Quick Tips on Recognizing Cutaneous Manifestations of Systemic Disease

FEATURE ARTICLE

2.0 Quick Tips on Recognizing Contact Hours Cutaneous Manifestations of Systemic Disease

Jennifer Cittadino

ABSTRACT: Although many skin manifestations are isolated This article will concentrate on nonmalignant cutaneous to a dermatological disorder, some skin manifestations can manifestations of systemic disease. The body systems will berelatedtoadeeper,moresystemicissue.Theskinis be reviewed, and their associated skin manifestations will be related to other body systems and functions. The impor- discussed. Some of the skin manifestations can be seen in tance of being able to recognize these dermatological multiple systemic disorders, such as erythema nodosum, manifestations and associate them with potential systemic which can be seen in pulmonary disorders, collagen and disease can be a critical diagnostic tool for the practitioner. vascular disorders, and gastrointestinal disorders. Pictures Sometimes, these skin manifestations can be the first sign will be provided when possible. of an internal disease. Although challenging, recognition, prompt diagnosis, and treatment can alter the course of a CARDIOVASCULAR AND PULMONARY SYSTEM life-threatening illness. There are several general cutaneous signs of cardiovascular Key words: Cutaneous, Dermatology, Systemic, Skin disease that may commonly be seen. These findings may include edema, cyanosis, clubbing of the nails, and corneal he skin is the largest organ in the body and one arcus. The corneal arcus appears as a gray-white ring around of the most visible body systems. The skin has the cornea and correlates with age and cholesterol levels. a reciprocal relationship between what is visu- A diagonal earlobe crease is also reported to be a marker for alized on the surface and what is occurring coronary artery disease (Uliasz & Lebwohl, 2008). below the surface, within the body. The ability Elevated cholesterol or lipid disorders may reveal themselves to identify these causal relationships may assist in early cutaneously in xanthomas and xanthelasma. Xanthomas diagnosisT of disease or potential risk factors associated with and xanthelasma are tan, yellow papules and/or plaques or a systemic illness. nodules that can be seen on any area of the skin but are most When assessing the skin, it is important to inspect and noticeable on the face (Porth, 2011; Rigopoulos, Larios, & palpate. During this time, the clinician/practitioner should Katsamba, 2011; see Figure 1). take note of color, moisture, temperature, texture, mobility, Chronic obstructive pulmonary disease and vascular dis- andturgoraswellasnoteifthereisedemaand/orlesions ease may show as clubbing of the fingernails, cyanosis, and (Hogan-Quigley, Palm, & Bickley, 2012). Assessment and delayed capillary refill. Nails may be thick and ridged when the health history are vital in determining an appropriate arterial disease is present (Jarvis, 2012; see Figure 2). diagnosis.

Jennifer Cittadino, PhD, MSN, ANP-BC, Nova Southeastern University, College of Nursing, Ft. Lauderdale, and House Calls Program, Lee Memorial Health Systems, Ft. Myers, FL. The author declares no conflict of interest. Correspondence concerning this article should be addressed to Jennifer Cittadino, 12600 Creekside La., Suite 7, Ft. Myers, FL 33919. E-mail: [email protected] FIGURE 1. Xanthloma and xanthlasma. Courtesy of Google DOI: 10.1097/JDN.0000000000000147 images, labeled for reuse.

VOLUME 7 | NUMBER 4 | JULY/AUGUST 2015 205

Copyright © 2015 Dermatology Nurses' Association. Unauthorized reproduction of this article is prohibited. Gastrointestinal System Cirrhosis of the liver can be identified externally by ob- serving for spider angioma (Figure 3), unilateral nevoid telangiectasis, jaundice (Figure 4) and alterations in pigment from deposition of bilirubin into the tissues, loss of axillar and pubic hair, and coagulation defects (Porth, 2011). Ulcerative colitis and Crohn’s disease may exhibit erythema nodosum, a delayed hypersensitivity reaction. This FIGURE 2. Clubbing of fingers. Courtesy of Google images, manifestation is also present in several other systemic ill- labeled for reuse. nesses such as strep pharyngitis, sarcoidosis, tuberculosis, Behcet’s disease, Hepatitis B, leukemia, and lymphoma (Cahill Sarcoidosis is an inflammatory illness that usually affects & Sinclair, 2005). There is also the possibility of vesiculo- the lungs first as they are the most common area for gran- pustular eruptions such as pyoderma gangrenosum. Pyoderma uloma formation. The granulomas may also invade other gangrenosum can appear as pustular, bullous, ulcerative, or tissues and organs. Skin involvement includes papules and vegetative. It is rare and appears because of an abnormal plaques and enlarged lymph nodes, especially in the chest immune reactivity (Jarvis, 2012). It may begin as a nodule (Porth, 2011). Erythema nodosum may also be present and progress through stages changing to a pustule, followed (Cahill & Sinclair, 2005). by a central necrosis, to edema with an erythematous border (Carlesimo et al., 2014; Figure 5). Musculoskeletal System Systemic lupus erythematosus can present externally with Renal System a malar or butterfly rash across the cheeks and nose. It can Some of the cutaneous manifestations of renal system disease also present itself with a discoid-appearing rash and vas- can include one of the most commonly seen skin conditions culitis including Raynaud’s phenomenon. Alopecia is com- in renal patients, uremic pruritus, and nail disorders. Uremic mon. Lesions of the mucus membranes occur and are most pruritus or renal itch is very common in renal patients, al- often seen during exacerbation of the illness (Porth, 2011). though 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).

