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Lupus and Skin Rashes

Most people with lupus have it affect the skin. The types of rashes can be divided into two large groups. First, when lupus affects the skin with problems only seen in lupus, it’s called cutaneous lupus erythematosus. When lupus causes rashes that can also be seen in other conditions, they are grouped under non-specific rashes seen in lupus. Learn how to recognize these conditions and keep your skin healthy.

What are the different types of cutaneous lupus?

There are 3 different types of cutaneous lupus (rashes that only occur in lupus patients). Each condition looks and feels different.

Chronic cutaneous lupus

There are many types of chronic cutaneous lupus. What they share is that they can last a long time (chronic), and they can cause permanent skin scarring. We will only mention discoid lupus since it is the most common.

Discoid lupus is so-named since the rash is often disc-shaped. The rash usually appears on the scalp and face, but sometimes it also appears on other body parts.

Only around 20% of discoid lupus patients also have systemic lupus erythematosus (SLE).

Discoid lupus sores are often red, scaly, and raised. Over time, these sores can cause scars, permanent hair loss, or skin discoloration (lighter or darker areas on your skin). Some patients with DLE have experienced itching, according to a 2021 study.

Working closely with a dermatologist and/or rheumatologist to treat discoid lupus and prevent permanent scarring and hair loss is crucial.

Subacute cutaneous lupus

Subacute cutaneous lupus is a rash with red, ring-shaped sores or scaly patches with distinct edges. The rash commonly occurs on the back, chest, and arms but sometimes extends to the buttocks. It does not affect the face or scalp very often. The rash usually does not scar (like discoid lupus), but it can cause skin discoloration. Subacute cutaneous lupus can occur by itself or as a complication of SLE. One of three cases of subacute cutaneous lupus is due to (or made worse by) commonly used drugs, such as proton pump inhibitors (like pantoprazole and omeprazole) and calcium channel blockers (like nifedipine and diltiazem). This can occur months to years after being on the causative drug.

Acute cutaneous lupus

Acute cutaneous lupus is a rash that happens when you have other lupus symptoms. As opposed to chronic cutaneous lupus, acute cutaneous lupus tends to come on quickly (acutely), doesn’t always last very long, and does not cause skin scarring. However, it can leave behind areas of skin discoloration, like with the subacute form above. Almost everyone with acute cutaneous lupus has systemic lupus erythematosus (SLE).

There are two main forms: localized and generalized.

You may have heard that some people with lupus get a “butterfly rash” or “malar rash.” This is the localized form of acute cutaneous lupus. The term refers to the rash being on the cheeks (malar areas) and bridge of the nose — so it’s shaped like a butterfly. Though many people think of this rash when they think of systemic lupus, the butterfly rash only occurs in around 30% of systemic lupus patients.

Generalized acute cutaneous lupus shows up as raised red rashes all over the body and typically occurs in sick SLE patients.

Non-specific rashes in lupus

Skin inflammation from lupus does not just cause the cutaneous lupus rashes mentioned above. Many SLE patients will have skin involvement with rashes that can occur in other inflammatory or autoimmune conditions. Considering that the mucosa in the nose and mouth are extensions of the skin, nose and mouth sores are two of the most common examples of nonspecific skin involvement. Other examples include hives (urticaria), angioedema, cutaneous vasculitis, skin ulcers, bruises, livedo reticularis, telangiectasias, palmar erythema (red palms), erythema nodosum, and vitiligo. These are too numerous and complicated to discuss here, but it is important to mention them since they do commonly occur in SLE patients.

Cutaneous lupus in people of color

Though lupus occurs much more frequently in people of color, there is a lack of photos on the internet. The Lupus Foundation is working on correcting this problem. The red and pink rashes that we commonly talk about occurring on light skin tones may appear dark purple or dark brown on dark skin tones, making them easy to miss by inexperienced healthcare providers.

Nonscarring Alopecia

SLE can cause reversible hair loss (nonscarring alopecia) and permanent hair loss (scarring alopecia). This photo shows a case of nonscarring alopecia. It was taken when her severe SLE was first diagnosed.

Thomas, Donald E., MD. The Lupus Encyclopedia: A Comprehensive Guide for Patients and Families. ©2014 The Johns Hopkins University Press. Reprinted with permission.

Nonscarring Alopecia Hair Growth

SLE can cause reversible hair loss (nonscarring alopecia) and permanent hair loss (scarring alopecia). This photo shows a case of nonscarring alopecia. After treatment, her SLE went into remission and her hair was almost completely grown back 12 months later.

