welcome
Patient itch/
Itchy Rash-2
Prof. DOULAT RAI BAJAJ
Professor & Chairman
Dept. of Dermatology
Goals of Presentation
At the end of presentation you would be able
to:
1. Identify the skin manifestations in a patient
who may have known or unknown
underlying systemic disease.
2. Manage it in concern with systemic disease
Diabetes Mellitus
Diabetes Mellitus

It is a clinical syndrome, characterized by:
 Chronic hyperglycemia, glycosuria
 Disturbance in CHO, protein, & lipid
metabolism
 Result from lack of insulin(partial or
absolute), receptor insensitivity to
insulin
Cutaneous Manifestations
Skin disorders due to Micro- or
macroangiopathy
 Specific cutaneous disorders
 Cutaneous Infections: bacterial, viral,
parasitic, fungal etc
 Skin disorders due to medication, Insulin
therapy

Macroangiopathy related Skin Ds

skin atrophy

hair loss

Cold Extremities

nail dystrophy

Pallor upon elevation, and mottling on
dependence
Micro-angiopathy Related Skin Ds
Microangiopathy results into:
retinopathy, nephropathy, neuropathy &
dermopathy.
Skin Ds include:

Diabetic Dermopathy (Diabetic Shin spots)

Erysipelas-like erythemy

Diabetic Rubeosis

Periungual Telangiectasia
Dermopathy
This
is
most
common
dermatosis associated


Lesions oval, dull red papules
0.5-1 cm.
Shins, forearms, thighs & over
bony prominences

Lesions evolves producing
superficial scale & healing
with atrophic brownish scar.

R/: Topical
histamines
steroids
Anti
ERYSIPELAS LIKE ERYTHEMA
- Dull erythematous plaques on legs feet, well
demarcated.
DIABETIC RUBEOSIS
- Occurs in long
standing disease
- Rosy
reddening
of
face, sometimes
of hands, feet.
PERIUNGUAL TELANGIECTASIA
The nail fold is an
excellent site for viewing
functional and structural
changes
in
the
microvascular of the skin.
DIABETIC FOOT

An umbrella term for
various foot problems seen
in diabetics.

Multiple factors involved in
pathogenesis: e.g. microangiopathy,
macroangiopathy neuropathy as
well as a tendency to
delayed wound healing,
infection or gangrene of
the foot is relatively
common.
CUTANEOUS INFECTION IN DIABETES
- Furuncle and carbuncle
- Non Clostridial gas gangrene: Mixed
anaerobic and aerobic organisms (E. Coli,
Pseudom. Klebsella, bacteriodes) produce
gas with foul odor.
- Candida Infections
- Phycomycetes Infections
- Dermatophytosis
CANDIDA INFECTIONS
- Yeast infections are common in diabetic patients.
Yeast infections may even be the presenting
manifestation of diabetes
- Involvement of the glans & vulva are common.
- Vaginal candidiasis: almost universal among
women with long term diabetes.
- Angular stomatitis due to Candida is a classic
complication in diabetic children. Result from
Increased concentrations of salivary glucose
Candidal Vulvovaginitis
ANGULAR STOMATITIS
SPECIFIC SKIN DISORDERS
1. Necrobiosis lipoidica
2. granuloma annulare
3. Scleredema
4. acanthosis nigricans
5. skin tags
6. vitiligo
7. diabetic bullae
8. eruptive xanthoma
9. finger pebbles
10. perforating dermatosis
NECROBIOSIS
LIPOIDICA
Sharply demarcated
plaques of atrophic
yellow skin, which may
ulcerate.
- Female ˃ males
- Common site shins,
but may occur on
face, limbs, trunk
NLD
GRANULOMA ANNULARE

characterized by skin coloured papules
occurring in a ring configuration.

Do not itch.

Common sites: dorsa of hands and feet.
May occur on wrists, arms trunk.

