Lupus

Monday, November 28, 2011

Lupus and skin

     There are different types of lupus some of them are confined to just the skin and SLE is skin and systemic (affects the entire body).  However, not everyone with systemic lupus will get a skin manifestation of the disease.  The skin manifestations of lupus can be very challenging and life altering, especially if they scar or last a long time.  Here is some information SLE skin issues and lupus disease confined to the skin.

Skin Changes in People with Systemic Lupus

Lupus Foundation of America


Introduction
Changes of the skin, hair, nails, and mucous membranes are very common in people with systemic lupus erythematosus (SLE), occurring in 85 percent of patients. In most of them, these abnormalities are not severe and are easily treated with corticosteroids (prednisone) or antimalarial drugs (hydroxychloroquine or chloroquine). In a small number of individuals, these problems are severe and may be somewhat unresponsive to the usual treatment. The rashes of SLE may be divided into specific and non-specific rashes.
Specific rashes
  1. The butterfly blush or rash is a faint or prominent red rash over the malar area and the bridge of the nose. The rash does not go into the sides of the nostrils or down the fold between the nose and the outer part of the lips. These areas are always spared and look white in contrast to the red rash of the cheeks and bridge of the nose. Sometimes the rash is flat, and sometimes it is elevated. It may be in the form of red blotches or may be completely red over the area. The rash may be itchy, especially if it looks more like a rash than a blush. This rash is typical of SLE but is present in only about 30 percent of patients.
    The butterfly rash is frequently confused by patients and by physicians with a similar red rash which also is over the cheeks. This rash is called acne rosacea. It does involve the areas of the outside of the nostrils and does involve the folds between the nose and the outer part of the lips. In addition, pimples may be seen on top of the red rash in acne rosacea.
     2) Subacute cutaneous lupus lesions are of two major types.
  • The first type looks like red pimples when the rash first comes out; as the rash persists, these pimples become bigger, and scales appear as the rash persists. Patients complain about the rash being very itchy. The rash usually appears on the face, chest, or arms and commonly comes on after sun exposure. The rash usually worsens after more sun exposure.
  • The second type starts out as a flat lesion and gets bigger by expanding outward. The center may become less red and may even clear up completely so that, after a while, this rash looks like many circular red areas with clear holes in their centers. The rash appears on the face, chest, arms, and back. It is very sensitive to the sun and, like the other form of subacute cutaneous lesions, usually is very itchy. The rash of subacute cutaneous lupus usually heals without scarring, or leaves a non-depressed scar or area of depigmentation where the rash had been.
People with subacute lesions are very sun-sensitive. These individuals also frequently have a specific nuclear autoantibody called anti-Ro. SLE patients with anti-Ro are more likely to have a sun-sensitive rash than SLE patients without anti-Ro.
  1. Chronic discoid lupus lesions are found in about 20 percent of people with SLE. Chronic discoid lupus also is found in people who have absolutely no trace of systemic lupus. In these people, the lupus is confined to the skin.

    These lesions are slightly elevated, pink or red areas which form crust or flakes on the surface. As the lesions mature, the central area becomes depressed and forms a scar. These lesions rarely are found below the chin and practically never on the legs. However, chronic discoid lupus frequently is found on the scalp and in the outer ear. Lesions are itchy and get bigger by spreading outward, leaving a central scar. In pigmented individuals, the central area may become depigmented; in all individuals, the outer red area may become hyperpigmented. These can be very disfiguring lesions and should be treated as soon as possible and as aggressively as necessary to stop them.
Non-specific rashes

Non-specific rashes are seen in diseases other than lupus, but are extremely common in people with SLE. Patients may develop a red blotchy rash similar to the rash caused by a number of viruses, and similar to the rash caused by a variety of drugs (so-called drug-rash). These blotches may or may not be elevated and may be pink or red. They generally are found on the face, chest, back, and upper arms, and may or may not be itchy. This type of rash disappears quickly if patients are treated with corticosteroids for their other complaints.

Vasculitic rashes are seen frequently in people with SLE, especially in acutely ill patients. These rashes are non-specific because they may be present in patients who do not have lupus. For example, a small number of individuals with rheumatoid arthritis develop vasculitic rashes. There are a wide variety of rashes due to vasculitis, including: tender bumps in the tips of the fingers or toes; rashes that look like splinters under the nailbeds; ulcers that form around the ankle joints or on the legs; and tender red bumps on the shins.
Some lesions in people with lupus, such as hives, may be due to inflammation of the small vessels of the skin.
Other non-specific lesions include nail bed redness and redness of the palms of the hands. Rarely, blisters due to lupus may be present.
Hair loss (alopecia)
Hair loss occurs in about 45 percent of people with lupus at some time during the course of their disease. Most frequently the hair loss occurs at the onset of the illness, and may be one of the first symptoms of the disease recognized by the person. Most often, the hair loss is from all over the head, but sometimes the hair falls out in patches. When the disease is brought under control, the hair should grow back. Sometimes there is a rash in the scalp—usually subacute or chronic discoid—that interferes with the hair follicle. In this situation, the individual is left with a permanent area of alopecia. Drugs used to treat lupus, such as prednisone and immunosuppressive therapies, also may be the cause of reversible hair loss.
Nail changes
Nail changes occur in about 10 percent of patients and consist of cracking, curling, and even loss of nails. These symptoms are due to the changes in the small vessels of the nail bed.
Mucosal ulcers
Mucosal ulcers usually are found on the roof of the mouth. They are painless, but are found because the physician looks for them. Patients may mistake painful canker sores for mucosal ulcers. Some individuals with lupus will have mucosal ulcers in the nose - when these are severe, they can lead to a hole in the septum of the nose.
Treatment
The mainstay of treatment is the use of antimalarial drugs such as hydroxychloroquine (Plaquenil). Some people are more responsive to chloroquine. Steroid creams should be used cautiously on the face since the strong creams may cause dilated blood vessels. Some lesions—particularly discoid lesions—can be injected with corticosteroids and may respond very well. Other agents that have been used include retinoids such as Accutane and thalidomide. Occasionally it is necessary to use moderate doses of corticosteroids or other immunosuppressive therapies orally, to control lesions. Vasculitic lesions may require the use of cyclophosphamide, especially when ulceration is present.
There also are a number of practical, general steps people with lupus can take to help their skin problems.
  1. The first rule is to stay out of the sun, especially during the middle of the day.
  2. The second rule is to wear a good protective sunscreen of SPF 30 or higher. Use the sunscreen on all exposed skin areas, including the hands.
  3. The third rule is to wear a hat with a broad brim.
  4. The fourth rule is to wear long sleeves.







