Synopsis
Classify acute, subacute and chronic cutaneous lupus, detect systemic organ involvement, prevent ultraviolet and scarring damage, and use local or antimalarial treatment with reproductive and retinal safeguards.
- Acute cutaneous lupus includes a photosensitive malar eruption that often spares nasolabial folds and usually tracks active systemic lupus rather than existing as an isolated diagnosis.
- Subacute cutaneous lupus forms annular polycyclic or papulosquamous lesions on upper trunk and arms, commonly associates with anti-Ro antibodies and can be medicine induced.
- Discoid lupus produces adherent scale, dyspigmentation, follicular plugging and atrophic scar on face, ears or scalp; destroyed hair follicles do not regrow.
- In richly pigmented skin, active inflammation may appear violaceous, grey or hyperpigmented and permanent dyspigmentation may be more conspicuous than redness.
- Assess every patient for systemic symptoms, blood pressure, urinalysis, FBC and renal function, then use ANA, dsDNA, ENA and complement according to phenotype and specialist pathway.
- Biopsy an active representative lesion for routine histology; direct immunofluorescence can support selected uncertain cases but sun-exposed normal skin can create a nonspecific lupus band.
- Core management is high-UVA broad-spectrum photoprotection, shade, clothing, smoking cessation and review of photosensitising or SCLE-associated medicines.
- Use a site-appropriate potent topical corticosteroid or off-label tacrolimus for limited disease, with an application amount, stop date and infection review.
- Hydroxychloroquine is the usual systemic foundation when topical care is insufficient, dosed no higher than 5 mg/kg actual body weight daily with retinal monitoring and renal-risk adjustment.
Key red flags
Rapidly ulcerating or vasculitic skin, digital ischaemia, extensive blistering, fever, mucosal disease, progressive scarring scalp loss or systemic symptoms requires urgent dermatology and rheumatology assessment.
Retiform purpura, ulcers, digital ischaemia, oedema, hypertension, chest or neurological symptoms shifts urgency toward systemic organ disease.
Investigation priorities
Confirm interface dermatitis, follicular involvement and mucin while excluding infection or malignancy.
Management branches
A photosensitive, annular or scarring eruption suggests cutaneous lupus.
- Map distribution, scale, follicular openings, scar and pigment in neutral light, ask about light, smoking, medicines and systemic symptoms and photograph activity with consent.
- Biopsy an active representative site for routine histology and add correctly planned direct immunofluorescence only when it will resolve a meaningful uncertainty.
- Check blood pressure, FBC, renal and liver profile, urinalysis with quantified protein where abnormal and phenotype-led antibodies and complement, then refer to dermatology and rheumatology according to risk.
Cutaneous lupus is confirmed or strongly supported regardless of current treatment intensity.
- Use broad-spectrum high-UVA sunscreen on exposed skin with shade, tightly woven clothing, hats and window protection where relevant, reapplying by product and exposure instructions.
- Offer smoking-cessation support and review photosensitising and SCLE-associated medicines with their prescribers rather than stopping essential therapy abruptly.
- Address vitamin D risk, camouflage and mental health so rigorous photoprotection does not create deficiency, isolation or an impractical daily plan.
Key medicines
HydroxychloroquineTake 200–400 mg by mouth once daily with food, using the lowest effective dose and never exceeding 5 mg/kg actual body weight per day.Review macular disease, eGFR, tamoxifen, QT drugs, cardiomyopathy, hypoglycaemia and pregnancy context and arrange risk-based retinal monitoring. Skin response takes months and smoking can reduce efficacy.
Site-appropriate topical corticosteroidApply a thin layer once daily to active plaques for the prescribed two-to-six-week course, then stop, reduce or use intermittently only after review.Match potency to face, scalp, ear, trunk or fold and monitor atrophy, telangiectasia, dyspigmentation and infection; avoid indefinite renewal and protect eyes and mucosa.