Dr. Lisa Zickuhr discusses differentiating cutaneous lupus in skin of color, including 3 principles for treatment and when to refer to a rheumatologist.
Dr. Lisa Zickuhr discusses differentiating cutaneous lupus in skin of color, including 3 principles for treatment and when to refer to a rheumatologist.
“When you talk about lupus, there are really two main categories. There is systemic lupus where patients have symptoms in any organ system and then there is cutaneous lupus where the manifestations are limited to the skin,” said rheumatologist Lisa Zickuhr, MD, MHPE, who presented “Cutaneous Lupus across Skin Tones” at the Mark Allan Everett, MD, Skin of Color Symposium at The University of Oklahoma.
“Oftentimes, the two coexist and the skin findings give us a clue about the ultimate diagnosis of systemic disease,” she said.
Patients who identify as Black or African American, Hispanic or Latinx, even Asian, tend to present with more severe and significant manifestations of systemic and cutaneous lupus, according to Dr. Zickuhr.
“It’s not that the disease is more prevalent in these populations, it’s just that it is more severe than in those who identify as White or Caucasian. That raises the stakes for physicians. It’s really important that these patients are diagnosed quickly and that treatment is started as soon as possible so that we can limit long-term damage, whether that’s scarring in the skin or kidney damage…, to preserve function and quality of life for our patients.”
Lupus Nuances in Skin of Color
How cutaneous lupus presents in general in skin of color is centered on how interface dermatitis looks in skin of color, said Dr. Zickuhr.
“It’s not so much the difference between how acute or subacute or even chronic cutaneous lupus looks, it’s more this umbrella of how interface dermatitis, which encapsulates all of these different types of cutaneous lupus, looks different in different skin types.”
Interface dermatitis looks red, erythematous, and is quite striking in White patients. That’s the image of interface dermatitis that most physicians have from medical educational materials, she said.
“Patients with skin of color have more melanin in their skin, so interface dermatitis actually takes on more violaceous or purple-looking hue. It’s not as red or erythematous and it’s not as striking. Because that purple hue is a little different, if your eye isn’t trained to look for that, you could overlook it.”
Different still is chronic cutaneous lupus, specifically, the discoid variant that is more common in patients with skin of color, according to Dr. Zickuhr.
“We’re used to an erythematous ring with a scarred or hypopigmented center mostly on the head and neck, though it can extend to other parts of the body. That’s kind of the classic picture that we typically conjure and see in medical education materials in patients with skin of color. In patients with fair complexions, it looks more red, more erythematous, and perhaps doesn’t follow that pattern, so a biopsy may be needed in order to rule out other things that might be more common on the differential.”
3 Principles for Treating Cutaneous Lupus
Dr. Zickuhr pointed out that she is a rheumatologist and not a dermatologist but that she is not aware of any research showing that any one cutaneous lupus treatment offers a better response based on race or ethnicity. Part of the reason for that, she said, is the lack of trials on lupus in skin of color patients, especially those who are Black and often have an inherent mistrust of medical research trials.
Describing cutaneous lupus treatment in a sound bite is difficult, with so many subtypes including acute cutaneous lupus, subacute cutaneous lupus, as well as about 10 to 15 subtypes of chronic cutaneous lupus, she said.
“But there are some overarching principles that I can share.”
The first is sun protection, said Dr. Zickuhr.
“Most of these rashes are photosensitive. I have a patient who has acute cutaneous lupus and systemic lupus. He was doing very well but went to Walt Disney World for spring break with his kids, didn’t wear sunscreen, and came back with a mega flare. In all these rashes, photoprotection is so important because it protects the cutaneous manifestations from evolving. Sometimes the systemic manifestations also are photosensitive.”
Second, if cutaneous lupus is associated with systemic disease, oftentimes treating the systemic disease will correlate with improvement in the cutaneous manifestations, said Dr. Zickuhr.
“So, which agent is selected is dependent on which organ system is involved.”
The third is, hydroxychloroquine (Plaquenil) is generally the mainstay of treatment, she said.
“I think every patient with lupus, as long as they can tolerate the medicine and have no other contraindications, should be on hydroxychloroquine. It is known to help the cutaneous manifestations. For those who have systemic disease, it prevents advancement of those manifestations as well as has the antithrombotic effect. Hydroxychloroquine does a lot of good for a lot of people with very minimal side effect.”
Often, hydroxychloroquine is enough to get skin conditions under control, according to Dr. Zickuhr.
“If not, you can go down the treatment algorithm… methotrexate, mycophenolate, or even thalidomide in some instances. There is also some data for belimumab and baricitinib, a JAK inhibitor.”
“The last treatment, which dermatologists are more familiar with than I am, is topical steroids, even intralesional steroids.”
When To Refer
When should dermatologists be concerned about systemic disease based on cutaneous findings?
According to Dr. Zickuhr, “If it looks like acute cutaneous lupus, that is almost always associated with systemic lupus and should be evaluated with basic labs, [complete blood count] CBC, [comprehensive metabolic panel] CMP, urinalysis, and referral to rheumatology.”
Patients with subacute cutaneous lupus have a moderate chance of also having systemic disease, said Dr. Zickuhr.
“In that case, I would get basic labs, CBC, CMP, urinalysis, and probably [antinuclear antibody] ANA and [extractable nuclear antigen] ENA panel. From there, I would leave it up to you about whether you refer.”
Chronic cutaneous lupus, or discoid, is more commonly just on the skin, especially if it is on the head and neck, she said.
“But if you see discoid lesions throughout the body in a generalized pattern on the trunk or below the neck, then that patient should be evaluated by a rheumatologist.”
Disclosure: Dr. Zickuhr is an educational consultant for Eli Lilly and Company.