Association with diabetes inconclusive
Diabetic bullae
SCLEREDEMA
- Seen mainly in over weight Type-1
diabetes.
- Characterized by a non-pitting woody
induration of the skin with occasional
erythema.
- Occurs mostly commonly over the back.
- No
specific
treatment,
may
try
methotrexate and cyclosporin.
ERUPTIVE XANTHOMAS
- Lesions typically erupt
as crops of small, redyellow papules
- Most commonly over
buttocks, shoulders,
arms & legs but may
occur anywhere.
- Hypertriglyceridemia
Acanthosis Nigricans
Skin Tags
Skin disorders due to medication
Insulin therapy
-
Bruising
-
lumps (lipodystrophy)
-
Subcutaneous fat deposition
(lipohypertrophy)
-
Subcutaneous Fat loss (lipoatrophy)
-
Erythema, Infections.
Liver Disease
1.Pruritus
10.Gynaecomastia
2.Jaundice
11.Clubbing
3.Erythema nodosum
4.Erythema multiforme
5.Lichen planus
6.Cryoglobulinemia
7.Porphyria cutanea tarda
8.Spider naevi
9.Palmer erythema
PRURITUS IN LIVER DISEASE




CAUSES : Primary biliary cirrhosis, Cirrhosis
Autoimmune hepatitis, Viral: B & C
Mechanism
 Exact mechanism is not clear
 Most probably due to presence of bile salts in the
skin and release of mast cell mediators
Treatment: treat underlying cause.
May use URSODEOXYCHOLIC ACID 10-15mg/kg
CHOLESTRYMINE 4-16g/day, Rifampicin, Ultraviolet rays,
Opoid antagonists(naloxone)
JAUNDICE

Yellow pigmentation of skin,sclerae and mucosa
due to raised bilirubin level

Clinically jaundice appears when bilirubin level
Rises above 3mg/dl
ERYTHEMA NODOSUM




Painful,red,raised lesions on
shin (may also on thighs or
arms)
May be single or multiple
MALAISE, FEVER, arthralgias
Treatment : treat underlying
cause
 Nsaids
 Saturated potassium
iodide solution , 5-15
drops three times daily
 Bed rest
ERYTHEMA MULTIFORME
Erythematous circular lesions with target
appearance.
 lesions may be urticaria-like or sometimes
bullous

CRYOGLOBULINAEMIA

Cryoglobulins are circulating immunoglobulins that
precipitate out in cold. Three types( i , ii and iii )

It is traid of skin, renal and joint disease

Pathogenesis unknown. May be Ag-Ab mediated.

Manifested by: palpable purpura over the lower
extremities, arthralgia, Raynaud’s phenomenon &
neuropathy.

For hcv-positive patients,interferon –alpha and
ribavirin is treatment of choice.
PORPHYRIA CUTANAE TARDA

Due to over production of porphyrin

Characterized by vesicles, blisters and milia
on the dorsal surfaces of hands

Confirmed by elevated elevated porphyrins
and their precursors in urine and faeces.
SPIDER ANGIOMA(NAEVI)

Small angiomata
appear on the surface
of the skin.

Common sites are face
,neck,upper part of
trunk and arms.

Size vary from a
pinhead to 0.5 cm in
diameter
PALMER ERYTHEMA

Reddening of the skin of palms especially over
thenar & hypothenar eminences.

Can involves soles of feet , where it is termed
planter erythema
GYNAECOMASTIA
CLUBBING
Thyroid Disease
Thyroid Hormones
The thyroid secretes predominantly
Thyroxine ( T4)
 Small amount Triodothyronine (T3).
 T3 & T4 circulate in plasma almost entirely (
>99.9%) bound to transport proteins, TBG.
And albumin.
 Thyroid diseases mostly result from
autoimmune process

MAJOR MANIFESTATIONS OF THYROID DISEASE

HYPERTHYROIDISM

HYPOTHYROIDISM

GOITRE
CLINICAL FEATURES
OF HYPERTHYROIDISM
-
Goitre
Diffuse ± Bruit
Nodular
-
GIT
Wt: loss*, hyperdefecation*, diarrhea,
steatorrhea, anorexia, vomiting.
Skin changes in Hyperthyroidism
- Thining of the epidermis
- Fast nail growth
- Soft velvety wet skin
- Increased pigmentation
- Increased skin temperature
- Diffuse alopecia
- Palmer erythema
- Pruritus
cont:
Flushed face
- Increased sweating palms, soles
- Acropachy
- Vitiligo
- Onycholysis (Plummer’s nail)
- Punctate telangiectases(spider naevi)
- Pretibial myxedema
-
Pretibial myxedema
- Non- pitting edema,
- Skin is waxy, translucent
with a ‘peau d orange’ appearance
. Maybe overlying
hypertrichosis/hyperhydrosis
Common sites are pretibial
areas, arms, shoulders &
neck.
Flushing of face
Thin Atrophic skin
Blotchy Pigmentation
Distal onycholysis Plummer’s nail
HYPOTHYROIDISM
CLASSIFICATION
-
GOITROUS
Hashimoto’s thyroiditis
Drug Induced
Iodine deficiency
Dyshormogenesis
cont:
CLINICAL FEATURES OF HYPOTHYROIDISM
-
General
Tiredness, somnolence, Wt: gain,
Cold intolerance, Hoarseness, goitre.
-
Cardiorespiratory
Bradycardia, HTN, Angina, cardiac failure,
Xanthelasma, Pericardial & pleural effusion.
-
GIT
Constipation, Ileus, Ascites.
DERMATOLOGICAL

