Malar Rash
A 34-year-old woman presented to the rheumatology clinic with a 3-month history of a rash on her cheeks and an 18-month history of joint pain in her hands and knees. Physical examination showed violaceous indurated plaques on both cheeks with sparing of the nasolabial folds (Panel A), as well as synovitis in multiple proximal interphalangeal joints. Laboratory studies showed leukopenia and positive anti-Smith and anti-RNP antibodies. Histopathological testing of a skin-biopsy sample showed a vacuolar interface dermatitis with superficial, deep, and periadnexal infiltrates. A diagnosis of systemic lupus erythematosus was made. The patient received counseling regarding the importance of strictly avoiding the sun by using a hat, full-coverage clothing, and sunscreen. Treatment with topical fluocinonide 0.05% ointment, hydroxychloroquine at a dose of 200 mg daily, and prednisone at a dose of 5 mg daily was initiated. The rash and arthritis resolved completely by 7 months after the initial presentation. Malar rash is a common dermatologic manifestation of acute cutaneous lupus erythematosus and may be the initial sign of systemic lupus erythematosus. Despite the importance of clinicians being able to recognize and diagnose autoimmune skin conditions, people of color are underrepresented in medical educational materials. Additional examples of malar rashes in women with systemic lupus erythematosus are shown in Panels B through D.