Butterfly rash: This rash appears on the nose and cheeks in the shape of a butterfly, skipping the skin under each side of the nose.
Lupus and your skin: Overview
Lupus is a disease that can affect the skin in many ways. It may cause a:
- Widespread rash on the back
- Thick scaly patch on the face
- Sore(s) in the mouth or nose
- Flare-up that looks like sunburn
Lupus can show up on the skin in other ways, too.
When lupus affects the skin, it is called cutaneous (medical term for skin) lupus. There are different types of cutaneous (cue-tane-e-ous) lupus. For many people who have cutaneous lupus, the lupus affects only their skin.
Some types of cutaneous lupus are more common in people who have systemic lupus erythematosus (SLE). SLE is a type of lupus that can affect different parts of the body, including the skin, joints, and lungs.
How a dermatologist can help
A dermatologist can tell you whether you have lupus or another skin condition. What looks like a lupus rash on your face could be another skin condition like rosacea or an allergic skin reaction.
If you have cutaneous lupus, a dermatologist can:
- Develop a sun-protection plan that’s right for you
- Create a treatment plan for your skin
- Recommend skin care products that are less likely to irritate skin with lupus
- Teach you how to camouflage lupus on your skin with makeup
- Help determine whether lupus affects other parts of your body
- Check your skin for signs of skin cancer
Lupus and skin cancer
Lupus can increase a person’s risk of developing skin cancer. If you take a medicine that works on your immune system, you may have a higher risk of getting skin cancer.
People who have a type of lupus called discoid lupus may also have a greater risk. When discoid lupus develops on the lip or inside the mouth, it increases a person’s risk for a type of skin cancer called squamous cell carcinoma.
Image used with permission of the American Academy of Dermatology National Library of Dermatologic Teaching Slides.
References:
Costner MI, Sontheimer RD. “Lupus erythematosus” In: Wolff K, Goldsmith LA, et al. Fitzpatrick’s Dermatology in General Medicine (seventh edition). McGraw Hill Medical, New York, 2008:1515-35.
Grönhagen CM, Nyberg F. “Cutaneous lupus erythematosus: An update.” Indian Dermatol Online J. 2014 Jan-Mar;5(1): 7–13.
Kuhn A, Rutland V, et al. “Cutaneous lupus erythematosus: Update of therapeutic options: Part 1.” J Am Acad Dermatol 2011 Dec;65:3179-93.
Okon LG, Werth VP, “Cutaneous lupus erythematosus: Diagnosis and treatment.” Best Pract Res Clin Rheumatol. 2013 Jun; 27(3): 391–404.
Discoid lupus: This often looks like a raised, thick, scaly patch. Most patches develop on the face, scalp, or ears. Treatment is important.
Lupus and your skin: Signs and symptoms
What’s the difference between cutaneous lupus and systemic lupus erythematous (SLE)?
Each is a different type of lupus. Cutaneous lupus affects the skin. SLE can affect the skin and other parts of your body, including the joints, lungs, and kidneys.
A person can have cutaneous lupus without having SLE. If you have lupus on your skin, however, it can be a sign that lupus is affecting other parts of your body. That’s why it’s so important to see a dermatologist for an accurate diagnosis.
Dermatologists have expertise in treating lupus on the skin.
Discoid lupus: Treatment can prevent scars and permanent hair loss.
Discoid lupus in the mouth: Lifelong skin cancer screenings are essential if discoid lupus forms in your mouth or on your lips.
Subacute cutaneous lupus: Some people develop a red, scaly rash that usually appears on the chest, upper back, or neck.
Subacute cutaneous lupus: This type of cutaneous lupus can also cause a rash that has a ring-like pattern.
Subacute cutaneous lupus: The skin can be so light sensitive that sunlight and even fluorescent light bulbs can trigger a flare.
Acute cutaneous lupus (ACL): A common sign of ACL is the butterfly rash, which can last for hours or days.
Lupus panniculitis: The first sign is often a rash with firm, deep, and painful growths, which reach into the fat beneath the skin.
Lupus panniculitis: In time, the inflammation often destroys the fat cells. This causes deep, recessed scars as shown on this woman’s arm.
ALupus tumidus (LT): Developing on skin that is extremely sensitive to sunlight, LT often feels like a smooth patch with raised borders.
Drug-induced lupus: Medicine can cause this type of lupus. The lupus usually clears when the drug is stopped.
