Cutaneous manifestations of internal diseases


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  • Highly purified or recombinant insulins have a reduced allergy prevalence (0.1-0.2%) (4)Observe the patient’s technique to make sure it isn’t intradermalTreatment includes substitution of a more purified insulin, discontinuation or desensitization for severe systemic rxns
  • In addition to having the general skin signs of hyperthyroidism described above, patients of grave’s disease may have the distinctive findings of grave’s dermopathy and thyroid acropachy.These patients can have all of the other previously mentioned cutaneous manifestations of hyperthyroidism in addition to several unique entities
  • Skin changes in hypothyroidism reflect a hypometabolic state and subsequent reduced core body temperature results in cutaneous vasoconstriction.
  • Thyroid hormone replacement therapy rapidly reverses many of the cutaneous features of hypothyroidism, with gradual dissappearance of excessive dermal mucopolysaccaharides
  • Herpes gestationisBullouspemphigoidDermatitis herpetiformis
  • Cutaneous manifestations of internal diseases

    2. 2. CUTANEOUS MANIFESTATIONS Diabetes Mellitus  Thyroid disease  Adrenal disease  Renal Disease  Liver disease  Rheumatologic disease  Nutritional disease 
    4. 4. DIABETES MELLITUS approximately 30% of patients with DM develop skin lesions at some point  Overall prevalence of cutaneous disorders does not differ between type I and type II diabetics  Type I patients get more autoimmunetype lesions  Type II patients get more cutaneous infections 
    5. 5. DIABETES MELLITUS   Cutaneous lesions usually appear after the development of DM, but may be the first presenting sign Four major groups of skin findings 1. 2. 3. 4. Skin diseases associated with DM Cutaneous infections Cutaneous manifestions of diabetic complications Skin reactions to diabetic treatment
    6. 6. NECROBIOSIS LIPOIDICA (NL) NL is 3x more common in women.  NL appears earlier (mean age 22) in Type I diabetics than Type II (mean age 49.)  Appearance       Begins as an oval, violaceous patch and expands slowly. Advancing border is red. Central area turns yellowish brown. Central area atrophies and telangiectasia become evident. 13% of cases progress to ulceration
    7. 7. NECROBIOSIS LIPOIDICA (NL) Classically, NL occurs bilaterally on the pretibial or medial malleolar areas.  Not painful.  Spontaneous resolution occurs in 13-19% with residual scarring. 
    8. 8. GRANULOMA ANNULARE (GA)  Appearance Ring of small, firm, flesh-colored or red papules  If localized, most frequently found on lateral and dorsal surfaces of hands and feet  Can spontaneously regress without scarring 
    9. 9. DIABETIC BULLAE  Approximately 0.5% of diabetics  Two types have been described  More frequent, non-scarring lesions with a histologic intraepidermal split without acantholysis  Less common, occasionally hemorrhagic bullae that heal with scarring, slight atrophy, and have a histologic subepidermal split o  Trauma and microvascular disease may play a role Appearance  Painless bullae on non-inflamed base that appear suddenly  Most common on the dorsa and sides of lower legs and feet, sometimes with similar lesions on the hands and forearms  Bullae contain clear, sterile fluid
    10. 10. DIABETIC BULLAE   Bullae tend to heal spontaneously in 2-5 weeks diagnosis of exclusion  DDx: bullous pemphigoid, epidermolysis bullosa acquisita, porphyria cutanea tarda, bullous impetigo, erythema multiforme  May recur in the same or new locations
    11. 11. ACANTHOSIS NIGRICANS Seen in situations of insulin resistance  Besides in DM, also seen in the following:        Carcinomas, especially of the stomach Secondary to drugs (nicotinic acid, estrogen, or corticosteroids) Pineal tumors Other endocrine syndromes (PCOS, acromegaly, Cushing‟s disease, hypothyroidism) Obesity Pathogenesis  it may be related to insulin binding insulin-like growth factor receptors on keratinocytes and dermal fibroblasts, thus stimulating growth.
