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Dermatologic Signs in Patients with Eating Disorders

  • Therapy in Practice
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American Journal of Clinical Dermatology Aims and scope Submit manuscript

Abstract

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, osteoporosis, growth delay and developmental delay. Dermatologic symptoms are almost always detectable in patients with severe anorexia nervosa (AN) and bulimia nervosa (BN), and awareness of these may help in the early diagnosis of hidden AN or BN. Cutaneous manifestations are the expression of the medical consequences of starvation, vomiting, abuse of drugs (such as laxatives and diuretics), and of psychiatric morbidity. These manifestations include xerosis, lanugo-like body hair, telogen effluvium, carotenoderma, acne, hyperpigmentation, seborrheic dermatitis, acrocyanosis, perniosis, petechiae, livedo reticularis, interdigital intertrigo, paronychia, generalized pruritus, acquired striae distensae, slower wound healing, prurigo pigmentosa, edema, linear erythema craquelé, acral coldness, pellagra, scurvy, and acrodermatitis enteropathica. The most characteristic cutaneous sign of vomiting is Russell’s sign (knuckle calluses). Symptoms arising from laxative or diuretic abuse include adverse reactions to drugs. Symptoms arising from psychiatric morbidity (artefacta) include the consequences of self-induced trauma.

The role of the dermatologist in the management of eating disorders is to make an early diagnosis of the ‘hidden’ signs of these disorders in patients who tend to minimize or deny their disorder, and to avoid over-treatment of conditions which are overemphasized by patients’ distorted perception of skin appearance. Even though skin signs of eating disorders improve with weight gain, the dermatologist will be asked to treat the dermatological conditions mentioned above. Xerosis improves with moisturizing ointments and humidification of the environment. Acne may be treated with topical benzoyl peroxide, antibacterials or azaleic acid; these agents may be administered as monotherapy or in combinations. Combination antibacterials, such as erythromycin with zinc, are also recommended because of the possibility of zinc deficiency in patients with eating disorders. The antiandrogen cyproterone acetate combined with 35μg ethinyl estradiol may improve acne in women with AN and should be given for 2–4 months. Cheilitis, angular stomatitis, and nail fragility appear to respond to topical tocopherol (vitamin E). Russell’s sign may decrease in size following applications of ointments that contain urea. Regular dental treatment is required to avoid tooth loss.

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References

  1. Counihan C. An anthropological view of western women’s prodigious fasting: a review essay. Food Foodways. 1989; 3: 357–75

    Article  Google Scholar 

  2. Diagnostic and Statistical Manual of Mental Disorders. 4th ed, text rev. Washington (DC): American Psychiatric Association, 2000: 589

  3. Mehler PS. Diagnosis and care of patients with anorexia nervosa in primary care settings. Ann Intern Med. 2001; 134: 1048–59

    PubMed  CAS  Google Scholar 

  4. Hsu LK. Epidemiology of the eating disorders. Psychiatr Clin North Am. 1996; 19: 681–700

    Article  PubMed  CAS  Google Scholar 

  5. Becker AE, Grinspoon SK, Klibanski A, et al. Eating disorders. N Engl J Med. 1999; 340: 1092–8

    Article  PubMed  CAS  Google Scholar 

  6. Herzog DB, Nussbaum KM, Marmor AK. Comorbidity and outcome in eating disorders. Psychiatr Clin North Am. 1996; 19: 843–59

    Article  PubMed  CAS  Google Scholar 

  7. Kann L, Kinchen SA, Williams BI, et al. Youth risk behavior surveillance: United States, 1999. MMWR CDC Surveill Summ. 2000; 49: 1–96

    PubMed  CAS  Google Scholar 

  8. Morton R. Phthsiologica: or a treatise of consumptions. London: Smith S, Watford B, 1694

    Google Scholar 

  9. Gull WW. Anorexia nervosa (apepsia hysteria, anorexia hysteria). Transactions of the Clinical Society of London. 1894; 7: 22–8

    Google Scholar 

  10. Russell G. Bulimia nervosa: an ominous variant of anorexia nervosa. Psychol Med. 1979; 9: 429–48

    Article  PubMed  CAS  Google Scholar 

  11. Larocca FEF. Concurrence of Turner’s syndrome, anorexia nervosa, and mood disorders: case report. J Clin Psychiatry. 1985; 46: 296–7

    PubMed  CAS  Google Scholar 

  12. Crisp AH, Burns T. The clinical presentation of anorexia nervosa in males. Int J Eat Disord. 1983; 2 (4): 5–10

    Article  Google Scholar 

  13. Case T, Lemieux S, Kennedy SH, et al. Elevated plasma lipids in patients with binge eating disorders are found only in those who are anorexic. Int J Eat Disord. 1999; 25: 187–93

    Article  PubMed  CAS  Google Scholar 

  14. Misra M, Aggarwal A, Miller KK, et al. Effects of anorexia nervosa on clinical, hematologic, biochemical, and bone density parameters in community-dwelling adolescent girls. Pediatrics. 2004; 114 (6): 1574–83

    Article  PubMed  Google Scholar 

  15. American Psychiatric Association Work Group on Eating Disorders. Practice guideline for the treatment of patients with eating disorders (revision). Am J Psychiatry. 2000; 157 Suppl. 1: 1–39