Images 1-8 used with permission of the American Academy of Dermatology National Library of Dermatologic Teaching Slides.
Images 9-11 used with permission of Journal of the American Academy of Dermatology:
- Image 9: J Am Acad Dermatol. 2001;45(3):325-61.
- Image 10: J Am Acad Dermatol 2008;58:217-23.
- Image 11: J Am Acad Dermatol. 2012;66(4):673-9.
References:
Habif TP, Campbell JL, et al. Dermatology DDxDeck. (cards #103 and 104). Dermatology DDxDeck. Mosby Elsevier 2006.
Okon LG, Werth VP, “Cutaneous lupus erythematosus: Diagnosis and treatment.” Best Pract Res Clin Rheumatol. 2013 Jun; 27(3): 391–404.
Panjwani S. “Early diagnosis and treatment of discoid lupus erythematosus.” J Am Board Fam Med 2009 Mar-Apr; 22(2) 206-13.
Patel RM, Marfatia YS. “Lupus panniculitis as an initial manifestation of systemic lupus erythematosus” Indian J Dermatol. 2010 Jan-Mar; 55(1): 99–101.
Neontal lupus: This rash may look like the above or cause a ring-like pattern on the skin.
Lupus and your skin: Who gets and causes
Who gets lupus?
People of all ages and races get lupus. Women are more likely to get some types of lupus. The following explains who is most likely to get the different types of lupus.
Systemic lupus erythematous (SLE): This type of lupus can affect many organs, including the skin, kidneys, and joints.
Women are much more likely to get SLE. It often begins between 15 and 45 years of age.
Smoking may increase the risk of developing SLE.
Cutaneous (affects the skin) lupus: Several types of lupus affect the skin. Most types are more common in women and often appear between 20 and 50 years of age.
Drug-induced lupus: Caused by taking medicine, this type seems more common in men.
Neonatal lupus: With medical help from specialists, mothers who have lupus can give birth to healthy babies. Occasionally, a baby is born with neonatal lupus. This type of lupus usually disappears by the time the baby is 6 to 8 months old — and never returns.
A thorough checkup is important if a baby is born with neonatal lupus. Some babies with neonatal lupus have permanent heart disease and need a pacemaker.
What causes lupus?
All types of lupus are autoimmune diseases. This means that the immune system attacks the body. When a person has systemic lupus erythematous (SLE), the immune system may attack different parts of the body, including the skin, kidneys, and lungs.
What causes people to develop this type of autoimmune disease isn’t certain. It may be a combination of genes, environmental triggers, and hormones.
Anything that triggers your immune system to attack itself can cause lupus to flare. When lupus affects the skin, common triggers for lupus are:
- Sunlight
- Ultraviolet (UV) light from tanning beds and fluorescent light bulbs
- An infection
- Some medicines
- Stress
- Surgery or a serious injury
If you believe that you could have lupus, early diagnosis and treatment are important.
Image used with permission of the American Academy of Dermatology National Library of Dermatologic Teaching Slides.
References
Costner MI, Sontheimer RD. “Lupus erythematosus” In: Wolff K, Goldsmith LA, et al. Fitzpatrick’s Dermatology in General Medicine (seventh edition). McGraw Hill Medical, New York, 2008:1515-35.
Piette EW, Foering KP, et. al. “The impact of smoking in cutaneous lupus erythematosus. Arch Dermatol. 2012 Mar;148(3): 317–22.
Lupus and your skin: Diagnosis and treatment
When lupus affects your skin, a dermatologist may be part of your care team. This doctor specializes in diagnosing and treating conditions that affect the skin, hair, and nails.
How do dermatologists diagnose lupus on the skin?
When lupus affects the skin, a dermatologist will examine your skin. The doctor will look closely at the rash, patch, or other skin (or hair) problem. Your dermatologist may also ask if you have sores inside your mouth or nose. If you have these, be sure to tell your dermatologist.
Different types of lupus affect the skin. To learn which type affects your skin, your dermatologist may remove a bit of the diseased skin so that it can be examined under a microscope.
Removing the skin is a simple procedure, which your dermatologist can perform during an office visit. Called a skin biopsy, this procedure is often enough to determine whether the rash or other skin problem is cutaneous (medical term for skin) lupus.
Your dermatologist may also ask you about the medicines that you take. Some medicines can cause a type of lupus called drug-induced lupus. Be sure your dermatologist has a list of all the medicines you take.
How do dermatologists treat lupus on the skin?
