From the Archives: Summer 2005 Lupus Now magazine
COLOR MATTERS: People of color may suffer more from lupus skin lesions
by Marie Karns
In the 1980s, Angela Holdredge, now 48 and living in Wilkes-Barre, PA, drove a cab -- often with her left arm hanging out of the window. Little did she know that years later the intense sun exposure from that habit would lead to scarring, discoloration, open sores, and fused joints on her arm and hand. Her skin, which was once uniformly brown, is now mottled with white patches. “I’ve had people ask me if I’m white or black,” she says.
Holdredge has systemic lupus, which can affect her internal organs and tissues, but she also has cutaneous (pronounced kew-TAIN-ee-us) lupus, which affects solely the skin, and can be seen either alone or in people with systemic lupus. Researchers are now linking ultraviolet (UV) radiation exposure to both the onset and flare-ups of cutaneous lupus.
According to Victoria P. Werth, M.D., a professor of dermatology and medicine at the University of Pennsylvania School of Medicine in Philadelphia, “Individuals of all races can have skin disease, scarring, and alopecia, but it’s pretty clear that African Americans have more of these problems.”
Werth and her colleagues theorize that in some ethnic populations, including African American and Hispanic, a number of genetic changes have occurred that increase the risk for developing specific types of skin lupus.
Defining Lupus of the Skin
The lesions, or sores, that result from cutaneous lupus can be divided into three types: chronic cutaneous lesions, also called discoid lesions because of their coin or disk shape; subacute cutaneous lesions, which are either red, scaly raised areas or are ring-shaped; and acute cutaneous lesions, which are flattened areas of red skin, usually on the face, that look like a permanent sunburn.
Cutaneous lupus can co-exist with systemic lupus, as in Holdredge’s case, but the likelihood of that varies depending on the type of cutaneous lupus. “Generalized chronic cutaneous lupus can be associated with underlying systemic disease about 20 percent of the time,” says Werth, “while subacute cutaneous lupus co-exists with systemic lupus about 50 percent of the time.”
People with systemic lupus who have skin involvement may have rashes that appear or get worse after UV exposure; one of the best known symptoms of lupus is the butterfly-shaped rash across the cheeks and bridge of the nose. Skin biopsies and blood tests that detect specific autoantibodies help diagnose lupus of the skin and also help distinguish it from other forms of skin disease.
Treating the Symptoms
Research carried out by numerous local, state, and federal agencies has shown that lack of access to healthcare can delay the diagnosis and treatment of complex illnesses like lupus; this in turn can lead to worsening disease. In addition, these disparities in access to healthcare and quality of health care are known to be more common in populations of color, as well as people in lower economic brackets.
This poses a significant problem for people with lupus who have skin disease, according to Andrew G. Franks, Jr., M.D., FACP, a clinical professor of dermatology and attending physician in rheumatology at New York University Medical Center in New York City. “The majority of people with skin lupus should be proactively treated because they can have significant disfigurement very rapidly,” Franks explains.
He says that antimalarial drugs like Plaquenil(hydroxychloroquinesulfate)are generally the first line of treatment, and about 70 percent of people with cutaneous lupus will go into remission with antimalarial treatment. However, some people have better responses with different types of medications, such as Thalomid (thalidomide), the anti-infective drug dapsone, or a combination of drugs. Topical corticosteroids such as Lidex (fluocinonide) also can help existing lesions heal.
Unfortunately, despite trying different combinations of medications, including Plaquenil, Holdredge’s cutaneous lupus has yet to go into remission.