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Liu Y, Zhao Y, Gao X, Liu J, Ji F, Hsu YC, Li Z, Nguyen MH. Recognizing skin conditions in patients with cirrhosis: a narrative review. Ann Med 2022; 54:3017-3029. [PMID: 36308406 PMCID: PMC9629063 DOI: 10.1080/07853890.2022.2138961] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Background: The skin is a major target organ for extrahepatic manifestations of liver diseases, and dermatologic abnormalities are common in patients with hepatic disorders. Clinical examination of the skin, nails and hair can allow for appropriate recognition, early diagnosis and treatment of liver diseases, and improvement in the quality of life and life expectancy of affected patients.Methods: We searched 3 databases (Pubmed,Medline and Embase) and selected studies about cirrhosis related skin manifestations and their pathophysiology.Results: A total of 73 articles were included in the review. Studies displayed the spectrum of cutaneous manifestations related to hormonal and vascular changes as well as nail and hair changes in patients with cirrhosis and/or portal hypertension.Conclusion: Cutaneous alterations are important clues or potential indications in the diagnosis of liver cirrhosis. Familiarity with skin conditions can be promptly diagnosed and appropriate management initiated.KEY MESSAGESManifestations of the liver and skin disorders are interrelated in various ways. Cutaneous changes may be the first clue that a patient has liver disease.The skin is a major target organ for extrahepatic manifestations of liver diseases. A broad range of cutaneous alterations can be present in patients with cirrhosis, such as vascular, nail, hair, hormonal changes, etc.Recognizing these signs is crucial so that potential underlying diseases including liver disease can be promptly diagnosed and appropriate management timely initiated.
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Affiliation(s)
- Ying Liu
- Department of Dermatology, The Second Affiliated Hospital of Xi'an Jiaotong University, Xi'an, China
| | - Yunyu Zhao
- Department of Infectious Diseases, The Second Affiliated Hospital of Xi'an Jiaotong University, Xi'an, China
| | - Xu Gao
- Department of Infectious Diseases, The Second Affiliated Hospital of Xi'an Jiaotong University, Xi'an, China.,Department of Gastroenterology, The Second Affiliated Hospital of Xi'an Jiaotong University, Xi'an, China
| | - Jiashu Liu
- Department of Dermatology, The Second Affiliated Hospital of Xi'an Jiaotong University, Xi'an, China
| | - Fanpu Ji
- Department of Infectious Diseases, The Second Affiliated Hospital of Xi'an Jiaotong University, Xi'an, China.,National & Local Joint Engineering Research Center of Biodiagnosis and Biotherapy, Second Affiliated Hospital of Xi'an Jiaotong University, Xi'an, China
| | - Yao-Chun Hsu
- Center for Liver Diseases, E-Da Hospital, School of Medicine, I-Shou University, Kaohsiung, Taiwan.,Division of Gastroenterology and Hepatology, Fu Jen Catholic University Hospital, New Taipei, Taiwan
| | - Zhengxiao Li
- Department of Dermatology, The Second Affiliated Hospital of Xi'an Jiaotong University, Xi'an, China
| | - Mindie H Nguyen
- Division of Gastroenterology and Hepatology, Stanford University Medical Center, Palo Alto, CA, USA.,Department of Epidemiology and Population Health, Stanford University, Palo Alto, CA, USA
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Abstract
Changes in nail color can provide important clues of underlying systemic and skin disease. In particular, white discoloration (leukonychia) has a high prevalence with a wide array of potential relevant causes, from simple manicure habits to life-threatening liver or kidney failure. Therefore, a reliable assessment of the patient with leukonychia is essential. In the past, two classifications for leukonychia have been presented. The morphological classifies the nail according to the distribution of the white lines: total, partial, transversal, and longitudinal leukonychia. Mees’ and Muehrcke’s lines are examples of transversal leukonychia, while Terry’s and Lindsay’s nails are examples of total and partial leukonychia. The anatomical classifies according to the structure responsible for the white color: the nail plate in true leukonychia, the nail bed in apparent leukonychia, and the surface only in pseudoleukonychia. In this review, both morphological and anatomical features have been combined in an algorithm that enables clinicians to approach leukonychia efficiently and effectively.
