CUTANEOUS
MANIFESTATIONS OF
INTERNAL DISEASES
JURAJ HEGYI

Cutaneus Manifestations
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Diabetes mellitus

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Thyroid disease

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Adrenal disease

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Renal disease

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Liver disease

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Rheumatologic disease

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Nutritional disease

Diabetes Mellitus
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Approximately 30% of patients with DM develop

skin lesions at some point
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Overall prevalence of cutaneous disorders does not

differ between type I and type II diabetics
Type I patients get more autoimmune type lesions
Type II patients get more cutaneous infections

Diabetes Mellitus
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Cutaneous lesions usually appear after the
development of DM, but may be the first presenting
sign
Four major groups of skin findings:
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Skin diseases associated with DM

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Cutaneous infections

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Cutaneous manifestions of diabetic complications

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Skin reactions to diabetic treatment

Necrobiosis Lipoidica (NL)
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NL is 3x more common in women.
NL appears earlier (mean age 22) in Type I diabetics
than Type II (mean age 49.)
Begins as an oval, violaceous patch and expands
slowly.

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Advancing border is red.

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Central area turns yellowish brown.

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Central area atrophies and telangiectasia become
evident.
13% of cases progress to ulceration

Necrobiosis Lipoidica (NL)
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Classically, NL occurs bilaterally on the pretibial or
medial malleolar areas
Not painful
Spontaneous resolution occurs in 13-19% with
residual scarring

Necrobiosis Lipoidica (NL)

Granuloma Annulare (GA)
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Ring of small, firm, flesh-colored or red papules
Localized, most frequently found on lateral and dorsal
surfaces of hands and feet

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Can spontaneously regress without scarring

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Scarification or cryotherapy as form of treatment

Granuloma Annulare (GA)

Diabetic Bullae (DB)
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Approximately 0.5% of diabetics

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Two types have been described

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More frequent, non-scarring lesions with a histologic
intraepidermal split without acantholysis

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Less common, occasionally hemorrhagic bullae that
heal with scarring, slight atrophy, and have a histologic
subepidermal split

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

Diabetic Bullae (DB)
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Bullae tend to heal spontaneously in 2-5 weeks

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Diagnosis of exclusion

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DDx: bullous pemphigoid, epidermolysis bullosa
acquisita, porphyria cutanea tarda, bullous impetigo,
erythema multiforme
May recur in the same or new locations

Diabetic Bullae (DB)

Acanthosis Nigricans (AN)
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Seen in situations of insulin resistance
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

Acanthosis Nigricans (AN)
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May be related to insulin binding insulin-like growth
factor receptors on keratinocytes and dermal
fibroblasts, thus stimulating growth
Hyperpigmented, velvety plaques in body folds, mostly
axillae and neck

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Can also present on groin, umbilicus, areolae,
submammary areas, and on the hands

Acanthosis Nigricans (AN)

Skin Infections in DM
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Occur in 20-50% of poorly controlled diabetics

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More common in Type II

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May be related to
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Abnormal microcirculation

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Hyperglycemia

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Neuropathy

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Decreased phagocytosis

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Impaired leukocyte adherence

Candidiasis

Bacterial Infections

Diabetic Dermopathy (DD)
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Pigmented pretibial papules

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Most common cutaneous manifestation of diabetes

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Benign asymptomatic red brown macules on shins

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Probably post microtraumatic

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No treatment needed

Diabetic Dermopathy (DD)

Cutaneus Manifestations of Diabetic
Complications
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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

Cutaneus Reactions to Diabetic
Treatment
Allergy
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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
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Circumscribed depressed areas of skin at the insulin injection site
6-24 months after starting insulin

Lipohypertrophy
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Soft dermal nodules that resemble lipomas at sites of frequent
injection
May be a response to the lipogenic action of insulin

Thyroid Diseases
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Hyperthyroidism

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Hypothyroidism

Thyroid Hormones and the Skin
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Thyroid hormones play a pivotal role in the growth and
formation of hair and sebum production
Thyroid hormones stimulate epidermal oxygen
consumption, protein synthesis, mitosis, and
determination of epidermal thickness
There is increased cutaneous blood flow and
peripheral vasodilation

Hyperthyroidism
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Skin is usually warm, moist, and smooth

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Facial redness (flushing)

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Palmar erythema

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Hyperpigmentation, esp. creases of palms and soles
(not mucous membranes)

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Hair is fine and friable, hair loss may be excessive

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History of early graying

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Hyperhydrosis, particularly of palms and soles

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Plummer's nail: concave contour, distal onycholysis

Scleromyxedema
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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

Scleromyxedema

Hypothyroidism
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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
Carotenemia (from decreased hepatic conversion of beta carotene to Vit
A) gives skin yellowish hue (palms, soles, nasolabial folds)
Hair is dry, brittle, coarse with partial alopecia
Loss of hair from lateral 1/3 of eyebrows (lateral superciliary madarosis)
Sign of Herthoge

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Hair growth slows down, the proportion of telogen hair is increased

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Myxedema (mucopolysaccharide deposition)

These changes normalise with normalization of thyroid hormone
levels

Adrenal Insufficiency
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Increased stimulation of melanocortin-2 receptor by
ACTH itself
Pigmentation is maximal over photoexposed areas,
also mucuos membranes, palmar creases, areas
subject to friction, genitalia, areola, axillae, perineum
as well as in scars.
Nails-longitudinal melanonychia

Adrenal Insufficiency

Hypercorticism
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Truncal obesity

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Buffalo hump

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Moon facies

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Slender limbs

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Cutaneous atrophy and telangiectasias

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Fragility with purpura

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Poor wound healing

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Acneform eruptions

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Hirsuitism

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Cigarette paper like wrinkling of skin on dorsum of
hands(liddle‟s sign)
Livid straie on abdomen, breasts, proximal part of limbs

Renal Disease
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Uremia
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Xerosis

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Pruritus

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Pigmentary alterations

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Purpura

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Bullous disease of dialysis

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Calcinosis cutis

Transplant patients
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Malignancies

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Infections

Liver Disease
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Jaundice

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Spider angiomas

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Palmar erythema

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Pruritus

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Xanthoma

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Lichen planus

Liver Disease

Rheumatologic Disease
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Systemic scleroderma
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Symmetrical thickening, tightening, induration of
skin of digits and dorsal hands; may affect entire
extremity and involve face and torso

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Sclerodactyly: Madonna fingers

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Digital pitted scars or loss of finger pad soft tissue

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Bibasilar pulmonary fibrosis

Rheumatologic Disease