Ethics Statement

Ethical approval was received from the institutional review boards. Patient consent was not required for the study, as data collection was retrospective. However, the photos used in the study were presented after receiving signed consent from the patients concerned for their scientific use.

Sociodemographic and Clinical Characteristics

Eighty-six (86) cases of lupus erythematosus were diagnosed out of 68,780 patients, representing a hospital prevalence of 0.13%. We were able to include 72 patients in our study. The socio-demographic characteristics of this population, presented in Table 1, reveal a clear female predominance (90.3%) and an average age of 37.9 years, with extremes of 13 and 69 years. The 30-39 age group was the most represented (33.3%). Pupils/students and the unemployed were most concerned (34.7%), followed by housewives (29.1%). Patients living in urban areas (94%) and those with higher education (38.9%) were the most represented. All patients had frequent exposure to the sun. There were 3 HIV-infected patients (4.2%) and one case of familial lupus.

Table 1: Sociodemographic data (n=72).

Clinical characteristics

Table 2 shows the clinical characteristics of our population. Cutaneous lupus accounted for 65.9% and systemic lupus for 30.5%. Chronic cutaneous lupus of the discoid type was the most common (90%), followed by acute (6%) and subacute (4%) lupus erythematosus.

Table 2: Clinical features.

Discoid plaques (Fig. 1a) accounted for 88.9% of cutaneous manifestations, followed by butterfly-wing erythema (Fig. 1b) (45.8%). They were mostly located in the cephalic region (72.2%), particularly on the face (31.9%). We also found hyperpigmented plaques close to discoid plaques in all patients. Twenty-five percent (25%) of our patients had mucosal involvement, especially in the mouth (23.6%) (Fig. 1c).

Figure 1: (a) Discoid plaques of the face in a 32-year-old adult woman. (b) Butterfly rash in a 34-year-old woman. Figure 1c: (c) Oral lip erosions in a 35-year-old woman. (d) Cicatricial alopecia in a 36-year-old woman.

Of the 72 lupus patients, 32 (44.4%) were affected on the skin, including 27 cases of alopecia (84.4%), mainly of the diffuse type (65.6%) (Fig. 1d).

Rheumatological involvement was the primary extra-dermatological manifestation (21.8%), mainly polyarthralgia. Pleuropulmonary manifestations were present in 14 patients (19.44%), with cough, dyspnea revealing pleurisy and interstitial pneumopathy. We noted 7 cases of neurological involvement (9.7%), with headaches and convulsions. Weight loss was reported in 34.72% of patients.

Paraclinical characteristics

Skin biopsy was performed on 39 patients (54.2% completion rate), of whom 35 (48.6%) had abnormalities of the acute, chronic, discoid and systemic type.

In our series, there were 44.4% cases of inflammatory anemia and 38.9% of lymphopenia. The sedimentation rate (SV) was accelerated at 56%.

Immunological data are summarized in Fig. 2, with an average antibody realization rate of over 80%. These examinations revealed the presence of anti-nuclear antibodies (84.1%), anti-native DNA (56.9%), anti-Sm (55.6%), anti-Ro-SSA (52.6%), and antiphospholipids (27.3%).

Figure 2: Distribution of patients by antibody type.

On imaging, abnormalities were noted on ECG (53.8%) and chest X-ray (21.5%), with cardiomegaly, interstitial syndrome, pleurisy and conduction disorders. High 24-hour proteinuria was reported in 52.4% of patients.

Therapeutic modalities and progression

These are summarized in Table 3. In our series, 98% of patients were treated with hydroxychloroquine, 47.2% with immunosuppressants and 37.5% with corticoids. Local treatment was based on dermocorticoids (77.8%) and calcineurin inhibitors. Protective clothing and sunscreen were recommended for all patients.

Table 3: Therapeutic modalities (n=72).

Progression under treatment after 6 months was favorable in 37.5% of cases. Patients were lost to follow-up in 51.2% of cases.

Sociodemographic characteristics

We identified 86 patients with lupus, representing a hospital prevalence of 0.13%.

LE is a ubiquitous disease affecting all populations and races. It is frequently found in Asian, African American, Hispanic American, and Caribbean populations, compared with Caucasians [2,4,5].

This study of lupus in West Africa highlighted specific characteristics. It is an uncommon disease in the region, with hospital frequencies ranging from 0.02% to 1.9% of cases yearly. The wide disparity in frequencies between countries generally sharing similar socio-demographic and economic contexts could be explained by the large number of under-diagnosed cases, often linked to a lack of awareness of the disease by non-specialist practitioners, sometimes due to clinical complexity or geographical and financial inaccessibility of paraclinical examinations complementary to diagnosis [4,6–14].

The predominance of women in our study was in line with the literature (80%). Lupus disproportionately affects women, with incidence rates 2 to 9 times higher in women than in matched male populations. Women’s susceptibility to lupus is the result of a complex interaction between several conditions: a high-risk genetic terrain linked to the double X chromosome carrying genes capable of causing dysfunction of the autoimmune system; a high-risk immunological terrain in which the expression of immune regulation is reduced, while immune reactivity is increased [15]; and finally, the impact of endocrine factors through the role of female sex hormones (estrogen) on the immune response. This influence of hormonal factors is reinforced by the fact that these diseases occur more frequently in women during the genital period, and by the sometimes-aggravating role of pregnancy and hormonal contraception [16].

The average age of our study population was 37.9 years. This was in line with data from various studies in sub-Saharan Africa. Usually, the literature describes systemic diseases in young adults, and more specifically in young women at the time of genital activity [2,4,5].

Clinical characteristics

Regarding symptoms, facial erythema dominated the reasons for consultation, accounting for 84.7% of all cases. These results bear witness to the symptomatology classically described in the literature for lupus erythematosus. Practically the same signs were found in studies carried out at dermatology departments by Sangaré et al. in Côte d’Ivoire [12] and Lèye in Senegal [14].

In our study, renal involvement (52.4%) was the second most frequent extradermatological clinical manifestation, after rheumatological involvement (37.5%). In non-dermatological studies, symptoms were dominated by rheumatological disorders such as polyarthralgia. In Louzir’s study in Tunisia [17], rheumatological involvement was the most frequent clinical manifestation (90%), whereas in Saudi Arabia, the most common manifestations of the disease were hematological abnormalities (82.7%), followed by joint involvement (80.4%), with mucocutaneous involvement at the third place (64.3%).

Therapeutic modalities and progression

As local treatment, the application of sun cream was the most widely used, followed by topical dermocorticoids, and complementary treatment and/or a hygienic-dietary regimen were recommended, if necessary, which was also found in Tunisia [17]. UV light is the main recognized risk factor for lupus erythematosus. UV rays are capable of inducing skin lesions, as well as progressive flare-ups of the disease, and certain signs are highly photosensitive.

Sun avoidance by wearing protective clothing and the use of a highly protective broad-spectrum sunscreen have a beneficial effect in the management of the lupus subject as demonstrated in this randomized clinical trial [21].

Statement of Human and Animal Rights

All the procedures followed were in accordance with the ethical standards of the responsible committee on human experimentation (institutional and national) and with the 2008 revision of the Declaration of Helsinki of 1975.

Statement of Informed Consent

Informed consent for participation in this study was obtained from all patients.