Endocrine-skin interactions. Cutaneous manifestations of pituitary disease, thyroid disease, calcium disorders, and diabetes

Cutaneous Manifestations in Autoimmune Polyendocrinopathy-Candidiasis-Ectodermal Dystrophy (APECED): A Comprehensive Review

Autoimmune polyendocrinopathy-candidiasis-ectodermal dystrophy (APECED), or polyglandular autoimmune syndrome type 1 (PAS-1/APS-1), is a rare autosomal recessive disorder linked to mutations in the autoimmune regulator (AIRE) gene. This review provides a detailed analysis of cutaneous manifestations in APECED, focusing on chronic mucocutaneous candidiasis (CMC), alopecia areata (AA), and vitiligo. The classic triad of hypoparathyroidism, adrenal insufficiency, and CMC serves as a diagnostic cornerstone. However, the varied clinical spectrum of APECED, particularly its cutaneous presentations, poses a diagnostic challenge. CMC, often an early sign, varies in prevalence across populations, including Finnish (100%), Irish (100%), Saudi Arabian (80%), Italian (60-74.7%), North American (51-86%), and Croatian (57.1%) populations. Similarly, AA prevalence varies in different populations. Vitiligo also exhibits variable prevalence across regions. The review synthesizes the current knowledge arising from a narrative analysis of 14 significant human studies published in English up to October 2023. Moreover, this paper underscores the importance of early detection and monitoring, emphasizing cutaneous manifestations as key diagnostic indicators. Ongoing research and clinical vigilance are crucial for unraveling the complexities of this rare autoimmune syndrome and enhancing patient care.

Dermatologic manifestations of endocrine disorders

The skin serves as a window for clinicians to understand, diagnose, and monitor endocrine disease. Dermatologic manifestations of endocrinopathies contribute significantly to an individual's health and quality of life. In this review, we outline various disorders of the hypothalamic-pituitary axis, thyroid gland, pancreas, adrenal gland, and androgen axis as well as hereditary endocrine syndromes. In acromegaly, glycosaminoglycan deposition contributes to a thickening of skin and soft tissue, which manifests as coarsening and enlargement of facial and acral structures. Stimulation of the thyrotropin receptor in hyperthyroidism results in mesenchymal tissue proliferation and consequent pretibial myxedema; other associated cutaneous features include onycholysis, and hyperhidrosis. Individuals with hypothyroidism exhibit cold, dry skin and brittle hair as well as a jaundice-like appearance due to carotene excess. The cutaneous features of diabetes mellitus (DM), mediated to a large extent by hyperglycemia and hyperinsulinemia, include necrobiosis lipoidica diabeticorum (NLD), diabetic dermopathy, and acanthosis nigricans. Pediatric patients with Cushing's syndrome almost invariably present with truncal obesity and growth retardation; disruption of collagen formation and the catabolic effects of hypercortisolism result in skin atrophy and purple abdominal striae. In patients with Addison's disease, generalized hyperpigmentation, secondary to elevated levels of melanocyte-stimulating hormone (MSH), is most prominent in sun-exposed areas. Due to hyperandrogenism, individuals with polycystic ovarian syndrome (PCOS) often exhibit hirsutism, acne vulgaris, and androgenetic alopecia. In multiple endocrine neoplasia (MEN) syndromes, specific gene mutations may lead to angiofibromas, lichen amyloidosis, and ganglioneuromas. Disruptions of immune regulation result in autoimmune polyglandular syndromes (APS) and associated clinical features including chronic mucocutaneous candidiasis, vitiligo, and alopecia areata. This paper highlights the underlying pathophysiology, dermatologic manifestations, and treatment of the aforementioned endocrine disorders.

Coexistence of diabetes mellitus type 1 with diffuse systemic sclerosis - case report and literature review

Diabetic sclerodactyly is a frequently recognized skin finding that may occur in patients with diabetes mellitus but coexistence of diabetes and systemic sclerosis is rare. We describe a case of coexistence of type 1 diabetes mellitus and systemic sclerosis in 42-year-old man with the history of Raynaud’s phenomenon, progressive diffuse hardening of the skin and sclerodactyly, slowly worsening with time. The medical history included type 1 diabetes since childhood with microvascular complications. The patient presented a typical capillaroscopic scleroderma-like pattern, antinuclear antibodies and sclerotic lesions in gastrointestinal system. Summing up, our case represents the rare coexistence of autoimmune diseases like diabetes mellitus type 1 and systemic sclerosis.

