CUTANEOUS

MANIFESTATIONS
OF SYSTEMIC
DISEASES
DR MRS CHALUKYA .N GUNASEKERA
CONSULTANT DERMATOLOGIST
NCTH- RAGAMA

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

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

diseases

Skin and internal malignancy

Due to
1. direct spread
2. metastases
3. physiological effects
eg; acne in some adrenal tumors
4. Non metastatic manifestations

Skin and internal malignancy ctd

1.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 yrs
4. Erythema gyrating repens
- carcinoma of lung
5. Necrolytic migratory erythema
- glucagon- secreating tumour of pancreas

Skin and internal malignancy ctd

2.Acquired icthyosis

Skin and internal malignancy ctd

3.Dermatomyositis

Skin and internal malignancy ctd

Necrolytic migratory erythema

Skin and internal malignancy ctd

6. Superficial thrombophlebitis
- carcinoma of the pancreas
7. Palmo-plantar Keratodema
8. Generalized pruritus

Skin and internal malignancy ctd

7. Palmo-plantar Keratodema

Endocrine disease , diabetes and the skin

Skin manifestations of diabetes
Specific and non specific lesions
Specific lesions
- necrobiosis lipoidica
- diabetic dermopathy
- diabetic bullae
- limited joint mobility with waxy skin

Endocrine disease , diabetes and the skin

Skin manifestations of diabetes
necrobiosis lipoidica

Endocrine disease,diabetes and the skin ctd

Skin manifestations of diabetes ctd
Non specific
- diffuse granuloma annulare
- xanthomas
- candidal infections
- staphylococal infections
- neuropathic ulceration
- ischaemic changes

Endocrine disease,diabetes and the skin ctd

Skin manifestations of diabetes ctd
diffuse granuloma annulare

Endocrine disease,diabetes and the skin ctd

Skin manifestations of diabetes ctd
xanthomas

Endocrine disease diabetes and the skin ctd

Hypothyroidism
- Alopecia( including eyebrows)
- Coarse hair
- Dry puffy yellowish skin
- Asteotoic eczema
- xanthomas

Endocrine disease diabetes and the skin ctd

Hypothyroidism

Endocrine disease ,diabetes and the skin ctd

Hyperthyroidism
- pretibial myxoedema- specific
- pink soft skin
- hyperhidrosis
- alopecia
- pigmentation
- onycholysis
- clubbing

Endocrine diseases ,diabetes and the skin ctd

Cushing,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 diseases

Systemic 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 ctd

Systemic lupus erythematosus
Disease specific manifestations
- acute skin lesions
butterfly rash
generalized erythema
bullous lesions

Skin manifestation of connective tissue diseases ctd

Systemic lupus erythematosus
butterfly rash

Cutaneous manifestation of connective tissue disease ctd

Systemic 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 diseases

Systemic 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 diseases

Systemic lupus erythematosus ctd
- Discoid lupus

Skin manifestations of connective tissue disorders

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

Skin manifestations of connective tissue diseases

Rheumatoid 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 ctd

Rheumatoid 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 ctd

Rheumatoid arthritis ctd
pyoderma gangrenosum

Skin manifestations connectinve tissue diseases ctd

Rheumatoid 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 ctd

Dermatomyositis
Is an idiopathic inflammatory myopathy
with characteristic cutaneous findings
Characteristic cutaneous features
heliotrope rash
Gottron papules

Skin manifestations of connective tissue diseases ctd

Dermatomyositis ctd
Other cutaneous features
- malar erythema
- poikiloderma in a photosensitive distribution
- violaceous erythema on extensor surfaces
- periungual and cuticular changes

Skin manifestations of connective tissue diseases ctd

Systemic sclerosis

Is a chronic disease of unknown cause

characterized 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 ctd

Systemic sclerosis ctd
Skin
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

Skin manifestations of connective tissue diseases ctd

Systemic sclerosis ctd
Skin
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 ctd

Systemic 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 ctd

Systemic sclerosis ctd

Skin manifestation of connective tissue diseases ctd

Systemic sclerosis
Vascular 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

Skin manifestations of liver diseases

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

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 skin

Malnutrition
itching
dryness
symmetrical pigmentation
brittle nails and hair
Protein malnutrition ( Kwashiorkor)
dry red brown hair
pigmented cracked skin

Nutrition and the skin ctd

Iron deficiency
pallor
itching
diffuse hair loss
koilonychia
smooth tongue
Vitamin A deficiency
dry skin
follicular hyperkeratosis

xeropthalmia

Nutrition and the skin

Vitamin B1deficiency
- Beri- beri oedema
Vitamin B7 ( Niacin) deficiency
- pellagra with dermatitis, dementia
and diarrhoea
- dermatitis on exposed areas,
pigmented

Nutrition and the skin

Vitamin 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