SKIN MANIFESTATIONS OF INTERNAL DISEASES

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SKIN MANIFESTATIONS OF INTERNAL DISEASES

• By,
• dr. karthik k m
• Intern ,
• Dept. of medicine
• Mmcri

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Introduction

• Skin is one of the sense organ it is the
  largest organ of the body
• It acts as
• 1 boundary between the body and outside
  environment
• 2 first line of body defence
• 3 insulator in cold weather ,helps to
  release heat by sweating
• 4 produces vit D from sunlight
• 2 layers ,outer EPIDERMIS stratum corneum
  
• 
  stratum lucidum
• 
  stratum granulosum
• 
  stratum spinosum
• 
  stratum basale
• Inner DERMIS

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Primary skin lesions

• MACULE a flat, colored lesion lt 2cm in
  diameter, not raised above the surrounding skin
• PATCH a large gt 2cm flat lesion ,color
  different from surrounding skin . This differs
  only in size
• PAPULE a small, solid lesion lt 0.5 cm , raised
  above the surface thus palpable . Eg. Closed
  comedone,acne
• NODULE larger 0.5 to 5 cm , firm lesion raised
  above the surface of surrounding skin differs
  from papule only in size. Eg large
  nevomelanocytic nevus
• TUMOR A solid raised growth gt 5 cm

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• VESICLE a small fluid filled lesion lt 0.5 cm ,
  raised above the plane , fluid is often visible.
• BULLA fluid filled , raised often translucent
  lesion gt 0.5 cm
• PUSTULE A vesicle filled with leukocytes ,
• WHEAL a raised erythematous, edematous papule
  or plaque usually representing short lived
  vasodilatation vasopermeability.
• TELANGIECTASIA A dilated , superficial blood
  vessel

• PLAQUE a large gt1cm ,flat topped , raised
  lesion edges may be either distinct eg in
  psoriasis or gradually blend with surrounding
  skin eg in eczematous dermatitis

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SKIN MANIFESTATIONS

• Diabetes mellitus
• Thyroid disease
• Adrenal disease
• Renal disease
• Liver disease
• Cardiac disease
• GIT disease
• Malignancy

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DIABETES MELLITUS
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DIABETES MELLITUS

• Approximately 30 of patients with DM develop
  skin lesions at some point
• Overall prevalence of cutaneous disorders does
  not differ between type 1 type 2 diabetics
• type 1 patients get more autoimmune
  type lesions
• type 2 patients get more cutaneous
  infections

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DIABETES MELLITUS

• Cutaneous lesions usually appear after the
  development of DM, but may be the first
  presenting sign
• Four major groups of skin findings
• Skin diseases associated with DM
• Cutaneous infections
• Cutaneous manifestations of diabetic
  complications
• Skin reactions to diabetic treatment

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NECROBIOSIS LIPOIDICA (NL)

• This is a necrotising skin condition usually seen
  in patients with DM
• NL is 3 more common in women
• NL appears earlier (mean age 22) in type 1
  diabetics than type 2 (mean age 48)
• Appearance
• begins as an oval, violaceous patch and
  expands slowly
• advancing border is red
• central area turns yellowish brown
• 13 of case progress to ulceration

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Contd.

• Classically , NL occurs bilaterally on the
  pretibial or medial malleolar areas
• Not painful
• Spontaneous resolution occurs in 13 to 19 with
  residual scarring

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DIABETIC BULLAE

• Approximately 0.5 of diabetics
• This is a distinct spontaneous , non inflammatory
  blistering condition of acral skin that is unique
  to patient with diabetes
• Two types have been described
• more frequent, non scarring lesions with a
  histologic
• intraepidermal split
• less common, occasionally haemorrhagic
  bullae that heal with scarring, slight
  atrophy and have a histologic subepidermal split
  .

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Histological intraepidermal split
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Contd.

• Appearance
• painless bullae on non inflamed base that
  appear suddenly
• most commonly on the dorsa and sides of
  lower legs and feet ,sometimes with similar
  lesions on the hands and forearm
• bullae contains clear , sterile fluid
• bullae tend to heal spontaneously in 2 to 5
  weeks

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ACANTHOSIS NIGRICANS

• Seen in situations of insulin resistance
• This is a brown to black poorly defined velvety
  hyperpigmentation of the skin. It is usually
  found in body folds such as ,,,posterior and
  lateral folds of the neck, armpits, groin, navel
  ,umbilicus, areola, sub mammary areas .