Skin manifestations of Cushing's syndrome

Among the most common diagnostic manifestations of Cushing's syndrome (CS) are those involving the skin; they include violaceous striae, facial acne, hirsutism, acanthosis nigricans (AN), fungal infections, hyperpigmentation (Hp) and easy bruisability. Fortunately, most resolve within a year or two after cure of CS, although light-colored striae can persist for years depending on the age of the patients. AN, Hp, and bruisability usually resolve within months after cure in almost all ages. Facial plethora (along with acne and other facial skin changes) is a typical sign of CS that is due to increased perfusion. It resolves immediately after curative therapy of CS. Typically, the severity of the manifestations does not correlate with the biochemical indices of the disease, pointing to age, gender, genetic and skin-type differences that determine the cutaneous manifestations of CS.

Dermatologic manifestations of diabetes mellitus: a review

Diabetes mellitus affects every organ of the body including the skin. Certain skin manifestations of diabetes are considered cutaneous markers of the disease, whereas others are nonspecific conditions that occur more frequently among individuals with diabetes compared with the general population. Diabetic patients have an increased susceptibility to some bacterial and fungal skin infections, which account, in part, for poor healing. Skin complications of diabetes provide clues to current and past metabolic status. Recognition of cutaneous markers may slow disease progression and ultimately improve the overall prognosis by enabling earlier diagnosis and treatment.

Skin signs of systemic diseases

The skin should not be considered as an isolated organ but rather as a definite functioning system that communicates with the internal environment. Skin signs of systemic diseases occur frequently and sometimes feature the first symptoms of an internal disease; furthermore, these manifestations may be the sole expressions of otherwise asymptomatic systemic disorders. A number of dermatologic signs, symptoms, and disorders can be invaluable as markers of systemic disease. Although a plethora of specialized modern diagnostic tests are available, the skin still remains the only organ of the body that is immediately and completely accessible to direct clinical examination. This contribution reviews the skin signs of systemic diseases. The description of the clinical features of skin lesions observed in several internal diseases will be useful to general physicians, internists, and dermatologists in the diagnosis of a systemic disease.

Thyroid hormone action on skin

The skin characteristics associated with thyroid hormone are classic. The name "myxedema" refers to the associated skin condition caused by increased glycosaminoglycan deposition in the skin. Generalized myxedema is still the classic cutaneous sign of hypothyroidism. It is caused by deposition of dermal acid mucopolysaccharides, notably hyaluronic acid. Despite its appearance, the skin does not pit with pressure.

The prevalence of diagnosed cutaneous manifestations during ambulatory diabetes visits in the United States, 1998-2002

BACKGROUND

The prevalence of diabetes has been rapidly increasing. Previous reports indicated that diabetics are prone to certain cutaneous diseases.

OBJECTIVE

To determine the frequencies of diagnosed skin conditions during ambulatory diabetes visits in the USA.

METHODS

We evaluated two national ambulatory medical care surveys between 1998 and 2002 and compared the diagnoses of 7 categories of skin conditions in diabetics (n = 9,626) to patients with hypertension (n = 15,997) or gastroesophageal reflux disease (GERD; n = 2,362) using chi2 tests and multivariate logistic regressions.

RESULTS

Diabetics were prone to chronic skin ulcers (odds ratio = 62.5, 95% confidence interval = 3.95-989 compared to GERD; 9.97, 6.34-15.7 compared to hypertension), bacterial skin infections (5.95, 2.86-12.4 compared to GERD; 5.15, 3.74-7.08 compared to hypertension) and fungal skin infections (2.66, 1.15-6.16 compared to GERD; 1.99, 1.32-3.01 compared to hypertension) but not to other skin conditions. These findings remained true during primary care physician visits.

CONCLUSION

Chronic skin ulcers, bacterial and fungal skin infections are more frequently diagnosed in diabetics. We could not verify that other skin conditions are associated with diabetes, in part due to potential underdiagnosis and underreporting.

