Skin Manifestations in Chronic Pancreatitis as Diagnostic Clues and Prognostic Factors

Dear Editor,

Pancreas-related diseases can be associated with a multitude of cutaneous features, such as pancreatic panniculitis, hemorrhagic manifestations such as Cullen’s sign, Grey Turner’s sign, Fox’s sign, cutaneous metastasis (Sister Mary Joseph nodule), livedo reticularis (Walzel’s sign), acanthosis nigricans, necrolytic migratory erythema, cutaneous fistula, obstructive jaundice-associated pruritus, etc.[1] Cutaneous manifestations play important role both as diagnostic clues for the pancreatic disease itself and serve as prognostic factors for the severity of the underlying conditions.

The pathogenesis of these cutaneous changes is variable and depends on the underlying pancreatic pathology. Chronic pancreatitis usually results in both exocrine and endocrine insufficiency on long-term follow-up, thus resulting in derangements in sugar control and disturbances in digestion and absorption. There is also a deficiency of various macro- and micro-nutrients. Hence, it can present with various cutaneous manifestations at the dermatology outpatient department.

A total of eight chronic pancreatitis patients with complaints of patchy to generalized pale erythema, scaling, and peeling of skin with anasarca presented to the dermatology outpatient department over the last four years. The onset was gradual and was associated with loss of appetite, abdominal bloating sensation, and passage of oily, greasy stools. The relevant points from history and associated symptoms have been listed in Table 1. Most of the male (2/4, 50%) patients had a history of heavy alcohol intake in the past. There was generalized pitting edema with patchy areas of erythema, peeling, and scaling [Figure 1a]. All of them had xerosis with eczema craquele-like changes [Figure 1b], and most (4/8, 50%) also had dull, lusterless, sparse hair [Figure 1c]. They also had features of atrophic glossitis (2/8, 20%), with one female having angular cheilitis [Figure 1d]. On close examination, the skin had a dry and charred look with brown scales [Figure 1e]. All of them also had blood sugar derangement, hypoproteinemia, and anemia. Three (3/8, 37.5%) of the patients also had hypothyroidism. Contrast-enhanced computed tomography (CECT) imaging showed atrophic parenchyma with dilatation of the pancreatic duct and calcifications in all [Figure 2]. All of them received pancreatic enzyme supplementation (25000 IU thrice daily], oral zinc (50 mg twice daily], and multivitamins along with correction of sugar levels. All of them noticed an improvement in the cutaneous features within one to four weeks. The improvement in atrophic glossitis, return of appetite, and improvement in stool frequency and consistency were the earliest changes noticed.

Table 1.

Table describing the demographic details and symptoms in chronic pancreatitis patients

Serial number	Age in years	Sex	Alcoholism	Duration	Symptoms
1 [Figure 1a, e]	56	Female	No	1 year	Loss of appetite, pedal edema, erythema, and frothy stool
2 [Figure 1b-d]	46	Female	No	2 years	Loss of appetite, lower limb swelling, skin exfoliation and weight loss, abdominal distension, frothy stool, gray hair, and atrophic glossitis
3	60	Male	No	10 days	Blisters with erythematous base, diarrhoea, angular chelitis and atrophic glossitis, and frequent frothy stool
4	37	Female	No	5 months	Loss of appetite, vomiting, erythema, scaling, and lesions of reactive perforating collagenosis
5	60	Female	No	1 month	Redness, peeling, charred look, thin lusterless hair, and frequent frothy stools
6	35	Male	Yes	3 months	Swelling of whole body, redness and peeling, itching, and thin lusterless gray hair
7	52	Male	Yes	6 months	Swelling of whole body, redness and peeling of skin, itching and pain, erosions in frictional sites, and frothy stools
8	42	Male	No	2 years	Swelling of whole body, redness and peeling of skin, itching and pain, erosions in frictional sites, frothy stools, and gray lusterless hair

Figure 1.

(a) Diffuse edema with patchy areas of peeling, erythema, and superficial erosions over lower limbs (b) Close-up image showing eczema craquele like changes (c) Pale hair in a patient of chronic pancreatitis (the patient had dyed her scalp hair) (d) Angular cheilitis with atrophic glossitis (e) Close up of affected area with dry charred looking skin with brown scales

Figure 2.

Contrast-enhanced computed tomography (CECT) abdomen showing diffuse atrophy of pancreas parenchyma with dilated main pancreatic duct with intraductal calcification

Cutaneous features are seen in various gastrointestinal diseases.[2] These features may be specific to the disease state or may be non-specific. Chronic pancreatitis results in damage to both the exocrine and endocrine portions of the pancreas, resulting in manifestations of the deficiency of various pancreatic hormones and enzymes. Endocrine pancreas deficiency manifests as uncontrolled diabetes mellitus, whereas exocrine deficiency results in deficiency of various macro- and micro-nutrients. Nutritional deficiencies are commonly seen as a result of derangement of absorption of nutrients. These patients can present to the dermatology outpatient department with features of erythroderma due to nutritional deficiency.

The typical histories among all the patients in the series were loss of appetite, generalized anasarca, frequent frothy and greasy stool, epigastric pain, and burning sensation on taking oily and fatty food. The duration of symptoms ranged from two weeks to two years. Two of the male patients, except the one with history of chronic calcific pancreatitis secondary to gallstones, had a prolonged history of significant alcohol intake. The common cutaneous features were pale erythema, with scaling and superficial peeling of the skin resulting in superficial erosions, more over the frictional sites such as the groin and perianal areas, atrophic glossitis, and angular cheilitis. The cutaneous changes were similar to acrodermatitis enteropathica. None of these patients had hemorrhagic manifestations or other classically described cutaneous findings.

The common laboratory abnormalities were anemia, hyperglycemia, hypoalbuminemia, and hypoproteinemia. All patients had evidence of chronic pancreatitis on CECT.

Simple measures such as the management of exocrine and endocrine pancreatic insufficiency usually help in the rapid improvement of the symptoms.[3] Replacement with appropriate doses of pancreatic enzymes with supplementation of micro- and macro-nutrients resulted in rapid improvement in all the cases.

In conclusion, various skin signs associated with chronic pancreatitis may lead to an early diagnosis and may also predict the severity of the underlying illness. In all of our patients, the common cutaneous features were nutritional, as none of these patients seemed to have the named signs of chronic pancreatitis mentioned in the introduction. These cutaneous changes often present late. Clinicians should be aware of these cutaneous signs in pancreatic pathology in order to recognize them promptly and initiate appropriate management, thus ensuring that patients do not land up in a further worsened state.

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The authors certify that they have obtained all appropriate patient consent forms. In this form, the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published, and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

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