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CORRESPONDENCE
Year : 2020  |  Volume : 38  |  Issue : 1  |  Page : 65-66

Discoid lupus erythematosus in a welder


Department of Dermatology, Fukushima Medical University, Fukushima, Japan

Date of Web Publication27-Feb-2020

Correspondence Address:
Toshiyuki Yamamoto
Department of Dermatology, Fukushima Medical University, Hikarigaoka 1, Fukushima 960-1295
Japan
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ds.ds_18_19

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How to cite this article:
Hanami Y, Yamamoto T. Discoid lupus erythematosus in a welder. Dermatol Sin 2020;38:65-6

How to cite this URL:
Hanami Y, Yamamoto T. Discoid lupus erythematosus in a welder. Dermatol Sin [serial online] 2020 [cited 2020 Apr 5];38:65-6. Available from: http://www.dermsinica.org/text.asp?2020/38/1/65/279594



Dear Editor,

A 53-year-old Japanese male visited the Dermatology Clinic at Omachi Hospital, complaining of multiple erythemas on the face with a duration of over 15 years. Physical examination revealed relatively well-circumscribed, keratotic infiltrative erythemas on the tip of the nose and left cheek [Figure 1]a and [Figure 1]b. He was engaged in welding for over 20 years. Several years after he started arc welding, erythemas appeared on the face and gradually worsened. Histological examination from the cheek revealed individual cell keratinization, liquefaction of epidermal basal membranes, and focal mononuclear cell infiltration in the entire dermis [Figure 1]c and [Figure 1]d. Lymphocytic cells were mainly composed of CD3-positive T-cells. Examination by direct immunofluorescence showed linear deposition of IgG, IgM, and C3. Laboratory examination showed positive antinuclear antibody (1:80, homogeneous and speckled), while other data such as complete blood count, liver and renal function, serum complement levels, anti-DNA antibody, anti-Sm antibody, and urinary examination were all within the normal range. A diagnosis of discoid lupus erythematosus (DLE) was made, and we strongly recommended shading the ultraviolet (UV) light. He gave up working as a welder and was treated with topical steroid and tacrolimus ointment and dapsone for nearly 1 year, which resulted in no effects. We then started treatment with PlaquenilR, (Sanofi Co., Ltd., Tokyo, Japan) (400 mg/day). The facial erythemas disappeared 4 months later [Figure 1]e; however, hydroxychloroquine was discontinued because of persistent diarrhea. Thereafter, the relapse of DLE was not observed.
Figure 1: (a) Clinical appearance showing wild keratotic infiltrative erythemas on the nose and left cheek. (b) Close-up view of the cheek erythema. (c and d) Histological features showing follicular plugging, liquefaction of basal layers of the epidermis, and focal lymphocytic infiltration in the entire dermis (H and E) ([c] ×100, [d] ×200). (e) Facial erythemas improved by oral hydroxychloroquine

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UV light is a major environmental triggering or precipitating factor in cutaneous lupus erythematosus (LE). DLE frequently occurs on the sun-exposed area, and patients are required to avoid sunlight. Our patient was engaged in welding for over 25 years, and he developed erythematous lesions on his face several years later, despite wearing protective glasses and clothing. Arc welding equipment is known to produce UV radiation in both UVB (280–315 nm) and UVC (100–280 nm),[1] and chronic exposure to welding light is reported to be a risk of many hazards involving the eye and skin.[2],[3],[4] Occupational arc welding is associated with photodermatitis[5] as well as the development of keratoacanthoma, basal cell carcinoma, and squamous cell carcinoma.[6],[7],[8],[9],[10] Skin problems were significantly associated with the age of the welders, duration of employment, and welding hours per day. Our patient developed DLE lesions on the tip of the nose and cheeks, which however did not develop skin cancers. The DLE lesions involved the nose and left cheek, and the distribution was speculated due to his right-handed working position. Although he usually wore whole defense mask, he stated that occasionally he took it off and changed to goggles.

To date, only one similar case has been reported.[11] Those cases suggest that the UV radiation during welding operations induces not only skin cancer but also cutaneous LE, and thus, caution is necessary. Our patient was initially treated with a topical corticosteroid, because hydroxychloroquine was not approved as yet, and change of occupation from welding. More than 1 year later, further treatment with hydroxychloroquine (400 mg/day) resulted in sufficient effects 4 months later. The patient, however, decided to discontinue hydroxychloroquine treatment due to severe diarrhea but without relapse of DLE.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Ramirez CC, Federman DG, Kirsner RS. Skin cancer as an occupational disease: The effect of ultraviolet and other forms of radiation. Int J Dermatol 2005;44:95-100.  Back to cited text no. 1
    
2.
Chauhan A, Anand T, Kishore J, Danielsen TE, Ingle GK. Occupational Hazard exposure and general health profile of welders in rural Delhi. Indian J Occup Environ Med 2014;18:21-6.  Back to cited text no. 2
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3.
Budhathoki SS, Singh SB, Niraula SR, Pokharel PK. Morbidity patterns among the welders of Eastern Nepal: A cross-sectional study. Ann Occup Environ Med 2016;28:62.  Back to cited text no. 3
    
4.
Dixon AJ, Dixon BF. Ultraviolet radiation from welding and possible risk of skin and ocular malignancy. Med J Aust 2004;181:155-7.  Back to cited text no. 4
    
5.
Dixon A. Arc welding and the risk of cancer. Aust Fam Physician 2007;36:255-6.  Back to cited text no. 5
    
6.
Shehade SA, Roberts PJ, Diffey BL, Foulds IS. Photodermatitis due to spot welding. Br J Dermatol 1987;117:117-9.  Back to cited text no. 6
    
7.
Wolfe CM, Green WH, Cognetta AB Jr., Hatfield HK. Multiple squamous cell carcinomas and eruptive keratoacanthomas in an arc welder. Dermatol Surg 2013;39:328-30.  Back to cited text no. 7
    
8.
Currie CL, Monk BE. Welding and non-melanoma skin cancer. Clin Exp Dermatol 2000;25:28-9.  Back to cited text no. 8
    
9.
Heltoft HN, Slagor RM, Agner T, Bonde JP. Metal arc welding and the risk of skin cancer. Int Arch Occup Environ Health 2017;90:873-81.  Back to cited text no. 9
    
10.
Donoghue AM, Sinclair MJ. Basal cell carcinoma after frequent episodes of cutaneous erythema and peeling induced by welding. Occup Environ Med 1999;56:646.  Back to cited text no. 10
    
11.
Wozniak KD. Erythematodes chronicus discoides as an occupational disease in an electric welder. Berufsdermatosen 1971;19:187-96.  Back to cited text no. 11
    


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