Rheumatologist, Julio Gonzalez, MD, discusses points from his lecture Beyond the Rash: Diagnosing Connective Tissue Diseases at the 6th Annual Elevate-Derm Alliance Conference at the JW Marriott Water Street in Tampa, Florida.

In this video

Speaking with dermatology NP Veronica Richardson, Dr. Gonzalez tackles one of his most common consults — "malar rash, rule out systemic lupus" — and stresses that "not all red cheeks are malar rash." He contrasts the fixed, longer-lasting malar rash of acute cutaneous lupus (which spares the nasolabial folds) with rosacea (not fixed, triggered) and dermatomyositis (photosensitive but complete, "hugging the whole face" with no sparing). Because the two can look identical on biopsy, he looks beyond the face for classic DM clues — the shawl sign, V-neck sign, holster and sleeve signs, Gottron's papules, and "kissing" inverse papules — noting how often he sees amyopathic dermatomyositis without weakness.

He also maps out prognosis by subtype: acute cutaneous lupus carries a near-100% chance of progressing to SLE, subacute roughly 40–50%, and chronic/discoid under 20% — and discoid that does progress tends to spare the kidneys and serious manifestations. He uses the ANA and Smith profile plus the extent of discoid involvement to decide who to watch closely, and cites the recent SMILE trial showing Plaquenil did not slow progression in incomplete lupus. On drug-induced disease, he flags anti-histone antibodies and minocycline/hydralazine for systemic cases, and — for the subacute cutaneous cases dermatology actually sees — an atypical older patient, SSA positivity, and PPIs as the leading offender.

  • A true lupus malar rash is fixed, long-lasting, and spares the nasolabial folds; dermatomyositis is complete and "hugs the whole face," and rosacea is neither fixed nor sun-sparing.
  • Since lupus and DM facial rashes can look identical on biopsy, look elsewhere for DM clues — shawl sign, V-neck sign, holster/sleeve signs, Gottron's papules, and inverse "kissing" papules.
  • Progression risk drives urgency: acute cutaneous lupus with systemic symptoms should be seen "tomorrow," while discoid (<20% progression) can be co-managed without the same urgency.
  • In a chronic discoid patient, watch ANA/Smith positivity and diffuse rather than localized scalp disease as signals of possible progression; discoid that converts to SLE carries a better prognosis.
  • Suspect drug-induced subacute cutaneous lupus in an atypical older, SSA-positive patient — review the medication list and think PPIs first; discontinuing the offender should clear the lesions.