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 Tdiagnosis 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 ery- thema 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 acan- thosis 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 ex- hibit 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