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Cutaneous Manifestations of Renal Disease


1

What skin changes are associated with renal disease?

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.

2

What cutaneous findings occur in renal failure?

See Table 37.1 .

Table 37.1
Cutaneous findings in chronic renal failure
Data from Pico MR, Lugo-Somolinos A, Sanchez JL, et al. Cutaneous alterations in patients with CRF . Int J Dermatol 1992;31:860–863 .
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%

3

Do cutaneous signs of chronic renal failure (CRF) resolve with hemodialysis?

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.

4

What cutaneous findings are present in patients on dialysis?

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.

Fig. 37.1, A, Tense vesicle with pseudoporphyria on the dorsal hand of a patient undergoing renal dialysis. B, Half-and-half nails in a patient with chronic renal failure.

Blaha T, Nigwekar S, Combs S, et al. Dermatologic manifestations in end stage renal disease. Hemodial Int . 2019;23:3–18.

5

Describe the nail changes in CRF

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.

6

What is uremic frost?

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.

Table 37.2
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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