Dermatologic manifestations of hypopituitarism

Hypopituitarism is characterized by diminished or absent secretion of one or more pituitary hormones. The clinical features of hypopituitarism vary depending on age, rapidity of onset, hormones involved, and degree of deficiency. Dermatologic signs of hypopituitarism may involve alterations in pigmentation, the epidermal and dermal skin structures, and the pilosebaceous unit. We describe the causes and presentation of hypopituitarism with an emphasis on its dermatologic manifestations.

Aspectos dermatológicos da acromegalia

Acromegalia é rara síndrome endócrina que se caracteriza pela hiperplasia mesenquimal. Em geral sua manifestação é insidiosa ao extremo, e, como cursa precocemente com alterações cutâneas, o dermatologista pode ser o primeiro profissional médico a ser procurado pelo paciente. Os autores fazem uma descrição dos achados clínicos e dermatológicos dessa afecção.

Autoimmune thyroid diseases: etiology, pathogenesis, and dermatologic manifestations

Autoimmune thyroid disease (AITD) including Graves' disease, Hashimoto's thyroiditis, and idiopathic hypothyroidism (atrophic Hashimoto's thyroiditis) is of vital concern to the dermatologist. This article reviews the cutaneous manifestations of Graves' disease and Hashimoto's thyroiditis. Recognition of dermatologic manifestations of AITD may alert practitioners to investigate for these disorders. The immune response involved in the pathogenesis of AITD is detailed. Current understanding of the role of genetic and environmental factors, antigens, and apoptosis are elaborated. The future holds exciting insight into the etiology, pathogenesis, and treatment of AITD.

Morfologia e histoquímica da pele de ratas hipotireóideas castradas e não castradas

Foram estudadas as alterações cutâneas de ratas Wistar adultas castradas e não castradas, mantidas em estado hipotireóideo por 120 dias. Dois grupos eutireóideos, um castrado e outro não castrado, serviram de controle. Secções da pele abdominal ventral e torácica dorsal foram coradas pelas técnicas de HE, PAS, azul de alcian (alcian blue), picro-sirius red-luz polarizada e Verhoeff. Adelgaçamento da epiderme, atrofia de glândulas sebáceas, redução parcial ou total de fibras elásticas e do colágeno do tipo III da derme caracterizaram tanto o hipotireoidismo quanto a castração. Retardo no crescimento dos folículos pilosos e hiperceratose foram vistos apenas na deficiência dos hormônios tireoidianos, independente do estado funcional das gônadas. A associação hipotireoidismo e castração caracterizou-se por adelgaçamento da epiderme da região abdominal ventral e espessamento e aumento da celularidade na região torácica dorsal, com derme adelgaçada e desprovida de fibras elásticas e de colágeno do tipo III. Conclui-se que a deficiência dos hormônios sexuais ou tireoidianos altera todos os componentes da pele e que as lesões são agravadas na associação hipotireoidismo-castração.

Cutaneous manifestations of diabetes mellitus

Diabetes is a common disease with many cutaneous manifestations encountered by dermatologists. Diabetes and the skin may be linked by association (e.g., necrobiosis lipoidica); infection; diabetic complication (e.g., neuropathic ulcer); or treatment reaction. Review of recent studies and reports focuses on pathogenesis and treatment of these many diabetic cutaneous changes.

Finger 'pebbles'. A dermatologic sign of diabetes mellitus

A 35-year-old obese man presented with a chief complaint of hand dryness of 5 years' duration. He was a store manager and denied exposure to chemicals, repetitive trauma, chronic irritation, and hard manual labor. However, he did admit to frequent hand washing. He had no itching or swelling in his hands, but on occasion he had tenderness in the dry areas. He had no personal or family history of diabetes, heart disease, or renal disease, and he stated that at his annual physical examination 6 months earlier, routine blood work was normal. He reported polyuria (every 2 hours), nocturia (five times per night), and polydipsia but no weakness, weight loss, visual changes, or neurosensory changes. Examination revealed xerosis of his hands and "pebbles" on the dorsal aspect of his fingers. The papules were most dense over the knuckles and interphalangeal joints (figures 1 through 3). He also had dozens of acrochordons (i.e., cutaneous papillomas, or skin tags) 1 to 4 mm in diameter on his neck, axilla, and groin. No other cutaneous lesions were noted. Specifically, there was no scleredema adultorum, necrobiosis lipoidica diabeticorum, acanthosis nigricans, bullae, or patchy pretibial pigmentation, although he did have several brown macules 1 to 5 mm in diameter on the sides of his lower legs. The macules had been present for years. Levels of hemoglobin A1c and glycated hemoglobin were 7.5% and 9.5%, respectively (normal, 4.4% to 5.9% and 5.0% to 7.3%). The patient was referred to his family physician, and his diabetes has been well controlled with insulin.

