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The skin manifestations of patients with liver disease are diverse, and it is clear that the various skin manifestations of liver disease can not only guide the diagnosis, but also help the management of underlying liver disease.
In liver disease, skin manifestations can be divided into general manifestations and specific manifestations.
Specific skin manifestations of specific chronic liver diseases are also different.
This article will review the above.
Yimaitong compiles and organizes, please do not reprint without authorization.
General skin manifestations of liver disease 1.
Itching Generally speaking, itching is the most common skin manifestation of liver disease.
In patients with liver disease, in primary biliary cholangitis, itching is usually associated with cholestasis, such as primary sclerosing cholangitis, obstructive choledocholithiasis, cholangiocarcinoma, and chronic viral hepatitis.
.
2.
Spider nevus Spider nevus can be observed in 10% to 15% of healthy people.
Multiple spider nevus is a manifestation of liver disease, especially alcoholic cirrhosis and hepatopulmonary syndrome.
Atypical lesions are related to liver disease, including larger spider nevus, papillary spider nevus, and localized spider nevus on the skin and mucous membranes.
Spider hemangioma is the expansion of the original small arteries in the skin, which is believed to be mediated by a variety of factors, including an increase in estrogen levels, vascular endothelial growth factor, basic fibroblast growth factor, and even substance P.
Spider moles often disappear with liver disease treatment.
3.
Palmar erythema Although palmar erythema can be seen in many clinical conditions, remember not to confuse the palm erythema of liver disease with the physiological erythema of the palm.
Physiological erythema usually appears on the entire palm due to location, temperature or pressure.
Palmar erythema in liver disease has been observed to be due to increased levels of free estrogen leading to dilation of the capillaries on the hand surface.
4.
Xanthomas in liver diseases, xanthomas are most common in primary biliary cholangitis (PBC). The total cholesterol of PBC patients is often elevated, and abnormal cholesterol metabolism in liver disease contributes to the formation of xanthomas.
According to reports, about 15% to 50% of PBC patients have xanthomas.
Xanthomas often resolve with treatment of underlying hyperlipidemia.
5.
Jaundice Jaundice refers to the yellow to brown discoloration of the skin and/or mucous membranes due to hyperbilirubinemia, usually exceeding 2.
5~3.
0mg/dL.
The color change usually corresponds to the level of bilirubin.
Mild hyperbilirubinemia can lead to a mild yellow, and a brown change indicates more severe hyperbilirubinemia.
When jaundice occurs, it is important to determine the cause of the jaundice, including bound or unbound, pre-hepatic, intrahepatic, or posterior hepatic.
Skin manifestations of specific liver diseases 1.
Primary biliary cholangitis (PBC) PBC is an autoimmune disease that causes the progressive destruction of small bile ducts in the liver.
Half of the patients have itching as the main symptom.
Pruritus with jaundice, pigmentation and xanthomas are unique manifestations of PBC, but PBC can also present many other skin manifestations.
Since PBC is an autoimmune disease, it can be combined with other autoimmune diseases that affect the skin (including Sjo¨gren syndrome and morphea).
2.
Hepatitis B (HBV) Hepatitis B is usually divided into pre-jaundice (prodromal) and jaundice.
Urticaria is common in the prodromal phase and is caused by the deposition of immune complexes and is characterized by wind masses and/or angioedema.
*Note: Wind masses are itchy edema papules or plaques in the superficial dermis, which usually develop severely within 24 hours; angioedema is more severe swelling that occurs in the dermis and subcutaneous/submucosal tissues and lasts for more than 24 hours.
Hepatitis B infection can also be accompanied by various types of vasculitis, including small vessel vasculitis, urticaria vasculitis and polyarteritis nodosa.
Obvious purpura and erythema papules appear on the skin.
Urticaria vasculitis is a variation of small vessel vasculitis, which is manifested as urticaria lesions rather than erythema or purpura lesions. Polyarteritis nodosa (PAN) is a medium-sized vasculitis, most commonly associated with hepatitis B.
