Page 158 - The Netter Collection of Medical Illustrations - Integumentary System_ Volume 4 ( PDFDrive )

Plate 4-73 Integumentary System

MUCOCUTANEOUS MANIFESTATIONS OF INFLAMMATORY BOWEL DISEASE
SKIN MANIFESTATIONS OF
INFLAMMATORY BOWEL DISEASE

Crohn’s disease and ulcerative colitis are two common
autoimmune gastrointestinal disorders with many cuta-
neous findings. Most patients do not have the cutaneous Aphthous
findings, but a small proportion of the population with ulcers
inflammatory bowel disease develop one of the cutane- (occur on
ous manifestations, which include pyoderma gangreno- buccal mucosa,
sum, aphthous ulcerations, oral candidiasis, erythema tongue, and
nodosum, metastatic Crohn’s disease, iritis, and con- palate)
junctivitis. Arthritis, although not a skin manifestation,
can produce red, tender swelling around an afflicted
joint space. Iritis (may precede intestinal symptoms)
Clinical Findings: Ulcerative colitis and Crohn’s
disease are more commonly seen in the Caucasian pop-
ulation. Crohn’s disease is slightly more common in
women, and ulcerative colitis affects men and women
equally. Up to 20% of individuals with inflammatory
bowel disease have a family history of the condition.
Ulcerative colitis affects the large intestine, whereas Pyoderma gangrenosum
Crohn’s disease has been shown to affect any part of the (occurs in <1%
gastrointestinal tract. of patients with
Skin manifestations occur in 5% to 10% of those inflammatory
affected by inflammatory bowel disease. The most bowel disease)
common skin finding is erythema nodosum. Erythema
nodosum manifests as tender dermal nodules predomi-
nantly on the shin region. They typically are symmetric
in location. There are many associations with erythema
nodosum in addition to inflammatory bowel disease,
including pregnancy, use of birth control medications, Erythema nodosum (occurs
sarcoidosis, deep fungal infections such as coccidiomy- in <5% of patients with
cosis, and an idiopathic form. The etiology and patho- inflammatory bowel disease)
genesis are unknown. Erythema nodosum can occur in Oral candidiasis (secondary to
areas other than the pretibial region, but this is chronic illness and use of antibiotics)
uncommon.
Pyoderma gangrenosum is one of the most severe
skin manifestations of inflammatory bowel disease. It
can manifest as a small, red papule or pustule that can
rapidly expand to form a large ulceration with a viola-
ceous undermined rim. The ulcer may form in a crib-
riform pattern. The skin involved develops small Sweet’s syndrome
cribriform ulcerations centrally that expand outward
and coalesce into one large ulcer. These ulcers are
extremely tender and cause significant morbidity. Pyo-
derma gangrenosum can also be seen as an idiopathic
finding or in association with an underlying malig-
nancy, typically in the lymphoproliferative group of
malignancies. It has been estimated that approximately
1% of patients with inflammatory bowel disease will
develop pyoderma gangrenosum.
Aphthous ulcers can occur anywhere within the oral
mucosa. They are shallow ulcerations with a white
fibrinous base. They are quite tender and can cause
patients to avoid eating because of the severe discomfort. Arthritis (occurs in <10% of patients
Oral candidiasis is typically an iatrogenic manifestation with inflammatory bowel disease)
of inflammatory bowel disease. Most patients are
prescribed systemic steroids to treat their underlying
disease, and this predisposes them to the development
of Candida infections, both oral and vaginal. draining papules and nodules. A peculiar variant has Other rare skin findings that have been seen in asso-
Arthritis is seen in approximately 10% of patients been described to occur along the inguinal creases. It ciation with inflammatory bowel disease are skin fistu-
with inflammatory bowel disease and is considered to appears as fissures or ulcerations that can penetrate las, vasculitis including polyarteritis nodosa, urticaria,
be in the seronegative classification of inflammatory deeply into the dermis and even the subcutaneous fat Sweet’s syndrome, epidermolysis bullosa acquisita, and
arthropathies. tissue. It has been described as slit-like or knife-like psoriasis.
Metastatic Crohn’s disease is unique to Crohn’s. It linear ulcerations. Isolated genital swelling is another Pathogenesis: The pathogenesis of these cutaneous
represents the spread of the granulomatous disease onto unusual presentation of metastatic Crohn’s disease. manifestations of inflammatory bowel disease is un-
the skin. It most commonly occurs in areas with close Metastatic Crohn’s disease has been described in many known. They are theorized to be caused by an autoim-
approximation to the gastrointestinal tract, such as the other cutaneous locations. This form of cutaneous mune mechanism of defective cell-mediated immunity.
perianal and perioral regions. It manifests as tender, disease can be difficult to treat. Metastatic Crohn’s disease is believed to be caused

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