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The kidneys play the important role of removing waste and excess fluids from the body. Common medical conditions like diabetes, hypertension, autoimmune disease, kidney infections and congenital polycystic kidneys contribute to chronic disease. Associated risk factors for disease include, smoking, obesity, high cholesterol, increasing age and family history. 

 

A variety of skin changes are associated with chronic renal failure. In addition to the significant threat to health posed by kidney disease, skin changes often reduce the quality of life. These diseases may be manifestations of an underlying illness or due to uraemia, which literally means urine in the blood. We will concentrate on a few of these skin problems, which suggest poor kidney function.

 

Anaemia due to low levels of red blood cells causes the (mucous membranes) lining of the eyes, mouth to appear pale. Uraemic stomatitis is an uncommon event resulting in a whitish thickening of the tongue and inner mouth, which can also result in ulcer formation. Dry mouth (Xerostomia), inflammation of the gums and angles of the mouth can also occur. The latter is called angular stomatitis.

 

Alteration in the general colour of the skin is a common association. A brown to slate grey generalised discoloration due to excessive haemosiderin deposition occurs as a consequence of iron overload from blood transfusions. Extensive darkening in the sun-exposed areas can be a possibility due to increasing hormone levels associated with melanocyte stimulation. It is important to avoid excessive sun exposure.

 

Generalised skin dryness (Xerosis) that is aggravated by cold weather or air conditioning is often present. Xerosis causes uncomfortable skin tightness and itching and can progress into other severe forms of dryness and thickening called icthiosis. Dry skin has excessive lines, cracks, lacks lustre and tends to be inelastic. It is best to use gentle cleansers and greasy moisturisers on a routine basis.

 

Pruritis (itching) is a very common problem faced by patients with renal failure and is called Uraemic Pruritis. Itching may be generalised or localised to the trunk, head arms or legs. These daily bouts of scratching tend to get worst at night and can prevent sleep. Dialysis reduces its severity significantly but unfortunately it may only take 48 hours to revert to maximum. In addition to dryness there may be numerous excoriations (scratch marks) with associated discoloration. Secondary bacterial infection is a complication of scratching which also has to be managed. Additional sequelae include eczema changes ranging from acute to chronic chronic as well as nodular prurigo. The latter refers to thickened dark nodules in itchy areas, which are very persistent. The severity of these symptoms can results in anxiety, depression, and agitation in over 50% of those affected.

Polymorphic eruption of pregnancy is an itchy rash, which occurs in the last trimester of pregnancy. This condition is also known as Pruritic Urticarial Papules and Plaques of Pregnancy (PUPPP).  It occurs in about one in every 160 pregnancies in the literature. The average dermatologist in Barbados would see one or two cases per year. Women of all races are affected.

Most cases begin during the last three months of pregnancy when there is significant stretching of the abdomen. PEP commonly occurs during the first pregnancy when the abdominal stretch is tightest and starts around the navel. Excessive weight gain, heavy babies and multiple births accentuate this stretching and are associated with the condition.

 

Itchy red papules or bumps form in the stretch marks around the umbilicus initially. They can join together to form wheals (like hives or nettle rash) and larger raised plaques affecting the abdomen, upper arms, buttocks, thighs and legs. The area around the navel is characteristically spared. There may also be scratch marks as some patient finds it difficult to sleep at night resulting in fatigue and frustration.

 

 

 

This severe itching can be a cause of great distress for first time mothers and can also baffle doctors causing other diagnoses like eczema, viral exanthems, hives, eczema and scabies to be considered.

 

A dermatologist usually makes this diagnosis based on the history of the episode and the clinical findings. Rarely a skin biopsy is required to confirm the diagnosis. Fortunately PEP resolves a few weeks after delivery and would only persist longer if there are retained products of conception. Except for the small possibility of having a mild PEP like rash, babies are unaffected.

 

 

 

General treatment measures avoid irritation of the skin via; cool soothing baths, moisturisers, wet soaks and wearing cool soft cotton clothing. Specific measures are directed at controlling itching as well as skin inflammation via the use of antihistamines and topical steroids. Frequently the symptoms can be controlled using these measures and the pregnancy can progress smoothly. Recurrent episodes are very uncommon and even if it occurs in a subsequent pregnancy it is likely to be very mild.

Paronychia refers to a common infection of the skin around the fingernails called the nail fold. This condition can be acute or chronic and is associated with defects in the cuticle that seals the space between the nail and its associated nail fold. 

 

 

Bacteria and yeast are the organisms involved in these infections. Staphylococcus aureus and Streptococcus pyogens are the common causative organisms. Opportunistic infections can also occur due to Pseudomonas bacteria or the yeast called Candida albicans.

Acute paronychia is the term used for short-lived episodes while chronic paronychia describes infections, which last for over six weeks. 

 

 

Acute infections develop over a few hours with pain, redness and swelling of the nail fold. Superficial infections form visible pus under the skin but deeper infections, can travel beneath the nail, and are associated with fever and painful lymph nodes.

 

Chronic infections wax and wane. Swelling of the nail fold is associated with absence of the cuticle and a space between the nail and the nail fold. This space provides a portal for recurrent infection resulting in episodes of redness and the discharge of small beads of pus. The nail matrix, which is the origin of nail growth, becomes infected. Initially horizontal ridges form in the nail but eventually it becomes irregular, thick and dark. Pseudomonas infection leads to a greenish black discoloration of the nail.

