Skin Care, Weight Control, and Feeling Good with Lupus

Skin Care, Weight Control and Feeling Good with Lupus

S.L.E. Lupus Foundation New York City Hospital Tour 2013

Harlem HospitalMay 7th, 2013

Amanda M. Sammut, MD and Sharon Isaac, MS, CDN

Outline of Talk• Introduction

– What is Lupus?• Skin

– Lupus effects on the skin– Skin issues and concerns with steroid use– Skin care tips – acne care, sunscreen use, and smoking cessation

• Weight Control– The effects of Lupus on weight– The effects of steroids on weight – Diet and exercise

• Feeling Good– Key elements of feeling good with Lupus– Fighting fatigue– Sleep hygiene

• Summary

What is Lupus?

• Lupus is an inflammatory, autoimmune disease

• Lupus affects many different organ systems in the body

• Lupus can range from mild to severe in terms of its manifestations

• It has a variable course and variable prognosis

Outline of Talk• Introduction

– What is Lupus?• Skin

– Lupus effects on the skin– Skin issues and concerns with steroid use– Skin care tips – acne care, sunscreen use, and smoking cessation

• Weight Control– The effects of Lupus on weight– The effects of steroids on weight – Diet and exercise

• Feeling Good– Key elements of feeling good with Lupus– Fighting fatigue– Sleep hygiene

• Summary

Lupus and The Skin

• The skin is often affected by lupus• Lupus may affect only the skin, without

affecting other organs, this is known as: “Cutaneous Lupus”

• Lupus may affect the whole body, this is known as: “Systemic Lupus Erythematosus”

• Treatments for lupus may affect the skin

Common Skin Manifestations of Lupus

• Butterfly/malar rash/acute cutaneous lupus erythematosus

• Discoid lesions • Loss of hair – generalized or localized• There are many more skin manifestations of

lupus that are less common (and not mentioned in this talk)

Common Skin Manifestations of Lupus

Common Skin Manifestations of Lupus

Butterfly/malar rash/acute cutaneous lupus erythematosus

Common Skin Manifestations of Lupus

Discoid lesions

Common Skin Manifestations of Lupus

Loss of hair – generalized or localized

Skin and Steroid Use

• Acne • Stretch marks/Striae • Skin Thinning • Bruising

Acne

• Acne is the medical term for pimples• Pimples occur when

pores get clogged with dead skin and oil, and bacteria build up• The skin gets

inflamed and can turn red or swell

Acne: Home skin care recommendations

Instructions on skin cleansing:•Apply a gentle cleanser with fingers•Do not scrub aggressively, massage skin gently with fingertips•Rinse with warm water twice daily

Choosing Products• Water-based lotions, cosmetics,

and hair products are less comedogenic (pimple-forming) than oil-based products

• Seek out “non-comedogenic” skin care and cosmetic products

• Do not pick acne lesions, as this may worsen scarring

• A number of treatments for acne are contraindicated in pregnancy, see a dermatologist for further care

Tip:

Avoid Minocycline!!!Minocycline is an oral antibiotic used

in the treatment of acne. It is generally recommended that

patients with lupus avoid minocycline as minocycline

may activate lupus or cause drug-induced lupus.

Stretch Marks/Striae• Seen in ~ 90% of

pregnant women, 70% of adolescent females, and 40% of adolescent males

• Striae from prolonged steroid use are usually larger and wider, and involve widespread areas, occasionally including the face

Stretch Marks/Striae

• Purple striae occur as the fragile skin stretches due to the enlarging trunk, breasts, and abdomen

• The striae appear as wide, reddish-purple streaks because the increasingly thin skin does not hide the color of venous blood in the underlying deep skin

Stretch Marks/Striae

• Avoid striae by avoiding rapid weight gain or weight loss• Striae are most likely to respond to treatment at an early

stage • Once they become white, only few treatments exist and they

become quite difficult to treat• Intensive moisturization of the stretch marks has been

advocated for the early treatment of striae • Tretinoins applied to the skin may improve the appearance of

early striae (note: tretinoins can not be used in pregnant or breastfeeding women; tretinoins increase photosensitivity) Tretinoins are prescribed by dermatologists

Sun Exposure

• Increases risk of skin cancer• Cosmetic issues: wrinkles, freckles, sun spots• In patients with Lupus, sun exposure

increases the risk of Lupus activity or a Lupus flare

A Few Words on Tanning Salons…

Tanning Salons are NOT recommendedThey emit UVA rays, which still

contributes to activating Lupus (as well as to increasing skin cancer risk)

Tips on Sunscreen Use• SPF 30 or higher• Look for “Protection

against both UVA and UVB rays”