In addition to vasculitis, metabolic diseases such as delayed skin porphyrin (PCT) can also be seen in hepatitis B.
The skin is manifested as blisters, erosions, miliary, or easily injured by sunlight.
The typical location is the back of the hands.
Among the various types of porphyria, PCT is most common in hepatitis infection.
It is worth mentioning that patients with PCT and chronic active hepatitis increase the risk of developing hepatocellular carcinoma.
Finally, it is known that hepatitis B infection can also cause dermatitis called Gianotti Crosti syndrome.
The lesions are symmetrically distributed on the face, limbs, and buttocks, and are most common in viral infections.
Although this syndrome is more common in children, it has been reported many times in adults with hepatitis B infection.
3.
Hepatitis C (HCV) Although hepatitis C treatment usually cures infected patients, failure to receive treatment or treatment failure may progress to chronic infection, causing various skin changes.
Some skin manifestations related to chronic hepatitis C infection are also seen in patients with hepatitis B infection, such as small vessel vasculitis, urticaria vasculitis, and PCT.
Other skin manifestations, such as cryoglobulinemia, necrolytic acral erythema, sarcoidosis, and lichen planus, are more specific to hepatitis C infection.
4.
Hemochromatosis Although primary biliary cirrhosis is most common in women, male patients account for 90% of hemochromatosis.
Hereditary hemochromatosis is one of the most common genetic diseases in white patients, and it is often clinically manifested in patients with inflammatory liver diseases (such as liver steatosis, alcoholic liver disease, and hepatitis).
In addition to the non-specific skin characteristics associated with comorbid liver disease, one of the most common skin manifestations is hyperpigmentation.
5.
Cirrhosis and Alcohol Cirrhosis The four most common liver diseases that cause cirrhosis are alcoholic liver disease, chronic viral hepatitis, hemochromatosis, and non-alcoholic liver disease. Skin manifestations of liver disease can be observed in nearly half of patients with chronic alcoholism, and nearly 3/4 of patients with alcoholic liver cirrhosis have spider veins, palmar erythema, and Dupuytren's contracture.
Cirrhosis of the liver can affect the appearance of skin, nails and hair.
See the following for details: ▷ Changes in vascular physiology have caused patients to develop palm erythema, spider veins and banknote-like skin.
Paper money-like skin is a rare variation of arachnoid tumors.
It usually appears as diffuse thin patches of superficial capillaries on the trunk.
When the slide is pressed against the skin, the lesion will turn white, and the thin blood vessels will look like banknotes.
The same as the silk thread seen on it.
The portal hypertension can cause the patient to develop a jellyfish head, that is, the abdominal veins are dilated and twisted.
▷ Nail changes include nail bed defects such as Mark’s line and Terry nails.
Mark’s line is characterized by double horizontal lines, which disappear when pressure is applied.
This pair of threads is caused by a decrease in serum albumin and an abnormality of the nail bed vascular system.
Terry nails are white in the proximal 2/3 of the nails, while the distal nails are normal in color.
Although Terry nails are usually associated with liver cirrhosis, in patients with liver cirrhosis, this performance is non-specific and can be observed in various other systemic diseases.
▷ When there is too much estrogen, pubic hair and axillary hair are often diffusely thinned or disappeared, or the range of female pubic hair is enlarged.
Skin manifestations may be markers of liver disease, and may even be related to the potential severity of liver disease.
Skin appearance is very important for liver disease recognition and treatment.
Recognizing these skin manifestations may help the early diagnosis and treatment of chronic liver disease, and the treatment of skin symptoms may also help provide patients with a more complete treatment plan.
Literature index: Ashaki D.
Patel, Kimberly Katz, Kenneth B.
Gordon.
Cutaneous Manifestations of Chronic Liver Disease[J].
Clin Liver Dis(2020).
Doi: https://doi.
org/10.
1016/j.
cld.