Endocrine System 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

FIGURE 3. Spider angioma. Courtesy of Google images, FIGURE 4. Jaundice. Courtesy of Google images, labeled for labeled for reuse. reuse.

206 Journal of the Dermatology Nurses’ Association

Copyright © 2015 Dermatology Nurses' Association. Unauthorized reproduction of this article is prohibited. FIGURE 5. Erythema nodosum. Courtesy of Google images, labeled for reuse. foot, yellowed skin because of carotenodermia, and acanthosis nigricans (Figure 6). Diabetic rubeosis, burning mouth (xerostomia), and yellowing of the nails may also FIGURE 7. Acanthosis nigricans. Courtesy of Google images, labeled for reuse. be found (Hogan-Quigley et al., 2012; Rigopoulos et al., 2011). atrophy of the skin, and truncal obesity (Porth, 2011; Thyroid disease and its skin manifestations are fairly Rigopoulos et al., 2011). common. In hypothyroidism, patients may complain of Addison’s disease, or adrenal insufficiency, may also hair loss on the pubic and axilla areas and/or the lateral manifest cutaneously. Patients with this disease can have a portion of eyebrows. The patient with hypothyroid disease darkening discoloration of the skin. Patients are often thought may also experience thinning or brittle hair of the scalp. The to be tanned (Figure 8). Hyperpigmentation may be noted nails can become brittle or show poor growth. The hypo- in such areas as the vermillion border, areola, perineum, thyroid patient can also experience periorbital edema and pressure points, and palmar creases (Jarvis, 2012; Rigopoulos thickening of the lips and tongue (Hogan-Quigley et al., et al., 2011). 2012; Rigopoulos et al., 2011). In hyperthyroidism, the patient may experience facial Integumentary System flushing; warm, moist, smooth skin; erythema of the palmar Nail changes may be seen in systemic illness such as mal- surface; alopecia; excessive sweating; pruritus; and onychol- nutrition. This can be exhibited as Beau’s lines, which are ysis. Graves’ disease has many of the same cutaneous man- horizontal depressions in the nail. Hypothyroidism can cause ifestations as hyperthyroidism, but in addition, there may brittle or splitting nails. Fungal or nail infections can be seen be goiter, myxedema, digital clubbing, and soft tissue swell- in systemic illness such as diabetes and in persons on ing 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,

FIGURE 6. Acanthosis nigricans. Courtesy of Google images, FIGURE 8. Addison’s disease. Courtesy of Google images, labeled for reuse. labeled for reuse.

