A patient with Lupus is usually in one of these stages: acute, subacute, chronic, or quiescent stage. The skin signs are different at different stages, and so is the care of the skin.
In acute Lupus, the disease is not yet controlled. It is typified by a ‘butterfly rash’ on the face, but it can also appear as a non-descript rash on the body. Patients often suffer from recurrent mouth ulcers which impair enjoyment and intake of food. One way to manage these ulcers is to numb them by applying salicylate gel (e.g. Bonjela gel), or to simply swish and swallow a mixture of one part (2.5ml) antacid (e.g. Mylanta, an over-the-counter syrup that reduces stomach acidity) with one part (2.5ml) diphenhydramine (e.g. Benadryl, a pharmacist-only medication with anti-histamine effects). Alternatively, one can reduce the inflammation by applying a steroid gel (e.g. Oracort E or Kenalog in Orabase), which can be purchased from a pharmacy. To reduce further aggravation of pain, avoid fried, sour, spicy, crispy, caffeinated and alcoholic food and beverage.
Another common complaint in the acute stage of Lupus is hair-fall. Some people may even recognize this as a symptom of disease relapse. The good news is hair-fall that is associated with acute Lupus is often temporary, and will reverse gradually as the disease gets under control. However, most females are very disturbed by this. To accelerate the regrowth of hair, one can purchase minoxidil 2% solution from a pharmacy, and massage it into the entire scalp twice daily. Upgrade to a 5% solution when the hair-fall fails to improve after 4 months of regular use. Alternatively, one can see a dermatologist to discuss the use of lasers and/or other medications.
A person with chronic Lupus has rashes on the body that are relatively more difficult to eradicate. These recalcitrant rashes are most often found on the ears and face, and are characterized by thick scaly dotty red-to-brownish islands. Such rashes necessitate the use of strong topical steroid creams/ointments. However, indiscriminate use of these topical steroid creams/ ointments can cause side-effects such as skin thinning and the appearance of fine blood vessels and stretch marks. To avoid these problems, apply the creams sparingly without rubbing onto surrounding unaffected skins. Apply no more than twice daily, and reduce to once daily or every other day when the lesions clear. Occasionally stick a plaster onto the affected skin overnight (after applying the topical steroid) to achieve a more powerful effect. A dermatologist can inject steroids directly into very difficult-to-treat lesions. Where side-effects have developed, a dermatologist can discuss with you the use of steroid-sparing ointments.
Skin complications of medication
Many patients with Lupus are on long-term oral steroid therapy. Steroids reduce one’s immunity, so a person can be more prone to developing a fungal infection on the skin. It typically manifests as circular red scaly patches (“ringworm”). One can apply an anti-fungal cream (e.g. miconazole, clotrimazole, terbinafine) twice daily. When the rash clears, it is important to continue using the cream for another 2-3 weeks to ensure that the fungus is thoroughly eradicated. Fungal infections may manifest as whitish patches on the tongue or sides of the mouth (“thrush”), or irritation and redness on the angles of the mouth. One can use miconazole oral gel twice daily to handle these infections.
Another common problem associated with long-term steroid therapy is acne. If there are few whiteheads, blackheads and red bumps, one can apply over-the-counter benzoyl peroxide cream or acne cream (or lotion) twice daily. A salicylic acid-based cleanser can help manage the whiteheads and blackheads. Anti-bacterial cleansers (containing trichlosan, cetrimide or chlorhexidine) cleansers are useful where there are predominantly red bumps. When the skin starts to clear, apply a retinol or retinaldehyde-based cream onto the whole face nightly for maintenance. For those with moderate to severe acne (many more inflamed lesions – red bumps, big bumps, pus-filled bumps), it is advisable to see a dermatologist.
Prevention of Lupus flare-ups
Whatever the stage of Lupus, it is imperative that all patients with Lupus protect themselves from the sun. Ultraviolet radiation is a well-known trigger of Lupus and can cause skin flare-ups, or other Lupus organ flare-ups. Although staying indoors and actively avoiding outdoor movement between the peak periods of 10am to 4pm are helpful, one cannot totally avoid ultraviolet radiation in Singapore. It is strongly advisable to apply a good sunscreen on all sun-exposed areas of the body at least twice daily. Use a sunscreen of SPF 30 and above (ultraviolet B protection), and one with adequate ultraviolet A protection (PPD >15 or PA +++). Choose the appropriate sunscreen for one’s needs and skin type. Consider whether you need a water-resistant sunscreen, whether your skin is acne-prone (select only a ‘non-comedogenic’ product), or whether you have a sensitive skin (select products with purely or mostly physical agents).
Author: Dr Derrick Aw