From pimples to elephant men, the gamut is vast, but the terrain is the same. Skin is as deep as you need go, to discover what lurks beneath. More than a mere peephole, the integument provides a panoramic view to the internist bent on providing appropriate diagnosis, treatment, or referral to a dermatologist. So, let’s dive in, but keep it simple. The terminology is long and romantic, but, while tongues twist, principles are relatively straightforward. Observation is the name of the game, my dear Watson.
As we open the window to the inner workings of our biologic machinery, we note that skin manifestations can be associated with cutaneous, oncologic, cardiovascular, pulmonary, rheumatic, gastrointestinal, endocrine, and metabolic disorders. One size does not fit all, however, and it is the astute and patient clinician who brings order to the chaos of sameness. For while a blemish may mean house arrest for a testosterone-charged adolescent, it can signify something far more sinister for those whose middle years have been breached. Shakespeare called the same entity by many names. Today we give many names to different entities that may all look the same.
Enough of the cryptic, it’s on to the concrete. Whether we call it seborrheic dermatitis, seborrheic keratosis, urticaria, erythema multiforme, vitiligo, or erythema nodosum, we must concede that something is “rotten in Denmark.” While the hard, warty plaques of seborrheic keratosis may warrant a deeper look for an underlying adenocarcinoma of the gastrointestinal tract, the depigmented skin patches of vitiligo are no less important, serving as beacons to illuminate possible cases of thyroid disease, diabetes mellitus, pernicious anemia, or Addison’s disease (insufficiency of the adrenal gland). And who hasn’t seen the fluid-filled, cutaneous bubbles of urticaria, commonly known as hives, brought on by penicillin, sulfa drugs, aspirin, shellfish, nuts, and chocolate.
We never forget our first kiss, the prom, that sleek, new hot-rod we hid from our parents, or the unexpected roll in the hay on a warm, summer night. No less memorable, for those in their crosshairs, are the cutaneous metastases of buried cancers of the breast, colon, lung, and genitourinary tract. Their slumber and our relative complacency is often disturbed by the sprouting of epidermoid cysts and plaques that demand our attention when the cause may already be lost. And what of acanthosis nigricans, whose bark may or may not be as big as its bite? While its smooth, hard, velvet-like, skin plaques in the groin, axillae, and neck areas may warrant alarm and a trip to the barrister to put one’s affairs in order, due to its association with abdominal cancer, it may be caused by something much less injurious such as obesity, insulin-resistant diabetes, or systemic corticosteroids.
As children, we crossed our hearts and hoped to die when we made assertions requiring blind credence on the part of an audience. Nothing bad ever happened to us. So, those little white lies served as judge, jury, and coat of armor. Not so with little brown freckles. While they look innocuous enough, they may signal underlying cardiovascular problems, colorfully named LEOPARD, LAMB, or NAME syndromes. Nor are all the incantations in the world a match for a broken heart, when the yellow skin papules of pseudoxanthoma elasticum and the blue eye sclerae of Ehlers-Danlos syndrome point to defects of elastic and collagen fibers, respectively, and a “wicker ticker.”
Do we dare breathe a sigh of relief through a purple nose? Perhaps for a Sioux warrior on the Little Bighorn that might have been possible. The war paint of today, however, in the form of red to purple plaques on the nose, raises smoke of an impending doom, reversing the historical tides of victory. Sarcoidosis, a multisystem, inflammatory disease with large cellular nodules in the lungs, bones, eyes, and skin, is a worthy and indomitable adversary who might have made even Custer proud.
It doesn’t end there, however. Patients with psoriatic arthritis, lupus erythematosus, and scleroderma are already behind the eight ball. They suffer from a battery of symptoms and signs resembling rheumatoid arthritis, as well as graver, more systemic manifestations. When it rains, they find themselves without umbrellas, and the facial rash, photosensitivity, skin calcification, oral ulcers, blisters, baldness, finger pallor, cyanosis, and redness, and further cutaneous incursions can be extremely annoying and demoralizing for their already ceaselessly trodden psyches.
The abdomen is a funny creature. We are alerted to its grumblings when nausea and vomiting point to our lack of self-control at the dinner table, a bug that has crept into our lives, or Montezuma’s revenge. But if that were not enough, just the sound of terms like Peutz-Jeghers syndrome and hereditary hemorrhagic telangiectasias (Osler-Weber-Rendu syndrome) are enough to scare the living daylights out of us. What we don’t know can hurt us, however, so the skin, lip, and oral freckles of Peutz-Jeghers and the dilated blood vessels in the lungs, liver brain, eye, and gastrointestinal tract of Osler-Weber-Rendu warrant a careful search for polyps of the small intestine and brain tumors, respectively. Throw the cutaneous manifestations of dermatitis herpetiformis, hepatitis C infection, and pyoderma gangrenosum into the mix, and we become painfully aware of the intricate nature of the tryst involving skin and gastrointestinal tract. In the case of pyoderma gangrenosum, the painful ulcers of the legs, often following trauma, may affect patients having inflammatory bowel disease or rheumatoid arthritis.
Which brings us to the stuff of nightmares. Who’s afraid of the big bad wolf, vampires, werewolves, gargoyles, goblins, ghosts, and mummies? Not us, you say. Well, that’s well and good, but the blistering skin lesions of porphyria and pseudoporphyria were once connected with folk tales, the living dead, and Count Dracula’s aversion to sunlight. Today we know the former disease processes to be connected to the ingestion of alcohol and medications (estrogen, diuretics, nonsteroidal anti-inflammatory drugs, tretracycline), to kidney dialysis, to hepatitis B or C infection, and to tanning bed use.
Finally, the best (or worst) for last. It has been noted that 30%-50% of diabetic patients have or will have skin disease. Truth in numbers gives added weight to the already widely held notion that strict blood glucose control can do much to ward off the evil complications of this ubiquitous malady.
While a thick skin can do much to buttress a fragile ego, in much the same way that a wetsuit protects from the blue depths, thinner is better when it sounds the medical alarm to dive skin deep.
© 2006, Albert M. Balesh, M.D. All rights reserved.
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