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Cutaneous lupus erythematosus

Author: Amanda Oakley, Dermatologist, Hamilton, New Zealand, 2001. Updated in January 2016.

Cutaneous lupus erythematosus — codes and concepts

What is lupus erythematosus?

Lupus erythematosus (LE) is a connective tissue disease and autoimmune disorder that can affect one or several organs. Circulating autoantibodies and immune complexes are due to loss of normal immune tolerance and are pathogenic. The clinical features of LE are highly variable. LE nearly always affects the skin to some degree.

What is cutaneous lupus erythematosus?

Cutaneous LE comprises several chronic and relapsing LE-specific and LE-nonspecific inflammatory conditions. There can be some overlap.

Who gets cutaneous lupus erythematosus?

Cutaneous LE most often affects young to middle-aged adult women (aged 20–50 years) but children, the elderly, and males may be affected.

Important predisposing factors for cutaneous LE include:

  • Female sex
  • Genes: ≥ 25 risk loci have been identified, and there are HLA associations
  • Skin of colour.

What causes lupus erythematosus?

LE is classified as an autoimmune disorder, as it is associated with pathogenic antibodies directed against components of cell nuclei in various tissues. UVB irradiation causes keratinocyte necrosis, immune system activation and antibody formation.

Factors that aggravate LE include:

  • Sun exposure
  • Cigarette smoking
  • Hormones
  • Viral infection
  • Certain drugs.

What are the specific features of cutaneous lupus erythematosus?

There are various types of cutaneous LE, classified as acute, subacute, intermittent and chronic cutaneous LE. The revised Cutaneous Lupus Erythematosus Disease Area and Severity Index (RCLASI) can be used to assess disease activity and damage.

Acute cutaneous lupus erythematosus

Acute cutaneous LE affects at least 50% of patients with systemic lupus erythematosus (SLE). Many are sick, young, fair-skinned females.

Specific features of acute cutaneous LE may include:

  • Malar eruption or ‘butterfly rash’ (erythema and oedema of cheeks, sparing nasolabial folds) lasting hours to days
  • Erythematous papular rash on arms, sometimes forming large plaques and spreading widely
  • Photosensitivity (a rash on all recently sun-exposed skin)
  • Cheilitis and mouth ulcers
  • Blisters (bullous SLE) and erosions.

SLE may also affect joints, kidneys, lungs, heart, liver, brain, blood vessels (vasculitis) and blood cells. It may be accompanied by the antiphospholipid syndrome.

Systemic LE

See more images of systemic lupus erythematosus.

Subacute cutaneous lupus erythematosus

About 15% of patients with cutaneous LE have subacute cutaneous LE. One-third of the cases are due to previous drug exposure.

Features of subacute cutaneous LE include:

  • Precipitation or aggravation by sun exposure
  • Non-itchy psoriasis-like papulosquamous rash on the upper back, chest and upper arms
  • Annular or polycyclic plaques that clear centrally
  • The absence of scarring when the rash has resolved.

Up to 50% of patients with subacute cutaneous LE may also have a mild form of SLE, resulting in arthralgia (painful joints) or arthritis (joint disease) and low blood counts. Severe SLE is rare in patients with subacute cutaneous LE.

Subacute LE

Drug-induced subacute cutaneous LE

More than 100 drugs have been associated with the onset of drug-induced lupus, and most present with subacute cutaneous LE. They include:

Drug-induced lupus

Neonatal cutaneous lupus erythematosus

Neonatal cutaneous LE arises within 2 months of birth to mothers with known or subclinical subacute cutaneous LE.

Features of neonatal cutaneous LE may include:

  • An annular erythematous rash, which slowly resolves over 6 months
  • The rash is most often periorbital
  • Photosensitivity
  • Blood count abnormalities: haemolytic anaemia, leukopenia, thrombocytopenia
  • Hepatobiliary disease
  • Persistent congenital heart block.

A paediatrician should assess all babies born to mothers with subacute LE (or carrying anti-Ro/La) at birth. Mortality in babies with heart block is up to 20%, despite pacemaker implantation.

Neonatal lupus

Intermittent cutaneous lupus erythematosus

Intermittent cutaneous LE, more often known as lupus tumidus, is a dermal form of lupus.

Features of lupus tumidus include:

  • Affects sun-exposed sites such as cheeks, neck, anterior chest
  • Erythematous, urticaria-like patches and plaques with a smooth surface
  • Round or annular shapes
  • Clears during the winter months
  • Non-scarring.

Lupus tumidus is similar to Jessner lymphocytic infiltrate, in which diagnostic criteria for lupus are absent.

Lupus tumidus

Chronic cutaneous lupus erythematosus

Chronic cutaneous LE accounts for 80% of presentations with cutaneous LE. About 25% of patients with chronic cutaneous LE also have systemic LE.

Discoid LE

Discoid LE is the most common form of chronic cutaneous LE. It is more prevalent in patients with skin of colour, who are at greater risk of postinflammatory hyperpigmentation and hypertrophic scarring.

