J,  I can't figure out how to copy and paste the article.  I also tried by
e[mailing the article but it came in Adobe Acrobat and it won't let me copy
and paste.  Sorry.

Hugs,
Sherry

Here.  I didn't understand what you wanted when you made the
request in the "House Windows" post.  Some of the file came
through in that  post, for some weird computer reason.

--Bill Thompson

LupusAmerica's Least Known Major Disease
SKIN (CUTANEOUS)
LUPUS
ANDREW G. FRANKS, JR., M.D., F.A.C.P.
Clinical Professor of Dermatology
Attending in Rheumatology
Chief, Connective Tissue Disease Clinic
New York University School of Medicine
www.lupusalliance.org
(866) 415.8787
SKIN (CUTANEOUS) LUPUS

The skin plays a very important role in the early diagnosis
of lupus. For example, four of the eleven American Rheumatism
Association's revised criteria for systemic lupus erythematosus
are skin manifestations: malar rash, discoid rash,
photosensitivity and oral ulcerations. Lupus rashes often mimic
other more common skin disorders, sometimes making early
diagnosis difficult.

Since at least 30% of people who will develop SLE will have skin
lesions as their first complaint, it is no surprise that the first
question most people newly diagnosed with skin lupus ask is, "What
are my chances of developing systemic lupus?". While we know that
only about 10% of people with skin lupus, in general, develop
systemic disease, there are established "Markers of Transition"
from skin-only disease to systemic disease (Table 1). These
markers greatly improve your doctor's ability to predict that
outcome for you with much greater accuracy. This is especially
important if you are in a higher risk category for systemic
disease. There are significant advantages to beginning treatment
with remittive type treatment (medicine that turns off the disease
itself rather than just treating symptoms) that may prevent any
further progression of the illness.

Skin lupus is further divided into acute, subacute, and chronic with
further subdivisions within each group (Table 2). The importance of
recognizing the many forms of skin lupus cannot be overemphasized.
Delay in diagnosis may lead to worsening and progression of your
illness. For example, many people with the malar (cheeks and nose)
"butterfly" rash of lupus are thought to have rosacea, psoriasis,
or eczema. If they have hair thinning they may be diagnosed with
alopecia areata, a coin shaped area of hair loss. These may initially
respond to topical treatments, further confusing and delaying the
correct diagnosis. Early diagnosis will allow appropriate treatment
that may induce remission of the skin disease as well as, most
importantly, preventing progression to more serious systemic disease.

EARLY DIAGNOSIS

If you are being treated for a skin disorder that is not improving
despite treatment, or is stubbornly recurrent, a skin biopsy by a
dermatologist is the simplest and quickest way to establish the
correct diagnosis. Special blood studies may also be helpful in
some instances. Using the "Markers of Transition", tell your doctor
if you have generalized joint achiness which persists, alert your
doctor to any skin rash on the rest of your body, and have your
blood and urine checked regularly. Being attentive to these details
will greatly empower you over the disease.

MANAGING CUTANEOUS LUPUS
PREVENTION

Most people are anxious to know if anything in their lifestyle or
diet caused their lupus. While we don't know all the reasons why
certain people get the disease over others, we do know that genetics
and environmental triggers play a role. Any blood relative with an
autoimmune disease such as thyroid problems, rheumatoid
arthritis, etc. may carry the gene that also predisposes you to lupus.

What are the environmental triggers? Photosensitivity (sensitivity
to light and other forms of radiation) is a major factor in the
induction of most skin lupus. It is extremely important to recognize
this and realize that this means an adjustment in lifestyle, not
just the use of sunscreen. Photosensitivity may occur 365 days a year,
on cloudy as well as sunny days.

Ultraviolet radiation that affects lupus is divided into UVA and UVB.
The UVB rays are those that we normally associate with sunburn and
tans. The UVA rays penetrate more deeply into the skin and do not
cause redness or burn. Therefore, they are more insidious and less
likely to be noted by you as the trigger for your lupus. Furthermore,
UVA rays are present winter and summer, from dusk until dawn. It is
imperative to reduce your exposure to these rays by limiting
unnecessary outdoor activity, wearing double layers of clothing,
wide brimmed hats, or special sun protective clothing, wearing a
broad-spectrum UVA-UVB protective sunscreen every day all year round,
preferably SPF 30, and reapply frequently. UVA rays penetrate through
window glass, are generated by halogen and fluorescent bulbs, and
are emitted from CRT computer screens. Make sure your windows have
plastic shields in them (most thermal windows do), use fluorescent
and halogen fixtures that are plastic encased, and use a polarizing
screen over your computer's CRT. If you are on any medications such
as diuretics (water pills), antibiotics, anti-inflammatory pills,
hormones (including birth control pills) that may increase
photosensitivity, alert your doctor and be especially careful.

Smoking has recently been shown to be a factor in skin lupus and
smoke cessation should be undertaken with the help of your doctor to
ensure that it is successful. Secondary smoke should also be avoided.
Eating a healthy, balanced diet is also very important. Alternative
medicines and supplements should be discussed with your doctor. Beware
of the many unsupported claims on the internet. They can be dangerous
if interpreted without the advice of your doctor.

