Cutaneous adverse effects of alcohol

Excessive alcohol (ethanol) intake or alcohol abuse can result in many health problems and is implicated as a cause or aggravating factor for several skin conditions.

What is alcohol abuse?

Alcohol abuse has been defined as recurrent alcohol use where it impacts on work, school or home, or to the point it is physically dangerous, gets you into trouble with the law, or continues despite the problems it has created.

Health problems due to alcohol

Alcohol intoxication

Effects of alcohol intoxication include:

• Heart: slow heart rate or irregular rhythm, low blood pressure
• CNS: headache, confusion, memory loss, disorientation, poor coordination, emotional lability
• Gastrointestinal: nausea and vomiting
• Respiratory: asthma, slow or heavy breathing.

Chronic alcohol abuse

Effects of chronic alcohol abuse include:

• Heart: high blood pressure, heart failure, irregular heart rhythm
• Haemostasis: clotting is impaired with reduced survival and aggregation of platelets and reduced thromboplastin
• Endocrine: low testosterone levels with loss of libido, testicular atrophy, impaired fertility and reduced facial hair, high oestrogen levels with gynaecomastia, change in fat distribution and loss of body hair
• Oesophagus: ulcer, varices, cancer
• Liver: hepatitis, cirrhosis, gall stones
• CNS: dementia, poor coordination, Wernicke Korsakoff syndrome (Vitamin B1 deficiency) associated with psychiatric and visual disturbances
• Immune system: direct toxic effect on bone marrow, reduced number and function of T-cells, reduced survival of immunoglobulins.

Vascular effects of alcohol

Facial redness

One of the earliest signs of alcohol abuse is a persistently red face due to enlarged blood vessels (telangiectasia). This appears because regulation of vascular control in the brain fails with sustained alcohol intake.

Flushing

Transient flushing is also a common side effect of alcohol, particularly in heavy drinkers. It is due to acetaldehyde, the main breakdown product of alcohol. Acetaldehyde is thought to cause flushing by stimulating release of histamine.

Up to 40% of northeastern Asians experience flushing and elevated heart rate after drinking even minimal amounts of alcohol, due to accumulation of acetaldehyde. This is because of a mutation in acetaldehyde dehydrogenase (ALDH2), the enzyme that converts acetaldehyde to acetate.

Vascular effects of alcohol

Facial redness

Telangiectasia

Flushing

Skin changes due to liver disease

Spider angiomas

Spider angiomas are given that name because of their appearance. Blood vessels (the spider legs) radiate out in all directions from a central blood vessel (its body). Like other blood vessels, spider angiomas blanch when pressure is applied. They may pulsate. They are most frequently found on the face, v of the neck, chest, arms, hands and abdomen.

Large numbers of spider angiomas are associated with liver cirrhosis (scarring of the liver) due to elevated oestrogen levels. A study of 82 patients with liver cirrhosis showed significantly higher numbers of spider angiomas in alcoholic cirrhotic patients than non-alcoholic cirrhotic patients, indicating there may be an additional effect such as vasodilation to account for this difference.

Small numbers of spider angiomas are seen in healthy children and adults. They are more common in women, especially during pregnancy, as they are influenced by the female hormone, oestrogen.

Palmar erythema

Chronic alcoholic liver disease may lead to reddening of palmar skin. This is also thought to be due to oestrogen, as it sometimes observed during normal pregnancy.

Caput medusa

High pressure within the venous system in the liver leads to high pressure in the venous system elsewhere in the body including the veins around the umbilicus (belly button). When these veins are dilated the appearance has been likened to ‘caput medusa’ (head of Medusa), referring to Greek mythology where a once beautiful woman was cursed and her hair turned into snakes.

Jaundice

The skin and sclera of the eyes often turn yellow in patients with alcoholic liver disease. The colour, known as jaundice, is due to bilirubin, a product broken down from haem derived from red blood cells. The metabolism of bilirubin is impaired in acute and chronic liver disease. Jaundice lessens as liver function improves.

