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Doc: Butterfly rash of lupus appears only on the face

December 6, 2017

Dear Dr. Roach: I’m a 54-year-old white female, and for the past six years or so, I have been getting butterfly-looking rash in the same exact place: under my breasts and around my rib cage. When the rash appears, I feel very sore, and it hurts to move. I just don’t feel good and have a mild headache. The rash used to appear about six times a year, but comes much more often lately. The rash is smooth and doesn’t itch. Sometimes I know it is going to be there by the way I feel. It appears only at bedtime and is usually gone by morning, but the last time it was in full bloom, it was red; in the morning, I felt very unwell. I went to a doctor (not mine, because she was booked), who said my rash was a lupus rash and that I had lupus symptoms. When I was tested for lupus three years ago, it was negative, but this doctor said I need to be retested. He said the rash doesn’t always present on the face. My rash is a perfect outline of a butterfly. What, besides lupus, could it be?


Dear L.B.: The butterfly rash of lupus is on the face, specifically on the cheeks and across the bridge of the nose, sparing the immediate sides of the lower nose and below. It appears after sun exposure, and is called acute cutaneous lupus erythematosus. It is one of 11 characteristics of systemic lupus, four of which need to be present in order to diagnose lupus by the standard criteria. (The term “lupus” is usually used for systemic lupus erythematosus, often called “SLE.” People with cutaneous lupus have skin findings of systemic lupus, but without the joint and internal organ findings that accompany SLE.)

There are other skin manifestations of SLE, but the butterfly shape is specific only on the face. The most common rash I see under and around a woman’s breasts is from a fungal infection, but that doesn’t usually come and go. It might seem worse in the heat. The anatomy of the region may make it appear like a butterfly. A visit with a dermatologist when the rash is there will be your best bet to answer the question definitively.

The other symptoms you describe are nonspecific and do not make me think you are likely to have SLE.

Dear Dr. Roach: I am a 75-year-old female who never had chickenpox. When the vaccine became available in 1993, I had a blood test that showed no antibodies, confirming my belief that I had not had chickenpox. I then received a series of two vaccinations. Now my question is: Should I have the shingles vaccination? Can I get shingles if I never had chickenpox, even though I’ve been vaccinated against it?


Dear S.T.: I would recommend getting the shingles vaccine. I also am hopeful that a new shingles vaccine, Shingrix, will be available within a few months. The new vaccine has been approved by the Food and Drug Administration. It appears to have longer-lasting immunity than the current one (Zostavax), which begins to wear off after several years. People who were vaccinated for chickenpox still can get shingles, although the risk seems to be smaller than in people who got chickenpox. The shingles vaccine is clearly recommended for people who had the chickenpox vaccine.

Email questions to ToYourGoodHealth@med.cornell.edu.