"Your Skin & Lupus" Chat Transcript for Dr. Andrew Franks

Moderator
Good afternoon. The Lupus Foundation of America is pleased to welcome Dr. Andrew Franks.

Dr. Franks is Clinical Professor of Dermatology and the Director of the Connective Tissue Disease Section of The Skin & Cancer Unit at New York University Medical Center and continues to train other dermatologists, rheumatologists, and students in this specialty.

Dr. Franks is one of the few physicians in the country who holds board certification in Dermatology, Rheumatology, and Internal Medicine. Over the past twenty five years he has earned a distinct reputation in the area of "skin manifestations of autoimmune disease" with particular emphasis on lupus erythematosus, scleroderma, morphea, dermatomyositis, Raynaud’s syndrome and related disorders. He is regarded as a leading clinical expert in this field and has published numerous articles and textbook chapters and lectured extensively during the course of his career.

Dr. Franks has received numerous honors including the NYU Alpha Omega Alpha Distinguished Clinical Teaching Award, and is also listed repeatedly in Best Doctors by Castle Connelly and New York Magazine. He is a Diplomat of the American Boards of Dermatology, Internal Medicine and Rheumatology, and is a Fellow of the American College of Physicians, American College of Rheumatology, and the American Academy of Dermatology. He is also a Founding Fellow of the American Rheumatism Association.

We welcome Dr. Franks, and thank him for joining us this afternoon.

Without further delay, let's begin. The first question comes to us from Tennessee.

Moderator
I have been diagnosed with lupus profundus. I have had it for years but it has just become active in my upper arms. I felt horrible months before my arms became inflamed. I am on Plaquenil and a small dosage of prednisone. Since I felt badly before the inflammation, could I possibly have systemic lupus also? Are my odds high for systemic lupus? -- Smyrna, TN

Dr. Franks
One of the first questions asked from a person first diagnosed with skin lupus is “what are the chances that I will develop systemic lupus erythematosus?” Generally what most lupus specialists assess are:

Does the person have lupus skin lesions below the neck
Are there other types of rashes that are commonly found concurrently with lupus, such as vasculitis
Does the person have generalized joint pain
Are there high levels of ANA or a positive dsDNA antibody, and
Is there evidence of renal involvement such as protein or blood in the urine?

If one or more of these “markers of transition” are found then the likelihood of systemic lupus increases and the person is evaluated more frequently for evidence of systemic involvement.

Moderator
I have a question concerning the sun and lupus. I own a jewelry company where I design and make my jewelry. All summer long I am going to be out in the sun doing street festivals. We are only allowed a canopy big enough for our tables, and the chairs we sit in are in the direct sunlight for 8 to 10 hours straight. I had heard that sunscreen does not help lupus patients since it is a blood disorder. Is this true? Also could you give me some sound advice on skin care? Several times already I have gotten really bad cases of sunburn. I have the lupus that is not discoid. -- Jamestown, NC

Dr. Franks
Prevention of skin lupus is not possible 100% of the time, but there are definitely some tips to avoiding flare. Sunscreens and more importantly sun precaution is always advised. There is no sunscreen that can completely block out ultraviolet radiation. Smoking is an important trigger for skin lupus of the scalp, face, and neck and makes it less likely that antimalarial treatment will be effective. Medicines and supplements for other conditions that a person is taking may increase the possibility of sun sensitivity and may have to be modified or avoided. Hormonal changes may have an effect on disease activity and this may need to be addressed. Sun protective clothing may be your solution when you sell your jewelry.

jingles
I develop acne on my arms, and around elbows, whenever my doctor reduces my dose of prednisone from 7.5mg to 5mg. My doctor doesn’t want to increase prednisone only for this, since I don’t have any other symptoms. We tried benzoyl peroxide but it didn’t help. Can you please suggest something?

Dr. Franks
You may do better with salicylic acid as opposed to benzoyl peroxide since the latter is more irritating and photo-sensitizing. There are many over the counter products that you can use that contain 2 - 4 % salicylic acid.

pom
I have had lupus SLE for 9 years. Two years ago I had breast cancer. Ever since I had my breast removed I have had a constant flare with my skin. Rash, hives, burning and itching. I have had my skin biopsy, and they have said dermatitis, and some vasculitis. Is this lupus related? If so, what can be done?

Dr. Franks
Pom … there are a number of reasons that this may have happened. Did you receive radiation or chemotherapy? If so, that would influence a chronic dermatitis. Also, did you have your ovaries removed or were you put on any hormonal manipulation?

pom
No chemo or radiation. I had one ovary removed in 2003. They did put me on Arimidex.