What Are the Different Types of Lupus?
There are several types of lupus that are recognized today. These include:
  • Discoid lupus. This was the first type of lupus to ever be diagnosed. This form of the condition affects only the skin, causing thick, red, scaly rashes on the face, neck, and scalp. After the rash goes away it can leave scarring and can cause hair loss in the scalp area. The rash of discoid lupus may last for a few days or a few years. It can go away for a long time and then come back. Discoid lupus is much more common in women than men and usually occurs between the ages of 20 and 45. In about 10 percent of people with discoid lupus, the condition progresses to systemic lupus.
  • Systemic lupus. Systemic lupus is the type of lupus diagnosis that is usually referred to generally as "lupus." This kind of lupus can affect almost any part of the body. Ninety percent of people diagnosed with systemic lupus are women in their child-bearing years. In the United States, the highest incidence is found in African-Americans. Symptoms of systemic lupus can be mild or severe and tend to come and go over time. Common symptoms include:
    • Painful joints
    • Fevers
    • Rashes caused by sun exposure
    • Hair loss
    • Loss of circulation in toes or fingers
    • Swelling in the legs
    • Ulcers inside the mouth
    • Swollen glands
    • Extreme tiredness
  • Different Types Of Lupus  http://www.skincareguide.ca/conditions/lupus/types_of_lupus.html

    There are different types of skin involvement in Lupus Erythematosus.

    Lupus Erythematosus – Specific Skin Disease:

    Discoid lesions:

    These are scarring, coin-shaped lesions commonly seen in areas of skin that are exposed to light, such as the scalp, and ears, and the central portion of the face and nose. More rarely, your lips, mouth, and tongue might be involved. These lesions can produce a scarring baldness, and because they often affect your face, you may consider getting cosmetic treatment. Only 1 in 10 to 1 in 20 of patients who are initially diagnosed with this type of skin involvement, will eventually develop the severe form of the disease that involves other organs in your body.


    Subacute cutaneous lesions:


    These are non-scarring, red and scaly lesions that are very photosensitive, that is they get worse when they are exposed to ultraviolet light. They tend to occur on the face in a butterfly shaped distribution or can be more widespread on the body. Even though these lesions do not result in scarring, their extent and color change can cause you major cosmetic concerns. About half of the patients who are diagnosed with this type of skin involvement will, in time, develop other organ involvement (also called systemic involvement or systemic disease), such as arthritis conditions with their blood. Kidney disease is unusual in patients with this type of skin disease.

    Lupus Profundus:

    This is a rare type of skin lupus erythematosus in which the subcutaneous fat is involved giving rise at first to tender nodules that can leave, in time, saucer like depressions in the skin surface. This type most commonly affects the upper arms and trunk. Patients with this type of skin involvement may have either systemic disease or disease limited to the skin.

    Acute Lutaneous Lupus Lesions:

    The malar rash or butterfly rash occurs in association with systemic lupus erythematosus. It is seen in up to 2/3 of patients with systemic disease and may be the presenting feature in up to 40%. It may vary in degree from a mild redness or "rosy cheeks", to multiple swollen red areas or plaques.

    Lupus Erythematosus – Non-Specific Skin Disease:

    The following are skin changes that are noted in some patients with lupus erytheamtosus but also occur in many patients without lupus erythematosus. Thus having one of the conditions listed below does not mean that there is a predisposition to developing lupus erythematosus.

    Hair loss:


    Up to 1/3 of patients with systemic lupus erythematosus get reversible form of hair loss associated with flares of their systemic disease. They may also note, that their hair is more brittle than previously and breaks easily giving rise to shortened hair ("lupus hair"). Another form of reversible hair loss that leaves distinct bald spots, alopecia areata, may also be more common in patients with lupus erythematosus.


    Vasculitis:


    Patients with systemic lupus erythematosus may develop inflammation of their blood vessels, this can result in varied manifestations running a spectrum from multiple scattered red bumps, that may crust and ulcerate to painful nodules.


    Varied skin manifestations:


    Raynaud's phenomenon:


    This is the blanching of the skin of the fingers and toes when exposed to cold and may be followed by a blue or red discoloration.


    Chilblains:


    This is a cold induced injury that results in tender nodules and plaques on the fingers and toes. 
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  • The Skin

    Approximately two-thirds of people with lupus will develop some type of skin disease. Skin disease in lupus can cause rashes or sores (lesions), most of which will appear on sun-exposed areas, such as your face, ears, neck, arms, and legs. In addition, 40-70 percent of people with systemic lupus will find that their disease is made worse by exposure to ultraviolet (UV) rays from sunlight or artificial light.
    Lupus skin disease, called cutaneous lupus erythematosus, can occur in one of three forms: chronic cutaneous (discoid) lupus erythematosus, subacute cutaneous lupus erythematosus, and acute cutaneous lupus erythematosus. Lupus skin rashes and lesions should be treated by a dermatologist, a physician who specializes in caring for the skin. To determine whether a lesion or rash is due to cutaneous lupus, your physician will usually want to look at the tissue under a microscope. Taking the tissue sample is called a biopsy.

    The Forms of Cutaneous Lupus

    Chronic cutaneous lupus (discoid lupus) appears as disk-shaped, round lesions. The sores usually appear on your scalp and face, but sometimes they will occur on other parts of your body as well. Approximately 10 percent of people with discoid lupus later develop systemic lupus, but these people probably had systemic lupus to begin with, with the skin rash as the first symptom.
    Discoid lupus lesions are often red, scaly, and thick. Usually they do not hurt or itch. Over time these lesions can produce scarring and skin discoloration (darkly colored and/or lightly colored areas). Discoid lesions that occur on your scalp may cause your hair to fall out. If the lesions form scars when they heal, your hair loss may be permanent. Cancer can develop in discoid lesions that you have had for a long time, so tell your doctor about any changes in the appearance of one of these lesions.
    Discoid lupus lesions can be very photosensitive, so preventive measures are important:
  • avoid being out in the sunlight between the hours of 10 a.m. and 4 p.m.
  • use plenty of sunscreen when you are outdoors
  • wear sun-protective clothing and broad-brimmed hats
  • limit the amount of time you spend indoors under fluorescent lights
Subacute cutaneous lesions may appear as areas of red scaly skin with distinct edges, or as red, ring-shaped lesions. The lesions occur most commonly on the sun-exposed areas of your arms, shoulders, neck, and body. The lesions usually do not itch or scar, but they can become discolored. Subacute cutaneous lesions are also photosensitive so preventive measures should be taken when spending time outdoors or under fluorescent lights.
Acute cutaneous lupus lesions occur when your systemic lupus is active. The most typical form of acute cutaneous lupus is a malar rash -- flattened areas of red skin on your face that resemble a sunburn. When the rash appears on both cheeks and across the bridge of the nose in the shape of a butterfly, it is known as the "butterfly rash." However, the rash can also appear on your arms, legs, and body. These lesions tend to be very photosensitive. They typically do not produce scarring, although changes in skin color may occur.

