The skin is the largest organ in the body and one of the most visible body systems. The skin has a reciprocal relationship between what is visualized on the surface and what is occurring below the surface, within the body. The ability to identify these causal relationships may assist in early diagnosis of disease or potential risk factors associated with a systemic illness.
When assessing the skin, it is important to inspect and palpate. During this time, the clinician/practitioner should take note of color, moisture, temperature, texture, mobility, and turgor as well as note if there is edema and/or lesions (Hogan-Quigley, Palm, & Bickley, 2012). Assessment and the health history are vital in determining an appropriate diagnosis.
This article will concentrate on nonmalignant cutaneous manifestations of systemic disease. The body systems will be reviewed, and their associated skin manifestations will be discussed. Some of the skin manifestations can be seen in multiple systemic disorders, such as erythema nodosum, which can be seen in pulmonary disorders, collagen and vascular disorders, and gastrointestinal disorders. Pictures will be provided when possible.
CARDIOVASCULAR AND PULMONARY SYSTEM
There are several general cutaneous signs of cardiovascular disease that may commonly be seen. These findings may include edema, cyanosis, clubbing of the nails, and corneal arcus. The corneal arcus appears as a gray-white ring around the cornea and correlates with age and cholesterol levels. A diagonal earlobe crease is also reported to be a marker for coronary artery disease (Uliasz & Lebwohl, 2008).
Elevated cholesterol or lipid disorders may reveal themselves cutaneously in xanthomas and xanthelasma. Xanthomas and xanthelasma are tan, yellow papules and/or plaques or nodules that can be seen on any area of the skin but are most noticeable on the face (Porth, 2011; Rigopoulos, Larios, & Katsamba, 2011; see Figure 1).
Chronic obstructive pulmonary disease and vascular disease may show as clubbing of the fingernails, cyanosis, and delayed capillary refill. Nails may be thick and ridged when arterial disease is present (Jarvis, 2012; see Figure 2).
Sarcoidosis is an inflammatory illness that usually affects the lungs first as they are the most common area for granuloma formation. The granulomas may also invade other tissues and organs. Skin involvement includes papules and plaques and enlarged lymph nodes, especially in the chest (Porth, 2011). Erythema nodosum may also be present (Cahill & Sinclair, 2005).
Systemic lupus erythematosus can present externally with a malar or butterfly rash across the cheeks and nose. It can also present itself with a discoid-appearing rash and vasculitis including Raynaud’s phenomenon. Alopecia is common. Lesions of the mucus membranes occur and are most often seen during exacerbation of the illness (Porth, 2011).
Cirrhosis of the liver can be identified externally by observing for spider angioma (Figure 3), unilateral nevoid telangiectasis, jaundice (Figure 4) and alterations in pigment from deposition of bilirubin into the tissues, loss of axillar and pubic hair, and coagulation defects (Porth, 2011).
Ulcerative colitis and Crohn’s disease may exhibit erythema nodosum, a delayed hypersensitivity reaction. This manifestation is also present in several other systemic illnesses such as strep pharyngitis, sarcoidosis, tuberculosis, Behcet’s disease, Hepatitis B, leukemia, and lymphoma (Cahill & Sinclair, 2005). There is also the possibility of vesiculo-pustular eruptions such as pyoderma gangrenosum. Pyoderma gangrenosum can appear as pustular, bullous, ulcerative, or vegetative. It is rare and appears because of an abnormal immune reactivity (Jarvis, 2012). It may begin as a nodule and progress through stages changing to a pustule, followed by a central necrosis, to edema with an erythematous border (Carlesimo et al., 2014; Figure 5).
Some of the cutaneous manifestations of renal system disease can include one of the most commonly seen skin conditions in renal patients, uremic pruritus, and nail disorders. Uremic pruritus or renal itch is very common in renal patients, although current literature reports it may be decreasing with effective and early dialysis and proper diet (The Merck Manual, 2013).
Half-and-half nails can be described as a nail that has a line of demarcation that separates the proximal white color from the distal pink or tan color. This is common in dialysis and renal transplant patients. They may also have splinter hemorrhages and brittle nails (Rigopoulos et al., 2011).
Diabetes mellitus can cause a diabetic dermopathy. It is one of the most common skin manifestations in diabetes mellitus and is thought to be related to vascular changes in the patient with diabetes. The patient with diabetes may also experience macroangiopathy and microangiopathy, peripheral edema, pruritus, thickening of the skin, diabetic foot, yellowed skin because of carotenodermia, and acanthosis nigricans (Figure 6). Diabetic rubeosis, burning mouth (xerostomia), and yellowing of the nails may also be found (Hogan-Quigley et al., 2012; Rigopoulos et al., 2011).
