Your Skin and Lupus
Q. How might chemical peels affect someone with cutaneous lupus, and are they contraindicated for people with lupus?
A. Chemical peels may irritate the skin, and thus could potentially induce skin lesions in patients with the underlying disease. This phenomenon can occur with scratching or any skin irritation and thus could be a potential risk. This procedure should be discussed with your dermatologist before using it.
Q. I have cutaneous lupus. Lately, I've heard people discussing UVA1 phototherapy as a potential option. I'm interested in this treatment option. But because I'm photosensitive, I'm skeptical as to how this would really help me.
A. Here is the consensus statement from the newly-formed North American Rheumatologic Dermatology Society (NARDS) on the issue of UVA1 therapy for lupus.
"There is some published evidence based on a relatively small number of patients studied that supports the use of UVA1 phototherapy for some of the skin lesions of lupus. However, there is also published evidence that raises the concern that UVA1 irradiation might induce or aggravate abnormal skin changes in lupus patients. The specific dose and wavelength spectrum of UVA1 radiation delivered to the skin of a patient during phototherapy might be critically important as to whether UVA1 phototherapy might help or worsen lupus skin disease. Therefore, we believe that UVA1 phototherapy is at this time considered by most clinicians and investigators to be experimental and in need of further scientifically valid study. We fully support further systematic research on the clinical value of this type of photobiologic treatment in lupus. In addition to its effects on lupus skin disease, more valid research is needed on the effects of UVA1 phototherapy on the systemic manifestations of lupus. A primary mission of the North American Rheumatologic Dermatology Society is to foster and facilitate such research."
Q. Is there any medication that helps to clean the scar on lupus butterfly [rash]?
A. According to Dr. Andrew Franks, Professor of Clinical Dermatology at the New York University School of Medicine: "It depends on what is meant by 'clean the scar.' If the area is flat but is darkened, most lightening creams will not work because the pigment stain is not in the epidermis or top layer, but is in the dermis. Recently, laser technology has been shown to be more effective, particularly with IPL or intense pulse light. This technology also works on residual dilated red blood vessels similar to its use in rosacea.
If topographical scars are present there are a few ways to correct. If depressed, the scars can be filled in with hyaluronic acid such as Restylane. If elevated, the CO2 LASER is effective but only with a physician experienced with its use in lupus patients, as with all the above procedures. For example, here at NYU at our Cutaneous Lupus Center, we have performed all these procedures on selected patients who meet our criteria for best risk-benefit ratio."
Q. I was wondering if you could provide information on Chilblain's lupus. I would like to know general information, symptoms/diagnosis, and treatment information. Is it likely that Chilblain's lupus may develop into SLE? How can you really distinguish between Chilblain's and SLE if you experience symptoms of both and have a positive ANA?
A. Chilblains (or pernio) are itchy and/or tender red or purple bumps that usually come on from cold exposure but can sometimes be precipitated by sun exposure or smoking. They are considered to be a form of skin vasculitis (blood vessel inflammation). They can occur in people with lupus or in otherwise healthy people, especially children and the elderly. Hormonal changes and/or poor nutrition, poor circulation and bone marrow disorders are also associated with pernio. Some reports have associated this condition with antiphospholipid antibodies also.
They usually come on a few hours after cold exposure, often on fingers, toes, heels, nose or ears, get better by themselves over one to two weeks by just avoiding exposure to precipitating causes. Some people use topical steroids for this condition when it is more severe. Occasionally the more severe lesions could get infected so antibiotics would be in order.
They do not necessarily lead to any further disease in and of themselves. The best way to limit or help this condition is to keep extremities warm, don't smoke, eat an adequate, healthy diet, and above all do not smoke (also it is important to avoid second hand smoke). You probably would not be able to prevent this 100% but with reasonable care, this condition is usually kept in check.
Q. Is massage therapy a contraindication for those with cutaneous lupus?
A. In general, massage therapy will have no negative impact on cutaneous lupus. However, there are a few specific instances where caution is advised. Thus, intense or deep, vigorous massage may induce subcutaneous bleeding or visible bruising. This may invoke koebnerization, the process whereby cutaneous lupus may be produced at the sites. Another issue is the use of various oils during massage. If they induce an allergic reaction, cutaneous lupus may also activate at the sites, also due to koebnerization. While these issues may be uncommon, and the benefit of massage for musculoskeletal disease is positive, it is worthwhile for cutaneous lupus patients to be aware and prudent.
Q. Can patients with SLE have laser hair removal safely? If so, which kinds of lasers are better for our skin?
A. There is some concern about the use of lasers in patients with lupus because of the slight risk of skin redness, swelling, and pigmentary changes. These types of changes could potentially cause skin lupus to flare, although there is no data about the risk of this. There is no data about the safety of lasers in SLE. In a recent review of studies, long-term hair removal was not obtained with any treatment, so the question is whether the risk is worthwhile if there is a chance of flaring lupus. More systematic studies are needed in this area to give a definitive answer.
Q. I'm wondering if you are aware of any contraindications with respect to intense pulsed light therapy (or photo facials) and systemic lupus.
A. There is some concern about longer wavelengths of light, as found in intense pulsed light therapy, potentially exacerbating lupus. UVA1 has actually been used as therapy for some patients, but in one phototesting study in Britain, longer wavelengths of light (beyond UV), as might be found in intense pulsed light (IPL) therapy could cause induction of lesions. I think there is probably a variability of response between patients and that this area needs more study before one can say much about safety or even potential therapeutic use.
Q. I am an African American woman who is having significant hair loss. I have scarring and itching. I was wondering ... would I be able to relax my hair? Or what hair treatment can I use to braid my hair or weave my hair? I am bothered by the hair loss.
A. The less manipulation, the better. Any treatments that could irritate the scalp may lead to further itching and scarring. A braid or hair weave should be fine, although minimizing pulling on the hair is best. Thus a tight braid should be avoided. Another option is a wig and there are some elegant options available. Sometimes insurance will cover this if the hair loss if for a medical condition.
Q. Please explain a rare disease called panniculitis.
A. Lupus panniculitis or lupus profundus is a rare inflammation of the fat beneath the skin, leading to a lumpy, sometimes painful dimpling of the skin and the tissue beneath it. It is an extension of skin lupus. It is rare and sometimes slow to respond to treatment (normally treatment is with plaquenil and occasionally with steroids). The cause is not known. It is usually not associated with more severe internal lupus.
Q. Does lupus cause hair loss?
A. According to Daniel J Wallace, M.D. in The Lupus Book, "there are many reasons why lupus may lead to hair loss. First of all, active disease is associated with the plugging of hair follicles, which results in clumps of hair simply falling out after being combed or washed (called "lupus hair"). Patients with discoid lupus can experience mild, generalized hair loss, bald spots (alopecia areata), or even total baldness -— in the temples and on top of the head. Also, infections, chemotherapy, emotional stress, and hormonal imbalances are associated with hair loss. All told, about 30 percent of patients with SLE and DLE report significant hair loss."
"The treatment of alopecia depends on its cause. For example, discoid lesions respond to local scalp injections with steroid preparations. If these areas form thick scars, hair may not regrow. Tapering off steroid use eliminates the "balding" pattern. Antimalarials and corticosteroids promote hair growth. Minoxidil (Rogaine) solution is a blood pressure preparation that promotes hair growth in balding men. It promotes hair growth in male and female lupus patients but does not decrease hair loss."
Dr Victoria Werth during her LFA webchat on December 20, 2006 stated that "Usually when the lupus comes under control, the hair will regrow if the problem is diffuse thinning from either the lupus or medications (and not scarring). Usually people do not lose all their hair, and the problem is one of thinning but not complete hair loss."
Q. Is there any connection between lupus and occurrence of erethyma nodosum?
A. There is an increased incidence of erythema nodosum in lupus. There are other diseases where the association is stronger (inflammatory bowel disease, Behcets, sarcoid). The mechanism for the disease is unknown.
Q. I have a DLE and now diagnosed with Tinea Versicolor. Is this normal with DLE or SLE?
A. Tinea versicolor is a common fungal infection of the skin. It can occur in anyone, especially in warm climates, but someone with immune suppression may be more likely to get it.
Q. I have discoid lupus on my face cheek, and would like to know if laser treatment for removal would help for it to disappear and then I could continue on with medication so that my face remains clear? Like starting meds as if I was using the meds to prevent any more flare ups.
A. There are some reports of the pulse dye laser helping in lupus. This approach to treatment has not been studied in an organized way, and it is possible that some patients might actually flare.
Q. Is the skin disease Lichen Planus related in any way to lupus?
A. Lichen planus is usually a separate skin disease from lupus erythematosus. However, there are patients who have an overlap between cutaneous lupus and lichen planus, meaning that they have both types of skin lesions. Since skin lupus and lichen planus frequently look very different clinically and under the microscope, it is possible to tell the difference between them, even in the same person. Both diseases are caused by inflammatory cells that home to the skin, often forming a "band-like" infiltrate between the first and second layer of skin. There are some differences in the type of cells in the skin between the two conditions.