    12. 12. ACANTHOSIS NIGRICANS  Appearance Hyperpigmented, velvety plaques in body folds, mostly axillae and neck  Can also present on groin, umbilicus, areolae, submammary areas, and on the hands 
    13. 13. SKIN INFECTIONS IN DM Occur in 20-50% of poorly controlled diabetics  More common in Type II  May be related to  Abnormal microcirculation   Hypohidrosis  PVD  Neuropathy  Decreased phagocytosis and killing activity  Impaired leukocyte adherence  delayed chemotaxis
    14. 14. CANDIDIASIS IN DIABETICS Fungal infections- most common  Candida  Candidial paronychia  Inframammary candida  Genital candida  Oral candidiasis  White, curdlike material adherent to erythematous, fissured oral commisure;  angular stomatitis 
    15. 15. CANDIDIASIS IN DIABETICS  Initial pustules on erythematous base that become eroded and confluent
    17. 17. SKIN INFECTIONS IN DM Bacterial Infections- can be more severe and widespread in diabetics  Malignant otitis externa  Pseudomonas aeruginosa  Fatal in over 50% patients  Can progress to chondritis, osteomyelitis, and bacterial meningitis 
    18. 18. SKIN INFECTIONS IN DM Bacterial infections in DM  Erythrasma  Sharply demarcated erythematous patches  upper inner thighs, axillae, toe web spaces, and inframammary creases  Gram positive Corynebacterium minutissimum  Identified with Wood‟s light coral fluorescence 
    19. 19. DIABETIC ERUPTIVE XANTHOMAS Seen in uncontrolled diabetes, hypertriglyceridemi a  Sudden crops on firm, non-tender yellow papules with a red rim on extensors  Control of glucose and lipid reduction reduce the lesions 
    20. 20. DIABETIC DERMOPATHY  AKA “shin spots” or pigmented pretibial papules  Most common cutaneous manifestation of diabetes  Benign asymptomatic red brown macules on shins  No treatment needed
    21. 21. CUTANEOUS MANIFESTATIONS OF DIABETIC COMPLICATIONS: FOOT ULCERS Peripheral neuropathy leads to unnoticed trauma  Vascular complications may lead to ulcers and complicate ulcer healing  Risk of amputation goes up 8x once these develop 
    22. 22. CUTANEOUS REACTIONS TO DIABETIC TREATMENT Insulin  Allergy may be local or systemic and usually occurs within the first month of therapy  Erythematous or urticarial pruritic nodules at the site of injection  Lipoatrophy can also occur  Circumscribed depressed areas of skin at the insulin injection site 6-24 months after starting insulin  More common in women and children  Lipohypertrophy can also occur  Soft dermal nodules that resemble lipomas at sites of frequent injection  May be a response to the lipogenic action of insulin  Treat and prevent by rotating sites of injection
    23. 23. CUTANEOUS REACTIONS TO DIABETIC TREATMENT-ORAL HYPOGLYCEMICS  Most rxns are associated with the first-generation sulfonylureas (chlorpropamide and tolbutamide)  1-5% of patients on these drugs will develop skin rxns during the first 2 months of treatment  Most commonly, they present with maculopapular eruptions that resolve despite continuation of the drug.
    24. 24. THYROID DISEASES Graves disease Hyperthyroidism Hypothyroidism
    25. 25. THYROID HORMONE AND THE SKIN  Thyroid hormone plays a pivotal role in the growth and formation of hair and sebum production.  Thyroid hormone stimulates epidermal oxygen consumption, protein synthesis, mitosis, and determination of epidermal thickness.  There is increased cutaneous blood flow and peripheral vasodilation.
