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Skin lesions in patients with inflammatory

bowel disease

Marta Idzior*, Marta Laskowska*, Beata Jastrząb*, dr n. med. Katarzyna Neubauer**,

dr hab. n. med. Adam Reich, prof. nadzw.****Studenckie Koło Naukowe Dermatologii Eksperymentalnej, Uniwersytet

Medyczny im. Piastów Śląskich we Wrocławiu**Katedra i Klinika Gastroenterologii i Hepatologii, Uniwersytet Medyczny

im. Piastów Śląskich we Wrocławiukierownik kliniki: dr. hab. n. med. Elżbieta Poniewierka, prof. nadzw.

***Katedra i Klinika Dermatologii, Wenerologii i Alergologii, Uniwersytet Medyczny im. Piastów Śląskich we Wrocławiu

kierownik kliniki: prof. dr hab. n. med. Jacek Szepietowski

ABSTRACTAnalysis of skin problems in patients with in- flammatory bowel disease

▶ KEY WORDS:inflammatory bowel disease, Lesniowski-Crohn disease, ulcerative colitis, skin lesions, photopro-tection, immunosuppressionIn the course of inflammatory bowel diseases (IBD)

skin lesions are relatively common. Sometimes they may even precede the symptoms of IBD and may facilitate the correct diagnosis of IBD. The aim of this study was to assess the prevalence and clinical characteristics of skin problems in pa-tients with IBD. Material and methods: The study included pa-tients with IBD hospitalized in gastroenterological department. All patients underwent a thorough

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medical history and physical examination. Based on achieved data and medical documentation the stratified questionnaire evaluating their skin con-dition, previous treatment, symptoms and know- ledge and habits associated with exposure to ul-traviolet radiation was completed by investigators. All data were analyzed statistically. Results: Active skin lesions were observed in al-most 80% of analyzed IBD patients. About half (n = 20, 46.5%) had skin xerosis, 20.9% (n = 9) present with excessive hair loss and 19.5% (n = 8) suffered from pruritus. About half of participants

(n = 24, 55.8%) declared the use of sunscreens, but most of patients apply them only during sun--bathing (n = 13, 30.2%). Only three patients (7%) applied sunscreens on daily basis. Conclusions: Skin problems are relatively common in patients with IBD, however, taking into account small number of analyzed patients further studies are necessary to assess the true prevalence of par-ticular dermatoses in IBD. Most patients with IBD are not aware of the hazardous role of immuno-suppressants and do not use photoprotection on a daily basis.

INTRODUCTION

Inflammatory bowel disease (IBD), which includes Crohn's disease and ulcerative colitis (UC, Latin colitis ulcerosa), is a group of disorders characterized by chronic inflammation of the gastrointestinal tract. The disorders can also cause parenteral symptoms including skin changes. Both the aetiology and pathomechanism of the skin-gut axis remain unexplained. Pyoderma gangrenosum (PG) and erythema nodosum p(EN) are specific skin lesions most commonly co-existing with IBD [1]. PG is referred to as IBD skin marker (revela-tor) [2]. It occurs in about 5% of patients; it can be the first symptom of an undetected gastrointestinal disease [2]. The same applies to erythema nodosum. Patients with Crohn's disease or UC also manifest skin lesions,

secondary to treatment and disease progression. Patients with IBD are usually subjected to long-term immunosu-ppressive therapy which can cause various types of skin lesions, and even predispose to skin cancers. Having in mind these data and observations, we have made an at-tempt to assess the incidence and nature of skin lesions in patients with IBD and to determine knowledge about the skin-gut axis and its importance in the early diagno-sis and treatment of this group of diseases. Additional-ly, photoprotection methods used in IBD patients were evaluated as part of the prevention of cancer caused by long-term immunosuppression.

MATERIAL AND METHODS

The study included 43 patients with inflam-matory bowel disease: ulcerative colitis (n = 24, 55.8%)

Table 1. Characteristics of analyzed patients with inflammatory bowel diseases

Sex - Women - Men

18 (41,9%) 25 (58,1%)

Age (years) - Average ± SD - Range

36,1 ± 12,5 19–68

Education - Primary - Vocational - Secondary - Uniwersity

2 (4,7%) 9 (20,9%)

11 (25,6%) 21 (48,8%)

Duration of inflammatory bowel disease (years)

- Average ± SD - Range

8,6 ± 6,2 0,25–23

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and Crohn's disease (n = 19, 44.2%), hospitalized at the Department of Gastroenterology and Hepatology of the Medical University of Wroclaw. All persons agreed to participate in the study. The characteristics of the group studied are presented in Table 1. The research was conducted with the use of the original questionnaire containing questions about demographic data, clinical symptoms and the course of IBD. It also included the information on current treatment, dermatological prob-lems and the methods of photoprotection. The question-naire was supplemented with patient medical records and medical history data. After taking medical history, each patient underwent a detailed physical examination. The results were subjected to statistical analysis using the Statistica program 12.0 (Stasoft, Krakow).

RESULTS Skin lesions in patients with inflammatory bowel disease Active skin lesions were observed in almost 80% of patients (n = 34, 79.1%). Nearly half of the subje-cts presented the features of skin dryness (n = 20, 46.5% of subjects); in 20.9% (n=9) excessive hair loss was re-ported and 19.5% (n = 8) complained of the itchy skin. Acne (n=6), eczema (n = 5) and non-specific papular rash (n = 5) were found slightly less often. Other der-matological problems were observed less frequently. These were swelling of the lower extremities (n = 3), nail changes: excessive fragility of the nail plates (n = 2), linear furrows (n = 3), onychomadesis (n = 1), ony-chomycosis (n = 1); also: boils (n=1), severe seborrhoea (n = 1), psoriasis (n = 1) and acne rosacea (n = 1) (Figure 1). Only three patients (7%) gave a history of erythema nodosum. No person suffered from pyoderma gangreno-sum. In addition, three subjects (7%) gave a history of reactive arthritis. Pruritus was more often manifested by people with the symptoms of skin dryness, but the dif-ference wa s not statistically significant (30% vs. 9.5%; p = 0.21). The duration of the disease, its form (Crohn's disease or UC), treatment and the age of patients did not have a significant impact on the incidence of skin lesions.

Sun protection Only three subjects (7%) declared that they

used sunbeds and did it less often than once a month. Sunbathing was reported by 34 individuals (79.1%), ho-wever the patients did it rarely (n=17; 39.5%) or spora-dically (n = 17; 39.5%). About half of the respondents (n = 24; 55.8%) admitted to using sunscreen, but most of them used the preparations only while sunbathing (n = 13; 30.2%). Only three (7%) subjects declared apply-ing sunscreen every day. Women used sunscreen much more often than men (77.8% vs 40%; p = 0.03). The du-ration of the disease, its form (Crohn's disease or UC), treatment and the age of patients did not have a signifi-cant effect on sunscreen habits..

DISCUSSION

As inflammatory bowel disease is often not limited to gastrointestinal abnormalities, but may also affect other organs and systems, it should be conside-red systemic. Parenteral manifestations usually include the involvement of the joints, skin, the organ of vision and less often - the liver, lungs and pancreas [3]. The frequency of parenteral manifestations varies from 6% to even 46%, depending on the country and population [4,5]. Parenteral IBD symptoms may be associated with the disease itself or result from pharmacotherapy imple-mented [6]. Specific IBD dermatological lesions include pyoderma gangrenosum and erythema nodosum [7]. The pathogenesis of these disorders and their relation-ship with IBD are not fully understood. The incidence of erythema nodosum in IBD patients is estimated at around 10–15% [7,8], whereas the incidence of pyoder-ma gangrenosum is much lower - around 0.4–2% [7,8]. None of our subjects manifested active lesions of this type, although three of them gave a history of erythe-ma nodosum. Although the lesions are rare, physicians treating IBD patients ought to be aware of the possibi-lity of their occurrence and the fact that their course is relatively severe. We have noticed in our research that IBD patients often present other dermatological lesions. Although relatively mild, they are often troublesome for the patient. Skin dryness, possibly due to chronic diarrhoea (up to several bowel movements per day), was the most frequently reported problem in patients with active inflammatory bowel disease. Itching was also common. Many patients might have suffered itching as

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a result of skin dryness, but at least in some of them other factors may have played an important role, e.g. in-flammatory mediators released in the intestines. Some dermatological diseases may be side effects of the therapy. The treatment of IBD, is ba-sed mainly on non-steroidal anti-inflammatory drugs (sulfasalazine and its derivatives), corticosteroids, im-munosuppressants, as well as biological medications. These drugs may cause various adverse events, inclu-ding dermatological lesions. Two independent research [9,10] into the use of 5-aminosalicylic acid preparations and its derivatives (olsalazine, mesalazine, balsalazide) revealed the presence of skin rash as a side effect in 2–4% of people with ulcerative colitis. These patients manifested skin lesions as often as fever or fatigue. Drug-induced acne caused by corticosteroids may be another skin problem related to the IBD pharmacologi-cal treatment [8]. The pathogenesis of acne in these pe-ople is not fully understood. Several reports have shown that the steroid-induced TLR-2 receptor may be respon-sible for exacerbation of the disease in patients with acne [12]. On the other hand, it cannot be excluded that people with IBD are predisposed to the development of a non-specific inflammatory response, and at least in some of them acne lesions are probably pathogenetically associated with IBD. Additionally, neutrophilic derma-tosis, which in some cases met the criteria for drug-in-

duced Sweet's syndrome, has been reported when using azathioprine [13]. According to literature, the use of immunosu-ppressive drugs in the treatment of IBD increases the risk of skin cancers [14,15]. This risk, which has increased in recent year [16], is particularly connected with the use of 6-mercaptopurine and its derivatives. Also, patients after transplantation taking immunosuppressants for a long time are at an increased risk of skin cancers [17]. Therefore, special educational programs are addres-sed to them, with dermatologists playing an important role as a part of the health care team. The aim of these programs is to broaden patients' awareness of the nega-tive effects of UV radiation on the skin and, as shown by studies, these actions give very good results [18,19]. That is why, patients taking immunosuppressive drugs for IBD should mandatorily use sunscreen, including creams with UVA/UVB protection to reduce the risk of skin cancers [20]. Only 7% of our subjects used pho- toprotection on a daily basis. This is a very low percen-tage compared to other studies [21] and indicates the urgent need to create and implement an educational program focusing on the negative impact of UV radia-tion on the skin. The study results also show the necessi-ty of effective sun protection methods to be used in IBD patients subjected to long-term immunosuppression.

CONCLUSIONS

▶ Skin problems are relatively common in IBD patients, but given the small number of cases analyzed further rese-arch is needed to study the incidence of individual dermatoses in this group of patients.▶ The vast majority of IBD patients are not aware of the dangers of long-term using immunosuppressive treatment and therefore do not apply effective photoprotection methods on a daily basis

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Adres do korespondencji:

Adam ReichKatedra i Klinika Dermatologii, Wenerologii i Alergologii, UM im. Piastów Śląskich we Wrocławiu

ul. Chałubińskiego 1, 50-368 Wrocław

e-mail: adi_medicalis@go2.pl

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