Other Skin Problems

There are several other conditions that can occur when you have lupus:
Calcinosis is caused by a buildup of calcium deposits under your skin. These deposits can be painful, and may leak a white liquid. Calcinosis can develop from a reaction to steroid injections or as a result of kidney failure.
Cutaneous vasculitis lesions occur when inflammation damages the blood vessels in your skin. The lesions typically appear as small, red-purple spots and bumps on the lower legs; occasionally, larger knots (nodules) and ulcers can develop. Vasculitis lesions can also appear in the form of raised sores or as small red or purple lines or spots in your fingernail folds or on the tips of your fingers. In some cases cutaneous vasculitis can result in significant damage to skin tissue. Areas of dead skin can appear as sores or small black spots at the ends of your fingers or around your fingernails and toes, causing gangrene (death of soft tissues due to loss of blood supply).
Hair loss can occur for other reasons besides scarring on the scalp. Severe systemic lupus may cause a temporary pattern of hair loss that is then replaced by new hair growth. A severe lupus flare can result in fragile hair that breaks easily. Such broken hairs at the edge of your scalp give a characteristic ragged appearance termed "lupus hair."
Raynaud’s phenomenon is a condition in which the blood vessels in your hands and feet go into spasm, causing restricted blood flow. Lupus-related Raynaud’s usually results from inflammation of nerves or blood vessels and most often happens in cold temperatures, causing the tips of your fingers or toes to turn red, white, or blue. Pain, numbness, or tingling may also occur. If you have Raynaud’s phenomenon try to avoid cold conditions, and, if necessary, wear gloves or mittens and thick socks when in an air-conditioned area.
Livedo reticularis and palmar erythema are caused by abnormal rates of blood flow through your capillaries and small arteries. You will have a bluish, lacelike mottling under your skin, especially on your legs, that gives a "fishnet" appearance. Like Raynaud’s phenomenon, these conditions tend to be worse in cold weather.
Mucosal ulcerations are sores in your mouth or nose or, less often, in lining of vaginal tissue. These ulcers can be caused by both cutaneous lupus and systemic lupus. It is important to differentiate lupus ulcers from herpes lesions or cold sores, which may be brought on by the use of immunosuppressive drugs. Lupus ulcers are usually painless and signs of inflammation will show up in the biopsy.
Petechiae (pah-TEE-kee-eye) are tiny red spots on your skin, especially on the lower legs, that result from low numbers of platelet in your blood, a condition called thrombocytopenia. Although thrombocytopenia is common in lupus, serious bleeding as a result of the low number of platelets usually does not occur.

Treating Cutaneous Lupus

The medication used to treat lupus-related skin conditions depends on what kind of cutaneous lupus you have. The most common treatments are ointments, such as steroid cream or gel. In some cases liquid steroids will be injected directly into the lesions.
A new class of drugs, called topical immuno-modulators, has been developed to treat serious skin conditions without the side effects found in corticosteroids: both tacrolimus ointment (Protopic®) and pimecrolimus cream (Elidel®) have been shown to suppress the activity of the immune system in the skin, including the butterfly rash, subacute cutaneous lupus, and possibly even discoid lupus lesions.
In addition, thalidomide (Thalomid®) has been increasingly accepted as a treatment for the types of lupus that affect the skin; it has been shown to greatly improve cutaneous lupus that has not responded to other treatments.

Treatments for Cutaneous Lupus

Preventative Treatments

  • Avoidance/protection from sunlight and artificial ultraviolet light
  • Seek shade
  • Sunscreens -- physical and chemical
Local/Topical Treatments

  • Corticosteroid creams, ointments, gels, solutions, lotions, sprays, foams
  • Calcineurin inhibitors
    • tacrolimus ointment (Protopic®)
    • pimecrolimus cream (Elidel®)
Systemic Treatments for Mild to Moderate Disease

  • Corticosteroids -- short term
  • Antimalarials
    • hydroxychloroquine (Plaquenil®)
    • chloroquine (Aralen®)
    • quinacrine (available from compounding pharmacies only)
  • Retinoids
    • synthetic forms of vitamin A—isotretinoin (Accutane®), acitretin (Soriatane®)
  • Sulfones
    • diaminodiphenylsulfone (Dapsone®)
Systemic Treatments for Severe Disease

  • Corticosteroids -- long term
  • Gold
    • oral—auronofin (Ridura®)
    • intramuscular—gold sodium thiomaleate (Myochrisine®)
  • Thalidomide (Thalomid®)
  • Methotrexate
  • Azathioprine (Imuran®)
  • Mycophenolate mofetil (CellCept®)
  • Biologics
    • efalizumab (Raptiva®)
It should be noted that most of the above treatments are not FDA-approved for cutaneous lupus.
Related Information
The Many Faces of Cutaneous Lupus
Spring 2008 issue of Lupus Now magazine
The Mysterious Aspects of Skin Lupus15 Questions with Dr. Victoria Werth Your Skin and Lupus
July 2009 webchat transcript with Dr. Andrew Franks
Skin Disease and Lupus
December 2006 webchat transcript with Dr. Victoria Werth

Frequently Asked Questions

I want to avoid the butterfly red marks across the face. Is there anything I can do with lotions or creams to help avoid them?
There are several helpful approaches for this. First, patients prone to getting a butterfly rash should practice sun avoidance and use of high SPF sunscreens with good UVA blocks, such as Mexoryl or Antihelios. There are some anti-inflammatory creams, such as mild topical steroids, tacrolimus, or pimecrolimus than also can be of benefit in treating the red marks.