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Gupta AK, Venkataraman M, Talukder M. Onychomycosis in Older Adults: Prevalence, Diagnosis, and Management. Drugs Aging 2022; 39:191-198. [PMID: 35102533 DOI: 10.1007/s40266-021-00917-8] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/16/2021] [Indexed: 11/03/2022]
Abstract
The risk of having onychomycosis increases with age. Data suggest that the prevalence of onychomycosis may be ≥ 20% in subjects aged ≥ 60 years and ≥ 50% in those aged ≥ 70 years. Older males are 2.1 times more prone to onychomycosis than are females. Although most nail dystrophies (approximately 50%) are caused by onychomycosis, proper clinical assessment followed by mycological examination is recommended to exclude other conditions such as nail trauma, lichen planus, and psoriasis. The US FDA-approved onychomycosis treatments are systemic antifungals (terbinafine and itraconazole) for severe onychomycosis and topical antifungals (ciclopirox 8%, efinaconazole 10%, and tavaborole 5%) for mild-to-moderate onychomycosis. Oral fluconazole is used off-label, and itraconazole may be considered for non-dermatophyte onychomycosis. Recently, fosravuconazole was approved in Japan for onychomycosis treatment. Although the treatment options and durations are the same for older patients as for other age groups, a clinical decision should take into account various age-related factors such as comorbidities, polypharmacy, hepatic and renal insufficiency, and noncompliance. Clinicians should also consider possible drug interactions and side effects when choosing a particular antifungal. Since the recurrence rate of onychomycosis is high, older patients should practice sanitization techniques, consider lifestyle changes, and perhaps consider using a topical antifungal as long-term maintenance therapy one to three times per week to prevent the recurrence of onychomycosis or to treat early disease.
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Affiliation(s)
- Aditya K Gupta
- Mediprobe Research Inc., 645 Windermere Road, London, ON, N5X 2P1, Canada. .,Division of Dermatology, Department of Medicine, University of Toronto, Toronto, ON, Canada.
| | | | - Mesbah Talukder
- Mediprobe Research Inc., 645 Windermere Road, London, ON, N5X 2P1, Canada
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Godara SK, Thappa DM, Pottakkatt B, Hamide A, Barath J, Munisamy M, Chiramel MJ. Cutaneous manifestations in disorders of hepatobiliary system. Indian Dermatol Online J 2017; 8:9-15. [PMID: 28217465 PMCID: PMC5297287 DOI: 10.4103/2229-5178.198760] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Hepatobiliary diseases are associated with various mucocutaneous changes that are directly and indirectly associated with these diseases. There is a dearth of studies from India dealing with cutaneous manifestations in liver disorders. AIM This study was conducted to know the spectrum of cutaneous changes and their correlation with liver function tests in patients with disorders of hepatobiliary system. METHODS This was a descriptive study conducted among in patients and outpatients with primary hepatobiliary disorders at a tertiary care center in South India. Detailed history taking and examination was done. Visual analog score (VAS) and 5D itch score was employed to quantify pruritus. Correlation of liver function tests with pruritus and comparison of skin changes in the major disease groups was attempted. RESULTS A total of 303 patients were recruited. Hepatic mass/malignancy followed by nonalcoholic liver disease were the most common diagnoses. Icterus followed by pruritus were the most common cutaneous complaints. The mean VAS and 5D itch scores among the patients with pruritus were 4.7 ± 1.9 and 13.6 ± 4.9. The most common mucocutaneous findings observed were icterus (241 patients; 79.5%), ichthyosis/xerosis (172 patients; 56.7%), pallor (131 patients; 43.2%), excoriations (118 patients; 38.9%), hyperpigmented palmar creases (118 patients; 38.9%), clubbing (113 patients; 37.2%), and pedal edema (85 patients; 28%). There was statistically significant correlation between serum bilirubin levels and pruritus. CONCLUSION The common mucocutaneous manifestations associated with primary hepatobiliary disorders were icterus, ichthyosis/xerosis, pallor, excoriations, hyperpigmented palmar creases, clubbing, and pedal edema.
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Affiliation(s)
- Shashi K Godara
- Department of Dermatology, Jawaharlal Institute of Medical Education and Research, Puducherry, India
| | - Devinder M Thappa
- Department of Dermatology, Jawaharlal Institute of Medical Education and Research, Puducherry, India
| | - Biju Pottakkatt
- Department of Medical Gastroenterology, Jawaharlal Institute of Medical Education and Research, Puducherry, India
| | - Abdoul Hamide
- Department of Medicine, Jawaharlal Institute of Medical Education and Research, Puducherry, India
| | - Jagadisan Barath
- Department of Paediatrics, Jawaharlal Institute of Medical Education and Research, Puducherry, India
| | - Malathi Munisamy
- Department of Dermatology, Jawaharlal Institute of Medical Education and Research, Puducherry, India
| | - Minu J Chiramel
- Department of Dermatology, Jawaharlal Institute of Medical Education and Research, Puducherry, India
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Abstract
Nail abnormalities can arise in conjunction with or as a result of systematic pathologies. These pathologies include single-organ diseases, multisystemic diseases, and drug-induced insults. Clinical signs associated with these conditions include dyschromias, vascular alterations, periungual tissue changes, textural dystrophies, contour alterations, and growth-rate alterations. The associated systemic pathologies may affect any part of the nail apparatus, including the nail matrix, the nail plate, the nail bed, the underlying vasculature, and the periungual tissues. The anatomical location and extent of damage determine the clinically manifested anomaly.
