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Lupus Pics from the Lupus Encyclopedia: Includes color images

Due to publishing restrictions, the photos from The Lupus Encyclopedia edition 1 were published in black and white. This page includes those photos in color. In addition, photographs that will be included in the second edition will also be placed here.

Includes photographs of cutaneous lupus affecting skin of color

Photographs of people of color are included. We need more photographs of cutaneous lupus (lupus affecting the skin) in people of color that are easy to find on the internet. Rashes in people of color are underrepresented in books and on the internet. It is important that they be published because it can be more difficult to notice redness (erythema) and pink colored rashes on darker skin. I hope more healthcare providers publish their photographs of cutaneous lupus in people of color.

Why are most lupus pics done of white skin? It is because rashes are much easier to see. Unfortunately, this trend of making things easy left out the largest population of lupus patients. Lupus occurs much more often in people of African, Asian, Hispanic and indigenous ancestry.

NOTE: If you have well-done photos of cutaneous lupus in people of color and would like to share them on this page (especially if that particular type of rash is not represented, contact Donald Thomas, MD for inclusion. You would get full credit, of course). The more photos accessible to health care providers and patients, the better

LUPUS PICS FROM CHAPTER 1

Mnemonic to remember the 1996 American College of Rheumatology classification criteria for systemic lupus. Someone needs 4 of these 11 criteria in order to fulfill the classification criteria
The mnemonic RASH ON MAIDS can help you remember the criteria used in the ACR classification criteria for systemic lupus erythematosus. RASH ON MAIDS was developed by Donald Thomas, MD
​Saint Martin and Saint Brice healing the Bishop of Liege of his lupus, “le loup,” in Tours, France at the Shrine of Saint Martin

Figure 1.1 Saint Martin and Saint Brice healing the Bishop of Liege of his lupus, 
“le loup,” in Tours, France at the Shrine of Saint Martin. Image copyright Donald Thomas, MD

​Saint Martin and Saint Brice Healing Éracle, the Bishop of Liège of lupus

The above beautiful wood cutting comes from a French book dated 1496, “Le vie et miracles de Monsigneur Saint Martin, translatee de latin en francoys.” I believe that this is the oldest depiction of someone with a disease called lupus. It comes from a 15th Century book, and it depicts Eraclus (Éracle), the Bishop of Liège, dying of lupus in the 10th Century. Above him are standing Saint Martin (whose tomb is depicted on the left) and Saint Brice (who was buried close by).

The page before this page with the wood cutting states that the Bishop had a disease commonly called “le loup” (French for lupus). Therefore, we know that “lupus” was used as the name of a disease as early as the 10th Century. The Bishop wrote that his body was full of open sores that looked like the bites of a wolf (lupus in Latin).

The Bishop of Liège, Belgium travelled to the Shrine of Saint Martin in Tours, France. He prayed inside Saint Martin’s shrine for seven days and seven nights to be healed of his lupus, since he was close to dying from it. On the seventh night the saints appeared. When he awoke in the morning, all his open sores were gone, and he was healed.

He then went back to Liège and built a church dedicated to Saint Martin. Today, you can go to Liège and see St. Martin’s Basilica (la basilique Saint-Martin de Liège or Basilica of Saint Martin). 

Outside of St. Martin’s Basilica in Liege, Belgium. A church built to thank God and Saint Martin for healing Éracle, the Bishop of Liege, of his lupus in the 11th Century. Note, this is not the original building. It burned and the building was rebuilt. Image copyright Donald Thomas, MD

For our Catholic readers: This is the location of the very first Fête-Dieu (the Feast of Corpus Christi). The first Feast of Corpus Christi was held here in 1246. Pope Urban IV, who was a prior archdeacon of the church, officially instituted the Feast of Corpus Christi on September 8, 1264 (the Thursday after Pentecost).

