The liver has many jobs: synthesizing proteins such as clotting factors, complements, and albumin; neutralizing toxins; and metabolizing lipids and carbohydrates. Insults to the liver can compromise any of these functions, affecting visceral organs, joints, gastrointestinal tissues, and the skin. Dermatologic signs of specific liver diseases include alopecia and vitiligo associated with autoimmune hepatitis, and xanthelasma in chronic cholestatic liver disease.
This article reviews the important cutaneous manifestations of specific liver diseases. We focus first on skin conditions that may represent liver disease, and then we discuss several major liver diseases and their typical cutaneous manifestations. Figure 1.
Dermatological Signs of Internal Disease : Plastic and Reconstructive Surgery
Characteristic yellowish discoloration of the sclera in the eye of a patient with end-stage liver disease. Establishing whether the excess bilirubin is conjugated or unconjugated gives a clue as to whether the cause is prehepatic, intrahepatic, or posthepatic. Prehepatic causes of jaundice include hemolysis and ineffective erythropoiesis, both of which lead to higher levels of circulating unconjugated bilirubin. Pruritus can be multifactorial or the result of a specific dermatologic or systemic condition.
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The liver neutralizes toxins and filters bile salts. If its function is impaired, these materials can accumulate in the body, and deposition in the skin causes irritation and itching. Although the severity of pruritus is not directly associated with the level of bile salts and toxic substances, lowering bile salt levels can mitigate symptoms.
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If the pruritus does not respond adequately to cholestyramine or the patient cannot tolerate the drug, then the antituberculosis drug rifampin Rifadin can be tried. Third-line drug therapies include opioid antagonists such as naltrexone ReVia and nalmefene Revex. Plasmapheresis can be considered if drug therapy fails. Prurigo nodularis, distinguished by firm, crusty nodules, is associated with viral infections eg, hepatitis C, human immunodeficiency virus , bacterial infections, and kidney dysfunction.
Skin signs and systemic disease
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AMA Citation Section Skin Manifestations of Internal Organ Disorders. Goldsmith L. Lowell A.