How might chemical peels affect someone with cutaneous lupus, and are they contraindicated for people with lupus?
Chemical peels may irritate the skin, and thus could potentially induce skin lesions in patients with the underlying disease. This phenomenon can occur with scratching or any skin irritation and thus could be a potential risk. This procedure should be discussed with your dermatologist before using it.

Is the use of tanning beds okay for people with lupus?
In general those with lupus should not use tanning beds. The bulbs in tanning beds produce ultraviolet light rays. It is the ultraviolet light rays that cause the skin to tan. The majority of people with lupus tend to be unusually sensitive to ultraviolet light. That is to say, exposure to excessive ultraviolet light, especially the UVB sun burning rays, can cause lupus skin lesions to appear, or make existing lupus skin lesions worse. Ultraviolet light can also activate the internal, or systemic, manifestations of lupus in some people.

There have been many examples of lupus skin disease patients who were thought to have psoriasis instead, and were then treated for psoriasis in medical phototherapy cabinets that are similar to tanning beds. A number of these people almost died from severe activation of their systemic lupus following such mistaken treatment.
Some research suggests that very long ultraviolet light wavelengths, in what is called the "UVA-1" range, can improve certain forms of lupus skin disease and mild forms of systemic lupus. This research has been somewhat controversial, because other research has found that higher doses of the same UVA-1 wavelengths are capable of aggravating the systemic manifestations of lupus. Therefore, the biological effects that people with lupus might experience (i.e. getting worse or better) are likely to be critically dependent upon the amount of the different wavelengths of ultraviolet light energy that their skin receives.
In a routine commercial tanning bed setting, it would be quite difficult for people with lupus to know how much of the various UV wavelengths they are receiving. Thus, for people with lupus, visiting a tanning salon may be too risky.
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  • Pictures of lupus skin rashes
  • http://www.picsearch.com/index.cgi?start=1&width=1345&q=Lupus%20erythematosus 
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  • Lupus pictures

    http://www.lupuspictures.org/ 

    This site is a collection of lupus pictures and treatment tips.
    Lupus pictures

    Lupus pictures Lupus rash pictures Discoid lupus pictures Tumid lupus pictures
            Lupus is one of the most common autoimmune diseases in the world. Three out of five people who suffer from this type of illnesses are diagnosed with lupus. The problem with lupus is that it is a tricky disease: it cannot be predicted, it cannot be stopped and, most certainly, it cannot be cured. In recent years, scientists studying the issue have discovered that lupus has a definite genetic cause and several environmental factors can trigger a latent condition. Thus, it is best to study your families' health file and check out the places you live in before you start to think that your deteriorating physical health is somehow related to lupus. However, once everything has been eliminated and the only answer that remains is that you do suffer from this autoimmune disease, be prepared for a lifetime long battle to alleviate the symptoms of lupus. Do not lose hope because, according to physicians, the cure is on its way. Not very close, but closer than it might have seemed ten years ago.
    Butterfly lupus pictures Lupus skin pictures Lupus symptoms pictures

    Lupus rash pictures

           One of the most important lupus symptoms is the lupus rash. It not only cannot be missed, but it is a certain sign of what the medical doctor is dealing with. On the upside of this problem, the rash can be easily alleviated and it even disappears with proper treatment. On the downside, scarring is inevitable when talking about a lupus - related skin problem.
    Lupus rash pictures Lupus rash pictures Lupus rash pictures Lupus rash pictures
           There are three types of lupus rashes that a patient should be aware of: the acute rash, the chronic rash and the subacute rash (this can be considered a passing point between the acute and the chronic phases of the rash). These three stages are not necessarily happening in order, nor do all three affect one person. There are people who will never stop having and acute lupus skin condition and people who will find their lupus rash getting worse by the day.
            ...see more Lupus rash pictures

    Discoid lupus pictures

           Discoid lupus is the most serious of all the forms of skin lupus out there. It usually appears in the cases where only the skin is affected by this autoimmune disease, but it can be a symptom of a more disturbing condition, one that could lead to some rather important changes in the body. The image that discoid lupus presents resembles a poorly treated case of measles: round, inflamed and red pustules that tend to itch. Do not, under any circumstances, scratch that particular itch. If you do, scarring will be almost unavoidable. In some cases, with the help of proper medication and diet, some of that scarring might go away, but that is not a certainty.
    Discoid lupus pictures Discoid lupus pictures Discoid lupus pictures Discoid lupus pictures
            ...see more Discoid lupus pictures

    Tumid lupus pictures

           Tumid lupus is a feminist disease: it affects, usually, only young women, from the ages of nineteen to twenty eight, of whatever race and social status. Because lupus, in any shape or form, is an autoimmune disease, it does not have a cure. However, very few forms of lupus can evolve into something else. Unfortunately, tumid lupus is one of those that can very easily turn into systemic lupus erythematosus, a full - body condition that can lead to some very serious health concerns.
    Tumid lupus pictures Tumid lupus pictures Tumid lupus pictures Tumid lupus pictures
            ...see more Tumid lupus pictures

    Cutaneous lupus pictures

           Cutaneous lupus is the scientific name for skin lupus. Exactly like the name says, cutaneous lupus describes every lupus - related skin condition out there. From a simple, yet so telling, butterfly rash, to the more complex discoid skin problems or even to some subacute conditions, everything is encompassed in that one term. Unfortunately, what it does not describe at all is the relation between cutaneous lupus and the evolution of this autoimmune disease.
    Cutaneous lupus pictures Cutaneous lupus pictures Cutaneous lupus pictures Cutaneous lupus pictures
            ...see more Cutaneous lupus pictures

    Butterfly lupus pictures

           Butterfly lupus is one of the most common lupus forms out there, affecting the skin of the face, appearing especially on the nose and the cheekbones. Its unique butterfly shape makes it easy to identify in its more serious phases, but in the beginning, for a less than experienced physician or nurse, the rash can be easily mistaken for sunburn.
    Butterfly lupus pictures Butterfly lupus pictures Butterfly lupus pictures Butterfly lupus pictures
           If left untreated for longs periods of time, it can escalate, invading the upper back, the shoulders and, eventually, the entire body. It itches, sometimes, and it leaves behind some pretty telling scars.
            ...see more Butterfly lupus pictures