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Contd.

• Besides in DM also seen in ,
• carcinomas especially of the stomach
• secondary to drugs ( nicotinic acid,
  estrogen or corticosteroids)
• pineal tumours
• other endocrine syndromes ( PCOS,
  acromegaly, cushings disease , hypothyroidism )
• obesity
• pathogenesis
• it may be related to insulin binding
  insulin-like receptors on keratinocytes and
  dermal fibroblasts, thus stimulating growth

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SKIN INFECTIONS IN DM

• Occurs in 20 to 50 of poorly controlled diabetes
• More common in type 2
• May be related to
• abnormal microcirculation
• neuropathy
• decreased phagocytosis and killing
  activity
• impaired leukocyte adherence
• PVD

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CANDIDIASIS IN DIABETICS

• Fungal infections most common
• Candida
• candidial paronychia
• oral candida
• genital candida
• ORAL CANDIDIASIS
• white , curd like material adherent to
  erythematous ,
• fissured oral comissure

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BACTERIAL INFECTION

• Can be more severe and widespread in diabetics
• MALIGNANT OTITS EXTERNA
• pseudomonas aeruginosa
• fatal in over 50 patients
• can progress to chondritis,
  osteomyelitis, and bacterial
• meningitis

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DIABETIC ERUPTIVE XANTHOMAS

• Seen in uncontrolled diabetics ,
  hypertriglyceridemia
• these are non tender yellow papules with red rim
  
• Sites extensor aspects of extremities, buttocks
  hands
• Control of glucose and lipid reduction reduce the
  lesions

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DIABETIC DERMOPATHY

• ALSO KNOWN AS SHIN SPOTS
• It is a most common skin lesion Usually seen in
  30 of people with diabetics
• Characterised by dull-red papules that progress
  to well circumscribed , small, round, atrophic
  hyper pigmented skin lesions usually on the shins
  
• The cause is unknown but is thought to be
  associated with diabetic neuropathy and vascular
  complications
• Seen more common in patients with longstanding
  diabetes and poor glucose control

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CUTANEOUS MANIFESTATIONS OF DIABETIC COMPLICATIONS

• FOOT ULCERS
• peripheral neuropathy
• unnoticed trauma
• ulcers
• Vascular complications may lead to ulcers and
  complicate ulcer healing

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CUTANEOUS REACTIONS TO DIABETIC TREATMENT

• INSULIN
• Allergy may be local or systemic and usually
  occurs within the first month of the therapy
• erythematous or urticarial pruritic nodules
  at the site of injection
• Lipoatrophy circumscribed depressed areas of
  skin at the site of injection 6 to 24 months
  after starting insulin
• Lipohypertrophy soft dermal nodules that
  resembles lipomas at site of frequent injections
• may be a response to lipogenic action of
  insulin
• can be prevent by rotating sites of
  injections

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• ORAL HYPOGLYCEMICS
• Most reaction associated with first generation
  sulfonylureas
• 1 to 5 patients on these drugs will develop skin
  reactions during first 2 months of treatment
• They present with maculopapular eruptions that
  resolve despite continuation of the drug

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THYROID DISEASES

• HYPERTHYROIDISM
• HYPOTHYROIDISM
• GRAVES DISEASE

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THYROID HORMONE AND THE SKIN

• Thyroid hormone plays a pivotal role in the
  growth and formation of hair and sebum production
  
• It also involved in protein synthesis, mitosis
  and determination of epidermal thickness
• Regulates cutaneous blood flow and peripheral
  vasodilatation

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HYPERTHYROIDISM AND SKIN

• Skin is usually warm , moist, and smooth
• Facial flushing
• Palmar erythema
• Hyperpigmentation , esp. creases of palms and
  soles
• Hair is fine and friable, hair loss may be
  excessive
• History of early graying
• Hyperhydrosis , particularly of palms and soles

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Scleromyxedema in hyperthyroidism

• Numerous firm white, yellow, or pink papules on
  face, trunk, axillae, and extremities
• Lesions results from accumulation of hyaluronic
  acid in the dermis, accompanied by large
  fibrocytes

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GRAVES DERMOPATHY

• Pretibial myxoedema (0.5 to 4 of patients )
• Late manifestation, accompanied by ophthalmopathy
  in 99
• presentation varies from peau d
  orange appearance to extensive infiltration
• most often bilateral , asymmetric ,
  raised, firm plaques or nodules
• can appear anywhere in the body,commonly
  pretibial area
• histologically the process involves
  dermal accumulation of hyaluronic acid

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Contd.

