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Skin Signs in eating disorders

Background: Eating disorders are significant causes of morbidity and mortality in adolescent females and young women. They are associated with severe medical and psychological consequences, including death, growth and developmental delay; significant medical complications in all of the primary human organ systems, including the skeleton and the skin.
Objective: The purpose of this study was to describe skin signs in eating disorder.
Methods: A clinical study was performed in 20 patients with eating disorders. The dermatological examination included the entire skin, oral cavity, hair and nails.
Results: The most frequent skin manifestations were Russell's sign, nail changes, diffuse hypertrichosis, seborrheic dermatitis, hyperpigmentation, alopecia, xerosis, cheilitis, gingivitis and acne. In all patients included in a two years follow-up, cutaneous signs improved in relation to the increase in BMI.
Conclusion: Eating disorders have a poor prognosis, marked addictive potential and a high risk of suicide. The earlier the eating disorder is diagnosed and treated, better is the prognosis: cutaneous signs may facilitate an early diagnosis and then an immediate treatment to obtain improvement of the prognosis.

Author:

A. Mazzola,

Infectious Disease, ARNAS Civico, Palermo

Angela Mazzola
Via Cimbali n.41 Palermo, Italy

Key Words:

Cutaneous abnormalities, anorexia nervosa, bulimia nervosa, eating disorders, skin signs

Introduction

Eating is controlled by many factors, including appetite, food availability, family, peer, and cultural practices, and attempts at voluntary control. Dieting to a body weight leaner than needed for health is highly promoted by current fashion trends, sales campaigns for special foods, and in some activities and professions. Eating disorders (ED) involve serious disturbances in eating behavior, such as extreme and unhealthy reduction of food intake or severe overeating, as well as feelings of distress or extreme concern about body shape or weight. ED are considered psychiatric disorders that have physical complications and can cause significant impairment in health and interpersonal relations (1); are associated with severe medical and psychological consequences, including death, osteoporosis, growth delay and developmental delay (2).
Eating disorders are increasing in Europe, particularly among young women. They mainly include anorexia nervosa and bulimia nervosa. Both develop as a result of worries about having too much body fat. Recent studies estimate that the incidence of anorexia lies between 0.2 and 1%, and of bulimia between 2% and 5% (3,4), whereas the prevalence in men is lower. Recent study demonstrate that risk factors for disordered eating and body dissatisfaction for men and women may be different, which can influence the aetiology understanding the and treatment execution (5).

Patients and Methods

From 1998 to August 2005 20 female patient with anorexia nervosa, according to ICD-10 criteria (aged between 9 and 24 years) were observed.
The investigation was approached with a self-designed database (“Cibus”, an SQL-based system) where all women referred to us were inserted; patient history, dermatological history and examination of the skin were collected.
The dermatological examination included the entire skin, oral cavity, hair and nails.

Results

Table 1 shows the complete compilation of findings.
The most frequent skin manifestations were Russell's sign (14), nail changes (10), diffuse hypertrichosis (7), seborrheic dermatitis (6), hyperpigmentation (6) alopecia (6), xerosis (4), cheilitis (4),gingivitis (3) and acne (3).

Table 1 Findings observed in all enrolled women (20)

	Age (years)	Skin signs
Case 1	18	Nail changes, diffuse hypertrichosis, alopecia
Case 2	20	Hyperpigmentation, seborrheic dermatitis, Russell's sign
Case 3	22	Nail changes, xerosis, cheilitis
Case 4	17	Nail changes, xerosis, cheilitis, Russel’s sign
Case 5	23	Hyperpigmentation, seborrheic dermatitis, Russell's sign
Case 6	19	Diffuse hypertrichosis, Russell's sign
Case 7	20	Diffuse hypertrichosis, Russell's sign
Case 8	21	Diffuse hypertrichosis, acne, nail changes
Case 9	16	Nail changes, xerosis, cheilitis, Russell's sign
Case 10	18	Hyperpigmentation, seborrheic dermatitis, and Russell's sign
Case 11	20	Nail changes, diffuse hypertrichosis, alopecia, Russel’s sign
Case 12	17	Alopecia, hyperpigmentation, Russell's sign
Case 13	17	Nail changes, xerosis, cheilitis, Russel’s sign
Case 14	21	Nail changes, diffuse hypertrichosis, alopecia
Case 15	19	Nail changes, Russel’s sign
Case 16	22	Gingivitis, acne, seborrheic dermatitis, Russel’s sign
Case 17	19	Hyperpigmentation, seborrheic dermatitis, Russell's sign
Case 18	16	Nail changes, diffuse hypertrichosis, alopecia
Case 19	23	Gingivitis, acne, seborrheic dermatitis, Russel’s sign
Case 20	21	Alopecia, hyperpigmentation, gingivitis

The prevalent nail changes observed were the presence of brittle, cracked and fragile nails.
2/20 studied patients showed a generalized rash identified as symptom adverse reaction to arising laxative and diuretic abuse.
1 women presented an hand dermatitis depending on compulsive handwashing.
In all patients inserted in a two years follow-up, cutaneous signs improved in relation to the increase with weight and in BMI.

Discussion

Eating disorders are significant causes of morbidity and mortality in adolescent females and young women. Eating disorders, although relatively uncommon, represent a public health concern because they are frequently associated with other psychopathology and role impairment, and are frequently under-treated (6).
They are associated with severe medical and psychological consequences, including death, growth delay and developmental delay , because they have influences on entire organism; the patient treatment should involve different physician , such as psychiatrist, gynaecologist, endocrinologist, dermatologist.
Skin changes are characteristic and are cardinal diagnostic symptoms and pointers to the diagnosis of eating disorders. They are a consequence of starvation and/or malnutrition, self-induced vomiting, drug consumption and concomitant psychiatric illness (7). In all our patients various cutaneous signs were observed. Russel’s sign was the most frequent skin sign observed: it consists of abrasions, small lacerations, and callosities on the dorsum of the hand overlying the metacarpophalangeal and interphalangeal joints. Most of our patient referred they usually induced vomiting by index and/or middle finger and calluses are the consequence of rubbing skin against teeth during the induction of the vomiting reflex with the fingers
The earlier the eating disorder is diagnosed and treated, better is the prognosis: a careful examination of the skin can identify cutaneous signs which may lead to the diagnosis of an occult eating disorder and then guide to a prognosis improving.

References

1. Pokrajac-Bullian A, Zivcic-Becirevic I, Calugi S, Dalle Grave R; 2006. Shool prevention program for eatin disorders in Croatia: a controlled study with six months of follow-up. Eating and Weight Disorders, 11:171-178.
2. Agras WS The consequences and costs of the eating disorders; 2001. Psychiatr. Clin North Am, 2,371-79.
3. Rebecca J. Frey; 2002. In Gale Encyclopedia of Medicine, Gale Group Ed;.
4. American Psychiatric Association; 1994. Diagnostic and Statistical Manual of Mental Disorders, 4th edn. Washington, DC: American Psychiatric Association.
5. J Elgin, M. Pritchard; 2006. Gender differences in disordered eating and its correlates. Eating and Weight Disorders. 11, 3: e96-e101;
6. Hudson JI, Hiripi E, Pope HG, Kessler RC; 2007. The Prevalence and Correlates of Eating Disorders in the National Comorbidity Survey Replication. Biological Psychiatry. 61:348-358.
7. Gupta MA, Gupta AK. Dermatologic signs in anorexia nervosa and bulimia nervosa; 1987. Arch Dermatol.123:1386–90.

First published May 2007

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