    Google Scholar 

  16. Kreipe RE, Bimdorf SA. Eating disorders in adolescents and young adults. Med Clin North Am. 2000; 84: 1027–49

    Article  PubMed  CAS  Google Scholar 

  17. Pritts SD, Susman J. Diagnosis of eating disorders in primary care. Am Fam Physician. 2003; 67: 297–304

    PubMed  Google Scholar 

  18. Keel PK, Dorer DJ, Eddy KT, et al. Predictors of mortality in eating disorders. Arch Gen Psychiatry. 2003; 60 (2): 179–83

    Article  PubMed  Google Scholar 

  19. Eckert ED, Halmi KA, Marchi P, et al. Ten-year follow-up of anorexia nervosa: clinical course and outcome. Psychol Med; 1995 Jan; 25 (1): 143–56

    Article  PubMed  CAS  Google Scholar 

  20. Theander S. Outcome and prognosis in anorexia nervosa and bulimia: some results of previous investigations, compared with those of a Swedish long-term study. J Psychiatr Res. 1985; 19 (2–3): 493–508

    Article  PubMed  CAS  Google Scholar 

  21. Tyler I, Wiseman C, Crawford RI, et al. Cutaneous manifestations of eating disorders. J Cutan Med Surg. 2002; 6: 345–53

    Article  PubMed  Google Scholar 

  22. Siddiqui A, Ramsay B, Leonard J. The cutaneous signs of eating disorders. Acta Derm Venereol (Stockh). 1994; 74: 68–9

    CAS  Google Scholar 

  23. Marshman GM, Hanna MJ, Ben-Tovim DI, et al. Cutaneous abnormalities in anorexia nervosa. Australas J Dermatol. 1990; 31 (1): 9–12

    Article  PubMed  CAS  Google Scholar 

  24. Strumia R, Varotti E, Manzato E, et al. Skin signs in anorexia nervosa. Dermatology. 2001; 203: 314–7

    Article  PubMed  CAS  Google Scholar 

  25. Strumia R, Manzato E, Gualandi M. Cutaneous manifestations in anorexia nervosa in males [abstract]. J Fur Acad Derm Venereol. 2002; 16 Suppl. 1: 303

    Google Scholar 

  26. Glorio R, Allevato M, De Pablo A, et al. Prevalence of cutaneous manifestations in 200 patients with eating disorders. Int J Dermatol. 2000; 39: 348–53

    Article  PubMed  CAS  Google Scholar 

  27. Hediger C, Rost B, Itin P. Cutaneous manifestations in anorexia nervosa. Schweiz Med Wochenschr. 2000; 130 (16): 565–75

    Google Scholar 

  28. Gupta MA, Gupta AK, Haberman HF. Dermatologic signs in anorexia nervosa and bulimia nervosa. Arch Dermatol. 1987; 123: 1386–90

    Article  PubMed  CAS  Google Scholar 

  29. Ishiguro N, Hirohara D, Hotta M, et al. Linear erythema craquelé due to acute oedema in anorexia nervosa. Br J Dermatol. 2001; 145: 357–9

    Article  PubMed  CAS  Google Scholar 

  30. Lee S, Leung CM, Wing YK, et al. Acne as a risk factor for anorexia nervosa in Chinese. Aust N Z J Psychiatry. 1991; 25 (1): 134–7

    Article  PubMed  CAS  Google Scholar 

  31. Schulze UM, Pettke-Rank CV, Kreienkamp M, et al. Dermatologic findings in anorexia and bulimia nervosa of childhood and adolescence. Pediatr Dermatol. 1999; 16 (2): 90–4

    Article  PubMed  CAS  Google Scholar 

  32. Comas JM, Archambeaud-Mouveroux F, Teissier MP, et al. Acute ischemia of an arm manifesting Buerger’s disease: predisposing role of anorexia nervosa. Rev Med Interne. 1992; 13 (5): 375–7

    Article  PubMed  CAS  Google Scholar 

  33. Gupta MA, Gupta AK, Voorhees JJ. Starvation-associated pruritus: a clinical feature of eating disorders. J Am Acad Dermatol. 1992; 27 (1): 118–20

    Article  PubMed  CAS  Google Scholar 

  34. Abella E, Feliu E, Granada I, et al. Bone marrow changes in anorexia nervosa are correlated with the amount of weight loss and not with other clinical findings. Am J Clin Pathol. 2002 Oct; 118 (4): 582–8

    Article  PubMed  CAS  Google Scholar 

  35. Lurie R, Danziger Y, Kaplan Y, et al. Acquired pili torti: a structural hair shaft defect in anorexia nervosa. Cutis. 1996; 57: 151–6

    PubMed  CAS  Google Scholar 

  36. Pines A, Olchovsky D, Bregman J. Finger clubbing associated with laxative abuse. South Med J. 1983; 76 (8): 1071–2

    Article  PubMed  CAS  Google Scholar 

  37. Garcia Hidalgo L. Dermatological complications of obesity. Am J Clin Dermatol. 2002; 3: 497–506

    Article  PubMed  Google Scholar 

  38. Gupta MA, Gupta AK. Dissatisfaction with skin appearance among patients with eating disorders and non-clinical controls. Br J Dermatol. 2001; 145: 110–3

    Article  PubMed  CAS  Google Scholar 

Download references

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No sources of funding were used to assist in the preparation of this manuscript. The author has no conflicts of interest that are directly relevant to the content of this manuscript.

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Correspondence to Renata Strumia.

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Strumia, R. Dermatologic Signs in Patients with Eating Disorders. Am J Clin Dermatol 6, 165–173 (2005). https://doi.org/10.2165/00128071-200506030-00003

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