TREATMENT

Localized skin lupus can be successfully treated with a broad array of
topical steroid preparations. These come in a number of strengths,
and initially the higher potency products are best, followed by a
reduction to the lowest potency that remains effective. In addition,
steroids can be injected directly into stubborn areas and are especially
useful in the scalp for localized areas of hair loss.

Generalized skin lupus, difficult to control local disease, and
in those individuals with any "Marker of Transition" regardless of
the type of skin lupus, are best treated with remittive medication.
The systemic antimalarial drugs such as hydroxychloroquine, quinacrine,
or chloroquine are the "standard of care" and offer you the best
chance of not only putting your skin lupus under control, but also
preventing any chance of progression to more serious forms of systemic
disease. Systemic steroids are sometimes used for short periods of
time, as well as many other drugs such as azathioprine, retinoids,
thalidomide, dapsone, mycophenolate mofetil, cyclosporine, and a
number of promising newer agents. Your doctor can provide you with
the rationale and indications for their use.

What can be done for lupus scars once the disease has been put
into remission? For minor defects, camouflage makeup has many
benefits. Initial consultation with a cosmetician experienced
in these techniques is preferable, but information can be obtained
directly from the companies themselves. Newer laser technology
has exciting potential to improve the scarring and pigment
disturbances left by skin lupus and is less risky than plastic
surgery. Sometimes both techniques are required on one individual.
Regardless of the approach, laser surgery or plastic surgery
should only be undertaken when your disease is in full remission,
and you are maintained on antimalarials to prevent post-operative
reactivation. These procedures should be performed by those
physicians knowledgeable about lupus scars and in cooperation
with the doctor treating your lupus.

TABLE 1
Markers of Transition

.
Rash above and below neck
.
Associated non-specific skin lesions (skin ulcers,
inflammation of blood vessels, calcium deposits, nodules)
.
High ANA titers (antinuclear antibody blood test)
.
Proteinuria (protein in urine)
.
Hematuria (blood in urine)
TABLE 2
Chronic Cutaneous LE

.
Localized Discoid
.
Generalized Discoid (above and below the neck)
.
Hypertrophic Discoid (LP/LE overlap)
.
Lupus Profundus (lobular panniculitis)
.
Scarring Alopecia
.
Acral LE (palmar/plantar)
.
Tumid LE
Subacute Cutaneous LE

.
Papulosquamous (psoriasiform)
.
Annular-polycyclic (+/- vesicles)
Acute Cutaneous LE

.
Malar rash
.
Bullous LE
.
Widespread photodistributed erythema

2003 Lupus Alliance of America, Inc.

SKIN (CUTANEOUS) LUPUS

The skin plays a very important role in the early diagnosis of lupus. For
example, four of the eleven

American Rheumatism Association's revised criteria for systemic lupus
erythematosus are skin manifestations:

malar rash, discoid rash, photosensitivity and oral ulcerations. Lupus
rashes often mimic other more

common skin disorders, sometimes making early diagnosis difficult.

Since at least 30% of people who will develop SLE will have skin lesions as
their first complaint, it is no

surprise that the first question most people newly diagnosed with skin lupus
ask is, "What are my chances

of developing systemic lupus?". While we know that only about 10% of people
with skin lupus, in general,

develop systemic disease, there are established "Markers of Transition" from
skin-only disease to systemic

disease (Table 1). These markers greatly improve your doctor's ability to
predict that outcome for you

with much greater accuracy. This is especially important if you are in a
higher risk category for systemic

disease. There are significant advantages to beginning treatment with
remittive type treatment (medicine

that turns off the disease itself rather than just treating symptoms) that
may prevent any further progression

of the illness.

Skin lupus is further divided into acute, subacute, and chronic with further
subdivisions within each group

(Table 2). The importance of recognizing the many forms of skin lupus cannot
be overemphasized. Delay

in diagnosis may lead to worsening and progression of your illness. For
example, many people with the

malar (cheeks and nose) "butterfly" rash of lupus are thought to have
rosacea, psoriasis, or eczema. If they

have hair thinning they may be diagnosed with alopecia areata, a coin shaped
area of hair loss. These may

initially respond to topical treatments, further confusing and delaying the
correct diagnosis. Early diagnosis

will allow appropriate treatment that may induce remission of the skin
disease as well as, most importantly,

preventing progression to more serious systemic disease.

EARLY DIAGNOSIS

If you are being treated for a skin disorder that is not improving despite
treatment, or is stubbornly recurrent,

a skin biopsy by a dermatologist is the simplest and quickest way to
establish the correct diagnosis.

Special blood studies may also be helpful in some instances. Using the
"Markers of Transition", tell your doctor

if you have generalized joint achiness which persists, alert your doctor to
any skin rash on the rest of your

body, and have your blood and urine checked regularly. Being attentive to
these details will greatly empower

you over the disease.

