The butterfly rash of lupus appears only on the face

Dear Dr. Roach: I’m a 54-year-old white female, and for the past six years or so, I have been getting a 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? — L.B.

Answer: 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.

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