• PATHOGENESIS
• Pretibial fibroblasts are the target for
  antithyroid antibodies
• T cells may be interacting with a dermal antigen
  similar to a thyroid autoantigen, with cytokines
  subsequently activating fibroblasts to secrete
  hyaluronic acid
• Can treat with topical steroids, intralesional
  steoids

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THYROID ACROPACHY IN GRAVES DISEASE

• Thyroid acropachy 1 of graves disease
• Triad of digital clubbing , soft tissue swelling
  of hands and feet, and periosteal new bone
  formation
• Usually accompanied by exophthalmos and
  dermopathy

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HYPOTHYROIDISM AND SKIN

• Skin is cool dry and pale
• pallor results from cutaneous
  vasoconstriction and increased deposition of
  water and mucopolysaccharides in the dermis,
  which alter the refraction of the light
• hypohydrosis may lead to palmoplantar
  keratoderma ( possibly along with reduced
  epidermal steroid synthesis)
• Carotenemia ( from decreased hepatic coversion of
  beta carotene to vitA) gives skin yellowish hue
• Hair nails will be dry brittle, partial
  alopecia . Hair growth slows down ,
• Easy bruising present , with impaired wound
  healing.

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HYPOTHYROIDISM FACIES WITH GENERALIZED MYXEDEMA

• CHARECTERISTIC SKIN SIGN
• Occurs as a result of deposition of PAS-
  positive dermal acid ,mucopolysaccharides ( esp.
  hyaluronic acid and chondroitin sulphate) in the
  skin
• skin is non pitting , with a firm waxy
  appearance
• characteristic facies swollen lips,
  broad nose, macroglosia and puffy eyelids
• carpal tunnel syndrome and facial nerve
  palsy may occur owing to nerve entrapment

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ASSOCIATION BETWEEN CUTANEOUS AND THYROID DISEASE

• VITILIGO
• due to higher levels of antithyroid peroxidase,
  antithyroid microsome, anti TSH
• ALOPECIA AREATA
• Rapid onset of total hair loss in a sharply
  defined, usually round ,area
• Regrowth begins in 1 to 3 months and may be
  followed by loss in the same or other areas

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ADRENAL DISEASE

• ADDISONS DISEASE
• HYPERCORTISM

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ADRENAL INSUFFICIENCY

• Increased stimulation of melanocortin-2 receptor
  by ACTH itself
• Pigmentation is maximal over photoexposed areas,
  mucous membranes, skin folds, scars, pressure
  points(elbows , knees, knuckles, toes, lips,
  mucous membrane
• Nails longitudinal melanonychia

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HYPERCORTISM

• Truncal obesity
• Buffalo hump
• Moon facies
• Slender limbs
• Cutaneous atrophy and telangiectasias
• Purpura
• Poor wound healing
• Acneform eruptions
• Hirsutism

Purplish striae on abdomen , breasts, proximal
parts of limbs
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RENAL DISEASES

• SIGNS OF END STAGE RENAL DISEASE
• SIGNS ASSOCIATED WITH DIALYSIS
• SIGNS IN RENAL TRANSPLANT PATIENTS

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CUTANEOUS MAIFESTATIONS OF UREMIA

• XEROSIS
• PRURITUS
• PIGMENTARY ALTERATIONS
• NAIL CHANGES
• HAIR CHANGES
• BULLOUS DIEASES OF DIALYSIS
• CALCINOUS CUTIS
• CALCIPHYLAXIS
• NEPHROGENIC SYSTEMIC FIBROSIS

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XEROSIS

• Most common cutaneous abnormality
• Is predominantly seen over extensor of the
  forearm, legs, thighs
• The abdomen and chest may show fine scaling
• Hypervitaminosis A, reduction in size of sweat
  glands, high dose diuretics are some of the
  causes of xerosis.

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UREMIC PRURITIS

• It is also called as CKD associated pruritis
• Characterised by daily bouts of itching that may
  disturb the sleep
• The itch may be generalised or localised to one
  or more area most often the back , abdomen, head,
  arms,
• In haemodialysis patients , the pruritus is
  lowest the day after dialysis and peaks 2 days
  after dialysis
• Cause dry skin, reduced sweat, abnormal
  metabolism of calcium and phosphorous
  ,accumulation of toxins.. co existing medical
  problems like diabetes and liver disease.

