How Does Your Skin Look?

The skin is the window to the body and many systemic diseases manifest with specific skin findings. Many liver problems will manifest on the skin and an astute observer can diagnosis liver conditions by carefully examining the skin. Unfortunately, most skin findings are overlooked in the current medical era unless a person is specifically evaluated by a trained dermatologist.  Therefore, a good understanding of the skin manifestations of liver disease will prepare the non-dermatologist for more accurate and improved diagnosis of liver disease.

Yellow Skin

Yellowing of the skin or jaundice is perhaps the best-known skin finding seen in liver disease. When liver disease, regardless of cause, leads to a rise in the levels of bilirubin in the blood, the skin can turn yellow. The higher the bilirubin in the blood, the deeper yellow a person’s skin may become. When people with liver dysfunction are unable to adequate produce clotting factors and/or have low platelet counts, easy bruising becomes common. Therefore, frequently noticed ecchymotic areas so called “black and blues” may also be a sign of liver disease.

Skin Findings

Palmar erythema or “liver palms” is a nonspecific red discoloration of the palms and fingertips of the hands associated with liver disease. About 25 percent of people with cirrhosis will have this finding that has been attributed to abnormally high serum estradiol levels. One of the more interesting common skin findings in people with liver disease is called spider nevi or spider angiomas. These are anomalies in the small blood vessels, in which a central arteriole is surrounded by smaller blood vessels, which radiate from its center. This gives an appearance resembling spiders’ legs, hence the name. These are caused by a failure of the musculature surrounding the arteriole to contract. Spider angiomas are classically in the upper chest. While spider angiomas do occur in healthy people, the presence of more than five “spiders” is highly suggestive of underlying liver disease.

Nails

Nails can show changes suggestive of liver disease. Terry’s nail is a physical finding in which affected nails have a bed that is white or pink with a distal transverse band that is pink to brown in color. The degree of pallor of the nail bed and the darkness of the distal band can predict how long the underlying disease has affected the patient. Of course, this is hard to determine if the patient comes to the office wearing nail polish.

Rashes

Liver disease does not lead to rashes, but rather rashes can be a manifestation of a systemic process. Hepatitis B, however, can cause the development of recurrent papular eruptions and skin nodules. Hepatitis C has been associated with such skin conditions as lichen planus, cryoglobulinemia and porphyria cutanea tarda. Primary biliary cholangitis commonly causes xanthelasma, a yellowish deposit of cholesterol underneath the skin most commonly seen around the eyelids. Most interesting, hereditary hemochromatosis causes a bronzing of the skin and affected people look as though they have a suntan. This is diagnosed by looking at the non-sun exposed areas of the body to ensure that no tan lines are present.

It is important to have one’s skin checked regularly, not just for the development of skin cancer, but also for skin changes that can be present in other systemic disease states such as liver disease.

David Bernstein
David Bernstein, MD, is a columnist for Long Island Weekly and chief of gastroenterology, hepatology and nutrition at North Shore University Hospital and Long Island Jewish Medical Center.

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The skin is the window to the body and many systemic diseases manifest with specific skin findings. Many liver problems will manifest on the skin and an astute observer can diagnosis liver conditions by carefully examining the skin. Unfortunately, most skin findings are overlooked in the current medical era unless a person is specifically evaluated by a trained dermatologist.  Therefore, a good understanding of the skin manifestations of liver disease will prepare the non-dermatologist for more accurate and improved diagnosis of liver disease.

Yellow Skin

Yellowing of the skin or jaundice is perhaps the best-known skin finding seen in liver disease. When liver disease, regardless of cause, leads to a rise in the levels of bilirubin in the blood, the skin can turn yellow. The higher the bilirubin in the blood, the deeper yellow a person’s skin may become. When people with liver dysfunction are unable to adequate produce clotting factors and/or have low platelet counts, easy bruising becomes common. Therefore, frequently noticed ecchymotic areas so called “black and blues” may also be a sign of liver disease.

Skin Findings

Palmar erythema or “liver palms” is a nonspecific red discoloration of the palms and fingertips of the hands associated with liver disease. About 25 percent of people with cirrhosis will have this finding that has been attributed to abnormally high serum estradiol levels. One of the more interesting common skin findings in people with liver disease is called spider nevi or spider angiomas. These are anomalies in the small blood vessels, in which a central arteriole is surrounded by smaller blood vessels, which radiate from its center. This gives an appearance resembling spiders’ legs, hence the name. These are caused by a failure of the musculature surrounding the arteriole to contract. Spider angiomas are classically in the upper chest. While spider angiomas do occur in healthy people, the presence of more than five “spiders” is highly suggestive of underlying liver disease.

Nails

Nails can show changes suggestive of liver disease. Terry’s nail is a physical finding in which affected nails have a bed that is white or pink with a distal transverse band that is pink to brown in color. The degree of pallor of the nail bed and the darkness of the distal band can predict how long the underlying disease has affected the patient. Of course, this is hard to determine if the patient comes to the office wearing nail polish.

Rashes

Liver disease does not lead to rashes, but rather rashes can be a manifestation of a systemic process. Hepatitis B, however, can cause the development of recurrent papular eruptions and skin nodules. Hepatitis C has been associated with such skin conditions as lichen planus, cryoglobulinemia and porphyria cutanea tarda. Primary biliary cholangitis commonly causes xanthelasma, a yellowish deposit of cholesterol underneath the skin most commonly seen around the eyelids. Most interesting, hereditary hemochromatosis causes a bronzing of the skin and affected people look as though they have a suntan. This is diagnosed by looking at the non-sun exposed areas of the body to ensure that no tan lines are present. It is important to have one’s skin checked regularly, not just for the development of skin cancer, but also for skin changes that can be present in other systemic disease states such as liver disease.
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