Palmar erythema

Case Report: Unusual oral cavity changes associated with methamphetamine abuse

Methamphetamine abuse is a growing global health concern, recognized for its highly addictive properties and severe effects on the human body. Commonly referred to as crystal, chalk, or ice, methamphetamine is a synthetic stimulant that can be administered in various ways. Methamphetamine abuse is associated with a spectrum of oral health issues known as "meth mouth," including rampant teeth caries, extensive occlusal tooth wear, periodontal diseases, xerostomia, bruxism, and poor oral hygiene. Despite the significant oral health impact, the exact pathogenesis remains unclear due to the limited number of reported cases and comprehensive studies performed. This case series details changes in oral and general health of different severity associated with methamphetamine abuse, highlighting unusual presentations such as the generalized decrease in teeth sensitivity, which can be associated with aseptic tooth pulp necrosis, hairy black tongue, rampant arrested caries, decreased periodontal inflammation, specific sunflower seed abrasions on antagonistic central incisors, pityriasis rosea skin lesion and palmar erythema. The clinical management was presented in detail and justified, which entails conservative dental, periodontal and oral mucosae treatments and highlighted the need for a comprehensive complex examination of these patients and financial consideration in treatment planning. This case series underscores the need to recognize the diverse oral and general health effects of methamphetamine abuse, which vary with duration and individual symptoms. Patients often withhold substance use, leading to delayed diagnosis until severe manifestations arise. Enhanced awareness among healthcare providers can improve diagnosis and management, offering valuable insights into underlying mechanisms and enabling better care for this high-risk population.

Considerations for cutaneous physiologic changes of pregnancy that fail to resolve postpartum

Pregnancy prompts many adaptive and unique physiologic modifications, with cutaneous changes being possibly the most noticeable. These cutaneous changes are of interest to physicians, since they must be diagnosed as anticipated normal physiologic changes or potentially harmful and managed accordingly. Research has been conducted on physiologically normal and abnormal cutaneous manifestations of pregnancy but is lacking in regard to the persistence of these changes after delivery. This prompts the question as to whether these are normal physiologic changes taking longer to resolve, abnormal changes that may have been previously misdiagnosed, or a separate underlying change that is incorrectly attributed to a common dermatosis caused by pregnancy. Some of the conditions that may persist longer than expected during or after pregnancy, and thus require further workup for an underlying condition, include telogen effluvium, severe hirsutism, palmar erythema, and striae. The objective of this review is to focus on these four common cutaneous physiologic changes of pregnancy, and what to consider when they do not resolve as expected.

Recognizing skin conditions in patients with cirrhosis: a narrative review

Background: The skin is a major target organ for extrahepatic manifestations of liver diseases, and dermatologic abnormalities are common in patients with hepatic disorders. Clinical examination of the skin, nails and hair can allow for appropriate recognition, early diagnosis and treatment of liver diseases, and improvement in the quality of life and life expectancy of affected patients.Methods: We searched 3 databases (Pubmed,Medline and Embase) and selected studies about cirrhosis related skin manifestations and their pathophysiology.Results: A total of 73 articles were included in the review. Studies displayed the spectrum of cutaneous manifestations related to hormonal and vascular changes as well as nail and hair changes in patients with cirrhosis and/or portal hypertension.Conclusion: Cutaneous alterations are important clues or potential indications in the diagnosis of liver cirrhosis. Familiarity with skin conditions can be promptly diagnosed and appropriate management initiated.KEY MESSAGESManifestations of the liver and skin disorders are interrelated in various ways. Cutaneous changes may be the first clue that a patient has liver disease.The skin is a major target organ for extrahepatic manifestations of liver diseases. A broad range of cutaneous alterations can be present in patients with cirrhosis, such as vascular, nail, hair, hormonal changes, etc.Recognizing these signs is crucial so that potential underlying diseases including liver disease can be promptly diagnosed and appropriate management timely initiated.

Cirrhosis

Cirrhosis is a chronic condition resulting from inflammation and fibrosis of the liver. Patients with cirrhosis may have a myriad of physical examination findings that reflect the severity of the underlying liver disease. Although many signs and symptoms related to cirrhosis are nonspecific, such as abdominal pain, nausea, and malaise, some findings are more specific and point to complications of liver disease. In this article, key physical findings in patients with cirrhosis, including hepatomegaly, splenomegaly, jaundice, ascites, encephalopathy, dilated abdominal wall veins, spider nevi, palmar erythema, and others, are discussed.

