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Skin Manifestation

Malar rash; discoid lupus erythematous; photosensitivity; oral ulcers; arthritis; serositis; renal disorder; central nervous systems disorders; hematological disorders; immunological disorders; antinuclear antibody.

This group of diseases is divided into three major subsets; namely, chronic cutaneous LE (CCLE), also called discoid LE, subacute cutaneous LE (SCLE) and systemic LE (SLE).

CCLE affects female and male at a ratio of 2:1,

  1. Essential Features Of The Major Le Subsets
    1. Discoid plaque is prototypic lesion in CCLE.
    2. The lesions frequently occur in the head and neck and exposed areas with sizes varying from a few millimetres to a few centimetres.
    3. It begins as erythematous, oedematous scaling papules which spread centrifugally and coalesce into a plaque that exhibits thick and adherent scales.
    4. Lifting of the scales produces a carpet-tack appearance, revealing dilated pilosebaceous orifices occupied by horny plugs (follicular plugging). Healing of lesion usually takes place in the centre producing atrophy, scarring, telangiectasia and pigmentary changes (hypopigmentation in the centre and hyperpigmentation in the active margin).
    5. Histopathology of an established lesion shows typical histologic changes. (q.v.) Systemic or serological abnormalities in these patients are absent or minimal
    6. In SCLE, skin lesions are annular or papulosquamous, and they share similar morphology with discoid lesions but healing is not accompanied with scarring and atrophy is minimal or absent.
    7. Photosensitivity and serological abnormalities are more frequent than CCLE.
  2. Pathogenesis of and Relationship Among Different Types of LE
    The pathogenesis of LE is not definitively known. A T-cell mediated injury is implicated in the discoid lesions. Anti-Ro (SSA) has strong implication in the production of disease in photosensitive SCLE and neonatal LE (NLE). Ultraviolet light induces Ro antigen expression on the keratinocytes, targeting it for binding by anti-Ro antibody and/or sensitized T cells. In SLE, many features are a consequence of antibody production and immune complex formation.
  3. Mucocutaneous Features
    Gillian classification for skin lesion associated with SLE.

Mucocutaneous lesions of LE are commonly divided into specific and non-specific types.


Table I shows the specific mucocutaneous lesions of LE. They are characteristic of LE and help us infer which particular LE subset the patient suffers; however, the three LE subsets are not mutually exclusive.

Table II tabulates the lesions that commonly occur during the course of LE but are not sufficiently specific to be indicative of LE.

  1. Significance Of Serologic Testing
    1. Antinuclear factor: in 90% of systemic lupus erythematous (SLE)
    2. Anti-DS DNA: only in SLE cases (40%)
    3. Anti-single-stranded DNA: in various collagen vascular diseases; in DLE cases, suggest disease progression
    4. Anti-Ro: subcutaneous lupus, neonatal lupus, C2 deficient lupus, late onset lupus overlap
    5. Anti-Sm: only in SLE cases (about 20%)
    6. Anti-RNP: frequently associated with systemic sclerosis
    7. Anti-histone: drug induced lupus
    8. Anti-cardiolipin: associated with venous and arterial thrombosis, fetal wastage and livedo with or without ulcer
  2. Management of Cutaneous Manifestations
    1. Avoidance of sun: Sunscreens to shield out UVB and UVA
      1. Topical:
        Topical steroid: potent topical or intralesional steroid is helpful for localized and mild disease.
      2. Systemic:
        1. Antimalarial: Hydroxychloroquine is effective for widespread cutaneous diseases and may prevent new eruptions.
        2. Dapsone: is effective for bullous SLE, vasculitis, oral ulcerations.
        3. Thalidomide: Alternative therapy when antimalarial fails or is contraindicated.
        4. Etretinate: reported to be useful for hyperkeratotic lesions.
        5. Prednisolone: Is very useful for cutaneous and systemic diseases. Side effects limit its prolonged use.
        6. Immunosuppressives - azathioprine is most commonly used,
N.B.: a) Greenwalds' hypothesis of Lupus states that anything happening to a patient with SLE which is not immediately otherwise explicable will automatically be blamed on the lupus, regardless of pathophysiologic validity.

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