Why Is Your Face Puffy with Lupus?
Facial puffiness in lupus is most commonly caused by kidney involvement (lupus nephritis) leading to fluid retention, or by corticosteroid medication side effects—both require immediate evaluation with urinalysis, kidney function tests, and blood pressure monitoring. 1
Primary Causes to Evaluate Immediately
Lupus Nephritis (Most Critical)
- Kidney involvement occurs in approximately 40% of people with SLE and is the most serious cause of facial swelling 2
- Lupus nephritis causes protein loss in urine (proteinuria), leading to low blood albumin levels and subsequent fluid retention that manifests as facial puffiness, particularly around the eyes 1
- You need urgent testing: urinalysis with microscopy, urine protein-to-creatinine ratio, serum creatinine, and serum albumin 1, 3
- Blood pressure must be checked, as hypertension commonly accompanies lupus nephritis and worsens outcomes 1
- Complement levels (C3, C4) and anti-dsDNA antibodies should be measured, as low complement with elevated anti-dsDNA strongly suggests active kidney disease 1, 3
Corticosteroid Side Effects (Most Common if on Treatment)
- If you're taking prednisone or other corticosteroids, facial puffiness (moon facies) is a well-known side effect from chronic use 1
- This represents Cushingoid features from glucocorticoid therapy rather than active lupus disease 1
- The goal is to reduce corticosteroids to less than 7.5 mg/day for chronic use by adding steroid-sparing immunosuppressive agents like azathioprine, mycophenolate mofetil, or methotrexate 1, 3
Secondary Causes to Consider
Active Cutaneous Lupus
- Acute cutaneous lupus can cause facial swelling, particularly the classic malar (butterfly) rash that may have associated edema 4, 5
- This presents as erythema across the cheeks and nasal bridge, often photosensitive 6, 7
- Requires evaluation by an experienced dermatologist and often skin biopsy for definitive diagnosis 1, 7
Cardiovascular Complications
- Hypertension from lupus or its treatment can contribute to fluid retention and facial swelling 1
- Pericardial effusion (fluid around the heart) may cause generalized fluid retention 3
What You Must Do Now
Immediate laboratory workup required:
- Complete blood count (check for anemia, low platelets, low white blood cells) 3
- Comprehensive metabolic panel with creatinine and estimated kidney filtration rate 3
- Urinalysis with microscopy plus urine protein-to-creatinine ratio 1, 3
- Serum albumin level 7, 3
- Complement levels: C3, C4, and CH50 3
- Anti-dsDNA antibodies 3
- Blood pressure measurement 1
Clinical assessment priorities:
- Document any new symptoms: decreased urine output, foamy urine, leg swelling, shortness of breath, or weight gain 1
- Review all current medications, particularly corticosteroid dose and duration 1
- Assess for other signs of lupus activity: joint pain, rashes, fever, fatigue 5, 8
Critical Pitfalls to Avoid
- Do not dismiss facial puffiness as merely cosmetic—it may signal life-threatening kidney disease requiring immediate immunosuppressive therapy 1, 2
- Do not delay evaluation if you have any abnormal urinalysis findings, as up to 10% of lupus nephritis patients progress to end-stage kidney disease within 10 years 2
- Do not continue high-dose corticosteroids without adding steroid-sparing agents, as this perpetuates the facial swelling and increases risk of infections, osteoporosis, and cardiovascular disease 1
Treatment Approach Based on Cause
If lupus nephritis is confirmed:
- Glucocorticoids combined with immunosuppressive agents (cyclophosphamide or mycophenolate mofetil) are required for proliferative lupus nephritis 1
- Newer agents like voclosporin or belimumab may be considered for lupus nephritis 2
- Blood pressure control with ACE inhibitors is essential 1
If corticosteroid-induced:
- Add steroid-sparing immunosuppressive agents to allow corticosteroid dose reduction 1, 3
- Ensure you're on hydroxychloroquine, which is standard of care for all SLE patients and reduces mortality 2
If active cutaneous lupus: