How to Identify Lupus Rash and Other Skin Symptoms of the Condition

“It’s thought that the rashes occur because of exposure to sunlight,” says George Stojan, MD, the director of medical affairs at the pharmaceutical company UCB and the former co-director of the Johns Hopkins Lupus Center in Baltimore.

“The UV radiation damages the cells in the skin, and that exposes antigens that the immune system recognizes, and that leads to an immune response in the skin,” says Dr. Stojan. An antigen is any substance that causes the immune system to react, often by producing antibodies to fight against it. “The immune response targets the skin cells and causes inflammation that leads to the rashes,” he says.

Lupus rash and skin changes often accompany other symptoms of lupus, which can include fatigue, pain, and swelling in the joints and swollen glands. “The outward manifestations of lupus on the skin can be a window into what’s going on systemically,” says Victoria P. Werth, MD, a professor of dermatology at the Hospital of the University of Pennsylvania in Philadelphia.

Learn what skin symptoms to watch out for, detailed below, to help yourself manage and treat the condition.

Butterfly Rash (Malar Rash)

It appears by the malar area of the cheeks — around your cheekbones — “and it has the shape of a butterfly as it goes across the bridge of the nose,” says Dr. Werth. The rash can also occur on the arms, legs, and body, she adds.

“About 90 percent of patients who get malar rash have systemic lupus. This type of rash, as well as most lupus rashes, is generally inflamed, and so it’s edematous [swollen], it’s raised, and it’s red. It has a lot of mimics, or other conditions that can appear to be butterfly rash, so it needs to be distinguished from those,” says Stojan.

One way to make that diagnosis is through a biopsy, in which a doctor takes a tissue sample and examines it under a microscope. “Not all butterfly rashes are lupus — that’s important to note; eczema is one example of a skin condition that may look like butterfly rash,” he says.

Malar rash is a classic photosensitive rash; it tends to be induced by sun exposure, says Stojan. “Many patients will report that when they’re in the sun their rash worsens, or maybe they notice that their rash gets worse during the summer months,” he says.

Circular Rash

Known as discoid lupus because of the round shape of the sores or lesions, this is a type of chronic cutaneous lupus. The patches are thick, raised, and scaly, says Stojan. “In people with white skin, the patches appear pink, and on people with darker skin, the patches can look darker,” he says.

This rash can appear on the face, ears, scalp, neck, and hands, and although it’s not usually itchy or painful, it can sometimes cause pigment changes, according to Stojan. “After it resolves, it can leave white patches or discolored patches or possibly scarring,” he says.

Subacute Cutaneous Lupus

“Papulosquamous lesions appear as red scaly areas and can be on the shoulders, back, and chest, whereas annular lesions can appear in circular, ring-type patterns and can look like a fungal infection,” says Stojan.

Nail Changes Due to Lupus

There are two kinds of changes that can happen around the nails in lupus. “The first kind is peritubular capillary changes, which are vascular changes in the little blood vessels around the nails,” notes Stojan. These tiny vessels can be dilated or broken near the surface of the skin and appear as fine pink or red lines.

This condition can occur with certain autoimmune diseases, including lupus, says Stojan. “We can sometimes distinguish between different autoimmune diseases based on how those capillaries look under a microscope.”

“The other change that you can see is a rash or reddening of the skin around the nail, which is referred to as a periungual rash or periungual erythema,” says Stojan.

Hair Loss With Lupus

“Sometimes when people have active systemic lupus, they can have a diffuse loss of hair,” says Werth. “It doesn’t mean that all their hair comes out. It’s just a thinning which we see,” she says, adding that there’s usually no redness or scale on the scalp.

“Once the lupus is under control, the hair grows back in again. Sometimes the hair can break off in the front, or maybe you can see new hair regrowing, which is termed ‘lupus hair,’” Werth says.

There can also be hair loss when lesions are on the scalp, and in some cases, the hair grows back as before, but not always, according to Werth. “In discoid lupus, the lesions can sometimes form scars, and hair will not grow back because the hair follicles are also scarred,” she says.

Raynaud’s Syndrome

“Raynaud’s is a reversible vasoconstriction of blood vessels in the fingers that is induced by cold. Vasoconstriction means that the blood vessels constrict and limit the blood supply to the fingers,” says Stojan.

The fingers can go through different color changes, says Stojan. “First, they turn white, then blue, and then, when the blood supply returns, they turn red. But you don’t need all three stages to have Raynaud’s,” he says.

Raynaud’s is usually temporary, and it gets better when you warm the fingers, says Werth. “It’s a very common manifestation that’s not specific for lupus; it can occur in many different autoimmune diseases,” she says. “It’s a symptom that you want to have evaluated, but it doesn’t mean you have lupus.”

Mouth Sores

Oral and nasal ulcers or sores are one of the most common manifestations of lupus, according to Stojan. “They can be on the inside of the cheek, the tongue, and gums. When they appear doesn’t necessarily correlate with disease activity; people can get them outside of their flares,” he says.

Generally, they’re not painful. “It’s worth noting that these lesions are not vesicles [fluid-filled cysts, such as a blister]. Lupus doesn’t cause blisters,” says Stojan.

Treatment Options for Lupus Rash

Avoiding and treating lupus rash involves modifying some everyday habits as well as taking certain medical approaches. “The nonpharmacologic approaches are general lifestyle changes that all people with lupus rashes need to implement,” says Stojan. These include:

• Avoid sun exposure between 10 a.m. and 4 p.m.
• Use a sunscreen with an SPF of 50 or higher when you go outside.
• Reapply sunscreen every two hours or more frequently if you are sweating or going in the water.
• If you’re going to be in the sun for a long time, wear wide-brimmed hats and long-sleeved shirts made of woven material that doesn’t allow the sunlight to pass through.

• Glucocorticoids (Corticosteroids) These should be used mainly to control active inflammation and flares as needed, for as short a time as possible.
• Immunosuppressive Therapies (Conventional or Biological). Use of these is encouraged early on as part of an ongoing treatment plan to achieve remission or a low level of disease activity (LDA). LDA is defined as a state in which the disease is linked with a lower probability of lupus flares and hospitalizations, as well as less organ or tissue damage.

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The Takeaway

• Lupus is an autoimmune disease in which your body's immune system attacks healthy tissue, often causing inflammation of the skin and other parts of the body.
• Skin conditions, including the butterfly rash and other types of lupus rashes, are common and can signal disease activity.
• A mix of lifestyle changes (such as applying and reapplying sunscreen) and use of medications (such as hydroxychloroquine) can help you manage your symptoms.