1. CUTANEOUS
MANIFESTATIONS OF
INTERNAL DISEASES

2. CUTANEOUS MANIFESTATIONS
Diabetes Mellitus
 Thyroid disease
 Adrenal disease
 Renal Disease
 Liver disease
 Rheumatologic disease
 Nutritional disease


3. DIABETES
MELLITUS

4. 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 diabetics

Type I patients get more autoimmunetype lesions
 Type II patients get more cutaneous
infections


5. DIABETES MELLITUS


Cutaneous lesions usually appear after the
development of DM, but may be the first
presenting sign
Four major groups of skin findings
1.
2.
3.
4.
Skin diseases associated with DM
Cutaneous infections
Cutaneous manifestions of diabetic complications
Skin reactions to diabetic treatment

6. 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

7. 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.


8. GRANULOMA ANNULARE (GA)
 Appearance
Ring 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


9. 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

10. 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

11. 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.

12. ACANTHOSIS NIGRICANS
 Appearance
Hyperpigmented,
velvety plaques in
body folds, mostly
axillae and neck
 Can also present
on groin, umbilicus,
areolae,
submammary
areas, and on the
hands


13. 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

14. CANDIDIASIS IN DIABETICS
Fungal infections- most
common
 Candida
 Candidial paronychia
 Inframammary candida
 Genital candida
 Oral candidiasis
 White, curdlike material
adherent to erythematous,
fissured oral commisure;
 angular stomatitis


15. CANDIDIASIS IN DIABETICS

Initial pustules on erythematous base that become eroded
and confluent

16. CANDIDIASIS IN DIABETICS

17. 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


18. 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


19. DIABETIC ERUPTIVE XANTHOMAS
Seen in
uncontrolled
diabetes,
hypertriglyceridemi
a
 Sudden crops on
firm, non-tender
yellow papules with
a red rim on
extensors
 Control of glucose
and lipid reduction
reduce the lesions


20. 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

21. 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


22. 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

23. 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.

24. THYROID DISEASES
Graves disease
Hyperthyroidism
Hypothyroidism

25. 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.

26. 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


27. 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)

28. 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

29. SCLEROMYXEDEMA IN HYPERTHYROIDISM
Firm
white, yellow, or pink papules on face, trunk, axillae, and
extremities

30. SCLEROMYXEDEMA IN HYPERTHYROIDISM
Firm
white, yellow, or pink papules on face, trunk, axillae, and
extremities

31. 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
Pathogenesis :pretibial fibroblasts are the
 Can appear anywhere (arms, shoulders, target for antithyroid antibodies
T cells may be interacting with a
head).
dermal antigen similar to a thyroid
 Histologically, the process involves
autoantigen, with cytokines
dermal accumalation of hyaluronic acid.
subsequently activating fibroblasts to
secrete hyalouronic acid.
Can treat with topical steroids,
intralesional steroids, IV pulse steroids,
or IVIG

32. 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.

33. 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.

34. 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.


35. 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

36. 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


37. 
Thyroid replacement therapy rapidly reverses many
of the cutaneous features of hypothyroidism, with
gradual disappeaarance of excessive dermal
mucopolysaccharides.

38. 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

39. 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

40. ASSOCIATION BETWEEN CUTANEOUS AND
THYROID DISEASE CONTD.

Pemphigus foliaceus
Herpes gestationis
Bullous pemphigoid
Dermatitis herpetiformis

Pemphigus vulgaris

41. ADRENAL DISEASE
Addison’s disease
Hypercortism

42. 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

43. 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

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

45. 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

46. 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

47. 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



o


o





Topical
Moisturizing creams
Capsaicin
Physical treatments
UVB light
parathyroidectomy
Systemic medications
Sedating Antihistamines
Cholestyramine
Alternative strategies
Acupuncture
homeopathy

48. 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 betamelanocyte 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

49. 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

50. 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
disorders
Kyrle’s disease
Elastosis Perforans serpiginosa
Perforating folliculitis
Reactive perforating collagenosis

51. 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

52. 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

53. UREMIC FROST




Was a frequent in the predialysis 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.

54. 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
Normal to red
brown distal half
Proximal half
opaque white

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

57. HAIR ABNORMALITIES
 Sparse
body hair and diffuse alopecia with dry,
lusterless hair
 Decreased secretion of sebum
 Chronic telogen effluvium
 Drugs – Heparin / Statins / Antihypertensives

58. CUTANEOUS MANIFESTATIONS IN PTS ON
DIALYSIS
Diffuse hyperpigmentation
 Accelerated cutaneous
aging




o
Actinic elastosis
Excessive wrinkling of neck(
cutis rhomboidalis nuchae)
Telangiectasias
Skin infections common

59. DERMATOLOGIC DISORDERS ASSOCIATED WITH
RENAL TRANSPLANTATION.
 Drugs
– Steroids, Immunosuppresants
 Infections




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

60. LIVER DISEASE
Chronic liver disease
Hepatitis B,C

61. CHRONIC LIVER DISEASES
Jaundice
 Because of raised
levels of bilirubin more
than 2.5-3.0mg/dl
 Diffuse
hyperpigmentation


62. 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.

