What Is Lupus (SLE)?
Systemic Lupus Erythematosus (SLE), commonly called Lupus, is a chronic autoimmune disease in which the immune system attacks multiple organs simultaneously — including skin, joints, kidneys, brain, heart, and lungs. It is unpredictable, fluctuating between flares (active disease) and remissions.
In India, lupus predominantly affects young women aged 15–45, often during their reproductive years. The disease is more severe in Indian and Asian patients compared to Caucasian populations, with higher rates of kidney involvement (lupus nephritis).
Symptoms of Lupus
Lupus is called “the great imitator” because it mimics many other diseases. Symptoms vary widely between patients:
- Butterfly (malar) rash — a red rash across both cheeks and the nose bridge, worsened by sunlight. Present in ~50% of patients.
- Joint pain and swelling — usually non-erosive (joints don’t get damaged as in RA)
- Photosensitivity — sun exposure triggers rashes and flares
- Oral ulcers — painless ulcers in the mouth
- Hair loss — diffuse hair thinning during flares
- Fatigue — often the most debilitating symptom
- Kidney involvement — dark/foamy urine, leg swelling, high blood pressure
- Serositis — pleurisy (chest pain on breathing) or pericarditis (heart sac inflammation)
- Neurological symptoms — headaches, seizures, cognitive fog
Red Flag Symptoms — See a Rheumatologist Immediately
- Butterfly rash on face after sun exposure
- Dark, foamy, or cola-coloured urine (may indicate lupus nephritis)
- Severe leg swelling
- Persistent unexplained fever with joint pain
- Chest pain on breathing
- Sudden neurological symptoms — confusion, seizures
Diagnosing Lupus
Diagnosis requires meeting criteria from the 2019 EULAR/ACR classification system — a combination of clinical features and blood tests:
- ANA (Anti-Nuclear Antibody) — the entry criterion. Present in 95–99% of SLE patients. However, ANA is also positive in 5–15% of healthy individuals — a positive ANA alone does NOT mean lupus.
- Anti-dsDNA antibody — specific for lupus; levels correlate with disease activity, especially kidney involvement
- Anti-Sm antibody — highly specific for lupus
- Complement levels (C3, C4) — low during active lupus
- CBC — anaemia, low white cells (lymphopenia), low platelets are common
- Urine analysis and 24-hour urine protein — to screen for kidney involvement
- Antiphospholipid antibodies (aPL) — associated with clotting complications
Lupus Nephritis — The Most Serious Complication in India
Lupus nephritis (kidney inflammation) occurs in 50–60% of Indian lupus patients — higher than in Western populations. It can lead to kidney failure if untreated. Every lupus patient must have regular urine tests and kidney function monitoring. Signs include: protein in urine, blood in urine, leg swelling, and rising creatinine.
Treatment of lupus nephritis requires immunosuppressants such as mycophenolate mofetil (MMF) or cyclophosphamide, combined with steroids.
Treatment of Lupus
Hydroxychloroquine — The Foundation Drug
Hydroxychloroquine (HCQ/Plaquenil) is prescribed to virtually all lupus patients. It reduces flares, prevents organ damage, reduces clotting risk, and improves long-term survival. It is safe during pregnancy. Annual eye examination is needed after 5 years of use.
Steroids
Prednisolone is used to control flares. The goal is to use the minimum effective dose — chronic high-dose steroids cause bone loss, diabetes, weight gain, and infections. Your rheumatologist will taper steroids as other drugs take effect.
Immunosuppressants
For organ-threatening lupus: azathioprine, mycophenolate mofetil (MMF), and cyclophosphamide are used. These require regular monitoring.
Biologics for Lupus
Belimumab (Benlysta) is approved for lupus. It reduces flares and allows steroid tapering. Available in India but expensive. Anifrolumab is a newer option.
Sun Protection Is Non-Negotiable in Lupus
Sun exposure (UV radiation) triggers lupus flares. In sunny India, this is especially important:
- Use SPF 50+ broad-spectrum sunscreen daily, even on cloudy days
- Wear full-sleeve clothing and a hat outdoors
- Avoid peak sun hours (10am–4pm) when possible
- Use UV-protective window film in your car and home
Lupus and Pregnancy
Women with lupus can have successful pregnancies. Planning is critical: lupus should be in remission for 6 months before conception. Hydroxychloroquine is safe and should be continued. Methotrexate and MMF must be stopped months before conception. Antiphospholipid antibodies increase miscarriage risk and need specific management with aspirin and heparin.
Myth: Women with Lupus Cannot Have Children
This is false. With proper planning and a rheumatologist supervising the pregnancy, most women with well-controlled lupus have healthy babies. The key is planned pregnancy — not accidental.
Frequently Asked Questions About Lupus in India
Is a positive ANA test always lupus?
No. ANA is positive in many conditions including thyroid disease, other autoimmune diseases, infections, and even in 5–15% of healthy people. Lupus requires multiple criteria beyond just a positive ANA.
Can lupus be cured?
No permanent cure exists, but remission is achievable. Many patients have minimal disease activity for years with appropriate treatment.
Does stress trigger lupus flares?
Yes. Physical stress (infections, surgery) and psychological stress can trigger flares. Stress management is a legitimate part of lupus management.
Written by Dr. Keerthivardhan, Assistant Professor, Clinical Immunology & Rheumatology, NIMS Hospital Hyderabad.