From the Archives: Summer 2006 Issue of Lupus Now Magazine
Ask the Experts
Q: If you don’t get the rashes associated with lupus, do you really need to avoid the sun?.
A: This is indeed a good, and common, question. Not all people with lupus develop rashes when in the sun, but most do. Some may not immediately develop a rash from sun exposure, only to develop one years later. What I recommend is prudence and caution. Too much sun exposure is bad because of the risk of developing skin cancer; the risk for a person with lupus is not just a rash, but an exacerbation of systemic symptoms—even renal disease.
Therefore what I recommend, if one really wants to be in the sun, is to start exposure gradually and slowly increase it, but stop if any rash or fever or any adverse symptoms develop. Basically that means going out in the morning or late afternoon, with SPF 30 sunscreen, for about 10 minutes, for one day. If nothing happens over 48 hours, one can increase to 20 minutes. As long as nothing happens one can increase in 10-minute increments, always avoiding the midday sun. I always would tell people to avoid sunbathing and tanning parlors because of the high level of exposure and high risk of not only a lupus flare but of skin cancer. Remember: "Pale is Beautiful." –Peter Schur, M.D
Q: I eat lots of green, leafy vegetables but my lupus blood tests still show that I am severely anemic. What else can I eat or do to correct this?
A: Eating a lot of green, leafy vegetables is a good start. Foods such as spinach and broccoli are reasonably good sources of iron. However, these foods contain a type of iron called "non-heme" iron, as opposed to "heme" iron, which is found in meat, fish and poultry (liver is a particularly good source). Heme iron is much better absorbed than non-heme iron, meaning that your body uses it more efficiently. The absorption rate for non-heme iron depends on other components of your diet, which can either increase or decrease the rate of absorption. Dairy products (because of the calcium), foods that are high in fiber, and items such as tea and coffee (which contain tannins) can reduce the amount of non-heme iron that your body absorbs by as much as 50 percent. On the other hand, vitamin C can help to increase the rate of non-heme iron absorption. This is why it's a good idea to have a breakfast of iron-fortified cereal with orange juice but no coffee! In general, try to include a variety of foods in your diet to increase your total dietary iron, include a source of vitamin C at every meal, include meat, fish or poultry in several daily meals, and avoid excessive amounts of coffee or tea (and if you do drink these beverages, consume them between meals rather than with meals). – Laura A. Coleman, Ph.D., R.D.
Q: What does a malar, or "butterfly" rash feel like? Does it itch, burn, or peel?
A: First, it's important to know that the malar rash comes in three basic types: 1) acute, subacute and chronic, with acute occurring in conjunction with systemic lupus; 2) subacute occurring with subacute cutaneous lupus (SCLE); and 3) chronic, which is mostly the discoid (disk shaped) type. Now, the question can be answered more clearly.
1. Individuals with systemic lupus and an acute malar rash will frequently feel a burning warmth on the face, not unlike a heat flush.
2. Individuals with SCLE will have the papulosquamous or annular polycyclic rash—not unlike psoriasis or a drug rash—and frequently will have low level pruritus (itching due to irritation of sensory nerve endings).
3. Individuals with chronic malar rash mostly will have a discoid rash that is usually painless without any sensation whatsoever.— Andrew Franks, Jr., M.D.
Q: What amount of protein loss in a 24-hour period would make my doctor concerned about my lupus nephritis worsening?
A: There is no single answer to this question. Having proteinuria—the presence of excess protein in the urine—is always abnormal, but sometimes it is benign. If a person with lupus has never been given a diagnosis of lupus nephritis and they have over 500 mg of protein per 24 hours they should alert their rheumatologist or a nephrologist. If a person has a past history of lupus nephritis and then has an abrupt doubling of proteinuria they should be concerned about a possible recurrence of the disease.
Having said that, proteinuria is a poor predictor of the type of lupus nephritis a person has. In other words, the class of lupus nephritis cannot be predicted by the amount of proteinuria, the level of anti-doublestranded-DNA antibodies, or the amount of hematuria (the presence of blood or blood cells in the urine). Patients are encouraged to be their own advocates and pursue a workup for lupus nephritis if they suspect proteinuria has developed. Signs to look out for are edema, or swelling, in the feet, ankles, and lower legs, in addition to swelling of the eyelids and the hands. And, while this is very imprecise, very foamy urine is a possible indication of protein in the urine. The protein always causes more prolonged bubble formation and will literally look like a head of beer.—James Tumlin, M.D.
Peter Schur, M.D. is a rheumatologist in the Department of Rheumatology/Immunology at Brigham and Women's Hospital in Boston, MA, where he also is co-director of the Lupus Clinic.
Laura A. Coleman, Ph.D., R.D. works at the Epidemiology Research Center of the Marshfield Clinic Research Foundation in Marshfield, WI. She is a member of the Lupus Now Advisory Board and the LFA Materials Review Panel. She is a frequent contributor to the “Ask the Experts” column.
Andrew Franks, Jr., M.D. is both a dermatologist and a rheumatologist. He practices and teaches in New York City. He is a member of the LFA's Medical-Scientific Advisory Council and frequently presents the dermatology lecture at the continuing medical education sessions that LFA holds around the country.
James Tumlin, M.D. is an Associate Professor of Medicine at Emory University in Atlanta, GA, and he is the Director of Clinical Nephrology at the Emory Clinic. He also is a member of the LFA's Medical-Scientific Advisory Council and frequently presents the nephrology lecture at the continuing medical education sessions that LFA holds around the country.