Aug 11, 2026 · 53 min · 12 segments
Lupus is a condition dermatologists know as one of the great diagnostic mimics. In this episode, Dr Jacqueline Jiang and Associate Professor Alvin Chong sit down with rheumatologist Professor Alberta…
Alberta HoiGuest
Laura ScardamagliaGuest
Alvin ChongHost
Jackie JiangHost
Has the understanding of the underlying cause of lupus changed in, in the past few years? What, what causes lupus?
I think we don't think there is a single cause, and so lupus seems to occur when the patients have a certain genetic tendency towards autoimmunity and then some sort of environmental trigger that helps set it off, and these trigger can involve a, a variety of things.
So what's well described in the literature are things like, for example, sunlight, uh, infections, particularly viral infections, some medications that we've sort of alluded to with drug-induced lupus, hormonal influence, smoking, and stress is a actually a very common and potent trigger.
What has changed in recent year in our understanding of the immune pathway that drives the disease is that we have a much better understanding or better picture of how the immune dysfunction occurs in both the innate and adaptive immune system, and these two pathway contribute equally to the lupus pathogenesis.
And these also include things like the abnormal activations of immune cells and signaling pathway that sustain inflammations and autoantibody productions.
And there's a, a growing understanding that shift our treatment actually from using broad spectrum immunosuppressants to more sort of targeted therapy that specifically blocks this immune pathway that we have a better understanding for.
Well, there's no one single test that can say, "Yes, this is lupus," in every cases.
Instead, clinician often make the diagnosis by building a picture, bringing together the patient's symptoms, examination findings, blood tests, urine tests, and sometime even biopsy results.
The most common one is the anti-nuclear antibody, the ANA, but there are specific autoantibodies that are also relevant.
And urine and kidney tests are also important because lupus can quietly affect the kidneys without causing a lot of obvious symptoms, and so we do screen for that as well.
So diagnosis is a combination of clinical pattern recognition via history and examination, histopathology, and systemic context in investigations.
So first you need to determine whether the morphology and clinical features fit acute, subacute, or chronic cutaneous lupus, and if there's diagnostic uncertainty, if the morphology is atypical or if confirmation will change management, then skin biopsy for both histopathology and immunofluorescence is useful, ideally from an active lesion.
And histologically, lupus typically shows an interface dermatitis pattern with basal vacuolar change, apoptotic keratinocytes, and often superficial and deep perivascular or periodnexal lymphocytic inflammation with increased dermal mucin.
In discoid lupus, you might also see follicular plugging and basement membrane thickening.
And direct immunofluorescence can help in selected cases, but we do view it as an adjunctive rather than mandatory positive sign, as it isn't always positive.
Has the understanding of the underlying cause of lupus changed in, in the past few years? What, what causes lupus?
I think we don't think there is a single cause, and so lupus seems to occur when the patients have a certain genetic tendency towards autoimmunity and then some sort of environmental trigger that helps set it off, and these trigger can involve a, a variety of things.
So what's well described in the literature are things like, for example, sunlight, uh, infections, particularly viral infections, some medications that we've sort of alluded to with drug-induced lupus, hormonal influence, smoking, and stress is a actually a very common and potent trigger.
What has changed in recent year in our understanding of the immune pathway that drives the disease is that we have a much better understanding or better picture of how the immune dysfunction occurs in both the innate and adaptive immune system, and these two pathway contribute equally to the lupus pathogenesis.
And these also include things like the abnormal activations of immune cells and signaling pathway that sustain inflammations and autoantibody productions.
And there's a, a growing understanding that shift our treatment actually from using broad spectrum immunosuppressants to more sort of targeted therapy that specifically blocks this immune pathway that we have a better understanding for.
Well, there's no one single test that can say, "Yes, this is lupus," in every cases.
Instead, clinician often make the diagnosis by building a picture, bringing together the patient's symptoms, examination findings, blood tests, urine tests, and sometime even biopsy results.
The most common one is the anti-nuclear antibody, the ANA, but there are specific autoantibodies that are also relevant.
And urine and kidney tests are also important because lupus can quietly affect the kidneys without causing a lot of obvious symptoms, and so we do screen for that as well.
So diagnosis is a combination of clinical pattern recognition via history and examination, histopathology, and systemic context in investigations.
So first you need to determine whether the morphology and clinical features fit acute, subacute, or chronic cutaneous lupus, and if there's diagnostic uncertainty, if the morphology is atypical or if confirmation will change management, then skin biopsy for both histopathology and immunofluorescence is useful, ideally from an active lesion.
And histologically, lupus typically shows an interface dermatitis pattern with basal vacuolar change, apoptotic keratinocytes, and often superficial and deep perivascular or periodnexal lymphocytic inflammation with increased dermal mucin.
In discoid lupus, you might also see follicular plugging and basement membrane thickening.
And direct immunofluorescence can help in selected cases, but we do view it as an adjunctive rather than mandatory positive sign, as it isn't always positive.
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