Recognizing skin conditions in patients with cirrhosis: a narrative review

Figures & data

Table 1. Dermatologic vascular manifestations associated with liver and non-liver conditions.

Cutaneous condition	Figure	Characteristics of skin lesions	Associated liver conditions	Prevalence	Pathogenesis of cirrhosis related skin conditions	Associated non-liver conditions
Hemodynamic and vascular changes
Palmar erythema	Figure 1(a)	Blanchable redness in the skin of the thenar eminence and fingertips	Cirrhosis	23%	Changes in peripheral  hemodynamics increased free oestrogen levels leading to vasodilation of surface capillaries	Rheumatoid arthritis Hyperthyroidism Diabetes Female of childbearing age
Spider angioma	Figure 1(b,c)	Central arteriole surrounded by capillaries radiating peripherally above the line joining the nipples	Alcohol-associated cirrhosis Hepatopulmonary syndrome	33%		Healthy young adolescent Pregnancy Rheumatoid arthritis Hypertrophic osteoarthropathy
Arteriovenous  haemangiomas	Figure 1(d–f)	Bluish erythematous papules or nodules with a diameter of 0.5–1.0 cm in the head and neck	Cirrhosis	NA	Elevated oestrogen levels	Cardiac arteriovenous haemangioma Composite hemangioendothelioma
Caput medusa	Figure 1(h)	Distended veins that radiate from the umbilicus across the abdominal wall resembling a ‘caput medusa’	Cirrhosis Schistosomiasis mansoni Sinus venous thrombosis	NA	Portal hypertension leading to paraumbilical veins that have closed since birth to reopen	Developmental venous anomaly

NA: Data unavailable.

Table 2. Nail changes associated with liver and non-liver conditions.

Cutaneous condition	Figure	Characteristics of skin lesions	Associated liver conditions	Prevalence	Pathogenesis of cirrhosis related skin conditions	Associated non-liver conditions
Terry’s nails	Figure 2(a–c)	White nail bed A distal brown to pink transverse band of 0.5–2.0 mm in width Absence of lunulae	Cirrhosis	25.6%	Decrease in vascularity and increase in connective tissue in the nail bed	Congestive heart failure Adult-onset diabetes mellitus Renal failure Human immunodeficiency disease Ageing
Muehrcke’s nail		One or more pale transverse white bands across the nail plate Parallel to the lunula Disappear on pressure	Cirrhosis	NA	Hypoalbuminemia Oedema of the nail bed causing abnormalities in the vasculature of the nail bed	Nephrotic syndrome Chemotherapy Renal insufficiency Cushing’s syndrome
Leukonychia	Figure 2(e)	Diffuse ground glass opacity White in the nail bed	Alcohol-associated cirrhosis	2%	Abnormalities in nail bed vascularization	Hereditary leukonychia totalis Onychopapilloma Psoriasis Chemotherapy HIV infection
Red and blue lunula		Red/blue discolouration of the lunula	Cirrhosis Wilson’s disease	NA	Unknown	Systemic lupus erythematosus Lichen planus Erythonychia Rheumatoid arthritis Alopecia areata Chemotherapy
Clubbing	Figure 2(g)	Increased curvature of the nails Lovibond’s angle Schamroth sign	Cirrhosis Hepatopulmonary syndrome	7%	Elevated platelet-derived growth factor and vascular endothelial growth factor	Cyanotic congenital heart disease Pulmonary fibrosis Inflammatory bowel disease Lung cancer Sarcoidosis HIV infection Tuberculosis Hypersensitivity pneumonitis
Onycholysis	Figure 2(f)	Detachment of the nail bed from the overlying nail plate	Cirrhosis	NA	Hypoalbuminemia	Psoriasis Pemphigus vulgaris Connective tissue diseases Thyroid diseases Hyperthyroidism Diabetes mellitus
Brittle nail	Figure 2(h)	Onychoschizia, onychorrhexis, superficial granulation of keratin and worn-down nail	Chronic liver disease Primary biliary cholangitis	10%	Impairment of peripheral circulation leading to reduced nail matrix vascularization with production of a thin nail plate.	Drug therapy Nutritional deficiencies Psoriasis Pregnancy
Longitudinal striations	Figure 2(i)	Embossed crista on the nail surface accompanied by nail thinning and fracture	Cirrhosis Chronic liver disease	17%	Unknown	Psoriasis Chronic kidney disease Vitiligo
Koilonychia	Figure 2(j)	Concave centrally and raised laterally nail plates	Cirrhosis Hemochromatosis	NA	Nail matrix changes due to blood flow abnormalities	Iron deficiency anaemia Psoriasis Familial koilonychia Trauma
Onychomycosis	Figure 2(k,l)	Nail discolouration, nail separation, brittleness and thickening	Cirrhosis Primary biliary cholangitis	49%	Fungal infection	Trauma Senility Tinea pedis Diabetes Immunosuppression Malignancies Pemphigus vulgaris

NA: Data unavailable.