63. 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)


64. CHRONIC LIVER DISEASES
Pruritus
 Recurrent purpura
 Xanthoma straitum
palmare

(Multiple xanthomas may appear
as yellowish plaques covering
large areas of skin in palmar
creases)

65. CHRONIC LIVER DISEASES

Ascites leads to
striae distensae

dupuytren's
contracture

66. 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

clubbing
Terry‟s nails
Muehrcke‟s nails

67. HEPATITIS C
Porphyria Cutanea Tarda
Lichen Planus
Necrolytic acral erythema

68. 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

69. LICHEN PLANUS
Variable association of
0.1% to 35%
 Associated with LP ,
especially in mucosal,
generalised or long
standing LP
 Purple, pruritic, polygonal
papules


70. 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

71. HEPATITIS B
About 30% may
have Urticaria or
present a serum
sickness like picture
(because of
circulating immune
complexes)
 Associated with 57% cases of
Polyarteritis nodosa




Classical PAN
Renal vasculitis present
ANCA negative

72. SYSTEMIC LUPUS
ERYTHEMATOSUS

73. SYSTEMIC LUPUS ERYTHEMATOSUS

Malar erythema

Discoid plaques or psoriasiform erythroderma

Photosensitivity, alopecia and mucosal ulcers

Raynaud‟s phenomenon

Periungual erythema

74. MALAR ERYTHEMA

75. MUCOSAL ULCERS

76. ALOPECIA

77. ANNULAR PSORIASIFORM MACULES AND PATCHES

78. ANNULAR PSORIASIFORM MACULES AND PATCHES

79. ANNULAR PSORIASIFORM MACULES AND PATCHES

80. Periungual erythema

81. DERMATOMYOSITIS

82. HELIOTROPE RASH IN
DERMATOMYOSITIS

Heliotrope rash
(violaceous erythema) of
periorbital skin

83. DERMATOMYOSITIS

Shawl sign

84. DERMATOMYOSITIS-HOLSTER SIGN

85. SYSTEMIC SCLEROSIS

86. CRITERIA FOR DIAGNOSIS: 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

87. SCLERODACTLY
Sclerodactyly

88. SCLERODERMATOUS PLAQUES

89. MASK LIKE
bird-like faciesFACIES
Smoothening of
lines of facial
expressions
 Pinched nose
 Radial furrows
around mouth


90. Periungual erythema and hemorrhage
NAIL FOLD CHANGES
Periungual erythema and hemorrhage

91. GASTROINTESTINAL DISEASES

92. 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

93. Henoch-Schönlein purpura

94. Henoch-Schönlein purpura

95. PYODERMA GANGRENOSUM

Seen in 10% of ulcerative
colitis patients

rapidly expanding ulcer
with purple undermined
border start as pustules

96. 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



97. CARDIAC
DISEASES

98. 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

99. 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 cyanosis
o Mixed
 Pulmonary odema
 Cardiogenic shock


100. 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


101. FLUSHING
Severe Mitral
stenosis
 Tumours
producing
vasoactive
sunstances
 Carcinoid
tumours
 Multiple
endocrine
neoplasia type
Iia
 Systemic
mastocytosis


102. 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


103. 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

104. 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

105. CUTANEOUS SIGNS INDICATIVE OF
INTERNAL DISEASES
oErythema
nodosum
oAcanthosis
oPyoderma
oAcquired
nigricans
gangrenosum
ichthyosis
oGeneralised
pruritus without an eruption

106. 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

107. Causes of Erythema Nodosum
Idiopathic
About 20% of cases
Bacterial
Streptococci, TB, leprosy, Yersinia,
Mycoplasma, Rickettsia
Fungal
Coccidioidomycosis
Viral
Cat-scratch fever
Drugs
Sulphonamides, oral contraceptives
Systemic
diseases
Inflammatory bowel disease,
sarcoidosis, Behçet’s disease,
malignancy (rare)

108. Acanthosis nigricans
Asymptomatic brown velvety plaques of coalescent papules
Affects flexures - neck, axillae, groin
Potential causes
obesity
endocrine disorders
(acromegaly, insulinresistant diabetes)
Inherited
GI malignancy

110. 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

111. 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)

112. 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

113. THANK YOU