    26. 26. HYPERTHYROIDISM AND THE SKIN Skin is usually warm, moist, and smooth (best assessed on the inner aspect of arm and over the chest)  Facial flushing  Palmar erythema  Hyperpigmentation, esp. creases of palms and soles  (buccal pigementation doesn’t occur) hair is fine and friable, hair loss may be excessive  History of early graying  Hyperhydrosis, particularly of palms and soles 
    27. 27. PLUMMER‟S NAIL IN HYPERTHYROIDISM “Plummer‟s nail”: concave contour and distal onycholysis, esp. the ring finger (not specific- also seen in hypothyroidism, psoriasis, after trauma, or in allergic contact dermatitis)
    28. 28. SCLEROMYXEDEMA IN HYPERTHYROIDISM  Numerous firm white, yellow, or pink papules on face, trunk, axillae, and extremities  Lesions result from accumulation of hyaluronic acid in the dermis, accompanied by large fibrocytes
    29. 29. SCLEROMYXEDEMA IN HYPERTHYROIDISM Firm white, yellow, or pink papules on face, trunk, axillae, and extremities
    30. 30. SCLEROMYXEDEMA IN HYPERTHYROIDISM Firm white, yellow, or pink papules on face, trunk, axillae, and extremities
    31. 31. GRAVES‟ DERMOPATHY  Pretibial myxedema (0.5-4% of patients)  Late manifestation, accompanied by ophthalmopathy in 99%.  Presentation varies from “peau d‟orange” appearance to extensive infiltration.  Most often, bilateral, asymmetric, raised, firm plaques or nodules varying from pink to brown, sometimes with woody induration Pathogenesis :pretibial fibroblasts are the  Can appear anywhere (arms, shoulders, target for antithyroid antibodies T cells may be interacting with a head). dermal antigen similar to a thyroid  Histologically, the process involves autoantigen, with cytokines dermal accumalation of hyaluronic acid. subsequently activating fibroblasts to secrete hyalouronic acid. Can treat with topical steroids, intralesional steroids, IV pulse steroids, or IVIG
    32. 32. THYROID ACROPACHY IN GRAVES‟ DISEASE •Thyroid acropachy (1% of Graves‟ patients). •Triad of digital clubbing, soft tissue swelling of hands and feet, and periosteal new bone formation •Usually accomapanied by exophthalmos and dermopathy (diamond triad) •May occur in hashimioto‟s thyroiditis and hurtle cell adenocarcinoma.
    33. 33. HYPOTHYROIDISM AND THE SKIN  Skin is cool, dry, and pale.        Pallor results from cutaneous vasoconstriction and increased deposition of water and mucopolysaccharides in the dermis, which alter the refraction of light Hypohydrosis may lead to palmoplantar keratoderma (possibly along with reduced epidermal steroid synthesis) Carotenemia (from decreased hepatic conversion of beta carotene to Vit A) gives skin yellowish hue (palms, soles, +nasolabial folds) Hair: dry, brittle, coarse; partial alopecia Loss of hair from lateral 1/3 of eyebrows (lateral superciliary madarosis) Hertog’s sign Hair growth slows down, the proportion of telogen hair is increased. These changes normalise with normalization of thyroid hormone levels.
    34. 34. HYPOTHYROIDISM AND THE SKIN Nails are brittle, grow slowly, purpura  Easy bruising  Wound healing is impaired.  Diminished levels of clotting factors may manifest as purpura. 
    35. 35. HYPOTHYROIDISM FACIES WITH GENERALIZED MYXEDEMA   Generalized myxedema Characteristic skin sign      Occurs as a result of deposition of PAS-positive dermal acid mucopolysaccharides (esp. hyaluronic acid and chondroitin sulfate) in the skin Skin is non-pitting, with a firm waxy appearance Characteristic facies: swollen lips, broad nose, macroglossia, and puffy eyelids Also apparent on the dorsa of hands and feet and in the supraclavicular fossa Carpal tunnel syndrome and facila nerve palsy may occur owing to nerve entrapment
    36. 36. CONGENITAL HYPOTHYROIDISM (CRETINISM) Myxodema  Yellowing (carotenemia or prolonged jaundice)  Pronounced clavicular fat pad  Coarse, dry, brittle hair with patchy alopecia  Persistent, long, lanugo hair on the upper back, shoulders, and extremities  Hypothermia  Reflex peripheral vasoconstriction may accentuate cutis marmorata  Poor nail growth  Delayed eruption of deciduous teeth  Retardation of mental and physical development  Delayed milestones 
    37. 37.  Thyroid replacement therapy rapidly reverses many of the cutaneous features of hypothyroidism, with gradual disappeaarance of excessive dermal mucopolysaccharides.
