Spider Nevi Research Articles

Nonvascular uses of pulsed dye laser in clinical dermatology.

Lasers are fast becoming the vogue of dermatology ranging from ablative, nonablative, fractional photothermolysis to vascular lasers. There are a range of vascular lasers including potassium titanyl phosphate (KTP 532nm), pulsed dye laser (PDL -595nm), diode (810nm), and Nd:YAG (1064nm). PDL is a laser that emits yellow light using Rhodamine dye as it is lasing medium. Typical vascular lesions which are treated by PDL include port wine stain, hemangioma, telangiectasia, spider angioma, and rosacea. This article focuses on the use of PDL beyond primary vascular conditions. We review the evidence, or lack thereof, of the use of PDL in acne vulgaris, scars, striae, warts, molluscum, psoriasis, rejuvenation, basal cell carcinoma (BCC), and miscellaneous dermatological sequelae.

A study to analyses the clinical features and various treatment modalities of varicose veins of lower limbs

Background: Varicose veins are defined by WHO as abnormally dilated saccular or cylindrical superficial veins, which can be circumscribed or segmental. This includes tiny spider telangiectasia’s as well as grossly dilated saphenous varicosities. It involves at least 1 out of 5 in the world and with increasing population, increased life span and change in life style, the problem is ever growing. The objective of this study is to analyse the clinical features and various treatment modalities adopted for the management of varicose veins of 40 has some form of varicosity or telangiectasia of the veins.Methods: A prospective study was conducted in CG hospital and Bapuji hospital attached to JJM Medical College, Davangere from June 2009 to May 2011. A total of 40 cases were included in the study duration. All patients who presented to the outpatient department with signs and symptoms of primary varicose veins were interviewed with preformed performa, meticulously examined and later subjected to color doppler studies before they underwent surgery for the same.Results: The incidence of varicose veins was seen most commonly in male when compared to female in this study. The family history of varicose veins was seen in only 12.5% of the subjects. In this study patients presented with varied symptoms, out of which dilated veins was most common 37 (92.5%) patients followed by aching pain 22 patients (55%).Conclusions: Varicosity of the lower limb is a common clinical entity. The number of cases reporting to the hospital is much less than the real incidence because in the absence of symptoms due to varicose veins patients do not seek treatment in our country. Most of the patient presented to the hospital for one or the other complications not for the cosmetic purpose.

Recurrent Hepatic Encephalopathy Due to Spontaneous Mesocaval Shunt

Spontaneous portosystemic shunting is a rare entity that can manifest as hepatic encephalopathy (HE) in longstanding liver disease. In cases of severe portal hypertension (pHTN) portal blood flow may reverse with shunting from the portal vein to the inferior vena cava through a portosystemic anastomosis. Shunting allows toxins to accumulate in the systemic circulation leading to encephalopathy. We present a case of spontaneous mesocaval shunting in a patient with recurrent HE. A 76 year old female with history of Hepatitis B cirrhosis, grade II varices, and multiple admissions for HE presented for acute altered mental status for 1 day. At baseline, she is functionally independent and takes lactulose, rifaxamin, nadolol, entecavir, spironolactone, furosemide, and omeprazole. On presentation, she was not alert or orientated, minimally responsive to voice, moving only to pain, eye-blink startle reflex present but without tracking. There were facial spider angiomas, but no jaundice, ascites or asterixis. She was hemodynamically stable with mild pan-elevation of liver tests, hyperammonemia, hypoalbuminemia, macrocytosis with thrombocytopenia and mild coagulopathy. Prior work-up was limited to head CT and abdominal ultrasound due to acute kidney injury, and negative infectious work-up. CT abdomen on presentation revealed stable appearance of cirrhotic liver, as well as pHTN including recanalization of the umbilical vein, esophageal and omental varices, and mesocaval shunt adjacent to the left portal vein consistent with AV shunting. Interventional radiology was consulted for closure of the shunt and after 3 days of medical therapy, her mental status improved to baseline. Initial attempt was unsuccessful in catheterizing the shunt through the inferior vena cava, while a second attempt through the transplenic portogram and embolization of mesocaval shunt was successful. Patient made a stable recovery after the intervention for discharge. Spontaneous mesocaval shunting is a rare collateral circulation that develops between the superior or inferior mesenteric veins and the inferior vena cava. Similar collateral vessels can manifest as patent paraumbical vessels arising from the left portal vein, as seen in this patient. A high index of suspicion in patients with HE with appropriate imaging is needed to make a diagnosis. Treatment of these shunts via occlusion is crucial in reducing the occurrence of recurrent HE in cirrhosis.2292_A Figure 1. Axial CT - Demonstrates large portosystemic shunt arising from the superior mesenteric vein with its confluence at the inferior vena cava. A transplenic approach was utilized to gain access into the portal system and the mesocaval shunt was subselected.2292_B Figure 2. Robust flow was noted on venograms through the shunt pre-embolization. The mesocaval shunt was embolized with multiple coils of varying sizes and with nBCA.2292_C Figure 3. Final venograms demonstrated complete occlusion of the shunt and preferential flow through to the portal vein post-procedure.

