Survey
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
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