Download Cutaneous signs of eating disorders

Cutaneous signs of
eating disorders
The GP may often be the first one to notice a patient’s numerous skin and
hair manifestations due to eating disorders, writes Angela Alani
Forum
Dermatology
Figure 1. Acne affecting forehead with diffuse
frontal hair thinning
Figure 2. Lanugo hair on the back
“I can’t live with my skin anymore” and “my acne is
awful” were statements made by two patients recently
referred to the dermatology department with cutaneous
signs of eating disorders.
A 21-year-old lady with severe anorexia nervosa, weighing
little more than 46kg (BMI of 16), was recently admitted
under the psychiatric services for control of her eating disorder. Dermatology review was requested because of ongoing
acne and diffuse hair loss over the previous three years. In
addition to her alopecia, she had inflammatory acne lesions
evident on the forehead and chin (see Figure 1), and prominent lanugo-like hair growth on her back (see Figure 2). Her
alopecia was a diffuse non-scarring hair loss compatible
with telogene effluvium and mirrored her recently worsened
eating disorder. Of all her cutaneous signs, she was particularly distressed by her acne, but her expression of this was
very exaggerated, indicating a degree of body dysmorphic
disorder.
“I have to hide my hands from people” was another powerful statement made by a 34-year-old primary school teacher,
mother of two children, aged three and six years. This lady
presented with painful fissuring over her proximal and distal
interphalangeal joints associated with severe hand dermatitis (see Figure 3). She has suffered from anorexia nervosa
with secondary bulimia nervosa for the past 20 years. She
reported excessive hand-washing (> 15 times per day), over
the past eight years. Her daily intake regime consists of
six segments of grapefruit for breakfast, six teaspoons of
low fat yoghurt for lunch and large helpings of vegetables
for supper. Her current weight was 39.3kg with a BMI of
14.9.
The clinical presentation of these two patients prompted
us to review the cutaneous signs seen in patients with
eating disorders.
Most people wish they could change or improve some
aspect of their physical appearance. Recent research car-
Figure 3. Unusual fissured erosions on the
dorsum of fingers secondary to irritant contact
dermatitis from compulsive washing; callosity
and poor wound healing from malnutrition
Figure 4.
Carotoderma:
orange palms
from excessive
ingestion of
carrots
Figure 5.
Linear erosions
from forceful
insertion of
fingers into
mouth to
stimulate
vomiting
Figure 6.
Callosities
on first two
metacarpophalangeal joints
from repeated
insertion of
fingers into the
mouth
ried out on 500 patients reported that 73% of people were
concerned with their skin,1 some of whom were extremely
critical of their overall physique and self-image.
Anorexia and bulimia nervosa are eating disorders affecting adolescents and young adults, more frequently in
females, and it is estimated that there are 200,000 people
in Ireland who suffer from them. Although common, they
can be undetected and thereby treatment may be delayed.
Patients with eating disorders have numerous skin and
hair manifestations, but these are often occult signs, and
the GP may be the first person to encounter them. Gupta et
FORUM September 2009 63
Dermatology/eating disorders.-NH2* 1
27/08/2009 12:31:07
Forum
Dermatology
Classification of dermatological signs of eating disorders
Our two patients’ cutaneous signs are italicised
Group 1
Due to starvation/
malnutrition
• Lanugo hair
• Telogen effluvium
• Brittle nails
• Xerosis
• Carotoderma
• Pellagra
• Scurvy
• Poor wound healing
Group 2
Secondary to vomiting
Group 3
Drug-induced phenomena
• Acute erosion of the
knuckles
• Callosities (Russell’s sign)
• Dental enamel erosions,
caries, parotitis, gingivitis
• Sub-corneal haemorrhage
and facial purpura.
• Fixed drug eruptions
• Urticaria and clubbing
• Photosensitivity
al2 described these dermatologic signs as an expression of
the medical consequences of the eating disorder, and helpfully categorised them into four main groups (see Table).
The conscious reduction of sufficient calorie intake in
anorexia nervosa leads to malnutrition – causing the first
group with common dermatological markers: Lanugo-like
body hair, presents as fine, darkly pigmented hair along
the sides of the face, back and limbs. It is a response
to a decrease in dihydrotestosterone and an increase in
etiocholanolone as a result of reduced activity of 5-alphareductase. Hypercarotenaemia may occur secondary to the
increased consumption of foods rich in carotene and vitamin A in the form of carrots or other yellow vegetables such
as cooked pumpkin which are low in calories. Carotene is
deposited in the skin, clinically noted by an orange pallor of
the face, trunk, and limbs (see Figure 4).
