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The Gut and the Skin LIONEL Postgrad Med J: first published as 10.1136/pgmj.46.541.664 on 1 November 1970. Downloaded from Postgraduate Medical Journal (November 1970) 46, 664-670. The gut and the skin LIONEL FRY B.Sc., M.D., M.R.C.P. Consultant Dermatologist, St Mary's Hospital, London, W.2 A CONSIDERABLE amount of work has been carried and in coeliac disease (Badenoch, 1960). The pig- out on the relationship between the small intestine mentation may occur on the oral mucosa and be and the skin in various disorders during the past indistinguishable from that found in Addison's decade and this article will be concerned with the disease. The pigmentation on the skin may be small intestine rather than the whole of the alimen- generalized but is more likely to occur in light- tary tract. exposed areas and as post-inflammatory hyper- The exact relationship between the small intestine pigmentation if there is associated eczema. The and skin disease has posed many problems in the palms, however, tend to be spared (Cooke, Peeney past and how one organ may influence the other is & Hawkins, 1953). still unknown in the majority of instances. Methods Dermatitis has been described in association with for the small intestine have coeliac disease by several authors, and the investigating improved incidence copyright. during the last few years particularly with the advent has been stated as seven out of fifteen patients of per-oral small intestinal biopsy. When a patient (Bennett, Hunter & Vaughan, 1932), 20% ofpatients has 'disorders' both of the small intestine and skin in a series of 100 reported by Cooke et al. (1953) and it is important that the 'primary' disease is estab- 10% in a series reported by Badenoch (1960). In a lished and appropriate treatment given and for this number of patients the skin disease may be severe purpose it has to be appreciated which investigations and be the presenting symptom of the small intesti- for the small intestine should be performed, and what nal disorder (Badenoch, 1960; Wells, 1962; Freid- are the limitations of these investigations, in asso- man & Hare, 1965). ciation with skin disease. The appearances of the dermatitis are variable At the present time the association of small and non-specific. It has been described as desqua- http://pmj.bmj.com/ intestine and skin disease may be considered under mating, psoriasiform, and frequently pigmented the following subgroups. (Cooke et al., 1953). Wells (1962) in his series of six 1. A non-specific relationship in which: (a) pri- patients with malabsorption described discoid mary disease of the small intestine causes non- eczematous lesions, generalized eczema (erythro- specific changes in the skin, (b) primary disease of derma) and prurigo nodularis. In the four patients the skin produces non-specific changes in the small described by Friedman & Hare (1965) the eczema was intestine. generalized in three and consisted of only dry scaly 2. A specific relationship. A particular disease- patches in the other one. The eczema is, therefore, on October 5, 2021 by guest. Protected entity of the skin is associated with a particular not always widespread. disorder of the small intestine. Acquired ichthyosis. A dry scaly skin has been 3. A generalized disease process which affects reported in association with coeliac disease (Thay- both the skin and the gut but which is not necessarily sen, 1932). confined to these two organs, e.g. systemic sclerosis Hair changes. Premature greying of the hair has or polyarteritis nodosa. Since these disorders are not been described in coeliac disease (Cooke et al., 1953) primary disorders of the skin or gut they will not and the hair is invariably of a fine texture. The hair be discussed in this article. tends to grow poorly: in men shaving may only be necessary two or three times a week, and in some Skin changes due to primary disorder of the small patients axillary hair is lost. intestine Nail changes. Clubbing of the nails may occur in Pigmentation of the skin has been described in coeliac disease, and koilonychia may be present due tropical sprue (Manson-Bahr & Willoughby, 1930) to iron deficiency. Brittle nails with transverse Postgrad Med J: first published as 10.1136/pgmj.46.541.664 on 1 November 1970. Downloaded from The gut and the skin 665 grooves have been described in coeliac disease and However, the high incidence of small intestinal attributed to hypocalcaemia (Simpson, 1954). abnormality and steatorrhoea due to skin disease Purpura. Purpura occurred in ten of the 100 reported by Shuster and his colleagues (Shuster & patients described by Cooke et al. (1953). The con- Marks, 1965, Shuster et al., 1967) has not been con- dition is thought to be due to prothrombin deficiency firmed by other reports. In a study of sixteen patients due to malabsorption of vitamin K. with eczema and three with psoriasis (Fry, McMinn Apart from the purpura due to vitamin K mal- & Shuster, 1966) structural