GENEVA – Careful warranting prompt initiation of long-term antiplatelet therapy, Dan Lipsker, MD, PhD, said in a plenary lecture at the annual congress of the European Academy of Dermatology and Venereology.
“Those patients are at very high risk. Those are the lupus patients with the poorest prognosis. Those are the lupus patients who still die today,” said Dr. Lipsker, professor of dermatology at the University of Strasbourg (France).
Dr. Dan Lipsker
Cutaneous clues suggestive of thrombosis in SLE patients include atrophie blanche, pseudo-Degos lesions, livedo racemosa, acral nonpalpable purpura or reticulate erythema, cutaneous necrosis, splinter hemorrhage, thrombophlebitis, and nailfold telangiectasias. These skin findings can occur simultaneously with or after potentially life-threatening thrombotic events, or in the best of all scenarios, beforehand.
Dr. Lipsker told his audience of dermatologists that, by demonstrating facility in identifying these cutaneous disorders, they can make themselves “indispensable” to the rheumatologists, nephrologists, internists, and/or pediatricians who often provide the bulk of specialized care for SLE patients.
Courtesy RegionalDerm.com
Atrophie blanche
“We know today that, 5 years after initial diagnosis of SLE, the chief causes of morbidity and mortality are thrombotic events. And it can be extremely difficult to distinguish between an acute autoimmune lupus flare and a thrombotic event when, for example, the CNS or eyes are involved. But you will find direct evidence of thrombosis by carefully examining the skin,” the dermatologist maintained.
Some of these cutaneous signs constitute unequivocal evidence of thrombosis in SLE patients. Others are more ambiguous but should raise suspicion of an ongoing systemic thrombotic process unless another explanation is found.
One example of a skin finding that always indicates thrombosis is pseudo-Degos lesions: ivory-colored or white depressed atrophic papules with a raised border composed of telangiectasias. Biopsy shows evidence of a cone-shaped dermal arteriolar infarct.
Courtesy RegionalDerm.com
Livedo racemosa in a patient with SLE, showing the irregular, net-like mottling surrounding pale skin.
“We have biopsied dozens of patients with this presentation, and you always find occluded vessels without a single inflammatory cell. These lesions are usually painful, and when you put those patients on low-dose aspirin they do better,” Dr. Lipsker said.
Atrophie blanche in a patient with SLE is also strong evidence of thrombotic vasculopathy. Atrophie blanche is a porcelain-white atrophic white scar with surrounding hyperpigmentation on the lower leg that occurs after skin injury in an area with venous insufficiency.
Livedo racemosa in a patient with SLE is also highly suggestive of a systemic thrombotic process. Characteristic of this dermatologic disorder is an irregular, netlike mottling surrounding pale skin.
“All of these skin signs allow identification of patients who have very high risk of thrombotic events,” Dr. Lipsker stressed.
He reported having no financial conflicts of interest regarding his presentation.