CUTANEOUS MANIFESTATIONS OF INTERNAL DISEASES

CUTANEOUS MANIFESTATIONS

Diabetes Mellitus Thyroid disease Adrenal disease Renal Disease Liver disease Rheumatologic disease Nutritional disease

DIABETES MELLITUS

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 diabeticsType I patients get more

autoimmune-type lesionsType II patients get more

cutaneous infections

DIABETES MELLITUS

Cutaneous lesions usually appear after the development of DM, but may be the first presenting sign

Four major groups of skin findings1. Skin diseases associated with DM2. Cutaneous infections3. Cutaneous manifestions of diabetic

complications 4. Skin reactions to diabetic treatment

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

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.

GRANULOMA ANNULARE (GA)

AppearanceRing 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

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

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

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.

ACANTHOSIS NIGRICANS

AppearanceHyperpigmented,

velvety plaques in body folds, mostly axillae and neck

Can also present on groin, umbilicus, areolae, submammary areas, and on the hands

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

CANDIDIASIS IN DIABETICS Fungal infections- most

common Candida

Candidial paronychia Inframammary

candidaGenital candida

Oral candidiasis White, curdlike material

adherent to erythematous, fissured oral commisure;

angular stomatitis

CANDIDIASIS IN DIABETICS

Initial pustules on erythematous base that become eroded and confluent

CANDIDIASIS IN DIABETICS

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

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

DIABETIC ERUPTIVE XANTHOMAS

Seen in uncontrolled diabetes, hypertriglyceridemia

Sudden crops on firm, non-tender yellow papules with a red rim on extensors

Control of glucose and lipid reduction reduce the lesions

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

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

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

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.

THYROID DISEASES

Graves disease

Hyperthyroidism

Hypothyroidism

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.

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

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)

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

SCLEROMYXEDEMA IN HYPERTHYROIDISM

Firm white, yellow, or pink papules on face, trunk, axillae, and extremities

SCLEROMYXEDEMA IN HYPERTHYROIDISM

Firm white, yellow, or pink papules on face, trunk, axillae, and extremities

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

Can appear anywhere (arms, shoulders, head).

Histologically, the process involves dermal accumalation of hyaluronic acid.

Pathogenesis :pretibial fibroblasts are the target for antithyroid antibodies

T cells may be interacting with a dermal antigen similar to a thyroid autoantigen, with cytokines subsequently activating fibroblasts to secrete hyalouronic acid.

Can treat with topical steroids, intralesional steroids, IV pulse steroids, or IVIG

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.

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.

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.

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

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

Thyroid replacement therapy rapidly reverses many of the cutaneous features of hypothyroidism, with gradual disappeaarance of excessive dermal mucopolysaccharides.

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

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

ASSOCIATION BETWEEN CUTANEOUS AND THYROID DISEASE CONTD.

Pemphigus foliaceus

Herpes gestationisBullous pemphigoidDermatitis herpetiformis

Pemphigus vulgaris

ADRENAL DISEASE

Addison’s diseaseHypercortism

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

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

RENAL DISEASES Signs of ESRD Signs associated with dialysis Signs in renal transplant patients

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

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

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

Topical Moisturizing creams Capsaicino Physical treatments UVB light parathyroidectomyo Systemic medications Sedating Antihistamines Cholestyramine Alternative strategies Acupuncture homeopathy

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 beta-melanocyte 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

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

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 disordersKyrle’s diseaseElastosis Perforans serpiginosaPerforating folliculitisReactive perforating collagenosis

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

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

UREMIC FROST Was a frequent in the pre-

dialysis 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.

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

Proximal half opaque white

Normal to red brown distal half

Yellow nail syndrome (YNS) is triad of yellow nails, lymphedema, and respiratory tract involvement

HAIR ABNORMALITIES

Sparse body hair and diffuse alopecia with dry, lusterless hair

Decreased secretion of sebumChronic telogen effluvium Drugs – Heparin / Statins /

Antihypertensives

CUTANEOUS MANIFESTATIONS IN PTS ON DIALYSIS

Diffuse hyperpigmentation

Accelerated cutaneous aging

Actinic elastosis Excessive wrinkling of neck(

cutis rhomboidalis nuchae) Telangiectasiaso Skin infections common

DERMATOLOGIC DISORDERS ASSOCIATED WITH RENAL TRANSPLANTATION.

