Cutaneous manifestations of systemic diseases

Skin manifestations associated with systemic diseases - Part II

The skin, by reflecting internal processes, externalizes what happens inside the body in many diseases. Thus, the skin, as an organ, extrapolates its functions of protection, barrier and signals the existence of systemic diseases, expanding the importance of the dermatologist beyond the skin surface. Thus, the dermatologist investigates diagnostic hypotheses for conditions related to all systems and refers patients to the appropriate specialty. Combined with examination by a trained eye, the skin, due to its easy access, is still the ideal place for performing biopsies, which often clarify the diagnosis. This manuscript is the second part of the article on cutaneous manifestations of systemic diseases. In the first part, the cutaneous manifestations of the main rheumatologic and granulomatous diseases were described, and vascular manifestations were also addressed. In the present article, it will be discussed how metabolic, cardiovascular, kidney, and gastrointestinal diseases can manifest themselves in the integumentary system. Malignant diseases and their cutaneous implications, will also be discussed. Pruritus and its clinical cutaneous correspondence will be discussed. Finally, an update on cutaneous signs of SARS-CoV2 coronavirus infection will be presented.

Global Skin Disease Morbidity and Mortality: An Update From the Global Burden of Disease Study 2013

Question

What is the burden of skin disease worldwide?

Findings

In this observational study, skin diseases contributed 1.79% to the global burden of disease measured in disability-adjusted life years (DALYs). Skin diseases arranged in order of decreasing global DALYs are as follows: dermatitis (atopic, contact, seborrheic), acne vulgaris, urticaria, psoriasis, viral skin diseases, fungal skin diseases, scabies, melanoma, pyoderma, cellulitis, keratinocyte carcinoma, decubitus ulcer, and alopecia areata.

Meaning

Skin diseases remain a major cause of disability worldwide. An objective measure of burden, such as the DALY, allows for comparison of diverse diseases across geography and time.

Importance

Disability secondary to skin conditions is substantial worldwide. The Global Burden of Disease Study 2013 includes estimates of global morbidity and mortality due to skin diseases.

Objective

To measure the burden of skin diseases worldwide.

Data Sources

For nonfatal estimates, data were found by literature search using PubMed and Google Scholar in English and Spanish for years 1980 through 2013 and by accessing administrative data on hospital inpatient and outpatient episodes. Data for fatal estimates were based on vital registration and verbal autopsy data.

Study Selection

Skin disease data were extracted from more than 4000 sources including systematic reviews, surveys, population-based disease registries, hospital inpatient data, outpatient data, cohort studies, and autopsy data. Data metrics included incidence, prevalence, remission, duration, severity, deaths, and mortality risk.

Data Extraction and Synthesis

Data were extracted by age, time period, case definitions, and other study characteristics. Data points were modeled with Bayesian meta-regression to generate estimates of morbidity and mortality metrics for skin diseases. All estimates were made with 95% uncertainty intervals.

Main Outcomes and Measures

Disability-adjusted life years (DALYs), years lived with disability, and years of life lost from 15 skin conditions in 188 countries.

Results

Skin conditions contributed 1.79% to the global burden of disease measured in DALYs from 306 diseases and injuries in 2013. Individual skin diseases varied in size from 0.38% of total burden for dermatitis (atopic, contact, and seborrheic dermatitis), 0.29% for acne vulgaris, 0.19% for psoriasis, 0.19% for urticaria, 0.16% for viral skin diseases, 0.15% for fungal skin diseases, 0.07% for scabies, 0.06% for malignant skin melanoma, 0.05% for pyoderma, 0.04% for cellulitis, 0.03% for keratinocyte carcinoma, 0.03% for decubitus ulcer, and 0.01% for alopecia areata. All other skin and subcutaneous diseases composed 0.12% of total DALYs.

Conclusions and Relevance

Skin and subcutaneous diseases were the 18th leading cause of global DALYs in Global Burden of Disease 2013. Excluding mortality, skin diseases were the fourth leading cause of disability worldwide.

