The Skin and Lupus

This site is intended for healthcare professionals as a useful source of information on the diagnosis, treatment and support of patients with lupus and related connective tissue diseases.
The development of some sort of rash is one of the commonest features of lupus and is often the presenting sign. In SLE, a photosensitive malar rash presents classically in the ‘butterfly’ shape across the cheeks, over the bridge of the nose and sparing the nasolabial folds. The rash is usually erythematosus although it can also be macular with raised papules and plaques with scar less healing.

‘Sub-acute cutaneous LE’ (SCLE) usually takes the form of red, scaly, round lesions over the face, neck and chest which are induced by sunlight and, like the butterfly rash, heal without scarring. SCLE is particularly associated with a specific blood autoantibody, the anti-Ro (SS-A) which may be involved in causing the rash.

Chronic cutaneous lupus includes ‘Discoid lupus’ (DLE) consisting of well-defined disc-like plaques on the skin or scalp which are long-lasting and which can lead to scarring and cosmetic problems.

Patients with lupus may suffer other skin problems which are not specific to lupus, such as vasculitic rashes, hair thinning, blisters, leg ulcers and prickly heat. Because of this diversity, a skin biopsy is sometimes required to help make an accurate diagnosis.

The following advice is recommended for lupus patients who are photo reactive to prevent flares wherever possible is as follows:-

• Plan holiday destinations so that exposure to strong sunlight and high temperatures is limited

• Always wear sun protection, SPF 50 or 60. Remind patients this only means 50-60 minutes protection from the sun’s damaging rays. So it is imperative to reapply sunscreen at least hourly when you are outside in the sunshine

• Wear a broad brimmed hat to shelter the face from the sun

• Avoid sitting outside in hottest part of the day, usually at midday

• Avoid sitting under an umbrella on slabs which can reflect the sunlight directly onto the face

• Buy thicker weave clothing that will block the sun’s rays from penetrating the skin. Clothing should be long sleeved, covering the legs, arms and neck area. Linen type fabric can be purchased that is cool to wear

• Topical treatments with steroid preparations are useful, but should only be used for short courses and small doses applied to the skin. Hydroxychloroquine is effective in treating rashes and arthralgias associated with lupus, some patients need to try other drugs such as Mepacrine, which although a response is found in most, is often limited due to its side effect profile (tends to make the skin turn yellow). Thalidomide is also an effective treatment but tends to cause peripheral neuropathy and so treatment can be sporadic dependent on response.

• Despite this range of therapies, some patients are left with long-term cosmetic problems, requiring expert advice provided by the Red Cross.