Dermal manifestations in liver disease
(肝病的皮膚表現)
The dermal lesions complicating liver disease have rather complex manifestations. Besides direct contact and subsequent infection by virus causing damage to skin and mucous membrane with resulted symptoms and signs, not few chronic hepatitis patients, through prolonged and repeated inflammatory course of development, have large amounts of deposit of antigen-antibody complex which often affect the immunologic system. Progression of the disease causes gradually dysfunction of liver and would invariably affect the endocrine system and result in metabolic dysfunction and, therefore, damage would be shown on the skin or mucosa. Some cases have demonstrated that the damage to the skin and mucosa is frequently an early sign of virus infection and also a marked sign of activity of chronic hepatitis and some are even clues to serious liver disease (such as spontaneous subcutaneous hemorrhagic purpura, the result of abnormal coagulation in early cirrhosis of liver and thrombocytopenia. Acute melanosis (senile disease) and dactyl edema are often signs of sudden failure of kidney gi, showing that the patient’s liver disease has passed into the cirrhotic or carcinoma late stage). It demonstrates that the liver disease has progressed gradually into the stage of failure of certain visceral functions.
These dermal manifestations are of some clinical value in diagnosis of chronic liver disease. The following has been mentioned by the book “Liver disease and systemic diseases of the body” edited by Wang Rongqi:
- Pale yellowish color of skin: 50-60% patients with chronic hepatitis and cirrhosis of liver have variable degrees of jaundice which indicates active pathologic changes of the liver. It is particularly clear on the skin of abdomen which is not exposed to sunlight.
- Pruritus of skin: Pruritus of skin may occur irrespective of the presence of jaundice and it may appear in the early stage of chronic hepatitis and cirrhosis of liver. It is considered generally that in liver disease bile salts can stimulate peripheral nerve endings and when the disease is prolonged, one may find dermal changes like coarseness, desquamation, hypertrophy and increase of pigmentation.
- Pigmentation: Pigmentation is in relation with the prolonged course and more serious condition of liver disease. It is considered usually due to the patient’s increase of female sex hormone and decrease of adrenal function. The skin of exposed areas of the patient with liver disease (such as face, skin around the orbit) is darker in color which is grayish and associated with pigmentation, the incidence of which is about 20%. In cirrhosis of liver, the pretibial region presents conglomerulate patches of pigmentation. When the chronic hepatitis patient passes into the weakness of liver and kidney stage, there is blood heat or insufficiency of blood and the skin is dark and coarse without luster. The skin of the patient’s whale body presents significant darkish appearance.
- Subcutaneous hemorrhage. Chronic hepatophilic virus disease patients often have a bleeding tendency or hemorrhagic manifestations. This is because, in liver disease patients, the synthesis of coagulation factors is decreased, their consumption is increased, and the raw materials for the production of coagulation factors are insufficient. There is also increase of splenic function and capillary fragility. Some other manifestations are dermal petechiae, ecchymosis, epistaxis, gingival bleeding, hematemesis, hematochezia and hematuria.
- Xanthoma: In chronic dysfunction of liver, there is persistent high blood lipid and cholesterol. This causes deposit of lipids which are taken up by tissue phagocytes forming xanthoma. The skin of the patient presents flat or nodular xanthoma; the flat ones usually appear on the eye lids, palm, neck, chest and back; the nodular ones on the wrist, elbow, knee, extensor surface of ankle joint and buttock.
- Liver palms, vascular spider, erythema, telangiectasis, and purpura: Symptoms and signs like liver palms, vascular spider, facial or lower extremity erythema, conglomerulate telangiectasis and purpura may appear in patients suffering from liver disease or cirrhosis of liver. These symptoms and signs are related to the increase of female sex hormone immunologic complex vasculitis leading to increase of capillary permeability or to hepatic thrombocytopenia and coagulopathy.
Introduction of cases
| Case 2
Chow (code number 1278), male, age 37 years. His first visit was on Judy 1999, with the complaint of fatigue, yellowish urine and for 5 years, suffered from stomache ache which was cured by medication. But he still had frequent gastrointestinal discomfort and went to stool 1-2 times a day. Several months ago, he had hematochezia. Presently, the weather changed and he felt sorethroat and coughed with large amount of sputum. Physical examination: abdomen distended, prominent veins over chest and abdominal wall, percussion tenderness over hepatic region, hepatomegaly of 3 cm; (+) edema of lower extremities. The diagnosis was chronic hepatitis with TCM classification of “liver stagnation and lung dryness form” and “wetness-heat vaporization form”. After 3 parcels of TCM drugs, the liver returned to normal. Clinical cure was obtained after systemic treatment for 5 week, at the end of which medication was discontinued. Eight months later, pruritic eruptions of skin began to appear and were associated with sudden hotness and redness of face and body and desquamation, being particularly severe at both ear lobes. He was diagnosed as eczema at the dermatology department and treated with injections but, of no avail. He had also itching of throat, cough and hypolingual ulcer. Physical examination revealed hepatomegaly of 3 cm. He received 3 parcels of TCM drugs, after which, the liver was normal, and one week later, the eruptions subsided and pruritities disappeared. Therapy ceased after 4 weeks of systemic TCM treatment. He was followed up to the present and no relapse was found.
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By WONG Kwok Hung
published on 9th October 2001
(translated by Professor ZHENG Hua En in 2003)