Does this facial eruption signal an underlying condition?

This 39-year-old man from India has had an itchy eruption on his face for a few months. He is otherwise healthy, takes no medications, and has no other rashes.

Which of the following do you suspect?

A. Rosacea.
B. Lupus erythematosus.
C. Seborrhea.
D. Contact dermatitis.
E. Polymorphous light eruption.

A skin biopsy was performed, and the findings were interpreted as consistent with seborrheic dermatitis. Desonide cream and ketoconazole cream were prescribed. When the patient returned 2 months later, there was no improvement.

What would you do next?

F. Order an antinuclear antibody titer.
G. Prescribe a mid-potent corticosteroid cream, such as fluticasone.
H. Prescribe metronidazole gel.
I. Repeat the skin biopsy.
J. Prescribe oral minocycline.
K. Prescribe oral ketoconazole.

A second skin biopsy, I (this time a 2-mm punch) revealed changes supportive of cutaneous lupus erythematosus, B. Treatment was started with hydroxychloroquine and a mid-potent topical corticosteroid. The patient was told to limit sun exposure and to use sunscreen with a high SPF.