Other signs noted are xerosis, brittle nails and hair. Xerosis can range from mild dryness to scaly, ichthyosiform
skin; these changes are secondary to prolonged caloric deprivation, mineral deficiency and reduced sebaceous gland
activity and is commonly displayed over the back and arms.
Patients often complain of heat intolerance, as the body
and skin core temperatures have been altered. Telogene
effluvium follows a diffuse hair loss pattern, sometimes
with frontal predominance and is related to deterioration of
the eating disorder.
The second group of skin manifestations occurs as a
result of self-induced vomiting. Linear erosions may be
found along the dorsum of the hand and are developed by
the repeated insertion of the hand into the mouth to self
induce vomiting by stimulating the gag reflex (see Figure
5). The second characteristic cutaneous sign are ‘knuckle
callosities’, known as Russell’s sign, secondary to regenerative epidermal hyperplasia and dermal fibrosis from
repeated or chronic insertion of fingers in to the mouth (see
Figure 6).
Prof Gerard Russell was the former head of the Eating
Disorder Unit at the Maudsley Hospital in London and he
described Bulimia Nervosa in 1973.3
Parotitis may be related to increased level of amylase in
the absence of pancreatitis and is a benign condition. Other
signs of forceful vomiting behaviour include facial purpura,
and subcorneal haemorrhage. The dental manifestations of
repeated exposure to gastric acid include enamel erosions,
gingivitis, caries and loss of teeth. Regular dental checkups are required to avoid dental caries and tooth loss.
The third group of cutaneous signs are related to der-
Group 4
Psychocutaneous
associations
• Self-inflicted trauma
• Irritant contact dermatitis
• Acne excoriee
• Trichotillomania
• Dermatitis artefacta
• Body dysmorphic disorder
matologic adverse reactions to the use of drugs such as
laxatives, diuretics, emetics and appetite suppressants. A
wide range of drugs can be consumed by the patient and it
takes a careful history to identify the signs and symptoms.
Thiazide diuretics can cause photosensitivity, while phenolphthaline laxatives used to relieve abdominal bloating may
give rise to urticaria or fixed drug reactions.
The final group comprises skin manifestations of concomitant psychiatric disorders associated with eating disorders.
This group includes conditions such as obsessive compulsive disorders causing the development of irritant contact
dermatitis due to excessive hand washing. Self-induced
trauma often co-exists with eating disorders and can include
trichotillomania, acne excoriee and severe self-destructive
behaviours such as dermatitis artefacta.
Acne, as described with the index patient in this article,
is a very common condition in young people. It may be a
risk factor for developing an eating disorder especially in a
psychologically vulnerable individual with an overwhelming desire to be perfect, as the individual may adapt new
diet behaviour to control the acne and as a result develop
an eating disorder. A manifestation of this may be acne
excoriee, where the patient tries to physically manipulate
improvements in their skin by squeezing acne lesions-leading to prominent excoriations.
In patients with eating disorders, dissatisfaction of the
skin appearance and distortion of body weight and shape
perception occurs. Body dysmorphic disorder (BDD) is a
condition where patients have a preoccupation with their
appearance and exaggerate a defect in their physical
appearance. It is said to occur in 0.7-13% of the general
population.4 BDD was observed in our patient, who had a
very powerful emotional response to her acne. It is important to forge a therapeutic alliance with such patients
and seek psychological support for them as up to 25% of
patients with BDD may attempt suicide.
The GP may be the first physician to see the patient and
therefore has an important role in detecting the early signs
of eating disorder. This will facilitate early diagnosis and
leads to a better chance of recovery from the condition.
Angela Alani is a trainee with the Western GP Training
Scheme, Galway
Acknowledgements: I wish to gratefully acknowledge that figures 4-6 were
kindly supplied by Prof Gerald Russell. I would also like to acknowledge
and thank the patients who kindly consented and agreed for their cutaneous
signs to be photographed and used in this article.
References on request
64 FORUM September 2009
Dermatology/eating disorders.-NH2* 2
27/08/2009 12:31:38