Improvement in facial discoid dermatosis with calcipotriol/betamethasone ointment and low-dose acitretin

Facial discoid dermatosis (FDD) is characterized by persistent, discrete, facial plaques that are unresponsive to topical therapies. It has histological features of pityriasis rubra pilaris (PRP) and, like PRP, it is cosmetically disfiguring and difficult to treat. A 56‐year‐old woman of Vietnamese descent presented with a 3‐year history of a facial eruption, which was asymptomatic and had been static since it developed. She had no concerning lesions on the rest of her body. She had a history of dyslipidaemia, treated with atorvastatin. She had no personal history of atopy, but she had a family history of lymphoblastic lymphoma. Physical examination showed multiple, orange, papulosquamous plaques that were slightly raised (Fig. 1a). (a) Multiple, orange, thin, papulosquamous plaques on the patient's face; (b) improvement after 2 months of calcipotriol/betamethasone ointment combined with low‐dose acitretin. Histological examination of a biopsy revealed parakeratosis, mild psoriasiform acanthosis and a perivascular infiltrate of lymphocytes with negative stains for fungi and mucin (Fig. 2). Multiple topical corticosteroids, such as mometasone furoate and beclomethasone dipropionate, were tried, as was topical tacrolimus, ciclopirox shampoo and ketoconazole cream, but all were ineffective. Similarly, oral fluconazole 200 mg for 14 days provided no benefit. The plaques were also unresponsive to narrowband ultraviolet B phototherapy (25 treatments) and 5 mg/mL intralesional triamcinolone. Acitretin 10 mg per day was initiated but it did not have a marked effect. Finally, calcipotriol/betamethasone ointment was tried, in addition to acitretin. This resulted in the lesions becoming less prominent, with some even resolving (Fig. 1b). Two plaques (left cheek and right temple) were also injected with 10 mg/mL intralesional triamcinolone, which also provided some benefit. The improvement with calcipotriol/betamethasone ointment was cosmetically important for the patient because, after the treatment, she could successfully camouflage the plaques completely, whereas before the plaques were visible under her cosmetics. Punch biopsy from a characteristic lesion on the patient's face, showing parakeratosis, mild psoriasiform acanthosis and a perivascular infiltrate of lymphocytes. Follicular plugging is also visible. Haematoxylin and eosin, original magnification × 40). Periodic acid–Schiff and Hale collodial iron staining were negative (not shown). Facial discoid dermatosis was first described in 2010 as facial plaques with histological features of PRP.1 Based on clinical morphology, the differential diagnosis for FDD includes seborrhoeic dermatitis, tinea faciei, psoriasis, contact dermatitis, mycosis fungoides and cutaneous lupus erythematosus. Histology of FDD typically demonstrates hyper/parakeratosis, follicular plugging and acanthosis.1 Several topical medications, such as corticosteroids, calcineurin inhibitors, antifungals and retinoids, have been tried, but no clinical improvement has been reported. Oral methotrexate, oral doxycycline and pulsed‐dye laser treatments have also been tried without success. From limited descriptions in the literature of 12 patients, FDD affects more women than men (M : F ratio 1 : 5) and more cases were of an East Asian background than any other ethnic background (eight Chinese, one Turkish, three unknown). One patient was reported as having progressed to type II PRP, and based on this finding, the authors of that study postulated that FDD was another form of PRP.2 In common with other cases of FDD, our patient's condition failed to respond to multiple therapies, including topical corticosteroids, phototherapy and systemic retinoids. However, calcipotriol/betamethasone ointment combined with low‐dose acitretin resulted in marked improvement of the lesions. We could not find any other reports of effective treatments in FDD, thus this treatment could be an option in other patients with this disfiguring and recalcitrant condition to see whether reproducible benefit is achieved. Conflict of interest: the authors declare that they have no conflicts of interest.

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