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Dermatologic Manifestations

Overview

Approximately 80 percent of patients with systemic lupus erythematosus have skin manifestations and may suffer from disfigurement. The classic sign of SLE is the “butterfly” rash extending over the cheeks (malar area) and bridge of the nose. This rash ranges from erythema to a severe eruption with scaling. It is photosensitive, and it may last several days or be fixed. Between 55 and 85 percent of patients develop this rash at some time in the course of the disease.

The most prevalent and severe form of cutaneous lupus, which affects primarily the skin, is called chronic cutaneous lupus. It is commonly known as discoid lupus, but has other forms as well (see below). Discoid lupus erythematosus (DLE) occurs in about 20 percent of patients with SLE. The lesions are patchy, crusty, coin-shaped, sharply defined skin plaques that may scar. These lesions are usually seen on the face or other sun-exposed areas. DLE may cause patchy, bald areas on the scalp and hypopigmentation or hyperpigmentation in older lesions. Biopsy of a lesion will usually confirm the diagnosis. Topical and intralesional corticosteroids are often not effective, even for localized lesions. Antimalarial drugs may be needed for some local lesions and for more generalized lesions. DLE progresses to SLE in about 5 percent of cases.

Other forms of chronic cutaneous lupus include:

  • Hypertrophic or verrucous DLE is characterized by either thickened lesions (hypertrophic) or wart-like lesions (verrucous).
  • Lupus profundus is characterized by firm lumps in the fatty tissue underlying the skin.
  • Mucosal DLE is characterized by lesions that occur in the mucus membranes of the mouth and nose.
  • Palmar-plantar DLE is characterized by lesions that occur in the hands and feet.
Another form of cutaneous lupus, subacute cutaneous LE is seen in about 10 percent of SLE patients. It produces highly photosensitive papules or cyclic lesions. Skin changes, especially the butterfly rash and the effects of subacute cutaneous LE, can be precipitated by sunlight.

Some patients may develop mouth, vaginal, or nasal ulcers. Hair loss (alopecia) occurs in about one-half of SLE patients. Most hair loss is diffuse, but it may be patchy. It can be scarring or nonscarring. Alopecia may also be caused by corticosteroids, infection, or immunosuppressive drugs.

Raynaud’s phenomenon (episodic blanching of the fingers and toes due to paroxysmal vasospasm) frequently occurs in patients with SLE. For most patients, Raynaud’s phenomenon is mild. However, some SLE patients with severe Raynaud’s phenomenon may develop painful skin ulcers or gangrene on the fingers or toes. Attacks of Raynaud’s phenomenon can cause a deep tingling feeling in the hands and feet that can be very uncomfortable.

Skin alterations in the lupus patient, particularly those of DLE, can be disfiguring. As a result, patients may experience fear of rejection by others, negative feelings about their body, and depression. Changes in lifestyle and social involvement may occur.

Potential Problems

1. alteration in skin integrity

2. alopecia

3. discomfort (pain, itching)

4. alteration in body image

5. depression


Potential Dermatologic Manifestations

    • butterfly rash on cheeks and bridge of nose
    • scaly, disk-shaped scarring rash (DLE)
    • erythematous, slightly scaly papules (subacute cutaneous LE)
    • psoriasiform or arcuate (curved) lesions on the trunk of the body (subacute cutaneous LE)
    • ulcers in the mouth, vagina, or nasal septum
    • atrophy (including striae or stretch marks from corticosteroids)
    • impaired wound healing
    • easy bruising
    • petechiae
    • increased body hair (hirsutism) from corticosteroids
    • steroid-induced ecchymosis
    • ulcers or gangrene on fingers or toes
    • alopecia
    • redness in the nail bed (periungual erythema)
    • a reddish or cyanotic pattern seen on arms, legs, or torso, especially in cold weather (livedo reticularis)


Nursing Interventions

Objective: Minimize appearance of lesions.

1. Document the appearance and duration of lesions and rashes.

2. Teach the patient to minimize direct exposure to UV rays from sun and from fluorescent and halogen light bulbs. (Glass does not provide complete protection from UV rays.)

3. Instruct the patient to use a sunscreen with an SPF of 15 or greater and wear protective clothing. Patients who are allergic to PABA will need to find a PABA-free sunscreen.

4. Provide information on hypoallergenic concealing makeup.

5. Instruct the patient to avoid topical applications, such as hair dyes and skin creams, and the use of certain drugs that may make her or him more sensitive to the sun.

Objective: Alleviate discomfort.

1. For patients with mouth lesions, suggest a soft-food diet, lip balms, and warm saline rinses.

2. Ask the physician to consider prescribing Kenalog® in Orabase®, which is applied twice a day to oral ulcers.

3. Suggested self-help measures for patients with Raynaud’s phenomenon include:
  • keep warm, particularly in cold weather; use chemical warmers, gloves, socks, hats; avoid air conditioning; use insulated drinking glasses for cold drinks; wear gloves when handling frozen or refrigerated foods
  • quit smoking
  • control stress
  • exercise as tolerated.
Objective: Help patients to cope with potential psychological manifestations.

1. See the nursing interventions dealing with psychological issues.



Source: National Institutes of Health, U.S.Dept of Health and Human Services


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