Does Dermatoscopy Facilitate the Detection and Diagnosis of Vascular Skin Lesions? A Case–Control Study

During dermatoscope-guided surgical procedures, we noticed that vasculature was easily identified. This study investigated the use of dermatoscopy in detecting and diagnosing vascular skin lesions. We retrieved records of patients with vascular skin lesions who underwent dermatoscopy over a 3month period, in two outpatient clinics affiliated with a university teaching hospital. Our controls were similar patients where dermatoscopy was not performed. Our new findings are: 1, clinical and dermatoscopic examinations diagnosed significantly more patients with vascular skin lesions than clinical examinations alone (risk ratio: 1.36; 95% confidence interval: 1.10-1.67); 2, the detection rate increase was significant for cherry angiomas (p<0.001), telangiectasias (p<0.01) and spider angiomas (p<0.01); 3, qualitatively, dermatoscopy revealed characteristic configurations, hues and colour saturations of the vascular skin lesions; and 4, the first reported dermatoscopic images of focal essential telangiectasia and petechial angioma. In our setting, clinical and dermatoscopic examinations significantly facilitated detecting and diagnosing vascular skin lesions, compared to clinical examination alone.

Correlations of MMP-2 and MMP-9 gene polymorphisms with the risk of hepatopulmonary syndrome in cirrhotic patients: A case-control study

Hepatopulmonary syndrome (HPS) increases the mortality of patients who suffered from liver cirrhosis, especially patients plagued by severe hypoxemia. Gene polymorphisms are reported to be related to the risk of HPS in cirrhotic patients. Thus, our study aims to elucidate the correlation between MMP-2 and MMP-9 gene polymorphisms and HPS in cirrhotic patients. A total of 152 cirrhotic patients suffering from HPS as well as another 152 cirrhotic patients without HPS were recruited. Polymerase chain reaction-restriction fragment length polymorphism (PCR-RFLP) was performed for MMP-2 and MMP-9 gene polymorphisms and logistic regression analysis for the relationship between clinicopathological features and HPS occurrence in cirrhotic patients. There were significant differences in genotype and allele frequency of MMP-2 rs243865 and MMP-9 rs3918242 polymorphisms between the HPS and control groups. CC/CT genotype and C allele of MMP-2 rs243865 polymorphism as well as CC/TT genotype and T allele of MMP-9 rs3918242 polymorphism increased the risk of HPS in cirrhotic patients. Genotypes of rs243865 and rs3918242 polymorphisms had remarkable correlations with spider nevi, clubbed fingers (toes), transaminase elevation, portal vein width, esophageal varices, Child-Pugh classification and partial pressure of arterial oxygen (PaO2). Logistic regression analysis showed that rs243865 and rs3918242 polymorphisms, spider nevi, clubbed fingers (toes), esophageal varices, and Child-Pugh classification were closely associated with the occurrence of HPS in cirrhotic patients. Our findings demonstrate that MMP-2 rs243865 polymorphism and MMP-9 rs3918242 polymorphism can increase the risk of HPS occurrence in cirrhotic patients, which provides a potential target for prevention of HPS in cirrhotic patients.

