From the Archives - Summer 2008 Issue of Lupus Now
Q. I was diagnosed with systemic lupus 12 years ago. Last year I gave birth to a baby boy who developed a skin rash with a circular shape all over his head. It lasted about three months. I took him to a dermatologist who said it was psoriasis, but now I am wondering if it may have been neonatal lupus. Is that a sign of a baby having lupus? Is it possible that he has lupus still? He is one year old now and has never had the circular rash again but he has red blotches on his head that never went away.
A. Your question regarding the possibility that neonatal lupus may be the diagnosis accounting for the baby’s skin rash is very important. Indeed, this is a very likely possibility. The first consideration is whether your blood has antibodies to proteins called SSA/Ro or SSB/La. These antibodies are almost always present in the mother’s blood when a baby develops this rash. (In more rare cases there may be antibodies to another protein, called RNP.)
The rash you describe can first appear at birth but is even more likely to first be noted several weeks after birth, and is often made worse by exposure to sunlight. The rash usually involves some area of the baby’s face, with the most characteristic feature being prominent red areas around the eyes, giving a sort of raccoon appearance. The rash is characteristically circular, may be scaly, and can involve the scalp. It can be misdiagnosed as cradle cap, fungus, and other dermatologic conditions. In rare cases the rash can be present on other parts of the body.
The rash usually disappears by the time the baby is six months old (or even sooner), because that is when the maternal antibodies are cleared from the baby’s circulation. The good news is that, in general, there is no need for treatment and the rash usually does not result in any permanent skin scarring.
However, the persistence of red blotches on your baby’s head is unusual and you may want to again discuss this with your dermatologist. A biopsy may be helpful since this rash is lingering a bit too long.
To clarify the term “neonatal lupus”: this term was coined because the rash can look like the rash seen in adult lupus. However, it does not mean that the baby has lupus. In fact the chances of a baby developing lupus are very slim—probably less than 10 percent.
One of the important reasons for knowing about neonatal lupus and whether you have anti-SSA/Ro or SSB/La antibodies is because of the potential these antibodies cause for you to have a baby with heart problems. Two percent of infants whose mother has these antibodies are at risk for a condition called congenital heart block. This condition is far more serious than the skin rash and can be permanent. Normally a fetal heart beats at 140 per minute, but if there is a heart block, the rate may drop down to less than 80 beats per minute. Therefore any woman with these antibodies should have her infant’s heart monitored with fetal echocardiograms which may pick up early warning signs. Also, if a woman has had a previous child with heart block, the risk of having another affected child with this condition climbs to 18 percent.
In your case it is also important to note that the presence of a rash in a first baby can also pose an increased risk for heart block in the next pregnancy—about 12 percent or slightly higher. There is currently a national ongoing study utilizing intravenous gamma globulin to prevent heart block in pregnancies of woman who have had previous babies with either heart block or skin rash.
For more information on neonatal lupus visit the National Research Registry for Neonatal Lupus Web site at neonatallupus.com.—Jill P. Buyon, M.D.
Q. Is the effect of dehydration, either mild or moderate, a greater potential problem for those with lupus than the general population? And can being dehydrated cause lupus to flare?
A. People with lupus could be more susceptible to the damaging effects of dehydration for the following reasons:
- Dehydration can worsen kidney function, a problem in particular for those with any kidney disease or involvement.
- Some people with lupus have autonomic nerve issues resulting in hypotension, meaning that their blood pressure drops when they simply stand up. Dehydration could definitely lead to complications for them.
- Being dehydrated may increase fatigue.
- Being dehydrated may have a negative impact on the body’s ability to clear medication from the system.
In addition, prolonged dehydration can lead to an increased heart rate, and could perhaps stress the body in a way that could increase the chances for, or the effects of, a flare.—Susan Manzi, M.D., M.P.H.
Jill P. Buyon, M.D. is Vice Chairman of the Division of Rheumatology and Professor of Medicine at New York University School of Medicine and Director of the SLE Clinic at the Hospital for Joint Diseases. She has been a member of the magazine’s Advisory Board since it began in 2003.
Susan Manzi, M.D., M.P.H. is Associate Professor of Medicine and Epidemiology and Co-Director Lupus Center of Excellence at University of Pittsburgh Schools of the Health Sciences. She is a member of the LFA’s Medical-Scientific Advisory Council.