Lupus is an autoimmune disease that can affect many parts of the body, including the skin. One of the most common symptoms of lupus is a distinctive red, scaly rash on the face and other sun-exposed areas of the body. This is known as a malar or butterfly rash due to its shape across the cheeks and nose. Here is some key information about the early signs and appearance of a developing lupus rash:
Where Does a Lupus Rash First Appear?
In most cases, the earliest signs of a lupus rash first appear across the cheeks and bridge of the nose. This results in a butterfly-shaped rash centered on the face. However, the rash can also begin in other sun-exposed areas like the chest, arms, and scalp before spreading to the face.
What Does the Initial Rash Look Like?
When a lupus rash first develops, it often looks like a mild sunburn with some pink or red discoloration of the skin. The rash may start as a small patch or patches that slowly spread and join together. As it progresses, the affected skin can become increasingly red, inflamed and scaly. The rash may spread down the neck and to the shoulders and arms, typically in a symmetrical pattern on both sides of the body.
Other Early Signs of a Lupus Rash
- Mild burning, itching or irritation of the skin
- Slight swelling of the facial skin, particularly around the cheeks and over the bridge of the nose
- Small raised red bumps or patches that look like acne
- Dry, flaky skin in the rash area
- A scaling or scaly texture to the facial skin
In people with darker skin tones, the inflammation may appear more brown or purple in color at first. The rash tends to worsen or flare with sun exposure, so symptoms are usually most noticeable on sun-exposed skin.
When to See a Doctor
It’s important to consult a doctor as soon as possible after noticing an unusual facial rash. Early diagnosis and treatment of lupus can help prevent complications and reduce the risk of damage to major organs later on. Dermatologists are specially trained to identify and treat autoimmune skin conditions like lupus.
Your doctor will examine the rash and review your medical history, including any other symptoms you may be experiencing. Blood tests looking for autoantibodies, particularly antinuclear antibodies (ANA), are usually ordered to confirm lupus. A small skin biopsy of the rash may sometimes be taken as well.
There is no single test that can definitively diagnose lupus. Doctors make the diagnosis based on a combination of:
- Clinical signs and symptoms
- Blood test results
- Skin biopsy findings
- Ruling out other potential causes
The most distinctive feature of lupus is the butterfly facial rash. However, not all rashes that look like a butterfly across the cheeks are caused by lupus. For example, rosacea can sometimes mimic a lupus rash. That’s why running tests and looking at the whole clinical picture is important.
What Causes the Rash?
The exact causes of the characteristic lupus facial rash are not fully understood. However, it is believed to be related to autoantibodies attacking components of the skin in sun-exposed areas. Some of the factors thought to play a role include:
- Sensitivity to ultraviolet (UV) rays in sunlight
- Damage and death of skin cells from inflammation
- Blood vessel inflammation reducing oxygen supply to the skin
- Antibodies binding to skin cells and marking them for destruction
The facial skin may be especially susceptible because UV light exposure activates autoantibodies, while the delicate skin around the eyes and over the nose and cheeks is more easily damaged. The inflammation, vasculitis and cell damage lead to the red, flaky, scaly rash.
Who Gets a Lupus Rash?
About half of people with lupus will develop a facial rash at some point. However, the timing can vary widely. Some people have an early lupus rash when symptoms first begin, while in others, it may not develop until many years after disease onset. Rashes tend to be most common in people who develop lupus at a younger age.
Women make up the vast majority of lupus cases, accounting for about 90% of people diagnosed. Hormonal factors may help explain why females are predominantly affected. Lupus symptoms also tend to be more severe in minorities such as those of African, Hispanic, Asian, and Native American descent.
Can the Rash Spread?
Yes, the characteristic malar rash of lupus frequently spreads beyond the cheeks and nose if not adequately treated. Areas the rash may spread to include:
- Upper back
- Upper arms
Less commonly, the rash can sometimes spread to the lower arms, hands, lower back and lower legs as well. However, it rarely affects skin on the stomach or in the skin creases.
Can the Rash Be Permanent?
Without proper treatment, lupus rashes can potentially cause scarring and skin discoloration. Early diagnosis and medications to reduce inflammation and immune system activity aim to limit any permanent damage to the skin.
However, some people with chronic lupus may be left with permanently red, lightly scarred patches of skin or darker discoloration, particularly if the rash flares repeatedly. Areas of skin damaged by long-standing rashes may lack normal pigment, appearing lighter or whiter.
Use of high potency topical steroids may also lead to permanent skin changes like streaks, dots, thinning and easy bruising, particularly on the face. However, with careful treatment these types of permanent problems are often avoidable.
Are the Rashes Always Visible?
Lupus rashes are not necessarily always obvious or visible to the naked eye. There may be times when the rash seems to fade or becomes much less noticeable, only to flare up again at a later point.
