Comedonal Lupus: Case Series and Literature Review

Introduction: Comedonal lupus (CL) is a rare variant of cutaneous lupus erythematosus. Objectives: This study aimed to describe the clinical, dermoscopic, and histopathological characteristics of CL. Methods: A retrospective review was conducted of patients diagnosed with CL in our dermatology department between January 2020 and August 2025, complemented by a literature review. Results: Seven patients were identified (sex ratio 0.4; mean age 48.2 years). Lesions predominantly affected the face, scalp, and ears. Four patients exhibited acneiform lesions combining comedones and milia-like pseudocysts, and two showed worm-eaten scars. The perioral region, cheeks, nose, and eyebrows were the most frequently involved facial sites. Three patients presented with sharply demarcated alopecic scalp plaques with a dirty-brown appearance and central comedones. Facial dermoscopy consistently demonstrated arborizing vessels, comedones, opalescent yellow structures, follicular keratotic plugs, rosettes, a blue-white veil, peripheral pigmentation, and, while trichoscopy revealed central whitish-red areas, loss of follicular openings, yellow keratotic plugs, irregular pigmentation, and comedones. Histopathology of skin and scalp lesions showed epidermal atrophy, orthokeratosis, basal vacuolar degeneration, basement membrane thickening, dilated follicular ostia with keratin plugs, and perivascular and perifollicular lymphocytic infiltrates. Direct immunofluorescence demonstrated granular C3 deposition along the basement membrane in four cases. ANA was positive in five patients, and anti-dsDNA antibodies were detected in the single systemic lupus erythematosus (SLE) case. Treatment with topical corticosteroids and hydroxychloroquine achieved partial improvement and stabilization in most cases, while the SLE patient showed marked improvement with systemic therapy and photoprotection. Conclusions: CL often mimics acne, which may delay diagnosis; dermoscopy assists recognition, yet treatment outcomes remain suboptimal.