• Apply before makeup or before moisturizer

• Apply at least 10minutes prior to sun exposure

• Re-apply every two hours if continued sun exposure

Tips on Sunscreen Use• Invest in sun-protective

clothing and wide-brimmed hats

• Certain medications may increase risk of photosensitivity, for instance: antibiotics, diuretics, anti-inflammatory drugs and birth control pills and many more

Cosmetically…

• Camouflage makeup, can often conceal skin discoloration and scarring

• Skin scars – filler and laser technology may improve scarring and skin discoloration – Buyer Beware!– Disease should be in full remission if this is to be

performed– See a dermatologist if you want more information

on filler and laser treatments– Shop around – get recommendations

Smoking Cessation

• Smokers have more active lupus • Smoking increases rates of lupus flares• Hydroxychloroquine is less effective in

patients who smoke• Other reasons to stop smoking:• Smoking is associated with higher rates of cancer

and of heart disease• Financial considerations• Cosmetic considerations

Skin Care Tips - Summary

• For skin lesions caused by Lupus: control Lupus activity, sun exposure avoidance, smoking cessation

• For acne: wash face with gentle cleanser twice daily, see a dermatologist for medications, avoid minocycline

• For stretch marks: In the early stage, keep them moist and see a dermatologist if you want to consider medications that can be applied to the skin

• Sunscreen Use and Protection from UVA and UVB rays• Smoking Cessation

Outline of Talk• Introduction

– What is Lupus?• Skin

– Lupus effects on the skin– Skin issues and concerns with steroid use– Skin care tips – acne care, sunscreen use, and smoking cessation

• Weight Control– The effects of Lupus on weight– The effects of steroids on weight – Diet and exercise

• Feeling Good– Key elements of feeling good with Lupus– Fighting fatigue– Sleep hygiene

• Summary

Lupus Activity and Weight

• When Lupus is active, patients may have active inflammation and fevers and may lose weight from the body’s increased energy consumption

• People with active Lupus may feel fatigue and lose stamina, resulting in inactivity, which results in rapid muscle loss

Steroids and Weight

• Steroids enhance appetite• This may result in significant weight gain• Some patients may lose weight on steroids

but the majority gain weight

Tips to Battle Weight Gain Associated With Steroids

• Keep mainly healthy food in your house• Grab healthy food when feeling hungry

(cucumbers, baby carrots, etc.)• Have a bowl of fresh fruits and vegetables

available• Keep a food diary• Keep hydrated with plenty of water

Diet

• Limited informative research on the effect of dietary modification in Lupus

• Balanced diet of carbohydrates, proteins and fats is generally recommended

• Diet should be modified based on disease activity and response to therapy

Healthy ways to add fruits and vegetables to your diet

• Eat fruits and vegetables throughout the day • Add vegetables to your soups, sandwiches,

and salads • Use fruits to make smoothies • Use fruit to your cereal and yogurt, also in

salads, like asian salad• Choose fruits, or vegetables that are fresh, or

frozen

• Fill ½ of your plate with fruits/veggies

• Fill ¼ of your plate with whole grains (i.e. brown rice or whole-wheat pasta)

• Fill ¼ of your plate with a protein (i.e. lean meat or fish)

Dietary Recommendation

Special Dietary Considerations• For patients on steroids: a low-fat and low salt

diet is recommended (because steroids can increase blood pressure and cholesterol)

• For patients with kidney disease: a low-fat and low sodium diet is recommended (because kidney disease can increase fluid retention and increase cholesterol)

Special Dietary Considerations

• Patients who are dieting or not able to obtain an adequate diet should take a daily multivitamin

• Patients with hypertension or nephritis should restrict salt intake

• All dietary modifications should be discussed with your physician

Watch out for…

• Herbal remedies – these are of unproven benefit, may be harmful, may interact with medications

• “Natural” does not equal “safe”

Exercise• Walking, swimming, bicycling, low-impact

aerobics, Pilates, stretching, or using an elliptical exercise machine – Strengthens bones and tones muscles without

aggravating inflamed joints– Helps to lower the risk of developing osteoporosis

• Avoidance of high-impact activity, ex. jogging, especially if joints are inflamed

• Vary the exercises, so that different muscle groups all get a regular workout

Exercise

• Pace yourself, especially if you tire easily• Don’t give up• Exercise should not be painful• Muscles that are not used may quickly

become weak

Exercise

• Regular exercise and even simple low-impact movement will:– reduce or minimize stress– help to keep your heart healthy– increase muscle strength and your range of

motion– help prevent osteoporosis– improve muscle stiffness

Outline of Talk• Introduction

– What is Lupus?• Skin

– Lupus effects on the skin– Skin issues and concerns with steroid use– Skin care tips – acne care, sunscreen use, and smoking cessation

