Ultraviolet light exposure from manicures in cutaneous lupus erythematosus

Rheumatology key message

• Ultraviolet light exposure from nail salon drying techniques can cause periungual cutaneous lupus erythematosus lesions.

Dear Editor, Ultraviolet (UV) light is a trigger of both SLE and cutaneous lupus erythematosus (cLE) [1]. Ultraviolet A (UVA) (320–400 nm) waves penetrate deeper than ultraviolet B (UVB) (290–320 nm) waves, and physiologic doses of UVA have been shown to induce pathologic cutaneous reactions in SLE patients [1]. In particular, UVA2 is thought to be harmful, while low-dose UVA1 shows some protective effects and is used in lupus treatments [2]. Nail lamps used in salons are predominantly comprised of UVA wavelengths and produce 4–54 W of power [3]. UV exposure from nail salon techniques may be an under-examined factor in the cLE disease course. Lamps emitting UV radiation have become commonplace in many salons as they are regularly used to speed the drying of regular polish manicures and are required to set certain varnishes, such as gel manicures.

Here, we present two patients who developed new periungual cLE lesions after having gel manicures dried under UV nail lamps. The first patient was a 35-year-old South Asian female with a history of SLE and DLE diagnosed 12 years prior with manifestations including oral ulcers, arthritis, photosensitivity, leukopenia and thrombocytopenia, and positivity for the following serologies: ANA, dsDNA, SSA and RNP (Fig. 1). Her treatment included 250 mg of chloroquine three times per week, 0.6 mg colchicine daily, 3000 mg of MMF daily and clobetasol 0.05% ointment. The second patient was an 40-year-old African American female with a history of SLE and DLE diagnosed 4 years prior with manifestations including lymphopenia, proteinuria, and arthritis of the wrists, hands and feet, and positivity for the following serologies: high-titer ANA 1:2560 and dsDNA antibody. The patient was being treated with 400 mg of HCQ daily, 100 mg of AZA daily and 6 mg of methylprednisolone daily, and topical steroids including pimecrolimus 1% cream, triamcinolone 0.1% ointment and clobetasol 0.05% ointment. Both patients had been receiving manicures for several years approximately once every 1–2 months. The first patient did not notice lesions on her hands until she underwent 6 months of regular gel manicures with a possible cumulative effect. The second patient noticed new erythema on her hands approximately a week after a gel manicure. Of note, although RNP antibodies can cause periungual lesions, our patient’s hand lesions were significantly exacerbated by receiving gel manicures. Biopsies and laboratory testing were not performed on either patient, due to high clinical suspicion of photo-induced cLE. The cLE lesions of both patients resolved over several weeks, as was the typical course for their cLE lesions at other sites.

Fig. 1.

New periungual cutaneous lupus erythematosus lesion following use of ultraviolet light during gel manicure in patient 1

Light has been implicated in the development of lupus erythematosus lesions with use of other common light sources such as dental or surgical lights [4]. Non-melanoma skin cancer has also been linked with UV nail lamps [3]. Both occupational and recreation-associated sources of UV light should be considered as exposures that may exacerbate cLE skin lesions. Standard varnish manicures using air-blowing fans for drying and adhesive patterned nail strips are good alternatives to UV-drying based polishes for this population. If patients are unwilling to forgo gel and acrylic manicures in favour of options that do not involve UV light, gloves and 100 SPF sunscreen on the hands, especially around the nails, should be recommended by dermatologists. Some gloves such as those manufactured by Coolibar can block ∼98% of UVA and UVB radiation; however, the fingerless styles used for manicures still leave the periungual area exposed. Clinicians should be aware of this phenomenon, and counsel their patients accordingly.

Funding: This study received funding from the United States Department of Veterans Affairs (Veterans Health Administration, Office of Research and Development and Biomedical Laboratory Research and Development) and National Institute of Health [R01AR076766] (to V.P.W.).

Disclosure statement: The authors have declared no conflicts of interest.

Data availability statement

Data are available upon reasonable request by any qualified researchers who engage in rigorous, independent scientific research, and will be provided following review and approval of a research proposal and Statistical Analysis Plan (SAP) and execution of a Data Sharing Agreement (DSA). All data relevant to the study are included in the article.