Skin Deep (Part 1)
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.”
While the “all clear” of an annual checkup evokes sighs of relief in those sailing uncharted waters, a sudden shift in surface tides may generate ripples indicative of the disturbed slumber of deeper demons.
© 2006, Albert M. Balesh, M.D. All rights reserved.
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.”
While the “all clear” of an annual checkup evokes sighs of relief in those sailing uncharted waters, a sudden shift in surface tides may generate ripples indicative of the disturbed slumber of deeper demons.
© 2006, Albert M. Balesh, M.D. All rights reserved.
posted by Dr. Al at
8/14/2006 01:06:00 PM
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