Dermatological manifestations of chronic liver disease

&lt;p class="abstract"&gt;&lt;strong&gt;Background:&lt;/strong&gt; The present study was conducted to assess the spectrum of cutaneous changes in chronic liver disease and to assess any correlation between the skin findings and the type of the liver disease.&lt;/p&gt;&lt;p class="abstract"&gt;&lt;strong&gt;Methods:&lt;/strong&gt; A total of 100 patients above 18 years of age suffering from chronic liver disease with cutaneous manifestations and attending the Gastroenterology and Dermatology and Venereology department of Gauhati Medical College and Hospital, Guwahati, India during the period from June 2016 to May 2017 were included in the study.&lt;strong&gt;&lt;/strong&gt;&lt;/p&gt;&lt;p class="abstract"&gt;&lt;strong&gt;Results:&lt;/strong&gt; Out of 100 cases, there were 84 males (84%) and 16 females (16%) with the male to female ratio of 5.25:1. Alcoholic liver disease comprised 62% of the patients in the study, other causes being cryptogenic liver disease (14%), chronic hepatitis infection (12%), Wilson’s disease (2%), autoimmune hepatitis (2%), hepatocellular carcinoma (2%), methotrexate induced liver disease (1%) and non-alcoholic steatohepatitis (1%). Most common skin finding was xerosis (62%). Other key findings included nail changes (60%), pigmentary changes (55%), hair changes (50%), jaundice (40%), cutaneous infections (31%), pruritus (27%).&lt;/p&gt;&lt;p class="abstract"&gt;&lt;strong&gt;Conclusions:&lt;/strong&gt; Patients with chronic liver disease can have a wide spectrum of cutaneous manifestations the most important being xerosis, nail changes, pigmentary changes, hair changes, jaundice, infections, pruritus and spider angioma. These changes can give a clue to the presence of the underlying liver disease and its severity. Hence, identifying these signs earlier can lead to prompt diagnosis and effective management of the underlying condition, thereby preventing its complications.&lt;/p&gt;

Sublingual microcirculatory alterations in cirrhotic patients.

To assess sublingual microcirculation in cirrhotic patients and its relationship to spider angiomas, complications, and outcome. Thirty-one cirrhotic patients were prospectively compared to 31 matched controls. Sublingual microcirculation was evaluated by videomicroscopy. We specifically looked for capillaries with increased RBCV, which was defined as a velocity higher than the percentile 100th of controls. Compared to controls, cirrhotic patients showed decreased total and PVD (14.4±2.2 vs 16.0±1.3 and 14.1±2.3 vs 15.9±1.6mm/mm2 , respectively, P<.001 for both) and increased HFI (0.64±0.39 vs 0.36±0.21, P=.001). They also exhibited high RBCV in 2% of the microvessels (P<.0001). Patients with MELD score ≥10 had higher RBCV than patients with score <10 (1414±290 vs 1206±239μm/s, P<.05). Patients with spider angiomas showed lower vascular densities. Microcirculation did not differ between survivors and nonsurvivors. Cirrhosis is associated with microcirculatory alterations that can be easily monitored in the sublingual mucosa. Alterations included decreased density and PPV and hyperdynamic microvessels. The most striking finding, however, was the microvascular heterogeneity. Patients with spider angiomas had more severe alterations. Larger studies should clarify the relationship between microcirculatory abnormalities and outcome.

Impact of spider nevus and subcutaneous collateral vessel of chest/abdominal wall on outcomes of liver cirrhosis.

