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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
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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)
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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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