Can Systemic Lupus Erythematosus (SLE) rash involve the forehead and chin?

SLE Rash Can Involve the Forehead and Chin

Yes, Systemic Lupus Erythematosus (SLE) rash can definitely involve the forehead and chin areas of the face. 1 The classic facial distribution of SLE rash is not limited to the malar (cheek) region and can extend to other facial areas including the forehead and chin.

Cutaneous Manifestations of SLE

SLE skin manifestations are classified into two main categories:

1. SLE-specific lesions:

   • Acute cutaneous lupus erythematosus (ACLE): Includes the classic malar or "butterfly" rash that can extend beyond the cheeks to involve the forehead and chin 1, 2
   • Subacute cutaneous lupus erythematosus (SCLE): Can present with papulosquamous or annular lesions that may appear on the face, including forehead and chin
   • Chronic cutaneous lupus erythematosus (CCLE): Most commonly discoid lupus erythematosus (DLE), which can affect any area of the face 2

2. SLE-nonspecific lesions: Various vascular manifestations that can appear anywhere on the face 3

Clinical Presentation of Facial SLE Rash

When SLE affects the face, the following characteristics may be observed:

• Distribution: While the classic "butterfly rash" typically involves the malar eminences and bridge of the nose, it can extend to involve the forehead and chin 1, 4
• Appearance: Erythematous (red), sometimes edematous, maculopapular rash that may be flat or raised 2
• Surface changes: May be smooth or have fine scaling
• Borders: Can be well-defined or diffuse
• Symmetry: Usually symmetrical, but rare unilateral presentations have been reported 5

Differential Diagnosis

It's important to distinguish SLE rash from other conditions that can affect the face, including:

• Rosacea
• Seborrheic dermatitis
• Contact dermatitis
• Drug eruptions
• Dermatomyositis
• Polymorphous light eruption
• Viral exanthems 6

Diagnostic Approach

When evaluating a suspected SLE rash involving the forehead and chin:

1. Skin biopsy: May be necessary to confirm the diagnosis, especially when clinical presentation is atypical 1
2. Repeat biopsy: Recommended if there is a change in clinical morphology or lack of response to treatment 1
3. Laboratory tests: ANA, anti-dsDNA, anti-Ro/SSA, anti-La/SSB, and complement levels can support the diagnosis 1

Key Distinguishing Features

• Photosensitivity: SLE rashes often worsen with sun exposure, which can help distinguish them from other facial rashes 4
• Sparing of nasolabial folds: Classic malar rash of SLE typically spares the nasolabial folds, unlike rosacea
• Associated symptoms: Look for other SLE manifestations such as oral ulcers, arthritis, or systemic symptoms 7

Clinical Pitfalls to Avoid

1. Missing atypical presentations: Not all SLE facial rashes present as the classic butterfly pattern; they can be limited to the forehead or chin 5
2. Confusing with other conditions: Particularly rosacea, seborrheic dermatitis, or contact dermatitis
3. Overlooking unilateral presentations: Rare cases of unilateral facial involvement in SLE have been reported and may be misdiagnosed as cellulitis or other conditions 5
4. Failing to consider drug-induced lupus: Similar rashes can occur in drug-induced lupus

Monitoring and Assessment

The European League Against Rheumatism (EULAR) recommends using standardized assessment tools like the Cutaneous Lupus Disease Area and Severity Index (CLASI) to monitor cutaneous manifestations of SLE, which includes evaluation of all affected facial areas including forehead and chin 1.

In conclusion, while the classic "butterfly rash" of SLE is well-known, it's important to recognize that SLE rash can extend beyond the malar region to involve the forehead and chin, and sometimes may even present primarily in these areas.