Skin Changes in Cirrhosis

Skin manifestations of systemic disorders give a clue to the organ involved and help identify the possible disease-causing injury. Skin changes of liver cirrhosis are not specific, as they may be seen in disorders not involving the liver. Thus, a constellation of skin changes along with systemic features may help us to identify the disease-causing liver cirrhosis. Pruritus is one of the most common and distressful symptoms of liver cirrhosis, severely affecting the quality of life, which further necessitates understanding cutaneous manifestations of cirrhosis. Other nonspecific cutaneous manifestations include spider telangiectasia, palmar erythema, paper money skin, xanthomas, pigmentation changes, nutritional deficiencies, hair changes, and nail changes. This review discusses the nonspecific skin manifestations associated with liver cirrhosis followed by specific cutaneous findings seen in common diseases causing liver cirrhosis, such as viral infections, biliary tract disorders, chronic alcoholism, and metabolic disorders. Early recognition of cutaneous features can help prevent or delay the development of complications and end-stage disease, decreasing morbidity and mortality.

The effects of alcohol and illicit drug use on the skin

Early identification of cutaneous manifestations of alcohol and illicit drug use can aid in the diagnosis and management of these uses, as well as their sequelae. In addition, the effects of alcohol and illicit drug use on the skin can result in significant morbidity. Alcohol misuse can present with jaundice, pruritus, pigmentary alterations, urticaria, hair and nail changes, and oral changes. It is also a risk factor for skin cancer and infections. Vascular disturbances associated with alcohol misuse include telangiectasias, palmar erythema, caput medusae, and flushing. Diseases related to alcohol misuse include nutritional deficiencies, porphyria cutanea tarda, psoriasis, seborrheic dermatitis, nummular dermatitis, and rosacea. Other conditions seen in alcohol misuse include Dupuytren contracture, Peyronie disease, and pancreatitis. Dermatologists should also be aware of hepatotoxic medications that are commonly prescribed for skin diseases so as to avoid initiating hepatoxicity in patients who use alcohol. Illicit drug use can manifest with cutaneous fibrosis, scarring, granulomas, ulceration, pruritus, infections, cocaine-levamisole-induced vasculitis, tooth decay, and oral disease. By recognizing the cutaneous stigmata of alcohol and illicit drug use, dermatologists can aid in the identification and treatment of patients suffering from these addictions.

Serum testosterone levels and testosterone supplementation in cirrhosis: A systematic review

BACKGROUND & AIMS

Cirrhosis disrupts the hypothalamic-pituitary-gonadal axis causing low testosterone. Testosterone deficiency is associated with sarcopenia and osteopenia, leading to a state of frailty and worse clinical outcomes, morbidity and mortality. We aimed to conduct a systematic review on the relationship between serum testosterone and laboratory, anthropometric and clinical outcomes in observational and interventional studies in cirrhosis.

METHODS

PubMed and EMBASE were searched from inception through 27 August 2020 and reviewed independently by two investigators; a third reviewer solved disagreement. A qualitative summary of relevant findings was done. Methodological quality was assessed using the Newcastle Ottawa Scale for non-interventional studies and the Cochrane Risk of Bias for interventional studies.

RESULTS

Out of 3569 articles, 15 met inclusion criteria with six observational studies of 1267 patients and nine interventional studies of 580 patients. In observational studies, low serum testosterone level was associated with sarcopenia, shorter median time to hepatic decompensation, transplant requirement, higher model for end-stage liver disease (MELD) scores, and death in cirrhotic patients. Nine interventional studies (361 treated with testosterone vs 219 placebo, 1-36 months) showed that testosterone supplementation improved serum testosterone, appendicular mass and bone mineral density. However, no trial reported improvement in liver-related scores, complications, readmission rates or death.

CONCLUSIONS

Low serum testosterone is associated with increased morbidity and mortality in cirrhosis patients. Testosterone supplementation improved intermediate endpoints, but there was no conclusive data on clinical outcomes. Testosterone supplementation may be a promising strategy to improve frailty and decrease significant clinical complications in cirrhosis.

