I still remember Dr. Lipscomb’s lectures during my medical student days at Texas A&M Health Science Center (HSC). He was a professor in family and community medicine and stressed the importance of physical examination in caring for patients. He used to always say that examination of the skin and nails was an essential part of diagnosis. I and many of my classmates were a bit amused by his statement. However, years of experience has led me to truely respect his skill and lifelong dedication to medicine. Sadly, there seems to be less time for physicians to cultivate the skills of the physical exam.
It may be surprising to learn that examination of the skin, which is the human body’s largest organ, or fingernails can reveal a wealth of information about a patient’s case in endocrinology. Most people believe that endocrinology is about a multitude of blood tests rather than actual physical examinations. I want to set the record straight and share with you some examples where the patient’s skin can tell a story for the endocrinologist and provide vital clues for diagnosis
Vitiligo is a pigmentation disorder that is believed to be caused by autoimmune destruction of pigment cells in the skin. The endocrine tie-in for vitiligo is its link to other autoimmune conditions with endocrine symptoms such as hypothyroidism, type 1 diabetes, and Addison disease. I’ve seen children with vitiligo diagnosed either before or after they have been diagnosed with one of these endocrine conditions.
Vitiligo is a chronic condition that primarily affects people between the ages of 10-30 and may or may not progress to a more advanced state. Sun screen protection is important for areas that lose pigment from vitiligo to prevent serious burns that could lead to skin cancer. A consultation with a dermatologist to discuss the diagnosis and treatment options can help children diagnosed with this condition.
CAFÉ AU LAIT SPOTS
Café au lait spots can be subtle or very striking in appearance. Overall, café au lait spots are fairly common and up to three spots can be seen on the skin of roughly 10% of the population. Most spots are round and average about ½ an inch across and are present at birth. The number and appearance of café au lait spots can give me important clues when I see a child. Six or more round café au lait spots in a child raises concern for neurofibromatosis a genetically-inherited disease in which nerve tissue grows tumors that can be harmless or cause serious problems. Abnormally early puberty, high blood pressure, and short stature are a few of the more common endocrine conditions that can coincide with neurofibromatosis.
Café au lait spot with neurofibromatosis
“Coast of Maine” café au lait spot
with McCune-Albright syndrome
McCune Albright syndrome is a rare and complicated condition that can have a very distinctive café au lait spot associated with it. The spot is large and irregular with irregular borders described as a “Coast of Maine” pattern. Growth hormone problems, bone problems, thyroid problems, and precocious puberty (onset before the age of 8 in girls and 9 1/2 in boys) are several of the multiple endocrine problems that children with this condition can have.
Fingernail and toenail changes can be seen in children with this illness – either before the diagnosis or during recovery. Beau’s lines are deep depressions that appear in the fingernails due to shut-down of the nail growth that occurs during systemic insults. The body will turn off non-essential functions like fingernail growth while it is fighting illnesses such as diabetes or cancer.
I’m excited that Cook Children’s Medical Center and Texas A&M HSC are moving towards collaboration in pediatric medical education and care of children in Central Texas as well as North Texas.
Here’s a link to the American Academy of Dermatology for more information on skin disorders as well as skin care.