A dermatologist, a physician who specializes in caring for the skin, should treat lupus skin rashes and lesions. He or she will usually examine tissue under a microscope to determine whether a lesion or rash is due to cutaneous lupus: taking the tissue sample is called a biopsy. The sores usually appear on the scalp and face but sometimes they will occur on other parts of the body as well. Approximately 10 percent of people with discoid lupus later develop lupus in other organ systems, but these people probably already had systemic lupus with the skin rash as the first symptom. Discoid lupus lesions are often red, scaly, and thick.
In this study, the female to male ratio was but Malaviya, et al. For this reason, sun protection is very important for people with lupus. Tell Your Story. Drug- and heavy metal—induced hyperpigmentation. Measurements of blood HCQ concentration were available for 22 patients with HCQ-induced pigmentation and for all controls by definition. Skin lesions in patients with SLE are classified as those for lupus-specific disease e.
Haida rubber. Introduction
There are different types of lupus, each of which cause different symptoms. People who have lupus often develop symptoms similar to that of the flu. On DermNet NZ Cutaneous faclal images Discoid lupus erythematosus Subacute cutaneous lupus erythematosus Systemic lupus erythematosus Chilblain lupus erythematosus Systemic lupus erythematosus images Jessner lymphocytic infiltrate Mixed connective tissue disease Facial rashes Psychological effects of cutaneous lupus erythematosus Skin signs of rheumatic disease Ultraviolet radiation Antimalarial medications in dermatology Other websites Do you have systemic lupus erythematosus lupus, Charmeuse pantie and are over 18 years of age? If the rash Lupus facial pigmentation on the scalp, hair loss may occur. A skin biopsy may be diagnostic, showing a lichenoid tissue reaction piigmentation features specific to the kind of cutaneous Lupus facial pigmentation. Mucosal lesions may predispose to squamous cell carcinoma. Hydroxychloroquine concentration-response relationships in patients with rheumatoid arthritis. Y, EB50, 4A Purchase access Subscribe to JN Learning for one year. Follow t hese five rules to minimize sun exposure and help prevent or at least reduce much of the discomfort from lupus rashes for those with photosensitivity.
A, Bluish-green pigmentation on the legs in a patient with systemic lupus erythematosus without lupus lesions at the time of the skin biopsy.
- Now that we have discussed and described the symptoms of rosacea rashes, here are the three types of lupus rashes in order to make contrasts and comparisons.
- A, Bluish-green pigmentation on the legs in a patient with systemic lupus erythematosus without lupus lesions at the time of the skin biopsy.
A, Bluish-green pigmentation on the legs in a patient with systemic lupus erythematosus without lupus lesions at the time of the skin biopsy. B, Brown pigmentation on the legs in another patient who had systemic lupus erythematosus associated with diffuse discoid lupus. The skin biopsy was performed on the brown area distant from discoid lesions. JAMA Dermatol. Our data support the hypothesis that hydroxychloroquine-induced pigmentation is secondary to ecchymosis or bruising. Skin biopsies were performed on 5 patients, both in healthy skin and in the pigmented lesions.
The statistical associations of HCQ-induced pigmentation with several variables were calculated using univariate and multivariate analyses. Our data support the hypothesis that HCQ-induced pigmentation is secondary to ecchymosis or bruising. Use of antimalarials ie, quinacrine, chloroquine, hydroxychloroquine [HCQ] can induce tissue pigmentation in a variety of organs, including skin, joint tissue, trachea, and cartilage in the nose and ears.
The aim of this study was to describe the clinical features and outcome of HCQ-induced pigmentation in 24 patients with SLE. All patients gave their informed consent, and the study protocol was approved by a French ethics committee. This diagnosis was made if the patient had typical pigmentation that was otherwise unexplained pigmentation induced by toxins or other drugs, dermatoses, endocrinopathies, or nutritional conditions were then ruled out.
An experienced dermatologist C. For each patient, we collected data about sex, age at diagnosis of SLE, clinical and laboratory manifestations of the disease, and treatment history of SLE. All patients were interviewed to specify the date, circumstances of initial appearance, and evolution of HCQ-induced pigmentation lesions.
Skin biopsies were performed on 5 patients in both healthy skin and pigmented lesions. The PLUS Study was a randomized, double-blind, placebo-controlled, multicenter trial to evaluate the interest of HCQ dose adaptation to its blood concentration. We compared both groups for clinical and biological data including SLE criteria, smoking status, weight, height, calculated ideal weight, creatinine level, and whole blood HCQ concentration. The HCQ concentration was determined as previously described.
