Lupus Rash Distribution: Nose and Cheeks
Yes, lupus characteristically presents with a rash involving both the cheeks and nose, forming the classic "butterfly" or malar rash pattern that is highly specific for acute cutaneous lupus erythematosus (ACLE). 1, 2
Classic Malar (Butterfly) Rash Presentation
The malar rash is one of the most recognizable manifestations of lupus and involves a specific anatomical distribution:
- The rash typically appears as erythematous (pink-violet) macules or plaques that span across both cheeks and the bridge of the nose, creating the characteristic butterfly-shaped pattern 1, 2
- This presentation occurs in approximately 80% of patients with systemic lupus erythematosus (SLE) and is the most common lupus-specific skin finding 3
- The malar rash is most strongly associated with systemic disease activity compared to other cutaneous lupus subtypes 1, 4
Clinical Characteristics to Recognize
When evaluating for lupus on the face, look for these specific features:
- The lesions present as well-demarcated, erythematous plaques with scales and follicular plugging in the butterfly distribution 5
- Photosensitivity is a key feature, with lesions appearing or worsening in sun-exposed areas including the face 1, 2
- The rash may be pruritic and cause stinging or burning sensations 1
- In chronic discoid lupus, the facial lesions can form a butterfly-like rash involving the cheeks and nose, though this form tends to be more scarring and atrophic than the acute malar rash 5
Diagnostic Approach
When you encounter a butterfly-pattern rash:
- Document the specific morphology and distribution to classify the lesion as acute cutaneous LE (ACLE), subacute cutaneous LE (SCLE), or chronic cutaneous LE (CCLE) per EULAR recommendations 6
- Perform a skin biopsy for histological confirmation when the diagnosis is uncertain 6
- Order comprehensive autoantibody testing including ANA, anti-dsDNA, anti-Ro/SSA, anti-La/SSB, anti-RNP, and anti-Sm, along with complement levels (C3 and C4) to assess for systemic involvement 6, 7
- Use the Cutaneous Lupus Disease Area and Severity Index (CLASI) to quantify disease activity and damage at baseline and follow-up 6
Important Clinical Pitfall
Do not exclude lupus based on the absence of skin findings—the American College of Rheumatology classification criteria make clear that SLE can be diagnosed without cutaneous manifestations 7. However, when the malar rash is present, it strongly suggests active systemic disease and warrants thorough evaluation for multi-organ involvement 3, 4.
Management Implications
Patients with malar rash require aggressive photoprotection with SPF 60+ sunscreen containing zinc oxide or titanium dioxide, sun avoidance, and protective clothing, as this is mandatory for all lupus patients due to high photosensitivity 6, 1