Q. Is treatment with lasers, collagen, restalyne, Botox or Thermage okay for people with either cutaneous or systemic lupus? What about microdermabrasion chemical peels and sclerotherapy for spider veins?
A. With the recent attention on plastic surgery and other cosmetic procedures, more people -- including those with lupus -- are questioning the safety of various skin treatments. Some may be considering dermatologic interventions for disease-related reasons, including side effects from lupus treatment (such as stretch marks) or from lupus itself (such as scars from discoid lupus).
However, a distinction should be made between reconstructive or reparative treatments for damaged skin and purely cosmetic procedures. Lupus patients in remission who are left with permanent scarring may be treated the same way as a person who has been in a car accident or in a fire. Certainly we are cautious with these treatments because any technique that manipulates the skin could reactivate the lupus. There are a number of criteria we establish before considering a person with lupus for these types of skin treatments.
First, the person's lupus must be in full remission -- and his or her rheumatologist and dermatologist must agree with the planned treatment.
In the last three to four years, pulsed-dye and other laser treatments have been particularly helpful in reducing the blood vessels caused by the lupus malar, or "butterfly," rash. This is the same technology that has been used on children with port-wine birthmarks on the face.
CO2 laser resurfacing of scars has also shown promise in selected patients. Again, all patients considered for laser treatment are pre-screened as outlined above. We also make sure that any drugs they are taking will not significantly delay healing. Striae (stretch marks) are a very troublesome problem subsequent to steroid treatment. No one technology works as well as we would like.
Collagen has been used for years to fill in scars in the skin, often caused by acne or burns. The use of collagen in lupus -- or any autoimmune disease -- has been quite controversial for many years. Dermatologists who treat lupus patients with collagen have not seen an increase in significant or unusual reactions, but caution is advised. And, although we pre-test everyone for any allergic reaction, there also can be problems if a person is on high doses of immunosuppressives or corticosteroids, since a false-negative test result may occur. Recently, a new form of collagen derived from a human cell line has been introduced, and no allergy pre-testing is required for its use.
The latest filler is Restalyne (pronounced REST-uh-lyn), a synthetic hyaluronic acid gel which is injected into the skin in tiny amounts with a very fine needle. A similar product has been injected into the joints of osteoarthritis patients. Restalyne is a natural substance, so theoretically there is should be minimal or no allergic reaction. However, since patients with lupus have increased levels of hyaluronic acid, or mucin (a characteristic of inflamed skin), we are proceeding carefully in treating such patients with restalyne. So far in our practice we have treated six such people with extremely low amounts of restalyne to monitor their responses. Over time, we feel this bioengineered filler will prove very useful -- especially for people who have scars that lasers cannot totally fill in.
As for Botox, we really don't have any issue with this as a skin treatment. In 2002 the FDA granted approval to use Botox Cosmetic (Botulinum Toxin Type A) as a treatment to reduce the severity of frown lines for up to 120 days. Small doses of the injectable form of sterile, purified botulinum toxin block the release of a chemical called acetylcholine by nerve cells that signal muscle contraction. The product is a protein complex produced by the bacterium Clostridium botulinum, which contains the same toxin that causes food poisoning, although there is no chance of contracting botulism from Botox injection. Since this treatment basically just paralyzes the muscles, no allergy testing is required, and it does not appear to have any side effects when used prudently.
Thermage (pronounced thur-MAJ), approved by the FDA in 2002, uses heat from a radio frequency device to tighten or lift the skin. It's currently being used in the eye and forehead areas. Heating up the skin causes new collagen to form -- a process similar to laser treatments. But thermage uses deeper, radio-frequency-produced heat rather than light-induced heat. So, theoretically, there is a greater possibility of reactivating skin involvement of lupus. Clinical trials are needed to determine if this treatment is safe for people with lupus.
Microdermabrasion is a relatively harmless procedure which addresses superficial skin problems such as blemishes and pore size. It should be used with caution to avoid potential reactivation of cutaneous lupus.
Finally, doctors are using injections of detergent-based sclerosing agents, or sclerotherapy, to reduce spider veins in the legs. Patients with lupus will be more susceptible to side effects such as local reactions and infection. This procedure is not recommended for larger blood vessels. Combination treatment with laser technology is sometimes helpful, but caution is advised until more studies are done.
NOTE: Any patient with clotting disorders, including the anti-cardiolipin antibody/antiphospholipid antibody and lupus anticoagulant should avoid these procedures.