Photo Rounds

Rash on face, chest, upper arms, and thighs

A 22-year-old woman presented to her family physician (FP) with a red rash of 6 days’ duration on her face, chest, upper arms, and thighs. The patient said that she’d been in the sun for a full day without sunscreen 6 days prior to the visit. On the day she saw her FP, the rash on her face and upper arms had become very red. The rash was mildly pruritic, but otherwise asymptomatic. Four days prior to seeing the FP, she’d gone to a local urgent care clinic and was given a Medrol Dosepak, but things did not improve. The patient said she felt a bit tired, but had no fever or other systemic symptoms.

What’s your diagnosis?


Rash on face, chest, upper arms, and thighs

The FP suspected acute systemic lupus erythematosus (SLE) with an acute cutaneous component. Laboratory testing showed a very high level of antinuclear antibodies. The patient was referred to Rheumatology and Dermatology. The dermatologist was available for a phone consult and suggested starting the patient on prednisone 60 mg/d as the Medrol Dosepak that the patient previously received had insufficient prednisolone for this severe flare of acute cutaneous lupus.

Although the classic description of acute SLE involves a butterfly rash, the rash of acute cutaneous lupus can include other areas of the face and body. As was seen in this case, the nasolabial fold tends to be spared and there are often skin erosions and crusting.

Based on the patient’s lab tests and symptoms, the dermatologist determined that the patient met the criteria for SLE. The patient was started on hydroxychloroquine 400 mg/d. The plan was to taper the patient’s prednisone slowly. By the following week, her skin and fatigue were much improved.

Photos and text for Photo Rounds Friday courtesy of Richard P. Usatine, MD. This case was adapted from: Pye A, Mayeaux EJ, Mishra V, et al. Lupus. In: Usatine R, Smith M, Mayeaux EJ, et al, eds. Color Atlas and Synopsis of Family Medicine. 3rd ed. New York, NY: McGraw-Hill; 2019:1183-1193.

To learn more about the newest 3rd edition of the Color Atlas and Synopsis of Family Medicine, see:

You can get the 3rd edition of the Color Atlas and Synopsis of Family Medicine as an app by clicking on this link:

Next Article: