The skin is often affected by lupus, and plays a very important role in diagnosing the illness—whether it’s the skin-only form—cutaneous lupus erythematosus—or the body-wide “systemic” lupus erythematosus.
Common types of cutaneous lupus include chronic cutaneous lupus, which often involves thick and scaly red “discoid” rash lesions and patchy hair loss, and acute cutaneous lupus, which often involves a malar “butterfly-shaped” rash across the cheeks and nose and in some cases the development of fluid-filled “bullous” lupus lesions.
In systemic lupus, the body's overactive immune system forms antibodies that attack and damage not just the skin but other crucial tissues and organs such as the kidneys, heart, lungs, blood and joints. Four of the 11 official criteria for systemic lupus are skin-related: malar rash, discoid rash, sensitivity to sunlight (photosensitivity) and oral ulcerations.
Most people are anxious to know if something in their lifestyle or diet caused lupus. It’s still not clear why certain people get the disease, but both genes and environmental triggers likely play a role. Any blood relative with an autoimmune disease such as rheumatoid arthritis may pass along the genes that predispose a relative to lupus. And then environmental triggers cause the disease to develop and flare.
What kinds of things happen to the skin in lupus?
Lupus can cause a range of skin reactions that mimic other more common skin disorders, making diagnosis of the illness challenging in many cases. The “butterfly” rash may be mistaken for rosacea, psoriasis, or eczema, for example, and delay the right diagnosis as they initially improve with topical treatments.
Common skin reactions in lupus include:
- Patches of red and raised “discoid” skin lesions on sun exposed areas such as the face and hands. Without treatment, discoid lesions often get worse. Prescription corticosteroid creams or injections can help eliminate them, and corticosteroid pills and anti-malarial drugs can be tried if the lesions don’t get better or are severe. But topical formulations are always tried first. A discoid rash on the scalp should be treated aggressively to prevent progression and permanent hair loss.
- A red butterfly-shaped “malar” rash across the nose and cheeks. Apply a broad spectrum sunscreen to avoid or minimize these rashes, and corticosteroid ointments or gels as recommended by your doctor. Careful management of lupus in other parts of body also helps.
- Loss of hair—strand by strand or in clumps. Sometimes hair loss is a direct result of the immune system activity destroying hair follicles, and can’t be stopped except through treatment for the lupus.
- Sores in the mouth, on the tongue, in the nose, and (rarely) in the vagina. Gargle several times daily with buttermilk or hydrogen peroxide diluted in a few ounces of water to ease the pain and prompt healing. Topical and oral corticosteroids, as well as anti-malarial drugs can help. For nose sores, try dabbing on petroleum jelly.
- Color (pigment) skin changes from dark or light can occur after lupus-related inflammation subsides, or anti-malarial or corticosteroid drugs are stopped. Cosmetics can be used to mask the color changes.
- Hives or welts (urticaria) are typically treated with antihistamines, anti-serotonin drugs, and corticosteroids. If persistent it may signal vasculitis, an inflammation of the blood vessels that requires extra treatments.
Other common lupus-related skin problems include Raynaud’s phenomenon in which fingertips turn red, white and blue in reaction to cold temperatures, vasculitis with a breakdown of the skin from inflammation of vessels near the skin’s top layer, a red mottling or lacelike appearance under the skin called livedo reticularis, and the appearance of red or purple discolorations under the skin (purpura) caused by bleeding. Also, corticosteroid drugs commonly used to treat lupus can cause complications such as black and blue marks and skin thinning.
How can lupus skin scars be treated or covered up?
Filler and laser technology has exciting potential to improve scarring and pigment disturbances and may be less risky than plastic surgery in some people—but shoudln’t be done unless the disease is in full remission and by a doctor knowledgeable about these techniques and about lupus. Camouflage makeup, when properly blended and applied, can often completely conceal skin discoloration and scarring.
Avoiding sunlight is one of the most important things you can do if you have lupus. The sun’s UVB and UVA ultraviolet rays are major lupus triggers and that can prompt photosensitivity reactions 365 days a year—on cloudy as well as sunny days—and in as little time as it takes to walk to the corner store. UVB rays are normally associated with sunburn and tans. UVA rays, which are present in all seasons and from dawn until dusk, penetrate more deeply into the skin but don’t cause redness or burn, and are therefore less likely to be recognized as lupus flare triggers.
If I have cutaneous lupus, what are the chances that I will get systemic lupus?
Many people worry about this, but in fact only 1 in 10 people with cutaneous lupus develop the systemic form of the disease. By protecting yourself from environmental triggers such as sunlight and cigarette smoke, as well as keeping watch for so-called “Markers of Transition” to systemic lupus with the help of experienced doctors, you can help to prevent this serious transition and even possibly reverse its course if it starts. The “markers” include the appearance of skin ulcers and calcium deposits and nodules under the skin, and the development of generalized joint and/or muscle pain, rash below the neck, and protein or blood in the urine.
Protect yourself from a lupus flare!
- Apply broad-spectrum UVA-UVB protective sunscreen every day of the year. Choose a product with a Sun Protection Factor of 30 or higher and which contains avobenzone (Parasol 1789), titanium dioxide, and/or zinc oxide, as these provide the broadest protection against both UVA and UVB. A newer ingredient, mexoryl, is available in some sunscreens and is very effective against UVA. Slather on before makeup, and no less than 10 minutes before going outside.
- Limit unnecessary outdoor activities—especially when the sun tends to be at its most intense between 10 AM and 3 PM—and invest in special sun-protective clothing and wide-brimmed hats.
- To minimize exposure to UVA rays, place plastic over window glass and encase halogen lights and fluorescent bulbs in plastic casings. Use a polarizing guard over your computer screen. Flat screens, such as on laptops, do not require this precaution.
- Check about the added risk for photosensitivity when taking certain medicines such as diuretics, antibiotics, anti-inflammatory drugs, and birth control pills.
Andrew G. Franks, Jr., M.D., FACP