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Singh A, Dhir V, Sekar A, Nada R, Jain S. Even the most severe of lupus skin lesions can heal. Rheumatology (Oxford) 2024; 63:e69-e70. [PMID: 37540181 DOI: 10.1093/rheumatology/kead394] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2023] [Revised: 06/24/2023] [Accepted: 07/03/2023] [Indexed: 08/05/2023] Open
Affiliation(s)
- Aakash Singh
- Department of Internal Medicine, Rheumatology Services, PGIMER Chandigarh, Chandigarh, India
| | - Varun Dhir
- Department of Internal Medicine, Rheumatology Services, PGIMER Chandigarh, Chandigarh, India
| | - Aravind Sekar
- Department of Histopathology, PGIMER Chandigarh, Chandigarh, India
| | - Ritambhra Nada
- Department of Histopathology, PGIMER Chandigarh, Chandigarh, India
| | - Sanjay Jain
- Department of Internal Medicine, Rheumatology Services, PGIMER Chandigarh, Chandigarh, India
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McKinley BJ, Allen ME, Michels N. Photodistributed Stevens-Johnson syndrome and toxic epidermal necrolysis: a systematic review and proposal for a new diagnostic classification. Eur J Med Res 2023; 28:188. [PMID: 37303053 DOI: 10.1186/s40001-023-01142-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2022] [Accepted: 05/15/2023] [Indexed: 06/13/2023] Open
Abstract
BACKGROUND Ultraviolet radiation (UVR) exposure is commonly reported as a risk factor for Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN). However, minimal evaluation of photo-induced SJS/TEN has been conducted. Thus, this review identifies all cases of SJS/TEN that are linked to an acute exposure of UVR and outlines the unifying characteristics of these cases. Furthermore, the theoretical pathogenesis, differential diagnoses, and proposed diagnostic criteria are defined. METHODS PubMed, Google Scholar, and other databases and websites were searched from inception to September 2021 to identify studies that met inclusion criteria. The following keywords were utilized: "Stevens-Johnson syndrome" and "toxic epidermal necrolysis" with "ultraviolet," "photodistributed," "photo-induced," "photosensitivity," and "photo." One reviewer assessed study characteristics, with confirmation by a second. The risk of bias was assessed independently by another. RESULTS Thirteen patient cases were identified, all reporting ultraviolet radiation prior to rash onset and an underlying causal drug. Case classifications included 7/13 SJS and 6/13 TEN. All cases described the rash as photodistributed with UVR exposure prior to rash onset (delay of 1-3 days) and a causal drug. 10 cases provided evidence that the photodistributed rash lacked linear demarcation (as in a sunburn) with satellite target-like lesions. No cases described a flu-like prodrome. DISCUSSION Mucositis, palmar and plantar rash, a positive Nikolsky sign, and a prolonged disease course can help distinguish from photosensitive reactions, while a negative direct immunofluorescence test is important to distinguish from other photo-induced disorders. CONCLUSION Physicians should be aware that UVR may precipitate SJS/TEN in patients taking susceptible drugs. After a 24-h delay from UVR exposure, a non-distinct, photodistributed rash appears with no flu-like prodrome and progresses for at least 48 h to include vesiculobullous eruptions and mucous membrane involvement. Photodistributed SJS/TEN appears to be photo-drug-induced with a unique onset and rash presentation that should be recognized as a distinct diagnosis.
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Affiliation(s)
- Blake Jeffrey McKinley
- Department of Internal Medicine, Mayo Clinic, 4500 San Pablo Rd S, Jacksonville, FL, 32224, USA.
| | - Mitchell Edger Allen
- Department of Primary Care, Rocky Vista University College of Osteopathic Medicine, Ivins, UT, 84738, USA
| | - Nicole Michels
- Department of Medical Humanities and Biomedical Sciences, Rocky Vista University College of Osteopathic Medicine, 8401 S. Chambers Road, Parker, CO, 80134, USA.
