1.
DERMATOLOGICAL MANIFESTATIONS
OF SYSTEMIC DISEASES
guide: dr.rahul nagar
candidate: dr.smit chopra

2.
CONNECTIVE TISSUE
DISORDERS

3.
LUPUS ERYTHEMATOSUS
Discoid lupus erythematous
Subacute cutaneous lupus erethematosus
Systemic lupus erythematosus

4.
DISCOID LUPUS ERYTHEMATOSUS
• Most patients have limited disease to head and
neck (localised DLE) but rarely may present as
disseminated disease potentially affecting any
area of skin (Disseminated DLE)
• It presents as rash (erythematous patches) with
adherent scale over it,
• Raynaud’s phenomenon found in 14% of
cases

5.
Localised DLE-
• Face is most commonly affected area f/b
scalp, ears, arms, legs, and trunks to a
lesser extent
• Discoid erythematous rash appear most
commonly over the cheeks, bridge of the
nose, ears , scalp and side of the neck
• Alopecia occurs in 1/3rd of the patients

6.
Disseminated DLE
• Characteristic lesions of DLE may occur in
widespread pattern on trunk and limbs
• This occur almost always in women and
they are cigarette smokers
• This variety tends to be persistent ,
resistant to therapy and associated with
psychological upset

7.
SUBACUTE CUTANEOUS LUPUS
ERYTHEMATOSUS
• Lesions usually occur above the waist
particularly around neck, on the trunk and on
the outer aspects of arm.
• Predominantly affects adult age group
• Skin lesions comprises of non scarring
papulosquamous (two thirds) and annular
polycystic lesions (one third)

8.
SYSTEMIC LUPUS ERYTHEMATOSUS

9.
Skin manifestation occurs approximately in
80% of the cases

10.
• Cutaneous erythema on light exposed area is the most common
feature
• Butterfly blush with fine scaling on butterfly area of the cheeks is
frequently found
• Epidermal necrosis may occur in some cases
• Alopecia occurs in around 50% of cases , hair becomes coarse
dry and fragile called ‘lupus hair’
• Persistent non itching urticaria like wheals are common
• Livedo reticularis(a mottled or bluish red discoloration, which
blanches on pressure and is not affected by temperature
changes) may develop over outer aspects of arms

11.
SCLERODERMA
• At first lesions are indurated and faintly purplish later they lose their
colour especially in centre and appear as thickened waxy areas with
smooth and shiny surface , hairs are usually absent over these
surfaces
• Morphea i.e patches of hardened skin, appears over face, hands, and
feet which lacks sweat gland and ability to make skin folds
• Skin induration initially affects the fingers (sclerodactyly) and extend
proximally
• Raynauds phenomenon is a common finding
• Infarction and dry gangrene of fingers may occur sometimes due to
severe vasospasm

12.
DERMATOMYOSITIS
A purplish-red or heliotrope erythema occurs on
the face, especially involving the eyelids, the
upper cheeks, forehead and temples
Oedema of the eyelids and periorbital tissues
may occur
Small erythematous or violaceous, flat papules
(Gottron’s papules) occur over the knuckles, on
the dorsa of the finger and around the nail folds .

13.
RHEUMATOID ARTHRITIS
Rheumatoid nodules these are subcutaneous
nodules affecting the extensor surfaces of the
forearms, back of hand, occipital region, auricular
region more commonly
Cutaneous small vessel vasculitis may lead to
purpura, bruise or ulcerative lesions over the skin.
Pyodermagangrenosum sterile pustules which
rapidly evolve over painful ulcers charactrized by
raised edges with erythematous purple covering

14.
INFECTIOUS DISEASE

15.
TUBERCULOSIS
MODE OF
INOCULATION
DISEASE
DIRECT INOCULATION
Tubercular
chancre(primary
inoculation)
CONTIGUOUS
SPREAD
Scrofuloderma
MULTIBACILLARY AUTOINOCULATION
Orofacial
tuberculosis
HEMATOGENOUS
SPREAD
Acute military
tuberculosis,
Tuberculous
gumma(abcess)

