Chronic Liver

Disease
By DR. Iqra Niazi
Resident Dermatologist
Ziauddin hospital
Chronic Live Disease (Skin manifestations) :-
1. Pruritis
2. Hyperpigmentation, Jaundice
3. Spider Naevi
4. Palmar erythema
5. Caput medusae
6. Easy bruising
7. Portal HTN
8. Liver failure
9. Loss of secondary sexual hair in Males.
10. Porphyria Cutanea tarda
11. Terry’s nails
12. Fatigue, Cirrhosis ,Ascites
Pruritis:-
 Most common skin symptom associated with liver diseases.
Itch is most prominent in;
1. PBC
2. Sclerosing cholangitis
3. Biliary tract obstruction cholestasis
Itch is less prominent in;
4. Haemochromatosis
5. Alcoholic Cirrhosis
6. Autoimmune Chronic Active hepatitis
7. sites—> Acal sites, Area of tight clothing
8. More prominent nocturnally.
 Cause of itch:-
1. The release of undefined putative pruritogens from
the liver in the presence of cholestasis
2. Bile salts contribute to itch.
3. Endogenous opiods and steriod metabolites also
seem to be part of the complex process that leads
to the development of cholestatic pruritis.
Management:-
4. Treat the underlying cause
5. Drug-withdrawal in Drug induced Cholestasis.
6. Surgery for mechanical biliary obstruction.
7. Oral Anti histamines.
Treatment for Chronic [Link].
• For Cholestatic pruritis ;
1)Bile salt Chelating resins
2)Rifampicin
3)Opiod Antagonists—> Naltrexone
4)Sertraline
5)UVB phototherapy
6) Albumin Dialysis
7) Plasmapheresis
8) Liver transplant
 Skin pigment changes:-
1) Yellowish hue of Sclera, Mucous Membrane,
2) Icterus ( Jaundice).
Yellow skin colour due to hyper bilirubinaemia [bilirubin > 2.5 to 3 mg/dl]
0.2to 1.2)
3)Green colored sweat
4)Green discoloration of the gingivae
5)Melanosis cutis—> Excess epidermal Melanin.
6) Muddy grey pigmentation—> blotch or diffuse.
 Sites->Aneda ,Peri-Oral , Peri orbital, Palmer creases
 Resembles—> Melasma Freckling
7)Spotty Hypomelanosis —> Back, Buttocks,
 Extremities Related to spider angiomas.
 Bier spots — small irregular hypopigmented macules on the limbs
which disappear with pressure
Vascular Changes:-
1) Spider telangiectases:
 Characteristic feature in patients with severe CLD.
 Pinhead upto lOmm*
 Mostly on skin drained by superior Vena Cava.
 Central arteriole visible as a red flat or slightly elevated point
surrounded by multiple small and tortuous radiating capillaries.
 Found in 1/3 of liver Cirrhosis patients.
 Hyper estrogenaemia —> an important factor for the
development.
 Secondary male pattern Hair.
 Gynaecomastia
 Testicular Atrophy
 Gingival bleeding.
2)Palmer Erythema:-
 Bright Red discolouration of the palms.
 Most pronounced on the Hypothenar eminence, Soles of the feet.
 Diffusely scattered tiny telangiectatic vessels are referred—-> Paper money
sign.
 Increased Peripheral blood flow with dilatation of digital pulp Arterio Venous
anastomosis—> thought to be the cause of finger.
3)Bleeding:-
Due to coagulation defects;
 Purpura
 Petechial
 Ecchymoses
 Mucosal bleeding —> Epistaxis, Gingival bleeding.
Caput Medusae:
 Dilated veins around the umbilicus.
 A sign of portal hypertension and liver cirrhosis.

Hair changes:-
 Body Hair is often thinned / partially lost.
 Males develop a female pubic hair pattern
 Association :-
1. Gynecomastia
2. Testicular atrophy
Nail Changes (Non-specific):-
1)Diffuse white color with an invisibleLunula
2)Terry nails —> Proximal white color with distal pink/Brownish color
3)Muehrke bands -> Multiple parallel transverse white bands
4) Altered digital blood flow
5)Soft tissue over growth
6)Hypo-albuminemia
Nail plate changes include
1) Clubbing milder variant “watch - glass deformity”
2) Flattened Nails
3) Koilonychia
4)Brittle nails
5) Pallor
Porphyria Cutanea Tarda:-
 Lesions consists of;
1. Bullae, Scarring
2. Hyperpigmentation  sun exposed areas.
3. Hypertrichosis of the face.
4. Milia (benign keratin filled cysts)
5. Fragile skin
6. This is acquired and familial disorder in which activity of heme
synthetic enzyme URO PORPHYRINOGEN DECARBOXYLSE İs
deficient.
 XANTHOMA STRAITUM:-
 Multiple xanthomas may appears as yellowish plaques covering
large areas opalmer creases.
STRIAE DISTENSAE:-
 Ascites leads to Striae Distensae.

Other cutaneous lesions:-

1. Lichen planus
2. Erosive Oral lesions PBC
3. Pyoderma Gangrenosum
4. Gianotti Crosti syndrome
5. Pseudo-glucagonoma syndrome  in Cirrhosis
6. Acquired Zine deficieny  in Cirrhosis)
LICHEN PLANUS:-

► Autoimmune disorder characterised by

pruritis, purplish colored lesions with flat
tops on the skin.
►► It is a skin lesion that is triggered by the
immune system contributing factors
include,.,
►Viral infections. ( hepatitis C)
► Drugs ( antibiotics, arsenic, diuretics, some
dyes.
► Genetics
Drugs & the liver:-
1. Drugs causing hepatitis / other liver damage
 Methotrexate
[Link] for the treatment of liver disease causing cutaneous side effect.
 Penicillamine (Elastosis perforans Serpiginosa)

3)Drugs that cause liver changes with secondary cutaneous sign.

Estrogens (PCT)
4) Drugs cause concurrent hepatitis—> Phenytoin and other
anticonvulsants.
5) Drugs whose hepatic metabolism is alteredby live disease.
Ciclosporin
Complications of chronic liver disease
 Ascites
 Hepato cellular Carcinoma
 Hepatic Encephalopathy
 Coagulopathy
 Osteoporosis
 Hepato renal Syndrome
 Hepato Pulmonary Syndrome
 Spontaneous Bacterial Peritonitis
 Gastrointestinal Bleeding
 Liver Failure
 Progressive Heart Failure
Investigations ::-

 CBC • Gamma-glutamyl
 transpeptidase test
Serum bilirubin test
• Lactic dehydrogenase test
 Serum albumin test • Liver Biopsy +
 Serum alkaline Histopathology
phosphatase test: • 5'-nucleotidase test
 Serum aminotransferases • Alpha-fetoprotein test
(transaminases) • Mitochondrial antibodies
 Prothrombin time (PTT) test test

• CT
Alanine transaminase (ALT)
test
 Aspartate transaminase
(AST) test
Treatment:-
 Abstinence from alcohol- • Liver function tests-
 Low-sodium diet • Imaging studies-
• Endoscopy-
 Weight management- • Liver transplantation-
 Vaccinations- • Shunting procedures-
 Screening for liver cancer TIPS( Transjuglar intrahepatic
portosystemic shunt
 Antiviral therapy • Liver resection
 Corticosteroids
 Immunosuppressants
 Diuretics
 High-protein diet
 Vitamin and mineral supplements
Thank you