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Sodani A, Kothari R, Kinra P, Hegde A. Oxcarbazepine-induced toxic epidermal necrolysis in lupus erythematosus: Turning into a "frequent" rarity but is it diagnosing that matters? Med J Armed Forces India 2023; 79:337-343. [PMID: 37193523 PMCID: PMC10182299 DOI: 10.1016/j.mjafi.2021.04.018] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2020] [Accepted: 04/25/2021] [Indexed: 01/24/2023] Open
Abstract
Classic Toxic Epidermal Necrolysis (TEN) in Lupus Erythematosus (LE) is rare and that caused by oxcarbazepine is even rarer. It can be triggered/induced by various insults, the most prominent being drugs. Herein, we describe a young female, a diagnosed case of LE with lupus nephritis, with recent-onset central nervous system vasculitis (incidentally detected on neuroimaging while she was being evaluated for a recent-onset behavioural change), who within a month of exposure to the drug developed an extensive exfoliating skin rash with mucosal lesions, which on histopathological evaluation showed TEN in LE, triggered by Oxcarbazepine, which was commenced for seizure prophylaxis. She was managed with pulse methylprednisolone, followed by intravenous immunoglobulin (IVIg), after which she made a satisfactory recovery. It is highlighted that TEN in LE patterns must be recognized in an emergency and Acute Syndrome of Apoptotic Panepidermolysis (ASAP) concept applied promptly without awaiting diagnoses. Further, many common drugs possibly trigger this pathology making the rara-avis not rare anymore!
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Affiliation(s)
- Adwait Sodani
- Resident, Department of Internal Medicine, Armed Forces Medical College, Pune, India
| | - Rohit Kothari
- Resident, Department of Dermatology, Armed Forces Medical College, Pune, India
| | - Prateek Kinra
- Professor, Department of Pathology, Armed Forces Medical College, Pune, India
| | - Arun Hegde
- Associate Professor (Medicine) & Rheumatologist, Command Hospital (Southern Command), Pune, India
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4
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Lee V, Sokumbi O, Onajin O. Collagen Vascular Diseases. Dermatol Clin 2023; 41:435-454. [DOI: 10.1016/j.det.2023.02.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/07/2023]
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5
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Stull C, Sprow G, Werth VP. Cutaneous Involvement in Systemic Lupus Erythematosus: A Review for the Rheumatologist. J Rheumatol 2023; 50:27-35. [PMID: 36109075 PMCID: PMC10152495 DOI: 10.3899/jrheum.220089] [Citation(s) in RCA: 13] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/25/2022] [Indexed: 02/08/2023]
Abstract
The majority of patients with systemic lupus erythematosus (SLE) have cutaneous manifestations at some point in their disease course. The skin findings in SLE are classified as SLE-specific or SLE-nonspecific based on histopathologic findings. SLE-specific skin diseases include chronic cutaneous lupus erythematosus (CLE), subacute CLE, and acute CLE. There are subsets of skin lesions within each group and the likelihood of associated SLE varies among them. SLE-nonspecific lesions are more common in patients with SLE and tend to coincide with active systemic disease. SLE-nonspecific lesions may be seen as a feature of another disease process, including other connective tissue diseases. It is important for the rheumatologist to be familiar with the spectrum of cutaneous diseases in SLE to help prognosticate the likelihood of systemic disease and to ensure patients receive timely dermatologic care with the goal of controlling disease activity to prevent damage.
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Affiliation(s)
- Courtney Stull
- C. Stull, MD, Corporal Michael J. Crescenz VAMC, and Department of Dermatology, University of Pennsylvania, Philadelphia, and Department of Rheumatology, University of Pittsburgh Medical Center, Pittsburgh
| | - Grant Sprow
- G. Sprow, BA, V.P. Werth, MD, Corporal Michael J. Crescenz VAMC, and Department of Dermatology, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Victoria P Werth
- G. Sprow, BA, V.P. Werth, MD, Corporal Michael J. Crescenz VAMC, and Department of Dermatology, University of Pennsylvania, Philadelphia, Pennsylvania, USA.