To treat the lupus on your skin, your dermatologist will:
- Tell you how to protect your skin from the sun
- Prescribe medicine, if necessary
- Recommend other lifestyle changes
Medicines that dermatologists prescribe to treat lupus on the skin include:
- Corticosteroid that you apply to your skin or take as a pill: This helps to reduce the inflammation and clear the skin.
- Corticosteroid that your dermatologist injects: This can help clear a thick patch on the skin or area of hair loss.
- Antimalarial medicine: Developed to treat and prevent malaria, this medicine can also effectively treat lupus on the skin.
- Steroid-sparing medicine that you apply to your skin: This works like a corticosteroid to reduce the inflammation and clear the skin.
- Medicine that works on the immune system: These medicines include methotrexate, cyclosporine, and mycophenolate mofetil. They help calm the immune system.
Your treatment plan may include more than one medicine. This can increase how well the treatment plan works.
The goal is to clear the skin.
Preventing hair loss due to discoid lupus
If you have discoid lupus, clearing your skin can reduce your risk of scars, permanent hair loss, and discolored skin.
When discoid lupus forms on the scalp, you want to treat it early. Early treatment can prevent permanent hair loss.
To treat discoid lupus, your dermatologist may inject a thick patch with a corticosteroid to help it clear. An antimalarial medicine or a corticosteroid that you apply to your skin can help clear thinner patches.
If the patch turns into a scar, hair cannot regrow.
Drug-induced lupus requires different treatment
If your dermatologist thinks that a medicine you take is causing the lupus, you may need to stop taking the drug. You should work with your dermatologist or another doctor to find out.
Stopping some drugs like heart medicines can have serious consequences. You may need to start another drug or therapy immediately.
If you have drug-induced lupus, though, stopping the drug is the only way to find out. Testing cannot find out which drug is causing the lupus. If the lupus starts to clear a few months after you stop taking the drug, then the drug is likely the cause.
Drugs that most frequently cause drug-induced lupus are medicines used to treat high blood pressure like hydralazine and medicines used to treat heart disease like procainamide and quinidine.
Once the drug that causes the lupus is stopped and the symptoms clear, drug-induced lupus is considered cured.
When lupus on your skin clears
You may see unwanted side effects after a rash or other skin problem clears. Some people have dark or light spots on their skin. You may see a scar. If this happens, talk with your dermatologist. Your dermatologist may be able to treat these unwanted side effects.
Outcome: What can someone with cutaneous lupus expect?
Most people who have cutaneous lupus can lead active and productive lives. Treatment helps because it can clear the skin and reduce the effects that lupus has on your life. There is currently no cure for cutaneous lupus.
References:
Costner MI, Sontheimer RD. “Lupus erythematosus” In: Wolff K, Goldsmith LA, et al. Fitzpatrick’s Dermatology in General Medicine (seventh edition). McGraw Hill Medical, New York, 2008:1515-35.
Kuhn A, Gensch K, et. al. “Efficacy of tacrolimus 0.1% ointment in cutaneous lupus erythematosus: A multicenter, randomized, double-blind, vehicle-controlled trial.” J Am Acad Dermatol. 2011 Jul;65(1):54-64.
Kuhn A, Rutland V, et al. “Cutaneous lupus erythematosus: Update of therapeutic options: Part 1.” J Am Acad Dermatol 2011 Dec;65:(6)179-93.
Okon LG, Werth VP, “Cutaneous lupus erythematosus: Diagnosis and treatment.” Best Pract Res Clin Rheumatol. 2013 Jun;27(3): 391-404.
Vedove CD, Simon JC, et al. “Drug-induced lupus erythematosus with emphasis on skin manifestations and the role of anti-TNFα agents.” J Dtsch Dermatol Ges. 2012 Dec; 10(12): 889–97.
Sun protection is essential: If you have lupus, protecting your skin from the sun every day with sun-protective clothing and sunscreen can prevent lupus from worsening.
Lupus and your skin: Tips to reduce flares
Dermatologists share the following tips with their patients who have lupus on their skin. Some tips may seem inconvenient, but the payoff can make these lifestyle changes worthwhile.
These tips can help you:
- Reduce flares
- Prevent lupus from getting worse
- Lessen your risk of long-term skin problems and other conditions
- Lower your risk of kidney disease
10 lifestyle changes that can help
- Protect your skin from the sun. When lupus affects your skin, you may be very sensitive to the sun. Just a short amount of time in the sun can cause lupus to flare or worsen.
