Skin problems are very common in lupus and many
different types of problems can occur. This fact sheet
will discuss some of the more frequent problems
encountered by those with lupus.
What types of skin problem occur in lupus?
There are many different skin manifestations in lupus,
which vary from person to person. The 'classical' skin
problem in lupus is the butterfly rash. This is a red rash,
sometimes no more than a mild blush that occurs
across the bridge of the nose and on the cheeks
resulting in a distinctive butterfly like appearance. This
type of rash tends to occur in the systemic form of the
disease where other organs in the body are also
involved. It is sometimes present at the beginning of the
disease, helping doctors make the diagnosis. Butterfly
rashes tend to come and go depending on how active
the underlying lupus is but it does not leave scars as it
Discoid lupus is a type of lupus that tends to be
confined to the skin, and other organs in the body are
not involved. Discoid lupus occurs in patches across
the body. These patches tend to be well defined,
thickened and scaly, they are slightly red in colour and
can itch. (The appearance can vary between individuals
and also appear on different areas of the body on the
same person). As the patches heal they tend to leave
scars and on darker skins the pigment in the skin can
be lost leaving white areas. If discoid lupus occurs on
the scalp the hair will be lost as the patches heal leaving
permanent bald areas.
Subacute cutaneous lupus is a distinct rash that usually
occurs in sun exposed areas of the body. It starts as
scaly patches which increase in size to form circular
areas, which gradually heal up without leaving scars.
This type of lupus falls in-between the systemic form
and the discoid form; people with subacute cutaneous
lupus often have some of the blood abnormalities found
in systemic lupus and frequently experience joint pains,
but they do not usually develop the serious
complications that can occur in the systemic disease.
Practically any type of rash can occur in systemic lupus
ranging from widespread mild rashes similar to those
seen in viral illnesses such as German measles to small
distinct patches of rash on the elbows and knees
resembling another skin condition, psoriasis. Two
particular problems that can occur are panniculitis and
urticaria. Panniculitis is inflammation of the fat below
the skin resulting in tender red lumps beneath the
surface of the skin; these heal slowly over time and can
leave dimpling of the skin when fully healed. Urticaria is
an itchy, raised red rash similar to nettle rash that can
occur with vasculitis (see below) or on its own; it heals
without leaving scars.
What about the blood vessels in the skin?
Lupus can affect the blood vessels in the skin whereby
the blood vessels themselves can become inflamed,
this is known as vasculitis. Vasculitis can cause painful
red spots frequently on the hands and feet and
sometimes chilblain type rashes. Vasculitis can also
occur in other areas of the body, for example the kidney,
which can be very serious and requires prompt
The blood flow through the skin blood vessels can
become sluggish in lupus patients who have proteins
that affect the clotting of the blood known as the
antiphospholipid antibody syndrome (APS/Hughes
Syndrome). In these people the skin may take on a
mottled net-like appearance known as livedo reticularis
usually on the legs and the arms.
What happens to the hair in Lupus?
The hair often thins and can become patchy when
lupus is active. It will usually regrow as the disease is
brought under control. This is not the case in discoid
lupus as already mentioned, when the scars left by the
skin rash leave permanent bald areas. Sometimes drug
treatment can make the hair thin in lupus patients. This
is known to happen in some people with steroid
treatment and in most people when cytotoxic drugs
such as cyclophosphamide are used. In both cases the
hair should regrow when the drug is discontinued.
What about sunlight and the skin in Lupus?
Approximately 60% of people with lupus will be
sensitive to the sun. Sunlight can cause an
exacerbation of skin rashes, generalised burning of the
skin and increased activity of lupus in other organs
within the body. Some people will also be sensitive to
certain types of lighting inside buildings such as
fluorescent tubes, halogen and 'energy saving' bulbs,
and any high intensity lighting. It is not clear why some
of those with lupus are sensitive to the sun and not
others. Sun sensitivity can develop at any point
throughout the course of the illness.
Why does Lupus affect the skin?
As doctors are not sure what causes lupus, the reasons
that lupus affects the skin are also unclear. It is known
that antibodies and other proteins that are used to fight
infection are deposited in the skin inappropriately and
cause inflammation. It is also known that proteins within
the skin of those with lupus are more sensitive to
ultraviolet rays contained in sunlight resulting in
What treatment is available for the skin in Lupus?
A number of treatments are available for the skin in
lupus. These can be divided into topical, injection and
Topical treatments tend to consist of steroid creams
and ointments. These can range from the mild creams
such as hydrocortisone to the stronger types such as betamethasone. These will sometimes be enough to
control mild lupus rashes but should not be used
continually, particularly on the face. In discoid lupus
particularly troublesome areas can be injected with long
acting steroids under the skin to promote healing.
Most people will require oral treatment to control their
skin problems. The antimalarials such as chloroquine,
hydroxychloroquine and mepacrine are all very useful in
controlling skin rashes. They tend to work slowly and
need to be taken for a number of months before any
effect is seen. Other oral treatments include steroids,
which can also be given intravenously if the skin lesions
are very severe. Oral and intravenous steroids obviously
have a number of side effects and are therefore usually
reserved for skin problems that have not responded to
topical treatments and antimalarials. Sometimes skin
rashes cannot be controlled with the above treatments
or they recur on steroid dose reduction. In these people
other drugs such as azathioprine or cyclosporin can be
used. These drugs are often given for other problems
in lupus such as kidney disease but they can be given
for the skin alone in difficult cases.
How can I help myself?
The main way in which those with lupus can help
themselves is to avoid sun exposure. This means
covering up with long sleeves and trousers in the
sunlight and wearing a hat if out in the sun for any
length of time. The use of UV film on windows may also
be necessary for those who are particularly sunsensitive.
Sun block cream, minimum sun protection
factor (SPF) 25, should be applied to exposed areas of
skin, although many patients will require higher
protection. Sun blocks are available on prescription so
ask your doctor for them. These creams need to be
applied regularly and repeatedly as they wear off over
time. Sunbeds should never be used as they give a
concentrated dose of ultraviolet light, which can be very
damaging to those with lupus, fake tans are a safer
alternative. If a rash develops that does not clear up
rapidly then it should be reported to the doctor as soon
as possible as a delay in treatment may result in