 

 

Jobs involving wet work predispose to paronychia. Bartenders, cleaners, car washers and nurses are examples of professions involving water, detergents and cleansers. Covering the hands for long periods in gloves containing moisture from water or sweat can also make things worst. Direct injury of the cuticle via poor manicures and nail biting or ill fitting artificial nails is not recommended.

Paronychia can be cured but it can take six months to one year in chronic cases. Recovery is dependent on lifestyle changes made by the patient as well as medical intervention. 

 

GENERAL MEASURES

 

• Wash your hands carefully after dirty work with soap and water. Rinse your hands and dry completely.
• Keep your hands dry and moisturised with hand cream.
• Apply a barrier cream or Vaseline to the cuticle/nail fold area.
• Avoid wet work or use cotton inners and totally waterproof gloves. It is important to avoid sweating or getting water inside your gloves.
• Avoid biting your nails, manicuring the nail folds and pushing back your cuticles.
• Avoid false nails and nail polish until the problem is resolved.
• Control underlying diabetes or poor circulation

Acute paronychia is treated with warm compresses and oral antibiotics. Small abscesses are incised and drained. Larger abscesses under the nail require a partial nail excision to allow proper drainage. Dressings are required until fully healed.

 

Chronic paronychia involves mixed infection by bacteria and yeasts. The condition does not resolve until the cuticle grows back. This can take six to twelve months. Antifungal liquids and creams are used to treat minor yeast infections and in severe cases oral antifungals are used at intervals or for extended periods. Bacterial infection is treated using topical and oral treatments as well. 

The disfigurement associated with chronic disease can cause depression and a poor quality of life when severe. The hands are used to touch and greet individuals we care about and this disease can result in shame and embarrassment. It is important to urge compliance and stress the need for the lifestyle changes necessary for recovery, as medical treatment alone does not work well. Early intervention can prevent acute disease from becoming chronic.

 

Visit your dermatologist early.

Melasma refers to a chronic, recurrent, symmetrical brownish discoloration affecting predominantly the curvatures of the face. The shoulders and upper arms are less commonly affected. It is also referred to as Chloasma or “the mask of pregnancy” when it affects pregnant women. Melasma originates from the Greek word for black while Chloasma has its origins in reference to the Greek for green.

 

 

This condition predominantly affects women and is seen between the ages of 20-40 yrs in all races. Individuals who tan well and have darker skin seem to be more susceptible but some families are affected more than others.

 

The exact cause is not known but there is an overproduction of melanin by the pigment cells (melanocytes) which results in pigment being found near the surface (epidermis) and/or deeper in the skin (dermis).

 

The most important risk factor for Melasma is sun exposure and its associated ultra violet damage to the skin. This is totally avoidable but more likely and prevalent in locations close to the equator. Hormonal contributions from pregnancy and contraception also play an important part. Hypothyroidism is also  an uncommon association with the condition.

Melasma appears as dark brown macules or larger patches on the face. The common patterns are:

 

• Centrofacial pattern– forehead, cheeks, nose and above the upper lip.
• Malar pattern – the cheeks and nose
• Lateral cheek pattern
• Mandibular pattern – along the jawline
• Brachial pattern – shoulders and upper arms

 

Your Dermatologist usually makes the diagnosis of this condition easily by clinical examination. Very rarely is a biopsy required unless there is ambiguity related to the diagnosis. A woods lamp examination is used to determine the depth of the pigment and therefore possible response and duration of treatment.

 

General measures are important in the effective control of this condition. In temperate countries with four seasons it is a disorder of summer. In Barbados with sunlight all year round, it is important to practice sun protection with broad spectrum SPF 60 or above. Camouflage make up can also cover and physically protect the skin. Hormonal contraception should be discontinued where possible. 

 

Lightening agents that work by inhibiting the tyrosinase enzyme are used to reduce pigment production. Azealic acid preparations are safe but can be associated with irritation and are available in lotions, gels and creams. Kojic acid soaps are widely available here and do a similar job of inhibiting melanin production. Hydroquinone should be used with caution and under medical supervision. It should not be used in concentrations greater than 4% and has to be applied accurately to avoid unwanted lightening of normal skin. The use of hydroquinone is banned in some parts of the world due to the possibility of paradoxical permanent darkening called ochronosis, which occurs with prolonged use of concentrations over 4%.

 

Superficial (epidermal) forms of melasma benefit from treatment with peeling agents such as Salicylic acid, topical retinoids, and alpha hydroxy acids e.g. Glycolic and lactic Acid.  70% Glycolic acid is frequently used in chemical peels by dermatlogists but usually a series of treatments are required. All peeling agents can cause irritation exhibited as redness or dryness and should to gradually introduced to any treatment regimen.

 

Combination topical therapy is most efficient as a single treatment option and variations of the Kligman’s formula, which consists of hydroquinone, tretinoin and a topical steroid, are often used.

 

Various forms of lasers and intense pulsed light (IPL) are the newest additions to the treatment armamentarium. Excessive lightening and darkening of the treatment areas are unwanted side effects in some cases. Experienced Dermatologists best perform these procedures. Darker skin types are more prone to adverse side effects. 

 

Due to the recurrent nature of the condition, patients must appreciate the need for lifestyle change and maintenance for sustained clearance. Exposure to excessive sunlight over a period of weeks can reverse successful clearance of pigmentation. Cases associated with pregnancy usually resolve months after delivery.