    38. 38. ASSOCIATION BETWEEN CUTANEOUS AND THYROID DISEASE  Vitiligo (higher levels of antithyroid peroxidase, antithyroid microsome, anti-TSH)  Connective tissue diseases  Dermatomyositis, SLE, scleroderma, polymyositis, sjogren‟s syndrome.  Generalised granuloma annulare, reticular erythematous mucinosis Chronic urticaria Melasma Chronic mucocutaneous candidiasis MEN syndromes      Patients with idiopathic chronic urticaria and/or angiodema should therefore be screened for thyroid autoimmunity
    39. 39. ASSOCIATION BETWEEN CUTANEOUS AND THYROID DISEASE CONTD.  ALOPECIA AREATA  Rapid onset of total hair loss in a sharply defined, usually round, area  Regrowth begins in 1 to 3 months and may be followed by loss in the same or other areas
    40. 40. ASSOCIATION BETWEEN CUTANEOUS AND THYROID DISEASE CONTD.  Pemphigus foliaceus Herpes gestationis Bullous pemphigoid Dermatitis herpetiformis  Pemphigus vulgaris
    41. 41. ADRENAL DISEASE Addison’s disease Hypercortism
    42. 42. ADRENAL INSUFFICIENCY    Increased stimulation of melanocortin-2 receptor by ACTH itself Pigmentation is maximal over photoexposed areas, mucuos membranes, palmar creases, areas subject to friction, genitalia, areola, axillae, perineum as well as in scars. Nails-longitudinal melanonychia
    43. 43. HYPERCORTISM            Truncal obesity Buffalo hump Moon facies Slender limbs Cutaneous atrophy and telangiectasias Fragility with purpura Poor wound healing Acneform eruptions Hirsuitism Cigarette paper like wrinkling of skin on dorsum of hands(liddle‟s sign) Livid, purplish straie on abdomen, breasts, proximal part of limbs
    44. 44. RENAL DISEASES    Signs of ESRD Signs associated with dialysis Signs in renal transplant patients
    45. 45. CUTANEOUS MANIFESTATIONS OF UREMIA  Xerosis  Pruritus  Pigmentary alteration  Nail Changes  Hair Changes  Acquired perforating disorder  Bullous disease of dialysis  Calcinosis cutis (metastatic)  Calciphylaxis  Nephrogenic systemic fibrosis
    46. 46. XEROSIS     Most common cutaneous abnormality Is predominantly seen over the extensor surfaces of the forearms, legs and thighs. The abdomen and chest may show fine scaling Hypervitaminosis A, reduction in size of eccrine sweat glands, high dose diuretic regimens are some of the causes of xerosis
    47. 47. UREMIC PRURITUS   Incidence is 50-90% Usually on forarms, back  Cutaneous manifestations of pruritus include excoriations, prurigo nodularis and lichen simplex chronicus      Decreased transepidermal elimination of pruritogenic factors Hyperparathyroidism Hypercalcemia Hyperphosphatemia Elevated histamine levels    o   o      Topical Moisturizing creams Capsaicin Physical treatments UVB light parathyroidectomy Systemic medications Sedating Antihistamines Cholestyramine Alternative strategies Acupuncture homeopathy
    48. 48. PIGMENTARY CHANGES PURPURA/ECHHYMOSIS   Pallor – Anemia  Yellow hue – Carotenoids and nitrogenous pigments (urochromes) in the skin.  Brown-black Hyperpigmentation -  Sunexposed areas  can be attributed to retention of chromogens and deposition of melanin in the basal layer and superficial dermis due to failure of kidney to excrete betamelanocyte stimulating hormone  Sunscreens, sun avoidance measures and clothing are advised for these pigmentary changes.    Defects in primary hemostasis like increased vascular fragility Abnormal platelet function Use of heparin during dialysis are the main causes of abnormal bleeding in these patients Dialysis treatment partially corrects these changes
    49. 49. CALCIFIC UREMIC ARTERIOLOPATHY (CALCIPHYLAXIS)         Metastatic skin calcification abnormally elevated level of parathyroid hormone (PTH) which may trigger the deposition of crystalline calcium pyrophosphate in the dermis, subcutaneous fat, or arterial walls. papular or nodular cutaneous lesions around large joints or flexural sites acute thrombosis of calcified vessels. This produces violaceous mottling of the skin that are acutely painful due to ischemia.Surrounding tissue may be inflamed with cellulitis. Lesions often progress to necrosis and gangrene. The condition is associated with a high mortality, particularly when the skin of the trunk is involved. Infectious complications – non healing ulcers
