Guest blog post by Mharlove Andre
- VisualDx Student Advisory Board Member and Medical Student, University of Florida College of Medicine Dermatology is a distinctive medical field where the foundation of diagnosis often relies on the direct observation of the skin. The formation of rashes and lesions can be indicative of a particular condition and can rapidly narrow one’s differential diagnosis. Although visual signs on the skin often provide reliable clues to a patient’s underlying condition, certain conditions may be more difficult to diagnose.
Diagnosis is especially challenging when documentation of how such conditions present in darker skin colors—most notably skin colors that fall within the Fitzpatrick III-V ranges—is lacking.
Among these conditions, systemic lupus erythematosus (SLE) and cutaneous lupus erythematosus (CLE) are particularly notable. Both are autoimmune diseases in which the body forms antibodies against healthy host tissue, leading to widespread inflammation and tissue destruction. Symptoms include damage to various elements of the integumentary system including skin rashes, mucocutaneous ulcers, and alopecia.
Although substantial research exists on the clinical manifestations of SLE and CLE, there remains a critical need to document their presentations in individuals with darker skin colors. Dermatologic manifestations of SLE include the malar rash, an erythematous facial rash that spans the nasal rim and extends to the malar regions while sparing the nasolabial folds. This is often accompanied by other co-occurring lupus symptoms including macular rashes induced by photosensitivity and permanent skin damage from discoid lesions.1
Despite all forms of lupus presenting earlier and at more severe stages in African American and Hispanic individuals compared to white individuals,2 patients with skin of color (SOC) remain underrepresented in medical textbooks3 and, therefore, the uniquely presenting dermatologic manifestations of SLE and CLE go underrecognized in darker-skinned patients.
Furthermore, SOC patients who are diagnosed with SLE or CLE late in their course tend to have more severe dermatologic outcomes, including hypertrophic scarring and postinflammatory hyperpigmentation.4 These complications can make treatment more difficult and may significantly impact a patient’s quality of life.5
To effectively address this disparity, it is essential to cultivate intentionality in educating future clinicians about the diverse manifestations of SLE and CLE. Given the potentially severe side effects that can occur after diagnosis, prompt disease recognition and treatment are key to preventing organ damage and other long-term sequelae.
Research initiatives are already underway to advance this effort: Through the creation of education modules and tools such as VisualDx, clinicians can learn how to better recognize when a SOC patient is presenting with dermatologic conditions concerning for lupus.6 Regular exposure to the different manifestations of lupus in SOC can help clinicians feel more comfortable in making their diagnoses and can make patients feel seen and cared for.
References:
- Uva L, Miguel D, Pinheiro C, Freitas JP, Marques Gomes M, Filipe P. Cutaneous manifestations of systemic lupus erythematosus. Autoimmune Dis. 2012;2012:834291. PubMedId: 22888407.
- Rana A, Witt A, Jones H, Mwanthi M, Murray J, Zickuhr L. Representation of skin colors in images of patients with lupus. Arthritis Care Res (Hoboken). 2022 Nov;74(11):1835-1841. PubMedId: 34057307. doi:10.1002/acr.24712
- Louie P, Wilkes R. Representations of race and skin tone in medical textbook imagery. Soc Sci Med. 2018 Apr;202:38-42. PubMedId: 29501717. doi:10.1016/j.socscimed.2018.02.023
- Nozile W, Adgerson CN, Cohen GF. Cutaneous lupus erythematosus in skin of color. J Drugs Dermatol. 2015 Apr;14(4):343-9. PubMedId: 25844606.
- Fija?kowska A, K?dziela M, ?ebrowska A. The spectrum of cutaneous manifestations in lupus erythematosus: a comprehensive review. J Clin Med. 2024 Apr 21;13(8):. PubMedId: 38673692. doi:10.3390/jcm13082419
- Tinianow A, Sous D, Abreu D, et al. Power of representation in educational materials: teaching cutaneous lupus across skin tones in an interactive module. Arthritis Care Res (Hoboken). 2025 Feb;77(2):195-200. PubMedId: 37485768. doi:10.1002/acr.25201
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