When to suspect an underlying systemic disease

• An unusual rash which does not have the features of one of the common primary inflammatory skin conditions

• Evidence of systemic illness—weight loss, and other symptoms such as breathlessness, altered bowel function or painful joints

• Erythema of the skin due to inflammation around the blood vessels, usually without epidermal changes—reactive erythema. Vasculitis, in which there are palpable erythematous lesions which may be painful or nodular

• Unusual changes in pigmentation or texture of the skin

• Palpable dermal lesions that may be due to granuloma, metastases, lymphoma, or deposits of fat or minerals

Rash from penicillin

Erythema multiforme

Rash from penicillin and the numerous ways in which it can present. In three quarters of the patients the skin is involved. There are four main types, with numerous variations.

In systemic lupus erythematosus (SLE) the commonest skin change is an acute erythematous eruption occurring bilaterally on the malar area of the face in a "butterfly" distribution. There may also be photosensitivity, hair loss, and areas of vasculitis in the skin. There is often intolerance of sunlight. It is more common in females with a female:male ratio of 8:1.

The systemic changes include fever, arthritis and renal involvement, but there may be involvement of a wide range of organs. The criteria for diagnosing the condition include at least four of the features in the box on the right.

Subacute lupus erythematosus is a variant in about 10% of patients with lupus erythematosus that presents with non-scarring erythematosus plaques mainly on the face, hands and arms. Papulo squamous lesions also occur. They may be annular. Systemic involvement is less common and severe than in SLE. It is associated with a high incidence of neonatal lupus erythematosus in children born to mothers with the condition. The antinuclear factor test is positive in 60% and anticytoplasmic antibodies are present in 80% of patients.

Discoid lupus erythematosus (DLE) is a condition in which circulating antinuclear antibodies are very rare. There are quite well defined photosensitive inflammatory lesions, with some degree of atrophy and hyperkeratosis of the follicles, giving a "nutmeg grater" feel. It occurs predominantly on the face or areas exposed to the sun, becoming worse in the summer months. Scarring is common causing hair loss in lesions on the scalp.

Treatment of SLE with the threatened or actual involvement of other organs is important. Prednisolone is usually required and sometimes immunosuppressant drugs such as azathioprine as well. Treatment of DLE is generally with topical steroids. Hydroxychloroquine by mouth is also used, generally in a dose of 200 mg daily. This drug can diminish visual acuity in higher doses and this should be checked every few months. A simple chart, the Amsler Chart, is available for patients to use, consisting of a central dot with a grid which becomes blurred when held at arm's length when there is any impairment of acutity.

How To Reduce Acne Scarring

How To Reduce Acne Scarring

Acne is a name that is famous in its own right, but for all of the wrong reasons. Most teenagers know, and dread, the very word, as it so prevalently wrecks havoc on their faces throughout their adolescent years.

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