Understanding Lupus Butterfly Rash

The butterfly rash—sometimes called malar rash—is one of the more iconic signs of lupus, an autoimmune disease.

Lupus symptoms vary widely and are different for everyone. Some people with lupus have no visible symptoms at all. Others can experience various skin problems like a rash.

The malar rash may come before other lupus symptoms, or it may appear alongside them. Here is what you need to know about the lupus rash and what you can do to keep flare-ups at bay.

What Exactly Is Butterfly Rash?

The butterfly rash is a facial rash that blooms across the cheeks and nose. It bypasses the folds of the skin around the mouth. This rash affects 46-65% of individuals who have lupus and is said to look like a wolf's bite or scratch.

When lupus affects the skin, it is called cutaneous lupus erythematosus (CLE). The three main CLE types are:

• Acute cutaneous lupus, or acute skin lupus: A rash consisting of cheek and nose redness
• Subacute cutaneous lupus, or subacute lupus: A rash that’s red, raised, and scaly but leaves no scarring 
• Chronic cutaneous lupus, or discoid lupus: A discolored, reddish to purplish rash that results in scarring

Aside from its signature shape, the butterfly rash is usually identified by its color. It can look like a sunburn: Depending on the individual, the rash can range from a very light to a deep shade of red.

The texture of a malar rash varies, from raised to scaly, and the rash may be more prominent after a person spends time exposed to sunlight. Additionally, the rash may last a few days, go away, and come back later.

What Causes the Rash?

There are various health conditions that can cause a butterfly rash. The most common conditions, other than lupus, include:

• Erysipelas, a skin infection with systemic symptoms like fever and chills
• Cellulitis, a skin infection that doesn’t usually have systemic symptoms
• Rosacea, an inflammatory disease affecting the face
• Pellagra, a systemic condition due to a lack of cellular niacin
• Dermatomyositis, an inflammatory skin condition that comes with hyperpigmentation

At the cellular level, the immune system can cause butterfly rash to appear. The rash is a reaction to ultraviolet (UV) light exposure. This is known as photosensitivity or sun allergy.

People with lupus are usually sensitive to UV light from the sun. It's also possible for some people with lupus to be sensitive to UV rays from artificial light, like indoor lighting in offices, schools, and gyms. That's because sunlight is not the only source of UV light—it can also come from artificial light.

Essentially, immune cells will create skin lesions in response to UV exposure. The lesions will then stimulate other cells in the immune system, causing flares and more immune system reactions simultaneously.

The reason for the rash's shape is unclear, but it might be related to the parts of the skin exposed to the sun. Rashes may sometimes only appear on spots that consistently get sunlight.

Lupus Rash Treatment

Triggers for lupus malar rash flares are ones such as emotional stress, exhaustion, infections, or serious injuries. However, there are treatments available when a person develops rashes due to lupus.

Treatment effectiveness can vary from person to person, depending on the type of lupus. The following are possible treatment options:

• Corticosteroids: Topical steroids, like creams and gels, are applied directly to the skin. Oral steroids come in pill form and are taken by mouth. A dermatologist may also use an injectable steroid to treat thick lupus patches.
• Antimalarial medications: Medications effective in treating malaria can also treat skin rashes in addition to symptoms of inflammation, joint pain, and fatigue.
• Immunosuppressants: These types of drugs reduce the body’s immune response and are sometimes used as a treatment option for severe lupus cases.

Preventing Flares

For people with lupus who experience the butterfly rash, there are a few things you can try to reduce your chances of having a flare-up. You can use the following tips:

• Avoid sunlight during peak hours. Try to keep outdoor activities limited to early morning or late evening. And while shade and cloud cover can help, they won't offer you full protection.
• Avoid touching any rashes on your skin. This will keep rashes from getting worse.
• Consider switching to LED or incandescent light bulbs. You can also try UV light filters or shields if replacing light bulbs is not an option.
• Cover up whenever you're outside in the sun. You can do this by wearing long sleeves, pants, and wide-brimmed hats, preferably made from fabrics that offer protection from the sun.
• Use a broad-spectrum sunscreen. Choose one with SPF 50 or higher that blocks the two main types of ultraviolet light coming from the sun (UVA and UVB).

A Quick Review

Malar rash, or butterfly rash, is associated with lupus. Other conditions, like rosacea or cellulitis, can cause the rash. However, it is ultimately the result of an immune system response after UV light exposure. Treatments like steroids can be helpful for treating the lupus butterfly rash. Additionally, there are ways to prevent rash flare-ups, such as protecting yourself while in sunlight.