CUTANEOUS MANIFESTATIONS OF SYSTEMIC LUPUS ERYTHEMATOSUS

Systemic lupus erythematosus (LE) is a heterogeneous, multisystem, autoimmune disease characterized by the production of auto-antibodies against several cell constituents. The skin is one of the target organs most variably affected by the disease can be yield valuable diagnostic & prognostic information. The present study was conducted to evaluate cutaneous manifestations of SLE in Bangladeshi patients. 100 cases of SLE were collected from the Department of Dermatology, BSMMU, Dhaka. The diagnosis was based on American Rheumatism Association Criteria. Cutaneous changes were recorded on a predevised pro forma. LE specific cutaneous changes noted were: Malar rash or butterfly rash (70.0%), maculopapular rash (19.0%), discoid rash (10.0%), and bullous LE (10.0%). Non specific LE lesions noted were: Photosensitivity (75.0%), alopecia (47.0%), oral mucosal lesion (34.0%), hyperpigmentation (20.0%), nail change (15.0%), Raynauds phenomenon (12.0%), Palmar erythema, genital lesion, periungual talangiectesia, leg ulcers, livedo reticularis, erythema multiform were rare. Systemic lupus erythematosus is a multisystem disease that predominantly affects women. Cutaneous lesions are the most important diagnostic tools as reflected by the fact that they account for four of the 11 revised American Rheumatism Association criteria of SLE. The pattern of skin changes may vary from place to place.

systemic lupus erythematosus. 2,7There is a tremendous variability and diversity in the type of involvement ranging from classical butterfly rash and atrophic hyperkeratotic lesions of discoid lupus to bullae, alopecia and vasculitis. 2 Cutaneous lesions are account for four of the 11 revised American Rheumatology Association criteria of systemic lupus erythematosus: Malar rash, Discoid rash, Photosensitivity (skin), Oral ulcers (oral or nasopharyngeal, usually painless). 1,2ny studies conducted on abroad address the cutaneous manifestations in patients with SLE; however, scanty data are available on the topic among Bangladeshi origin.The present study was conducted to evaluate the cutaneous manifestations of SLE in Bangladeshi patients.

Material and methods:
This cross sectional study was conducted at the department of Dermatology and Venerealogy, BSMMU, Dhaka from 1 st January 2007 to 31 st December 2007.Hundred patients of SLE (diagnosed on the basis of American Rheumatology Association criteria) were enrolled in the study.A detailed history and physical examination were recorded.The relevant biochemical and hematological profile were carried out.
Data was collected in a pre-design and pre-tested data collection sheet.Data were processed and analyzed using software SPSS-12 (Statistical Package for Social Sciences).Data processed on categorical scale were presented as frequency and percentage.While the data presented on continuous scale were presented as mean and SD.The summarized data were then presented in the table and chart.

Results:
We have assessed the cutaneous signs in 100 patients with systemic lupus erythematosus seen during one year period in BSSMU.All patients fulfilled the ARA criteria for SLE.84% patients of the present study group were female and 16% were male with male to female ratio of 1:5.25.Mean age of the patients was 30.04 years (9.12) with an age range from 15 to 54 years.76.0% patients were married, 54.0% house wife.Maximum patients were from middle class family (50.0%).Demographical variables of SLE patients are shown in Table I.
We classified cutaneous lesions as LE-specific (acute, subacute and chronic) and LE-non specific related, e.g.photosensitivity, Raynauds phenomenon, vasculitis, hair change and some others.

Discussion:
The skin findings seen in lupus erythematosus can present with either lupus-specific or lupus-nonspecific findings, with lupus-specific skin disease showing findings histopathologically distinct for cutaneous lupus erythematosus.Lupus-specific skin diseases include chronic cutaneous, subacute cutaneous, and acute cutaneous lupus erythematosus.The types of skin lesions in each group are clinically distinct and recognizing the specific subsets helps in prognosticating the likelihood of underlying systemic lupus.Lupus nonspecific skin lesions are not histopathologically distinct for cutaneous lupus and/ or may be seen as a feature of another disease process. 8onspecific disease-related skin lesions are telangiectasia, dermal vasculitis, rheumatoid nodules live do reticularis, alopecia, urticaria, photosensitivity, Raynauds phenomenon, oral mucosal lesion, leg ulcers etc. 1,9 High prevalence and diverse spectrum of cutaneous changes in SLE patients were noted from our study that is comparable with the findings of some other studies by Rabbani et al. 2 , Yell et al 9 and Cardinali et al. 10 Cutaneous manifestations were initial presentation in 15.0% of our patients as against 25.0% mentioned by Watson 11 and Kapadia 12 and 10.0% by Rabbani 2 .Female dominant picture of our study was closely matched with other study (e.g.28 out of 32 in an Indian study conducted by George et al 13 , 73 out of 78 in an Austratian study by Weinstein et al 14  Malar rash was the most common LE specific finding of our study.17][18] 21 where they note it is 8.4%.This difference could be due to excessive exposure to sunlight in our subcontinent and a general tendency to post inflammatory melanosis. Non scarring alopecia was a frequent finding of our study (seen in 42% of our patients) as compared to 37.0% quoted by Akhtar and khan, 22  Oral mucosal lesion were observed more in our study than some other studies 2,3,20 Raynauds phenomenon was observed 12.0% in our study.It is nearly correlated with Cervera et al's 19 findings but much less than from some others findings. 9,20lmar erythema, genital lesion, periungual talangiectesia, leg ulcers, livedo reticularis, and erythema multiform were also noted on varying scale of our study.

Conclusion:
Systemic lupus erythematosus is a multisystem disease that predominantly affects women.Cutaneous lesions in SLE are important as a diagnostic aid as reflected by the fact that they account for four of the 11 revised American Rheumatism Association criteria of SLE.The pattern of skin changes may vary from place to place.

Table - I
Demographical variables of patients with SLE At the time of presentation only 15 (15.0%) patients had only cutaneous lesions, 56 (56.0%) patients had both cutaneous and systemic lesions and 29 (29.0%) had only systemic lesions.