Dr. Franks
Yes, the Arimidex is a hormonal medication and may cause dermatitis in some individuals.

Meg
Hello Dr. Franks. I have discoid lupus. What can be done about facial scarring from lesions? At one point I had a prescribed skin lighting cream for the darker spots; I didn't find it very effective. Can anything be done about the depressed or sunken in scarring due from burnt out lesions?

Dr. Franks
We are doing a lot of work here at NYU on people like you who have had scarring from lupus. First, the dark areas generally do not respond to the bleaching creams because the pigment is too deep. We have currently utilized laser technology to correct the pigment disorder. Second, the depressions caused by lupus can be treated with fillers such as hyaluronic acid and greatly improve the contour of the depressions. Of course, the lupus must be in remission and we always confer with your lupus specialist before proceeding.

jmj
Does that laser technology work for people with darker colored skin?

Dr. Franks
We are currently working with laser technology that works on darker color skin. The results are promising, but we do need some further testing before I would recommend attempting treatment. We have a Skin of Color Center here at NYU that concentrates on this issue.

KarinE
I have always been sensitive to the sun, but over the past four days I have developed horrible thick scaly patches on my face. It has been very painful, and my doctors aren't sure if it’s because of sun exposure or another kind of infection. Does this sound like something lupus could cause?

Dr. Franks
It could possibly be related to lupus, but sounds like other things such as infection or allergy to sunscreen etc. should be ruled out.

Rose
Is itching skin -- off and on -- a lupus symptom, or is it from Livedo Reticularis or APS?

Dr. Franks
Itching may be a manifestation of any of the three conditions you have mentioned, but in general lupus does not cause intractable itching.

jingles
My dermatologist put me on some topical steroid ointment, but that led to itching and worsening of the acne. Will salicylic acid still work? Also what can be done about stretch marks?

Dr. Franks
Yes, the salicylic acid may still work.

flash
I have had “sore mouth” for the last six months. I really believe this is related to my lupus because I never had this until I had my first flare up. Is there anything that can help with this problem?

Dr. Franks
Yes, oral erosions are not uncommon in lupus, and may be painless or painful. There are a number of treatments for this, but they vary by the exact nature of the lesions from swish and swallow type meds to pills. For example, some patients may require using a steroid containing swish solution if necessary.

ash
I have had SLE for 25 years. I recently had a vasculitic rash on my legs which went away with 20 mg a day of prednisone. Is this manifestation more of a skin issue, or more of a systemic issue?

Dr. Franks
Good question! Since this is a new finding in you, further studies should be done to determine the cause of the vasculitis. In some people, it is only a skin feature, whereas in others it may indicate a flare of SLE.

Cecilia
Is LymphoStat intended to replace Plaquenil, and when will it be commercially available?

Dr. Franks
No, Plaquenil is still considered the drug of choice for cutaneous lupus, and it has a number of different actions that LymphoStat B may not do.

Law lady
I was diagnosed with SLE and discoid lupus about 5 years ago. Sometimes the discoid lupus rashes appear in the back of my hair line. These rashes seem more swollen than the ones that appear on my chest area. When this happens I get severe headaches. Is there any correlation between the headaches and the rashes?

Dr. Franks
Generally the scarring alopecia of the scalp is not related to the headache but it can correlate with global disease activity.

colleen
Is it possible for skin rash to spread to other areas not exposed to sun?

Dr. Franks
Your question suggests that does sun exposure to other areas of the body increase the risk of lupus rash on other non sun exposed areas. The answer is controversial, but we suggest sun precautions in general. Lupus lesions are not contagious but can occur from trauma such as burns, infections or scratching.

nancyjones
So … lesions can be an indication of SLE as well as discoid?

Dr. Franks
Yes, the lesions which occur below the neck area suggest an increased incidence of systemic disease. Discoid lesions may occur in up to 30% of patients with SLE.

shoulder
I was diagnosed with discoid lupus 8 years ago and have never gone into remission. I find that the lesions in my scalp get really inflamed and sore around my menstrual cycle. Is that normal?

Dr. Franks
Many women note changes in lupus activity with their cycle. Some flare pre-menstrually, others during ovulation, and others at other times of the cycle. We know that estrogen and progesterone influence skin lupus activity.

Meg
I've had some pulse dye laser treatments, but can you explain how the hyaluronic acid treatments are administered? And how it works? Any side effects? Thanks so much!