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6
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Salah E. TEN mimics: Classification and practical approach to toxic epidermal necrolysis-like dermatoses. Indian J Dermatol Venereol Leprol 2022; 89:337-346. [PMID: 36688885 DOI: 10.25259/ijdvl_244_2022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2022] [Accepted: 08/01/2022] [Indexed: 12/15/2022]
Abstract
Toxic epidermal necrolysis (TEN) is an acute life-threatening dermatologic emergency. However, many dermatoses can present with a TEN-like eruption. Those "TEN-mimics" are a true diagnostic challenge and an alarming differential diagnosis to such a serious condition. Herein, we will expose and classify the landscape of TEN-mimics. Also, the key differentiating clinical and/or laboratory points will be highlighted to help an accurate diagnosis of either a TEN or a TEN-like presentation.
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Affiliation(s)
- Eman Salah
- Department of Dermatology, Venereology & Andrology, Faculty of Medicine, Zagazig University, Egypt
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7
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Camacho García D, Vallés Blanco L, Santonja Garriga C. Exfoliación cutánea extensa en paciente de edad avanzada. ACTAS DERMO-SIFILIOGRAFICAS 2021; 113:895-896. [DOI: 10.1016/j.ad.2020.11.029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2020] [Accepted: 11/23/2020] [Indexed: 11/30/2022] Open
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8
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Tanaka A, Bun S. Stevens‐Johnson syndrome/toxic epidermal necrolysis‐like acute cutaneous lupus erythematosus in a patient with systemic lupus erythematosus. JOURNAL OF CUTANEOUS IMMUNOLOGY AND ALLERGY 2021. [DOI: 10.1002/cia2.12207] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Affiliation(s)
- Aya Tanaka
- Department of Dermatology Sakai City Medical Center Sakai‐shi Japan
| | - Shota Bun
- Department of Dermatology Sakai City Medical Center Sakai‐shi Japan
- Department of Dermatology National Hospital Organization Osaka National Hospital Osaka‐shi Japan
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Loghmani A, Ford B, Derbes S. A Rare Case of a Patient with Systemic Lupus Erythematosus who Presented with Rowell Syndrome Responding to Treatment with Hydroxychloroquine and Prednisone with One Year of Relapse Free Survival on Belimumab. Mod Rheumatol Case Rep 2021; 6:33-35. [PMID: 34491356 DOI: 10.1093/mrcr/rxab013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2021] [Revised: 06/22/2021] [Accepted: 07/02/2021] [Indexed: 11/14/2022]
Abstract
Rowell Syndrome, first described in 1963 by Rowell et al., is an infrequently reported and unique syndrome occurring in patients with Systemic Lupus Erythematosus (SLE). This syndrome characteristically presents with erythema multiforme-like lesions as well as other specific immunologic and histopathologic manifestations. Since Rowell's original description, diagnostic criteria have been proposed and modified to better describe the syndrome. We describe a 32-year-old African American female patient with a previous history of SLE who presented with dermatologic, immunologic, and histopathologic manifestations that fit the modified diagnostic criteria for Rowell Syndrome.
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Affiliation(s)
- Arya Loghmani
- Department of Internal Medicine, Louisiana State University, New Orleans LA, USA
| | - Barrett Ford
- Department of Rheumatology, Louisiana State University, New Orleans LA, USA
| | - Stephen Derbes
- Department of Rheumatology, Louisiana State University, New Orleans LA, USA
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10
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Morgado-Carrasco D, Mascaró Jr J. Hallazgos de inmunofluorescencia indirecta en una paciente con lupus eritematoso cutáneo de tipo necrólisis epidérmica tóxica. ACTAS DERMO-SIFILIOGRAFICAS 2021. [DOI: 10.1016/j.ad.2021.01.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022] Open
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11
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Bitar C, Menge TD, Chan MP. Cutaneous manifestations of lupus erythematosus: A practical clinicopathologic review for pathologists. Histopathology 2021; 80:233-250. [PMID: 34197657 DOI: 10.1111/his.14440] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2021] [Accepted: 06/30/2021] [Indexed: 11/27/2022]
Abstract
Accurate diagnosis of connective tissue diseases is often challenging and relies on careful correlation between clinical and histopathologic features, direct immunofluorescence studies, and laboratory workup. Lupus erythematosus (LE) is a prototype of connective tissue disease with a variety of cutaneous and systemic manifestations. Microscopically, cutaneous LE is classically characterized by an interface dermatitis, although other histopathologic patterns also exist depending on the clinical presentation, location, and chronicity of the skin lesions. In this article, we review the clinical, serologic, histopathologic, and direct immunofluorescence findings in LE-specific and LE-nonspecific skin lesions, with an emphasis on lesser known variants, newly described features, and helpful ancillary studies. This review will guide general pathologists and dermatopathologists in accurately diagnosing and subclassifying cutaneous LE.
