Lupus Site - a guide for lupus patients and their families

Skin problems are very common in lupus and many different types of problems can occur. This fact sheet will discuss some of the more frequent problems encountered by lupus sufferers.

What types of skin problem occur in lupus?

There are many different skin problems in lupus, which vary from person to person. The 'classical' skin problem in lupus is the butterfly rash. This is a red rash, sometimes no more than a mild blush, that occurs across the bridge of the nose and on the cheeks resulting in a distinctive butterfly-like appearance. This type of rash tends to occur in the systemic form of the disease where other organs in the body are also involved. It is often present at the beginning of the disease, helping doctors make the diagnosis. Butterfly rashes tend to come and go depending on how active the underlying lupus is but it does not leave scars as it heals.

Discoid lupus is a type of lupus that tends to be confined to the skin and other organs in the body are not involved. Discoid lupus occurs in patches across the body. These patches tend to be well defined, thickened and scaly, they are slightly red in colour and can itch. The appearance can vary between people and also on different areas of the body on the same person. As the patches heal they tend to leave scars and on darker skins the pigment in the skin can be lost leaving white areas. If discoid lupus occurs on the scalp the hair will be lost as the patches heal leaving permanent bald areas.

Subacute cutaneous lupus is a distinct rash that usually occurs in sun-exposed areas of the body. It starts as scaly patches which increase in size to form circular areas which gradually heal up without leaving scars. This type of lupus falls in-between the systemic form and the discoid form: people with subacute cutaneous lupus often have some of the blood abnormalities found in systemic lupus and frequently joint pains, but they do not usually develop the serious complications that can occur in the systemic disease.

Practically any type of rash can occur in systemic lupus ranging from widespread mild rashes similar to those seen in viral illnesses such as German measles, to small distinct patches of rash on the elbows and knees resembling another skin condition, psoriasis. Two particular problems that can occur are panniculitis and urticaria. Panniculilis is inflammation of the fat below the skin resulting in tender red lumps beneath the surface of the skin; these heal slowly over time and can leave dimpling of the skin when fully healed. Urticaria is an itchy raised red rash similar to nettle rash that can occur with vasculitis (see below) or on its own; it heals without leaving scars.

What about the blood vessels in the skin?

Lupus can affect the blood vessels in the skin. The blood vessels themselves can become inflamed. This is known as vasculitis. Vasculitis can cause painful red spots frequently on the hands and feat and sometimes chilblain type rashes. Vasculitis can also occur in other areas of the body for example the kidney which can be very serious and requires prompt treatment The blood flow through the skin blood vessels can become sluggish in lupus patients who have proteins that affect the clotting of the blood known as the antiphospholipid antibody syndrome. In these people the skin may take on a mottled net-like appearance known as livedo reticularis usually on the legs and the arms.

What happens to the hair in Lupus?

The hair often thins and can become patchy when lupus is active. It will usually regrow as the disease is bought under control. This is not the case in discoid lupus as already discussed when the scars left by the skin rash leave permanent bald areas. Sometime drug treatment can make the hair thin in lupus patients. This is known to happen in some people with steroid treatment and in most people when cytotoxic drugs such as cyclophosphamide are used. In both cases the hair should regrow when the drug is discontinued.

What about sunlight and the skin in Lupus?

Approximately 60% of people with Lupus will be sensitive to the sun. Sunlight can cause an exacerbation of skin rashes, burning of the skin and increased activity of lupus in other organs within the body. Some people will also be sensitive to certain types of lighting inside buildings such as fluorescent tubes and high intensity lighting. It is not clear why some lupus sufferers are sensitive to the sun and not others. Sun sensitivity can develop at any point throughout the course of the illness.

Why does Lupus affect the skin?

As doctors are not sure what causes lupus, the reasons that lupus affects the skin are also unclear. It is known that antibodies and other proteins that are used to fight infection are deposited in the skin inappropriately and cause inflammation. It is also known that proteins within the skin of lupus sufferers are more sensitive to ultraviolet rays contained in sunlight resulting in inflammation.

What treatment is available for the skin in Lupus?

A number of treatments are available for the skin in Lupus. These can be divided into topical, injection and oral treatments. Topical treatments tend to consist of steroid creams and ointments. These can range from the mild creams such as hydrocortisone to the stronger types such as betamethasone. These will sometimes be enough to control mild lupus rashes but should not be used continually, particularly on the face. In discoid lupus particularly troublesome areas can be injected with long acting steroids under the skin to promote healing.

Most people will require oral treatment to control their skin problems. The antimalarials such as chloroquine, hydroxychloroquine and mepacrine are all very useful in controlling skin rashes. They tend to work slowly and need to be taken for a number of months before any effect is seen. Other oral treatments include steroids, which can also be given intravenously if the skin lesions are very severe. Oral and intravenous steroids obviously have a number of side effects and are therefore usually reserved for skin problems that have not responded to topical treatments and the antimalarials. Sometimes skin rashes cannot be controlled with the above treatments or they recur on steroid dose reduction. In these people other drugs such as azathioprine or cyclosporin can be used. These drugs are often given for other problems in lupus such as kidney disease but they can be given for the skin alone in difficult cases.

How can I help myself?

The main way in which lupus sufferers can help themselves is to avoid sun exposure. This means covering up with long sleeves and trousers in the sunlight and wearing a hat if out in the sun for any length of time. The use of UV film on windows may also be necessary for those who are particularly sun-sensitive. Sun block cream, minimum sun protection factor (SPF 15), should be applied to exposed areas of skin, although many patients will require SPF 25 or higher. Sun blocks are available on prescription so ask your doctor for them. These creams need to be applied regularly and repeatedly as they wear off over time. Sunbeds should never be used as they give a concentrated dose of ultraviolet light, which can be very damaging to a lupus sufferer; fake tans are a safer alternative. If a rash develops that does not clear up rapidly then it should be reported to the doctor as soon as possible as a delay in treatment may result in scarring.