Drugs – Steroids, ImmunosuppresantsInfections 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

LIVER DISEASE

Chronic liver disease

Hepatitis B,C

CHRONIC LIVER DISEASES

Jaundice Because of raised

levels of bilirubin more than 2.5-3.0mg/dl

Diffuse hyperpigmentation

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.

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)

CHRONIC LIVER DISEASES Pruritus Recurrent purpura Xanthoma straitum

palmare(Multiple xanthomas may

appear as yellowish plaques covering large areas of skin in palmar creases)

CHRONIC LIVER DISEASES

Ascites leads to striae distensae

dupuytren's contracture

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 Terry’s nails

Muehrcke’s nails

clubbing

HEPATITIS C

Porphyria Cutanea Tarda

Lichen Planus

Necrolytic acral erythema

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

LICHEN PLANUS Variable association of

0.1% to 35% Associated with LP ,

especially in mucosal, generalised or long standing LP

Purple, pruritic, polygonal papules

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

HEPATITIS B About 30% may

have Urticaria or present a serum sickness like picture (because of circulating immune complexes)

Associated with 5-7% cases of Polyarteritis nodosa

Classical PAN Renal vasculitis

present ANCA negative

SYSTEMIC LUPUS ERYTHEMATOSUS

SYSTEMIC LUPUS ERYTHEMATOSUS

Malar erythema Discoid plaques or psoriasiform

erythroderma Photosensitivity, alopecia and mucosal ulcers Raynaud’s phenomenon Periungual erythema

MALAR ERYTHEMA

MUCOSAL ULCERS

ALOPECIA

ANNULAR PSORIASIFORM MACULES AND PATCHES

ANNULAR PSORIASIFORM MACULES AND PATCHES

ANNULAR PSORIASIFORM MACULES AND PATCHES

Periungual erythema

DERMATOMYOSITIS

HELIOTROPE RASH IN DERMATOMYOSITIS

Heliotrope rash (violaceous erythema) of periorbital skin

DERMATOMYOSITIS

Shawl sign

DERMATOMYOSITIS-HOLSTER SIGN

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

CRITERIA FOR DIAGNOSIS: SYSTEMIC SCLEROSIS

Sclerodactyly

SCLERODACTLY

SCLERODERMATOUS PLAQUES

bird-like facies MASK LIKE FACIES

Smoothening of lines of facial expressions

Pinched nose Radial furrows

around mouth

Periungual erythema and hemorrhage NAIL FOLD CHANGES

Periungual erythema and hemorrhage

GASTROINTESTINAL DISEASES

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

Henoch-Schönlein purpura

Henoch-Schönlein purpura

PYODERMA GANGRENOSUM

Seen in 10% of ulcerative colitis patients

rapidly expanding ulcer with purple undermined border start as pustules

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

CARDIAC DISEASES

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

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 cyanosiso Mixed Pulmonary odema Cardiogenic shock

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

FLUSHING

Severe Mitral stenosis

Tumours producing vasoactive sunstances

Carcinoid tumours

Multiple endocrine neoplasia type Iia

Systemic mastocytosis

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

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

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

CUTANEOUS SIGNS INDICATIVE OF INTERNAL DISEASES

oErythema nodosumoAcanthosis nigricansoPyoderma gangrenosumoAcquired ichthyosisoGeneralised pruritus without an eruption

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

Causes of Erythema Nodosum

Idiopathic

Bacterial

Fungal

Viral

Drugs

Systemic diseases

About 20% of cases

Streptococci, TB, leprosy, Yersinia, Mycoplasma, Rickettsia

Coccidioidomycosis

Cat-scratch fever

Sulphonamides, oral contraceptives

Inflammatory bowel disease, sarcoidosis, Behçet’s disease, malignancy (rare)

Acanthosis nigricans Asymptomatic brown velvety plaques of coalescent papules

Affects flexures - neck, axillae, groin

Potential causes

obesity

endocrine disorders

(acromegaly, insulin-

resistant diabetes)

Inherited

GI malignancy

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

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)

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

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