Makindo Medical Notes

Related Subjects: |Systemic Lupus Erythematosus (SLE) |Drug induced Lupus Erythematosus |Discoid lupus erythematosus (DLE) |Neonatal Lupus Erythematosus

Classical findings include indurated plaques, scarring alopecia and hyperkeratosis over the hair follicles.

Lupus Rash

About

• 20-40 per 100,000 affected

Aetiology

• Disordered immune response
• Females > males x 5
• Commoner with darker skin
• More severe in smokers

Causes/Precipitants

• Genetic predisposition
• Sunlight in past few weeks
• Smoking, Hormones

Clinical

• Lesions are discrete plaques, often erythematous
• Covered by scales that extend into dilated hair follicles.
• Tend to occur on the face, scalp, in the pinnae, behind the ears and on the neck.
• They can exist in areas not exposed to the sun.
• Lesions can progress, with active indurated erythema at the periphery.
• Central atrophic scarring is characteristic.

Investigations

• FBC, U&E, LFT, CRP
• ANA: usually in low titre, Extractable nuclear antibody (ENA). Autoantibodies in 50%
• Anti-annexin 1 antibodies-these may be a diagnostic marker for DLE
• Skin Biopsy: interface and peri adnexal dermatitis, follicular plugging, atrophy and scarring. Direct immunofluorescence is often positive. Positive lupus band test.

Prevention Management

• Preventative measures: reduce the chance of flares of DLE with year-round protection from sun exposure using clothing, accessories and thickly applied SPF 50+ broad-spectrum sunscreens. Sunscreens alone are not adequate. Some patients may also need to stay away from glass windows or these can be treated with UV-blocking films. Vitamin D supplements should be recommended for those who strictly avoid the sun. Smoking cessation.

Topical Management

• Steroids: potent topical corticosteroids applied accurately to the skin lesions for several weeks. Potency should be selected to suit the body site and thickness of the plaque. Very potent topical steroids may cause thinning of the surrounding skin and increase blood vessel formation (telangiectasia). Intralesional injections of corticosteroids are sometimes used, especially for hypertrophic DLE.
• Calcineurin inhibitors tacrolimus ointment can also be used.
• Camouflage makeup is useful to improve appearance.

Systemic Management

• Hydroxychloroquine and other antimalarials response rates are about 80% in CLE. It is thought to be less effective in smokers.
• Systemic corticosteroids such as prednisone or Prednisolone
• Others: Methotrexate, Retinoids isotretinoin and acitretin, Mycophenolate Azathioprine, Dapsone

References

• Excellent New Zealand Dermatology site