Dermatological markers of chronic hepatological diseases

Skin color changes

Jaundice. One of the most important symptoms of liver disease - jaundice - can be detected at a bilirubin level of 34.2 µmol/l (2 mg%), it becomes visible when bilirubinemia is 120 µmol/l (7 mg%). Even with complete obstruction of the biliary tract, the intensity of jaundice may vary. Following a rapid increase in serum bilirubin levels, they begin to decline after approximately 3 weeks, even if obstruction persists. The severity of jaundice depends on both the production of bile pigment and the secretory function of the kidneys.

With prolonged cholestasis, the skin acquires a greenish tint, probably due to the deposition of biliverdin, which is not involved in the diazoreaction (Van den Berg), and possibly other pigments.

With hemolytic jaundice, the skin becomes pale yellow, with hepatocellular jaundice - with an orange tint, and with prolonged biliary obstruction, it becomes green.

Pale skin accompanying anemia can be observed with hemolysis, cirrhosis of the liver, especially after bleeding from varicose veins and hepatoma.

Bronze skin pigmentation with a gray coloration of the palms and axillary areas is characteristic of hemochromatosis. Melanosis can sometimes accompany liver cirrhosis of various etiologies.

Pigmentation and ulcers on the legs appear in some forms of congenital hemolytic anemia.

Slate-gray pigmentation is most pronounced in the axillary areas, in the groin, on the external genitalia, on old scars and exposed parts of the body with hemochromatosis. It can also appear in the mouth. This pigmentation is due to the increased content of melanin in the basal layer and its translucency through the atrophic surface layers of the epidermis. The skin is thinned, dry and shiny, as in eunuchoidism.

The presence of bruises may indicate a blood clotting disorder. Thrombocytopenia that develops with cirrhosis may manifest as purpura on the forearms, axillae, or legs. Other skin changes in cirrhosis include spider veins, palmar erythema, white nails, and hair loss in areas of secondary hair growth.

In chronic cholestasis, scratch marks, pigmentation caused by excess melanin deposition, changes in the fingers in the form of drumsticks, xanthoma on the eyelids (xanthelasma), extensor surfaces and in the folds of the palms, as well as hyperkeratosis can be found.

You should pay close attention to nodules on the skin, which may turn out to be a malignant tumor. In case of multiple vein thrombosis, pancreatic body cancer is excluded. Swelling of the ankles may indicate cirrhosis, as well as obstruction of the inferior vena cava by a tumor of the liver or pancreas.

With decompensated cirrhosis, pigmentation may appear on the skin. Sometimes the nail phalanges take on the appearance of drumsticks. Purpura on the hands, shoulders and legs may be due to thrombocytopenia. When prothrombin levels are low, spontaneous bruising and nosebleeds appear. Body hair loss, spider veins, palmar erythema, white nail plates, and testicular atrophy are often observed.

Spider veins, synonyms: arterial spiders (spiders), telangiectasia, stellate angiomas. Arterial asterisks are detected in the vascular basin of the superior vena cava and only in some cases - below the line connecting the nipples of the mammary glands. Most often they occur in the décolleté area, on the face, forearm and back of the hands. Sometimes they are found on the mucous membrane of the nasal cavity, mouth and pharynx. After the death of a person they become discolored.

The arterial asterisk consists of a central arteriole and numerous small vessels radiating from it, resembling the legs of a spider. Its dimensions range from 0.1 to 0.5 cm in diameter. If the stars are quite large, you can observe or palpate their pulsation, which intensifies when pressing on it with a glass slide. When you press precisely on the central part of the star, it turns pale; such a reaction is characteristic of arterial damage.

As liver function improves, arterial stars may disappear, and the appearance of new ones indicates that the disease is progressing. In addition, the asterisk may disappear if blood pressure drops due to shock or bleeding, and it may begin to bleed.

In combination with spider veins and in the same areas of the body (most often, on the arms), expansion of many chaotically located small vessels can be observed. It resembles the arrangement of silk threads on American dollar bills, which is why this symptom is called the “money bill” symptom.

In addition, the stars can be combined with the appearance of white spots on the skin of the arms and buttocks when the skin cools. When viewed through a magnifying glass, a star can be seen forming in the center of each of these spots.

