From the Archives: Fall 2007 Issue of Lupus Now
Ask the Experts
Q. I recently had a skin biopsy. The biopsy report says, “Suggestive features of discoid lupus erythematosus [one form of cutaneous lupus].” Does that mean that it is lupus only? And is this an STD?
A. The language of a pathology report may vary from lab to lab. Sometimes a biopsy report that states findings are “suggestive of discoid lupus” means that there are some features in the tissue sample that may be seen in people with discoid lupus, but these features are not totally diagnostic for this skin disease. A biopsy showing discoid lupus could also be seen in people with other types of cutaneous lupus. In addition, dermatomyositis—an autoimmune disease that affects the muscles and causes a skin rash—can have biopsy findings identical to lupus. Discoid lupus is not a sexually transmitted disease (STD). It is caused by an abnormal response of the immune system, and is likely a combination of genetic and environmental factors.
—Victoria Werth, M.D.
Q. Is systemic lupus a degenerative illness that is going to get worse over time, or will it stay the same?
A. A degenerative disease is one with progressive degenerative changes in tissue, as in arteriosclerosis, diabetes, or osteoarthritis. Lupus is typically not characterized this way, but rather as an inflammatory disorder due to a malfunction of the immune system. If the inflammation is prolonged and not adequately controlled with treatment, it has the potential to cause scarring, and the organ affected may malfunction (as in kidney disease). This is why we emphasize treatment for the inflammatory phase of lupus, to prevent scarring and organ malfunction.
Furthermore, the inflammation is periodic—often it occurs for unknown reasons, but can be brought on by sun exposure. This is why we emphasize prevention by recommending the use of adequate sunscreens (SPF 30 or greater, applied frequently) and avoidance of sun exposure as much as possible (even on a cloudy or rainy day), as well as immunization to common viruses (flu vaccine) and bacteria (pneumococcal vaccine).
Flares can happen periodically—sometimes close together and sometimes far apart—and in some cases, the disease may be inactive for years. Flares are usually mild, but are sometimes severe.
We also recommend early, vigorous treatment of inflammation with NSAIDs, antimalarials (e.g., hydroxychloroquine), corticosteroids (e.g., prednisone), and/or immunosuppressives (e.g., cyclophosphamide, methotrexate, azathioprine, mycophenolate mofetil) to suppress inflammation quickly and effectively.
—Peter H. Schur, M.D
Q. My doctor told me that I have “stage 3 lupus.” What are the stages of lupus and what do they mean?
A. There are no “stages” of lupus. However, lupus nephritis—that is, lupus that affects the kidneys and renal system—is classified by the World Health Organization (and by the International Society of Nephrologists/Renal Pathology Society) according to various manifestations and disease activity.
—Ellen Ginzler, M.D., M.P.H.
Q. I have recently been diagnosed with lupus. I was wondering if there is any correlation between lupus and migraine headaches. Also, can massage therapy be beneficial for this?
A. Many people with lupus also have migraine headaches. The research on the relationship between lupus and migraine is split on whether the two are related.
Migraine is much more common in young women than in men, and so is lupus. It is possible that a person could have lupus and migraines that are not related to each other. Sometimes, though, the migraines do seem to get worse with a flare of lupus, and with treatment of the flare the migraines get better. It is important to remember, irrespective of whether the migraines and lupus are causally related, that medication to treat migraines in people without lupus works for lupus patients as well.
Regarding massage therapy, there has been no research that I am aware of about this form of treatment for migraine in people with lupus. We have been using relaxation techniques and biofeedback to treat migraine in people without lupus for years, to great benefit for some. I would certainly give this a try, and if it works, it is a great alternative to taking more medicine for the problem! n
—Robin Brey, M.D.
Q. Where can I get information on the tools used for diagnosing lupus? My wife had a series of tests, and her doctor indicated there were several markers they were looking at—this made me think they were genetic markers.
A. The word “markers” can refer to genes, but in this instance it more likely refers to a set of tests for autoantibodies and complement that may become abnormal in people with lupus. There are no genetic markers that accurately predict the presence of clinical lupus, or even a very high chance of developing lupus later.
The laboratory test marker for lupus used most widely is ANA (antinuclear antibody). The ANA is positive in more than 95 percent of people with lupus, and this laboratory finding usually precedes the disease by a few years. However, antinuclear antibodies are not specific for lupus, which means that the ANA test can be positive in many other medical conditions, and also in some people who are healthy.
Other antibodies, particularly antibodies to DNA and antibodies to Sm, are more specific for lupus than ANA, and your wife may also be tested for these. Low white blood cell counts, low platelet counts, protein in the urine, and low levels of complement may also be markers of lupus, although they, too, can occur in many medical situations unrelated to lupus.
The diagnosis of lupus is not made by analysis of genes at this time, although some genes that increase risk for disease are known. The presence of autoantibodies and complement levels are used most often to support the clinical suspicion that someone has lupus.
—Bevra Hahn, M.D.
Victoria Werth, M.D., is in the Department of Dermatology at the University of Pennsylvania School of Medicine in Philadelphia. She also is a member of the LFA Medical-Scientific Advisory Council.
Bevra Hahn, M.D., is chief of rheumatology in the School of Medicine at University of California-Los Angeles.
Peter H. Schur, M.D., is in the Department of Rheumatology at Brigham & Women’s Hospital in Boston. He is also professor of medicine at Harvard Medical School. He is a longtime member of the Lupus Now Advisory Board and editor of UpToDate in Rheumatology.
Ellen Ginzler, M.D., M.P.H., is chief of rheumatology in the SUNY College of Medicine at State University of New York-Downstate Medical Center in Brooklyn.
Robin Brey, M.D., is assistant dean in the Division of Neurology at the University of Texas Health Science Center-San Antonio. She is a longtime member of the Lupus Now Advisory Board and serves as president of the LFA South Central Texas Chapter. She also is on the LFA’s Medical- Scientific Advisory Council.