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• Treatment
• optimising dialysis efficacy
• Topical moisturising creams
• UVB light
• Sedating anti histaminics

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PIGMENTARY CHANGES

• Pallor anemia
• Yellow hue carotenoids and nitrogenous pigments
  ( urochrome )in the skin
• Brown black hyperpigmentation
• sun exposed areas
• can be attributed to retention and
  deposition of melanin in the basal layer and
  superficial dermis due to failure of kidney to
  excrete beta melanocyte stimulating hormone
• sunscreens, sun avoidance measures and
  clothing are advised

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PURPURA / ECHHYMOSIS

• Defects in primary hemostasis like increased
  vascular fragility
• Abnormal platelet function
• Use of heparin during dialysis are the main
  causes of abnormal bleeding in these patients
• Dialysis treatment partially corrects these
  changes

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CALCIPHYLAXIS ( CALCIFIC UREMIC ARTERIOLOPATHY)

• abnormal elevated level of parathyroid
  hormone
• trigger deposition of
  crystalline calcium pyrophosphate
• in the dermis , subcutaneous
  fat or arterial walls
• METASTATIC SKIN CALCIFICATION
  

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• Papular or nodular cutaneous lesions around large
  joints or flexure sites
• Acute thrombosis of calcified vessels,
• This produces violaceous mottling of the skin
  that are acutely painful due to ischaemia.
  Surrounding tissue may be inflamed with
  cellulitis
• Lesions often progress to necrosis
• and gangrene

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BULLOUS DISEASE OF DIALYSIS

• Syndrome of cutaneous fragility and blistering
• Etiology due to the elevated plasma porphyrin
  levels in individuals with chronic renal failure
• Resembels porphyria

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NEPHROGENIC FIBROSING DERMOPATHY

• IT is a disease of fibrosis of the skin and
  internal
• organs reminiscent but distinct from scleroderma
• It is caused by gadolinium (contrast) exposure
  used in imaging in patients with renal
  insuffiency
• Typically , symmetrical skin plaques with a peau
  d orange surface and advancing ameboid edges
  develop on limbs and trunk sparing head and neck
• Treatmet corticosteroids,, plasmapheresis,
  hemodialysis can be effective in removing
  gadolinium contrast from the body

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NAIL CHANGES

• Lindsays nail ( half and half nails , prevalence
  30 to 50)
• Koilonychia( spoon nails)
• Subungual hyperkeratosis
• Onycholysis ( sepration of finger nails)
• Splinter haemorrhage ( blood clots that tend to
  run vertically
• under nails)
• Beau lines(deep groved lines run from side to
  side)
• Mees lines( transverse white lines without
  depressions)

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DISORDERS ASSOCIATED WITH RENAL TRANSPLANTATION

• INFECTIONS
• SEVERE herpes zoster
• Candidal infections
• Viral warts and condyloma accuminata
• MALIGNANCIES
• Kaposis sarcoma- oral cavity, limbs
• SCC gt BCC

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LIVER DISEASES

• CHRONIC LIVER DISEASE
• HEPATITS B , C

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CHRONIC LIVER DISEASE

• Jaundice
• Because of raised levels of bilirubin gt 2.5 to 3
  mg/dl ( 0.2 to 1.2)
• SPIDER NEVUS / SPIDER ANGIOMAS
• pinhead upto 10mm
• mostly on skin drained by superior
  venacava
• central arteriole visible as a red flat
  or slightly
• elevated point surrounded by multiple
  small
• and tortuous radiating capillaries
• commoner in alcoholic cirrhosis.

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Contd.

