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					Dermatologic Signs in
Anorexia Nervosa and Bulimia Nervosa
Madhulika A.    Gupta, MD, FRCP(C); Aditya K. Gupta, MD; Herbert             F.   Haberman, MD, FRCP(C)

   \s=b\ The dermatologic changes in anorexia nervosa and           the severity of their symptoms,1 even in the face of
bulimia nervosa may be the first signs to give the clinician        serious medical complications and severe psychopa-
a clue that an eating disorder is present, as many of these         thology such as suicidal intent. A significant number
patients either deny their symptoms or secretly refuse to           of patients with bulimia nervosa may have body
comply with treatment. The dermatologic signs are a                 weights that are normal or above the normal range;
result of (1) starvation or malnutrition, eg, lanugolike            hence only a strong index of suspicion will lead to the
body hair, asteatotic skin, brittle hair and nails, and             diagnosis of this disorder.
carotenodermia; (2) self-induced vomiting, eg, hand cal-               According to some studies, the incidence of
luses, dental enamel erosion, gingivitis, and a Sj\l=o"\grenlike    anorexia nervosa appears to have doubled over the
syndrome; (3) use of laxatives, diuretics, or emetics and           past two decades3; however, this may reflect an
their dermatologic side effects; and (4) other concomi-             increased awareness and reporting of this disorder
tant psychiatric illness, eg, hand dermatitis from compul-          rather than a true increase in incidence.1 Annual
sive handwashing. Further, as most of the cutaneous                 mortalities in anorexia nervosa range from 0.3% to
signs are not specific to anorexia nervosa and bulimia              1.6% in various studies.4 Studies that have reported
nervosa, failure to include eating disorders in the differ-         significantly higher raw mortalities5 are usually
ential diagnosis may lead to misdiagnosis of the cutane-            based on patient populations with more intractable
ous symptoms.                                                       disease and poorer long-term prognosis.6 About 5%
  (Arch Dermatol 1987;123:1386-1390)                                of patients with anorexia nervosa die of suicide14 and
                                                                    approximately 1% of medical complications of star¬
                                                                    vation.4 In bulimia nervosa, death may result from
  Anorexia nervosa and bulimia nervosa are eating                   suicide or acute complications resulting from purg¬
 *"* disorders associated with potentially serious
medical complications12 and psychiatric morbidity.                  ing,   eg,    hypokalemia.17
                                                                       An   awareness  of the dermatologie associations of
They may both present with dermatologie signs. The                  these disorders837 (Table 1), which the patient typi¬
American College of Physicians recently emphasized                  cally cannot hide or deny, is important as they may
that physicians need to become more familiar with                   first give the clinician a clue that an eating disorder
eating disorders, especially since many of these                    is present. This may further minimize unnecessary
patients appear to be healthy on initial examination.2              dermatologie investigations and misdiagnosis of the
They frequently either deny their illness or minimize               cutaneous       symptoms.
                                                                       The core psychopathologic features of both
  Accepted for publication May 21, 1987.                            anorexia nervosa and bulimia nervosa is a fear of
  From the Departments of Psychiatry (Dr M. Gupta) and
Dermatology (Dr A. Gupta), University of Michigan, Ann Arbor;       fatness and related pursuit of thinness.38 In both
and the Departments of Psychiatry (Psychodermatology Clinic)        syndromes the patients present with an intense
(Dr M. Gupta) and Dermatology (Dr Haberman), Toronto West-          preoccupation with food.1 In bulimia nervosa there is
ern Hospital, University of Toronto.
                                                                    a mild to marked fluctuation in body weight, while
  Reprint requests to Department of Psychiatry, University of
Michigan Hospitals, Box 0704, 1500 E Medical Center Dr, Ann         anorexia nervosa is associated with severe weight
Arbor, MI 48109-0704 (Dr M. Gupta).                                 loss.1 Anorexia nervosa is frequently associated with




