• Chronic, scarring, photosensitive plaques
• Favour head and neck, scalp (→ alopecia)
• May occur alone or as part of systemic lupus
• Malar (butterfly) rash: spares nasolabial folds
• Photosensitivity: exacerbated by sunlight
• Oral and nasal ulcers: typically painless
• Non-scarring, transient
• Annular or psoriasiform plaques
• Highly photosensitive
• Strong association with anti-Ro/SSA antibodies
• Heliotrope rash: violaceous periorbital oedema
• Gottron’s papules: flat-topped violaceous papules over knuckles
• Gottron’s sign: erythematous rash over extensor surfaces (elbows, knees)
• "Shawl sign" and "V-sign": photosensitive erythema on upper back and chest
• Nailfold capillary changes: dilated capillary loops, drop-out
• Strong link with underlying malignancy (especially in older patients): ovarian, lung, colorectal, pancreatic
• Also interstitial lung disease
• Skin thickening (sclerodactyly): tight, shiny skin; flexion contractures
• Mask-like facies: reduced expression, beaked nose
• Calcinosis cutis: calcium deposits in skin (part of CREST)
• Telangiectasia: especially face, hands
• Raynaud’s phenomenon: often first presentation; digital ulcers possible
• Calcinosis
• Raynaud’s
• Esophageal dysmotility
• Sclerodactyly
• Telangiectasia
• Associated with anti-centromere antibodies
o Firm, non-tender, often on pressure points (e.g., elbows)
o Associated with severe seropositive disease
o Purpura
o Livedo reticularis
o Ulcers
o Painful, rapidly expanding ulcers with undermined violaceous edges
o Often precipitated by minor trauma (pathergy)
o Also associated with IBD
Extra Revision Pearls
• Photosensitivity is a unifying clue for lupus and dermatomyositis
• Anti-Ro/SSA: associated with subacute cutaneous lupus and neonatal lupus (risk of congenital heart block)
• Heliotrope rash + proximal weakness: classic dermatomyositis clue
• Raynaud’s + sclerodactyly: think systemic sclerosis or CREST
• Pyoderma gangrenosum: also linked to ulcerative colitis, not specific to RA
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Author & Educational Disclaimer
Author:
Dr Phillip Cockrell BM FRCP DipClinEd
Dr Phillip Cockrell is a UK Consultant Physician in Internal Medicine, currently working at Queen Alexandra Hospital, Portsmouth University Hospitals NHS Trust. He has previously worked as a registrar across Intensive Care Medicine, Gastroenterology, Cardiology, Stroke Medicine, Acute Medicine, and Respiratory Medicine.
He has held senior leadership roles including Associate Clinical Director of the Acute Medical Unit, Clinical Director of Internal Medicine, and Chief of Medicine. Dr Cockrell has over 15 years’ experience in postgraduate medical education, having lectured extensively across the MRCP syllabus and contributed to MRCP revision teaching and course development.
Dr Cockrell holds a Bachelor of Medicine (BM), Fellowship of the Royal College of Physicians (FRCP), and a Diploma in Clinical Education (DipClinEd). His teaching approach is based on structured consolidation of complex medical topics to support efficient and effective revision for postgraduate examinations.
Purpose of this content:
The material on this page is intended solely for educational purposes to support revision for the MRCP (UK) Part 1 examination. It reflects examination-relevant principles of internal medicine and is designed to aid learning and pattern recognition.
Medical disclaimer:
This content is designed for postgraduate medical examination revision and does not constitute medical advice, diagnosis, or treatment guidance and must not be used as a substitute for professional clinical judgement, local guidelines, or specialist consultation. Clinical decisions should always be made in the context of individual patient circumstances and current national guidance.