• Weight Control– The effects of Lupus on weight– The effects of steroids on weight – Diet and exercise

• Feeling Good– Key elements of feeling good with Lupus– Fighting fatigue– Sleep hygiene

• Summary

Key Elements of Feeling Good With Lupus

• Control Lupus• Exercise and Diet• Fight fatigue• Rest and Good Sleep Hygiene• Support System – Don’t be afraid to ask for

help• Managing stress, anxiety and depression• Smoking Cessation

Controlling Lupus

• Ongoing patient-doctor communication• Compliance with medications and follow up• Alleviate symptoms• Prevent and treat relapses• Lessen side effects related to drug therapy• Coordinate care with your primary care

physician

Fatigue• Up to 80 percent of people with

lupus experience fatigue• Fatigue may be the main

symptom and can be debilitating• Contributing Factors:– Disease activity, pain, age, and

medications– Poor physical and mental health – Lack of good social support– Smoking

Fatigue• Other medical conditions may contribute to

fatigue• A few examples include:– Anemia– kidney failure– Hypothyroidism– Depression

Tips to Help Manage Fatigue

• Alternate activities with periods of rest throughout the day

• Establish good sleep patterns• Plan ahead; for example, shop for gifts

throughout the year• Prepare meals in advance• Eat a healthy diet and exercise regularly• Stop smoking if you smoke

Rest• Especially important during periods of disease

activity• Inflamed or damaged muscles require rest to heal• Too little or too much sleep isn’t healthy• Napping during the day may be helpful during

periods of lupus activity• Try to allow extra time in your daily schedule for

rest

• Keep the same bedtime and wake time every day.

• Limit liquids, heavy meals, tobacco and alcohol within 3 hours of bedtime.

• Limit caffeine at least 6 hours before bedtime.

• Exercise regularly, but not within 3 hours of bedtime.

• Wind down for at least 1 hour before bed in dim lights. Engage in something quiet, calm and relaxing. • Keep the bedroom quiet, cool and dark. • Take a hot shower or bath 1.5-2 hours before bedtime, not right before bed. • Limit any screen time (TV, tablets, phone, computer) within an hour of bedtime and during the nighttime hours.• Limit time in bed to 7½ to 8 hours at most.

Outline of Talk• Introduction

– What is Lupus?• Skin

– Lupus effects on the skin– Skin issues and concerns with steroid use– Skin care tips – acne care, sunscreen use, and smoking cessation

• Weight Control– The effects of Lupus on weight– The effects of steroids on weight – Diet and exercise

• Feeling Good– Key elements of feeling good with Lupus– Fighting fatigue– Sleep hygiene

• Summary

Summary• Lupus is a complex autoimmune disease

characterized by symptom diversity and periods of disease activity and remission

• Important principles of skin care, weight control and feeling good include:– Controlling Lupus – patients and physicians, together– Battling side effects of steroids– Protection against UVA and UVB rays– Smoking Cessation– Diet, Exercise, Rest, Sleep Hygiene– Recognizing need to seek help

Thank You

• S.L.E. Lupus Foundation• Eric Mariuma, MD• Michelle Coombs• Harlem Hospital

References• Subramanyan K, Johnson AW. Role of mild cleansing in the management of

sensitive skin. Poster presented at the American Academy of Dermatology 61st Annual Meeting, San Francisco, CA, March 21 to 26, 2004.

• Draelos ZD. Cosmetics and cosmeceuticals. In: Dermatology, 2nd ed, Bolognia JL, Jorizzo JL, Rapini RP, et al (Eds), Elsevier, 2008. p.2301.

• Images, if not otherwise mentioned, from google image• Acne treatment algorithm image from: www.uptodate.com • Draelos ZD. Cosmetic therapy. In: Comprehensive Dermatologic Drug Therapy, 2nd

ed, Wolverton SE (Ed), Elsevier Inc, 2007. p.761.• Management of acne: a report from a Global Alliance to Improve Outcomes in

Acne. Gollnick H, et. Al. J Am Acad Dermatol. 2003;49(1 Suppl):S1.• E-medicine article “Striae Distensae Treatment & Management” Author: Samer

Alaiti, MD, RVT, RPVI, FACP; Chief Editor: William D James, MD • “Lupus Intangibles” slide borrowed from the Lupus Initiative• Fatigue, Rest and Exercise information from a variety of sources including patient

information websites from the Lupus Foundation of America• Sleep Hygiene slides from Eric Mariuma, MD

The End