Overgrowth of skin in growth hormone transgenic mice depends on the presence of male gonads

Growth hormone has been shown to possess stimulatory effects on various connective tissues. We observed that skin growth in male rat phosphoenolpyruvate carboxykinase-bovine growth hormone transgenic mice (serum growth hormone levels: 740-1940 ng per ml) is progressive with age, resulting in an "oversized coat" phenotype with a marked increase in absolute and relative skin weight and surface area, and in thickness of the dermis. Histologic changes include severe dermal fibrosis and replacement of subdermal adipose tissue by fibrous tissue. Apart from an increase in skin surface area, these changes were not noted in female transgenic mice, arguing for a specific interaction of growth hormone with male sex hormones. To clarify this point, 6 wk old male transgenic mice and control mice were castrated and compared with their noncastrated counterparts in parameters of skin growth at an age of 8 mo. The skin weight of castrated transgenic mice was smaller (p < 0.01) than that of intact transgenic mice both absolutely and relative to body weight. The relative skin weight of castrated transgenic mice was in the same range as in intact and castrated control mice. Absolute and relative skin area of castrated transgenic mice was greater (p < 0. 001 and p < 0.05) than in controls but lower than in intact transgenic mice (p < 0.001 and p < 0.05). When compared with control mice, intact transgenic mice displayed an increase (p < 0.01) in the thickness of dermis. In castrated transgenic mice the thickness of the dermis was in the same range as in control mice. Our findings demonstrate a specific interaction of growth hormone with male sex hormones resulting in a marked stimulation of skin growth.

Skin lesions in diabetes mellitus: prevalence and clinical correlations

With the aim to assess the prevalence and the main clinical correlations of skin lesions in diabetes mellitus, 457 diabetic subjects consecutively attending an outpatient clinic underwent a dermatological examination. Neurovascular foot lesions were excluded. Thirty-five of 64 IDDM patients (54%) had skin alterations mainly consisting of vitiligo (9% of all patients), psoriasis (9%) and eczema (8%). The most frequent skin lesions observed in 240/393 NIDDM subjects (61%) were represented by infections (20% of all patients) and diabetic dermopathy (12.5%), while other lesions were not common. NIDDM patients with skin infections had a worse metabolic control, and those with diabetic dermopathy had a greater prevalence of neuropathy and large vessel disease than patients without skin lesions. These data show that the prevalence of skin diseases in a large, unselected diabetic population is higher than expected and indicate that, in most cases, a careful dermatological examination and a better metabolic control are needed in order to improve quality of life in these patients.

Cutaneous manifestations of diabetes mellitus

Diabetes mellitus (DM) is a heterogeneous group of disorders characterized by a high serum glucose level and by disturbances of carbohydrate and lipid metabolism. It is estimated that 11 million persons in the United States have DM, 90% of whom have non-insulin-dependent DM. At least 30% of persons with diabetes have some type of cutaneous involvement during the course of their chronic disease. This review classifies the cutaneous findings in DM into four categories: (1) skin diseases with strong to weak association with DM; (2) cutaneous infections; (3) cutaneous manifestations of diabetic complications; and (4) skin reactions to diabetic treatment. Each of these categories is reviewed as well as the pathophysiology of the normal and diabetic basement membrane for a better understanding of the cutaneous manifestations of DM.