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                                                                       nervosa and bulimia nervosa (Table 1) usually result
  Table   1.—Dermatologie Associations of Anorexia Nervosa             from four major features of these disorders: (1)
               (AN) and Bulimia Nervosa (BN)                           starvation, idiosyncratic eating habits, and/or mal¬
   Complications Associated With Starvation, Idiosyncratic             nutrition, typically present in anorexia nervosa; (2)
      Eating Habits, and/or Malnutrition                               self-induced vomiting, encountered in anorexia ner¬
   Increased lanugolike body hair89 in 29% of cases9 of AN             vosa and bulimia nervosa; (3) abuse of laxatives,
   Excessive loss of subcutaneous fat in AN10
   Pedal or pretibial pitting edema without                            diuretics, and emetics in an attempt to lose weight,
     hypoproteinemia9,11,12 in 26% of cases of AN11                    encountered in both anorexia nervosa and bulimia
   Dry skin with fine asteatotic scales in 24% cases of AN11           nervosa; and (4) other psychiatric illness that may be
   Brittle hair and nails frequently present in AN in association      associated with the eating disorders.
     with hypothyroid state due to starvation9
   Hypercarotenemia in 72% cases of AN,13 occasionally with                       COMPLICATIONS ASSOCIATED WITH
     frank carotenodermia9'13-14; may be present in BN
     associated with weight loss15
                                                                            STARVATION, IDIOSYNCRATIC EATING HABITS,
   Case report of pellagra in AN due to deficient intake of                           AND/OR MALNUTRITION
     niacin16                                                             The increased lanugolike body hair on the back,
   Case report of scurvy in AN due to severely deficient intake
     of vitamin C17                                                    arms,  legs, and sides of the face89 in patients with
   Petechiae and purpura in association with hypoplastic bone          anorexia nervosa is not a sign of virilization. On the
     marrow and thrombocytopenia11 in AN                               contrary, anorexia nervosa has been associated with
   Complications Associated With Self-Induced Vomiting                 decreased activity of the 5a-reductase enzyme sys¬
   Single or multiple calluses on dorsum of hand18"21 usually
     reported in BN; may be also seen with repetitive
                                                                       tem,41 which converts testosterone to androsterone
     self-induced vomiting in AN                                       and dihydrotestosterone. This leads to decreased
   Dental enamel erosion and gingivitis in AN or BN22                  levels of dihydrotestosterone, the physiologically
   Benign, usually bilateral, painless parotid gland                   active androgen, and a relative increase in etiochola-
     enlargement23'25 mimicking Sjögren's syndrome23 or                nolone, a weaker androgen that is the product of
     sarcoidosis,25 usually reported in BN; may be seen with
     repetitive vomiting in AN                                         5/3-reductase activity.41 The lowered activity of the
   Case report of subcutaneous emphysema and spontaneous               5a-reductase activity may be due to the apparent
     pneumomediastinum in AN26                                         hypothyroid state associated with anorexia nervo¬
   Transient facial purpura from increased intrathoracic               sa.41 Furthermore, the scalp hair may be shed in
     pressure associated with vomiting27; may be present in AN         anorexia nervosa, which tends to emphasize the
     or BN.
   Case report of vitamin K deficiency with coagulopathy and           presence of facial hair that may be confused with
     bruising in BN28; possibly secondary to decreased                 hirsutism.
     absorption of fat-soluble vitamins as a result of bile salt          Dry, scaly skin"1 is observed in anorexia nervosa
     deficiency associated with vomiting and purging                   in association with cold intolerance, decreased skin
   Complications Associated With Drugs Consumed to Lose                and core body temperature,11 brittle hair and nails,9
     Weight
   Fixed drug eruption, eg, with phenolphthalein-containing            and hypercholesterolemia.42 This may be due to the
     laxatives                                                         hypothyroid state observed in anorexia nervosa,
   Photosensitivity with thiazide diuretics                            which appears to result from a primary hypothalam-
   Case report of dermatomyositislike syndrome, secondary to           ic dysfunctional state as manifested by a delayed
     ipecac,29 associated with myopathy29,30
   Other drug-related dermatoses, depending on drug consumed           thyrotropin response to protirelin943 or from a defect
   Finger clubbing associated with laxative abuse31,32                 in the peripheral conversion of thyroxine to triiodo-
   Complications Associated With Concomitant Psychiatric
     Illness
                                                                       thyronine, with increased conversion to the inactive
                                                                       isomer reverse triiodothyronine.44 The hypothyroid-
   Self-inflicted dermatoses in AN,33 eg, dermatitis artefacta,
     acne excoriée
                                                                       ism most likely represents a compensatory response
   Hand dermatitis from repetitive hand washing in AN10,34             to the starved, hypercatabolic state, since the thyroid
   Case of trichotillomania in BN35                                    function normalizes with weight gain.
   Complaints of skin conditions, eg, acne associated with               In a study involving anorexics and controls with
     multiple food "allergies" in atypical forms of AN36               similar core body temperature and normal thyroid
   "Dermatologie nondisease"37 or dermatologie complaints in
     absence of physical disease, secondary to distorted body          function, the skin temperature required to evoke
     image                                                             maximal subjective pleasantness was significantly
                                                                       higher among the anorexics.45 Thermal sweating is
                                                                       observed to occur at lower core and skin tempera¬
bulimia nervosa.10 Both disorders involve attempts at                  tures in patients with anorexia nervosa than in
weight control to gain a sense of personal control and                 controls.46 It has been proposed that some anorexics
effectiveness.7 A large number of these patients                       have a central thermoregulatory disorder, which is
suffer from a perceptual distortion in that they                       another feature of their hypothalamic dysfunc¬
overestimate their body size and underestimate their                   tion.45-46
nutritional requirements.7 In both disorders the                           Hypercarotenemia often differentiates anorexia
patient may attempt to lose weight by vomiting or                      nervosa from other forms of malnutrition and
abusing laxatives, diuretics, emetics, or "diet                        weight loss.9 In comparison with patients with
pills."110 The two syndromes have some distinct clin¬                  cachexia from other causes, who show decreased
ical features, which are summarized in Table                           mean serum levels of /3-carotene and retinyl esters,
2 iA6j,io,39,4o The dermatologie complications of anorexia             anorexics have significantly increased levels of