    Lupus treatment pictures

           There is one thing that any lupus patient must be told from the moment he or she is diagnosed: lupus has no cure. Not yet. The question then becomes what is the role of the treatment if the disease itself cannot be cured. Well, the answer is pretty obvious and may seem somewhat anticlimactic: the same as the flu treatment. It cannot cure, but it does a great job at alleviating the symptoms, which can be truly bothersome in some cases. Just like with any other full - body condition, lupus treatment implies both a medical approach, trying to keep the unnatural antibodies at bay with drugs, and a lifestyle change, which the patient must be willing to make in order to prolong his or hers existence.
    Lupus treatment pictures Lupus treatment pictures Lupus treatment pictures Lupus treatment pictures
            ...see more Lupus treatment pictures

    Lupus skin pictures

           Lupus skin conditions are known for being extremely troublesome and, more importantly, scarring. They can be classified in several groups, starting with the chronic conditions, going down for the subacute ones and ending with the acute problems. All of them are symptoms of a much more severe underlying condition: systemic lupus erythematosus.
    Lupus skin pictures Lupus skin pictures Lupus skin pictures Lupus skin pictures
            ...see more Lupus skin pictures

    Lupus complications pictures

           Sometimes patients tend to forget that lupus is a full - body illness. That is understandable under the idea that this condition attacks only one system at a time, in its early stages. Thus, the patient and the doctor will most likely be concerned with that specific problem and ignore the changes happening in other parts of the body.
    Lupus complications pictures Lupus complications pictures Lupus complications pictures Lupus complications pictures
           Lupus complications are known for their viciousness and their instability, as well as their diversity. The damage caused by an untreated complication can extend to the lungs, the liver, the kidneys, the skin or even the central nervous system.
            ...see more Lupus complications pictures

    Lupus symptoms pictures

    Lupus symptoms pictures Lupus symptoms pictures Lupus symptoms pictures Lupus symptoms pictures
            ...see more Lupus symptoms pictures
           The easiest to spot lupus symptoms are the rashes, the pain in the joints and the muscles and the unexpected fever bouts. However, if somehow the patient does not report those to the physician, then the medic should be able to discern that his or her patient suffers from lupus simply on their sleeping pattern: if the patient is a night - owl, preferring to lead his or hers existence during the sun - deprived hours of the day, than they might be affected by lupus.








     

Saturday, November 26, 2011

Lupus and cancer

     Lupus can cause and or put one at higher risk of certain cancers.  Sometimes the drugs used to treat SLE can also cause certain cancers.  A lot of people do not know this about lupus and I think it is very important to have knowledge on  this subject when one has lupus or when a friend or family member is suffering.  It is also not so well known that one that suffers with major organ involvement in lupus use the same chemotherapy drugs as someone being treated for cancer.  I want to spread understanding  and knowledge about how potentially serious this disease can become and that it can cause the big C word.

Lupus Linked to Increased Risk of Cancer

Higher Lymphoma Rates Among Systemic Lupus Patients Appears to Drive Trend
By
WebMD Health News
Reviewed by Laura J. Martin, MD
40-ish woman
Nov. 9, 2010 (Atlanta) -- People with systemic lupus are 15% times more likely to develop cancer compared with the general population, suggest findings of a study involving nearly 13,500 people with systemic lupus.
The higher malignancy rate among people with systemic lupus is driven mainly by an increased risk of cancers of the white blood cells, particularly a threefold increased risk of lymphoma, says researcher Sasha R. Bernatsky, MD, assistant professor in the divisions of rheumatology and clinical epidemiology at McGill University in Montreal.
Because lymphoma is a relatively rare cancer, however, the absolute risk of any person with lupus developing it is still quite low, she tells WebMD.
"If you follow 200 patients with lupus for a year, maybe you would see one lymphoma," Bernatsky says. "Although important ... we don't want to be overstating the finding."
Not all the news is bad. In what she calls one of the most surprising findings, she says that women with systemic lupus were less likely to develop estrogen-sensitive cancers, specifically those of the breast (30% decreased risk), endometrium (51% decreased risk), and ovary (44% decreased risk).
"This raises the possibility that something about how women with lupus metabolize estrogen may be involved," Bernatsky says.
She presented the findings here at the American College of Rheumatology Annual Scientific Meeting.

More Cancer Cases Than Expected Among People With Systemic Lupus

Systemic lupus is a chronic inflammatory disease that can affect the skin, joints, nervous system, kidneys, lungs, and other organs in the body. The most common symptoms include skin rashes and arthritis, often accompanied by fatigue and fever. Lupus occurs mostly in women and typically develops in people in their 20s and 30s.
The same research group previously demonstrated an association between systemic lupus and cancer in a smaller study. The current study was designed to more precisely estimate cancer rates among people with lupus, compared with the general population.
The study involved 13,492 people with lupus from 24 medical centers followed for an average of nine years. Using regional tumor registries, the researchers pinpointed people with systemic lupus and compared their cancer rates to what was expected in the general population.
Over the course of the study, 632 cases of cancer were noted among people with systemic lupus, "more than what we expected," Bernatsky says.

Younger Women With Systemic Lupus at Particularly High Risk of Cancer

Compared with the general population, people with systemic lupus were:
  • 3.4 times more likely to develop non-Hodgkin's lymphoma
  • 3.2 times more likely to develop any lymphoma
  • 2.8 times more likely to develop vulvo-vaginal cancers
  • 2. 2 times more likely to develop liver cancer
  • 1.7 times more likely to develop leukemia
  • 1.7 times more likely to develop cervical cancer
  • 1.2 times more likely to develop lung cancer
"When stratified by age, people with lupus who are younger than 40 appear to have a particularly high risk. They are 1.7 times more likely to develop cancer than the general population,"

Lupus Linked to Increased Risk of Cancer

Higher Lymphoma Rates Among Systemic Lupus Patients Appears to Drive Trend
(continued)

Drugs, Disease May Drive Tumor Growth in People With Systemic Lupus

The study does not prove cause and effect, and no one knows for sure why people with lupus are at increased risk of certain cancers, Bernatsky says.
"The drugs used to treat lupus may play a role," she says. "But there is just as much evidence that lupus itself may drive tumor growth."
In the case of cervical cancer, "lupus patients are more likely to get precancerous lesions of the cervix and they are less likely to get regular screening because of their disease."
"It's important for these women to get regular Pap smears," Bernatsky says.