abnormality of the small absorption there is as yet no satisfactory explanation intestinal mucosa was found in only three patients for the skin changes (described above) seen in pri- with eczema, one patient had a macroscopically flat mary malabsorptive states. Dent & Garretts (1960) biopsy and was subsequently shown to have gluten- described a patient with hypocalcaemia and steator- sensitive enteropathy by response to a gluten-free rhoea whose eczema improved when the serum cal- diet, and the other two patients had a convoluted cium was raised with AT 10. Hypocalcaemia has appearance of the small intestinal mucosa. Faecal also been reported to exacerbate psoriasis, and cor- fat excretion was not measured in the patients re- rection of the serum calcium improves the skin dis- ported by Fry et al. (1966) and the patients with order (Vickers & Sneddon, 1963). However, hypo- eczema were investigated because the condition was calcaemia was not present in the four patients with extensive and/or chronic, and those with psoriasis probable coeliac disease and eczema reported by because the condition was extensive. In another study Friedman & Hare (1965). These patients' skin con- Doran, Everett & Welsh (1966) performed intesti- dition improved with a gluten-free diet, and when nal biopsies in four patients with extensive eczema gluten was re-introduced to the diet in one patient and estimated faecal fat excretion in three patients, the skin condition relapsed within 2 hr suggesting a but found no abnormality in either of these investi- possibly hypersensitivity reaction to gluten. The gations. Correia, Esteves & Brandao (1967) investi- possibility exists that the changes in the skin are not gated fifteen patients with psoriasis; the faecal due to any specific deficiency but to a combination of excretion was normal in all, and the jejunal biopsy multiple deficiencies. Dryness of the skin, acquired was normal in fourteen of fifteen patients. However, ichthyosis, defective hair and nail growth, and pig- no information was given as to the extent of the copyright. mentation are also seen in malnutrition from causes psoriasis in these patients. other than coeliac disease. At the present time it is not known if the small intestinal changes described in eczema and psoriasis Effect of skin disease on the small intestine (by Shuster & Marks, 1965, and Shuster et al., 1967) Shuster & Marks (1965) coined the term dermato- revert to normal after treatment of the skin (Shuster genic enteropathy in their report of ten patients with et al., 1967), but apparently the steatorrhoea does extensive eczema or psoriasis. Nine of the ten patients regress (Shuster & Marks, 1965). had steatorrhoea (faecal stearic acid excretion above The significance and cause of the steatorrhoea 5 g daily). On treatment of the skin disease with and structural abnormality of the small intestine in http://pmj.bmj.com/ topical measures only, the faecal fat excretion fell in eczema and psoriasis are speculative. The structural seven patients, and it fell below 5 g per day in four changes described by Shuster & Marks (1965) and patients. However, intestinal biopsies were not per- Shuster et al. (1967) have been described in control formed before and after treatment in any one patient. subjects by Baker et al. (1962), but these were Asians As a result of these findings Shuster & Marks sug- and the changes were not found in European sub- gested the gut changes were due to the skin disease. jects by Girdwood et al. (1966). However, Townley, In a subsequent study of forty-six patients with Cass & Anderson (1964) have suggested that a psoriasis, Shuster, Watson & Marks (1967) reported 'leafy' and convoluted appearance in the upper small on October 5, 2021 by guest. Protected steatorrhoea in approximately 50%4 of the patients intestine does not necessarily mean a disease process, studied and found a correlation between the extent as the changes can be brought about by hydro- of skin involvement and the steatorrhoea; the more chloric acid. Thus the stomach contents may be extensively the skin was involved, the more likely important in determining the appearances of the the patients were to have steatorrhoea. In addition, small intestine. It could well be asked why, if the in twelve of the twenty-four patients in whom in- structural changes of the small intestine are sig- testinal biopsy was performed, some structural nificant in psoriasis, are they not related to the abnormality of the small intestinal mucosa was found extent of the disease, as is the steatorrhoea? Shuster but the abnormality was not severe in that none had et al. (1967) suggested that the small intestinal a flat biopsy macroscopically (subtotal villous atro- changes seen in psoriasis were mild compared with phy histologically). Unlike the steatorrhoea there those in coeliac disease, but similar to those found in was no connection between the extent of the skin tropical sprue.
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