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The prevalence of dermatological features in the liver cirrhosis group was 95%, this high figure agrees with reports in the literature. However this is in contrast to the findings of George et al¹⁵ who found dermatological features in 56% of liver cirrhosis patients studied.

The common dermatological features found in this study were leuconychia, jaundice, pallor, fluffy hair and palmar erythema. Although frequencies of these features reported in liver cirrhosis vary in the literature, the pentad signs of leuconychia, pallor, jaundice, fluffy hair, and female pubic hair pattern in males have been more often reported in previous studies of cutaneous signs in liver cirrhosis. George et al¹⁵ in a study of 60 patients with liver cirrhosis in Ibadan, Nigeria, reported jaundice, fluffy hair, leuconychia and change to female pattern of pubic hair distribution as the common findings. Also Khan et al¹⁶ who studied 50 patients with chronic liver disease found the signs of Terry’s nails, nonscarring hair loss and palmar erythema to be the commonest finding.

Leuconychia presented as Terry’s nail with a proximal white and distal pink band seen, Terry’s nails have also being documented to be the most common feature seen in liver cirrhosis in other studies, Kamal et al¹²² in a study of 100 cirrhotic patients reported a prevalence of 40%, Achinge et al¹²³ reported 53.8%

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The prevalence of jaundice found in this study of 30.8% is similar to the 26%

reported by Sayal et al¹⁰⁰

The frequency of pruritus reported in this study was 10%, this is similar to 10.8%

reported by Sayal et al,¹⁰⁰ prevalence of pruritus reported in previous studies varies widely, values between 12%¹²⁴ and 80% have been reported. The possible reasons for the variation in the prevalence may be due to differences in individual tolerance and threshold to itch in different populations, moreover the assessment of itch is also subjective and influenced by other factors. Pruritus found in this group of patients was generalized and of mild to moderate intensity, there were no associated skin lesions and it resolved spontaneously.

The precise cause of pruritus in liver disease is not fully understood, however bile salts, histamine and other pruritogens have been implicated. Pruritus was found in 5 patients in the chronic hepatitis group, previous reports have recorded the presence of pruritus in the early stages of chronic viral hepatitis but the significance of this is not known, and further research is needed to clarify this. There were seven of the patients with liver cirrhosis and HCC who had pruritus, xerosis is a possible factor which may contribute to pruritus in these patients.

Pallor was noticed in the conjunctiva, buccal mucosa and tongue and was found in 20% of subjects. Higher values have been reported by other authors due to the differences in aetiology and stage of disease included in the study. Occult blood loss, malnutrition, hypersplenism could be contributory towards the anemia found.

Xerosis was seen in 30% of the patients studied, it was present predominantly over extensor surfaces of the forearms, legs or thighs, values up to 78%¹²⁵ have been

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reported in different studies of cutaneous features of chronic liver disease, Humidity and temperature differences may account for the varying values reported in literature.

Palmar erythema in this study showed as a patch of erythema over the thenar and hypothenar eminences and other parts of the hands. It was present in 14.2% of patients in this study. This is lower compared to the 25% reported by Onyekwere et al¹²⁶ in their study of CLD patients, but is similar to 18% reported by Kamal et al¹²⁷ in Pakistan. The reason for the lower figure could be also be due to composition of types of CLD studied.

Hyperpigmentation was seen in 10% of patients, similar to previous reports in literature. It presented as generalized hyperpigmentation in 2 patients and as palmoplantar macules in 10 patients, this finding was reported by George et al,¹⁵ the significance of the palmoplantar hyperpigmentation is unclear, impaired metabolism in relation to estrogen or melanocyte stimulating hormone has been implicated.¹²⁸

Parotid fullness was seen in 10% of the patients. The parotid glands were considered enlarged when they were both visible and palpable. Onyekwere et al¹²⁰ found parotid fullness in 90% of his study subjects, this large difference may be due to difference in inclusion criteria of their study participants compared to that of this study.

Dupuytren’s contracture was seen in 3% of subjects, this is similar to the 3%

reported by Gavli et al¹¹⁹ and the 5% reported by Kamal et al¹²¹ in Pakistan, but is in contrast to that reported by this difference may be explained by the study composition which was mainly composed of those with alcoholic cirrhosis.

Other nail findings in this study apart from leuconychia were onycholysis and finger clubbing. Similar nail findings were reported by George et al,¹⁵ in contrast Salem et al¹²⁹ in a study of nail changes in 100 patients with CLD reported onychomycosis as

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the most common nail finding, they also reported finger clubbing, leuconychia and longitudinal melanonychia in their patients.

The most commonly seen hair change was fluffy hair, which presented as sparse silky hair. Loss of pubic hair with a change to female hair pattern were also noted, this pattern has been reported by other studies. Alopecia areata which presented as bald shiny patches which were otherwise asymptomatic was noticed in one patient with HBV associated liver cirrhosis. Alopecia in this setting is thought to be due to CD8 T lymphocyte mediated reaction leading to hair loss.¹³⁰

No observation of caput medusae, vasculitis, spider naevi, prurigo nodularis, porphyria cutanea tarda, lichen planus or cutaneous metastasis of HCC was made in this study.

Reasons that could account for this include the rarity of some of these cutaneous features in liver disease e.g. cutaneous metastasis in HCC, the low prevalence of these features in our population, differences in aetiology of chronic liver disease studied or ethnic skin differences.