Inside St. Martin’s Basilica you can see this replication of the sarcophagus of Éracle (Eraclus), Bishop of Liege. The first person written down in history as having lupus. He was cured of lupus by Saint Martin in the 10th Century. Image copyright and photograph Gary O’Connor, JD

You can watch the 3 videos of my visit to St. Martin’s Basilica on YouTube. I’ll take you outside and inside the historic basilica. This is Part 1 of 3 videos

lupus pics from chapter 7

Jaccoud’s arthropathy in a woman with severe SLE. This developed over many years due to uncontrolled lupus tendinitis and arthritis. Image copyright by Donald Thomas, MD
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Jaccoud’s Arthropathy

Most SLE patients with arthritis and tendinitis will not develop deformities. Unfortunately some will develop a problem where the tendons will be damaged from inflammation and slip over the joints, causing the above appearance. This is called Jaccoud’s (pronounced yah-KOOZ’) arthropathy. SLE is the most common cause of Jaccoud’s.

The photo above and below will appear in the 2nd edition of The Lupus Encyclopedia

Doppler ultrasound of lupus tenosynovitis and lupus tendinitis. The red and blue dots are areas of inflammation.

lupus pics from chapter 8

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Malar (butterfly) rash: a type of acute cutaneous lupus erythematosus

The malar rash occurs on those areas of the face that are most exposed to ultraviolet rash (the nose and cheeks). It typically spares the crease under the cheeks (nasolabial fold). Although this is the most well known rash of systemic lupus, it only occurs in around 30% of patients with SLE.
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Lupus profundus (lupus panniculitis)

Lupus profundus is a type of chronic cutaneous lupus. It is due to inflammation of fat (panniculitis) under the skin. It can be quite painful to the patient. If not treated quickly, it can leave permanent loss of tissue under the skin, causing a large indentation. We usually call it lupus “profundus” rather than just panniculitis when there is involvement of the superficial skin by discoid lupus (like this patient has).

Lupus profundus is a type of chronic cutaneous lupus erythematosus (CLE). Discoid lupus erythematosus (DLE) is the most common type of CLE.

Discoid lupus erythematosus

Discoid lupus erythematosus (DLE) is the most common type of chronic cutaneous lupus erythematosus. If not treated quickly and brought into remission, it leaves permanent skin damage and scarring. DLE starts off as small inflamed red or pink areas. Untreated, they grow wider. They are oval or round. This is why they called “discoid.” They are disc shaped.

Note how the border is red. It is actively inflamed and will continue to grow wider if not brought under control.

Note how the inside is a light color without the redness. This is permanently scarred, damaged skin. It can be very disturbing for the patient due to the cosmetic appearance changes. It is especially devastating when it occurs in people with skin of color.

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Her discoid lupus was brought under control when her SLE went into remission on treatment. She was left with scarred areas of skin that was lighter in color, but the areas did not enlarge.

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Discoid lupus on skin of color

Lupus rashes can look quite different on skin of color compared to white skin. Notice the differences between the discoid lupus affecting the cheek and ear of this black man cared for in the dermatology clinic at Howard University by Dr. Okoye. 

It is imperative that we treat these aggressively as soon as they are first noticed. Hydroxychloroquine (Plaquenil) should be used in most patients. Cortisone creams and injections also help.

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Scarring alopecia due to discoid lupus erythematosus

When DLE affects the scalp and destroys the hair follicles, hair loss (alopecia) occurs. These lost hair follicles can never come back, so the person is left with areas of permanent hair loss (scarring alopecia).

It is important that the person with DLE be treated quickly and aggressively to prevent permanent, cosmetic changes from occurring. People suffering from DLE have high levels of poor self esteem and subsequent poor quality of life related to these changes and needs to be taken seriously.

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Nonscarring alopecia

When SLE causes the hair follicles to shut down, rest, and stop producing hair, nonscarring alopecia occurs. It most commonly happens at the frontal areas. There are often brittle and fragile hair in the area of hair loss as well, called “lupus hair.” Since the hair follicles are still present under the skin, they can produce hair again when the SLE is treated successfully. Hair grows in cycles of around 3 months. So, it can take 3-6 months after successful treatment of SLE before hair growth is noticeable. The lupus pics above shows one of my patients who had devastating hair loss when she first saw me. With proper treatment of her systemic lupus, her hair grew back beautifully.
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Lupus tumidus (tumid lupus)

Lupus tumidus is classified as a type of chronic cutaneous lupus by most lupus skin experts. However, some think that it is a separate disease. The vast majority of tumid lupus patients do not have systemic lupus. In addition, the biopsy appears very different under the microscope compared to other types of cutaneous lupus.