The t test was used for comparison of quantitative parameters. Values of quantitative variables are expressed as mean standard deviation. When several independent variables appeared significant in the univariate analysis, a logistic regression test was performed for multivariate analysis to rule out possible confounding variables.
Odds ratios ORs were calculated to assess the risk of each variable. We found 24 patients with HCQ-induced pigmentation 23 women and 1 man. The main characteristics of the patients are summarized in Table 1.
Skin pigmentation appeared after a median duration of HCQ treatment of 6. Hyperpigmentation was localized on the anterior side of the legs in all patients, on the arms in 5, and on the palate in 1. One patient also presented HCQ retinopathy that occurred prior to the skin pigmentation anomaly. Another patient developed an atrioventricular block of the first degree that was reversible after discontinuation of HCQ treatment. Treatment with HCQ was discontinued definitively because of skin pigmentation in 2 patients who reported a gradual incomplete fading of hyperpigmentation.
Pigmentation remained stable in the other patients. During follow-up, 22 patients had measurements of blood HCQ concentration. The median number of measurements per patient was 3 range, Hematoxylin-eosin—stained biopsy specimens showed brown pigmented granules throughout the dermis and hypodermis in interstitial and perivascular macrophages and fibroblasts Figure 2 A. Perls staining was strongly positive, suggesting the presence of iron Figure 2 B. A Fontana-Masson stain highlighted some of these granules, also supporting the presence of melanin in the same areas.
Increased melanin in the epidermal layer was also visible Figure 2 C. In 5 patients we measured the concentration of iron in skin specimens from healthy skin as well as pigmented lesions. The characteristics of both groups are summarized in Table 1. Measurements of blood HCQ concentration were available for 22 patients with HCQ-induced pigmentation and for all controls by definition. Using multivariate logistic regression, we found that HCQ-induced pigmentation was independently associated with treatment with oral anticoagulants OR, 6.
To our knowledge, only 13 cases of HCQ-induced pigmentation have been reported in the literature. The incidence of HCQ-induced pigmentation is unknown. Given that patients with HCQ-induced pigmentation may sometimes stop HCQ treatment for aesthetic reasons—when informed of the relationship—or because of an associated toxic effect, this rate may be slightly underestimated. Skin pigmentation related to antimalarials is described as yellow brown to slate gray or black pigmentation, which predominates on the anterior side of the shins but can also be seen in the face, forearms, mouth mucosa essentially hard palace and gingivae and nail beds.
Antimalarial drug-induced pigmentation has been suggested as a marker for patients at risk of ocular adverse effects. Hydroxychloroquine-induced pigmentation lesions usually begin after a few months or years of treatment. When we compared our patients with the controls, we found no significant association with the duration of HCQ treatment or with the cumulative dose of HCQ. Few histological studies have been performed in patients with antimalarial-induced pigmentation, 1 , 11 , 12 , 18 and the majority of reports do not specify which antimalarial treatment was used.
These findings led us to measure for the first time the concentration of iron in skin biopsy specimens from 5 patients, taken from both healthy skin and from pigmented lesions.
The median concentration of iron was fold higher in the pigmented lesions than in normal skin. This is emphasized by the fact that hyperpigmentation can be rarely localized on the palate and the nails. The mechanism involved in such cases is unknown. Blood HCQ concentration can be measured by high-performance liquid chromatography in whole blood. This result is interesting from a physiopathological point of view.
However, given the small differences between cases and controls and the lack of difference of blood HCQ concentrations between the PLUS Study patients with and without HCQ-induced pigmentation and given the wide range of distribution in blood HCQ concentrations, this result is probably not relevant for predicting the risk of HCQ-induced pigmentation in clinical practice.
The limitations of our study are mainly due to its retrospective nature. Although we showed that HCQ-induced pigmentation is not rare, the relatively long delay of onset of these pigmented lesions 6. To overcome the retrospective nature of our study, an experienced dermatologist C. Its localization and association with factors facilitating bruising, interviews with patients, and data from skin biopsies support the hypothesis that HCQ-induced pigmentation is secondary to ecchymosis or bruising.
Published Online: July 3, Author Contributions: All authors had full access to all of the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis. Conflict of Interest Disclosures: None reported. The company had no role in the initiation, planning, conduct, data assembly, analysis, or interpretation of the study.
All Rights Reserved. Figure 1. View Large Download. Histologic Analysis of Biopsy Specimens. Table 1. Hydroxychloroquine-induced hyperpigmentation: the staining pattern. J Cutan Pathol. PubMed Google Scholar Crossref. Cutaneous hyperpigmentation caused by systemic drugs.