MANAGING CUTANEOUS LUPUS

PREVENTION

Most people are anxious to know if anything in their lifestyle or diet
caused their lupus. While we don't know

all the reasons why certain people get the disease over others, we do know
that genetics and environmental

triggers play a role. Any blood relative with an autoimmune disease such as
thyroid problems, rheumatoid

arthritis, etc. may carry the gene that also predisposes you to lupus.

What are the environmental triggers? Photosensitivity (sensitivity to light
and other forms of radiation) is a

major factor in the induction of most skin lupus. It is extremely important
to recognize this and realize that

this means an adjustment in lifestyle, not just the use of sunscreen.
Photosensitivity may occur 365 days a year,

on cloudy as well as sunny days.

Ultraviolet radiation that affects lupus is divided into UVA and UVB. The
UVB rays are those that we normally

associate with sunburn and tans. The UVA rays penetrate more deeply into the
skin and do not cause redness

or burn. Therefore, they are more insidious and less likely to be noted by
you as the trigger for your lupus.

Furthermore, UVA rays are present winter and summer, from dusk until dawn.
It is imperative to reduce your

exposure to these rays by limiting unnecessary outdoor activity, wearing
double layers of clothing, wide

brimmed hats, or special sun protective clothing, wearing a broad-spectrum
UVA-UVB protective sunscreen

every day all year round, preferably SPF 30, and reapply frequently. UVA
rays penetrate through window glass,

are generated by halogen and fluorescent bulbs, and are emitted from CRT
computer screens. Make sure your

windows have plastic shields in them (most thermal windows do), use
fluorescent and halogen fixtures that are

plastic encased, and use a polarizing screen over your computer's CRT. If
you are on any medications such as

diuretics (water pills), antibiotics, anti-inflammatory pills, hormones
(including birth control pills) that may

Lupus

America's Least Known Major Disease

SKIN (CUTANEOUS)

LUPUS

ANDREW G. FRANKS, JR., M.D., F.A.C.P.

Clinical Professor of Dermatology

Attending in Rheumatology

Chief, Connective Tissue Disease Clinic

New York University School of Medicine

www.lupusalliance.org

(866) 415.8787

increase photosensitivity, alert your doctor and be especially careful.

Smoking has recently been shown to be a factor in skin lupus and smoke
cessation should be undertaken with the help of your doctor to ensure

that it is successful. Secondary smoke should also be avoided. Eating a
healthy, balanced diet is also very important. Alternative medicines and

supplements should be discussed with your doctor. Beware of the many
unsupported claims on the internet. They can be dangerous if interpreted

without the advice of your doctor.

TREATMENT

Localized skin lupus can be successfully treated with a broad array of
topical steroid preparations. These come in a number of strengths,

and initially the higher potency products are best, followed by a reduction
to the lowest potency that remains effective. In addition, steroids

can be injected directly into stubborn areas and are especially useful in
the scalp for localized areas of hair loss.

Generalized skin lupus, difficult to control local disease, and in those
individuals with any "Marker of Transition" regardless of the type of

skin lupus, are best treated with remittive medication. The systemic
antimalarial drugs such as hydroxychloroquine, quinacrine, or chloroquine

are the "standard of care" and offer you the best chance of not only putting
your skin lupus under control, but also preventing any

chance of progression to more serious forms of systemic disease. Systemic
steroids are sometimes used for short periods of time, as well

as many other drugs such as azathioprine, retinoids, thalidomide, dapsone,
mycophenolate mofetil, cyclosporine, and a number of promising

newer agents. Your doctor can provide you with the rationale and indications
for their use.

What can be done for lupus scars once the disease has been put into
remission? For minor defects, camouflage makeup has many benefits.

Initial consultation with a cosmetician experienced in these techniques is
preferable, but information can be obtained directly from the companies

themselves. Newer laser technology has exciting potential to improve the
scarring and pigment disturbances left by skin lupus and is

less risky than plastic surgery. Sometimes both techniques are required on
one individual. Regardless of the approach, laser surgery or plastic

surgery should only be undertaken when your disease is in full remission,
and you are maintained on antimalarials to prevent post-operative

reactivation. These procedures should be performed by those physicians
knowledgeable about lupus scars and in cooperation with the

doctor treating your lupus.

TABLE 1

Markers of Transition

. Rash above and below neck

. Associated non-specific skin lesions (skin ulcers,

inflammation of blood vessels, calcium deposits, nodules)

. High ANA titers (antinuclear antibody blood test)

. Proteinuria (protein in urine)

. Hematuria (blood in urine)

TABLE 2

Chronic Cutaneous LE

. Localized Discoid

. Generalized Discoid (above and below the neck)

. Hypertrophic Discoid (LP/LE overlap)

. Lupus Profundus (lobular panniculitis)

. Scarring Alopecia

. Acral LE (palmar/plantar)

. Tumid LE

Subacute Cutaneous LE

. Papulosquamous (psoriasiform)

. Annular-polycyclic (+/- vesicles)

Acute Cutaneous LE

. Malar rash

. Bullous LE

. Widespread photodistributed erythema

8 2003 Lupus Alliance of America, Inc.