Spider veins appear more often with liver cirrhosis, including alcoholic cirrhosis. For some time they may occur with viral hepatitis. They are rarely found in healthy individuals, especially children. During pregnancy, they appear in the 2-5th month and disappear within 2 months after birth. It is impossible to diagnose liver disease solely on the basis of the presence of several stars, but the appearance of a large number of new stars and an increase in the size of existing ones requires a thorough examination to identify them.

Spider veins should be distinguished from hereditary hemorrhagic telangiectasia. The latter are usually located in the upper part of the body. They often appear on the mucous membrane of the nasal cavity, on the tongue, lips, palate, pharynx, esophagus and stomach. They often develop on the nail bed, palms and fingers. With visceral angiography they can be detected in internal organs.

Telangiectasia is a punctate formation, flat or slightly raised and with sharply defined boundaries. It is associated with one or more vessels, making it look like a spider vein. The pulsation of this formation is difficult to detect. The affected vessel is thinned, but hypertrophy of the muscle layer is noted in the veins.

Telangiectasia can be combined with cirrhosis. In primary biliary cirrhosis, it is possible to detect calcification, Raynaud's syndrome, sclerodactyly and telangiectasia (CRST syndrome).

Campbell de Morgan spots occur very often, and their size and number increase with age. They are bright red, flat or slightly raised on the surface of the skin, and are especially common on the front of the chest and abdomen.

A spider vein appears when venous pressure increases and is usually located on the main tributary of a large vein. Its diameter is 2-3 cm, it is not subject to obliteration during compression, blood flows through it from the periphery to the central vein (in the spider vein, blood flows in the opposite direction). Star veins appear on the backs of the feet, legs, back, and along the lower edge of the ribs.

The reason for the peculiar distribution of spider veins is unknown. Perhaps the upper parts of the body come into contact with some elements that increase their sensitivity to the corresponding endogenous stimuli, and this leads to the appearance of stars. In children, stars may appear on their knees. Their number does not correspond to the severity of hyperdynamic changes in blood circulation, although with a significant increase in cardiac output, the pulsation of stars becomes especially pronounced.

Typically, spider veins and palmar erythema are considered a manifestation of excess estrogen. They are also observed during pregnancy, when the level of estrogen in the blood increases. Estrogens promote enlargement and dilatation of endometrial spiral arterioles; perhaps a similar mechanism underlies the appearance of skin stars. Their development is due to the action of estrogen in men, although spider veins rarely form when these drugs are prescribed for prostate cancer. The liver is known to inactivate estrogen, although estradiol levels are often normal in cirrhosis. The estrogen to androgen ratio may be important. In men with cirrhosis, serum free testosterone levels are reduced, but estradiol levels remain normal. The highest values ​​of the estradiol/free testosterone ratio were found in men suffering from liver cirrhosis who had spider veins.

Palmar erythema (“liver palms”). With palmar erythema, a person's hands are warm and the palms are bright red, especially the thenar, hypothenar, and fingertips. Islands of erythema may appear at the base of the fingers. A similar lesion can be observed on the feet. When pressed, the erythema turns pale, but then its color quickly returns. When pressing on the palm with a glass slide, the color of the erythema changes synchronously with the pulse. Possible sensations of pulsation and itching of the palms.

Palmar erythema in cirrhosis is not detected as often as spider veins. Although a combination is possible, they can occur independently of each other, making it difficult to identify a common cause.

It should be noted that many healthy people have hereditary redness of the palms in the absence of liver disease. Similar changes are possible with a long course of rheumatoid arthritis, pregnancy, chronic febrile diseases, leukemia and thyrotoxicosis. It is assumed that hepatic palms are caused by the presence of arteriovenous anastomoses.

White nails, due to the opacity of the nail plate, were found in 82 out of 100 patients with cirrhosis of the liver and sometimes in some other diseases. The tips of the nails become pink; in severe cases, it may be impossible to identify nail dimples. The lesion is bilateral, especially pronounced on the thumbs and index fingers.

Xanthomas. The development of xanthomas is observed in chronic cholestasis. A type of xanthoma, xanthelasma, is a flat or soft yellow formation, slightly raised, usually localized around the eyes. Xanthomas can also be observed in the palmar folds, under the mammary glands, on the neck, chest or back. Tuberous xanthomas appear later and appear on the extensor surfaces, especially in the area of ​​the wrist, elbow, knee joints, buttocks, in places subject to pressure, in scars. Bones may be affected, and sometimes peripheral nerves. Local accumulations of xanthoma cells end up in the liver.