2020.
04 .
003 Contribution Email: tougao@medlive.
cn
In liver disease, skin manifestations can be divided into general manifestations and specific manifestations.
Specific skin manifestations of specific chronic liver diseases are also different.
This article will review the above.
Yimaitong compiles and organizes, please do not reprint without authorization.
General skin manifestations of liver disease 1.
Itching Generally speaking, itching is the most common skin manifestation of liver disease.
In patients with liver disease, in primary biliary cholangitis, itching is usually associated with cholestasis, such as primary sclerosing cholangitis, obstructive choledocholithiasis, cholangiocarcinoma, and chronic viral hepatitis.
.
2.
Spider nevus Spider nevus can be observed in 10% to 15% of healthy people.
Multiple spider nevus is a manifestation of liver disease, especially alcoholic cirrhosis and hepatopulmonary syndrome.
Atypical lesions are related to liver disease, including larger spider nevus, papillary spider nevus, and localized spider nevus on the skin and mucous membranes.
Spider hemangioma is the expansion of the original small arteries in the skin, which is believed to be mediated by a variety of factors, including an increase in estrogen levels, vascular endothelial growth factor, basic fibroblast growth factor, and even substance P.
Spider moles often disappear with liver disease treatment.
3.
Palmar erythema Although palmar erythema can be seen in many clinical conditions, remember not to confuse the palm erythema of liver disease with the physiological erythema of the palm.
Physiological erythema usually appears on the entire palm due to location, temperature or pressure.
Palmar erythema in liver disease has been observed to be due to increased levels of free estrogen leading to dilation of the capillaries on the hand surface.
4.
Xanthomas in liver diseases, xanthomas are most common in primary biliary cholangitis (PBC). The total cholesterol of PBC patients is often elevated, and abnormal cholesterol metabolism in liver disease contributes to the formation of xanthomas.
According to reports, about 15% to 50% of PBC patients have xanthomas.
Xanthomas often resolve with treatment of underlying hyperlipidemia.
5.
Jaundice Jaundice refers to the yellow to brown discoloration of the skin and/or mucous membranes due to hyperbilirubinemia, usually exceeding 2.
5~3.
0mg/dL.
The color change usually corresponds to the level of bilirubin.
Mild hyperbilirubinemia can lead to a mild yellow, and a brown change indicates more severe hyperbilirubinemia.
When jaundice occurs, it is important to determine the cause of the jaundice, including bound or unbound, pre-hepatic, intrahepatic, or posterior hepatic.
Skin manifestations of specific liver diseases 1.
Primary biliary cholangitis (PBC) PBC is an autoimmune disease that causes the progressive destruction of small bile ducts in the liver.
Half of the patients have itching as the main symptom.
Pruritus with jaundice, pigmentation and xanthomas are unique manifestations of PBC, but PBC can also present many other skin manifestations.
Since PBC is an autoimmune disease, it can be combined with other autoimmune diseases that affect the skin (including Sjo¨gren syndrome and morphea).
2.
Hepatitis B (HBV) Hepatitis B is usually divided into pre-jaundice (prodromal) and jaundice.
Urticaria is common in the prodromal phase and is caused by the deposition of immune complexes and is characterized by wind masses and/or angioedema.
*Note: Wind masses are itchy edema papules or plaques in the superficial dermis, which usually develop severely within 24 hours; angioedema is more severe swelling that occurs in the dermis and subcutaneous/submucosal tissues and lasts for more than 24 hours.
Hepatitis B infection can also be accompanied by various types of vasculitis, including small vessel vasculitis, urticaria vasculitis and polyarteritis nodosa.
Obvious purpura and erythema papules appear on the skin.
Urticaria vasculitis is a variation of small vessel vasculitis, which is manifested as urticaria lesions rather than erythema or purpura lesions. Polyarteritis nodosa (PAN) is a medium-sized vasculitis, most commonly associated with hepatitis B.