    50. 50. ACQUIRED PERFORATING DERMATOSIS ( APD ) Hyperpigmented papules, up to 1 cm in diameter, with a central keratinous plug in patients of CRF.  The exclusive feature of the perforating disorders is the trans-epidermal elimination of altered dermal substances.  The changes are significantly more prevalent in diabetic patients  Excessive scratching + diabetic vasculopathy - dermal necrosis- eliminated through the epidermis  The extensor surfaces of the limbs are more commonly affected but the trunk and face may be involved.  oDistinct from primary perforating disorders Kyrle’s disease Elastosis Perforans serpiginosa Perforating folliculitis Reactive perforating collagenosis
    51. 51. BULLOUS DISEASE OF DIALYSIS  Syndrome of cutaneous fragility and blistering  Sun-exposed skin, most often on the dorsal hands  Resembles Porphyria  Plasma porphyrin levels are normal or only minimally elevated
    52. 52. NEPHROGENIC FIBROSING DERMOPATHY (NFD)  Scleroderma like fibrosing skin condition  Typically, symmetrical skin plaques with a peau d’orange surface and advancing ameboid edges develop on limbs and trunk sparing the head and neck.  Nodules and contractures can be seen in patients with disease of long duration.  Skin biopsy-marked fibrosis
    53. 53. UREMIC FROST     Was a frequent in the predialysis era blood urea nitrogen level of more than 250-300 mg/dl. The concentration of urea in sweat is increased and, after evaporation, there is a deposition of urea crystals on the skin surface. The frost consists of a white or yellowish coating of urea crystals on the beard area and other parts of the face, neck and on the trunk.
    54. 54. NAIL CHANGES   Lindsay's nails (half and half nails, prevalence 30-50 %) Others        Koilonychia Subungual hyperkeratosis Onycholysis Mees’ lines Muehrcke’s lines Splinter hemorrhages Beaus lines Normal to red brown distal half Proximal half opaque white
    55. 55. Yellow nail syndrome (YNS) is triad of yellow nails, lymphedema, and respiratory tract involvement
    56. 56. HAIR ABNORMALITIES  Sparse body hair and diffuse alopecia with dry, lusterless hair  Decreased secretion of sebum  Chronic telogen effluvium  Drugs – Heparin / Statins / Antihypertensives
    57. 57. CUTANEOUS MANIFESTATIONS IN PTS ON DIALYSIS Diffuse hyperpigmentation  Accelerated cutaneous aging     o Actinic elastosis Excessive wrinkling of neck( cutis rhomboidalis nuchae) Telangiectasias Skin infections common
    58. 58. DERMATOLOGIC DISORDERS ASSOCIATED WITH RENAL TRANSPLANTATION.  Drugs – Steroids, Immunosuppresants  Infections     Severe herpes zoster Viral warts and condylomata accuminata are more common later Pityriasis versicolor commonest fungal infection Candidal infections  Malignancies    Kaposi sarcoma- oral cavity, limbs, trunk; associated with edema SCC> BCC Younger age, multiple, extracephalic, HP features of HPV infection, spindle cell morphology is more common Transplant patients should be counselled on minimizing UV light exposure, regular sunscreen use, self screening for skin lesions
    59. 59. LIVER DISEASE Chronic liver disease Hepatitis B,C
    60. 60. CHRONIC LIVER DISEASES Jaundice  Because of raised levels of bilirubin more than 2.5-3.0mg/dl  Diffuse hyperpigmentation 
    61. 61. SPIDER ANGIOMAS/ SPIDER NEVUS/NEVUS ARANEUS       Pinhead to upto 2mm Mostly on skin drained by superior vena cava Central arteriole visible as a red, flat or slightly elevated point surrounded by multiple, small and tortuous radiating capillaries Commoner in alcoholic cirrhosis Presence may indicate an increased risk of bleeding from oesophageal varices Abundant cutaneous spider angiomata –clinical marker of hepatopulmonary syndrome, where circulatory and gas-exchange abnormalities in lungs occur secondary to advanced CLD.
