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Dermatological Manifestations of Chronic Liver Disease

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Dermatological Manifestations of Chronic Liver Disease International Journal of Research in Dermatology Choudhury BN et al. Int J Res Dermatol. 2018 May;4(2):224-229 http://www.ijord.com DOI: http://dx.doi.org/10.18203/issn.2455-4529.IntJResDermatol20181824 Original Research Article Dermatological manifestations of chronic liver disease 1 2 2 Bikash Narayan Choudhury *, Anita Jain , Urmila Das Baruah 1 2 Department of Gastroenterology, Department of Dermatology and Venerology, Gauhati Medical College, Guwahati, Assam, India Received: 16 February 2018 Accepted: 21 March 2018 *Correspondence: Dr. Bikash Narayan Choudhury, E-mail: [email protected] Copyright: © the author(s), publisher and licensee Medip Academy. This is an open-access article distributed under the terms of the Creative Commons Attribution Non-Commercial License, which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited. ABSTRACT Background: The present study was conducted to assess the spectrum of cutaneous changes in chronic liver disease and to assess any correlation between the skin findings and the type of the liver disease. Methods: A total of 100 patients above 18 years of age suffering from chronic liver disease with cutaneous manifestations and attending the Gastroenterology and Dermatology and Venereology department of Gauhati Medical College and Hospital, Guwahati, India during the period from June 2016 to May 2017 were included in the study. Results: Out of 100 cases, there were 84 males (84%) and 16 females (16%) with the male to female ratio of 5.25:1. Alcoholic liver disease comprised 62% of the patients in the study, other causes being cryptogenic liver disease (14%), chronic hepatitis infection (12%), Wilson’s disease (2%), autoimmune hepatitis (2%), hepatocellular carcinoma (2%), methotrexate induced liver disease (1%) and non-alcoholic steatohepatitis (1%). Most common skin finding was xerosis (62%). Other key findings included nail changes (60%), pigmentary changes (55%), hair changes (50%), jaundice (40%), cutaneous infections (31%), pruritus (27%). Conclusions: Patients with chronic liver disease can have a wide spectrum of cutaneous manifestations the most important being xerosis, nail changes, pigmentary changes, hair changes, jaundice, infections, pruritus and spider angioma. These changes can give a clue to the presence of the underlying liver disease and its severity. Hence, identifying these signs earlier can lead to prompt diagnosis and effective management of the underlying condition, thereby preventing its complications. Keywords: Skin manifestations, Chronic liver disease 2 INTRODUCTION etiology of the disease. Often skin manifestations can be the first sign of liver disease.3 Jaundice, pigmentation, Chronic liver diseases are one of the leading causes of spider telangiectasias, striae distensae, leukonychia, major health problems worldwide and present as one of palmar erythema, xerosis and loss of pubic and axillary 4-6 the most important cause of morbidity and mortality in hair are recognized sequelae of chronic liver diseases. India. An association between the skin and the liver There are certain dermatoses frequently associated with disease has been recognized since ancient times. The hepatobiliary disorders including lichen planus, urticaria, term spider originated in the New York underworld, porphyria cutanea tarda, Vitiligo, malakoplakia, behcet’s 7,8 where barmaids noted “spiders” as evidence of advanced disease, erythema multiforme and nodosum. Other liver disease in their customers.1 manifestations which are seen with hepatitis B virus and hepatitis C virus infection include rashes, papular Chronic liver diseases can give rise to numerous acrodermatitis, thrombocytopenic purpura, lichen planus, extrahepatic disorders among which dermatological mooren's ulcer, porphyria cutanea tarda, necrotising diseases occupy a central place and at times point to the cutaneous vasculitis. International Journal of Research in Dermatology | April-June 2018 | Vol 4 | Issue 2 Page 224 Choudhury BN et al. Int J Res Dermatol. 