16.
MODE OF
INOCULATION
DISEASE
DIRECT INOCULATION
Warty
tuberculosis
(verruca cutis)
PAUCIBACILLARY
HEMATOGENOUS
SPREAD
Lupus vulgaris,
Lichen
scrofulosorum,
Nodular
tuberculid,
Erethema
induratum

17.
PRIMARY INOCULATION
Tubercular chancre skin
lesion may vary from brownish
papule ,nodule to an ulcer with
undermined edge. On
diascopy it shows apple jelly
nodules
Warty tuberculosis (verruca
cutis) leisions occur on area
exposed to trauma.Starts with
a small indurated warty
papule. Irregular extension
may cause finger like

18.
SCROFULODERMA
At first bluish-red nodule
overlying the infected
gland forms which breaks
down to form undermined
ulceration with granulating
tissue at the base

19.
LUPUS VULGARIS
Plaque form

20.
Vegetative form Tumor like form

21.
LEPROSY
CLINICAL TYPE PERCATAGE DISTRIBUTION
Tuberculoid (TT) 8
Borderline tuberculoid (BT) 41.33
Borderline (BB) 5.3
Borderline lepromatous (BL) 26.66
Lepromatous (LL) 18.66

22.
HIV
seborrhoea dermatitis
psoriasis
herpes simplex
viral warts
mollusca
oral and vaginal
candidiasis
scabies
squamous cell
carcinoma
kaposis sarcoma

23.
ENDOCRINE
DISORDERS

24.
THYROID DISORDERS
Cutaneous features of hyperthyroidism
• SKIN- palmar erythema ,facial flushing
,increased skin temp.,increased sweating,
hyper pigmentation , pretibial myxoedema
• NAILS- soft nails ,koilonychia,distal onycholysis
(plummer’s nail)
• HAIR- fine thin hair ,diffuse alopecia

25.
Cutaneous features of Hypothyroidism
• SKIN-Pale, cold, scaly and wrinkled skin, Ivory-
yellow skin colour, Xerosis, Absence of sweating,
puffy oedema of hands, face and eyelids
• NAILS- Brittle and striated nails
• HAIR- Coarse sparse scalp hair, Loss of pubic,
axillary and facial hair, Loss of lateral eyebrows
(madarosis)

26.
ADRENAL DISORDERS
Cutaneous manifestation of cushing’s syndrome
• Truncal obesity (classically deposits of fat over the clavicles and back of
the neck, the ‘buffalo hump’)
• Facial fullness and plethora (‘moon facies’)
• Slender limbs
• Skin atrophy
• Fragility, bruising and poor healing leading to Striae (typically white and
red)
• Hirsuties,Acneiform lesions
• Male-pattern baldness in women

27.
Cutaneous manifestation of Addison’s disease
• Hyperpigmentation of the skin, due to increased secretion of
pituitary MSH and ACTH as a response to low adrenal
corticosteroid levels, is the cardinal dermatological feature
• Patterns of addisonian pigmentation -
1. Light-exposed areas i.e.face, dorsa of hands,
2. Areas subject to friction—elbows, knees, waistline
3. Accentuation of normally high pigmentation areas—genital,
perineum, axillae, areolae, umbilicus
4. Palmar creases
5. Tongue and mucous membranes

28.
DIABETES MELLITUS
Periungual talengectasia-
A microangiopathic
complication seen in upto
49% of diabetics
Acanthosis nigricans- a
verrucous hyper pigmented
plaques seen over axilla ,
nape of neck which is due to
hyperinsulinemia

29.
Granuloma annulare-
annular leisions with
raised skin colour having
symmetrical distribution
on arms,neck and upper
half of the trunk
Necrobiosis lipodica-
sharply demarcated
slightly depressed yellow
waxy plaques with
erythematous raised
border

