Adapted from public talk presented at the 2024 UMMC Patient Forum on SLE (1 June 2024)

Skin problems in lupus can range from acute cutaneous lupus erythematous (LE) (e.g. malar rash), subacute cutaneous LE (annular or papulosquamous types) to chronic cutaneous LE (e.g. discoid lupus, lupus tumidus, hypertrophic LE, lupus profundus, chillblains lupus and lichenoid discoid LE). Non-specific skin disease can include vasculitis, livedo reticularis, Raynaud phenomenon, dermal mucinosis and bullous LE.

Here are a few practical tips to manage skin and hair problems as well as oral ulcers in SLE:

Skin and hair problems in SLE

Topical steroids

• Strong topical steroids may be needed to treat skin lesions
• Apply maximum twice daily to lesions only
• Do not rub onto surrounding unaffected skin
• Can apply for 2 weeks followed by 2-week rest period (where topical calcineurin inhibitors can be used) to avoid local side effects
• Ointments are more effective for thick lesions
• To increase efficacy, stick a plaster over affected skin after applying topical steroids (caution of local side effects e.g. skin thinning, fine blood vessels, stretch marks)

Topical calcineurin inhibitors

• Examples include pimecrolimus 1% cream, tacrolimus 0.1% ointment
• Can be used during rest periods from topical steroids
• Can cause local burning/stinging when first used
• Place in fridge for 10 minutes before use
• May also overlap with mild topical steroid e.g. hydrocortisone 1% cream for the first 3 days of use

Other treatments for discoid lupus

• Steroid injections for small lesions
• Hydroxychloroquine
• Acitretin (thick lesions)
• Thalidomide (caution)

Raynaud’s phenomenon

• Protect skin from the cold (use coat, hat, gloves, socks)
• Hand warmers
• Avoid caffeine or nicotine

Other tips

• Cover-up makeup for uneven skin colour, blotches and scars (green hues can offset redness)
• Dark spots: bleaching creams with hydroquinone (not for long-term use)
• Lumpy/pitted scars: consider filler
• Laser for red or dark spots only if lupus is not active (check with doctor)
• Vaseline for sores in the nose

Hair loss in SLE

Acute LE

• Minoxidil 2% solution twice daily
• Upgrade to 5% if does not improve after 4 months

Other tips

• Protect scalp from sun (wide-brimmed hat, sunscreen)
• Prevent breakage (avoid rough brushing/heat styling/bleach/dyes/chemical treatments, use gentle shampoo and massage gently, use detangling products)
• Careful styling (e.g. short layered cut to make hair look thicker)
• Hair extensions if not actively losing hair, but protect the scalp
• Wigs, scarves, wraps

Oral ulcers

• Salicylate gel e.g. Bonjela
• Steroid gel e.g. Kenalog in Orabase
• Steroid mouthwash
• Swish and swallow a mixture of 2.5 ml antacid with 2.5 ml diphenhydramine
• Avoid fried, sour, crispy, caffeinated and alcoholic food and beverages

Complications of treatment

• Fungal infection on skin: antifungal cream (e.g. miconazole, sertaconazole, terbinafine) twice daily, continue 2 weeks after clearance
• Fungal infection in the mouth (oral thrush or irritation/redness on angle of the mouth): miconazole oral gel, nystatin mouthwash (swish and swallow)
• Acne: benzoyl peroxide gel, cleansers, retinols, etc.

Prevention of flares

UV Protection

• Sunscreen at least twice daily 15 minutes before going out (ideally reapply every 2 hours; SPF 30 and above with adequate UVA protection)
• Avoid outdoor movement between 10 am to 4 pm
• Protective clothing
• Sunglasses
• Wide-brimmed hat
• Seek shade
• Replace fluorescent/halogen light bulbs with LED/incandescent bulbs or use a UV light filter or light shield
• UV-blocking film for home and automobile windows
• Corrective camouflage cosmetics
• Before taking a medication, ask if it can increase light sensitivity
• Consider vitamin D supplements

Others

• Quit smoking
• Stop touching patches/rashes on the skin
• If anything on the skin looks different or changes, itches or bleeds, see your dermatologist to rule-out skin cancer