Skin changes due to liver disease

Spider naevi

Palmar erythema

Jaundice

Hyperpigmentation

Skin darkening (hyperpigmentation) around the eyes, mouth and on the legs may be associated with chronic liver disease. The reason this occurs is unclear.

Generalised pruritus

Generalised skin itching (pruritus) may occur due to the build up of poorly metabolised substances that stimulate nerve endings in the skin. These substances may include bile salts, histamine, corticosteroids and opioids.

Nail changes

Nail changes associated, but not specific to alcohol-related liver disease include:

• Clubbing: the nail bulges out instead of dipping in slightly before it meets the skin at the root of the nail, resembling a club. The angle between the nail plate and proximal nail fold is called the Lovibond angle and is normally less than 180° (indicating a dip and rise where the nail and skin meet).
• Koilonychia: the opposite of nail clubbing. Instead of bulging out, the nail plate is flat or sunken in (concave or spoon-shaped). This finding is often related to iron deficiency.
• Terry nails: two-thirds of the nail is white and the last 2mm is pink. This may be due to reduced capillary blood flow in the nail bed.
• Muehrcke nails: white bands running parallel to the lunula (moon of the nail) with normal pink nail between the bands. This sign may be due to low protein in the blood (hypoalbuminemia).
• Red lunula: change in colour of the moon of the nail to red, possibly due to increased blood flow and vasodilation

Nail changes sometimes associated with liver disease

Clubbing

Koilonychia

Muehrcke nail

Porphyria cutanea tarda

Porphyria cutanea tarda (PCT) results in photosensitivity, skin fragility, blistering, erosions, crusts, milia, scleroderma and increased hair growth (hypertrichosis) on sun-exposed sites such as face and hands.

Alcohol is the most common cause of acquired or type 1 PCT in susceptible individuals and is associated with chronic liver disease. Porphyrins build up because of deficiency in uroporphyrinogen decarboxylase (UROD), an enzyme important in the sythesis of the blood protein haem.

Other factors that may trigger type 1 PCT include oestrogen, iron and viral infections (especially hepatitis C). Familial or type 2 PCT is due to genetic deficiency in UROD.

Porphyria cutanea tarda

Skin cancer

Along with increasing the risk of liver, pancreatic and breast cancer, alcohol increases the risk of skin cancer including squamous cell carcinoma, basal cell carcinoma, and melanoma. Alcohol is also associated with an increased risk of oral cancer.

The reasons why excessive alcohol consumption may cause cancer include:

• Alcohol suppresses the immune system and impairs adequate nutrition, reducing the body's natural defense against skin cancer.
• Its main metabolite, acetaldehyde, is a carcinogen (cancer causing chemical). Acetaldehyde produces reactive free radicals and damages DNA.
• The effects of ultraviolet radiation may be enhanced by photosensitising byproducts of alcohol.
• Alcohol abuse is associated in many people with tobacco smoking.

Skin cancers

Squamous cell carcinoma

Basal cell carcinoma

Oral squamous cell carcinoma

Nutritional deficiency

Nutritional deficiency can develop when alcohol replaces normal food in the diet and the digestive tract and liver do not digest and process food the way they should resulting in malabsorption. With little calorie or protein intake the skin becomes dry and loses elasticity.

Vitamins are essential to maintain healthy looking skin:

• Vitamin A deficiency results in xerosis (dry skin) and follicular hyperkeratosis (rough follicles).
• Vitamin B1 (thiamine) deficiency results in waxy skin and a red thickened tongue.
• Vitamin B2 (riboflavin) deficiency presents with angular cheilitis (cracked corners of the mouth), atrophic glossitis (inflamed tongue) and a rash on the face that resembles seborrhoeic dermatitis.
• Pellagra is a deficiency of niacin (vitamin B3) and presents with the three ‘d’s: diarrhoea; dementia and dermatitis on sun-exposed areas. Cheilitis and glossitis are also a feature.
• Vitamin C deficiency (scurvy) results in swollen gums, follicular hyperkeratosis and corkscrew hairs.
• Zinc deficiency causes a condition known as acquired acrodermatitis enteropathica with dermatitis around the mouth, hands, feet and anus.