In addition to vasculitis, metabolic diseases such as delayed skin porphyrin (PCT) can also be seen in hepatitis B.
The skin is manifested as blisters, erosions, miliary, or easily injured by sunlight.
The typical location is the back of the hands.
Among the various types of porphyria, PCT is most common in hepatitis infection.
It is worth mentioning that patients with PCT and chronic active hepatitis increase the risk of developing hepatocellular carcinoma.
Finally, it is known that hepatitis B infection can also cause dermatitis called Gianotti Crosti syndrome.
The lesions are symmetrically distributed on the face, limbs, and buttocks, and are most common in viral infections.
Although this syndrome is more common in children, it has been reported many times in adults with hepatitis B infection.
3.
Hepatitis C (HCV) Although hepatitis C treatment usually cures infected patients, failure to receive treatment or treatment failure may progress to chronic infection, causing various skin changes.
Some skin manifestations related to chronic hepatitis C infection are also seen in patients with hepatitis B infection, such as small vessel vasculitis, urticaria vasculitis, and PCT.
Other skin manifestations, such as cryoglobulinemia, necrolytic acral erythema, sarcoidosis, and lichen planus, are more specific to hepatitis C infection.
4.
Hemochromatosis Although primary biliary cirrhosis is most common in women, male patients account for 90% of hemochromatosis.
Hereditary hemochromatosis is one of the most common genetic diseases in white patients, and it is often clinically manifested in patients with inflammatory liver diseases (such as liver steatosis, alcoholic liver disease, and hepatitis).
In addition to the non-specific skin characteristics associated with comorbid liver disease, one of the most common skin manifestations is hyperpigmentation.
5.
Cirrhosis and Alcohol Cirrhosis The four most common liver diseases that cause cirrhosis are alcoholic liver disease, chronic viral hepatitis, hemochromatosis, and non-alcoholic liver disease. Skin manifestations of liver disease can be observed in nearly half of patients with chronic alcoholism, and nearly 3/4 of patients with alcoholic liver cirrhosis have spider veins, palmar erythema, and Dupuytren's contracture.
Cirrhosis of the liver can affect the appearance of skin, nails and hair.
See the following for details: ▷ Changes in vascular physiology have caused patients to develop palm erythema, spider veins and banknote-like skin.
Paper money-like skin is a rare variation of arachnoid tumors.
It usually appears as diffuse thin patches of superficial capillaries on the trunk.
When the slide is pressed against the skin, the lesion will turn white, and the thin blood vessels will look like banknotes.
The same as the silk thread seen on it.
The portal hypertension can cause the patient to develop a jellyfish head, that is, the abdominal veins are dilated and twisted.
▷ Nail changes include nail bed defects such as Mark’s line and Terry nails.
Mark’s line is characterized by double horizontal lines, which disappear when pressure is applied.
This pair of threads is caused by a decrease in serum albumin and an abnormality of the nail bed vascular system.
Terry nails are white in the proximal 2/3 of the nails, while the distal nails are normal in color.
Although Terry nails are usually associated with liver cirrhosis, in patients with liver cirrhosis, this performance is non-specific and can be observed in various other systemic diseases.
▷ When there is too much estrogen, pubic hair and axillary hair are often diffusely thinned or disappeared, or the range of female pubic hair is enlarged.
Skin manifestations may be markers of liver disease, and may even be related to the potential severity of liver disease.
Skin appearance is very important for liver disease recognition and treatment.
Recognizing these skin manifestations may help the early diagnosis and treatment of chronic liver disease, and the treatment of skin symptoms may also help provide patients with a more complete treatment plan.
Literature index: Ashaki D.
Patel, Kimberly Katz, Kenneth B.
Gordon.
Cutaneous Manifestations of Chronic Liver Disease[J].
Clin Liver Dis(2020).
Doi: https://doi.
org/10.
1016/j.
cld.
2020.
04 .
003 Contribution Email: tougao@medlive.
cn