The number of skin xanthomas increases in direct proportion to the level of serum lipids. The appearance of xanthomas is preceded by a long-term (more than 3 months) increase in serum cholesterol levels of more than 11.7 µmol/l (450 mg%). Xanthomas disappear when cholestasis resolves and cholesterol levels return to normal, or in end-stage liver failure.

Skin itching is considered as a consequence of the retention and deposition of bile acids. However, even with the help of precise biochemical methods, it is not possible to detect a correlation between the severity of itching and the concentration of endogenous bile acids in the serum and skin. Moreover, in end-stage liver failure, pruritus may disappear while serum bile acid concentrations remain high.

Itchy skin most often occurs when the common bile duct is blocked by a tumor. L. T. Schoenfild found skin itching in 75% of patients with extrahepatic cholestasis (skin itching accompanies cholestasis and is believed to be associated with delayed biliary obstruction by malignant tumors) and in 50% with extrahepatic blockage of non-tumor origin. According to him, itching caused by intrahepatic cholestasis affects 20% of patients with chronic hepatitis, 10% of patients with macro- and micronodular cirrhosis of the liver and 75% of patients with primary biliary cirrhosis.

Data from experimental animal studies and drug trials suggest a role for endogenous opioid peptides in the development of itch. Animals with cholestasis develop a state of analgesia due to the accumulation of endogenous opiates.

Hair loss in the armpits and pubic area is characteristic of chronic liver diseases. Gynecomastia and female hair growth are common symptoms of significant liver dysfunction in men caused by hyperestrogenemia.

Dilated veins on the anterior abdominal wall have an anastomosis between the portal vein systems and the inferior and superior vena cava. The anastomoses around the navel are called "jellyfish heads". Through collaterals in the abdominal wall located above the umbilicus, blood from the portal vein enters the superior vena cava, and through collaterals below the umbilicus - into the inferior vena cava. When blood flow through the inferior vena cava is obstructed, collaterals develop between the systems of the inferior and superior vena cava, which are located in the lateral sections of the abdominal wall.

Skin changes in other liver diseases

Familial hypercholesterolemia is an autosomal dominant disease caused by the absence of the gene encoding the low-density lipoprotein receptor on the cell membrane. Individuals suffering from this disease develop cutaneous xanthomas; Most homozygotes die from coronary heart disease before the age of 30.

Kwashiorkor. Protein deficiency syndrome in children is called “kwashiorkor”. It is detected throughout the world, especially in the tropics and subtropics, in overpopulated areas, and in populations with low levels of economic development. In Europe and other temperate regions, kwashiorkor is rarely detected.

The child looks exhausted, growth is delayed, and generalized edema occurs. A kind of depigmentation of the hair appears, it becomes dull, thinner, stops curling and loses its rigidity. In the groin and perineum (points of contact with the diaper), a characteristic dermatosis develops, which spreads to other areas of the skin that are subject to pressure and irritation. Dark red spots appear, the skin turns pale and peels.

With ascites, the skin of patients usually has a sallow color, dry, signs of dehydration and pronounced muscle atrophy are noticeable. Thin limbs and an enlarged abdomen make the patient look like a spider. Striae may form on the skin of the abdomen.

Acute alcoholic hepatitis, cholestatic variant - for alcohol abusers is characterized by significant enlargement and pain of the liver, often accompanied by multiple spider veins on the skin.

Primary biliary cirrhosis (PBC) is a disease of unknown etiology in which the intrahepatic bile ducts are gradually destroyed. When serum cholesterol levels are high and xanthomas are present on the skin, the disease is also called xanthomatous biliary cirrhosis. Xanthomas on the skin sometimes appear acutely, but in many cases the disease proceeds without their formation; in the terminal stage of the disease, xanthomas may disappear. The skin on your fingers, ankles, and shins thickens and becomes rough. Xanthomatosis can cause peripheral polyneuropathy, which manifests itself as pain in the fingers and toes. There may be a butterfly-like area of ​​intact skin on the back that is impossible to reach and shows no signs of scratching.

Other associated skin lesions include immune complex capillaritis and lichen planus. Autoimmune thyroiditis develops in approximately 20% of cases. The development of diffuse toxic goiter has been described.

So, we tried to consider the clinical aspects of possible skin changes in chronic liver diseases, which can be a valuable clinical sign in the work of practicing dermatocosmetologists.