IntroductionSpider nevus and subcutaneous collateral vessel of the chest/abdominal wall are common in liver cirrhosis. This prospective study aimed to evaluate the impact of spider nevus and subcutaneous collateral vessel of the chest/abdominal wall on the outcomes of cirrhotic patients.Material and methodsWe prospectively enrolled patients with a diagnosis of liver cirrhosis consecutively admitted to our department. We recorded the number and location of spider nevi and subcutaneous collateral vessels of the chest/abdominal wall. Clinical profiles and survival were compared according to the presence of spider nevus and subcutaneous collateral vessel of the chest/abdominal wall. The study was registered (NCT02468479).ResultsOverall, 198 patients were enrolled between June 2015 and May 2016. The median follow-up duration was 350 days. The prevalence of spider nevus and subcutaneous collateral vessel of the chest/abdominal wall was 47% and 29.8%, respectively. Patients with spider nevi had a significantly higher proportion of alcohol abuse (54.84% vs. 26.67%, p < 0.001). Both spider nevus and subcutaneous collateral vessel of the chest/abdominal wall were significantly associated with higher Child-Pugh (8.35 ±2.19 vs. 7.47 ±1.91, p = 0.005; 8.57 ±2.20 vs. 7.60 ±1.98, p = 0.002) and MELD scores (9.91 ±6.41 vs. 7.43 ±5.40, p = 0.008; 10.77 ±6.76 vs. 7.68 ±5.42, p = 0.003). The cumulative survival was not significantly different between patients with and without spider nevi of the chest/abdominal wall (p = 0.951). Patients with subcutaneous collateral vessels of the chest/abdominal wall had significantly worse cumulative survival (p = 0.018).ConclusionsPresence of spider nevus and subcutaneous collateral vessel of the chest/abdominal wall indicated more severe liver dysfunction. Subcutaneous collateral vessel of the chest/abdominal wall should be a simple and important predictor for the overall survival of cirrhotic patients.

Hypertrophic osteoarthropathy: estrogens, prostaglandinE2, prostaglandin A2, and the inflammatory reflex.

It has been claimed that hyperestrogenism occurs in hypertrophic osteoarthropathy (HOA), but not in simple clubbing. However, one of our patients had simple clubbing and hyperestrogenism. We therefore measured estrogens, androgens, sex hormone-binding globulin (SHBG), and gonadotropins in five patients with HOA and in 18 patients with simple clubbing. Of the patients with HOA, 80% had a high urinary estriol concentration. In their serum, 80% had high estrone, 0% high estradiol, and 40% high SHBG. Of the patients with simple clubbing, 89% had a high urinary estriol concentration. In their serum, 76% had high estrone, 6% high estradiol, and 31% high SHBG. In all patients, urinary estriol concentration correlated positively with the degree of clubbing. Serum concentration of androstenedione, testosterone, luteinizing hormone (LH), and follicle-stimulating hormone (FSH) was mostly normal, but androstenedione concentration correlated positively with the degree of clubbing. Spider angiomas were present in 74%, palmar erythema in 39%, and gynecomastia in 9%. Urinary creatinine concentration was low in 48% and correlated positively with the degree of clubbing. We reject the claim that hyperestrogenism occurs in HOA, but not in simple clubbing. Hyperestrogenism occurs both in HOA and in simple clubbing. Our results also support earlier reports that clubbing and HOA are associated with spider angiomas, palmar erythema, gynecomastia, adrenal cortical hyperfunction, muscle atrophy, and water retention. These results led to a new hypothesis on the pathogenesis of HOA, involving estrogens, prostaglandin E2, prostaglandin A2, and the inflammatory reflex.

