Cutaneous lupus erythematosus
Also called CLE, lupus of the skin, malar rash, systemic lupus erythematosus (skin signs)
Lupus in the skin spans three tempos: an acute malar blush that mirrors systemic disease, subacute photodistributed rings, and chronic discoid discs that scar. The pattern predicts the systemic risk, which is the whole reason to name it precisely.
How it looks
Well-demarcated, indurated erythematous discs with adherent scale, follicular plugging, central atrophic scarring, and peripheral hyperpigmentation over the head and neck.
Rose is the lesion, grey the pattern the lesions make, green where on the body it lives.
Across skin tones
Discoid lupus is more common and more destructive in deeply pigmented skin, where erythema reads subtle but the pigment changes are dramatic: striking central hypopigmentation ringed by hyperpigmentation, and scarring alopecia that is easily mistaken for other central scalp disease.
Don't miss
New SCLE deserves a drug review before a lupus label: thiazides, proton-pump inhibitors, and terbinafine are repeat offenders, and the eruption resolves with the culprit.
Forms & variants
Acute cutaneous lupus (ACLE)
The malar 'butterfly': erythema over cheeks and nasal bridge sparing the nasolabial folds, flaring with sun; almost always a face of active systemic lupus.
Subacute cutaneous lupus (SCLE), annular and psoriasiform
Photodistributed rings or psoriasis-like plaques over the shoulders, upper back, and arms; strongly anti-Ro associated, and a substantial minority are drug-induced (thiazides, PPIs, terbinafine).
Chronic cutaneous / discoid lupus (DLE)
Indurated scaly discs with follicular plugging that heal with atrophy, scarring, and pigment change; on the scalp it is a scarring alopecia, and skin-limited disease is common.
Lupus panniculitis
Tender, deep subcutaneous nodules, often on the face, upper arms, and hips, with skin that may look normal on the surface; it heals with disfiguring lipoatrophy.
Symptoms & course
- Photosensitivity, flares after sun
- Discoid lesions may itch or be tender
- Scarring hair loss when the scalp is involved
Diagnostic approach
- Biopsy of an established lesion
- ANA, anti-Ro/La, complement, urinalysis to place the skin in systemic context
- Drug history for SCLE specifically
Differential, and how to separate them
- Rosacea
Favours it: Centrofacial flushing with papulopustules and telangiectasia
Against it: Rosacea does not spare the nasolabial folds, and it does not scar or plug follicles
- Tinea corporis
Favours it: Annular scaly plaques resembling SCLE rings
Against it: KOH positive, asymmetric, and indifferent to sunlight
- Psoriasis
Favours it: Well-demarcated scaly plaques resembling psoriasiform SCLE
Against it: Extensor, symmetric, micaceous scale, no photosensitivity or atrophy
Management principles
- Rigorous photoprotection, the intervention that outperforms most prescriptions
- Potent topical or intralesional corticosteroids for discoid lesions
- Hydroxychloroquine as the systemic backbone; treat scarring disease early
Clinical pearl: Discoid plaques plug follicles: look for the carpet-tack scale on the underside of a peeled fragment.
Clinical pearl: The malar rash spares the nasolabial folds; seborrheic dermatitis lives in them. That crease answers most 'red face' consults.
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