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Affiliation(s)
- Carole Bitar
- Department of Pathology, Michigan Medicine, University of Michigan, Ann Arbor, MI, USA.,Department of Dermatology, Michigan Medicine, University of Michigan, Ann Arbor, MI, USA
| | - Tyler D Menge
- Department of Pathology, Michigan Medicine, University of Michigan, Ann Arbor, MI, USA.,Department of Dermatology, Michigan Medicine, University of Michigan, Ann Arbor, MI, USA
| | - May P Chan
- Department of Pathology, Michigan Medicine, University of Michigan, Ann Arbor, MI, USA.,Department of Dermatology, Michigan Medicine, University of Michigan, Ann Arbor, MI, USA
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12
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Bhattarai D, Vignesh P, Chaudhary H, Bharadwaj N, Saini L, Gupta K, Rawat A. Epidermal necrolysis as the presenting manifestation of pediatric lupus. Pediatr Dermatol 2020; 37:1119-1124. [PMID: 32770777 DOI: 10.1111/pde.14324] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/11/2019] [Revised: 06/30/2020] [Accepted: 07/21/2020] [Indexed: 01/03/2023]
Abstract
Stevens-Johnson syndrome (SJS)/toxic epidermal necrolysis (TEN) represents the spectrum of skin lesions characterized by rashes, exfoliation, and sloughing usually following drug intake. Occasionally, TEN-like cutaneous manifestations have also been described with systemic lupus erythematosus. Recognition of lupus in a child presenting with TEN-like skin changes is clinically challenging and requires a high degree of suspicion. We describe the case of a child who had epidermal necrolysis as the presenting feature of lupus and had severe neurological complications. TEN-like skin changes in association with severe neurological complications in pediatric lupus are uncommon. Lupus must be considered in the differential diagnosis of a child presenting with epidermal necrolysis with no provocative risk factors such as a history of exposure to medications.
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Affiliation(s)
- Dharmagat Bhattarai
- Advanced Pediatrics Centre, Post Graduate Institute of Medical Education & Research, PGIMER, Chandigarh, India
| | - Pandiarajan Vignesh
- Advanced Pediatrics Centre, Post Graduate Institute of Medical Education & Research, PGIMER, Chandigarh, India
| | - Himanshi Chaudhary
- Advanced Pediatrics Centre, Post Graduate Institute of Medical Education & Research, PGIMER, Chandigarh, India
| | - Niteesh Bharadwaj
- Advanced Pediatrics Centre, Post Graduate Institute of Medical Education & Research, PGIMER, Chandigarh, India
| | - Lokesh Saini
- Advanced Pediatrics Centre, Post Graduate Institute of Medical Education & Research, PGIMER, Chandigarh, India
| | - Kirti Gupta
- Department of Histopathology, Post Graduate Institute of Medical Education & Research, PGIMER, Chandigarh, India
| | - Amit Rawat
- Advanced Pediatrics Centre, Post Graduate Institute of Medical Education & Research, PGIMER, Chandigarh, India
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13
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Konstantinov NK, Pearson DR. Systemic Lupus Erythematosus: Considerations in Diagnosis and Management for the Inpatient Dermatologist. CURRENT DERMATOLOGY REPORTS 2020. [DOI: 10.1007/s13671-020-00312-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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14
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Santiago L, Mascarenhas R, Tellechea Ó, Gonçalo M. Toxic epidermal necrolysis-like subacute cutaneous lupus erythematosus associated with lung carcinoma. BMJ Case Rep 2019; 12:12/10/e231152. [DOI: 10.1136/bcr-2019-231152] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Specific vesiculobullous skin lesions in lupus erythematosus (LE) are rare and must be differentiated from toxic epidermal necrolysis (TEN), TEN-like dermatoses and other vesiculobullous conditions. We report a patient with typical subacute cutaneous lupus erythematous that progressed with large sheet-like areas of epidermal detachment and Nikolsky sign resembling TEN. She had a serological profile suggestive of underlying connective tissue disease, histological findings of interface dermatitis with a lymphocytic infiltrate, positive direct immunofluorescence, resolution with immunomodulation and lack of a culprit drug, features observed in TEN-like cutaneous lupus erythematous. Furthermore, she was diagnosed with lung carcinoma, an association that has been previously reported. Differentiating a bullous eruption in the context of pre-existing LE remains difficult requiring a thorough analysis of clinical and histopathological data.