30.
Insulin reactions
(Lipodystrophy)- soft
nodules resembling
lipoma are formed, these
are local response to
lipogenic action of
insulin, preventable by
rotating injection sites

31.
GASTROINTESTINAL
DISEASES

32.
LIVER CIRRHOSIS
Skin lesions associated with chronic liver disease
•Spiderangiomas , telangiectasis
•Palmar erythema
•Dilated abdominal/chest veins (including periumbilical
caput medusae)
•Jaundice
•Increased melanin pigmentation
•Thin ‘paper-money’ skin
•Loss of secondary sexual hair in males

33.
ACUTE PANCREATITIS
Grey Turner sign (Turner
sign)—tracks from the
pararenal space to the edge
of the quadratus lumborum
muscle then through a
defect in the fascia to the
subcutaneous tissues of the
flank (left sided in
pancreatitis)

34.
Bryant’s sign—tracks to
the scrotum to produce
the ‘blue scrotum’ sign.
Cullen’s sign—tracks
into the falciparum
ligament then through the
connective tissues of the
round ligament to the
periumbilical area

35.
NUTRITIONAL AND
METABOLIC DISORDERS

36.
IRON DEFICIENCY DISORDER
• Paleness of skin, palm creases and conjuctiva
• Painful cracks at corner of mouth (angular
cheilitis)
• Shiny smooth tongue (atrophic glossitis)
• Spoon shaped nails (koilonychiya)
• Dry and brittle hair

37.
VITAMIN B COMPLEX DEFICIENCIES
VitB3 (niacin)deficiency - Pellagra
• Red skin with large blebs or blisters that exfoliates
• Erethema over the dorm of hands
• Scaling over the sun exposed area of the skin
• Dry ,scaly and hyperkeratotic darkly pigmented skin
• Site- mostly over face, neck ,arms, hands and feet

38.
B12 Deficiency -
• Skin hyperpigmentation with accentuation
in flexural areas ,palms ,soles and oral
cavity
• Angular stomatitis , glossitis(hunters
glossitis), xerostomia
• Vitiligo

39.
VITAMIN C DEFICIENCY
SCURVY
• Perifollicular hemmorage with blood
pigment discolouration especially on the
trunk and lower limbs (purpuric rash)
• Swollen bleeding gums
• Epistaxis may occur sometimes

40.
SYSTEMIC AMYLOIDOSIS
Myeloma associated cutaneous amyloidosis
(AL amyloid)
Secondary systemic amyloidosis (AA amyloid)
Dialysis associated amyloidosis

41.
Myeloma associated cutaneous amyloidosis (AL
amyloid)
• Almost 40% of patients with AL amyloidosis
have skin manifestation
• leisions tend to aggregate around
mucocutaneous junctions like orbit, lips and
genital skin
• purpura is also a common finding which
results from vascular fragility due to amyloid
deposition in blood vessels

42.
Secondary systemic amyloidosis (AA amyloid)
• The amyloids are composed of fibrils of a protein
designated as AA
• AA protein is an acute phase reactant
• secondary amyloidosis occurs as a complication of
many chronic inflammatory diseases
• Skin lesions are wage and are non specific
• Most common are renal manifestation leading to
nephrotic syndrome

43.
Dialysis associated amyloidosis
• cutaneous involvement is rare
• manifests as hyper pigmentation
,lichenoid eruptions,or nodules that
demonstrate amyloid deposition on HPE
examination

44.
TAKE HOME MESSAGE
CUTANEOUS MANIFESTATIONS CAN HELP IN
EARLY DIAGNOSIS AND INTERVENTION OF MANY
HIDDEN SYSTEMIC DISEASES
IT ALSO HELPS IN UNDERSTANDING THE
PROGNOSIS AND MANAGING THE DISEASE

45.
THANK YOU