Simultaneous detection of antibacterial sulfonamides in a microfluidic device with amperometry

A highly sensitive and robust method for simultaneous detection of five sulfonamide drugs is developed by integrating the preconcentration and separation steps in a microfluidic device. An ampetrometry is performed for the selective detection of sulfonamides using an aluminum oxide-gold nanoparticle (Al(2)O(3)-AuNPs) modified carbon paste (CP) electrode at the end of separation channel. The preconcentration capacity of the channel is enhanced by using the field amplified sample stacking and the field amplified sample injection techniques. The experimental parameters affecting the analytical performances, such as pH, % of Al(2)O(3), volume of AuNPs, buffer concentration, and water plug length are optimized. A reproducible response is observed during the multiple injections of samples with RSDs<4%. The calibration plots are linear with the correlation coefficient between 0.991 and 0.997 over the range between 0.01 and 2025pM. The detection limits of five drugs are determined to be between 0.91 (±0.03) and 2.21 (±0.09)fM. The interference effects of common biological compounds are also investigated and the applicability of the method to the direct analysis of sulfonamides in real meat samples is successfully demonstrated. Long term stability of the modified electrode was also investigated.

Atypical calciphylaxis in a patient receiving warfarin then resolving with cessation of warfarin and application of hyperbaric oxygen therapy

Calciphylaxis is a rare, usually fatal vasculopathic disorder characterized by cutaneous ischemia and necrosis due to calcification of arterioles. Although calciphylaxis is most frequently associated with end-stage renal disease (ESRD) and secondary hyperparathyroidism, it has been reported infrequently among patients on warfarin. No standard treatment has been established for atypical calciphylaxis; however, a potentially beneficial treatment is hyperbaric oxygen therapy (HBOT). A high degree of clinical suspicion, early diagnosis, and understanding the pathophysiology of this disease promotes the optimal management of this extremely morbid and often fatal condition.

CASE REPORT

We present a 63-year-old Polynesian woman with biopsy-proven calciphylaxis in the absence of ESRD or elevated serum calcium levels while taking warfarin. Therapeutic dose enoxaparin was substituted for warfarin and she received 40 sessions of HBOT during which lower extremity ulcers resolved.

DISCUSSION

Warfarin has been implicated when calciphylaxis presents in an atypical fashion. No guidelines exist for treatment of atypical calciphylaxis in the setting of concomitant warfarin therapy. Up to 80% of calciphylaxis patients die within 1 year of diagnosis. Our patient was changed to low-molecular-weight heparin and received HBOT.

CONCLUSION

We present what we believe is the first case of atypical calciphylaxis thought to be attributable to warfarin treated with a therapeutic substitution of anticoagulant and HBOT leading to resolution of cutaneous lesions.

Case reports of etanercept in inflammatory dermatoses

Skin disfigurations and pruritus can pose severe threats to quality of life, and treatment options for patients with recalcitrant diseases are limited. Tumor necrosis factor alpha, a proinflammatory cytokine, appears to play a central role in mediating the symptoms of many skin disorders. We report cases in which etanercept (Enbrel; Immunex Corp, Thousand Oaks, Calif), a tumor necrosis factor alpha antagonist that is approved for the treatment of moderate to severe psoriasis, was administered to ameliorate the symptoms of acute and chronic dermatologic conditions, including Hailey-Hailey disease, severe psoriasis, dermatomyositis, and subacute cutaneous lupus erythematosus. Treatment with etanercept substantially improved the clinical symptoms and quality of life in these patients, and may offer a therapeutic option for some patients with severe skin disorders.

A rare association of Sweet's syndrome with cervical cancer

BACKGROUND

Approximately 10-20% of patients with Sweet's syndrome have an associated malignancy. To our knowledge, Sweet's syndrome has been reported in cervical cancer in only three other patients.

CASE

We report a case of a 44-year-old female diagnosed with cervical cancer (FIGO IIIB), treated with concurrent chemotherapy and radiation therapy. Approximately 5 months after completing treatment, she presented with nausea, vomiting, and bullous pustular lesions on the hand. She was found to have a small bowel obstruction due to recurrence of her cervical cancer, and a biopsy of the skin lesion showed a marked dermal neutrophilic infiltrate consistent with Sweet's syndrome.

CONCLUSION

We report a case of Sweet's syndrome associated with cervical cancer, which is a rare finding.