Skin is your body's biggest organ and it makes sense that autoimmune disease will cause changes on your skin. Normally, when the immune system works well, your complicated immune system attack things that are harmful, foreign and that your body needs to protect you from. This includes things such as viruses and bacteria.
When your body attacks normal and healthy parts of itself, we call the result an autoimmune disease; your immune system sees your normal and healthy cells and tissue as foreign invaders and attacks them. Your immune system may see cells in your skin as foreign and the attack shows up as a rash on the skin. It can attack other organs, your joints, and the process can lead to generalized inflammation.
The common theme between all autoimmune diseases is inflammation. Some autoimmune diseases restrict themselves to certain organs (for example, Graves’ disease, which for the most part, is a disease that only attacks the thyroid). Other diseases like lupus can affect almost any part of the body. Inflammation that is organ specific, like Graves, or more generalized, like lupus, can also cause abnormal inflammation in the body as a whole. Autoimmune diseases are complex, your skin is large and visible, and it is common to see skin changes when you have an autoimmune disease.
How do autoimmune diseases happen?
We don’t completely understand why autoimmune diseases occur. Some people are genetically predisposed to these diseases and some ethnic groups are more prone to certain autoimmune diseases. It’s also possible that an outside influence like a virus or other infection may trigger the onset of autoimmune disease.
Where does dermatology fit into autoimmune diseases?
Dermatologists evaluate and treat autoimmune diseases as part of their practice. The skin is a big and visible organ and often the 'tip of the iceberg' for an autoimmune disease. Often, we are the first to make a diagnosis that then also needs treatment and care by general physicians and rheumatologists who treat the internal consequences of a misfiring immune system.
Certain autoimmune diseases that have classic skin manifestations and we are trained to recognize them.
What are the most common autoimmune diseases and which are most likely to show skin changes?
Some of the more common autoimmune diseases are listed here. I've bolded the autoimmune conditions that often present first as a skin problem.
- Alopecia areata
- Autoimmune hemolytic anemia
- Autoimmune hepatitis
- Diabetes (type 1)
- Graves’ disease
- Guillain-Barré syndrome
- Idiopathic thrombocytopenic purpura
- Myasthenia gravis
- Some forms of myocarditis
- Multiple sclerosis
- Lupus erythematosus
- Bullous pemphigoid
- Pemphigus vulgaris
- Granulomatosis with polyangiitis
- Polyarteritis nodosa
- Rheumatoid arthritis
- Lichen Planus
Lupus is an important autoimmune disease that often first shows up first as a skin problem.
One of the more common symptoms of lupus is a photosensitive skin rash. The skin is "allergic" to the sun and when a person with lupus goes out into the sun, they feel sick and develop a rash. One of the rashes of lupus is the “malar” (butterfly) rash that covers the cheeks and nose.
The sun can trigger both a rash and a flare-up of the disease inside the body too. The malar rash is a warning sign that the disease is active. The rash of lupus is important to recognize because, when lupus is untreated, it has the potential to cause damage to other organs such as the kidneys, lungs or heart. We call this systemic lupus and it can affect almost any organ.
Other skin findings with systemic lupus are ragged cuticles and tiny dilated blood vessels around the edge of the cuticles. It seems like a small thing to worry about but it can indicate a bigger autoimmune problem inside of the body.
Lupus rashes can also occur on any area that is exposed to the sun. Sun sensitivity is important to take seriously because skin problems may be one of the first symptoms of systemic lupus.
Another type of lupus is called subacute cutaneous lupus. It doesn’t typically have internal involvement but it does cause sun-sensitive rashes.
A dermatologist will do a skin biopsy to look for lupus if sun sensitivity and a rash is suspicious for this diagnosis.
How does a person know if they have the autoimmune disease systemic lupus?
The diagnosis is made when a person meets a certain number of diagnostic criteria. One needs to have 4 of the following problems to be diagnosed with lupus:
- Skin rashes: either a malar rash, discoid rash (somewhat circular-shaped scarring skin lesions) or a rash on sun-exposed areas
- Mouth sores
- Pleurisy (inflammation of the lungs) or pericarditis (inflammation of the heart)
- Abnormal blood tests such as low white blood cell counts or platelets
- Kidney problems consistent with lupus
- Neurologic problems such as psychosis or seizures that can happen due to inflammation in the brain
- Abnormal autoantibody tests such as a positive ANA (anti-nuclear antibody test); almost all patients with lupus have a positive ANA. However, many people without lupus have a positive ANA as well so it’s important for this to be interpreted by a rheumatologist.
For those that do have lupus, one of the most important practices to prevent flare-ups of the disease is meticulous sun protection.
This is another important role for your dermatologist. Teaching you how to prevent UV ray exposure on your skin is really important for controlling lupus. A really good broad spectrum sunscreen should be used every day on all exposed skin.
- The best sun protection comes from physical mineral sunscreen zinc oxide.
- Broad spectrum zinc oxide sunscreen with SPF 30 or higher must be applied regardless of whether you plan to go outdoors because UVA rays come through windows and can set off lupus.
In my 35+ years of dermatology practice here in California, I've taken care of many patients with lupus, autoimmune diseases, photosensitivity diseases and predisposition to skin cancer. Together, we've put sun protection to the test.
Click here to see the sunscreens and sun protection hats and tools that are patient-proven, dermatologist-approved and backed by science.
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