THE OFFICIAL NEWS SOURCE OF ACR CONVERGENCE 2022 • NOVEMBER 10-14



Skin manifestations may offer clues to lupus pathogenesis and prognosis

The myriad of cutaneous manifestations in lupus can be challenging for the rheumatologist.

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Andrea Kalus, MD

In the Monday morning symposium Cutaneous Lupus in All Its Varieties: Judging a Book By Its Cover, Andrea Kalus, MD, Associate Professor, Division of Dermatology, at the University of Washington in Seattle, will review and update practicing rheumatologists on common, and not so common, lupus-associated skin diseases and how to approach diagnosis and treatment. The symposium begins at 9:00 am in Hall E.

While some skin manifestations commonly seen in lupus patients are directly related to the disease, others, such as vasculitis or erythema multiforme, are not specific for lupus and can occur in other conditions, as well. In many cases, she said, a skin biopsy might be required in order to clinically differentiate the exact type and pathology of a given skin manifestation.

An internist and dermatologist by training, Dr. Kalus participates in a combined dermatology and rheumatology clinic at the University of Washington. In her presentation, she will discuss the role for skin biopsy and its interpretation and will review current therapies, including the use of topical therapy that rheumatologists might prescribe.

Dr. Kalus hopes that rheumatologists who attend this session will have a stronger understanding of ways in which skin manifestations can help to distinguish the different subtypes of lupus, be able to draw connections to their patients’ potential risk for systemic lupus based on identifying the lupus subtype, and have renewed their toolkit for managing the skin findings in lupus.

“It’s estimated that about 80 percent of lupus patients will have some type of skin manifestation of their lupus,” Dr. Kalus said. “Among the skin manifestations of lupus, some are classic and come to mind quickly, such as a butterfly (malar) rash, but there are also less common variations in the way cutaneous lupus can present.”

It’s important for rheumatologists to recognize these variations, she noted, because the different subtypes of lupus can often be distinguished by the ways in which the skin findings present.

“The various subtypes of lupus have differences that affect what the prognosis will be for patients and whether or not they’re going to have systemic lupus involvement as well,” Dr. Kalus said. “About a quarter of patients may have skin manifestations of lupus as the first presentation of their disease, so if we’re astute at trying to identify what we see, we may be able to diagnose more readily, as well as identify it as a subtype. That can give us an indication of a patient’s trajectory and what kind of interventions we might want to consider.

“In addition to acute cutaneous lupus, rheumatologists should also be looking for subacute cutaneous lupus manifestations, which are often extremely sun-sensitive, and patients tend to present with a rash in sun-exposed areas of the skin,” Dr. Kalus said. “Interestingly, while acute cutaneous lupus patients have a high likelihood of having systemic disease, most patients with subacute cutaneous lupus don’t go on to have systemic lupus.”

When it comes to photosensitivity and the photoinitiation of lupus, Dr. Kalus said that current understanding of the pathogenesis of lupus includes the idea that exposure to ultraviolet light may involve processing of dying skin cells.

“What we see with sun exposure and sunburns in all people, not lupus patients specifically, is that skin cells go through a process of programmed cell death in response to ultraviolet light and sunburn,” she said. “It’s possible that some faulty processing of those dying cells can trigger responses in lupus, so it’s important for rheumatologists to understand the relationship of lupus to sun exposure, both in pathogenesis and also as it relates to management and treatment of lupus.”

CLINICAL PRACTICE TRACK
Cutaneous Lupus in All Its Varieties: Judging a Book By Its Cover
9:00 – 10:00 am Monday • Hall E