Role of Nerve Growth Factor (NGF) and Its Receptor Tyrosine Kinase A (TrK A) in Egyptian Cirrhotic Patients with Pruritus

Background: Pruritus is a distressing symptom of cholestatic, inflammatory, and malignant liver diseases. It is a common symptom in many biliary and cholestatic disorders such as primary biliary cirrhosis (PBC). Several mechanisms are generally accepted as possible explanations to the underlying basis of itch. However, the exact pathophysiology of pruritus in liver diseases remains unclear. The cutaneous and central neurobiology of pruritus is complex and underlies a regulation of variable mechanisms. At present, not all mechanisms including neuromediators and receptors are known. Objective: Our objective is to evaluate whether the expression pattern of NGF and its receptor TrK A has a role in pruritus in a group of Egyptian cirrhotic patients. Patients and Methods: Forty Patients with liver cirrhosis were enrolled in the study depending on clinical evidence of stigmata of chronic liver disease (e.g. jaundice, ascites, palmar erythema, spider naevi, etc.) and ultrasonographic features of liver cirrhosis (e.g. coarse echo texture, shrunken liver, etc.). Patients were divided into two groups. Group (1): included 20 patients cirrhotic patients without pruritus. Group (2): included 20 patients cirrhotic patients with pruritus. A group of age and sex matched healthy twenty volunteers as a control. Results: After evaluation of histopathological using hematoxylin and eosin stained sections (H&E) was done. There was positive correlation between NGF protein expression and severity of pruritus in cirrhotic patients with pruritus (r = 0.876, p value ≤ 0.001). Also there was positive correlation between TrK A protein expression and severity of pruritus in cirrhotic patients with pruritus (r = 0.44, p value ≤ 0.05). Conclusions: We report, for the first time, role of these proteins (NGF/TrK A) in the mechanism of pruritus in cirrhotic patients and may provide a potential target for new treatment of pruritus in cirrhotic.

Wilson's disease presenting during pregnancy: A diagnostic and therapeutic dilemma.

Wilson's disease is an autosomal recessive genetic disorder affecting copper transport leading to hepatic and/or neuropsychiatric manifestations. Changes in pregnancy can mimic certain clinical features of chronic liver disease such as spider naevi, and constraints for the use of various investigation for diagnosis pose a challenge to physicians. A high index of suspicion, multi-disciplinary team approach, use of correct non-invasive testing including viral serology, autoantibodies and copper studies and ultrasonography help to diagnose most of the pre-existing, de novo or pregnancy-specific hepatological conditions. We report a case of Wilson's disease diagnosed during pregnancy and discuss the challenges in diagnosis and treatment in pregnancy.

Spectrum of cutaneous manifestations in Wilson’s disease in children in a tertiary care center in South India: a prospective study

Background: Wilson’s disease in children is the most common inherited disorder of copper metabolism in India with varied clinical manifestations secondary to deposition of copper in various organs including skin. Methods: The aim of the study was to study various cutaneous manifestations of Wilson’s disease in south Indian children. A prospective study for a period of one year was conducted at Dermatology and Pediatric Gastroenterology clinic in Government Rajiv Gandhi Hospital, Chennai. Clinical, demographic details, various cutaneous manifestations and results of skin biopsy were analysed. Results: Out of the total 30 children with Wilson’s disease, 93.3% had at least one cutaneous, mucosal, hair or nail findings but not statistically significant between naive and on treatment group. Cutaneous findings, mucosal involvement, hair changes and nail findings were observed in 90%, 36.7%, 46.7% and 60% respectively. Cutaneous findings were more common in liver disease (P value&lt;0.05). Xerosis was the most common cutaneous manifestation seen in 63.3% patients, followed by pigmentation in 36.7% and infection in 30%. KF ring was noted in 53.3%. Icterus and pruritus were seen in one fifth of study children and majority had portal hypertension. Vascular changes like spider nevi, purpura and other features of portal hypertension were noted in 16.6% of study population. Trichomegaly was one of the common hair manifestation found in 9 (30% especially in children already on treatment (p value &lt;0.05). There was no evidence of stainable copper on skin biopsy. Conclusions: The physicians should be aware of various cutaneous manifestations of Wilson’s disease in children.

Videodermoscopy and doppler-ultrasound in spider naevi: towards a new classification?