Using makeup to cover up facial rashes can also hide the outward appearance of inflammation temporarily. However, the skin will usually still feel hot, irritated or itchy even if visibly redness has faded.
What Makes the Rash Worse?
Certain triggers can exacerbate existing lupus rashes and cause them to worsen or spread. Factors that tend to aggravate the rashes include:
- Sunlight, UV rays
- Hormonal changes
- Medications like antibiotics
- Chemicals in cosmetics or skin care products
- Infections or illnesses
- Dry air
- Heat or cold temperatures
- Cigarette smoke
Avoiding or minimizing these triggers where possible helps prevent rash flare-ups. Using a broad-spectrum sunscreen, managing stress, and taking care of overall health and wellbeing all help lessen the severity of lupus rashes.
How is the Rash Treated?
Doctors often prescribe a range of medications to control lupus rashes and reduce facial inflammation. Typical treatment approaches include:
- Corticosteroids – Potent anti-inflammatory steroids like prednisone or hydrocortisone creams.
- Antimalarial drugs – Such as Plaquenil (hydroxychloroquine), which dampens immune system overactivity.
- Immunosuppressants – Including methotrexate, azathioprine or mycophenolate to inhibit the overactive immune response.
- Biologics – Newer injections like Benlysta (belimumab) to reduce abnormal antibody production.
- Topical creams – Calcineurin inhibitors like tacrolimus or pimecrolimus reduce inflammation when applied to the skin.
- Avoiding triggers – Sunscreen, protective clothing/hats, avoiding harsh chemicals, moisturizing dry skin.
In mild cases, topical creams plus sun protection and trigger avoidance may be enough. More severe, stubborn rashes often need systemic medications like antimalarials, immunosuppressants or steroids to get the inflammation under control.
Does the Rash Need to be Covered?
There is no medical necessity to keep a lupus facial rash covered. However, many people prefer to use makeup to conceal the outward signs of redness and irritation, for cosmetic reasons.
A range of special makeup and skincare products are available designed for sensitive or damaged skin. Non-comedogenic brands that won’t clog pores are best for lupus rashes.
Look for liquid foundations, concealers, setting powders and primers formulated for very dry, flaky or easily irritated complexions. Always remove makeup gently at the end of the day to avoid scrubbing delicate facial skin.
Lifestyle Changes for Lupus Skin Problems
Certain healthy lifestyle measures can help minimize lupus flares and improve symptoms when applied along with medical treatment. Self-care tips include:
- Use sunscreen diligently
- Wear hats, sunglasses and protective clothing outdoors
- Don’t smoke and avoid secondhand smoke
- Follow a balanced, nutritious diet
- Reduce stress through yoga, meditation, therapy, journaling, etc
- Get enough sleep and rest when tired
- Exercise regularly at a gentle, moderate pace
- Hydrate by drinking plenty of fluids
- Take steps to avoid infection and illness
Living as healthy a lifestyle as possible, reducing stress, and limiting sun exposure all help prevent lupus rash flare-ups.
What is the Outlook for Lupus Skin Problems?
The outlook for lupus rashes varies from person to person. Mild cases can often be managed well, with minimal permanent damage, using topical creams and avoiding rash triggers.
However, severe, recurrent rashes related to chronic lupus may be harder to control. Over time, areas of skin damaged by repeated flares can develop scarring and skin discoloration. Aggressive medications may be needed to treat serious rash outbreaks.
Working closely with your dermatologist and rheumatologist to find the right mix of medications, lifestyle measures and smart skin care provides the best chance of protecting your skin from permanent problems.
When to Seek Emergency Care
In most instances, lupus rashes are not immediately life-threatening. However, a very rare lupus complication called toxic epidermal necrolysis causes severe detachment of large areas of skin. It is considered a medical emergency requiring urgent treatment.
Emergency care should be sought immediately if you develop:
- Widespread peeling and shedding of skin
- Large, fluid-filled blisters
- Extreme redness and irritation of mucous membranes such as eyes, mouth, genitals
- Rapid sloughing off skin over 30% or more of body surface area
- Fever and flu-like illness
This extreme skin reaction, similar to a burn, requires intensive medical support to prevent potentially fatal fluid loss and infections.
- The earliest sign of a lupus rash is typically mild redness over the cheeks and nose that gradually worsens.
- With time, the rash can spread to the scalp, neck, shoulders, upper back and arms, especially if untreated.
- It’s crucial to see a doctor at the very first signs of an unexplained facial rash to get proper diagnosis.
- Early treatment helps prevent complications and further skin damage from repeated flares.
- A mix of sun protection, medications, trigger avoidance and self-care habits gives the best control over lupus rashes.