa. This mucosal damage may be mistaken for lichen planus. Herein, we report three cases of oral lupus.

Observation 1: A 41-year-old female, with a seven-year history of systemic LE (SLE) treated with hydroxychloroquine, presented for recent food discomfort. An examination of the oral mucosa found an erythematous plaque on the palate (Fig. 1) and whitish macules on the cheek mucosa. A palatal biopsy was in favor of lupus.

Figure 1: Erythematous patch of the palate (patient 1).

Observation 2: A 47-year-old female presented with a clinical picture of SLE, with diffuse lichenoid ulcerations of the oral cavity (Figs. 2a and 2b). The workup confirmed SLE with severe renal impairment requiring treatment with oral methylprednisolone combined with cyclophosphamide boluses. Oral involvement improved markedly.

Figure 2: (a) Superficial ulcerations with a whitish, lichenoid background of the palate; erosive cheilitis (patient 2). (b) Similar lesions in the right cheek mucosa (patient 2).

Observation 3: A ten-year-old child presented with photosensitivity. An examination found erythematous plaques on the cheekbones and nose and atrophic hypochromic macules with a scaly surface on the forearms. A skin biopsy concluded the diagnosis of subacute lupus (SAL). Direct immunofluorescence was negative. Four months later, at follow-up, erythematous macules were noted on the palate and on the inside of the lips with angular stomatitis (Figs. 3a and 3b). A mucosal biopsy was refused by the patient.

Figure 3: (a) Erythematous macules of the palate; bilateral perlèche (patient 3). (b) Erythematous macules on the inside of the lips (patient 3).

Oral involvement in LE is rare. In a study by Menzies et al., 50% of patients with lupus showed positive oral findings [1]. This condition is associated with a worsened health-related oral quality of life [2]. During SLE, the involvement of the oral mucosa may manifest as erosions or atrophic lesions with whitish striations, which may mimic lichen planus. The lips, palate, cheek mucosa, and tongue could be affected [3]. Oral involvement may persist for years or occur only during relapses [4]. In SAL, the most frequent oral involvement is that of the palate with erythematous plaques, sometimes petechial or keratotic patches or erosions [5]. The labial and gingival mucous membranes could also be affected. Chronic lupus causes mucosal damage similar to that in SLE [3].

The specific involvement of the oral mucosa in LE is difficult to diagnose. It seems to be underdiagnosed. An examination of the oral cavity should be part of the clinical examination of any patient with lupus.

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