Skin LESIONS and SLE
Skin disorders are very common in Lupus
- Cutaneous manifestation of lupus are as follow:
- Discoid lupus: lesions present as urticarial patch, scaly patch (follicular plugging), scarred patch, with pigmentary changes.
- The palms can be involved with atrophy, erosion or hyperkeratosis.
- During acute flare up of systemic lupus erythematous, patient often develops transient maculopapular butterfly rash affecting both cheeks. (commonly known as the malar rash or mask)
- In subacute lupus (SCLE), the eruption can be urticarial (annular), papulosquamous (psoriasiform).
- Mucosal involvement is also commonly seen and these include ulceration or nosebleed.
- Scalp involvement is not uncommon and both diffuse or scarring alopecia can be seen.
- Vascular lesions seen in lupus include: Raynaud's phenomenon, nail fold telangiectasia and infarct, splinter haemorrhages, chilblain LE, acquired C1 esterase deficiency, vasculitis, urticarial vasculitis, purpura, thrombophlebitis, livedo reticularis, antiphospholipid syndrome, Degos syndrome and calcinosis.
- Others less common cutaneous manifestations are Bullous LE, LE profundus, erythema multiforme.
- The term discoid is a very confusing term which, unfortunately, is inappropriately used by many people, including physicians.
- The term discoid simply means coin-shaped.
- The scarring coin-shaped lupus lesion commonly seen on areas of the skin that are exposed to light has been termed discoid lupus erythematosus.
- This term refers only to the description of the lupus lesion on the skin and should not be employed to distinguish cutaneous lupus from systemic lupus erythematosus.
- A physician cannot determine whether or not a discoid lupus lesion on the skin is occurring in the presence or absence of systemic features just by examining the shape of the lesion.
- This can only be done by taking a complete history and physical examination and interpreting the results of appropriate blood tests.
- Lupus erythematosus should be viewed as a continuum of a spectrum of this autoimmune disease.
- At one end of the spectrum, in its most mild form, it is characterized by coin-shaped, scarring, skin lesions which we term discoid lesions.
- At the other end of the spectrum are those systemic lupus erythematosus patients who have no skin lesions, but have systemic features.
- People with only discoid lesions and no systemic features commonly have no auto-antibodies in their serum and their antinuclear or anti-DNA tests will be negative.
- On the other hand, people with systemic lupus erythematosus are characterized by the presence of one or more types of auto-antibodies in their blood.
- From reviewing the literature, it has been estimated that between 5 and 10% of patients initially presenting with only the coin-shaped lesions of discoid lupus will, with time, develop systemic features.
- As noted above, approximately 20% of people with systemic lupus erythematosus will at the time of the initial presentation of their disease have discoid lupus lesions.
- Therefore indicating that with time, a small percentage of those patients who only have discoid lupus lesions will eventually develop systemic disease
- In addition to these coin-shaped, scarring lesions, there are several different types of discoid lupus lesions with which patients should be familiar.
- Occasionally, the discoid lupus lesions may occur in the scalp producing a scarring, localized baldness termed alopecia.
- At times, these discoid lesions may appear over the central portion of the face and nose producing the characteristic butterfly rash or 'malar rash'.
- This type of lupus obviously has significant cosmetic implications.
- The discoid lupus lesions may develop thick, scaly (hyperkeratotic) formations and are termed: hyper-keratotic or hyper-trophic, cutaneous lupus lesions.
- Discoid lupus lesions may also occur in the presence of thickening of the layers of underlying skin, a condition which is termed lupus profundus.
- At the present time, research indicates that discoid lupus lesions are the result of an inflammatory process in the skin in which the patients' lymphocytes play a major role.
- This is in contrast to systemic lupus erythematosus, where auto-antibodies and immune complex formation are responsible for many of the clinical symptoms.
- This type of specific lupus lesion was most recently described by Sontheimer and Gilliam during the late 1970's.
- This lesion is characterized as a non-scarring, erythematosus, or red, coin-shaped lesion which is very photosensitive, meaning it gets worse when exposed to UV light.
- This type of lesion, which is characteristic of subacute cutaneous lupus, occurs in lupus patients who, approximately half of the time, demonstrate features of systemic lupus erythematosus.
- Renal disease, however, is unusual in these patients.
- These skin lesions also occur in people who only have clinical evidence of skin disease (discoid lupus), and do not show any symptoms of systemic lupus.
- Approximately 70% of people with these lesions have anti-Ro antibodies.
- The subacute cutaneous lupus lesion can sometimes mimic the lesions of psoriasis or they can appear as non-scarring, coin-shaped lesions much like hives.
- These lesions can occur on the face in a butterfly distribution, or can cover large areas of the body.
- Unlike the discoid lupus lesions, these lesions do not produce permanent scarring, but can be of major cosmetic significance.
Treatment for skin issues with lupus may include:
- Topical steroid creams.
- The use of plastic wrapping over the skin to increase the absorption of steroid creams.
- Injections of medication in the case of exceptionally thick skin lesions that don't respond to creams.
- Anti-malarial drugs.
- Other medications, such as those used for psoriasis.
- Oral steroids if SLE is also present.
Avoid sun exposure
Staying out of the sun is perhaps the most crucial strategy for the management of discoid lupus. The ultraviolet radiation in sunlight can trigger or worsen an attack. Suggestions include:
- Avoid exposing yourself to direct sunlight whenever possible.
- Cover as much of your skin as you can with clothes such as long-sleeved shirts, trousers, gloves, broad brimmed hat and so on.
- Always wear sunscreen lotion on all exposed areas of skin when you go outside.
- Choose sunscreens that protect against both UVA and UVB.
- Wear sunscreen even in winter or on cloudy days - any degree of ultraviolet radiation on the skin should be avoided.
- Remember that ultraviolet radiation is not stopped by window glass, and is reflected off surfaces like concrete, snow and water.
- Some fluorescent tubes emit ultraviolet radiation.
- Wind and cold temperatures may affect some people with discoid lupus.
Where to get help
Support Groups (lupus patients)
Things to Remember
- Discoid lupus is a chronic skin condition characterised by reddened scaly patches that develop in sun-exposed areas of the body such as the face and hands.
- It is unclear whether discoid lupus is a separate disease, or a milder version of systemic lupus.
- Staying out of the sun is perhaps the most crucial strategy for the management of discoid lupus.
- Treatment options include topical steroids and anti-malarial medication. (however, be very careful with your research on meds, as some have irreversible occular side effects *for some patients* -i.e.: chloroquin)