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When Lupus Targets Your Skin

Learn about cutaneous lupus and related skin conditions.

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Systemic lupus erythematosus (SLE) is a chronic autoimmune disease that can cause inflammation throughout the body, including the skin. But one form of SLE, called cutaneous lupus erythematosus (CLE) affects just your skin, without other lupus symptoms.

 CLE occurs when your immune system attacks healthy skin tissue. People who have this condition can go on to develop other SLE symptoms. It can be an early warning sign of the systemic disease. And patients with SLE often have skin symptoms, including various is  just a part of developing SLE or is a disease in its own right. One thing is clear: Unlike SLE, which mainly affects women, CLE is far more common in men.  

There are three subtypes of cutaneous lupus – acute, subacute and chronic. All can cause rashes that range from mild and localized to more widespread and severe. Some go away without a trace; others leave significant scars. Here’s a closer look:

  • Acute cutaneous lupus. The most recognizable sign of this type – is a painless malar (butterfly) rash that stretches across the nose and cheeks. Mild cases look like a blush; severe rashes are red and itchy. According to Henry Lee, MD, a dermatologist at New York Presbyterian Hospital and assistant professor at Weill Cornell Medical College in New York City, half of SLE patients will develop a malar rash, usually after sun exposure and often years before other symptoms.
  • Subacute cutaneous lupus erythematosus (SCLE). This can cause two kinds of lesions: red, ring-shaped sores that sometimes overlap like interlocking circles; and a raised rash that resembles psoriasis. Some people have both. SCLE can occur anywhere on your body except your face, and like other types of cutaneous lupus, is often triggered by sunlight.

Certain prescription drugs can also cause SCLE, especially some heart medications, proton pump inhibitors, antifungals, chemotherapy medications and tumor necrosis factor blockers. In one of the largest case series of cutaneous lupus to date, 20% of patients were found to have symptoms caused by medications. David Wetter, MD, a professor of dermatology at Mayo Clinic in Rochester, Minnesota says doctors should always consider medications as a possible cause of the disease. And, because a certain percentage of people with SCLE develop SLE or other autoimmune diseases like Sjogren’s syndrome, they should be checked for those, too.

  • Chronic Cutaneous Lupus. This form of cutaneous lupus has different subtypes, but the most common is discoid lupus erythematosus (DLE) – named for the coin-shaped sores that mainly appear on the face, ears and scalp. These can cause permanent scarring, changes in pigmentation and sometimes irreversible hair loss. Early diagnosis and treatment are important.

Treating Cutaneous Lupus

There is no cure for cutaneous lupus, so the goal is to improve the way your skin looks, prevent scarring and help you feel better overall. Drs. Lee and Wetter agree that nondrug treatments are the first line of defense. That means avoiding drugs that can trigger symptoms; not smoking; and protecting yourself from the ultraviolet light. Wear a broad spectrum, SPF 30 sunscreen and protective clothing (long sleeves, long pants and a broad-brimmed hat) whenever you’re outdoors or in a car – and even under fluorescent lights.

The type of drugs prescribed largely depends on the kind of cutaneous lupus you have and how severe or widespread it is. Steroid ointments are often the first choice for mild-to-moderate symptoms and relatively small areas. But steroids can cause other problems, including thin or slow-to-heal skin and cataracts if used near your eyes for long periods.

To avoid steroids’ side effects, your doctor may prescribe a topical calcineurin inhibitor like tacrolimus (Protopic, Prograf) or pimecrolimus (Elidel). These creams are effective for skin lesions, but the pills have been linked to certain cancers. And, because they’re relatively new, their long-term safety isn’t known. 

First-line systemic treatments include antimalarial drugs, with hydroxychloroquine the preferred choice. Studies suggest it works for about 60% of people with cutaneous lupus, but may be less effective in those who have SLE. When anti-malarials don’t help, your doctor may try low-dose methotrexate or an anti-inflammatory drug such as dapsone (Aczone). Both have their own side effects, some of them serious. Be sure you understand all the potential side effects of any medications you take.

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