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Background. Hemodialysis patients experience frequent and various cutaneous manifestations of often hypothetical
pathogenesis. Chronic renal failure (CRF) presents with an array of cutaneous manifestations. Objective. To evaluate
the prevalence and nature of cutaneous lesions, associated with CRF patients on hemodialysis in Egyptian patients.
Patients and methods. One hundred patients with CRF on regular hemodialysis from nephrology units were examined
for cutaneous changes. Specific investigations like skin biopsy, culture and sensitivity for bacterial infections, potassium
hydroxide mount and fungal culture were done when indicated. Results. All patients included in this study had at
least one cutaneous manifestation attributable to CRF. The most prevalent findings was pruritus (55%), followed by
xerosis (54%), hyperpigmentation (54%) and pallor (45%). Other cutaneous manifestations were wrinkles (40%),
fungal infections (33%), ecchymosis (27%), dermatitis (23%), yellow face (22%), Petichae (19%), delayed wound
healing (11%), follicular hyperkeratosis (10%), bacterial infections (5%), viral infections (2%) and uremic frost (1%).
Nail changes were koilonychia (39%), half and half nail (28%), splinter hemorrhages (16%), Muehrcke’s lines (12%),
subungual hyperkeratosis (10%), Mees’ lines (8%), brown nail (6%), onycholysis (3%) and Beau’s lines (2%). Hair
changes were brittle and lusterless hair (47%), sparse scalp hair (46%) and sparse body hair (27%). Oral changes
were macroglossia (42%), xerostomia (35%), coated tongue (27%), angular cheilitis (15%), ulcerative stomatitis (9%),
acquired perforating dermatosis (3%). Some rare manifestations of CRF like calciphylaxis (2%) were seen. There
was no association between any particular etiology of CRF and certain mucocutaneous, nail or hair abnormalities.
Conclusion. At least one cutaneous manifestation is found in all CRF patients. The most prevalent findings were
pruritus followed by xerosis and hyper-pigmentation then pallor. With the advent of hemodialysis, the life expectancy of
these patients has increased giving time for more and newer cutaneous changes to manifest. The aetiology of CRF does
not affect the development of cutaneous, nail or hair abnormalities. (J Egypt Women Dermatol Soc 2010; 7: 49 - 55)
Corresponding Author. Maha M. Sultan, M.D., Lecturer of Conflict of interest. None declared.
Dermatology and Venereology, Faculty of Medicine for Girls, Al-Azhar Copyright © 2009 Egyptian Women Dermatologic Society. All rights
University, Cairo, Egypt. E-mail. dr.maha_derm@yahoo.com reserved.
49
Cutaneous Manifestations in Egyptian Patients with Chronic 50
Renal Failure on Regular Hemodialysis
was expressed as mean ± SD and non parametric Table 2. Etiology of chronic renal failure.
data was expressed as number and percentage of the
Causes n%
total.
HTN 60 (60%)
RESULTS
DM 14 (14%)
They were 66 males and 34 females. Their age Obstruction 7 (7%)
ranged from 15 - 73 years with mean age of 49.53
+ 18.54 years. The total duration of hemodialysis Analgesic 5 (5%)
ranged from 0.08 - 20 years with a mean of 4.95 + Unknown 4 (4%)
4.03 years (Table 1). The various causes leading to SLE 3 (3%)
renal failure are shown in table (2).
Polycystic kidney 2 (2%)
Oral HTN DM Obstructive Analgesic FMF Polycystic R UTI Reflux SLE Wegener
Figure 1. Chronic scratching resulting from uremic pruritus. Figure 3. Extensive wrinkling as a sign of actinic elastosis in 42 aged female.
Figure 6. Mees’ line (white transverse band) secondary to chronic Figure 9. Acquired perforating dermatosis (Kyrle’s) secondary to
renal failure. chronic renal failure.
60% in the indian patients. Pallor is due to anemia in 46% and sparse body hair was found in 27% of
which was reported as the hallmark of CRF. Anemia CRF patients while, Udayakumar et al.17 found sparse
is primarily the result of inadequate erythropoietin body hair in 30%, sparse scalp hair in 11% and dry
production by the failing kidneys. Other contributory hair in 16% of CRF patients. This higher incidence
factors of anemia in CRF patients include iron of sparse scalp hair in the Egyptian patients of the
deficiency, folic acid or vitamin B12 deficiency and present study in comparison with the Indian patients
decreased erythrocyte survival11. of Udayakumar et al.17 study may be due to racial
Skin infections were seen in 40% of patients in this variation.
study, fungal (33%), bacterial (5%) and viral (2%). Oral mucosal changes have been reported in up
Udayakumar et al.17 reported skin infections in 67% to 90% of patients with CRF24. Teeth marking with
of patients while Bencini et al.8 reported the fungal macroglossia (tongue sign of uremia) was seen in
infection only in 67% of CRF patients. Skin infections 42% of patients compared with Udayakumar et al.17
in CRF patients may be due to associated diabetes result which was 35%. This finding was first described
mellitus, low albumin, elevated intracellular calcium, by Mattew et al. in 92% of patients with CRF25.