Spider naevi (SN) are considered a subtype of telangiectasias, currently classified as low-flow vascular malformations. To describe the videodermoscopy and Doppler-ultrasound (US) features of a large group of SN. A retrospective study of cases of SN collected at our Dermatology department during the period between June 2015 and June 2017 was performed. Clinical images, dermoscopic, videodermoscopic and Doppler-US files were reviewed. For each case, the age of the patient, time since onset, size and dermoscopic pattern of the lesions were recorded. The presence of pulsatility was also evaluated visually on the videodermoscopy. Two hundred and thirty-three SN in 189 patients were included. The mean age was 39.5years (range: 10-76years). Mean size of the lesions was 4.1±2.0mm. We described three dermoscopic patterns: network, star and looping. Older age, longer time since onset and larger size were found associated with higher frequency of the looping and star patterns compared to that of network pattern (P<0.01). Pulsatility during videodermoscopy was found in 88 patients (37%). This pulsatility phenomenon was more commonly associated with the looping pattern (64.7%) than star- (40.3%) or network-like patterns (29.9%) (P<0.001). In Doppler-US studies, a high-flow with arterial biphasic waveform was found. In the light of the results, we support that SN could be reconsidered in upcoming classifications as lesions closer to the group of high-flow arteriovenous malformations.

Schistosomiasis and hepatopulmonary syndrome: the role of concomitant liver cirrhosis.

BACKGROUND Hepatopulmonary syndrome (HPS) is defined as an oxygenation defect induced by intrapulmonary vasodilation in patients with liver disease or portal hypertension. It is investigated in patients with liver cirrhosis and less frequently in those with portal hypertension without liver cirrhosis, as may occur in hepatosplenic schistosomiasis (HSS).OBJECTIVES To investigate the prevalence of HPS in patients with HSS, and to determine whether the occurrence of HPS is influenced by concomitant cirrhosis.METHODS We evaluated patients with HSS with or without concomitant liver cirrhosis. All patients underwent laboratory testing, ultrasound, endoscopy, contrast echocardiography, and arterial blood gas analysis.FINDINGS Of the 121 patients with HSS, 64 were also diagnosed with liver cirrhosis. HPS was diagnosed in 42 patients (35%) and was more frequent among patients with concomitant liver cirrhosis than in those without cirrhosis (42% vs. 26%), but the difference was not significant (p = 0.069). HPS was more common in those with spider naevi, Child-Pugh classes B or C and high model for end stage liver disease (MELD) scores (p < 0.05 each).MAIN CONCLUSIONS The prevalence of HPS was 35% in this study. The occurrence of liver cirrhosis concomitantly with HSS may have influenced the frequency of patients presenting with HPS.

Dual-wavelength pulsed dye laser for the treatment of spider angioma in children: an observational clinical study

Objective To evaluate the clinical efficacy and adverse effect of dual-wavelength pulsed dye laser for the treatment of spider angioma in children, and to observe recurrence of spider angioma after treatment with it. Methods A dual-wavelength approach with 585-nm and 1 064-nm pulsed-dye lasers was used to treat 233 children with spider angioma, who were followed up for at least 6 months. Correlations of the clinical efficacy with disease duration, skin complexion, age, gender and so on were analyzed, and adverse reactions and recurrence were evaluated. Results The clinical efficacy of the dual-wavelength pulsed dye laser was good in the treatment of spider angioma in children, with the recovery rate and response rate being 87.1% and 100% respectively, and was negatively correlated with the disease duration. There was no significant difference in the clinical efficacy among children with different skin complexions, but treatment sessions for recovery increased in children with Fitzpatrick skin type Ⅳ compared with those with Fitzpatrick skin type Ⅲ. Additionally, no significant difference in the clinical efficacy was observed among children of different age and gender. After the laser treatment, purpura, blisters and swelling occurred instantly, hyperpigmentation and hypopigmentation occurred in a short-term period, and no obvious long-term adverse reactions were observed. Of 233 children, 21 (9.4%) experienced recurrence between 6 months and 2 years after the laser treatment, with a mean recurrence interval of 7.3 ± 3.4 months. Conclusion The dual-wavelength pulsed dye laser is effective and safe for the treatment of spider angioma, and can serve as the first-line therapeutic method for childhood spider angioma. Key words: Telangiectasis; Child; Lasers, dye; Spider veins; Pulsed dye laser

