CUTANEOUS MANIFESTATIONS OF SYSTEMIC DISEASESDR MRS CHALUKYA .N GUNASEKERACONSULTANT DERMATOLOGISTNCTH- RAGAMA

Introduction Some dermatoses are seen with many internal disorders Cutaneous manifestations may be the presenting feature Dermatologist can therefore recognize undiagnosed systemic diseases

The skin and internal malignancy Endocrine disease ,diabetes and the skin Skin manifestations of connective tissue diseases The skin in liver disease Skin and gastrointestinal tract The skin in renal disease Nutrition and the skin Systemic causes of pruritus

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Skin and internal malignancyDue to 1. direct spread2. metastases3. physiological effects eg; acne in some adrenal tumors4. Non metastatic manifestations

Skin and internal malignancy ctd1.Acanthosis nigricans - velvety thickening and pigmentation of major flexures eg; gastrointestnal adenocarcinoma

2.Acquired icthyosis - especially lymphoma 3.Dermatomyositis - genital system malignancy in women over40 yrs4. Erythema gyrating repens - carcinoma of lung5. Necrolytic migratory erythema - glucagon- secreating tumour of pancreas

Skin and internal malignancy ctd2.Acquired icthyosis

Skin and internal malignancy ctd3.Dermatomyositis

Skin and internal malignancy ctdNecrolytic migratory erythema

Skin and internal malignancy ctd6. Superficial thrombophlebitis - carcinoma of the pancreas7. Palmo-plantar Keratodema8. Generalized pruritus

Skin and internal malignancy ctd7. Palmo-plantar Keratodema

Endocrine disease , diabetes and the skin Specific and non specific lesions Specific lesions - necrobiosis lipoidica - diabetic dermopathy - diabetic bullae - limited joint mobility with waxy skin

Skin manifestations of diabetes

Endocrine disease , diabetes and the skin necrobiosis lipoidicaSkin manifestations of diabetes

Endocrine disease,diabetes and the skin ctdSkin manifestations of diabetes ctd Non specific - diffuse granuloma annulare - xanthomas - candidal infections - staphylococal infections - neuropathic ulceration - ischaemic changes

Endocrine disease,diabetes and the skin ctdSkin manifestations of diabetes ctd diffuse granuloma annulare

Endocrine disease,diabetes and the skin ctdSkin manifestations of diabetes ctdxanthomas

Endocrine disease diabetes and the skin ctdHypothyroidism- Alopecia( including eyebrows)- Coarse hair- Dry puffy yellowish skin- Asteotoic eczema- xanthomas

Endocrine disease diabetes and the skin ctdHypothyroidism

Endocrine disease ,diabetes and the skin ctdHyperthyroidism - pretibial myxoedema- specific - pink soft skin - hyperhidrosis - alopecia - pigmentation - onycholysis - clubbing

Endocrine diseases ,diabetes and the skin ctdCushing,s syndrome Caused by adreanal tumour, hyperplasia or administration of corticosteroids Skin signs thinning - striae - hirsutism - acne - obesity - buffalo hump

Skin manifestations of connective tissue diseasesSystemic lupus erythematosus SLE is an autoimmune disorder involving multisystem microvasculture inflammation and the generation of autoantibodies The specific cause of SLE is unknown, multiple factors are associated with the development of the disease These include genetic ,hormonal ,and environmental factors Disease specific and non specific skin manifestations

Skin manifestation of connective tissue diseases ctdSystemic lupus erythematosus Disease specific manifestations - acute skin lesions butterfly rash generalized erythema bullous lesions

Skin manifestation of connective tissue diseases ctdSystemic lupus erythematosusbutterfly rash

Cutaneous manifestation of connective tissue disease ctdSystemic lupus erythematosus ctd Disease specific skin manifestations ctd - sub acute lesions erythematous papules or plaque Annular and scaly lesions occur on sun exposed skin - chronic skin lesions chronic discoid lesions with scaling with central atrophy and scarring

Cutaneous manifestations of connective tissue diseasesSystemic lupus erythematosus ctd Disease specific skin manifestations ctd - Discoid lupus occurs in the absence of other systemic symptoms or organ involvement

Cutaneous manifestations of connective tissue diseasesSystemic lupus erythematosus ctd - Discoid lupus

Skin manifestations of connective tissue disordersSystemic lupus erythematosus ctd - Patchy or generalized alopecia - Vasculitic purpura - Nasopharyngeal ulceration - Raynaud,s phenominon Skin lesions related to but not specific to SLE

Skin manifestations of connective tissue diseasesRheumatoid arthritis Occurs in 20 -30 % of patients with Rheumatoid arthritis Specific cutaneous manifestations Rheumatoid nodules - few mm to a few centimeters - usually found over bony prominences - associated with a positive RF titer and erosive arthritis

Skin manifestations of connective tissue diseases ctdRheumatoid arthritis ctd Specific cutaneous manifestations ctd - rheumatoid vasculitis - Felty syndrome triad arthritis leucopenia splenomegaly skin manifestations- rheumatoid nodules, hyperpigmentations, and leg ulcers - pyoderma gangrenosum

