That red, scaly spot on your head could be lupus

Abigail is a newly diagnosed case of lupus, just about five weeks. She’s had the lupus rashes for three years now, but at the outset, she had no idea that the rash had something to do with lupus. She had gone to three dermatologists who all gave her a cream which improved her rashes a bit but did not improve her condition. Her hairstylist was the first to notice the singular slightly red, scaly spot on her head and told her about it. But the carefree person that she is, Abigail just dismissed it as something brought about by scratching and it would eventually heal. Well, it never did. In the months that followed, the red spot on Abigail’s head gradually enlarged, becoming hollow and bald. But still, Abigail did not feel the urgency to seek medical treatment. It was not until her senior year in college, after a series of stressful events which occurred in school, that Abigail started noticing the lesions, which began showing up on her hairline and even on her face. At first, they looked like mosquito bites, with some tiny depressions at the center, but then the color began to change from red to dark brown to black that did not disappear. The hair in those depressions started to vanish one by one. And that was the turning point that finally made Abigail decide to seek medical help. She describes the flare as a rash that progressively became more itchy, with significant amount of flaking. She remembers placing ice cubes on the rash, which helped for a while, but soon it came back with a vengeance so it became clear to Abigail that something was really, really wrong. The itching, plus apparent balding, and the fear that she may have acquired some kind of hair infection, like a ringworm, made Abigail quickly make an appointment with a dermatologist.

After examining her entire body, I looked at Abigail and asked, “Is there anyone in your family who has lupus?” Abigail was quite stunned because for her, there was no way that she could have lupus! She knew of one or two relatives who were actually diagnosed with lupus, but it simply can’t be her.

Lupus attacks all organs of your body. It leaves you drained, depressed, hospitalized forever. She told me she has never been to a hospital, except for that one time when she had abdominal pains for eating too much grapefruit.

So, I did a skin biopsy and two to three weeks later, Abigail is now a certified “luppie,” which she really has not accepted fully. Surprisingly, she did not scream or cry. She just sat and asked me, “Will it get worse? Will it kill me? What is discoid lupus anyway?”

I explained to her that discoid lupus (DLE) is different from systemic lupus (SLE). DLE is not a death sentence. In fact, it is the best lupus one would wish for because it is quite benign and really not a life-threatening condition. I explained that patients with DLE had a five to 10-percent chance of developing SLE and that with treatment, and being on top of any new rashes, DLE could be handled without much interference in her life. I started her on topical steroids, antihistamine, and sunblock. All this stopped the intense itching, and seemingly slowed the progression of her lupus.

Lupus is a disease where your body’s self-protection mechanism (immune system) attacks your own body rather than a foreign invader (microorganisms, for example). The cause of lupus is unknown, and the disease usually takes one of three forms: systemic lupus erythematosus (SLE), which can affect any body organ, discoid lupus erythematosus (DLE), which is milder and usually affects only the skin. About five to 10-percent of patients with discoid lupus erythematosus will progress to systemic lupus. The last form is the subacute lupus erythematosus which could also develop into systemic lupus.

Who is at risk? Discoid lupus erythematosus most commonly afflicts young adult females, especially blacks and Hispanics, though it may occur at any age. Lupus sometimes runs in families. The face ( bridge of the nose, cheeks, lower lip, ears, or inside the mouth) and/or the scalp are most often affected in localized DLE. Sometimes, the trunk as well as the arms and legs (extremities) are more extensively involved in widespread DLE. The skin lesions may vary in appearance. A red bump or patch may appear first and is usually painless or only slightly itchy. The area may be scaly or even wart-like. With time, the center of the lesion becomes white and scarred, with permanent hair loss. Lesions in darker-skinned people may be darker brown, changing to a purple color at the edges. Overtime, lesions slowly expand, producing areas of peripheral inflammation or hyperpigmentation (darkening), leaving a central region of scarring with telangiectasia (spider veins) and hypopigmentation (whitening). The age of onset is usually between 20 and 40 years old. Lesions are often aggravated by UV light exposure, but smoking is also considered a risk factor.

Here are some self-care guidelines:

• Avoid sunlight exposure. Sunscreens with UVB and UVA blockers (such as Parsol 1789, zinc, or titanium dioxide) are recommended.

• Remember that clothing (dark colors and closely woven fabrics) and hats are very effective sun-blockers.

• Avoid excessive heat, excessive cold, as these may make the condition worse.

• Stop smoking, as it can aggravate the condition and interfere with the effectiveness of some medications.

• Eat a healthy diet low in red meat and dairy products and high in cold-water fish (e.g. salmon, tuna, halibut, mackerel) to help decrease inflammation. • Use cosmetics to cover affected areas. When should you seek medical help? Because discoid lupus erythematosus can cause permanent scars and hair loss, you should seek medical care if you suspect you may have this condition.

Blood tests and a biopsy will be done to confirm the diagnosis. There is no cure, but treatment will control symptoms until the disease improves on its own, usually after months to years of treatment. Topical anti-inflammatories are generally used first for small areas, corticosteroids may be injected into the lesions. Other topical immunosuppressive agents may be helpful. Antimalarial drugs can be used for severe cases. Other oral medications may include dapsone, acitretin, isotretinoin, or gold. All oral medications have potential side effects. Recent studies have shown thalidomide to be effective, but it is generally reserved for severe cases that do not respond to other treatments, and doctors administer it with great caution due to its potential side effects.

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