Management of vascular lesions using advanced laser technology

&lt;p&gt;One of the most widely used cutaneous applications of Light Amplification by Stimulated Emission of Radiation (laser) concerns the treatment of vascular lesions. During the past two decades, very significant advances in the application of laser technology in dermatology have occurred, with selective photothermolysis being the most important. This review focuses on the application of modern laser devices (Pulsed Dye Laser, or PDL; potassium titanyl phosphate laser, or KTP; diode laser; and neodymium-doped yttrium-aluminium-garnet laser, or Nd:YAG), as well as the combination of laser and photodynamic therapy (PDT) for the treatment of vascular lesions. In particular, both congenital (haemangiomas and port-wine stains) and acquired vascular lesions (facial and leg telangiectasias, rosacea, Poikiloderma of Civatte, spider angioma, pyogenic granuloma, and venous lakes) are discussed. The review of many recent research studies demonstrates that modern applications of lasers in dermatology constitute the finest method for the treatment of vascular lesions, combining the advantages of invasive therapy with the security offered by non-invasive therapy, while in certain cases they are the single and only choice for the treatment of these lesions.&lt;/p&gt;

Association of Dermatoses with Duration and Quantum of Alcohol Intake: A Comparative Cross-sectional Study.

Background:Chronic alcohol intake impacts skin directly, through organ dysfunction or by modifying preexisting dermatoses. However, dermatoses afflicting chronic alcoholics figure in a few studies only.Aim:This study aims to correlate the spectrum of dermatoses in chronic alcoholics with the quantum/duration of alcohol intake and raised liver transaminases.Materials and Methods:Adult males, totaling 196, ascertained to fulfill the Royal College of Psychiatry criteria for chronic alcoholism by the de-addiction center and referred for dermatological consult were enrolled as cases, and similar number of age-/sex-matched teetotallers, as controls. Data emanating from detailed history, clinical examination, and routine liver functions tests were summarized and subsequently analyzed, including statistically using the Chi-square, independent “t” and Spearman's rank correlation tests, and compared with data from previous studies.Results:Majority (104) drank 41–50 units of alcohol/week since 3–40 (mean: 20.01 ± 9.322) years. Generalized pruritus (odds ratio [OR]: 31.15, P < 0.001), xerosis (OR: 3.62, P = 0.008), and seborrheic dermatitis (OR: 12.26, P < 0.001) were significantly more common in cases than controls. Infections (73; 37.2%), eczemas (45; 22.9%), and generalized hyperpigmentation (28; 14.2%) were the major presenting complaints. Spider nevi, gynecomastia, and pellagroid dermatitis were present in 34 (17.3%), 19 (9.7%), and 8 (4.1%) respectively exclusively in cases only. Commonly seen systemic abnormalities were an alcoholic liver disease (45; 22.9%), diabetes mellitus (23; 11.7%), and peripheral neuropathy (19; 9.7%).Conclusion:Knowledge of cutaneous manifestations of chronic alcoholism could prompt in-depth history taking of alcohol intake, lead to specialist referral and thereby enable timely de-addiction, hopefully before serious adversities in the chronic alcoholics.

Portal Hypertension in Benign Recurrent Intrahepatic Cholestasis: A New Clinical Feature of a Rare Diagnosis?