• abundant cutaneous spider angiomata clinical
  marker of hepatopulmonay syndrome, where
  circulatory and gas exchange abnormalities in the
  lung occur secondary to advanced CLD
• Also seen in THYROTOXICOSIS, ESTROGEN EXCESS
  STATE ( PREGNANCY, OCP USE ),, LIVER FAILURE,
  CIRRHOSIS
• PALMAR ERYTHEMA
• exaggerated mottling or well defined
  hypothenar erythema that spreads
  to fingers and rest of the palm.
• GYNAECOMASTIA ( hyperestrgenemia)
• PRURITUS
• XANTHOMA STRAITUM (multiple xanthomas may
  appears as yellowish plaques covering large areas
  of skin in palmar creases)

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• ASCITES LEADS TO STRIAE DISTENSAE
• CLUBBING
• BRITTLENESS
• LEUCONYCHIA
• TERRYS NAIL ( whitening of the entire
• nail plate except for a narrow pink
• band distally)
• MUEHRCKES NAILS (multiple parallel
• transvers white bands)

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HEPATITIS C

• PORPHYRIA CUTANEA TARDA
• LICHEN PLANUS
• NECROLYTIC ACRAL ERYTHEMA

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PORPHYRIA CUTANEA TARDA

• Vesicles and bullae on sun exposed area with
  scarring and milia (benign keratin filled cysts)
• Hypertrychosis
• Fragile skin
• This is acquired and familial disorder in which
  activity of heme synthetic enzyme
  UROPORPHYRINOGEN DECARBOXYLSE is deficient

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LICHEN PLANUS

• It is a skin rash that is triggered by the immune
  system ,
• the contributing factors include,,,
• Viral infections,( hepatitis C)
• Allergens( antibiotics, arsenic, diuretics, some
  dyes)
• Genetics
• Autoimmune disorder
• Charaterised by purplish colored lesions or bumps
  with flat tops on the skin
• Itching at the site of the rash blisters , which
  bursts and become scabby

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Contd.

• TREATMENT
• Corticosteroids
• Antihistaminics
• Light therapy
• Home therapy( avoid scratching, applying cool
  compress to the rash applying anti itch cream)

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NECROLYTIC ACRAL ERYTHEMA

• Starts as erythematous papules and sometimes
  blisters
• that coalesce into well circumscribed dusky
  areas with
• scaling and erosions
• Hyperkeratotic surface develops in older lesions
• Most common on dorsal surface of feet , great
  toes
• NAE is thought to be a reliable diagnostic marker
  of hepatitis C infection
• There will be a bilaterally symmetrical well
  demarcated , scaly plaques on dorsum of hand and
  feet,, these lesions are surrounded by
  erythematous margins
• Treatment oral ZINC therapy( deficiency causes
  reduction in serum transport proteins like
  retinol binding protein and prealbumin which
  impair deliver of nutrients such as vitA to the
  tissues

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SYSTEMIC LUPUS ERYTHEMATOSUS

• it is an autoimmune disease in which organ and
  cells undergo damage initially mediated by tissue
  binding autoantibodies immune complexes.
• MALAR ERYTHEMA
• DISCOID PLAQUES OR PSORIASIFORM ERYTHRODERMA
• PHOTOSENSITIVITY, ALOPECIA,MUCOSAL ULCERS
• PERIUNGUAL ERYTHEMA

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• MALAR RASH also called butter fly rash
• It is a red or purplish mildly scaly.
  charectaristically it has the shape of butterfly
  involves the nose bridges the rash spares the
  nasolabial folds of the face which contributes to
  its charectaristics appearance
• Usually macular with sharp edges not
  itchy,,,progressive with involvement of the
  facial skin
• Also seen in pellagra, dermatomyositis etc

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GASTROINTESTINAL DISEASE
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HENOCH-SCHONLEIN PURPURA

• This is an acute immunoglobulin A(IgA) mediated
  disorder characterised by ,,,Vasculitis with
  arthritis, abdominal pain, hematuria,
  subcutaneous edema, bloody stools , duodeal ulcer
  , massive GI bleeding.
• Mainly affects children
• Often follows streptococcal infection
• In skin,, the disease causes purpura
  (hemorrhages)
• Treatment ensuring adequate hydration,
  symptomatic treatment,

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Sweets syndrome ( by Robert douglas sweet)

• Skin disease charectarised by sudden onset of
  fever , raised WBC count,, Erythematous tender
  papules, nodules and plaques with marked lesional
  edema
• May occur in patients with inflammatory bowel
  disease, ulcerative colitis

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Pyoderma gangrenosum

• Rapidly expanding ulcer with purple
• undermined border, start as pustules
• Often affects the legs
• Causes
• 50 idiopathic
• 10 associated with ulcerative colitis
• other associations crohns disease,
  hronic active hepatitis, rheumatoid arthritis,
  HIV, leukemia, myeloma.

