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A highly contagious psoriasiform eruption on the scalp of a patient with systemic lupus erythematosus.

A 44-year-old woman who had a 23-year history of systemic lupus erythematosus (SLE) presented with an intensely itchy scaling eruption on her scalp of 2 months’duration. She was diagnosed to have SLE in 1988 when she presented with alopecia and photosensitivity. Antinuclear antibody titer was 1/1080 at the time of diagnosis, and antiYdouble-stranded DNA titer was elevated. Anti-Ro antibody was also present. Tests revealed leukopenia and neutropenia. In addition, she complained of exertional dyspnea, and a restrictive pattern on lung function test was detected. Transbronchial biopsy confirmed interstitial pneumonitis. She had been put on hydroxychloroquine and systemic corticosteroid therapy. Azathioprine was started as steroid-sparing agent. She developed heavy proteinuria in 1996, and renal biopsy confirmed focal proliferative glomerulonephritis (class III lupus nephritis). Her renal condition had been in quiescence for years, and she was on low-dose maintenance corticosteroid therapy (prednisolone 5 mg daily). One month before the onset of the rash, routine laboratory investigations revealed active lupus serology: antiYdouble-stranded DNA, 351 IU/mL (reference range, 0Y35 IU/mL); C3, 44 mg/dL (reference range, 76Y150 mg/dL); and C4, 7.8 mg/dL (reference range, 9Y35 mg/dL). There was also new occurrence of pancytopenia (white blood cells, 3.8 10/L [reference range, 4.4Y10.1 10/L]; hemoglobin, 10.5 g/dL [reference range, 11.7Y14.8 g/dL]; platelet, 153 10/L [reference range, 170Y380 10/L]). Prednisolone was stepped up to 15 mg daily accordingly. In subsequent follow-up, the patient complained of an extremely itchy rash on the scalp then later spread to the trunk and limbs. There were no other cutaneous manifestations of SLE including alopecia, photosensitivity, and oral ulcer. Physical examination showed confluent scaling plaques with a thick crust on the whole scalp (Figure). An active inflammatory border was present at the hairline. Scattered ill-defined papules and excoriation marks were found on hands and trunk. Burrows typical that of scabies were noted over the antecubital fossae (Figure). Skin scraping at the occipital scalp for microscopy on potassium hydroxide preparation revealed numerous scabies mites and confirmed the diagnosis of crusted scabies. Oral ivermectin at a dose of 200 Kg/kg