    62. 62. CHRONIC LIVER DISEASES Palmar erythema  Exaggerated mottling or a well defined hypothenar erythema that later spreads to fingers and rest of the palm  gynaecomastia (Because of hyperestrogenemia) 
    63. 63. CHRONIC LIVER DISEASES Pruritus  Recurrent purpura  Xanthoma straitum palmare  (Multiple xanthomas may appear as yellowish plaques covering large areas of skin in palmar creases)
    64. 64. CHRONIC LIVER DISEASES  Ascites leads to striae distensae  dupuytren's contracture
    65. 65. CHRONIC LIVER DISEASES Clubbing  Longitudinal ridging  Thickening  Brittleness  Total leuconychia  terry‟s nails  (whitening of the entire nail plate except for a narrow pink band distally)  Muehrcke‟s nails (multiple parallel transverse white bands  clubbing Terry‟s nails Muehrcke‟s nails
    66. 66. HEPATITIS C Porphyria Cutanea Tarda Lichen Planus Necrolytic acral erythema
    67. 67. PORPHYRIA CUTANEA TARDA      Vesicles and bullae on sun-exposed areas, scarring with milia Hypertrichosis Fragile skin with sclerodermoid changes Anti HCV antibodies found in upto 2/3rd of cases of these patients HCV serology should be a part of routine investigative work up in patients with PCT
    68. 68. LICHEN PLANUS Variable association of 0.1% to 35%  Associated with LP , especially in mucosal, generalised or long standing LP  Purple, pruritic, polygonal papules 
    69. 69. NECROLYTIC ACRAL ERYTHEMA     Starts as erythematous papules and sometimes blisters that coalesce into well-circumscribed dusky areas with scaling and erosions. Hyperkeratotic surface develops in older lesions Mc site- drsal surface of feet-great toes Spares periorificial areas-d/f with other necrolytic erythemas such as necrolytic migratory erythemas and zinc deficiency
    70. 70. HEPATITIS B About 30% may have Urticaria or present a serum sickness like picture (because of circulating immune complexes)  Associated with 57% cases of Polyarteritis nodosa     Classical PAN Renal vasculitis present ANCA negative
    72. 72. SYSTEMIC LUPUS ERYTHEMATOSUS  Malar erythema  Discoid plaques or psoriasiform erythroderma  Photosensitivity, alopecia and mucosal ulcers  Raynaud‟s phenomenon  Periungual erythema
    73. 73. MALAR ERYTHEMA
    74. 74. MUCOSAL ULCERS
    75. 75. ALOPECIA
    79. 79. Periungual erythema
    81. 81. HELIOTROPE RASH IN DERMATOMYOSITIS  Heliotrope rash (violaceous erythema) of periorbital skin
    82. 82. DERMATOMYOSITIS  Shawl sign
    85. 85. CRITERIA FOR DIAGNOSIS: SYSTEMIC SCLEROSIS Major criteria: Proximal Scleroderma : Symmetrical thickening, tightening, induration of skin of digits and dorsal hands; may affect entire extremity and involve face and torso Minor criteria: 1. Sclerodactyly: skin changes (above) limited to digits 2. Digital pitted scars or loss of finger pad soft tissue 3. bibasilar pulmonary fibrosis Diagnosis requires 1 major or 2 minor criteria
    86. 86. SCLERODACTLY Sclerodactyly
    88. 88. MASK LIKE bird-like faciesFACIES Smoothening of lines of facial expressions  Pinched nose  Radial furrows around mouth 
    89. 89. Periungual erythema and hemorrhage NAIL FOLD CHANGES Periungual erythema and hemorrhage
    91. 91. HENOCH-SCHÖNLEIN PURPURA vasculitis with arthritis, abdominal pain, and hematuria  mainly affects children  often follows streptococcal infection  In the skin, the disease causes palpable purpura (small hemorrhages)  chronic kidney disease- loss of small amounts of blood and protein in the urine
    92. 92. Henoch-Schönlein purpura
    93. 93. Henoch-Schönlein purpura
    94. 94. PYODERMA GANGRENOSUM  Seen in 10% of ulcerative colitis patients  rapidly expanding ulcer with purple undermined border start as pustules
