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A 22-year-old woman presents with a red rash on her face, chest, upper arms, and thighs for the past 6 days (Figures 188-1 and 188-2). She had been diagnosed with systemic lupus erythematosus (SLE) 5 years ago but has never had a skin rash like this before. This rash had some itching associated with it but was otherwise asymptomatic. Her original SLE diagnosis was made at age 17 when she presented with a deep venous thrombosis. Six days ago she was in the sun for an extended period of time while cycling. Later that day the rash became very red on her face and upper arms. She was given a Medrol Dosepak in a local urgent care without any benefit. She was experiencing fatigue but no fever or other systemic symptoms. Laboratory testing showed a very high antinuclear antibody (ANA) with a white blood cell count of 1.1. The patient was referred to rheumatology and dermatology. They started her on prednisone 60 mg daily, as a Medrol Dosepak has insufficient prednisolone for this severe flare of acute cutaneous lupus. The hydroxychloroquine of 400 mg daily was continued, but her azathioprine was discontinued to make sure it was not responsible for the low white blood cell count. The following week the patient's skin and fatigue were much improved. In reviewing her SLE diagnosis, she met 8 of 11 criteria for SLE (see Table 188-1).

TABLE 188-1American College of Rheumatology Criteria for Diagnosis of Systemic Lupus Erythematosus

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