unexplained chronic skin lesions in an older male consider the iatrogenic factor hydralazine induced cutaneous lupus

What could be the possible etiology for chronic discoid dermal lesions in an older adult with hypertension under one’s care? A seventy-nine-year-old male with uncontrolled hypertension, coronary artery disease, hyperlipidemia and status / post radiotherapy for prostate cancer (now in remission) presented to the geriatrics clinic with skin lesions over the extremities and trunk. The lesions apparently persisted for months; they were annular, circumscribed, 1-2 inches in diameter and scaly. The patient was on multiple medications; a cardiologist whom he visited had prescribed hydralazine for hypertension, initially 25 mg thrice daily, increasing the dose to 100 mg thrice daily, a dose continued for 7 years. He was also on losartan for hypertension. Dermatology evaluation was requested; skin biopsy suggested nummular eczema, erythema annular centrifugum or purpuric spongiform dermatitis, with eosinophils. The patient did not manifest lung or pulmonary disease; he had chronic kidney disease, a consequence of severe hypertension and obstructive uropathy. The skin lesions did not improve with topical steroid creams prescribed by the dermatologist. The patient continued to use the cream intermittently, however, until the present.