Skin, hair and lupus

This site is intended for healthcare professionals as a useful source of information on the diagnosis, treatment and support of patients with lupus and related connective tissue diseases.
The development of some sort of rash is one of the commonest features of lupus and is often a presenting sign. In SLE, a photosensitive malar rash presents classically in the ‘butterfly’ shape across the cheeks, over the bridge of the nose and sparing the nasolabial folds. The rash is usually erythematosus although it can also be associated with raised papules and plaques with scarless healing.

Hair loss is a common occurrence in SLE and may well be a first symptom a patient notices, whether male or female. This can be quite distressing. In many NHS Trusts, a referral for hair pieces or wigs can be made with Dermatology when there is severe hair loss. Usually when lupus is brought under control hair regrowth recovers; however, it can take several months, and seem a very long time for the patient for hair to return to “normal”.

In patients with diagnosed lupus, hair loss occurring together with mouth ulcers, skin rash, and/or increased joint pain and stiffness, along with abnormal blood tests (for example rising double-stranded DNA, and/or falling complement levels) indicates an SLE flare is occurring. Fortunately, the DMARD (disease modifying anti-rheumatic drugs) treatments for lupus rarely cause hair loss in the lupus patient, although listed as a side effect, so if hair loss is occurring it is worth looking for other symptoms before stopping treatments. Hair loss continues long after other symptoms have improved and can take 3 to 6 months to resolve after a flare, even with appropriate therapy.

Subacute cutaneous lupus erythematosus (SCLE) usually takes the form of red, scaly, round lesions over the face, neck and chest which are induced by sunlight and, like the butterfly rash, heal without scarring. Chronic cutaneous lupus includes ‘discoid lupus’ (DLE) consisting of well-defined disc-like plaques on the skin or scalp which are long-lasting and which can lead to scarring and cosmetic problems. Patients with lupus may suffer other skin problems which are not specific to lupus, such as vasculitic rashes, blisters, leg ulcers and prickly heat. A skin biopsy is sometimes required to help make an accurate diagnosis. The following advice is recommended for lupus patients who are photosensitive to prevent flares wherever possible is as follows. Remind patients that they are protecting their whole body, their whole immune system, not only a specific area of skin:-
• Plan holiday destinations so that exposure to strong sunlight and high temperatures is limited. NB Snowy destinations too.
• Always wear sun protection, SPF 50+ with 4*or 5* UVA rating. This is only about 50-60 minutes protection from the sun’s damaging rays, so it is imperative to reapply sunscreen at least hourly when you are outside in the sunshine. Don’t forget the top of the head and tops of ears.
• Remember to reply sunscreen after being in water and after washing hands. There is no water-proof sunscreen, only water-resistant.
• Wear a broad-brimmed hat to shelter the face and neck from the sun.
• Avoid sitting outside in hottest part of the day, usually 11.00 to 15.00.
• Remember that sitting in a paved area, waterside, and by snow will all give additional exposure as they reflect sunlight, even when under an umbrella or parasol.
• Thicker weave clothing will block the sun’s rays from penetrating the skin. Clothing should be long sleeved, covering the legs, arms and neck area.
• Natural fibre fabrics, such as pure cotton, linen or silk are cooler to wear in hot weather and warmer in colder weather when they can be layered.

Topical steroid preparations are useful treatments, but should only be used for as short a course as possible, and at as low a dose to treat the skin effectively. Hydroxychloroquine is effective in treating rashes and arthralgias associated with lupus. Some patients need to try other drugs such as mepacrine, though this is often limited due to its side effect profile (it can make the skin turn yellow). Thalidomide is also an effective treatment but is rarely used, and tends to cause peripheral neuropathy. (As it is teratogenic, effective contraception must be used by men and women of child-bearing potential.)

Despite this range of therapies, some patients are left with long-term cosmetic problems. There is good expert advice available, provided by the charity Changing Faces with contact points around the UK VISIT THEIR WEBSITE HERE Techniques can be taught for all skin tones, types and genders.

Henna, mehndi, tattooing, implants and piercings

Patients sometimes ask about henna, mehndi (also referred to as mendi, or mendhi), tattooing, silicone implants and about piercings. ALL patients (even those without lupus), should be warned away from black or natural henna. Due to the disorganised lupus immune system, anything that may cause further immune response should be considered very carefully first, however our role as health professionals is always to give good and accurate information, and leave our adult patients to make their own choices, after appropriate consultation.

With tattooing, both temporary and permanent, there are two elements that need consideration; the pigment itself used in designs, and the insertion process of that pigment. As the tattoo process goes through the top skin layer, breaking this immune barrier, this can be enough to trigger a skin immune response. Previous tattoo without flare is a helpful indicator, but unfortunately is only an indication.

The really key point for us as lupus clinicians is to advise our patients about infections and what to do if a flare occurs. As with any other skin infection their GP is their first point of access (not the tattoo professional). If necessary further antibiotic advice can of course be sought from the SLE clinic. If the patient believes they are flaring, they will need seeing in clinic for full assessment and a likely change to their baseline treatment.

With each of these, tattoos, piercings, implants and even temporary holiday henna tattoos, it is well worth advising patients to take their time to consider these points;
• Expect at least two visits to the business treatment facilities, the first to really see inside the shop or round the stall and ask polite but probing questions, and the second for potential treatment.
• An established practitioner will welcome questions, especially when you explain the reason for needing clarity, that their immune system is challenged.
• Always be prepared to walk away; health is invaluable; do make an excuse to get away if something doesn’t seem right.
• Ask to see and talk to the specific practitioner who is offering the service. Are they well recommended, preferably by people you know or can contact independently?
• Can previous work be seen, preferably on another client, as well as beautiful polished sales photos?
• Is the shop well-kept and scrupulously clean?
• Although obvious to us, some patients may not know or appreciate that all equipment that touches them as a client must be single use, and practitioners must wear single use disposable gloves throughout.

Healing time for a lupus patient is likely to be extended, probably closer to double the usual length and especially when on steroid treatment; so for a tattoo, 2-3 days rather than 1-2 to be able to come out from a wrap; up to 14 days being oozy and forming a scab; and up to 28 days being scabby or flaky; and then potentially up to 3 months for full depth skin healing to have occurred.
The patient with lupus is potentially more likely to be itchy and for longer, and more moisturisers might be needed. If they are prone to scarring, this is also more likely to occur and with no guarantee how it will look at each treatment.