Thyroid disease and its skin manifestations are fairly common. In hypothyroidism, patients may complain of hair loss on the pubic and axilla areas and/or the lateral portion of eyebrows. The patient with hypothyroid disease may also experience thinning or brittle hair of the scalp. The nails can become brittle or show poor growth. The hypothyroid patient can also experience periorbital edema and thickening of the lips and tongue (Hogan-Quigley et al., 2012; Rigopoulos et al., 2011).
In hyperthyroidism, the patient may experience facial flushing; warm, moist, smooth skin; erythema of the palmar surface; alopecia; excessive sweating; pruritus; and onycholysis. Graves’ disease has many of the same cutaneous manifestations as hyperthyroidism, but in addition, there may be goiter, myxedema, digital clubbing, and soft tissue swelling of hands and feet as well as vitiligo and pemphigus (Hogan-Quigley et al., 2012; Rigopoulos et al., 2011).
Cushing syndrome occurs when the patient is exposed to excessive amounts of glucocorticoids. The patient will exhibit several manifestations such as buffalo hump (Figure 7), moon face, poor wound healing, easy bruising, hirsutism, atrophy of the skin, and truncal obesity (Porth, 2011; Rigopoulos et al., 2011).
Addison’s disease, or adrenal insufficiency, may also manifest cutaneously. Patients with this disease can have a darkening discoloration of the skin. Patients are often thought to be tanned (Figure 8). Hyperpigmentation may be noted in such areas as the vermillion border, areola, perineum, pressure points, and palmar creases (Jarvis, 2012; Rigopoulos et al., 2011).
Nail changes may be seen in systemic illness such as malnutrition. This can be exhibited as Beau’s lines, which are horizontal depressions in the nail. Hypothyroidism can cause brittle or splitting nails. Fungal or nail infections can be seen in systemic illness such as diabetes and in persons on immunosuppressive therapy such as transplant patients. Spoon-shaped nails may be seen in iron deficiency anemia (Weber & Kelley, 2010).
Hair changes can be seen from malnutrition, anemia, and hormonal disorders. Similar to hypothyroidism, iron deficiency may cause hair to become dry, brittle, and dull or cause hair loss (Ngan, 2014). In the African American population, malnutrition can cause hair color to change to a copper red color (Weber & Kelley, 2010). Hirsutism, an increase in fine hair on the body such as the upper lip or sides of face, can be caused by certain medications or hormonal abnormalities such as increased androgen and cortisol, steroids use, or ovarian tumors (Porth, 2011).
Toxic erythema may present in cases of toxic shock syndrome or Stevens–Johnson syndrome. Investigative history taking is key to early diagnosis for these manifestations. The ability to ask the right questions will assist the provider in determining if the rash is a viral exanthema or drug reaction or a more serious rash such as toxic epidermal necrolysis (Cahill & Sinclair, 2005).
This article provides the clinician with a foundational awareness for identification of common cutaneous manifestations of systemic disease, which may present during a physical assessment. This article is not meant to be a comprehensive list of these manifestations. When a patient presents with a cutaneous manifestation and possible concurrent systemic illness, it is imperative to perform a comprehensive diagnostic workup. The practitioners’ understanding and early intervention of cutaneous manifestations of systemic disease may improve patient outcomes and quality of life.
Cahill J., Sinclair R. (2005). Cutaneous
manifestations of systemic
disease. Australian Family Physician
, 34 (5), 335–340.
Carlesimo M., Narcisi A., Rossi A., Saredi I., Orsini D., Pelliccia S., Cox M. C. (2014). Cutaneous
manifestations of systemic
non-Hodgkin lymphomas (NHL): Study and review of literature. Journal of the European Academy of Dermatology and Venereology
, 28 (2), 133–141. doi:10.1111/jdv.1201
Hogan-Quigley B., Palm M. L., Bickley L. (2012). Bates’ nursing guide to physical examination and history taking
. Philadelphia, PA: Lippincott Williams & Wilkins.
Jarvis C. (2012). Physical examination and health assessment
. St. Louis, MO: Elsevier Saunders.
Porth C. M. (2011). Essentials of pathophysiology
(3rd ed.). Philadelphia, PA: Lippincott Williams & Wilkins.
Rigopoulos D., Larios G., Katsambas A. (2011). Skin
signs of systemic
diseases. Clinics in Dermatology
, 29 (5), 531–540. doi:10.1016/j.clindermatol.2010.09.021
Uliasz A., Lebwohl M. (2008). Cutaneous
manifestations of cardiovascular diseases. Clinics in Dermatology
, 26 (3), 243–254. doi:http://dx.doi.org/10.1016/j.clindermatol.2007.10.014
Weber J., Kelley J. (2010). Health assessment in nursing
(4th ed.). Philadelphia, PA: Lippincott Williams & Wilkins.