Thomas, Donald E., MD. The Lupus Encyclopedia: A Comprehensive Guide for Patients and Families. ©2014 The Johns Hopkins University Press. Reprinted with permission.

Diffuse Patchy Alopecia with Scattered Erythematous, Thin Plaques

This photo shows patchy alopecia spread over the left side of the scalp with scattered red and scaly patches. There are also areas where the skin is darker (hyperpigmentation) and lighter (hypopigmentation) than the surrounding skin. This type of alopecia can get better with treatment, but it’s possible not all of the hair will grow back.

Photo courtesy of Joseph F. Merola, MD MMSc

Scarring Alopecia from DLE in SLE

This photo shows scarring alopecia from discoid lupus erythematosus. This patch of skin shows hypopigmentation (it’s lighter than the skin around it). The term scarring alopecia means that the hair follicles have been damaged by inflammation and the hair can’t grow back because of the damage.

Photo courtesy of Joseph F. Merola, MD MMSc

Pink Papules with Scale and Hyperpigmentation

On the inside and outside of the ear, as well as on the earlobe and cheek, there are thin pink papules with associated scale and regions of associated hyperpigmentation. Note the fine scale present in the scalp, and on the left side of the scalp the presence of erythema (somewhat obscured by hair shafts).

Photo courtesy of Joseph F. Merola, MD MMSc

Plaques and Papules

On both arms, violaceous to erythematous thin plaques and papules with associated fine scale. Lupus skin manifestations often appear dark brown or purple on darker skin.

Photo courtesy of Joseph F. Merola, MD MMSc

Vitiligo

Vitiligo is an autoimmune disease of the skin where the immune system destroys pigment-producing skin cells. It causes light-colored patches surrounded by normal skin. This patient of African ancestry also has SLE. It is common for SLE patients to have one or more additional autoimmune diseases (called overlap syndrome or polyimmunity). Dermatologists are having success treating vitiligo in many patients.

Thomas, Donald E., MD. The Lupus Encyclopedia: A Comprehensive Guide for Patients and Families. ©2014 The Johns Hopkins University Press. Reprinted with permission.

Hydroxychloroquine (HCQ) Hyperpigmentation

Long-term use of hydroxychloroquine (HCQ) can cause areas of increased skin pigmentation (typically bluish-black). These were on an older Black SLE patient who had been on HCQ for 10 years. It is due to HCQ depositing in the skin at areas of bruising, especially in patients on blood thinners. She was taking low-dose aspirin. It tends to be permanent but can decrease in intensity with lower HCQ doses.

Thomas, Donald E., MD. The Lupus Encyclopedia: A Comprehensive Guide for Patients and Families. ©2014 The Johns Hopkins University Press. Reprinted with permission.

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How can I keep my skin healthy?

There are steps you can take to protect your skin.

Protect yourself from UV rays

The ultraviolet (UV) rays in sunlight and some indoor lights can make rashes and other lupus symptoms worse. Learn how to protect your skin from UV rays.

See a doctor

A dermatologist is a type of doctor who treats skin health problems. There are many types of dermatology, such as cosmetic dermatologists and surgical dermatologists. It is important to find a dermatologist who knows a lot about lupus.

The best type of dermatologist for lupus patients is a medical dermatologist. Medical dermatologists specialize in caring for skin involvement from medical conditions, like lupus. A good way to find a medical dermatologist is to contact a dermatology clinic associated with a large medical center or teaching hospital, ask your rheumatologist, or search for one online who states they specialize in medical dermatology or lupus.

They can do tests to find out if your rashes or sores are related to lupus. Be sure to tell the doctor how long you’ve had the rash — and if you’ve noticed any changes in how it looks.

The dermatologist may take a sample of your skin called a biopsy. That way, they can look at the sample under a microscope to see the rash up close.

Realize that it is common to develop rashes for other things other than lupus, for example, drug reactions, allergies or sensitivities, or unrelated inflammatory problems, like eczema or psoriasis. It is imperative to have a correct diagnosis to get the correct treatment. Consider building a close relationship with a medical dermatologist in your area as your first point of contact for any new rash, and ensure they work closely with your rheumatologist (if you have one).

Lupus and the Skin

Treating Lupus Skin Problems

Video: Skin Lupus - Beyond the Butterfly Rash

Can you have a butterfly rash and not have lupus?