VOLUME 7 | NUMBER 4 | JULY/AUGUST 2015 207

Copyright © 2015 Dermatology Nurses' Association. Unauthorized reproduction of this article is prohibited. immunosuppressive therapy such as transplant patients. a cutaneous manifestation and possible concurrent systemic Spoon-shaped nails may be seen in iron deficiency anemia illness, it is imperative to perform a comprehensive diagnostic (Weber & Kelley, 2010). workup. The practitioners’ understanding and early inter- Hair changes can be seen from malnutrition, anemia, vention of cutaneous manifestations of systemic disease may and hormonal disorders. Similar to hypothyroidism, iron improve patient outcomes and quality of life. h deficiency may cause hair to become dry, brittle, and dull or cause hair loss (Ngan, 2014). In the African American pop- ulation, malnutrition can cause hair color to change to a REFERENCES copper red color (Weber & Kelley, 2010). Hirsutism, an in- Cahill, J., & Sinclair, R. (2005). Cutaneous manifestations of systemic disease. Australian Family Physician, 34(5), 335Y340. crease in fine hair on the body such as the upper lip or sides Carlesimo, M., Narcisi, A., Rossi, A., Saredi, I., Orsini, D., Pelliccia, S., I Cox, M. C. of face, can be caused by certain medications or hormonal (2014). Cutaneous manifestations of systemic non-Hodgkin lymphomas (NHL): abnormalities such as increased androgen and cortisol, steroids Study and review of literature. Journal of the European Academy of Der- matology and Venereology, 28(2), 133Y141. doi:10.1111/jdv.1201 use, or ovarian tumors (Porth, 2011). Hogan-Quigley, B., Palm, M. L., & Bickley, L. (2012). Bates’ nursing guide Toxic erythema may present in cases of toxic shock to physical examination and history taking. Philadelphia, PA: Lippincott syndrome or StevensYJohnson syndrome. Investigative history Williams & Wilkins. Jarvis, C. (2012). Physical examination and health assessment. St. Louis, taking is key to early diagnosis for these manifestations. MO: Elsevier Saunders. The ability to ask the right questions will assist the provider Ngan, V. (2014). Iron deficiency. Retrieved from http://www.dermnetnz.org/ in determining if the rash is a viral exanthema or drug systemic/iron-deficiency.html Porth, C. M. (2011). Essentials of pathophysiology (3rd ed.). Philadelphia, PA: reaction or a more serious rash such as toxic epidermal Lippincott Williams & Wilkins. necrolysis (Cahill & Sinclair, 2005). Rigopoulos, D., Larios, G., & Katsambas, A. (2011). Skin signs of systemic diseases. Clinics in Dermatology, 29(5), 531Y540. doi:10.1016/j.clindermatol .2010.09.021 CONCLUSION The Merck Manual. (2013). Chronic kidney disease. Retrieved from http:// www.merckmanuals.com/professional/genitourinary_disorders/ This article provides the clinician with a foundational aware- chronic_kidney_disease/chronic_kidney_disease.html ness for identification of common cutaneous manifestations Uliasz, A., & Lebwohl, M. (2008). Cutaneous manifestations of cardiovascular of systemic disease, which may present during a physical as- diseases. Clinics in Dermatology, 26(3), 243Y254. doi:http://dx.doi.org/10.1016/ j.clindermatol.2007.10.014 sessment. This article is not meant to be a comprehensive Weber, J., & Kelley, J. (2010). Health assessment in nursing (4th ed.). list of these manifestations. When a patient presents with Philadelphia, PA: Lippincott Williams & Wilkins.

Instructions: & No Internet access? Call 1-800-787-8985, for other The ANCC’s accreditation status of Lippincott & Read the article on page 205. rush service options. Williams & Wilkins Department of Continuing Education & Take the test, recording your answers in the test answers & Questions? Contact Lippincott Williams & Wilkins: refers only to its continuing educational section (Section B) of the CE enrollment form. Each 1-800-787-8985. activities and does not imply Commission on question has only one correct answer. Registration Deadline: August 31, 2017 Accreditation approval or endorsement of any & Complete registration information (Section A) and commercial product. course evaluation (Section C). Provider Accreditation: & Mail completed test with registration fee to: Broad Data Lippincott Williams & Wilkins, publisher of Journal of Disclosure Statement: Dermatology Nursing, will award 2.0 contact hours for this Systems, Inc, 74 Brick Blvd, Bldg 4, Suite 206, The authors and planners have disclosed that they have no continuing nursing education activity. Brick, NJ 08723. financial relationships related to this article. & Within 4Y6 weeks after your CE enrollment form is Lippincott Williams & Wilkins is accredited as a provider of Payment and Discounts: received, you will be notified of your test results. continuing nursing education by the American Nurses & The registration fee for this test is $10.00 members; & If you pass, you will receive a certificate of earned contact Credentialing Center’s Commission on Accreditation. $20.00 nonmembers. hours and answer key. If you fail, you have the option This activity is also provider approved by the California & If you take two or more tests in any nursing journal of taking the test again at no additional cost. Board of Registered Nursing, Provider Number CEP 11749 published by LWW and mail them together, then deduct & A passing score for this test is 13 correct answers. for 2.0 contact hours. Lippincott Williams & Wilkins is $0.95 from the price of each test. & Need CE STAT? Visit www.nursingcenter.com for also an approved provider of continuing nursing education & We offer special discounts for as few as six tests immediate results, other CE activities, and your by the District of Columbia and Florida #50-1223. Your and institutional bulk discounts for multiple tests. personalized CE planner tool. certificate is valid in all states. Call 1-800-787-8985, for more information.

For more than 33 additional continuing education articles related to dermatology, go to NursingCenter.com\CE.

208 Journal of the Dermatology Nurses’ Association