Systemic Diseases and theSkin By: Dr. Kazhan Ali Tofiq Kadir December 2011
The following is a summary ofsystemic diseases mostcommonly encountered inpractice which manifestthemselves by changes in theskin:
hyperlipidaemiaSkin manifestations of hyperlipidaemiainclude: flat yellow deposits around the eye xanthelasma). Elsewhere on the body theypresent as yellowish papules or nodulescalled xanthoma. Sudden eruptions canappear in large numbers over thebuttocks, trunk and limbs, or a few largerlesions can develop on theelbows, knees, hands and over the Achillestendon.
Gastrointestinal disease Inflammatory bowel diseaseThis can include pyoderma gangrenosumand erythema nodosum. Oralmanifestations include aphthousstomatitis, mucosal nodularity(cobblestoning) and pyostomatitisvegetans erythematous thickened mucosa(.
Carcinoid syndromeCutaneous metastases can present asdeep nodules, hyperkeratosis andpigmentation changes similar to thoseseen in pellagra ( Niacin/ Vitamine B 3deficiency).
Diabetes mellitusRecurrent skin infections are common, eitherdue to fungi (e.g. genital candidiasis) or bacteria(e.g. folliculitis). Blisters on the feet may befound as granuloma annulare. when theseblisters develop the condition is called bullosisdiabeticorumBrown macules sometimes develop on the shinNecrobiosis lipoidica diabeticorum can also occuron the shins. The lesions have the appearanceof plaques with dark red or purplewe on the surface. edges, atrophic centres and
Liver diseaseThe cutaneous manifestationscharacteristically includeJaundiceErythema of the palmsPurpuraSpider naeviGeneralised itchingLichen planus is known to be linked tohepatitis C infection.
Human immunodeficiency virus/acquiredimmunodeficiency syndromeA variety of skin conditions can occur inhuman immunodeficiency virus(HIV)/acquired immunodeficiencysyndrome (AIDS)
Dermatitis•The appearance can resemble psoriasis ReitersDisease or seborrheic dermatitis and has beentermed psoriasiform dermatitis of AIDSInfectionsBacillary angiomatosis is a treatableinfection caused by a rickettsia-likeorganismViral infections such as chronic herpeszoster can also occur
Malignancy•Kaposis sarcoma is an AIDS-definingillness characterized by initial bruise-like macules developing into brown-red or purple firm-to-hard nodules. InAIDS these are widespread, especiallyon the face and trunk.
SarcoidosisSarcoidosis can present with erythemanodosum, or with plaques, papules ornodules. The latter are commonly seen assmooth, dark brown/violaceous lesionsarranged in an annular pattern. Infiltration ofan old scar is characteristic so that itbecomes brightly purple coloured. Lupuspernio is a slowly developing form thatspreads into large areas of plaque on thechin and nose thatresults usually in clear deformity.
MastocytosisThis is a condition in which there isproliferation of mast cells. In the skin it cancause single or multiple, dark red nodulesor plaques that develop into a blister orwheal when rubbed. This is commonest inbabies. It can also cause urticariapigmentosa either as skin wheals in infancyoften following a bath, or extensive areas ofdark brown macules that swell and go redwhen stroked in adults.
AmyloidosisAmyloidosis appears in middle age withbruising petechiae and purpura related todeposition of amyloid in the dermal bloodsupply. This is most frequently seen in theanogenital, periorbital and peri-umbilicalregions, at the side of the neck and in theaxillae. Atrophic waxy lesions with areas ofpurpura inside them may sometimes beseen, or as shiny smooth firm flat toppedpapules of waxy colour.
The tips of the fingers may exhibitsoftening and loosening of the skin. Acase of advanced primary amyloidosispresenting as a non-healing leg ulcerhas also been reported.
Cutaneous amyloidosis isassociated with variousautoimmune/immune disordersand associations with sarcoidosisand IgA nephropathy have beenreported.
AcromegalyCutaneous changes in acromegalycan include skin puffiness, oily skinwith largepores, hypertrichosis pigmented skintags, acanthosis nigricans andpsoriasis. Skin creases in the headarea are deeper than normal (cutis head verticis gyrata or ‘ Klingon
HypopituitarismThe skin is dry, scaly and puffy and thenails become brittle. The hair is coarseand sparse, especially in the axillae.Fine wrinkles around the eyes andtypical. mouth are
HypothyroidismThe skin in myxoedema is cool to thetouch, doughy, dry and puffy and theremay be hair loss. Peri-orbital oedemamay be accompanied by a yellowishcolour to the skin.
HyperthyroidismThe skin in thyrotoxicosis is theobverse of that seen in myxoedema. Itis warm and moist and flushing of theface and palms is sometimes seen.Pre-tibial myxoedema is characteristic.
Cushings syndromeAbdominal striae may be a prominentfeature, caused by skin atrophy. Theskin may bruise easily and skininfections and acne may be frequentproblems. Skin darkening may occurin the palmar creases, on areassubject to pressure and the axillae.
PorphyriaThere are a number of different forms ofporphyria, e.g. porphyria cutaneatarda, erythropoietic porphyria. All arecharacterized by photosensitivity, withfragility and blistering of the skin whenexposed to sunlight or ultravioletrays.
Rheumatoid arthritisRheumatoid nodules - subcutaneouslumps seen near an affected joint –in about 25% of the patients. occurThe phenomena include thinning ofthe skin, translucency of the skin onthe back of the hands, brittle nailswhich split lengthwise and reddened palms erythema).
Dermatitis in which neutrophils areprominent on biopsy neutrophilicdermatosis may present aserythematous areas, and interstitialgranulomatous dermatitis is a rarecondition in which rheumatoid papulesmay appear on the trunk. Cutaneousvasculitis may present as purpuricareas on the skin.
Reiters diseaseKeratoderma blennorrhagicum issometimes seen in this condition. It ischaracterised by hyperkeratotic lesions onthe palms of the hands or the soles of thefeet. Clear vesicles on an erythematousbase develop which then progress tomacules, papules and nodules. The lesionsmay be impossible to distinguish frompustular psoriasis.
Myelodysplastic syndromeVarious cutaneous manifestations canoccur including leukaemiacutis, photosensitivity, prurigo nodularis andpurpura. Cutaneous conditions are thoughtto indicate that the patient belongs to ahigh-risk group, associated with bonemarrow transformation andhypergammaglobulinaemia.