Cutaneous Involvement in Systemic Lupus Erythematosus: A Review for the Rheumatologist

Abstract

The majority of patients with systemic lupus erythematosus (SLE) have cutaneous manifestations at some point in their disease course. The skin findings in SLE are classified as SLE-specific or SLE-nonspecific based on histopathologic findings. SLE-specific skin diseases include chronic cutaneous lupus erythematosus (CLE), subacute CLE, and acute CLE. There are subsets of skin lesions within each group and the likelihood of associated SLE varies among them. SLE-nonspecific lesions are more common in patients with SLE and tend to coincide with active systemic disease. SLE-nonspecific lesions may be seen as a feature of another disease process, including other connective tissue diseases. It is important for the rheumatologist to be familiar with the spectrum of cutaneous diseases in SLE to help prognosticate the likelihood of systemic disease and to ensure patients receive timely dermatologic care with the goal of controlling disease activity to prevent damage.

Keywords: autoimmune; skin; systemic lupus erythematosus.

Figure 1:

Typical CLE lesions: (A) Active DLE lesions with erythema and scale are shown along with areas of damage, i.e., dyspigmentation and scarring, from prior active lesions. (B) Erythematous DLE lesions are shown on the leg. (C) Annular SCLE lesions are seen on the arm and chest as well as (D) the legs.

Figure 2:

This biopsy demonstrates the vacuolar interface dermatitis found in most LE specific skin conditions.

Figure 3:

Careful clinical examination is often required to distinguish CLE from dermatomyositis. (A) Dermatomyositis of the hands often shows confluent erythema of the skin overlying the MCP and ICP joints and the extensor tendons while (B) DLE lesions are less likely to be localized to these areas and can resolve with scarring. Involvement of the v-area of the neck can appear very similar in (C) dermatomyositis and (D) CLE and requires clinical correlation with other areas of involved skin to arrive at the correct diagnosis.

Figure 4:

A “butterfly rash” may be due to a variety of dermatological conditions. (A) The malar rash of ACLE refers to erythema over the nasal bridge and cheeks that spares the nasolabial folds. Erythema of ACLE can be found in other areas of the face, such as the forehead here. (B) Facial erythema in dermatomyositis tends to involve the nasolabial folds. (C) Rosacea can mimic the facial erythema of ACLE but tends to worsen with specific triggers such as alcohol, heat, and spicy foods.

Figure 5:

Alopecia due to (A) CLE can be difficult to distinguish from mimickers such as alopecia due to (B) lichen planopilaris; correlation between clinical and histologic findings may be required to correctly identify the cause of hair loss.