Race for the Case
Race for the Case is a clinical quiz feature published quarterly in DermWorld Directions in Residency — and right here!
Answer the questions below to enter. Looking for the Fall 2025 answers? Review them now. To submit cases and questions, email Emily Margosian at emargosian@aad.org.
Diagnose this new case by Haowei Han, DO, and Aysham Chaudry, DO
A 64-year-old woman presented to the dermatology clinic with a two-year history of a widespread rash involving the scalp and left ear. She reported associated joint pain but denied fevers, fatigue, weight loss, oral ulcers, photosensitivity, or Raynaud phenomenon. Social history is notable for cigarette smoking and lack of regular sunscreen use.
On physical examination, there were bilateral preauricular hyperpigmented, atrophic plaques. The parietal scalp demonstrated violaceous to hyperpigmented, atrophic plaques accompanied by alopecia.
Laboratory evaluation revealed a positive antinuclear antibody (ANA) with a speckled pattern at a titer of 1:160 and an elevated Sjögren’s syndrome-related antigen A (SS-A/Ro) antibody level of 3.6 (reference range: 0.0–0.9). Anti-double-stranded DNA (anti-dsDNA) and anti-Smith antibodies were negative. Complete blood count (CBC), comprehensive metabolic panel (CMP), and urinalysis (UA) were all within normal limits.
A 4-millimeter (4 mm) punch biopsy of the scalp revealed follicular plugging, perifollicular fibrosis, periadnexal lymphocytic inflammation, increased dermal mucin deposition, and pigment incontinence. Vacuolar interface changes were noted, along with increased thickness of the basement membrane zone.
Based on the clinical, histopathologic, and laboratory findings, what is the most likely diagnosis?
What is the likelihood that this condition will progress to systemic lupus erythematosus (SLE)?
Which stain can be used to highlight the thickened basement membrane zone seen in this condition?
What stain can be used to highlight the increase in mucin deposition?
Infants born to mothers with positive SS-A (Ro) antibodies are at increased risk for which condition characterized by congenital heart block, annular lesions, and thrombocytopenia?
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