  • Discoid LE is confined to the skin above the neck in most patients but can spread below the neck to affect upper back, V of neck, forearms and backs of hands.
  • Scalp, ears, cheeks, nose are the most common sites.
  • Most patients have photosensitivity.
  • New lesions are destructive, erythematous scaly plaques with follicular prominence.
  • Scalp discoid LE presents as red, scaly and bald plaques.
  • Slow healing leads to post-inflammatory pigmentation and white scars.
  • Hair growth may partially or completely recover with treatment. Cicatricial (scarring) alopecia can be permanent.

Hypertrophic LE

Hypertrophic LE is a variant of discoid LE in which there are thickened and warty plaques resembling viral warts or skin cancers. Hypertrophic LE can occur on palms and/or soles. This is also called palmoplantar LE and is a form of acquired keratoderma.

Mucosal LE

Mucosal LE presents with plaques, ulcers and scaling. Mucosal lesions may predispose to squamous cell carcinoma. Common sites are:

  • Lips and inside the mouth
  • Lower eyelid with madarosis (loss of eyelashes)
  • Rarely, vulva/penis.

Discoid lupus erythematosus

See more images of cutaneous lupus erythematosus.

Lupus profundus

Lupus profundus affects subcutaneous tissue. Other names for lupus profundus are lupus panniculitis and subcutaneous LE.

  • Lupus profundus may develop at any age, including childhood.
  • It may involve face, buttocks, limbs or anywhere.
  • Firm deep and tender nodules persist for some months.
  • Lesions resolve leaving dented, atrophic scars (lipoatrophy).

Lupus profundus

What are the nonspecific cutaneous features of lupus erythematosus?

LE nonspecific cutaneous features are most often associated with SLE. They include:

Chilblain lupus

What are the complications of cutaneous lupus erythematosus? 

Chronic cutaneous LE causes facial deformity and scarring. Active and burned-out disease can lead to social isolation and depression.

Systemic LE may involve heart, lung and brain with significant morbidity and mortality. Vasculitis and antiphospholipid syndrome involving internal organs can be serious.

How is cutaneous lupus erythematosus diagnosed?

  • SLE is associated with high titre antinuclear antibodies.
  • About 70% of patients with subacute LE have antiRo/La extractable nuclear antigens (ENA).
  • The severity of LE may be reflected in the titre of ANA and/or ENA.
  • ANA and ENA are often negative in a patient with chronic cutaneous LE.
  • Mild anaemia or leukopenia may be present in patients that do not have SLE

A skin biopsy may be diagnostic, showing a lichenoid tissue reaction and features specific to the kind of cutaneous LE. Direct immunofluorescence tests may show positive antibody deposition along the basement membrane (lupus band test).

Diagnostic features on biopsy are more likely to be found in LE-specific skin lesions than in LE-nonspecific cutaneous LE.

Note: All women with positive anti-Ro or anti-La antibodies should be advised that if they become pregnant there may be a risk to their infant of developing neonatal lupus and congenital heart block. Women with these antibodies should be referred to an obstetrician and consideration may be given to prophylactic administration of </span

>hydroxychloroquine or low dose prednisone to prevent heart block in the fetus.

How can cutaneous lupus erythematosus be prevented?

  • Carefully protect all exposed skin from sun exposure with covering clothing and SPF50+ broad-spectrum sunscreen (see sun protection).
  • Smoking cessation is essential – it is best to avoid nicotine replacement as nicotine in any form may exacerbate cutaneous LE.
  • If subacute LE is drug-induced, stop the responsible medication.

What is the treatment for cutaneous lupus erythematosus?

The aim of treatment for cutaneous LE is to prevent flares, improve appearance and to prevent scarring.

Local therapy

Systemic therapy

Treatment for cutaneous and systemic LE may include:

Severe disease may require more aggressive treatment:


What is the outlook for cutaneous lupus erythematosus?

The prognosis for cutaneous LE is variable.

The skin involvement in SLE tends to mirror systemic involvement.

Drug-induced SCLE clears within a few weeks of withdrawal of the responsible drug.

Untreated chronic cutaneous LE tends to persist, but the severity is lessened by strict sun protection and avoidance of nicotine.

See smartphone apps to check your skin.
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  • Kuhn A, Meuth AM, Bein D, Amler S, Beissert S, Böhm M, Brehler R, Ehrchen J, Grundmann S, Haust M, Ruland V, Schiller M, Schulz P, Ständer S, Sauerland C, Köpcke W, Luger TA, Bonsmann G. Revised Cutaneous Lupus Erythematosus Disease Area and Severity Index (RCLASI): a modified outcome instrument for cutaneous lupus erythematosus. Br J Dermatol. 2010 Jul;163(1):83-92. doi: 10.1111/j.1365-2133.2010.09799.x. Epub 2010 Apr 12. PubMed.
  • Moura Filho JP, Peixoto RL, Martins LG, et al. Lupus erythematosus: considerations about clinical, cutaneous and therapeutic aspects . Anais Brasileiros de Dermatologia. 2014;89(1):118-125. doi:10.1590/abd1806-4841.20142146. PubMed Central.
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