Table 3. Hair, hormonal and other changes associated with liver and non-liver conditions.

Cutaneous condition	Figure	Characteristics of skin lesions	Associated liver conditions	Prevalence	Pathogenesis of cirrhosis related skin conditions	Associated non-liver conditions
Hair
Loss of pubic hair  or beard	Figure 3(a)	Loss of pubic hair	Cirrhosis	NA	Elevated oestrogen level	Trichotillomania Hypothalamic dysfunction XYY-male Sheehan’s syndrome Menopause Treatment with glucocorticoids
Hormonal changes
Gynaecomastia	Figure 3(b)	Breast enlargement	Cirrhosis	44%	Elevated oestrogen level	Extreme obesity Hypogonadism Adrenal disease Tumours of the adrenal glands, pituitary, lungs and testes Use of digoxin, thiazides, oestrogens, phenothiazines and theophylline Use of methotrexate, alkylating agent, imatinib and vinca alkaloids Use of marijuana Transexual woman Thyroid disorders
Others
Pruritus			Cholestatic liver diseases Cirrhosis	40-60%	Bile salts, endogenous opioids, serotonin, progesterone metabolites and lysophosphatidic acid	Medications Allergies Atopic dermatitis Psoriasis Kidney disease
Xanthelasma	Figure 3(e)	Pale yellow, planar or slightly bulged, soft plaques around the eyelids	Cholestatic liver disease	NA	Hypercholesterolaemia	Autosomal dominant form of hereditary hypercholesterolaemia Hypercholesterolaemia
Pigmentation	Figure 3(f–h)	Blotchy or diffuse muddy gray coloured hyperpigmentation in the pretibial area	Cirrhosis	46.9%	Red blood cells extravasation and deposition of hemosiderin due to lower extremity edoema and obstruction of venous reflux	Physical dermatosis Inflammatory dermatoses Immunologic dermatoses Allergic/hypersensitivity Cardiac abnormalities
Leg ulcer	Figure 3(i)	Necrotic tissue adhering to basilar part and raised edge	Cirrhosis	NA	Hypoxia-ischemia induced by lower extremity edoema and obstruction of venous reflux	Chronic venous insufficiency Peripheral arterial occlusive disease Vasculitis Diabetes Pyoderma gangrenosum Martorell hypertensive leg ulcer
Coagulation defects		Skin petechiae, ecchymosis, or mucosal bleeding	Cirrhosis	NA	Thrombocytopenia, hyperfibrinolysis, reduction in most factors and inhibitors of clotting and fibrinolytic systems	Haematological diseases Trauma Diabetes Uraemia Anticoagulant therapy for thrombotic diseases

NA: Data unavailable.

Figure 1. Vascular alterations in patients with chronic liver disease. (a) Palmar erythema, (b, c) Spider angioma, (d) Arteriovenous haemangioma, (e, f) arteriovenous haemangioma on the upper lip of a 38-year-old cirrhotic male with HBV infection, with remission after 10 years of antiviral treatment. (g) Paper money skin, (h) caput medusa, (i) abdominal varicose veins in inferior vena cava obstruction syndrome.

Figure 2. Nail changes in patients with chronic liver disease. (a–c) Terry’s nails, (d) Lindsay’s nails, (e) leukonychia, (g) clubbing nails, (f) onycholysis, (h) brittle nails, (i) longitudinal striations, (j) koilonychia, (k, l) onychomycosis.

Figure 3. Hair, hormonal and other dermatologic manifestations in patients with chronic liver disease. (a) Loss of pubic hair, (b) gynaecomastia, (c) jaundice, (d) prurigo nodularis, (e) xanthelasmas, (f–h) pigmentation, (i) leg ulcer.

Data availability statement

The datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request.