2018 May;4(2):224-229 Liver diseases can also result in various forms of was considered to be significant. Anova test and secondary dyslipoproteinemias like hypertriglyceridemia independent t-test were also done wherever required. and low levels of high-density lipoproteins, which manifest in the form of xanthelasmas in the skin, RESULTS presenting as soft, yellowish asymptomatic plaques especially over the eyelids.9 Out of 100 cases, there were 84 males (84%) and 16 females (16%) with the male to female ratio of 5.25:1. In Patients with chronic liver disease may develop thinning this study, most of the patients had more than one of hair and hair loss. Nail changes in cirrhosis includes cutaneous manifestation. The most common cause of clubbing, thickening of nails, longitudinal ridging, white chronic liver disease was alcoholic liver disease. bands (Muehrke’s bands), and brittle nails.10,11 Those Alcoholic liver disease comprised 62% of the patients in with advanced cirrhosis can present with Terry’s nails the study, other causes being cryptogenic liver disease characterized by a ground glass opacity of nail plate (14%), chronic hepatitis infection (12%), Wilson’s which turns powdery white at its proximal end.12 Bluish disease (2%), autoimmune hepatitis (2%), hepatocellular discoloration of lunulae may be found in patients with carcinoma (2%) methotrexate induced liver disease(1%) Wilson’s disease known as Azure lunulae. Splinter and non-alcoholic steatohepatitis (1%). 4% of the patients hemorrhages and hypertrophic osteopathy can also occur had both hepatitis B and alcohol induced liver disease in cirrhosis.13 (Figure 3). A number of patients with chronic liver disease have nutritional deficiencies predominantly of vitamin B- 70 complex and folic acid. Deficiency of these vitamins 60 leads to changes in skin, nails, hair, and mucosa. 50 Deficiency of iron and zinc also commonly present in 40 patients with chronic liver disease and may lead to certain 30 skin changes. 20 Early detection by recognizing skin manifestations may 10 help to initiate early treatment and reduce serious 0 complications, sequelae, morbidity and mortality of chronic liver diseases. The present study is aimed to study the cutaneous manifestations and particular pattern linked to etiology of liver disease. METHODS Hospital based cross- sectional observational study was Figure 1: Cutaneous features in chronic liver disease. conducted in Gauhati Medical College and Hospital, Guwahati, Assam, India after taking approval from the Xerosis was the commonest skin manifestation seen in institutional ethical committee. 100 patients suffering 62% of the patients. 66.7% of the patients with chronic from chronic liver disease with cutaneous manifestations viral hepatitis and 64.5% of patients with alcoholic liver above 18 years of age who didn’t have established skin disease had xerosis. However, the association was not disease prior to the onset of chronic liver disease, statistically significant (p>0.05). Pigmentary changes presenting to the Department of Gastroenterology and were seen in 55% cases which manifested in two forms, Department of Dermatology and Venereology of Gauhati as guttate hypopigmentation (40% cases) and Medical College and Hospital from June 2016 to May hyperpigmentation (24% cases). Out of which, 9 patients 2017 were included in this study. had both guttate hypopigmentation and hyperpigmentation. Other important changes seen were Detailed history taking and complete clinical examination jaundice (40%), skin infections (31%), pruritus (27%), was done and the clinical data was recorded as per the ecchymosis (22%), striae distensae (18%), dilated veins proforma. Routine and relevant investigations were over the abdomen (15%), spider angiomas (14%) and recorded for all patients. Dermatological investigations palmar erythema (3%) (Figure 1). including nail clippings and skin scrapings with 10% potassium hydroxide mount, skin biopsy for There was a positive correlation between increased histopathology, pus for culture and sensitivity whenever international normalized ratio (INR) values and presence required were done. of petechiae/purpura/ecchymosis (p<0.05). The mean INR in patients who had petechiae/purpura/ecchymosis Data was analyzed using the Statistical Package for the was 1.54 as compared to 1.22 in patients without the Social Sciences (SPSS) version 17. Significance was findings (Table 1). tested using chi-square test; a p value of less than 0.05 International Journal of Research in Dermatology | April-June 2018 | Vol 4 | Issue 2 Page 225 Choudhury BN et al. Int J Res Dermatol. 2018 May;4(2):224-229 Table 1: Petechiae/purpura/ecchymosis and INR. clubbing (10%), brittle nails (8%), onychomycosis (5%) and longitudinal melanonychia (5%). Petechiae/ No. of INR Std purpura/ patients (Mean) deviation ecchymossis 18 16 Present 22 1.54 0.284 14 12 Absent 78 1.22 0.188 10 8 6 4 Table 2: Petechiae/purpura/ecchymosis and MELD 2 0 score. Petechiae/ Mean No. of Std purpura/ MELD patients deviation ecchymossis score Present 22 15.23 5.299 Absent 78 12.76 5.046 Figure 2: Nail changes in chronic liver disease It was also found that patients with petechiae/purpura/ patients. ecchymosis had more severe liver disease compared to patients who didn’t have the lesions. The mean model Leuconychia was seen in 6% of the patients and end stage liver disease score (Table 2) in patients with onycholysis was seen in 3%
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