Can the Systemic Lupus Erythematosus (SLE) face rash spare the nose?

Systemic Lupus Erythematosus Face Rash Can Spare the Nose

Yes, the malar rash in Systemic Lupus Erythematosus (SLE) can spare the nose, though this is not the classic presentation. While the typical "butterfly rash" of SLE involves both cheeks and the bridge of the nose, atypical presentations can occur where the rash is unilateral or spares the nasal bridge 1.

Characteristics of SLE Facial Rash

Classic Presentation

• The hallmark malar or "butterfly" rash of SLE typically:
  • Extends across both cheeks
  • Crosses the bridge of the nose
  • Forms a butterfly-like pattern
  • Is erythematous and may be flat or raised
  • Usually spares the nasolabial folds

Atypical Presentations

• Unilateral facial involvement has been documented in SLE patients 2
• A case report describes a 62-year-old woman presenting with isolated unilateral erythematous patches on the left cheek and eyelid as the initial manifestation of SLE 2
• These atypical presentations can pose diagnostic challenges as they may mimic other dermatological conditions

Differential Diagnosis When Nose Is Spared

When the nose is spared in a facial rash, consider these alternatives:

• Contact dermatitis
• Rosacea (typically affects central face but can spare nasal bridge)
• Seborrheic dermatitis
• Dermatomyositis (heliotrope rash)
• Photosensitive drug reactions
• Sweet's syndrome (neutrophilic dermatosis) 3

Diagnostic Approach for Atypical Facial Rash

1. Detailed skin examination:

   • Document distribution pattern
   • Note presence of scaling, induration, or telangiectasias
   • Assess for other cutaneous manifestations of SLE (discoid lesions, oral ulcers)

2. Skin biopsy:

   • Essential for definitive diagnosis when presentation is atypical
   • Look for interface dermatitis, basement membrane thickening, and immunoglobulin deposits 1

3. Laboratory evaluation:

   • ANA testing (positive in >95% of SLE patients)
   • Anti-dsDNA and anti-Smith antibodies (more specific for SLE)
   • Complete blood count (may show cytopenias)
   • Complement levels (often decreased in active SLE)
   • Urinalysis (to assess for renal involvement)

Clinical Implications

The presence of an atypical facial rash that spares the nose should not exclude the diagnosis of SLE. Clinicians should maintain a high index of suspicion, especially when:

• The rash is photosensitive
• There are other systemic symptoms (arthralgia, fatigue, fever)
• Laboratory findings suggest autoimmunity

Management Considerations

• Photoprotection is essential regardless of rash distribution 1
• Topical corticosteroids may be used for localized facial lesions
• Hydroxychloroquine is effective for cutaneous manifestations of SLE and should be prescribed to all SLE patients unless contraindicated 1
• For resistant cases, consider systemic corticosteroids or other immunosuppressants based on disease severity

Key Points to Remember

• The absence of nasal bridge involvement does not rule out SLE
• Unilateral facial erythema can be a rare initial presentation of SLE
• Atypical presentations may delay diagnosis and appropriate treatment
• Skin biopsy is valuable when clinical presentation is not classic
• Consider SLE in the differential diagnosis of persistent facial erythema that doesn't respond to conventional treatments

The diagnosis of SLE should be based on a comprehensive evaluation of clinical and laboratory findings rather than the specific pattern of facial rash alone.