Skin manifestations of connective tissue diseases ctdRheumatoid arthritis ctd pyoderma gangrenosum

Skin manifestations connectinve tissue diseases ctdRheumatoid arthritis ctd Non specific cutaneous manifestations - erythema nodosum - atrophy of digital skin - palmer erythema - diffuse thinning and skin fragility

Skin manifestations of connective tissue diseases ctdDermatomyositis Is an idiopathic inflammatory myopathy with characteristic cutaneous findings Characteristic cutaneous features heliotrope rash Gottron papules

Skin manifestations of connective tissue diseases ctd Dermatomyositis ctdOther cutaneous features - malar erythema - poikiloderma in a photosensitive distribution - violaceous erythema on extensor surfaces - periungual and cuticular changes

Skin manifestations of connective tissue diseases ctdSystemic sclerosis Is a chronic disease of unknown causecharacterized by affection of small blood vessels and excessive synthesis and accumulation of extra cellular matrix proteins and tissue ischemia. Vascular endothelial damage and autoimmunity are thought to be important in the pathogenesis Most characteristically involves the skin.

Skin manifestations of connective tissue diseases ctdSystemic sclerosis ctd Skin appears thick and tight It becomes difficult to raise a fold of skin. Thickening of the skin starts in the fingers and progresses proximally - limited cutaneous sleroderma thickening distal to elbow and knee may involve face and neck - diffuse cutaneous scleroderma thickening affects the trunk and proximal extremities in addition to face and acral body

Skin

Skin manifestations of connective tissue diseases ctdSystemic sclerosis ctdSkin Face skin shiny and tightly bound - beak like nose - lip becomes thin and opening of the mouth becomes smaller - linear furrows radiate from angle of the mouth - difficult to depress the lower eyelid with fingers

Skin manifestations of connective tissue diseases ctdSystemic sclerosis ctd Skin Fingers - spindle shaped with flexion contractures - pulp space atrophy - dilated nail fold capillaries and ragged cuticles Pigmentory changes - mottled hypo and hyper pigmentations Telangiectasia Calcification

Skin manifestations of connective tissue diseases ctdSystemic sclerosis ctd

Skin manifestation of connective tissue diseases ctdSystemic sclerosisVascular changes Raynaud phenomenon - results from abnormal vasomotor control - Pallor, cyanosis ,and then erythema - triggered by cold, smoking,viabration or emotional stress - severe vasospasm lead to infarction and dry gangrene of the digits

Skin manifestations of liver diseases Vascular - spider telangiectasia - palmar erythema - caput medusa Nail changes - clubbing Jaundice Pruritus Hyperpigmentations Specific dermatologic manifestations

Skin manifestations of liver diseases ctd Alcohol induced diseases /disease states with associated dermatologic manifestations Nutritional deficiencies - marasmus - kwashiorkor - pellagra Endocrine diseases - pseudo- cushing,s syn Porphyria cutanea tarda

Cutaneous manifestations of liver diseases ctd Exacerbations of skin diseases- Psoriasis- Rosacea- Discoid eczema

Skin and gastrointestinal tract Numerous relationships Dermatitis herpetiformis - itchy blistering disorder - associated with absorption defect of the small bowel Peutz- jeghers syndrome - autosomal dominant disorder - perioral and labial pigmented macules occur in association with jejunal polyps

Nutrition and the skinMalnutrition itching dryness symmetrical pigmentation brittle nails and hairProtein malnutrition ( Kwashiorkor) dry red brown hair pigmented cracked skin

Nutrition and the skin ctdIron deficiency pallor itching diffuse hair loss koilonychia smooth tongueVitamin A deficiency dry skin follicular hyperkeratosis xeropthalmia

Nutrition and the skinVitamin B1deficiency - Beri- beri oedemaVitamin B7 ( Niacin) deficiency - pellagra with dermatitis, dementia and diarrhoea - dermatitis on exposed areas, pigmented

Nutrition and the skinVitamin C deficiency( scurvy) - skin haemorrhages especially around follicular keratoses containing coiled hairs - bleeding gums - oedematous woody swelling of limbs in elderly

The skin in renal disease Signs and symptoms skin colour changes pallor shallow yellowish cast hyperpigmentation xerosis acquired icthyosis pruritus uraemic frost half- and- half nails

The skin in renal diseases ctd Specific disorders - perforating disorders - metastatic calcification - bullous dermatoses porphyria cutanea tarda pseudoporphyria

Systemic causes of pruritus Pruritus is un unpleasant sensation that provokes the desire to itch Two groups of patients 1. pruritus is caused simply by surface causes eg; eczema, scabies 2. who may or may not have internal cause for their itching

Systemic causes of pruritus Causes of generalized pruritus Liver diseases Chronic renal failure Iron deficiency Polycythaemia Thyroid diseases Diabetes Internal malignancy eg; lymphoma

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