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Renal disease can manifest in the skin in three ways:
Skin changes that associated with renal failure
Systemic diseases with renal and cutaneous manifestations (e.g., Henoch-Schönlein purpura)
Diseases affecting the kidney where skin biopsy may be helpful in making the diagnosis, even if cutaneous findings are not prominent (e.g., primary systemic amyloidosis).
Gagnon AL, Desai T. Dermatological diseases in patients with chronic kidney disease. J Nephropathol. 2013;2:104–109.
See Table 37.1 .
Finding | Percent affected | Finding | Percent affected |
---|---|---|---|
Changes in pigmentation | 70% | Keratotic pits of palms and soles | 14% |
Yellow tinge to skin | 40% | Perforating disorder | 4% |
Hyperpigmented palmoplantar skin | 30% | Finger pebbles | 86% |
Hyperpigmentation that is diffuse or photodistributed | 22% | Calcinosis cutis | 1% |
Pallor | 8% | Calciphylaxis | 1% |
Nail changes | 66% | Uremic frost | 3% |
Half-and-half nails | 39% | Porphyria and pseudoporphyria | 1.2%–18% |
Pale nails | 23% | Cutaneous infections | 70% |
Splinter hemorrhages | 11% | Onychomycosis | 52% |
Xerosis (dry skin) and/or pruritus | 63% | Tinea pedis | 25% |
Unfortunately, many of the cutaneous changes that are associated with CRF persist even after hemodialysis. In fact, some complaints, such as pruritus (itching), may worsen upon starting hemodialysis.
Many skin changes described in patients with CRF are also found in patients undergoing peritoneal dialysis or hemodialysis. A large percentage of patients receiving dialysis complain of severe pruritus, although aggressive dialysis may, over time, lessen this symptom. Patients on renal dialysis may develop a bullous eruption similar to porphyria cutanea tarda (PCT) ( Fig. 37.1 A ). Acne can occur with dialysis and with exogenous testosterone. Several perforating diseases are associated with CRF, either with or without renal dialysis, including Kyrle disease, reactive perforating collagenosis, and perforating folliculitis. Sometimes, people group these perforating diseases under one term— acquired perforating dermatosis of CRF . Dialysis patients may develop cutaneous complications from treatment, such as infections or contact dermatitis in the area of the peritoneal cannula or arteriovenous fistula.
Blaha T, Nigwekar S, Combs S, et al. Dermatologic manifestations in end stage renal disease. Hemodial Int . 2019;23:3–18.
Both “half-and-half” nails (Lindsay nails) and Muehrcke nails are associated with CRF. In “half-and-half” nails, the proximal nail is white while the distal portion retains a normal pink color ( Fig. 37.1 B). It is believed that edema of the nail bed leads to this appearance. Muehrcke nails are associated with hypoalbuminemia and consist of two transverse white bands, parallel, and separated by normal nailbed.
Muehrcke RC. The fingernails in chronic hypoalbuminaemia: a new physical sign. BMJ. 1956;9:1327–1328.
Uremic frost of the face was as a classic manifestation of CRF, but it is rarely seen in modern times. White dusty deposits were noted about the face and neck and were believed due to crystallized urea from sweat. Table 37.2 summarizes the abnormalities of skin color associated with renal failure.
Skin finding | Color | Distribution | Etiology |
---|---|---|---|
Uremic frost | White | Face, nostrils, neck | Deposition of crystallized urea from sweat |
Pallor | Yellowish | Generalized | Anemia, urochrome deposition |
Hyperpigmentation | Brown | Photodistributed or generalized | Increased β-melanocyte–stimulating hormone |
Bruising | Red-purple-green-yellow-brown | Sites of trauma | Hemostatic abnormalities |
Saardi KM, Schwartz RA. Uremic frost: a harbinger of impending renal failure. Int J Dermatol . 2016;55:17–20.
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