To protect your skin, dermatologists recommend the following:
Apply sunscreen every day before going outdoors.
The sunscreen should offer:
• Broad-spectrum protection
• SPF of 30 or higher
• Water resistance
To get the protection you need:
• Apply the sunscreen 15 minutes before you step outside.
• Slather sunscreen on all skin that will be exposed to the sun, such as your face and hands.
The sunlight that hits your skin when you walk to the bus stop or ride in a car can cause lupus to flare.
Wear sun-protective clothing every day.
Your dermatologist can recommend clothing that can do this. You can also find sun-protective clothing online.
Seek shade when outdoors.
This is especially important if you must be outdoors between 10:00 a.m. and 4:00 p.m. The sun’s rays are strongest during this time.
Even in the shade, you should wear sun-protective clothing and reapply sunscreen at least every 2 hours.
Even on overcast days and in the winter, the sun’s rays can trigger lupus.
If you spend a lot of time in the car or sit next to a window, you should also protect your skin from the sun. Regular glass lets in some of the sun’s ultraviolet (UV) rays. - If you lie in the sun or use tanning beds, stop. Tanning exposes you to harmful UV rays. The UV rays that tanning beds emit can be stronger than the sun’s rays. This intense exposure can cause lupus to flare. It can eventually lead to organ failure.
- If you smoke, quit. Findings from research studies suggest that smoking worsens cutaneous lupus and makes some medicines used to treat it less effective — or ineffective. Studies have also shown that when patients quit smoking, the medicine that failed to clear their rashes and other skin problems starts to work.
Quitting can seem overwhelming. You’ll find resources to help you quit at smokefree.gov. - Stop touching the patches and rashes on your skin. When you touch, rub, or pick at the rashes, sores, and patches, new ones can develop.
- Replace fluorescent, compact fluorescent, and halogen light bulbs. These light bulbs emit some UV light. If you are very light sensitive, this UV light can cause a flare or itchy skin. Replacing these bulbs with an incandescent bulb can help.
If you cannot replace the bulbs, a UV light filter may help. Some people say this filter reduces the skin flares and itching that occur when they spend hours under fluorescent lights, such as at work.
If you cannot replace bulbs or get a UV filter, you may want to wear a wide-brimmed hat, sunscreen, and sun-protective clothing while indoors. - Before taking a medicine, ask if it can increase light sensitivity. Some medicines make a person more light sensitive. If the medicine makes people more light sensitive, ask your doctor if you could take another medicine.
- Ask your dermatologist if you need a vitamin D supplement. Our bodies need vitamin D for healthy bones. If you are not getting enough, you may need to take a supplement. A blood test can tell your dermatologist whether you’re getting enough vitamin D.
- If you see anything on your skin that is changing in size, shape, or color, make an appointment to see your dermatologist. These can be signs of skin cancer. Some types of cutaneous lupus increase a person’s risk of developing skin cancer. With early detection and treatment, skin cancer has a high cure rate.
- Before trying an herb, vitamin, or other alternative treatment, tell your dermatologist. Some of these may interact with medicine you use to treat lupus on your skin, causing unwanted side effects.
- Connect with others who have lupus. You can find others who have lupus on Facebook, Twitter, and other social media sites.
You may find a lupus support group in your area or online at:
Lupus Foundation of America
Local chapters across the U.S.
Molly’s Fund
Support groups for patients, friends, family, and caregivers
Related resource:
Q&A with Dr. Victoria Werth - Photosensitivity in cutaneous lupus
References:
Klein R, Moghadam-Kia S, et al. “Quality of life in cutaneous lupus erythematosus.” J Am Acad Dermatol. 2011 May;64(5):849-58.
Kuhn A, Gensch K, et. al. “Photoprotective effects of a broad-spectrum sunscreen in ultraviolet-induced cutaneous lupus erythematosus: A randomized, vehicle-controlled, double-blind study.” J Am Acad Dermatol. 2011 Jan;64(1):37-48.
Kuhn A, Rutland V, et al. “Cutaneous lupus erythematosus: Update of therapeutic options: Part 1.” J Am Acad Dermatol 2011 Dec;65(6):179-93.
Okon LG, Werth VP, “Cutaneous lupus erythematosus: Diagnosis and treatment.” Best Pract Res Clin Rheumatol. 2013 Jun; 27(3): 391–404.
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