acidosis21, iron overload17, inhibition of chemotactic Xerostomia was found in 35% compared with 31% in
factors and repetitive vascular procedures21. Also, Udayakumar et al.17 study. It was attributed to mouth
CRF patient´s host defence response is disrupted by breathing and dehydration. Ulcerative stomatitis
depressed neutrophil function, leucopenia related was found in 9% which is less than that reported by
to complement activation, impaired phagocytosis, Udayakumar et al.17 (29%). The high percentage of
diminished T and B lymphocytes function and a ulcerative stomatitis was attributed to elevated blood
reduction in natural killer cell activity. In addition urea levels which were more than 150 mg/100 ml in
to these, the presence of inflammation has been their patients and due to bad oral hygiene24. Angular
suggested as a cause for reduced immunity. cheilitis was found in 15% while Udayakumar et al.17
Inflammation in hemodialysis patients may be due study reported angular cheilitis in 12%. Coated tongue
to the use of non sterile dialysate, non biocompatible was found in 27% which is much higher than that
membranes and evidenced by accumulation of pro- reported by Udayakumar et al.17 (11%). This difference
inflammatory agents5. may be due to associated candidal infection which
Ecchymosis was seen in 27% of hemodialysis may be due to cigarette smoking26 and associated
patients and petichae in 19% in the current study. The xerostomia27 which showed high percentage in the
causes may be due to defects in primary hemostasis present study.
like increased vascular fragility, abnormal platelet Perforating disorders such as perforating
function and the use of heparin during dialysis22. folliculitis, Kyrle’s disease and reactive perforating
Early wrinkles which occurred at the age of 38 collagenosis have been described in CRF3. Perforating
- 45 years were seen in 40% of CRF patients of the disorder of renal disease or acquired perforating
present study. It occurs due to early occurrence of disorders has been used to describe the hyperkeratotic
actinic elastoses in patients undergoing long-term follicular papules present in these patients. Acquired
haemodialysis3. perforating disorders was seen in 3% of the present
Koilonychia was the most common nail study patients while other studies showed acquired
abnormality (39%) followed by half and half nail perforating disorders in 4.5 – 17% 5,15,17 of patients
(28%). The results of the present study disagreed on hemodialysis. The exact pathophysiological
with Amatya et al.1 who found white nail the most mechanism of acquired perforating disorders in CRF
common followed by brown and half and half nail; patients is unknown, but it may occur as a result
while Udayakumar et al.17 and Salem et al.23 found of dermal connective tissue dysplasia and decay.
half and half nail the most common in 21% and 20% Microvascular deposition of calcium may interrupt
respectively. The highest prevalence of koilonychia blood flow to connective tissue in the dermal layer
in patients of the present study may be due to the causing death and necrosis. Trauma to the skin in
long duration of the disease as 55% of patients of patients with pruritus secondary to CRF could be
the present study were on hemodialysis more than the inciting agent in producing these lesions28.
5 years. In half and half nail, the white appearance Calciphylaxis was seen in 2% of the patients
of proximal half of the nail is due to nail bed edema in the current study. This result is in concordance
associated with a dilated capillary while the other with the international prevalence of calciphylaxis
half of the nail bed appears normal21. Salem et al.23, in end stage renal disease patients which is
in an Egyptian study, concluded that the cause of nail 1- 4 % 29. It is primarily described in patients
changes in uremic patients undergoing hemodialysis with CRF associated with hemodialysis. It is
remained obscure and could not be traced to a characterized by local calcinosis, inflammation and
particular abnormality in the renal condition, necrosis. Calciphylaxis results from secondary or
medication or the procedure itself. tertiary hyperparathyroidism. Abnormal elevated
In the present study, brittle and lusterless hair was level of parathyroid hormone triggers deposition
found in 47% of patients, sparse scalp hair was found of crystalline calcium pyrophosphate in the dermis,
subcutaneous fat or arterial wall. Calcified vessels management. Dermatol Clin 2002; 20: 459,72.
may thrombose acutely, resulting in calciphylaxis30. 14. Imazu LE, Tachibana T, Danno K, Tanaka M, Imamura S.
Histamine-releasing factor(s) in sera of uraemic pruritus patients
Conclusion in a possible mechanism of UVB therapy. Arch Dermatol Res 1993;
At least one cutaneous manifestation is found in 285: 423 - 7.
all CRF patients. The most prevalent findings were 15. Tawade YV, Gokhale BB. Dermatological manifestations of
pruritus followed by xerosis and hyper-pigmentation chronic renal failure. Indian J Dermatol Venereol Leprol 1996;
then pallor. With the advent of hemodialysis, the life 62: 155 - 6.
expectancy of these patients has increased giving time 16. Siddappa K, Nair BK, Ravindra K, Siddesh ER. Skin in systemic
for more and newer cutaneous changes to manifest. disease. In: valia RG, Valia AR, editors. IADVL Textbook and
The aetiology of CRF does not affect the development Atlas of Dermatology. 2nd ed. Mumbai: bhalani Publishing
of cutaneous, nail or hair abnormalities. House; 2000. p. 938 - 84.
17. Udayakumar P, Balasubramanian S, Ramalingam KS, Lakshmi C,
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