Dr. Franks
The fillers such as hyaluronic acid work to fill contour deficits and are not for the blood vessels which you had with the PDL. As always, any reconstructive or cosmetic treatment can have side effects, but so far our lupus center at NYU has been successful in this regard and minimized any problems to patients as long as they are in remission and have no other complicating issues.

hmom
My 14 year old daughter was diagnosed with SLE 2 years ago. She frequently gets lupus “spots” on her face about the size of a quarter. When we discuss this with her rheumatologist, he says there really is no need for her to see a dermatologist since this is just a symptom of her SLE. In your opinion would a dermatologist be beneficial to her?

Dr. Franks
Many rheumatologists are very well versed in lupus of the skin and yours may be one of them. However, a second opinion never hurts.

Awita
Hi Dr. Franks. I was diagnosed with SLE lupus about 4 years ago. My biggest problem so far is the intense skin "burning tenderness.” I get it from time to time and it lasts about 24 hrs. It hurts when I shower or when I'm touched. What is this about? My doctors cannot explain it. Please help.

Dr. Franks
I need to know what medications you are on as this may be a side effect of one of them.

Awita
I'm on Plaquenil. Sometimes I’m given Naproxen for migraines but that’s it.

Dr. Franks
Naproxen is probably the culprit as this causes photosensitivity. Remember that Alleve also contains Naproxen.

Leah
My skin cannot breathe with any type of sunscreen or lotion on it. Even dry skin areas. Do you know of any "breathable" type sunscreen? I have very low tolerance for heat, so covering more with clothes seems unbearable.

Dr. Franks
All the new spray sunscreens have little residue on the surface and are very much acceptable to people like yourself who find the average cream too thick. I'm the same and use the sprays when I play golf or tennis.

beth
I thought laser treatments were contraindicated in persons with lupus?

Dr. Franks
The laser treatments vary as there are more than 100 different types of laser technology. The lasers we use at NYU have been safe and effective in our hands and when the patients have been chosen correctly to minimize side effects.

Moderator
I've read about lupus chilblains on the fingers, toes, ears, etc. I have APS and SLE and often get small, red-purple nodules on the inside of the cheeks of my mouth which become crater-like, painless ulcers when the nodule disappears. Are these related? -- Rehoboth, MA

Dr. Franks
Absolutely. What you have is also called perniosis and is due to the vascular instability caused by the APS. This is often benefited by Plaquenil and also low dose aspirin.

Moderator
Are symptoms of scleroderma and skin lupus related?

Dr. Franks
There can be some overlap in the skin findings of the two. Loss of pigmentation and hyperpigmentation with hardening may be seen in both. A biopsy will help.

noel5
I have had discoid lupus for years. Recently the flare ups underneath my eyes have become so bad that my skin becomes extremely swollen and very sore to the touch. I currently take Plaquenil, prednisone, and use protopic. My dermatologist is suggesting Imuran. What are your thoughts on this particular drug? Some of the research I have done has me scared to try it!! What are some other alternatives?

Dr. Franks
First, we should be certain you don't have any overlap component with dermatomyositis which targets the eyelids. If not, periocular discoid lupus may be recalcitrant to standard treatment and we have had success with low dose Imuran or CellCept.

ginny
I was diagnosed with SLE and discoid lupus and have been on prednisone and Plaquenil for almost thirty years. (I have also had blood clots and am on Warfarin almost as long.) In the past year or so I have begun to develop all sorts of rashes -- the one on my chest tests in biopsies as lupus, another on my face as rosacea, and an aggravating itchy hive-like rash with scabbing all over my scalp that has yet to be diagnosed. The rheumatologist, dermatologist, and general practitioner don't have any solutions for the itchy scalp. What kind of doctor should I even be seeing? Can these be caused by long-term medication use, or is it from the lupus? Any ideas?

Dr. Franks
It mostly likely is caused by the lupus, which targets the hair follicles and the inflammation is manifested as itching and scale. Some dermatologists specialize in hair and may be able to better define the condition for you and devise a more specific treatment. We have a hair center here at NYU that deals with these types of issues.

Moderator
I have tumid lupus. The lesions I get on my arms, face and neck are always much smaller and less vivid in color as the ones on my abdomen and chest area. Why the difference? Also, why do some of them hurt severely when pressed while others have no pain or itching at all?

Dr. Franks
Tumid lupus is a form of chronic cutaneous lupus that doesn’t scar but can have varied clinical manifestations. It is treated the same way as discoid lupus and responds to Plaquenil. Some may be more painful if they rest over or near a blood vessel, as the nerves are more focused in these areas.

Moderator
That is all the time we have for today’s chat. Thank you to Dr. Andrew Franks for joining us.

Please join us Wednesday, September 9 at 3 p.m. Eastern Time for our guest Mr. Ken Getz, who will discuss participating in a clinical trial.

Help spread the word about our lupus chats. Enjoy your August, and we’ll see you here in September.