Due to slow metabolic rate: Cold, dry, pale skin &
extreme dryness (Keratoderma)

Coarse, dry scalp & hair, Loss of sweating

Hair loss ( scalp, groin & lateral eyebrows)

Yellow skin color ( Carotenemia).

Puffy edema ( hands, face, eyelids)
 Brittle thick nails

Erythema ab igne (Granny’s tartan)
 Xanthalesma
Dry icthyotic skin
Paler, Puffiness around eyes
Carotenemia
Xanthelasma
Erythema ab igne
Erythema ab igne

Erythema ab igne
Renal Disease
Cutaneous disoredres
1.
2.
3.
4.
5.
6.
7.
8.
Xerosis with fine scaling
Pruritus
Pigmentation generalized
Calciphylaxis (Calcifying panniculitis)
Perforating disorders
Pseudoporphyria
Calcinosis cutis
gynaecomastia
Xerosis with fine scaling









Actual cause unknown
Uremia, Dehydration
Mast cell proliferation
Following dialysis
: Hydrate skin with
Emollients, Moisturizers
keratolytics
UVB phototherapy
Oral cholestyramine/charcoal
Generalized melanosis
Perforating Disorders
 Hyperpigmented papules up to 1 cm in diameter
 with a central keratinous plug.
 Sites: Extensor surfaces of the limbs, trunk and
face.
The pathogenesis is uncertain
 Reactive perforating collagenosis is the
common presentstion.
Calcinosis cutis
Pseudoporphyria
Calciphylaxis
Characterized by erythematous plaques,
nodules central necrosis & gangrene
 Metastatic calcification in BV wallsischemia
 gangrene
 Risk factors included obesity, liver disease,
 systemic steroid use, and a high calcium
phosphate product

Calciphylaxis
“Do not go
where the path may lead,
go instead
to where there is no path
and leave a trail.”
Ralph Waldo Emerson
Zinc Deficiency
Causes

Zinc deficiency may be caused by

A specific absorptive defect: acrodermatitis
enteropathica,
 Malabsorption: acquired, zinc defi ciency).
Due to diseses of Liver, Pancreas and GIT
Skin Lesions

General: septicaemia, photophobia, depression.
 Skin changes:
 eczematous eruptions on face, hands, feet, in the
anogenital regions AND Around the body orifices.
 Bullous lesions surrounded by brownish
erythema over finger & palm skin creases.
 Oozing lesions on the sacral area & heels in
bedridden patients.
 Angular stomatitis with perioral lesions sparing
the vermilion border.
Vitamin A Deficiency
Generalized Dry, Rough, Scaly skin
 Follicular hyperkeratosis → phrynoderma

Phrynoderma: vit A deficiency
Phrynoderma: vit A deficiency
Follicular Hyperkeratosis
Vit: B 2 (Riboflavin) Deficiency
 Photophobia due to conjunctivitis,
 angular stomatitis (perlèche)
 sore lips, tongue & mouth: The tongue is
purplish red and smooth.
 A scaly seborrhoeic dermatitis-like eruption
around the nose, eyes, ears and genital
area (oro-oculo-genital syndrome)
Vitamin C Deficiency: Scurvy
Initial
 Follicular Keratosis
 Coiled Hairs: Upper Arm, Back, Buttock.
& Lower extrimities)
Later
Perifollicular haemorrhage with purpura esp. on
Legs
Large Skin Haemorrhages.
Swollen & Bleeding Gums.
IRON DEFICIENCY ANEMIA
 PALLOR
SKIN
 KOILONYCHIA
 ANGULAR
 SMOOTH
CHEILITIS
TONGUE
ANGULAR CHEILITIS
PALLOR SKIN
KOILONYCHIA
SMOOTH TONGUE