Rashes

Clinical Description

• Well demarcated coin shaped, red, and scaly papules or plaques in sun–exposed areas
• Result in atrophic (central) scarring and dyspigmentation (borders)

Brief Histopathologic Description

• Interface dermatitis with disrupted dermo-epidermal junction

Differential Diagnosis

• Discoid lupus: 28 % with generalized rash can develop SLE
• Discoid mimics:
  • Actinic keratosis
  • Cutaneous tuberculosis
  • Subcutaneous sarcoidosis

Recommended Workup

• ANA
• Skin biopsy may be required.

Clinical Description

• Annular polycyclic plaques with a raised red scaly border and central clearing
• Can lead to post-inflammatory dyspigmentation
• Non-scarring
• Distribution usually photosensitive areas – shoulders, arms, upper torso, upper back

Brief Histopathologic Description

• Interface dermatitis with disrupted dermo-epidermal junction

Differential Diagnosis

• SCLE occurs in 10-15% with SLE; 50% of SCLE progresses to SLE
• Drug associations include but not limited to: tamoxifen, lansoprazole, statins, ACEi, TNFi, anti-epileptics, PPIs, naproxen, etc.
• Tinea corporis
• Erythema annulare centrifugum
• Psoriasis
• Lichen planus
• Eczema

Recommend Workup

• ANA, SSA autoantibodies

• Heliotrope, facial rash, and Gottron’s papules
• Gottron sign asymmetrical violaceous macules can also be observed

Clinical Description

• Flat violaceous scaly rash on the face
• Involves nasolabial folds and eyelids
• Symmetrical erythematosus papular lesions over the metacarpophalangeal and interphalangeal joints
• Periungueal erythema

Brief Histopathologic Description

• Interface dermatitis – unable to differentiate from skin histopathology of lupus

Differential Diagnosis

• Systemic lupus erythematosus: apares nasolabial folds and eyelids

A skin biopsy cannot help distinguish between SLE and DM.

Recommended Workup

• Creatinine kinase and aldolase levels, ANA, myositis panel
• Classic presentation may not need a skin biopsy.
• Screen for an underlying malignancy!

Clinical Description

• Limited or diffuse skin thickening and tightness (face, torso, extremities, finger “sclerodactyly“)
• Coexistence of hyperpigmentation and hypopigmentation (“salt-pepper lesions”)
• Lesions sparing the perifollicular area
• Telangiectasias on the cheeks, nose, and lips

Brief Histopathologic Description

• Thickened collagen in the dermis and dermal fibrosis

Differential Diagnosis

• Scleroderma mimics (scleromyxedema, scleredema, eosinophilic fascitis)
  • No Raynaud’s phenomenon
  • No sclerodactyly
  • No nailfold abnormalities
  • Negative serology
  • Face rarely affected

Recommended Workup

• Autoantibody profile (Scl-70 [or anti-topoisomerase I], anti-centromere, RNA polymerase III)
• Screen for lung or cardiac involvement

Clinical Description

• Salmon colored edematous plaques or salmon colored edematous rash
• Evanescent rash coinciding with fever spikes
• Non-pruriginous

Brief Histopathologic Description

• Neutrophilic inflammation in the dermis

Differential Diagnosis

• Urticaria: pruriginous transient lesions
• Urticarial vasculitis:
  • Hives usually persist for longer than 48 hours.
  • Can be associated with low complement levels

Recommended Workup

• C-reactive protein, sedimentation rate, ferritin levels

Many conditions can be associated with finding of LCV on histopathology.

• Different infections including but not limited to: streptococcal upper respiratory tract infection, mycobacterium, staphylococcus aureus, chlamydia, neisseria, and HIV, hepatitis B, hepatitis C, and syphilis.
• Systemic diseases including: any small vessel vasculitis, ANCA-associated vasculitis, cryoglobulinemic vasculitis, various connective tissue diseases, erythema elevatum diutinum
• Malignancies including but not limited to: lymphomas, leukemias, lung cancer
• Various drug associations including but not limited to: beta-lactams, erythromycin, clindamycin, vancomycin, sulfonamides, furosemide, allopurinol, NSAIDs, amiodarone, gold, thiazides, phenytoin, beta-blockers, TNF-alpha inhibitors, selective serotonin reuptake inhibitors, metformin, warfarin, valproic acid

Clinical Description

• Clusters of small and large red-purple non-blanchable discoloration in the lower extremities

Brief Histopathologic Description

• Neutrophilic inflammation around the blood vessels leads to vessel wall inflammation. This causes vascular injury and extravasation of red blood cells into the dermis, hence the purpuric appearance.

Differential Diagnosis

• Leukocytoclastic vasculitis: petechia and palpable purpura (dependent areas)
• Small vessel vasculitis
• ANCA-associated vasculitis
• Cryoglobulinemic vasculitis
• Associated with connective tissue diseases
• Urticarial vasculitis syndrome
• Hypersensitivity vasculitis
• Scurvy (view images)
• Meningococcemia
• IgA vasculitis (Henoch-Schonlein purpura) (view image)
• Disseminated intravascular coagulation
• Thrombotic thrombocytopenic purpura
• Emboli: cardiac myxoma, cholesterol emboli, septic and infectious emboli
• Pigmented purpuric dermatosis
• Schamberg disease
• Gardener Diamond syndrome

Recommended Workup

• ANA, ANCA with PR3/MPO specificity, cryoglobulin, complement level, IgA
• Urinalysis with sediment
• Skin biopsy is required.

Associated Systemic Conditions

Of the rheumatic diseases, sarcoidosis and Behcet’s are the most commonly associated

• Sarcoidosis
• Behcet’s syndrome
• Inflammatory bowel disease
• Strep-related illness
• TB

Clinical Description

• Several tender red subcutaneous nodules on the legs

Brief Histopathologic Description

• Inflammation in the subcutaneous fat (“septal panniculitis”) with giant cells

Differential Diagnosis

• In contrast to lupus panniculitis (lobular), E. nodosum does not cause scarring or involve the face
• Eosinophilic fasciitis
• Insect bites

Recommended Workup

• ANA, extractable nuclear antigens, rheumatoid factor, vitamin D 1,25, angiotensin converting enzyme level
• Chest x-ray
• Pathergy test, if history of recurrent oral or genital ulcerations