Int J Dermatol. Pigmentation of the gums following hydroxychloroquine therapy. PubMed Google Scholar. Cutaneous hyperpigmentation during therapy with hydroxychloroquine. Clin Exp Dermatol. Hydroxychloroquine-induced pigmentation in two patients with systemic lupus erythematosus. J Eur Acad Dermatol Venereol. J Clin Rheumatol. Persistent cutaneous hyperpigmentation due to hydroxychloroquinone one year after therapy discontinuation.
Dermatol Online J. Hyperpigmentation of the skin due to hydroxychloroquine. Scand J Rheumatol. Clinical images: Hydroxychloroquine-associated mucocutaneous hyperpigmentation. Arthritis Rheum.
Skin pigmentation in a patient with systemic lupus erythematosus [in French]. Rev Med Interne. Hyperpigmented forearms and nail: a quiz. Acta Derm Venereol. Pigmentation from antimalarial therapy: its possible relationship to the ocular lesions.
Arch Dermatol. Updating the American College of Rheumatology revised criteria for the classification of systemic lupus erythematosus. Ann Rheum Dis. Google Scholar. Low blood concentration of hydroxychloroquine is a marker for and predictor of disease exacerbations in patients with systemic lupus erythematosus. Antimalarials and systemic lupus erythematosus.
Systemic Lupus Erythematosus.
Disc-shaped rash. There are different types of lupus, each of which cause different symptoms. Original Investigation. They include:. The American College of Rheumatology has created a set of criteria to assist physicians in making a diagnosis of lupus. An experienced dermatologist C. Systemic LE may involve heart, lung and brain with significant morbidity and mortality.
Lupus facial pigmentation. What is lupus erythematosus?
Lupus-Specific Skin Disease and Skin Problems : Johns Hopkins Lupus Center
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Access archive. By Warren R. Heymann, MD Dec. Biopsy of the left distal thigh shows interface dermatitis, dyskeratosis, superficial perivascular lymphocytic infiltrate, focal red blood cell extravasation, and pigment incontinence.
Credit: JAAD Lettie not her real name was an elderly, charming, courtly, soft-spoken African-American woman whose facial skin was getting progressively darker. Although asymptomatic, she was embarrassed by it, and was reluctant to go to church. Only after I drew routine laboratory studies and found marked thrombocytopenia, did I entertain the diagnosis of lupus, which was subsequently confirmed by biopsy and serologies.
We all have cases that alter our perspective on a particular disease. One patient had pigmented macules on the dorsal hands. Histologic examination was characteristic for lupus vacuolar interface dermatitis, a perivascular and perifollicular mononuclear infiltrate, and pigment incontinence. All three women had positive direct immunofluorescence; serologic lupus studies were confirmatory in two of the three women. None had systemic symptoms. The patients demonstrated improvement with hydroquinone, fluticasone, and sunscreen.
Her ANA was positive at and the biopsy confirmed lupus. He then performed a retrospective analysis of 11 similar cases 9 women, 2 men, average age 68 years. Photosensitivity was rare and there were no other stigmata of lupus. Patients responded well to topical corticosteroids. Of course this needs to be differentiated from hydroxychloroquine-induced pigmentation in those patients with lupus who are being treated with antimalarials.
A recent study has supported the hypothesis that ecchymosis, platelet antiaggregants and oral anticoagulants may be the main predisposing factors to hydroxychloroquine-induced hyperpigmentation. The diagnosis of the pigmented macular variant of chronic cutaneous lupus erythematosus is worth remembering when assessing hyperpigmented patches in a photodistribution. Lettie appears to have been unusual in that she had systemic disease. The literature suggests that the prognosis is good.
It was for her. With topical steroids and sunscreen, the hyperpigmentation diminished. Feeling better about her appearance, she went to church, met a widow, and got married. Pramatarov KD. Chronic cutaneous lupus erythematosus — clinical spectrum. Clin Dermatol ; Khullar G, et al. Pigmented macular variant of chronic cutaneous lupus erythematosus: An under-recognized subset in dark skin. Clin Exp Dermatol ; Boyd AS. Localized chronic cutaneous lupus erythematosus masquerading as pigmented lesions: A new clinical subset?
Lupus ; Bahloul E, et al. Hydroxychloroquine-induced hyperpigmentation in systemic diseases: Prevalence, clinical features, and risk factors: A cross-sectional study of 41 cases. DW Insights and Inquiries archive Explore hundreds of Dermatology World Insights and Inquiries articles by clinical area, specific condition, or medical journal source. Access archive Advertisement.