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time to time, painful red nodules can form on the legs. Occasionally, these red nodules may
also ulcerate. Steroid therapy may make the skin thin, and more prone to damage and
infection.
Nails must be cut carefully; it is often easier and safer to file them rather than cut them,
particularly if they are thick or uneven. The patients feet should be washed and examined
daily for any damage or problems. Any dry skin should be kept moist with a good
moisturizing cream, to prevent cracks from occurring [113-114]. It is vital to wear well-
fitting, supportive footwear.
Ideally, shoes should also have a soft cushioned sole, a pliable yielding upper and fasten
firmly around the instep. There should be no high-pressure areas on the shoes which rub the
skin. Also, the feet must be kept warm. Two thin pairs of socks are warmer than one thick
pair; in cold weather, thermal insoles should be put into shoes and bed socks worn at night.
Lupus patients should visit a podiatrist on at least one occasion for foot care advice [113-
114].

Lupus and the Mucosae

One of the most common features of lupus is oral ulcers [115]. Bullous SLE represents a
rare but serious disease, in which patients have antibodies against their own skin and/or oral
mucosa. Lesions associated with this condition consist of grouped blisters, typically
presenting on the head and neck; blisters may also present on the arms and legs [116].
Systemic corticosteroids and immunosuppressives represent the classic treatment for this
disease [116].
Herpes simplex (fever blisters) may appear as a side effect of immunosuppressive therapy
[117]. These lesions appear as small groups of painful, fluid filled blisters that usually resolve
without medical treatment within 2-4 weeks [117]. Oral and intranasal ulcers may also occur
in some lupus patients [118].
These ulcers may cause soreness, difficulty chewing, and visible sores in the mouth
[118]. Oral candidiasis may occur usually a side effect of immunosuppressive therapy. Oral
candidiasis appears as whitish red, flaky plaques that can affect any area of the mouth;
plaques often affect the esophagus. Patients may feel a burning sensation, or have difficulty
swallowing. Oral anti-fungals are utilized for therapy. If the mouth is particularly sore, a soft
toothbrush and gentle brushing of teeth, flossing and smoking cessation should be
recommended.
Depending on the type of lesion, steroid paste may also be utilized, coupled with
antimalarial tablets such as hydroxychloroquine. In many cases, an antifungal nystatin
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mouthwash may be warranted. Approximately a third of lupus patients have some sort of eye
problem related to their disease. Fortunately, in most people only the surface of the eye is
affected [119]. Corneal dryness does not significantly affect the vision, and is readily treated
with eye drops. Much less commonly, the disease may involve the interior of the eye or the
visual pathways within the brain.
These complications may reduce vision and usually require systemic treatment, either by
oral or intravenous routes. A retinopathy due to antimalarial medications should also be
excluded in patients receiving this treatment [120]. Lupus may cause scleritis, which may

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