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Alves F, Gonçalo M. Suspected inflammatory rheumatic diseases in patients presenting with skin rashes. Best Pract Res Clin Rheumatol 2019; 33:101440. [PMID: 31585842 DOI: 10.1016/j.berh.2019.101440] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
Skin lesions occur, often at very early stages, in many of the most frequent inflammatory rheumatic diseases such as in systemic lupus erythematosus (SLE), dermatomyositis (DM), systemic sclerosis (SSc), Sjögren's syndrome, rheumatoid arthritis (RA), and psoriatic arthritis. It is important to recognize the different specific cutaneous lesions in SLE (e.g., "butterfly" rash in acute, annular or psoriasiform photosensitive lesions in the subacute form, and discoid lesions in the chronic form) for an early diagnosis and to estimate the associated risks of internal disease, whereas nonspecific lesions (exanthema, vasculitis, and alopecia) can be part of SLE flares. Cutaneous lesions in DM (Gottron's papules and sign, heliotrope rash, dystrophic cuticles, and nailfold capillary abnormalities) may occur before any clinically evident muscular or systemic organ involvement and are of utmost importance for early diagnosis. The pattern of cutaneous lesions and associated autoantibodies also allow the distinction of different phenotypes, either more prone to life-threatening interstitial lung disease (MDA-5) or with higher risk for neoplasia (TIF1-γ). Many other skin lesions, although not specific, require further investigation to look for a possible underlying inflammatory rheumatic disease: non-pruritic urticarial lesions in anti-C1q-associated urticarial vasculitis, Still's disease or hereditary auto-inflammatory syndromes, transient macular purpura of vasculitis in Sjögren's syndrome, Behçet's disease, or RA, Raynaud's phenomenon in SSc and mixed connective tissue disease, erythema nodosum or other panniculitis in RA, Behçet's disease and SLE, pustular eruptions in Behçet's disease, psoriasis, and hereditary auto-inflammatory syndromes. After reviewing in detail the cutaneous manifestations of the most frequent inflammatory rheumatic diseases, we describe a topographic and morphological approach to skin rashes, calling attention to facial rashes, hand involvement, scalp, nail, or leg lesions or to some morphological aspects of skin lesions (annular, pustular, urticarial, or exanthematous) that may be the initial manifestations of inflammatory rheumatic diseases. The importance of skin lesions is confirmed by their presence as part of the classification criteria of many inflammatory rheumatic diseases. They also contribute to early diagnosis, to characterize disease phenotypes, to aid in effective patient management, and, ultimately, to impact on disease prognosis.
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Affiliation(s)
- Francisca Alves
- Clinic of Dermatology, University Hospital of Coimbra, Portugal
| | - Margarida Gonçalo
- Clinic of Dermatology, University Hospital of Coimbra, Portugal; Faculty of Medicine, University of Coimbra, Coimbra, Portugal.
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