Computational analysis for identification of early diagnostic biomarkers and prognostic biomarkers of liver cancer based on GEO and TCGA databases and studies on pathways and biological functions affecting the survival time of liver cancer

BACKGROUND

Liver cancer is the sixth most commonly diagnosed cancer and the fourth most common cause of cancer death. The purpose of this work is to find new diagnostic biomarkers or prognostic biomarkers and explore the biological functions related to the prognosis of liver cancer.

METHODS

GSE25097 datasets were firstly obtained and compared with TCGA LICA datasets and an analysis of the overlapping differentially expressed genes (DEGs) was conducted. Cytoscape was used to screen out the Hub Genes among the DEGs. ROC curve analysis was used to screen the Hub Genes to determine the genes that could be used as diagnostic biomarkers. Kaplan-Meier analysis and Cox proportional hazards model screened genes associated with prognosis biomarkers, and further Gene Set Enrichment Analysis was performed on the prognosis genes to explore the mechanism affecting the survival and prognosis of liver cancer patients.

RESULTS

790 DEGs and 2162 DEGs were obtained respectively from the GSE25097 and TCGA LIHC data sets, and 102 Common DEGs were identified by overlapping the two DEGs. Further screening identified 22 Hub Genes from 102 Common DEGs. ROC and survival curves were used to analyze these 22 Hub Genes and it was found that there were 16 genes with a value of AUC > 90%. Among these, the expression levels of ESR1,SPP1 and FOSB genes were closely related to the survival time of liver cancer patients. Three common pathways of ESR1, FOBS and SPP1 genes were identified along with seven common pathways of ESR1 and SPP1 genes and four common pathways of ESR1 and FOSB genes.

CONCLUSIONS

SPP1, AURKA, NUSAP1, TOP2A, UBE2C, AFP, GMNN, PTTG1, RRM2, SPARCL1, CXCL12, FOS, DCN, SOCS3, FOSB and PCK1 can be used as diagnostic biomarkers for liver cancer, among which FOBS and SPP1 genes can also be used as prognostic biomarkers. Activation of the cell cycle-related pathway, pancreas beta cells pathway, and the estrogen signaling pathway, while on the other hand inhibition of the hallmark heme metabolism pathway, hallmark coagulation pathway, and the fat metabolism pathway may promote prognosis in liver cancer patients.

Fluctuating Palmar Erythema in a Toddler during COVID-19 Pandemic: Do You Know the Offender?

Palmar erythema in children can be due to various reasons, such as chronic liver disease, rheumatological disorders, medications, irritant contact dermatitis and atopic dermatitis. Recently, there are few reports about contact dermatitis caused by frequent, daily use of hand sanitizers during this COVID-19 pandemic. A 3-year-old toddler brought with the concern of waxing-waning bilateral palmar erythema for the past 2 weeks. The parents revealed that the child liked the bright color of a recently bought hand sanitizer bottle so much he used to wash his hands every 20-30 min throughout the day. The atypical presentation of contact dermatitis might be because the child was using the sanitizer more frequently during the daytime. The dermatitis resolved with stopping excessive use of the hand sanitizer by the toddler. Clinicians should be aware of contact dermatitis during these pandemic times. Instead of investigating them extensively, careful history taking and merely advising them to judicially utilize the sanitizer can lead to complete reversal of symptoms.

Palmar Erythema as the Sole Manifestation of COVID-19

The new pandemic COVID-19 is now recognised as a multisystem disease. Variety of skin lesions have been reported in 0.2-20.4% of cases of COVID-19. In some cases of COVID-19, skin lesions have been reported as the initial or the only manifestation. We are reporting a case of bilateral palmar erythema as the sole manifestation of COVID-19 in a 37-year-old female who had a family history of COVID-19 like illness and was later found positive for anti-SARS-CoV-2 antibodies.

Cutaneous Manifestations of Chronic Liver Disease

Given the visibility of cutaneous findings, skin manifestations are often a presenting symptom of underlying systemic disease, including chronic liver disease. Many cutaneous signs and symptoms that correlate with chronic liver disease are common physical examination findings in patients with no history of liver disease. It is nonetheless important to be aware that these cutaneous findings may be an indication of underlying liver disease and often occur in the setting of such hepatic dysfunction. This article covers general cutaneous signs that may correlate with various liver diseases and describes specific cutaneous signs as they relate to more specific liver diseases.