Lupus and Cancer

The Johns Hopkins Lupus Center

Systemic lupus erythematosus (“lupus” or “SLE”) and other autoimmune diseases are linked to an increased risk of certain types of cancer. Specifically, lupus patients may experience an elevated risk of lymphoma and other cancers, such as cancer of the cervix. Researchers have elucidated certain connections between lupus and cancer. For example, it is widely accepted that immunosuppressive medications, such as azathioprine (Imuran) and mycophenolate mofetil (Cellcept) contribute to elevated cancer risk. However, one of the largest studies to investigate this connection suggests that the risk of cancer is actually greatest during the earlier stages of lupus, indicating that exposure to immunosuppressive therapy is not the only link between lupus and cancer. Physicians do not yet understand the precise relationship between lupus and cancer.

Lupus and lymphoma

Studies show an increased risk of both Hodgkin’s and non-Hodgkin lymphoma in lupus patients. It is believed that the elevated risk of lymphoma results from the disease process of lupus—specifically the overstimulation of B-cells coupled with defects in the immune system’s surveillance system—and not just from medications or other associated risk factors. Some suggest that immunosuppressive medications also increase the risk of lymphoma and other blood cancers, especially 5 or more years after taking the drug. In addition, people with Sjogren’s syndrome, which is relatively common in lupus, experience an even greater elevation of lymphoma risk, suggesting that lymphoma in lupus patients may also be linked to this condition.

Lupus and breast cancer

Some data indicate that women with lupus experience an increased risk of breast cancer. Increased estrogen levels might contribute to a higher risk of breast cancer in women with lupus.

Lupus and lung cancer

Lung cancer is about 1.4 times more common in people with lupus than in the general population. Interestingly, people with lupus and lung cancer are more likely to experience rare types of lung cancer. However, like the general population, many of the people with lupus who develop lung cancer are smokers. In fact, 85% of lung cancer is caused by tobacco. It is very important that people with lupus do not smoke. Smoking not only increases the chance of developing lung cancer, it also ups the risk for cardiovascular disease (which is also markedly increased in people with lupus), and prevents lupus drugs like Plaquenil from working properly. If you need help quitting, talk to your doctor. S/he can help you find the most effective strategy to curb your smoking habit.

Lupus and cervical cancer

Certain studies have shown an elevated risk of cervical cancer and abnormal PAP tests in women with lupus. One study linked the increased incidence of abnormal PAP tests with histories of sexually transmitted disease, contraceptive use, and immunosuppressive medications. Some physicians suggest that either the use of immunosuppressives or flawed inherent immunity lead to a decrease in the ability of lupus patients to fight off human papilloma virus (HPV), a virus associated with cervical cancer. [Gardasil (the HPV vaccine)  is recommended for young women with lupus to reduce the risk of later cervical cancer.] However, like much of our knowledge of cancer in lupus, these connections are not fully known or understood.

Lupus and endometrial cancer

New evidence suggests that lupus patients also experience an elevated incidence of endometrial cancer, although the cause for this risk is unknown.

NSAIDs and cancer

It has been found that people with Rheumatoid Arthritis, another autoimmune disease, experience a lower incidence of colorectal cancer than the general population. Although the precise cause of this phenomenon is unknown, it has been attributed to the long-term (10 years or more) use of non-steroidal anti-inflammatory drugs (NSAIDS) and aspirin. Evidence has also been found that long-term aspirin and NSAID use may also reduce the risk of colorectal, breast, and prostate cancer in the general population. It is likely that this benefit also holds for people with lupus, but that does not mean that one should begin taking aspirin and NSAIDs for this reason. In fact, long term NSAID use can increase cardiovascular disease. Therefore, you should only take medications as directed by your physician.

The importance of regular cancer screenings

Despite the increased risk of cancer in people with lupus, studies show that lupus patients are actually equally or even less likely than the general population to undergo cancer screenings. Thus, it is very important that you speak with your doctor about lupus and cancer to ensure that you see the appropriate physicians for cancer screenings as often as recommended.

Healthy habits

Certain risk factors, such as smoking, obesity, hormone replacement therapy, and exposure to immunosuppressive medications, increase the chance that an individual will develop cancer. Therefore, it is also important that you practice healthy lifestyle habits. Obesity also increases the risk of certain cancers, so try to eat foods that help you maintain a healthy weight.
Sunlight causes lupus flares and also increases the risk of skin cancer. People with lupus should avoid the sun whenever possible. If you need to be outdoors, wear sunscreen with an SPF of 85 or greater and be sure that your sunscreen contains Helioplex to protect you from both UV-A and UV-B rays.

Sources

  • Gayed M, Bernatsky S, Ramsey-Goldman R, Clarke A, Gordon C. Lupus and cancer. Lupus. 209; 18(6); 479-85.

Tuesday, November 22, 2011

Lupus and the holidays..

     The holidays can be a fun and exciting time, but for many it is a very stressful time as well.  Stress is not good for anyone but when you have lupus it can be very harmful.  Control your stress level: Since some researchers believe that stress could be both a lupus trigger and a flare trigger for those with lupus, reducing stress is a must. Stress also has a direct effect on pain: it often increases its intensity. Do your best to manage those areas of your life that cause the most stress. And consider relaxation techniques and deep breathing exercises can as a tool to help reduce stress. Exercise is a great way to help reduce stress.  Here is some information about lupus and stress, and also how to manage stress.

Does Stress Affect Lupus?

Medical Author: William C. Shiel Jr., MD, FACP, FACR
Medical Editor: Leslie J. Schoenfield, MD, PhD
Let's start by discussing what is meant by stress. Stress means different things to different people based on their backgrounds and their current emotional and physical condition. For some people, milk spilling on the table causes a major emotional reaction. To others, a tank rolling through the living room might be viewed as just another life experience!
For the purpose of this topic, I will define stress as human reactions to forces that tend to disturb our normal functional (physiologic) balance (equilibrium). Stress, in this general sense, refers to any adverse condition or state that affects our normal well-being. Such stress can be imposed on us by, for example, work, a spouse, other people, ourselves, or by setting our daily schedule too rigorously.
For nearly all of us, our first real stress was being engulfed by cold air when we slipped from the warm comfort of our mother's womb. (I don't know about you, but I cried like a baby!)
In what ways may stress affect the patient with lupus?

First of all, in some lupus patients (as in people without lupus), stress may cause no direct or indirect effects. Stress, however, may affect a person with lupus in one of three ways.
  • Stress may cause the same reactions that can occur in any person who does not have lupus.
  • Stress can be associated with (precipitate or initiate) the first appearance of their lupus.
  • Stress may be associated with a flare-up of their already existing disease.
What reactions can stress cause in a person with lupus that are the same as in a healthy individual?

