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.
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Keywords:Copyright © 2015 by the Dermatology Nurses' Association.
Cutaneous; Dermatology; Systemic; Skin