Changes in color of the skin and systemic disease

When looking for diseases of the skin, this is usually done in a holistic way, automatically and unconsciously, by recognizing localization, distribution, and appearance of the primary or secondary skin lesions. When Robert Willan (1757-1812) introduced the concept of morphology of skin lesions, it became the basis for the classification of dermatoses. Apart from ethnic factors, the various dermatoses comprise a rainbow of colors ranging from the most common red color to yellow, blue, brown, silver, green, black, and white.

Lane's Disease (Erythema Palmare Hereditarium): A Report of Five Cases and a Review of the Literature

BACKGROUND

Erythema palmare hereditarium (EPH), also known as Lane's disease, is a rare, benign condition presenting as persistent erythema involving the palms. EPH can appear at birth or later in life and usually in at least two members of the same family, although a sporadic case has been reported.

METHODS

We report five cases of EPH and offer a review of the current literature. The first and second cases are twin boys presenting with erythema mainly on the thenar and hypothenar eminences and on the phalanges that appeared 8 months after birth. The third case is a girl with congenital palmar erythema and two other capillary malformations. The fourth case is a 58-year-old woman with palmar erythema that appeared after pregnancy. Her 32-year-old daughter had presented with the same palm redness since birth.

RESULTS

A review of the literature shows that women are affected almost three times more than men. Dermoscopic evaluation showed red structureless areas with arborizing vessels, mainly running parallel along follicular openings.

CONCLUSION

EPH should be considered in all patients presenting with palmar erythema, especially in familial long-lasting forms. It can be congenital or acquired, but the pathogenetic mechanism is unclear. To the best of our knowledge, this is the first dermatoscopic study of EPH and the largest case series reported in the literature, involving two families and one sporadic case.

Mucocutaneous Manifestations in Patients with Rheumatoid Arthritis: A Cross-sectional Study from Eastern India

BACKGROUND

Cutaneous manifestations are fairly common in rheumatoid arthritis (RA) and they can help in early diagnosis, prompt treatment, and hence reduced morbidity from the disease.

AIMS

The objective of the present study was to find out the different patterns of dermatoses in a group of patients with RA from Eastern India.

METHODOLOGY

Consecutive patients fulfilling the American Rheumatism Association 1987 revised criteria for the classification of RA and who had different dermatoses were included in this cross-sectional study done over a period of 8 years in a tertiary care hospital in Eastern India. Thorough clinical examination and appropriate laboratory investigations were performed as needed. Data were recorded in a predesigned schedule, and appropriate statistical analysis was done.

RESULTS

We studied 111 evaluable patients with an age range of 19-71 years and a female to male ratio of 7:1. The mean disease duration of RA was 6.5 years. Cutaneous infections as a group was the most common mucocutaneous manifestation (34.2%) followed by xerosis including ichthyotic skin changes (27%), pigmented purpuric dermatoses (14.4%), leg ulcer (9.9%), periungual telangiectasia (9.9%), rheumatoid nodules (RNs) (8.1%), purpura and ecchymoses (7.2%), small vessel vasculitis in (7.2%), corn and callosities (6.3%), palmar erythema (4.5%), and neutrophilic dermatosis (4.5%). Raynaud's phenomenon was found in 3.6% patients and panniculitis in (3.6%) patients. Rheumatoid factor (RF) and anti-cyclic citrullinated peptides antibody were positive in 74.8% and 88.3% patients, respectively. No statistically significant difference of incidence of leg ulcer, small vessel vasculitis, RN, or Raynaud's phenomenon could be noted between RF positive and negative groups.

LIMITATIONS

Being an institution-based study, the study findings may not reflect the true situation in the community which remained a limitation of this study.

CONCLUSION

While some of the features of this study were analogous to Western data, other features showed discordance which may be due to ethnic variations among the patients with RA.

Hepatic Failure

The progression of liver disease can cause several physiologic derangements that may precipitate hepatic failure and require admission to an intensive care unit. The underlying pathology may be acute, acute-on chronic, or chronic in nature. Liver failure may manifest with a variety of clinical signs and symptoms that need prompt attention. The compromised synthetic and metabolic activity of the failing liver affects all organ systems, from neurologic to integumentary. Supportive care and specific therapies should be instituted in order to improve outcome and minimize time of recovery.

