Highlighting Clinical Pearls in Dermatology Through the Eyes of a Rheumatologist

During the 2025 Dermatology Education Foundation (DERM) NP/PA CME Conference in Las Vegas, rheumatologist Karim Ladak, MD, presented a fast-paced session titled ‘Rheum with a View: A Look at Dermatology Pearls through the Eyes of a Rheumatologist,’ highlighting a variety of clinical pearls for clinicians in dermatology.

Ladak, known for his role as a rheumatologist and as a Clinical Assistant Professor at McMaster University, grounded his talk in real-world insights and case-based teaching. Ladak focused on the diagnosis and management of cutaneous lupus erythematosus (CLE), a photo-sensitive skin manifestation of systemic lupus erythematosus (SLE). He highlighted not pharmacologic means to address CLE.

“Photo protection is essential,” Ladak said. “These are photo-sensitive lesions, number one. Number two, smoking cessation [will help]. We find that a lot of patients with active cutaneous lupus are smokers. If you get them off their cigarettes or help support them to quit, the level of disease activity will fall as well."

The third non-pharmacologic intervention, Ladak noted, applies to everybody with cutaneous lupus: vitamin D supplementation.

"There was one trial in 2014 in Spain," Ladak explained. "It was a small study of individuals with cutaneous lupus who are vitamin D deficient…What they found was that when they [increased] the vitamin D level, it helped control the immune system better, which makes sense if you look at other fields in medicine.”

Ladak clarified that CLE can present in isolation or as part of systemic disease. He noted that only 15% of patients with cutaneous lupus will go on to develop systemic lupus, though he also emphasized that risk stratification is crucial. CLE is most common in women of childbearing age and tends to be more prevalent and severe in women of color, Ladak noted.

He broke CLE down into a set of 3 main subtypes—acute, subacute, and chronic—all of which Ladak highlighted are united by photo-sensitivity and the shared histologic feature of interface dermatitis. This is a pattern of inflammation seen in patients.

Regarding acute cutaneous lupus, Ladak described this subtype as including the classic malar or "butterfly" rash, typically impacting patients’ cheeks and bridge of the nose while sparing the nasolabial folds. Ladak noted that these lesions typically heal without scarring or discoloration and are strongly associated with systemic disease.

In his discussion of subacute cutaneous lupus, Ladak highlighted this subtype as photo-sensitive, manifesting as either annular or papulosquamous lesions, which may resemble psoriasis or eczema. Ladak went on to say that it favors sun-exposed areas such as the shoulders, torso, and neck, but typically spares the face. Lesions are known to heal with depigmentation but not scarring. He added that around 50% of subacute cases may evolve into systemic lupus, although the systemic involvement is usually mild. Approximately a third of subacute cases, Ladak commented, are drug-induced and are more common among older males. Prompt discontinuation of the offending drug within 3 months typically stops additional lesion development.

In his discussion of chronic cutaneous lupus, Ladak noted that this most common and severe subtype of CLE will frequently appears as discoid lesions. These are scarring and can result in permanent hair loss. He added that chronic lesions often involve the scalp, face, neck, and ears. Despite the severity of skin involvement, Ladak explained that progression to systemic lupus is uncommon.

With regard to treatment, inflammation was described by Ladak as a "fire" that needs to be extinguished and then kept at bay. He highlighted that topical or systemic corticosteroids are first-line therapies for those facing acute flares, noting that potent topical steroids may be used cautiously on the face to prevent permanent damage from chronic lesions.

Long-term maintenance often includes antimalarials, particularly hydroxychloroquine, which Ladak noted can be both effective and well-tolerated. To screen for progression to systemic lupus, Ladak expressed that clinicians may ask patients about joint pain, fatigue, and oral or nasal ulcers. These questions help capture early signs of systemic involvement.

Finally, for monitoring progression to systemic lupus, Ladak shared four screening questions: "Ask about joint pain, dry eyes or mouth, fatigue, and ulcers. You’ll capture most evolving SLE that way."

Ladak’s dynamic session left attendees with memorable takeaways and a practical framework for recognizing and managing CLE across the condition’s spectrum.

For any further information on Ladak’s session, as well as other clinical pearls highlighted at the meeting, view our latest conference coverage.

The quotes in this interview summary were edited for clarity.