[Aggie69]

Was just interested to know what people's cutaneous lesions look like when they first start as I've nothing to compare to. How does it differ from the start of a psoriasis plaque? My first ever one started off as small red 'pimples' which grew into a single disc shape with a defined red edge. I was on holiday and initially thought it a heat rash or insect bites and put a plaster on it!

Despite inconclusive skin biopsies D D'Cruz is sure the one on my elbow is psoriasis, however, is concered as others 'look suspiciously like SCLE', also noting marked hair loss, mild livedo reticularis/lymphadenopathy in the neck, eczematous changes in ears, positive parietal cell antibodies and FM.

He's mentioned SCLE as a 'differential diagnosis' as my bloods came back OK apart from low haematocrit and high MCHC/ESR. Don't quite understand how it can be cutaneous lupus if this is the case.....need to ask lots of questions when I see him next.

Anyway, I believe he's considering a course of methotrexate (can't have the anti malarial) so I'll be happy just to try some treatment which might help, whatever the rash is. Are there any major side effects with this medication?

 

[Maia]

I'm not a skin lupus expert, but I find it a bit unusual to treat possible lupus skin issues with methotrexate. If anti-malarials cannot be used then I thought doctors would tend to prescribe Imuran. Methotrexate is very successful with joint pain of lupus though - so perhaps that is why he is thinking methotrexate.

There are many posts in the past about methotrexate and side effects... you can try doing a search to read them. Most common side effects include nausea for the first 1-2 days and fatigue/general malaise. Side effects can be minimized by starting with a low dose and working up over a few weeks, and many here have reported fewer side effects with the injectible version.

It is important to take folic acid supplementation per your doctor's orders, and also important to have monthly blood work as the drug can also cause some things in the CBC to go off.

Hopefully our resident SCLE expert will be along soon to answer your more specific question about how lesions start off and how they may look different.

 

[Aggie69]

I'm not a skin lupus expert, but I find it a bit unusual to treat possible lupus skin issues with methotrexate. If anti-malarials cannot be used then I thought doctors would tend to prescribe Imuran. Methotrexate is very successful with joint pain of lupus though - so perhaps that is why he is thinking methotrexate.

Thanks Maia. He wrote to my GP stating that I couldn't have anti malarial therapy as it contraindicates with psoriasis, so that's all I know. I will chat to him about the possible methotrexate as although I suffer terribly with joint stiffness/pain I've learnt to live with that......it's the skin and hair issues that I'm desperate to get sorted!

 

[Clare.T]

Hello Aggie

Yes, the antimalarials have to be used with great care in psoriasis, but methotrexate is used for psoriasis. I have only had psoriasis once on inner elbows- it was a white flakey circle effect with a clear centre with fine white lines across them, nothing like my subacute. But there are different sorts of psoriasis and obviously some do resemble the subacute type of plaques or they couldn't be confused diagnostically. I think my psoriasis started as a very small itchy papule. But my SCLE was very itchy too.

Subacute often starts as a "papular eruption" A papule is defined as a solid raised, round/ dome shaped area, red/ irritated / inflamed but no pus and 'small'. Small can mean anything beteen 0.5 cms to 1.5 cms but is most often described as less than 1 cm ( 3/8"). That's exactly how my first area on one cheek started. I thought it was the start of an enormous spot but it expanded gradually over several weeks into a rough red plaque. Many of my lesions started that way. Sometimes the bump would go away only to return several months later a bit bigger until over time it morphed into these red 'psoriaform' plaques.
I also had the annular sort - wavy red rings with very clear centres and occasionally a blistering sort especially before my periods.

The following description is from the emedicine article at


http://emedicine.medscape.com/article/1065657-overview

Physical

• The primary lesion of SCLE is an erythematous papule or a small plaque with a slight scaling (Media File 1). Primary lesions expand and may merge and eventually form either plaques with scaling (Media File 2) in the papulosquamous variant or annular and/or polycyclic lesions in the annular variant (Media File 3).
• Papulosquamous lesions may mimic psoriasis or lichen planus, while annular lesions may mimic erythema annulare centrifugum. Most patients exhibit one predominant type of lesion, and some also manifest isolated lesions of DLE.
• SCLE lesions primarily are photodistributed. When they occur on the lower extremities, they often are purpuric.
• Early lesions of SCLE may be difficult to distinguish from polymorphous light eruption (PMLE). In this author's opinion, PMLE and SCLE are distinctive disorders, but patients with recurrent photosensitive pruritic eruptions who are anti-Ro (SS-A) positive blur the distinction and might well be better classified as having SCLE rather than believed to have both disorders, as has been suggested by some investigators in Europe

About your question how can it be lupus in the absence of lupus related blood work: The majority of people with SCLE skin do have enough criteria to get an SLE diagnosis. Figures range from 50% -75%. They may also have all the typical symptoms of 'mild' SLE. People with SCLE are more likely to have such symptoms than people with discoid without supporting blood work.

Good Luck !


Clare

 

[Aggie69]

All my lesions (apart from the one on my outer elbow) have started as small 'pimples' and then grown together to form one plaque. I've also had to go through the stage of wondering whether it is a spot, bite or whatever. They don't really itch (strangely my non affected skin does though)! The wavy plaques that I have in my groin/leg have a defined red edge with clear middle but no scale.

The lesions on my face and ears are red plaques. Again, very little scale....more like dry/sunburnt skin that you can easily peel off. The scale on the plaque on my outer elbow is relatively easy to peel off too.

I had a friend with psoriasis whose scale was really thick/stubborn and bled little pin prick areas when you attempted to scrape the top layer off.....I actually thought this was a psoriasis symptom but it doesn't happen to me.

Anyway, I'm just glad to be getting somewhere at last. Thanks once again Clare....you really are an angel!