Patient: [Patient Name]
Date: [Date of Encounter]
I. Chief Complaint:
Skin rash (describe location, appearance – redness, scaling, discoid lesions, malar rash)
Hair loss (alopecia) – may or may not be present
Joint pain (arthralgias) – may or may not be present
Fatigue
II. History of Present Illness:
Onset and duration of skin rash
Changes in the rash over time (aggravating factors – sunlight)
Previous diagnoses or treatments for skin conditions
Symptoms suggestive of systemic lupus erythematosus (SLE) – joint pain, fatigue, fever (although not all patients with CLE will have these)
III. Past Medical History:
Underlying medical conditions (SLE, autoimmune diseases)
Family history of autoimmune diseases
IV. Medications:
Current medications (including topical medications for the rash)
V. Social History:
Sun exposure habits (sun exposure can worsen CLE)
Occupational exposures (certain chemicals may trigger flares)
VI. Physical Exam:
Vital signs (BP, HR, RR, Temp) – may be normal unless there is systemic involvement
Skin exam:
Location and distribution of rash (malar, discoid, other)
Characteristics of rash (redness, scaling, photosensitivity)
Mucosal involvement (oral ulcers) – may be present in some cases
Musculoskeletal exam (if joint pain is present)
VII. Laboratory Studies (consider as appropriate):
Antinuclear antibody (ANA) test – often positive in CLE, but not diagnostic alone
Anti-Ro (SSA) and anti-La (SSB) antibodies – more specific for CLE
Complete blood count (CBC) – may show abnormalities if there is systemic involvement
Other tests (inflammatory markers, urinalysis) – may be indicated depending on suspected systemic involvement
VIII. Imaging Studies (consider as appropriate):
Skin biopsy with direct immunofluorescence (DIF) – gold standard for diagnosing CLE, differentiates from other skin conditions
IX. Assessment:
Suspected CLE based on clinical presentation (characteristic rash) and positive ANA test (if performed).
Specific CLE subtype (e.g., discoid LE, subacute LE) may be determined based on rash morphology and distribution.
Need for further workup to rule out systemic lupus erythematosus (SLE) – consider history, physical exam, and additional laboratory tests.
X. Plan:
Treatment depends on the severity and type of CLE:
Topical corticosteroids: First-line treatment for most cases of CLE.
Antimalarials: May be used for more widespread or photosensitive CLE.
Immunomodulatory medications: In severe cases or those unresponsive to other treatments.
Sun protection: Essential for all patients with CLE to prevent flares.
Referral to a dermatologist may be indicated for complex cases or those requiring systemic therapy.
XI. Prognosis:
CLE is a chronic condition, but symptoms can be controlled effectively with treatment.
Early diagnosis and treatment can help prevent scarring and other complications.
Discuss the importance of sun protection and regular follow-up to monitor the disease.
XII. Notes:
Include any additional observations or concerns, such as patient’s understanding of the diagnosis and treatment plan, potential side effects of medications, need for emotional support, and the potential for developing systemic lupus erythematosus (SLE).
XIII. Resources:
Consider providing patient education materials on CLE from reputable sources (e.g., American Academy of Dermatology, Lupus Foundation of America).