Dermatologic manifestations in renal diseases

1. DERMATOLOGIC MANIFESTATIONS
OF RENAL DISEASES
Dr. Raiz Iqbal
Junior Resident
Dept. of General Medicine

2. • Dermatologic manifestations of renal disease are common findings in
patients with end-stage renal disease (ESRD).
• A high prevalence of cutaneous disorders is expected, because most
patients with ESRD have an underlying disease process with
cutaneous manifestations.
• In addition, uremia and conditions associated with renal replacement
therapy are fraught with numerous and, often, relatively unique
cutaneous disorders.

3. • Clinical entities with coexisting dermatological and renal
manifestations.
• Cutaneous manifestations of chronic renal failure.
• Cutaneous manifestations in patients undergoing dialysis.
• Cutaneous manifestations in renal transplant patients.

4. Clinical Entities with Coexisting Dermatological and Renal Manifestation

23. Cutaneous Manifestations of Chronic Renal Failure
• Icthyosis, xerosis (most common; severity can be assessed with modified Morton’s scale
as: 0-smooth skin, 1-rough skin without scaling, and 2-rough skin with scaling)
• Pruritus, prurigo nodularis: pruritus occurs due to vitamin A, parathyroid levels, mast
cell hyperplasia, peripheral neuropathy, and xerosis. Clinically, skin may appear normal
or demonstrate variety of lichenified or hyperkeratotic lesions
• Acquired perforating disorders: keratotic papules, nodules, and verrucous plaques
• Bullous disorders: porphyria cutanea tarda (nonresponsive to chloroquine, treated with
erythropoietin and iron chelation); pseudoporphyria (normal level of porphyrin and
presence of bullous lesions)
• Nephrogenic fibrosing dermopathy

25. • Calcifying disorders: calcinosis cutis; calciphylaxis (calcific uremic
arteriopathy, bilaterally symmetrical painful purpuric plaques and
nodules, deep angulated stellate ulcers; rarely reported)
• Recurrent skin infections due to decreased T-cell count
• Anemia of chronic disease, pallor
• Hyperpigmentation (photodistributed, palmoplantar and mucosal)
• Yellowish hue of skin—urochromes
• Purpura, ecchymosis: platelet dysfunction, increased vascular fragility
and use of heparin during dialysis; incidence has decreased with
treatment .

27. • Uremic frost: whitish powdery residue left behind on skin of face, neck, trunk and beard after
evaporation of sweat due to high concentration of urea in sweat; no longer prevalent with better
availability of hemodialysis facilities.
• Uremic fetor: ammoniacal odor due to increased urea in saliva and its breakdown to ammonia
• Gynaecomastia: may be explained by “re-feed” phenomenon. Due to chronic kidney disease and
protein energy malnutrition, pituitary and gonadotropin function is suppressed. Thus, after
treatment increased food intake induces “second puberty” leading to transient gynecomastia
• Oral mucosa: macroglossia with teeth markings (tongue sign of uremia), angular cheilitis, ulcerative
stomatitis, and xerostomia.
• Hair: telogen effluvium, lusterless, sparse hair
• Nail: Lindsay’s nails (half and half nails)—opaque white proximal half and normal to red-brown distal
half, onycholysis, koilonychias, subungual hyperkeratosis, Mees’ lines, Muehrcke’s lines

29. Dermatological Manifestations in Patients
Undergoing Hemodialysis
• Pruritus: due to disturbance of calcium and phosphorus metabolism and alteration of
serum parathormone levels, dialysis component allergic reactions
• Xerosis: most commonly seen in patients on maintenance dialysis
• Hyperpigmentation
• Accelerated cutaneous aging: actinic elastosis, extensive wrinkling on neck (cutis
rhomboidalis nuchae), and telangiectasia
• Skin infection: pyodermas
• Acquired perforating disorders

30. • Poor wound healing
• Raynaud’s phenomenon
• Dupuytren’s contracture
• Pseudoporphyria
• Malignant skin tumors
• Sites of AV shunt for dialysis may develop infections of cannula,
extravasation, thrombophlebitis, hematoma, allergic contact dermatitis,
irritant contact dermatitis, vascular complications like digital ischemia and
aneurysm

31. Dermatological Manifestations in Patients Who Have
Undergone Renal Transplant
Infections
• Bacterial: pyodermas
• Fungal: Tinea versicolor, candidal infections
• Viral infections: viral warts, herpes eruptions, condylomata acuminata; varicella eruptions
can be recurrent and florid with associated systemic complications (encephalitis and
pneumonia); herpes zoster: multidermatomal
• Parasitic: acanthamoeba may progress to encephalitis and can be fatal
Inflammatory
• Seborrheic dermatitis, lichen planus, perioral dermatitis

32. Drug induced cutaneous side effects
• Gingival hyperplasia and hypertrichosis due to cyclosporine; acneiform eruption and cushingoid
appearance caused by glucocorticoids
Premalignant and malignant
• Porokeratoses, Kaposi’s sarcoma (earliest to manifest), squamous cell carcinoma is seen in greater
frequency than basal cell carcinoma (as against general population where basal cell carcinoma
occurrence rates are higher than squamous cell carcinoma).
• Other cutaneous tumors include appendageal tumors of sebaceous apparatus and merkel cell
carcinoma
Others
• Pruritus (2% of patients), xerosis

33. Nephrogenic Fibrosing Dermopathy (NFD)
• Is a distinct entity characterized by sclerodermoid skin changes .
• can be seen in acute, transient or chronic renal failure and in renal transplant patients.
• clinical manifestations : symmetrical plaques or nodules with peau-de-orange appearance , amoeboid
borders on the trunk and extremities
• These evolve into rapidly confluent fibrotic skin associated with lumpy nodular plaques,
pigmentary changes, and flexion contracture of extremities.
• There is an evidence based association of NFD with the use of gadolinium enhanced MRI.

35. Thank you