In this chapter we will discuss the definition, clinical manifestations, workup, and management of acute and chronic liver failure and the general principles of treatment of these patients. Management of liver failure secondary to certain common etiologies will also be presented. Finally, liver transplantation and alternative therapies will also be discussed.

Dermatologic manifestations of diabetes mellitus: a review

Diabetes mellitus affects every organ of the body including the skin. Certain skin manifestations of diabetes are considered cutaneous markers of the disease, whereas others are nonspecific conditions that occur more frequently among individuals with diabetes compared with the general population. Diabetic patients have an increased susceptibility to some bacterial and fungal skin infections, which account, in part, for poor healing. Skin complications of diabetes provide clues to current and past metabolic status. Recognition of cutaneous markers may slow disease progression and ultimately improve the overall prognosis by enabling earlier diagnosis and treatment.

Skin signs of systemic diseases

The skin should not be considered as an isolated organ but rather as a definite functioning system that communicates with the internal environment. Skin signs of systemic diseases occur frequently and sometimes feature the first symptoms of an internal disease; furthermore, these manifestations may be the sole expressions of otherwise asymptomatic systemic disorders. A number of dermatologic signs, symptoms, and disorders can be invaluable as markers of systemic disease. Although a plethora of specialized modern diagnostic tests are available, the skin still remains the only organ of the body that is immediately and completely accessible to direct clinical examination. This contribution reviews the skin signs of systemic diseases. The description of the clinical features of skin lesions observed in several internal diseases will be useful to general physicians, internists, and dermatologists in the diagnosis of a systemic disease.

Cutaneous manifestations of common liver diseases

Skin functions as a window to our overall health and a number of systemic diseases result in various cutaneous changes. Knowledge of these manifestations helps in suspecting an underlying systemic illness. Cutaneous abnormalities are quite common in patients with liver diseases and this article aims to focus on these dermatoses. Cutaneous manifestations seen in patients with liver disease though common are nonspecific. They can also be seen in patients without liver diseases and generally do not indicate about a specific underlying hepatic disorder. The presence of a constellation of signs and symptoms is more useful in pointing toward an underlying hepatobiliary condition. The commonest symptom in patients with liver disease is pruritus which is often protracted and disabling. Other common features include spider angiomas, palmar erythema, paper money skin, xanthelasmas, pigmentary changes, and nutritional deficiencies. In this article, first the common cutaneous manifestations that may be associated with liver disorders are discussed and then common liver diseases with their specific cutaneous findings are discussed. Cutaneous abnormalities may be the first clue to the underlying liver disease. Identifying them is crucial for early diagnosis and better management.

Dermatologic disorders and the liver

Chronic liver disease is associated with several cutaneous manifestations. Although many of these changes are nonspecific, some are associated with distinct liver diseases and correlate with the severity of hepatic pathology. Often the first clue to a liver disease is manifested through skin. Although cirrhosis is associated with spider nevi and palmar erythema, disorders can result in noncirrhotic cutaneous manifestations. It is important for physicians to be familiar with the spectrum of these manifestations, to recognize, help detect, and treat the underlying hepatic disease. This article reviews the medical literature and discusses the spectrum of dermatologic manifestations of liver disorders and their pathogenesis, significance, and treatment.

Erythema multiforme associated with gemfibrozil monotherapy

BACKGROUND

A case of erythema multiforme associated with gemfibrozil monotherapy.

METHODS AND RESULTS

A 46-year-old man with hyperlipidemia was treated with 600 mg gemfibrozil twice a day. On the fifth day of treatment, skin lesions consistent with erythema multiforme appeared. With the discontinuation of the treatment and start of a topical steroid treatment, the lesions recovered after 4 weeks. After 6 months, when gemfibrozil therapy was restarted, lesions reappeared on the fourth day of therapy. Lesions recovered again following the previous treatment strategies after 4 weeks. An objective casualty assessment suggests that erythema multiforme was probably related to gemfibrozil monotherapy.

CONCLUSION

Patients starting gemfibrozil therapy should be warned about the occurrence of erythema multiforme in addition to previous reported and established side effects.