Physiology of endocrine skin interrelations

Hormones influence the skin and play a role in normal biologic processes. Keratinocytes can convert and synthesize endocrine hormones. Endocrine dysregulation of the skin and abnormalities of endocrine functions of keratinocytes may produce abnormal changes in the skin. Knowledge of the cutaneous metabolism of thyroid hormones, steroids, peptide hormones, and vitamin A derivatives is being rapidly updated. Skin manifestations of endocrine disorders result from imbalance in feedback loops maintaining endocrine homeostasis. Define molecular mechanisms of hormonal action on target cells underlie functional agonism and antagonism of hormonal signals aimed at governing epidermal turnover. The molecular synergism between vitamin A and other hormones may explain the therapeutic efficiency of combining retinoids with other therapies.

Effect of age and diet on stratum corneum barrier function in the Fischer 344 female rat

Stratum corneum barrier function in the female Fischer 344 rat was assessed in animals ranging from 11 to 144 weeks of age, which were either fed ad libitum or a caloric-restricted diet at 60% ad libitum. Caloric restriction has been shown to increase the life span of rodents and delay age-associated degenerative diseases. The penetration of water, lidocaine, and hydrocortisone were measured in vitro using the finite-dose technique in Franz diffusion chambers. Water permeability did not significantly change with either age or diet condition (with the single exception of the ad libitum 144-week animals). However, between 11 and 44 weeks, both lidocaine and hydrocortisone permeability increased with age in both diet groups. By 44 weeks the caloric restriction animals had significantly greater permeability to lidocaine and hydrocortisone then their ad libitum age cohorts. Between 44 and 144 weeks, skin permeability in the ad libitum animals continued to increase with age, whereas permeability in the caloric restriction animals declined. By 144 weeks the caloric restriction skin was less permeable than the age-matched ad libitum animals but still more permeable than the 11-week animals. The data show that the barrier properties of stratum corneum change with age in the female rat and that this change can be modulated by caloric restriction.

Cutaneous manifestations of thyroid disease

Cutaneous manifestations of thyroid disease are protean in nature and affect all age groups. This review focuses on normal thyroid gland physiology, specific cutaneous/thyroid lesions such as the thyroglossal duct cyst and metastatic thyroid malignancies, nonspecific cutaneous alterations of the hyperthyroid and hypothyroid states, and the numerous associations of thyroid disease with other cutaneous and/or systemic disorders.

Does prolactin play a role in skin biology and pathology?

Despite its extensive repertoire of biological activities, which include the growth- and osmoregulation of epithelial tissues as well as immunoregulatory properties, the potential significance of the pituitary hormone prolactin (PRL) for human skin biology and pathology has yet to be fully appreciated. In this essay, the hypothesis is presented that PRL acts as a neuroendocrine modulator of skin epithelial cell proliferation and of the skin immune system by forming a 'prolactin-circuit' between the central nervous system and the skin. Binding to specific skin receptors, modulation of cytokine release in the skin, and stimulation of somatomedin release by mesenchymal cells are among the suggested pathways by which PRL could affect epithelial cell growth in the skin. Potential feedback signals, arising from the skin and modifying pituitary PRL release, are briefly outlined. Centering on the role of PRL in both psoriasis and hair growth as models for studying the proposed PRL-skin connection, clinical and experimental evidence in support of this theory is discussed in the context of a 'neuroimmune-dermatological' perspective.

Necrolytic migratory erythema: dyskeratotic dermatitis, a clue to early diagnosis

A 57-year-old woman with a 6-year history of a dermatitis that evolved into typical necrolytic migratory erythema is reported. Four biopsy specimens were obtained in 5 years. The early lesions revealed superficial perivascular inflammation in the dermis, minor epidermal spongiosis, and scattered dyskeratotic cells in the upper epidermis. The differential diagnosis of this pattern of dyskeratotic dermatitis, particularly in a chronic eruption, should include consideration of hyperglucagonemia and the possibility of an associated pancreatic islet cell tumor.

Eruptive seborrheic keratoses in a young woman with acromegaly

The sign of Leser-Trélat, or eruptive seborrheic keratoses, is purported to be a cutaneous marker for many underlying malignancies. Elevation in levels of growth factors has been postulated to be the stimulus for the sudden eruption of multiple new seborrheic keratoses. In support of this hypothesis we present a case of eruptive seborrheic keratoses in a young woman with acromegaly and elevated levels of growth hormone.