Signs of vitamin deficiency

Dry skin

Follicular keratosis

Angular cheilitis

Oral changes due to chronic alcohol use

Changes found in the mouth often relate to nutritional deficiency or poor oral hygiene. These include:

• Dry lips (cheilitis)
• Inflamed swollen gums/gingiva (gingivitis)
• Tooth decay (caries)
• Beefy red smooth tongue associated with Vitamin B deficiency
• Black hairy tongue associated with overgrowth of bacteria

In addition, swelling of the parotid gland may be a result of chronic alcohol use.

Oral changes associated with chronic alcohol use

Black hairy tongue

Black hairy tongue

Parotid swelling

Skin conditions affected or caused by alcohol

All of these skin conditions may occur without any history of alcohol abuse.

Rosacea

Alcohol induces vasodilation and facial flushing in people who have rosacea. However, alcohol is not the cause of the skin disease in most people.

Although the classic ‘drinker's nose’ (rhinophyma) was thought to be related to excess alcohol consumption, it has never been proven. In a case-control study of 175 people with rosacea and 145 people with normal skin, there was no significant difference in alcohol consumption between the two groups.

Rosacea

Telangiectatic rosacea

Papulopustular rosacea

Rhinophyma

Psoriasis

High intake of alcohol is a risk factor for new onset of psoriasis. The distribution of psoriasis has been observed to be particularly prominent on the fingers and hands of heavy drinkers. People who have psoriasis and drink more than 80g of alcohol per week have been found to have more severe treatment-resistant psoriasis, including erythrodermic psoriasis. The reasons for the association may be relative immune suppression induced by alcohol and/or that it induces proinflammatory cytokines.

Heavy drinking reduces options for treatment of psoriasis, as some medicines are contraindicated if the drinking has led to liver disease (methotrexate) or to high levels of triglyceride (acitretin). Patients with psoriasis and high alcohol intake are also more likely to suffer from depression.

Psoriasis

Seborrhoeic dermatitis

Seborrhoeic dermatitis has been observed to be more frequent in heavy drinkers.

Seborrhoeic dermatitis

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Nummular dermatitis

Nummular or discoid dermatitis occurs more frequently in alcohol abusers, particularly in those with abnormal liver function tests.

Nummular dermatitis

Skin infections

Skin infections occur more frequently in patients who drink alcohol excessively due to impairment of the immune system, nutritional deficiency and increased trauma. These include:

Bacterial skin infections that may lead to septicaemia (spread to the blood):

• Group A and G streptococcus
• Staphylococcus aureus
• Corynebacteria resulting in erythrasma and pitted keratolysis

Fungal skin infectionsare common but rarely cause sepsis. They include:

• tinea infection
• onychomycosis
• pityriasis versicolor

Tuberculosis is also seen more frequently in alcoholics. Skin involvement is called cutaneous tuberculosis.

Skin infections sometimes associated with heavy alcohol use

Wound infection

Cellulitis

Widespread tinea corporis

Urticaria

Urticaria (hives) may occur within minutes to hours of drinking alcohol and is sometimes due to allergic reaction. Flushing and overheating after drinking alcohol may also indicate cholinergic urticaria. This is a physical type of urticaria is brought on my heat, exercise or stress.

Urticaria

Sensitivity to alcohol

Alcohol can give rise to allergic or allergy-like symptoms. Along with urticaria (see above), patients may develop low blood pressure, diarrhoea, shortness of breath and low heart rate (anaphylaxis). Even tiny amounts of alcohol may induce urticaria in people who have had a severe reaction previously, although allergy testing is often negative.

Some apparent allergic reactions to alcohol are due to inherited defects in alcohol metabolising enzymes or allergy to other contents of the drink such as colouring agents, preservatives or flavouring.

Draft 25 September 2011.