Benign Recurrent Intrahepatic Cholestasis (BRIC) is an autosomal recessive condition that usually presents in the first two decades of life. It has a prevalence of less than 1 in 100,000 and is caused by mutations in either the ATP8B1 gene encoding a hepatic ATPase at the canalicular membrane (BRIC1) or the ABCB11 gene encoding the bile salt export pump (BRIC2). Both present with recurrent episodes of pruritus and jaundice and features that can include malaise, hepatomegaly, and steatorrhea. BRIC has not been associated with portal hypertension. A 28 year-old male presented with 2 weeks of severe pruritus, nausea, 10 lb weight loss, and dark urine. He reported similar episodes occurring intermittently for the past five years but otherwise had a negative medical history. He took no prescribed, OTC or herbal medications and denied alcohol or drug use. His paternal grandfather had similar episodes of intermittent jaundice and pruritus without a known diagnosis. Examination revealed scleral icterus and mild hepatomegaly. There was no evidence of spider angiomata, asterixis, or ascites. Labs were significant for an ALT 64 U/L, AST 43 U/L, bilirubin 4.6 mg/dL (direct 3.2 mg/dL), alkaline phosphatase 129 U/L, GGT 66 U/L, INR 0.9 and platelet count of 95,000 x10ˆ6/mL. Testing for hepatitis A, B, and C, as well as ANA, AMA, ASMA, and ceruloplasmin were negative. Contrast enhanced abdominal CT showed evidence of portal hypertension with splenomegaly and large perisplenic varices (figure 1). Subsequent liver biopsy revealed evidence of cholestasis without fibrosis (figures 2 and 3). With supportive care, he had resolution of symptoms and complete normalization of his liver tests and platelet count. He did well for 1 year until developing a more severe episode treated with nasobiliary drainage. Given his relapsing course, cholestasis with a normal GGT, family history, and extensive negative workup for other causes, he was diagnosed with BRIC. This case was unusual given the evidence of transient portal hypertension seen on both blood work and imaging, resolving after resolution of his episode. BRIC has been associated with hepatomegaly, but has not previously been associated with portal hypertension. We hypothesize that during episodes of cholestasis, liver swelling led to this transient portal hypertension. There are no known documented reports of BRIC presenting with portal hypertension.Figure 1Figure 2Figure 3

A brief discussion on relationship among spider angioma, liver cirrhosin and hepatopulmonary syndrome

A brief discussion on relationship among spider angioma, liver cirrhosin and hepatopulmonary syndrome

Skin diseases of the nose.

The goal of this study was to review the main lesion types of the nasal skin and appropriate treatment strategies rather than to present a comprehensive list of all diseases that affect the skin that can involve the nose. We reviewed the main nasal skin lesion types and available treatment strategies. Nasal skin lesions were classified as benign, premalignant, or malignant. Benign lesions of the nose include nonmalignant tumoral lesions (i.e., freckles, comedo, adenoma sebaceum [Pringle disease], hydrocystoma, fibrous papules, sebaceous hyperplasia, and rhinophyma), autoimmune and inflammatory conditions (i.e., pemphigus, sarcoidosis, systemic lupus erythematosus, facial eosinophilic granuloma, rosacea, herpes zoster infection, leishmaniasis, and leprosy), and vascular lesions (i.e., telangiectasis, hemangioma, and spider nevus). Premalignant lesions are actinic keratosis and keratoacanthoma; and malignant tumors are melanoma, basal cell carcinoma, and squamous cell carcinoma. Regardless of whether or not they are malignant, all facial lesions can yield significant cosmetic discomfort that should be evaluated carefully before commencing any curative or corrective intervention. In general, benign lesions are treated with dermabrasive modalities, such as trichloroacetic acid, phenol, salicylate, and laser ablation. Electrocautery, cryosurgery, and surgical excision are also used, although these methods may result in scar formation, which can sometimes be more problematic than the original lesion itself. Any disease that affects the skin, especially those diseases that are triggered by ultraviolet exposure, can involve the face and nose. Cosmetic defects due both to the lesion itself and the intervention must be discussed with the patient, preferably in the presence of a first-degree relative, before commencement of treatment. As a result of heterogeneity of skin lesions of the nose, appropriate education of general practitioners as well as otorhinolaryngologists is mandatory.