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Clin Rheumatol. 2019 Sep;38(9):2541-2546. doi: 10.1007/s10067-019-04536-y. Epub 2019 Apr 24.

Malar rash is a predictor of subclinical airway inflammation in patients with systemic lupus erythematosus: a pilot study.

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Department of Transplant and Medico-Surgical Physiopathology, University of Milan Dermatology Unit, IRCCS Fondazione Ca' Granda, Ospedale Maggiore Policlinico, Via Pace 9, 20122, Milan, Italy.
Young Dermatologists Italian Network (YDIN), Centro Studi GISED, Bergamo, Italy.
Clinical Dermatology, IRCCS Galeazzi Orthopedic Institute, Milan, Italy.
Department of Biomedical, Surgical and Dental Sciences, University of Milan, Milan, Italy.
Department of Transplant and Medico-Surgical Physiopathology, University of Milan Dermatology Unit, IRCCS Fondazione Ca' Granda, Ospedale Maggiore Policlinico, Via Pace 9, 20122, Milan, Italy.
Department of Biomedical and Clinical Sciences (DIBIC), University of Milan Pulmonary Unit, Luigi Sacco University Hospital, ASST Fatebenefratelli-Sacco, Milan, Italy.
Department of Dermatology, University of Tartu, Tartu, Latvia.
Department of Mathematics and Geoscience, University of Trieste, Trieste, Italy.
St. George's University School of Medicine, St. George's, West Indie, Grenada.
Rheumatology Unit, Luigi Sacco University Hospital, Milan, Italy.
Rheumatology Unit, Department of Internal and Experimental Medicine, University of Messina, Messina, Italy.
Padeh and Ziv Hospitals, Azrieli Faculty of Medicine, Bar-Ilan University, Ramat Gan, Israel.
Section of Musculoskeletal Disease, NIHR Leeds Musculoskeletal Biomedical Research Unit, Leeds Institute of Molecular Medicine, University of Leeds, Leeds, England.
School of Public Health, Department of Health Sciences (DISSAL), University of Genoa, Genoa, Italy.
Department of Medicine 'B', Sheba Medical Center, Tel-Hashomer and Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.
Chapel Allerton Hospital, Leeds, LS7 4SA, UK.
Department of Internal Medicine, University of Brescia, Brescia, Italy.



Systemic lupus erythematosus (SLE) is a chronic, auto-immune, multi-organ disease that can affect both the skin and the lungs. Malar rash is a common skin manifestation of SLE and is linked to SLE disease activity, whereas lung involvement is a generally negative prognostic factor for these patients. However, a sensitive and non-invasive screening tool for potential lung involvement in SLE patients is still not available.


This study aimed to investigate the relationship between malar rash and airway inflammation in adult SLE patients who were not known to have any lung involvement (clinical or radiologic). The study comprised of the measurement of the concentration of NO in exhaled breath or fraction of exhaled nitric oxide (FeNO) and levels were compared between those with and without malar rash. This tool is considered as a sensitive and non-invasive method that is routinely used in patients with asthma or other respiratory diseases to identify airway inflammation.


A total of 125 patients (100 females, 25 males) were enrolled during the study period from January 2011 to December 2014. Patients with malar rash (N = 35) had a significant decrease in serum levels of C4 (p < 0.05) compared to patients without malar rash (N = 90). The mean levels of FeNO in overall patients were 36.44 ± 8.87 ppb. A statistically significant difference in FeNO50 values between patients with malar rash (43.46 ± 6.72 ppb) and without (29.43 ± 3.64 ppb) was found (p < 0.001). FeNO50 values were inversely correlated only with serum C4 (p < 0.01). However, no correlation between FeNO50 values and SLE clinical disease activity scores was found.


The presence of a malar rash may predict sub-clinical airway inflammation in SLE patients. Further prospective studies are needed to confirm the usefulness of FeNO measurements in monitoring SLE-associated airway inflammation.


Airway inflammation; FeNO; LFA-REAL; Malar rash; Systemic lupus erythematosus

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