Many symptoms have been associated with stress in normal persons as well as those with lupus. These symptoms include poor or inadequate sleep (insomnia), anxiety, depression, panic attacks, headaches, poor concentration, muscle aches, skin inflammation (eczema), inflammation of the joints (arthritis), irritable bowel syndrome (spastic colitis), constipation and diarrhea, high blood pressure (hypertension), certain types of stomach ulcers, asthma attacks, decreased sex drive, and even some cancer. Any of these symptoms, or any combination of them, can affect a person who is suffering from stress.  
Banish Your Holiday Stress 
from the Lupus Foundation of America
 
Your gift list is bigger than your bank balance. Your office holiday party is the same time as your child's school play. And just the thought of decorating, cooking, or braving a crowded shopping mall fills you with dread. If this sounds familiar, you are not alone.
The holiday season can be more than hectic, and for people with lupus, the financial, physical, and emotional demands of the season may add health-compromising stress that can turn a joyful time of year into a miserable one. But there is good news! You can cope with the chaos and stay healthy just by making a few simple changes.
Just Say No!
Don't overcommit yourself-you don't have to accept every party invitation. Figure out what is manageable and eliminate what you can't handle. Don't feel guilty. No one will complain if you bring cookies from a bakery instead of homemade ones. And if you decide to skip a party, you can make it up to the hostess with an invitation to lunch sometime early in the New Year. Put yourself and your health first.
Delegate
You can't do it all yourself. Ask family members for help with decorating, cooking, and cleaning. Consider splurging for maid service or having your holiday meal catered or hold it at your favorite restaurant. Offer a teenage neighbor a few dollars to do your gift wrapping or put up holiday lights.
Shop Smart
Too many gifts to buy and too little cash? Avoid the guilt that can come with buying too many things you just can't afford. Although using credit cards may seem like an easy solution, this habit can be a stressful burden when the bills start to roll in. One way to relieve the financial pressure of the holidays is to become a shopper who's savvy and smart:
  • Talk with family, friends, and co-workers about setting spending limits on gifts.
  • Play the Christmas Angel game, where everyone's name goes into a hat and you buy only for the person whose name you select.
  • Consider buying presents only for the children in the family.
  • If you're crafty and have the time, save money by decorating inexpensive picture frames or terra cotta flowerpots you can fill with candies or a cutting from your favorite plant. Or decorate a plain, inexpensive T-shirt with paint or embellish it with ribbons or sequins.
  • Save time by shopping the Internet for books, music, event tickets, gift baskets, and just about anything else, and the shipping will be done for you.
  • Make donations to the Lupus Foundation of America in gift recipients' names, or make purchases from the LFA online store or from LFA chapter sites to support lupus awareness in your area.
  • Plan ahead for next year. Look for bargains year-round, starting with after-holiday sales.
Take Care of You
Avoid holiday burnout by getting plenty of rest, pacing yourself, and napping when you need to. Don't set unrealistic expectations for yourself or others that can lead to disappointment and depression.
Take a walk, do yoga, or read a book to replenish your body and spirit. If you need a good laugh, nothing beats renting a good holiday movie like Love, Actually or The Santa Clause for a great pick-me-up.
And last, reach out. Talking about your feelings with friends, loved ones, or a support group can help you get through the season-joyfully.

Sunday, November 20, 2011

Lupus can damage any part of the body

     SLE lupus can damage any part of the body at anytime, which means that there are many specialists used together to treat patients.  This team of doctors should work together when organ or multiple organ involvement has occurred.  Having lupus means a lot of tests being done to check if or on organ involvement, if certain tests show an organ is being attacked by SLE then a specialist of that specific part of the body will be referred. 

