Elsevier

Clinics in Dermatology

Volume 26, Issue 3, May–June 2008, Pages 274-282
Clinics in Dermatology

Cutaneous manifestations of liver diseases

https://doi.org/10.1016/j.clindermatol.2008.02.001Get rights and content

Abstract

The cutaneous manifestations of liver disorders are protean. In addition to the well-recognized stigmata of liver cirrhosis, various infectious, metabolic, autoimmune, hereditary, developmental, and neoplastic liver disorders can result in various cutaneous and mucosal changes as well as in pruritus and abnormal hair and nail growth. Although many of these changes are nonspecific, some are associated with distinct liver diseases and correlate with the severity of hepatic pathology. Familiarization with the spectrum of these manifestations is important for early detection and treatment of hepatic diseases. We review the medical literature and discuss the spectrum of dermatologic manifestations of liver cirrhosis and of important liver diseases, their etiopathogenesis, significance, and treatment.

Introduction

The liver is the largest internal organ and the second largest organ in the human body after the skin, with blood supply from the hepatic artery and the portal vein. It performs many interrelated functions, including storage and filtration of blood; carbohydrate, protein, and fat metabolism; vitamins and iron storage; synthesis of most serum proteins (like clotting factors and their inhibitors); and bile production. These different functions may become impaired simultaneously in various combinations depending upon the nature of the liver disorder. Among all the extrahepatic manifestations of liver diseases, the cutaneous manifestations are the most common. In addition, they are easily recognizable and may provide the first clues of liver disease allowing for early diagnosis and therapy. This review deals with the dermatologic manifestations of liver cirrhosis in general and of various infectious, metabolic, autoimmune, hereditary, developmental, and neoplastic liver disorders. Emphasis will be placed on important clinical features, their etiopathogenesis, significance, and treatment. The cutaneous manifestations of liver transplantation are also reviewed.

Section snippets

The liver and the skin

An association between the skin and the liver has been recognized for centuries. Several types of interactions between these 2 organs are encountered:

  • 1.

    Liver disease may cause skin changes (the topic of this review).

  • 2.

    The skin and the liver may be involved by the same pathologic process (such as seen in histiocytosis diseases [X and non-X], hemangiomas, sarcoidosis, α1-antitrypsin deficiency, hemochromatosis, and dyslipidemia).

  • 3.

    Skin disease may cause liver abnormality (such as metastatic melanoma to

Cutaneous manifestations of liver cirrhosis

The cutaneous stigmata of liver cirrhosis are protean and reflect the impairment of the various functions of the liver in different combinations. Racial differences have been reported. For instance, when compared with age- and sex-matched controls, cirrhotic African patients had significantly lower body temperature, onycholysis, and hyperpigmented palmoplantar macular areas.2

Direct (contiguous) cutaneous involvement

The skin is rarely involved through direct cutaneous extension/fistulation of hepatic infections such as actinomycosis,33 amebiasis,34 and hydatid cysts.35

Hepatitis B virus infection

The cutaneous manifestations of hepatitis B virus (HBV) infection are protean and nonspecific. Twenty to thirty percent and 7% to 8% of acute HBV infection patients develop a serum sickness-like disease and polyarteritis nodosa (PAN), respectively. Serum sickness-like picture usually appears 1 to 6 weeks before the onset of clinical liver

Conclusions

In conclusion, patients with liver disorders present a wide variety of cutaneous manifestations. The exact mechanisms of most of these skin findings remain obscure rendering the evaluation of their significance difficult. These manifestations, however, may be specific to the hepatic diseases or even reflect the severity of the liver pathology.87 Thus, recognition of these associations is of paramount importance for early and prompt diagnosis of certain liver disorders and/or for monitoring the

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