    95. 95. SWEET‟S SYNDROME Erythematous tender papules,nodules and plaques with marked lesional edema resulting in pseudovesiculation  May occur in pts with inflammatory bowel disease, UC  
    97. 97. CYANOSIS         Capillary concentration of reduced Hb is more than 4g/Dl. Best observed in fulorescent lightening Most prominent in areas with thin vascular surfaces Oral mucosa Lips Earlobes Nail beds Palms and soles in children
    98. 98. CYANOSIS May be  Central (decreased arterial oxygen saturation)     Congenital heart disease Impaired pulmonary function Tongue is the most reliable site for detecting cyanosis. Peripheral (owing to poor blood flow)  Cold exposure  Peripheral vascular disease  Congestive heart failure  Polycytemia  Oral mucosa is often spared in peripheral cyanosis o Mixed  Pulmonary odema  Cardiogenic shock 
    99. 99. CLUBBING Increase in the angle between the proximal nail fold and the nail plate (Lovibond‟s angle)  Due to connective tissue proliferation between the nail matrix and the underlying distal phalanx 
    100. 100. FLUSHING Severe Mitral stenosis  Tumours producing vasoactive sunstances  Carcinoid tumours  Multiple endocrine neoplasia type Iia  Systemic mastocytosis 
    101. 101. CUTANEOUS ASSOCIATIONS OF CORONARY ARTERY DISEASE Xanthomas: localized lipid infiltrates in the dermis or tendons.  Indicative of abnormal lipid profile and risk of coronary artery disease 
    102. 102. INFECTIVE ENDOCARDITIS         Subungual splinter hemorrhages 1-2mm brown streaks under the finger/toe nails Proximal appearance has more diagnostic value Petechiae Osler‟s nodes tender purpuric nodules on the finger pads and toes) Janeway lesions nontender purpuric macules of the palms and soles
    103. 103. RHEUMATIC FEVER  Subcutaneous nodules:  Extensor aspect of elbows and knees Exclusively seen in pts of rheumatic carditis     Erythema marginatum Seen in 10% pts of rheumatic fever Dull red ,flat or palpable, discrete or confluent, annular lesions on the trunk, esp the abdomen and proximal parts of the extremities
    104. 104. CUTANEOUS SIGNS INDICATIVE OF INTERNAL DISEASES oErythema nodosum oAcanthosis oPyoderma oAcquired nigricans gangrenosum ichthyosis oGeneralised pruritus without an eruption
    105. 105. Erythema Nodosum Due to panniculitis (inflammation of the subcutaneous fat) deep, firm, and tender reddish-blue nodules, 1-5 cm diameter Most commonly at calves and shins
    106. 106. Causes of Erythema Nodosum Idiopathic About 20% of cases Bacterial Streptococci, TB, leprosy, Yersinia, Mycoplasma, Rickettsia Fungal Coccidioidomycosis Viral Cat-scratch fever Drugs Sulphonamides, oral contraceptives Systemic diseases Inflammatory bowel disease, sarcoidosis, Behçet’s disease, malignancy (rare)
    107. 107. Acanthosis nigricans Asymptomatic brown velvety plaques of coalescent papules Affects flexures - neck, axillae, groin Potential causes obesity endocrine disorders (acromegaly, insulinresistant diabetes) Inherited GI malignancy
    108. 108. Pyoderma Gangrenosum rapidly expanding ulcer with purple undermined border, start as pustules Often affects legs Causes  50% idiopathic;  10% associated with ulcerative colitis;  Other associations: Crohn‟s, chronic active hepatitis, rheumatoid arthritis, HIV, leukemia, myeloma
    109. 109. ACQUIRED ICHTHYOSIS   If develops in adulthood, consider: underlying malignancy (e.g. Hodgkin‟s disease),  essential fatty acid deficiency (e.g. due to malabsorption from intestinal by-pass or from lipid lowering drugs)
    110. 110. Generalized pruritus without an eruption Causes:  Idiopathic („senile‟)  Iron deficiency  Liver disease  Malignancy (e.g. Hodgkin‟s lymphoma)  Neurological disorders  Polycythemia  Renal failure  Thyroid dysfunction
    111. 111. THANK YOU
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