How Lupus Affects the Body

How Lupus Affects The Body 300x299 How Lupus Affects the BodyIn people with lupus, the immune system begins to recognize and attack the body’s own tissues. This phenomenon is similar to “friendly fire” and causes inflammation in various parts of the body. It is important to realize, however, that lupus can affect different people in different ways and that signs and symptoms can come and go, producing periods of flares and remission. The following articles provide an introduction to how lupus may affect different parts of the body.
  • Antiphospholipid Antibodies Antiphospholipis antibodies are antibodies directed against phosphorus-fat components of your cell membranes called phospholipids, certain blood proteins that bind with phospholipids, and the complexes formed when proteins and phospholipids bind. Approximately 50% of people with lupus possesses these antibodies, and over a twenty-year period of time, one half of lupus patients with one of these antibodies—the lupus anticoagulant—will experience a blood clot.
  • Arthritis “Arthritis” is a broad term used to describe inflammation of the joints. There are many subsets of arthritis, but the arthritis seen in lupus closely resembles rheumatoid arthritis
  • Cardiovascular System Lupus can affect the cardiovascular system, which includes your heart and blood vessels. In fact, cardiovascular disease, not lupus itself, is the number one cause of death in people with SLE. Therefore, it is very important that you take steps to maintain optimal cardiovascular health.
  • Immune System in lupus and other autoimmune diseases, the immune system begins to recognize and attack “self.” In other words, the cells of the immune system begin to injure the body’s own tissues. This phenomenon is similar to “friendly fire” and can cause permanent scarring that ultimately jeopardizes the function of certain organs and systems in the body. Certain cells and processes of the immune system have been identified as playing a role in lupus.
  • Kidneys About one half of people with lupus experience kidney involvement, and the kidney has become the most extensively studied organ affected by lupus.
  • Lungs About 50% of people with SLE will experience lung involvement during the course of their disease. Five main lung problems occur in lupus: pleuritis, acute lupus pneumonitis, chronic (fibrotic) lupus pneumonitis, pulmonary hypertension, and “shrinking lung” syndrome.
  • Nervous System Lupus can affect both the central nervous system (the brain and spinal cord) and the peripheral nervous system. Lupus may attack the nervous system via antibodies that bind to nerve cells or the blood vessels that feed them, or by interrupting the blood flow to nerves. Conditions associated with or sometimes seen in lupus include cognitive dysfunction, fibromyalgia, headaches, organic brain syndrome, and CNS vasculitis.
  • Skin Most people with lupus experience some sort of skin involvement during the course of their disease. In fact, skin conditions comprise 4 of the 11 criteria used by the American College of Rheumatology for classifying lupus. There are three major types of skin disease specific to lupus and various other non-specific skin manifestautions associated with the disease.
  •  
  • Specialists Who Treat Lupus Patients
    In addition to muscles and joints, lupus also commonly affects the skin, kidneys, heart, nervous system, and blood cells. That’s why a lupus treatment team will often include the following specialists:
  • Dermatologists. These medical specialists can deal with lupus-related skin disease. Lupus can cause a serious rash called "discoid lupus" that flares up with exposure to the sun. Your dermatologist may perform a skin biopsy to diagnose a lupus rash, prescribe medication, and advise you on proper sunscreen use.
  • Nephrologists. These are specialists who treat patients with kidney disease, a common complication of systemic lupus. A nephrologist may perform a kidney biopsy and will work with your rheumatologist to manage kidney disease.
  • Cardiologists. People with lupus have a higher risk of heart disease and may develop inflammation around the heart or in the valves inside the heart, and in that case a person with lupus would be referred to a cardiologist.
  • Neurologists. Lupus can also involve the nervous system to varying degrees. Symptoms of nervous system lupus may include headaches, seizures, and psychiatric disturbances. A neurologist can help determine which symptoms are caused by lupus and which could be due to other health problems.
  • Hematologists. These specialists deals with problems involving the blood. The majority of people with lupus have some type of blood abnormalities, such as decreased numbers of white and red blood cells or problems with blood clotting.
  • High risk obstetricians. For women with lupus who are pregnant or wish to become pregnant, an obstetrician is a critical member of the team. While it is possible to become pregnant when you have lupus, the pregnancy is considered high risk, requiring an obstetrician with special training and experience.
Treating Lupus Patients: Other Healthcare Professionals Who Treat Lupus
Working along with your doctors will be a number of other healthcare professionals who play important roles in lupus treatment. They include:
  • Nurses. Registered nurses, advanced practice nurses, and nurse practitioners can all be important members of your care team. A nurse can assist in many areas of your treatment, whether that means serving as a link between you and your doctors, or being an excellent educational resource for you.
  • Occupational and physical therapists. These healthcare professionals can help you maintain fitness and mobility, advise you on how to manage lupus symptoms, and help you manage everyday activities despite lupus.
  • Psychologists, psychiatrists, or counselors. Living with lupus can be stressful. A mental health professional can help you adjust to the emotional challenges of having a chronic disease.
  • Dieticians and nutritionists. For lupus patients, it is important to maintain a healthy diet. This may include watching your salt intake and keeping your cholesterol low. A dietician or nutritionist can offer diet information and advice tailored to your specific needs.
  • Social workers and patient advocates. School problems, financial issues, your job, and your health insurance are all areas that can become complicated and even overwhelming when you are trying to deal with a chronic disease like lupus. These professionals can be a great help when you're in need of someone to turn to about such issues.
Lupus patients today are living healthier and more active lives than ever before. But lupus is still a chronic, complicated disease that is best treated by a team of doctors and professionals who work together. And studies show that people who are best able to cope with a chronic illness are those who educate themselves about their condition, work closely with their medical team, and take an active role in their medical care.
  • It may take some time for a person to be definitively diagnosed with lupus. During this time, you may be confused or frustrated by the seeming inability of the doctors you visit to confirm the diagnosis. Part of the difficulty, both for the patient and the doctor, rests in the fact that the diagnosis may seem to be hiding in a forest of confusing, vague, or changeable symptoms.
    A rheumatologist is a specialist who treats autoimmune diseases as well as problems with joints, muscles and bones. These are board certified doctors who treat lupus. Local lupus agencies have a list of local doctors who treat lupus and other autoimmune diseases.
    You can contact the alliance for a group in your area or you can go to this directory: American College of Rheumatology
    If you would like to find a Dermatologist in your area, go to this directory: American Academy of Dermatology
    With so many manifestations of lupus you may need to see many different specialists to treat your disease. Here is a list and explanation of medical specialty areas.
    Cardiologist: a doctor who can diagnosis and treat problems with the heart and blood vessels.
    Dermatologist: specializes in treatment of the skin and skin disorders.
    Endocrinologist: diagnoses and treats the diseases caused by gland and hormone problems, like diabetes and thyroid disease.
    Gastroenterologist: treats aliments of the digestive tract as well as diseases of the esophagus, stomach, liver, gallbladder and intestines.
    Hematologist: One who specializes in the treatment of blood disorders.
    Internist: A physician who specializes in diagnosis and treatment, as opposed to surgery and obstetrics, of diseases of the internal organs.
    Nephrologist: A physician that specializes and treats kidney disease.
    Neurologist: A specialist who treats conditions involving the brain and the nervous system.
    Oncologist: A doctor who specializes in treating cancer.
    Opthalmologist: A doctor who specializes in the treatment of the eyes and eye-related disorders.
    Otolaryngologist: This doctor specializes in treating ear, nose, throat, head, and neck problems.
    Orthopedist: Corrects and prevents disorders of bones, joints, ligaments, tendons and muscles.
    Pathologist: One who is well versed in detecting changes in tissues.
    Psychiatrist: A physician who is trained to treat mental and neurotic disorders and the changes that occur with them.
    Psychologist: a person who specializes in the mental processes and their effect on behavior. They can help the patient, or the patient’s family cope with problems, disease, sudden illness and accidents.
    Pulmonologist: A doctor who concentrates on lung problems such as asthma.
    Rheumatologist: An internist who has additional training to treat problems involving the joints, muscles and bones as well as autoimmune diseases.
    Before a diagnosis is made, many of a patient’s primary needs are emotional. A lupus patient will, in all likelihood, be on intimate terms with her or his symptoms long before their cause is known. Realistically, she or he is the best authority on these symptoms. A patient may feel frustrated if, after describing symptoms, others do not respect her or his knowledge or do not share the conviction that something is wrong. If the doctor, family, or friends are unsupportive, the patient’s fear, anger, and sense of isolation will only increase. These feelings add stress, which in turn can exacerbate the disease.
    Health professionals can help ease these feelings by showing empathy during this difficult time and by reassuring the patient that the symptoms are real and merit serious attention. In addition, treating the patient as a whole person, and not just as a subject with a disease, can be immensely valuable in establishing a trusting relationship with the patient. Such a relationship will help the patient speak freely about symptoms or concerns that she or he may have been unwilling to discuss previously.