Butterfly rash
Butterfly rash: Excerpt from Signs & Symptoms: A 2-in-1 Reference for Nurses
The presence of a butterfly rash is typically a sign of systemic lupus erythematosus (SLE), but it can also signal dermatologic disorders. Generally, butterfly rash appears in a malar distribution across the nose and cheeks. (See Recognizing butterfly rash.) Similar rashes may appear on the neck, scalp, and other areas. Butterfly rash is sometimes mistaken for sunburn because it can be provoked or aggravated by ultraviolet rays, but it has more substance, is more sharply demarcated, and has a thicker feel in relation to surrounding skin.
History
Ask the patient when he first noticed the butterfly rash and if he has recently been exposed to the sun. Has he noticed a rash elsewhere on his body? Also, ask about recent weight or hair loss. Does he have a family history of lupus? Is he taking hydralazine or procainamide (common causes of drug-induced lupus erythematosus)?
Physical assessment
Inspect the rash, noting any macules, papules, pustules, or scaling. Is the rash edematous? Are areas of hypopigmentation or hyperpigmentation present? Look for blisters or ulcers in the mouth, and note any inflamed lesions. Check for rashes elsewhere on the body.
Medical causes
Discoid lupus erythematosus
With discoid lupus erythematosus, a localized form of lupus erythematosus, the patient may have a unilateral or butterfly rash that consists of erythematous, raised, sharply demarcated plaques with follicular plugging and central atrophy. The rash may also involve the scalp, ears, chest, or any part of the body exposed to the sun. Telangiectasia, scarring alopecia, and hypopigmentation or hyperpigmentation may occur later. Other accompanying signs include conjunctival redness, dilated capillaries of the nail fold, bilateral parotid gland enlargement, oral lesions, and mottled, reddish blue skin on the legs.
Erysipelas
Occurring primarily in infants and adults older than age 30 following a streptococcal infection, erysipelas causes rosy or crimson swollen lesions, mainly on the neck and head and commonly along the nasolabial fold. It may cause hemorrhagic pus-filled blisters. Other signs and symptoms include fever, chills, cervical lymphadenopathy, and malaise.
Rosacea
Initially, with rosacea, butterfly rash may appear as a prominent, nonscaling, intermittent erythema limited to the lower half of the nose or including the chin, cheeks, and central forehead. As rosacea develops, the duration of the rash increases; instead of disappearing after each episode, the rash varies in intensity and is commonly accompanied by telangiectasia. With advanced rosacea, the skin is oily, with papules, pustules, nodules, and telangiectasis restricted to the central oval of the face. In men with severe rosacea, butterfly rash may be accompanied by rhinophyma — a thickened, lobulated overgrowth of sebaceous glands and epithelial connective tissue on the lower half of the nose and, possibly, the adjacent cheeks. This is more common in elderly patients.
Seborrheic dermatitis
With seborrheic dermatitis, butterfly rash appears as greasy, scaling, slightly yellow macules and papules of varying size on the cheeks and the bridge of the nose, in a “butterfly” pattern. The scalp, beard, eyebrows, portions of the forehead above the bridge of the nose, nasolabial fold, or trunk may also be involved. Associated signs and symptoms include crusts and fissures (particularly when the external ear and scalp are involved), pruritus, redness, blepharitis, styes, severe acne, and oily skin. Severe seborrheic dermatitis of the face occurs in acquired immunodeficiency syndrome.
Systemic lupus erythematosus
Occurring in about 40% of patients with SLE (a connective tissue disorder), butterfly rash appears as a red, commonly scaly, sharply demarcated macular eruption. The rash may be transient in patients with acute SLE or may progress slowly to include the forehead, chin, the area around the ears, and other exposed areas. Common associated skin findings include scaling, patchy alopecia, mucous membrane lesions, mottled erythema of the palms and fingers, periungual erythema with edema, reddish purple macular lesions on the volar surfaces of the fingers, telangiectasia of the base of the nails or eyelids, purpura, petechiae, and ecchymoses.
Butterfly rash may also be accompanied by joint pain, stiffness, and deformities, particularly ulnar deviation of the fingers and subluxation of the proximal interphalangeal joints. Related findings include periorbital and facial edema, dyspnea, low-grade fever, malaise, weakness, fatigue, weight loss, anorexia, nausea, vomiting, lymphadenopathy, photosensitivity, and hepatosplenomegaly. (See Associated disorder: Lupus.)
Other causes
Drugs
The drugs hydralazine and procainamide can cause a lupus-like syndrome, which is evidenced by the butterfly rash.
Special considerations
Prepare the patient for immunologic studies, complete blood count and, possibly, liver studies. Obtain a urine specimen if needed. Withhold photosensitizing drugs, such as phenothiazines, sulfonamides, sulfonylureas, and thiazide diuretics.
Pediatric pointers
Rare in pediatric patients, a butterfly rash may occur as part of an infectious disease such as erythema infectiosum, or “slapped cheek syndrome.”
Patient counseling
Instruct the patient to avoid exposure to the sun or to use a sunscreen. Suggest that he use hypoallergenic makeup to help conceal facial lesions. Provide the patient with contact information for the Lupus Foundation of America.
Pictures
Book Source Details
- Book Title: Signs & Symptoms: A 2-in-1 Reference for Nurses
- Author(s): Springhouse
- Year of Publication: 2007
- Copyright Details: Signs & Symptoms: A 2-in-1 Reference for Nurses, Copyright © 2007 Lippincott Williams & Wilkins.
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Copyright notice for book excerpts: Copyright © 2008 Lippincott Williams & Wilkins. All rights reserved.
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