What are the cutaneous signs of internal malignancy?

Intemal malignancy may have the following cutaneous maniesations

• Acanthosis nigricans is seen in adenocarcinoma of GIT
• Palmo-plantar keratoderma is the thick hard hyperkeratotic skin seen in carcinoma bronchus and oesophagus 
• Necrolytic migratory erythema is seen in glucagonoma
• Pityriasis rotunda seen in association with hepatocellular Carcinoma
• Sign of Leser-Trelat is the sudden eruption of intensly pruritic multiple seborrhoeic keratosis in Carcinoma stomach
• Migratory thrombophlebitis is a sign of Carcinoma  pancreas
• Cutaneous hamartoma are seen in carcinaoma  breast, thyroid, gastrointestinal polyposis-cowdens disease
• Pellagra like skin lesions are seen in Carcinoid syndrome
• Pruritus is seen in association with Lymphoma, polycythemia vera
• Dermatomyositis  can be seen in GI malignancy.

Cutaneous manifestations of chronic kidney disease

Certain skin changes are seen in patients with chronic renal failure

• Uraemic frost
• Erythema papulaturn uraemicum are erythematous nodules over palms, soles and forearm 
• Generalized pruritus
• Kyrle's disease is characterised by multiple discrete or confluent hyperkeratotic follicular papules over lowerextremities
• Nail changes (half-half nail—proximal white and distal half pink, mees lines are the nail manifestation of CKD
• Oral manifestations (coating of tongue, xerostomia, ulcerative stomatitis).
• Metastatic calcification

What are the cutaneous markers in Collagen Vascular disease?

Manifestations of SLE

• Butterfly rash
• Telangiectasia

Polyarteritis nodosa and anti-phospholipid syndrome

• Livido reticularis
• Purpura

Dermatomyosistis

• Heliotropic rash
• Periorbital edema
• Gottron's papules

Skin in Hematological Diseases

Following are the cutaneous manifestations of haematological disease

Hyperpigmentation in megaloblastic anemia

Urticaria after hot water bath and palmarerythema is seen in polycythenria vera

Painful ecchymosis at the site of minor trauma is called autoerythrocyte sensitization syndrome sensitization to extravasated RBCs 

Cutaneous bleeds are classified as given below

• Petechiae < 2 mm size
• Purpura   2-5 mm size
• Ecchymosis > 5 mm size 

What are the cutaneous manifestation of Diabetes mellitus?

Diabetes mellitus is associated with following cutaneous manifestation

• Necrobiosis lipoidica diabeticorum is characterised by papulonodular lesions enlarging to form brownish yellow plaques with waxy surface over the front of legs.
• Diabetic dermopathy are  dull red, oval, flat-topped papules over both legs
• Diabetic bullae are seen the over legs, hands and feet bilaterally and  healing with atrophic scars.
• Diabetic rubeosis is the flushed skin of face.
• Scleredema diabeticorum is a diffuse, waxy nonpitting induration_of skin particularly over back of the neck and upper trunk
• Carotenoderma is the yellowish tint of skin due to deposition of carotene
• Granuloma annulare is characterised by the papular lesion over central areas of body and flexures of neck, arm and thigh.
• Infections like furuncle, carbuncle, candidalparonychia, balanoposthitis, intertrigo, recurrent dermatophytosis are common in diabetic patients

What is Cafe au lait spot?

Cafe au lait spots are macule that are seen in more than 90 percentage of people with Neurofibromatosis Type 1 and 2

• They appear as light brown round to ovoid macules with smooth borders often located over the nerve trunk with their long axis parallel to the cutaneous nerves
• It is significant when the number is more than 6 and each more than 1.5 cm in diameter 

Cafe au lait macules are also seen in McCune-Albright syndrome.
They differ from neurofibromatosis in the following

• They have irregular borders 
• They are seen in the midline

Alterations in colour of skin

Alterations in colour of skin is seen in following conditions

Pigmentation of skin vary from dark skinned to fair individuals depending on the race to which they belong

Pale skin -Pallor

Is seen anemia, hypopituitarism, CRF

In pallor the patient appears pale,it is seen over the skin, mucous membranes, lower palpebral conjunctiva, finger nails and palms of thehands. Loss of pigmentation of the palmar creases of the hands gives a clue that the Hb may be less than 7 gm% .

Bluish discoloration—cyanosis

Yellowish—jaundice

Yellow pigmentation of the skin is seen in 

• Jaundice is the yellowish discoloration of the skin ,mucous  membranes' and the sclera seen  when the serum bilirubin exeeds 2mg percentage
• Carotenerma is due to excessive ingestion of carotene.It is associated with yellowish discolouration of skin and mucous membrane but sparing sclera
• Lemon yellow discotoration of skin may be  seen in long standing severe anemia

Generalised Hyperpigmentation of skin 

Flushing of Skin (facial plethora)is seen in 

• Chronic alcoholism.
• Cushing's syndrome
• Polycythemia
• SVC syndrome
• Chronic cor pulmonale.
• Carcinoid syndrome

Primary and secondary skin lesions

Skin is a mirror of systemic disease. Examination of skin will reveal specific sign of systemic disease.
Skin lesions can be classified as 
Primary skin lesions

• Macules are flat lesions < 1cm circumscribed alteration of color of skin <1cm
• Papules are palpable solid elevation < 1cm .Maculopapular rash include both macule and papule
• Plaque are papular lesions of size > 1cm
• Patch is a circumscribed alteration of color of > 1cm.
• Vesicles are lesions < 1 cm these are fluid filled epidermal elevations.
• Bullae are > 1cm fluid filled elevation 
• Pustules are epidermal elevations < 1cm containing pus
• Nodule areSolid palpable lesion ->0.5 cm
• Papilloma - Pedunculated projecting lesion
• Wheal - Elevated central white lesion with red margin
• Telangiectasia - Dilated small cutaneous blood vessel
• Petechiae - Pinhead size macule of blood into the skin.
• Purpura -Larger petechiae which do not blanch on pressure
• Ecchymosis -Large extravasation of blood into resulting in  haematoma 
• Erythema - Redness of the skin.

Secondary skin lesions are the following

• Scales—Desquamated epithelium
• Ulcers—Loss of epidermis, dermis and often with loss of underlying tissue
• Crust are dried up exudates
• Scar are replacement by fibrous tissue
• Excoriation are Loss of skin substance produced by scratching
• Fissure—Any linear slit or discontinuity of skin.