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Dinis-Oliveira RJ, Magalhães T, Moreira R, Proença JB, Pontes H, Santos A, Duarte JA, Carvalho F. Clinical and forensic signs related to ethanol abuse: a mechanistic approach. Toxicol Mech Methods 2013; 24:81-110. [PMID: 24274640 DOI: 10.3109/15376516.2013.869782] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
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Anbar T, Hay RA, Abdel-Rahman AT, Moftah NH, Al-Khayyat MA. Clinical study of nail changes in vitiligo. J Cosmet Dermatol 2013; 12:67-72. [PMID: 23438144 DOI: 10.1111/jocd.12022] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/17/2012] [Indexed: 11/30/2022]
Abstract
Both vitiligo and alopecia areata (AA) are associated together, associated with other autoimmune diseases, and autoimmunity is one of the important theories in their etiology. Nail changes are a known association with AA, thus we hypothesized that nail changes can be found in vitiligo patients. On revising the literature, only two types of nail changes were described in association with vitiligo. Our aim was to study the frequency and types of nail changes among vitiligo patients in comparison with normal healthy volunteers. This multi-centric study was carried on 91 patients with vitiligo, as well as 91 normal healthy control subjects who were age- and sex-matched. Nails were examined for changes in nail plates as regards striations, texture, curvature, dystrophy, and pigmentation. The presence or absence of the thumb lunula was also reported. Nail changes were observed in 62 patients (68.1%) and 46 (50.5%) control subjects with a statistically significant difference (P = 0.016). Longitudinal ridging and absent lunula were significantly higher in patients than in the controls (P = 0.001 and 0.037, respectively). Other reported nail abnormalities in the current study included punctate leukonychia, pitting, flag sign, and Terry's nails. Awareness of this association will widen the clinician's perspective to carefully examine the nail changes in vitiligo patients and conversely examine patients with nail changes for vitiligo.
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Affiliation(s)
- Tag Anbar
- Dermatology Department, Al-Minya University, Al-Minya, Egypt.
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Baran B, Soyer OM, Karaca C. Terry's nail: an overlooked physical finding in cirrhosis. Hepatobiliary Pancreat Dis Int 2013; 12:109. [PMID: 23392809 DOI: 10.1016/s1499-3872(13)60017-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
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Takehara K, Oe M, Tsunemi Y, Nagase T, Ohashi Y, Iizaka S, Ueki K, Tsukamoto K, Kadowaki T, Sanada H. Factors associated with presence and severity of toenail onychomycosis in patients with diabetes: a cross-sectional study. Int J Nurs Stud 2011; 48:1101-8. [PMID: 21367414 DOI: 10.1016/j.ijnurstu.2011.02.005] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2010] [Revised: 02/02/2011] [Accepted: 02/05/2011] [Indexed: 01/18/2023]
Abstract
OBJECTIVE To identify the factors associated with toenail onychomycosis in patients with diabetes. METHODS In this cross-sectional, observational study, the presence and severity (area of nail involvement and nail thickness) of toenail onychomycosis and related factors were examined. One hundred and thirteen patients with diabetes were surveyed at the Diabetic Foot Outpatient Clinic at the University hospital. Toenails of all patients enrolled in the survey were examined whether onychomycosis was present or absent by mycological examination. The severity of onychomycosis was assessed by clinical evaluation, using the area of nail involvement and the nail thickness. RESULTS Fifty eight (51.3%) patients had toenail onychomycosis. The presence of onychomycosis was significantly associated with not washing of feet every day (the unadjusted model, OR: 3.45, 95% CI: 1.24-9.65, P=0.018). The median area of nail involvement was 50.0% (range 5.0-100.0%). A larger area of involvement was significantly related to a lower toe brachial index (β=-67.46, P=0.040). The median nail thickness with onychomycosis was 1.14 mm (range 0.68-9.86 mm). Increasing thickness was significantly correlated with higher hemoglobin A(1)c levels (β=0.98, P=0.003). CONCLUSIONS This study suggested that daily washing of feet may reduce the risk of onychomycosis in patients with diabetes. This suggested that education regarding the importance of the washing of feet every day and support for continuous self-care might be effective in the prevention of onychomycosis in patients with diabetes. Furthermore, good control of blood glucose might prevent increasing nail thickness. This study may highlight importance of early nursing educational intervention to improve patients' daily life style for prevention of onychomycosis induced diabetic foot ulcers.
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Affiliation(s)
- Kimie Takehara
- Department of Gerontological Nursing/Wound Care Management, Division of Health Sciences and Nursing, Graduate School of Medicine, University of Tokyo, Japan
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