Discoid Lupus Erythematosus
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Intoduction
Discoid lupus erythematosus (DLE) is the most common type of lupus affecting the skin. Many medical practitioners think it represents an entirely different disease to systemic erythematosus (SLE) although they share some common features.
DLE is a long lasting (chronic) condition confined to the skin. It does not usually have any serious consequences and can usually be well controlled with medical therapy.
It is more common in females and usually occurs in adults. It may occasionally affect children and sometimes has its onset in the elderly.
DLE can be a distressing condition even when only a few spots are present as it usually occurs on the head and neck, including the face, scalp and ears. DLE is occasionally more widespread, also involving the skin below the neck.
The Causes Of Discoid Lupus
The cause of DLE is unclear. It appears to occur due to a combination of factors. Individuals inherit certain genes from their parents which predispose them to DLE. When there is exposure to certain outside factors, DLE occurs. The basis of this abnormal reaction to environmental agents is not entirely understood.
Skin manifestations of DLE
The skin manifestations of DLE mainly occur above the neck, but can occur on other parts of the body. The affected areas are most often red and scaly and if not treated promptly may go on to form depressed scars with irregular pigmentation. If DLE occurs on the scalp or other hair-bearing areas it may cause a permanent patch of hair loss. It can also affect the lips and mouth.
Occasionally other forms of skin lesion occur. These include, deeper tender lumps in the layer of fat just under the skin or painful chilblain-like lesions on the hands and feet.
Sun exposure and sunburn are the most important triggers of DLE lesions in the majority of patients. DLE is more active in the summer than winter. Other triggers which may cause exacerbations and new spots include:
- Trauma/scars
- Mental stress
- Infections
- Exposure to cold
- Rarely, pregnancy
- Certain medications such as griseofulvin and isoniazid
Often the exacerbations occur spontaneously.
You will be more sensitive to natural light than you were before your DLE began. Thus, it is very important that you protect yourself from sunlight. This is hard to do in Australia. By following the guidelines below you will minimise the occurrence of lesions and decrease their severity.
How To Protect Yourself From Ultraviolet Light
- Avoid spending prolonged periods in direct sunlight between the hours of 10am and 4pm.
- If you are going outside, wear a wide brim hat and sunscreen. Sunscreens which contain titanium dioxide are the best cosmetically acceptable sunblocks for a broad range of wavelengths of light. Examples of sunscreens which contain titanium dioxide include, some of the Cancer Council Shop products, Ego Sunsense Milk and some of the Hamilton sunscreens. Long sleeves and collars will also help, especially if the clothes have a tight knit (look through the shirt into light to see how much light passes through the fabric). A lipbalm containing a sunscreen should also be used. Look for moisturisers and makeup containing sun protection factor - there are many available now.
- Ultraviolet light can pass through glass. Thus, you should also avoid sitting without protection for prolonged periods in sunlight which is passing through a window.
Treatment of DLE
If lesions are not treated, they tend to persist and will ultimately result in scarring. You can cover up spots while they are active with camouflage makeup such as Coverup (The Red Cross Camouflage Clinic can provide excellent advice in this respect).
As mentioned above, preventing lesions by sun protection is the best treatment. Topical (to the skin) treatment is primarily with cortisone creams. Various strengths are used depending on the severity of the disease. Your doctor will give you instructions on their safe use. By following these instructions, there should be minimal risk of side effects from the cortisone creams. The side effects of cortisone creams include thinning of the skin and permanent dilatation of the skin blood vessels if too strong a preparation is used for too long a period on the same spot. It is important to remember that untreated lupus itself can more often cause permanently dilated blood vessels.
More severe lesions will require cortisone injections. For more widespread, or slow to resolve spots, oral medication may be used. This may include:
- Antimalarials such as Plaquenil (hydroxychloroquine)
- Short courses of Prednisone
- Leprosy drugs, clofazamine and dapsone
- Or even, thalidomide.
Scars may be treated with camouflage make up, plastic surgery, laser or dermabrasion.
Regular follow-up with your doctor for tailoring the treatment to your disease activity and severity is important. This will help to prevent complications from your DLE such as scarring and will also monitor for any early side effects from treatment.
Other Types Of Lupus Erythematosus
The two other major types of lupus are:
- Subacute cutaneous lupus erythematosus (SCLE)
- Systemic lupus erythematosus (SLE)
These diseases usually involve many organs of the body including the skin, whereas DLE is confined to the skin. People with either SCLE or SLE often suffer from arthritis, or may have involvement of their kidneys, lungs or other internal organs.
As mentioned above these are probably entirely different diseases but occasionally a patient with DLE may also develop Systemic lupus erythematosus. Your doctor will have done blood tests screening for this.
Summary
- DLE is a purely cutaneous (skin) disease
- It is probably an entirely different disease to systemic lupus erythematosus and subacute lupus erythematosus
- Sun protection is the most important factor in minimising skin lesions and their severity
- Treatment needs to be tailored to disease activity. By promptly treating your lesions, you should be able to prevent scarring.
Information compiled by: Royal Newcastle Hospital
Departments of Dermatology and Immunology
Dr John R Sullivan
Sr Rachel Robinson - Nov, 1996
Reviewed by: Sue Barwick - Registered Nurse, July 2002