It appears as purple/blue color areas of raised skin, similar in appearance to welts or hives (urticaria). With successful treatment, they tend to resolve.

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Vitiligo

Vitiligo is an autoimmune disease of the skin where the immune system attacks the cells that produce melanin (pigmentation). This leaves a lack of pigment in the affected areas. Note how there is a sharp demarcation between the light colored skin and the surrounding normal skin with no inflamed or scaly borders.
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Livedo reticularis

Notice the mottling of the skin above the wrists. This is an area of livedo reticularis. “Reticularis” comes from the Latin for “net.” Note how the mottling is “net-like.” This occurs from decreased blood flow to the skin when tiny arterioles are narrowed. It is more common in patients who are positive for antiphospholipid antibodies.
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Telangiectasia

Telangiectasia are areas of dilated tiny blood vessels under the skin. When you press your finger on one and lift it up quickly, it is normal skin colored but quickly becomes red again. This is due to your finger pressure squeezing out the blood from the blood vessels, causing the normal skin color to appear. Then when the blood rushes back into the blood vessels, they turn red again. This is a permanent problem that does not go away after successful treatment of the SLE. However, when a person goes into remission with treatment, the treatment can prevent new areas from forming.
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Erythromelalgia

Erythromelalgia is a rare complication of SLE. The appearance above itself is actually common in SLE patients, due to palmar erythema or cutaneous vasculitis. 

However, erythromelalgia is painful (distinguishing it from common palmar erythema and cutaneous vasculitis). This patient would keep putting her hands under the cold water in the exam room. Erythromelalgia feels better in cold and worse with warmth (the opposite of Raynaud’s which is worse in cold). After treatment with aspirin and immunosuppressant therapy, this resolved.

Raynaud’s Phenomenon

If lupus causes the blood vessels of the fingers and toes to become narrow, decreased blood flow can occur in the digits with stress or cold exposure. These tiny arterioles normal constrict with stress or cold. Normally, enough blood flows that there is no problem. However, in the person with systemic lupus who has this, the decreased blood flow can cause finger tips to first blanch (turn white) due to loss of blood flow. This is followed by a bluish color (as above) due to oxygen being used up by the tissues (oxygen deprived blood appears blue like in our veins). With rewarming, as blood rushes back in, the digits can sometimes become red. So, the order of color changes are white, then blue, then red. However, most patients develop only one or two color changes.
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lupus pics from chapter 14

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Tongue in Sjögren’s with Thrush

Mouth dryness in Sjögren’s can cause the tongue to develop deep furrows. Think of when your skin gets wrinkly from dryness; it is a similar process. Decreased saliva leads to the loss of beneficial bacteria and bad organisms can take over such as the yeast Candida albicans. This is called thrush.

When there is some moisture, a white coating can form as in this patient. This is called “pseudomembranous candidiasis.”

However, in severely dry mouths, the yeast is unable to grow as much on the surface. Instead, it infects the tissues, causing a red colored tongue with a loss of papillae (the tiny bumps on the tongue surface) that is usually tender and sore. This is called “atrophic candidiasis.”

The image above will appear in the 2nd edition of the book.

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Schirmer’s Test

Schirmer’s test can easily be done in the exam room by rheumatologists to help identify dry eyes from Sjögren’s overlap syndrome in lupus patients. The pieces of paper are placed under the lower eyelid on the outer third of the eye. They are left there for five minutes at which time they are removed. A normal result in a healthy person is usually 15 mm or more. A positive Schirmer’s test for Sjögren’s is less than 5mm. 5mm to 9 mm is considered borderline.