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CARDIAC DISEASES
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CYANOSIS

• It Is the bluish discolouration of the skin
  mucous membrane resulting from an increased
  quantity of reduced haemoglobin ( deoxygenated
  haemoglobin) or haemoglobin derivatives ie
  methemoglobin, sulfhemoglobin in the small
  blood vessels
• Most marked in areas with thin vascular surfaces
  ,oral mucosa, lips, nail beds, ear lobes, palm
  and soles
• In general cyanosis becomes apparent when the
  concentration of reduced haemoglobin in capillary
  blood exceeds 4 g/dl.

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Contd.

• CENTRAL (deceased arterial oxygen saturation)
• CHD
• Impaired pulmonary function
• Tongue is the most reliable site for detecting
  cyanosis
• PERIPHERAL (due to poor blood flow,,, oral mucosa
  is spared )
• Cold exposure
• Peripheral vascular disease
• CHF
• Polycythemia

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CLUBBING

• Bulbous enlargement of distal segments of the
  fingers and toes due to proliferation of
  connective tissue, particularly on the dorsal
  surface (increase in the angle b/w nail fold
  nail plate) lovibonds
• Seen in CCHD
• Infective endocarditis
• Primary and metastatic lung cancer
• Bronchectasis, lung abscess, cystic fibrosis,
• TB , mesothelioma,
• Asbestosis, sarcoidosis.
• IBW, hepatic cyrrhosis

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Infective endocarditis

• Subungual splinter haemorrhage
• 1 to 2 mm brown streaks under the finger /toe
  nails
• Petechiae
• Oslers nodule ( painful, red, raised lesions
  found on the hands and feet)
• janeway nodules( non tender , small erythematous
  or hemorrhagic macular or nodular lesions on
  palms and soles
• Non tender purpuric macules on palms soles

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RHEUMATIC FEVER

• Subcutaneous nodules
• Extensor aspect of elbows knees
• Seen in pts with rheumatic carditis
• Erythema marginatum
• Seen in 10 pts of rheumatic fever
• Dull red, flat or palpable, discrete or confluent
  , annular lesions on the trunk, abdomen, proximal
  parts of extremities.

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CUTANEOUS MANIFESTATIONS OF INTERNAL MALIGNANCY
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COWDEN SYNDROME

• Autosomal dominant condition ,,,due to mutation
  in PTEN/MMAC1 tumour suppressor gene which
  encodes tyrosine phosphatase protein that
  regulates cell proliferation.
• More often in women than in men
• Charactrised by multiple non cancerous tumour
  like growths called hamartomas, which typically
  found in skin mucous membranes, thyroid glands
  and breast tissues
• People with cowden synd. Are at increased risk of
  
• Certain cancers including breast , thyroid ,
• uterus , kidneys

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GLUCAGONOMA SYNDROME

• neoplastic proliferation of alfa cells of
  pancreas
• overproduction of glucagon
• enhances blood glucose level
• NECROLYTIC MIGRATORY ERTHEMA
• Classical symptom observed in pts. With
  glucagonoma
• spread of erythematous blisters and
  swelling across areas subject to friction
  pressure ,including lower abdomen ,buttocks,
  groin

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GARDNERS SYNDROME

• Autosomal dominant disorder characterised by
  adenomatous polyps of GIT, especially colon
  rectum
• The skin lesions includes, large deforming
  epidermoid cyst , fibromas, lipomas, leiomyomas,
  neurofibromas

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NEURO CUTANEOUS MARKERS

• This is a group of genetic disorders, which
  produce variety of developmental abnormalities
  that frequently involve skin , along with
  increased risk of nervous system tumours
• 1 café au lait spots
• dark brown hypermelanotic macuels with
  smooth or irregular borders, commonly on back,
  buttocks, trunk.
• 2 neurofibroma
• these are multiple subcutaneous papules and
  nodules
• in NF
• 2types fusiform ( firm discrete subcutaneous
  nodules )
• plexiform ( subcutaneous elastic
  tumours)

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• 3 adenoma sebaceum
• numerous discrete , smooth, glistening,
  round rubbery ,papules , pinhead size to pea
  size, over butterfly area of face
• 4 subungual periungual fibromas
• 5 ash leaf spots ( hypomelanotic polygonal
  macules grow upto 5cm over buttoks trunk)
• 6 cutaneous telangiectasia
• 7 shagreen patch ( connective tissue naevi
  ,,,cobblestone like plaques in lumbosacral areas

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THANK YOU