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                       Table 2.—Clinical and       Epidemiologie Features          of Anorexia Nervosa and Bulimia Nervosa

                    Feature                                   Anorexia Nervosa                                    Bulimia Nervosa
  Prevalence                                   0.2% in F   >16 y39; 1%-3% in high                      8%-19% in F and 6% in M from
                                                  socioeconomic groups39 at higher risk                  self-reportson questionnaires39; 1%-3%
                                                                                                         in F and 0.3% in M using strict clinical
                                                                                                         diagnostic criteria6,39
 Sex                                           90%-95% F1,39                                           96%-98%      F1,39
 Mean age at onset                             Peaks at 14 and 18      y1,39                           18 y'
 Weight loss                                   Loss of 2:15% of      original body   weight10,40       Frequent body weight fluctuations of
                                                                                                         >4.5 kg; patient may be of normal
                                                                                                         weight or overweight
 Disturbed eating behavior                     Weight loss by food restriction because patient         Loss of control of eating, with fear of not
                                                  fears loss of control   over   eating7,10              being able to stop eating voluntarily7,10
                                               Disproportionate decrease in high carbohydrate-         Recurrent episodes of binge eating, with
                                                 and fat-containing foods                                binges frequently consisting of
                                                                                                         high-energy, easily ingestible foods10
                                               Most   patient deny   disorder and resist               Patients usually hide disorder but
                                                  treatment10                                            acknowledge that eating pattern is
                                                                                                         abnormal and experience
                                                                                                         self-deprecating thoughts after binges10
                                               Weight loss    may be accomplished by                   Binge frequently terminated by self-induced
                                                  self-induced vomiting, use of laxatives or             vomiting10;    may use      laxatives, diuretics,
                                                  diuretics, and excessive exercising10                  or   emetics10
  Associated   psychopathologic   features      Patients usually deny or report less subjective        Patients report      more   psychological distress
                                                  psychological distress
                                                History of having been "model" children10              More histrionic features in personality7
                                                Perfectionistic and immature personality traits7       Often undue concern about physical
                                                                                                         appearance and sexual attractiveness
                                               Compulsive    behaviors such as       repetitive hand   Problems with impulse control, eg, alcohol
                                                  washing10                                              and drug abuse, stealing
  Clinical course                               Mild episodes may be self-limited and not              Many    cases   probably short-lived, lasting
                                                  receive medical attention                              <6    mo
                                                5-y relapse rate of 23%, with 25%-30% of               Clinical   course    variable4
                                                  patients remaining chronically ill4
                                                Frequent conversion to bulimia nervosa4,10             May occasionally       convert to food-restrictive
                                                                                                         anorexia nervosa 4,10




serum   /3-carotene, retinyl esters, retinol, and retinoic                        of an eating disorder.50 Neurofibromatosis has been
acid.14 This        finding in anorexia          nervosa        may be            reported to be exacerbated as a result of the endo¬
secondary to increased carotene and vitamin A                                     crine changes that accompany anorexia nervosa.51
intake by the patients, in the form of carrots and
other low-energy yellow vegetables, or an acquired                                             COMPLICATIONS ASSOCIATED WITH
defect in the metabolism or utilization of vitamin A.14                                            SELF-INDUCED VOMITING
The relationship, if any, of hypercarotenemia to the
abnormalities of lipid metabolism or hypothyroid-                                    Single or multiple calluses or abrasions on the
                                                                                  dorsum of the hand18 21 may occur as a result of the
ism observed in anorexia nervosa is not clear.14                                  friction of the fingers against the teeth during
   Malnutrition in general may result in cutaneous                                induction of vomiting by manual stimulation of the
anergy, which reverses after the patients have                                    gag reflex. This is also referred to as Russell's sign.
received nutritional support.47 It is possible that
                                                                                  Benign parotid enlargement is associated with an
delayed cutaneous hypersensitivity test results may                               elevation in serum amylase levels in the absence of
be negative in some malnourished patients with
                                                                                  pancreatitis25 and hypokalemic alkalosis secondary
eating disorders. There have been case reports of                                 to   vomiting.
increased susceptibility to infections, such as herpes
simplex encephalitis,48 in anorexia nervosa. However,                                      COMPLICATIONS ASSOCIATED WITH DRUGS
there also have been reports of enhanced humoral                                                CONSUMED TO LOSE WEIGHT
immunity and normal cell-mediated immunity in
anorexia nervosa.49 The dermatologist must be aware                                  Patients with bulimia nervosa and anorexia nervo¬
that eating disorders can be associated with nonspe¬                              sa   frequently consume laxatives, emetics, "diet
cific changes in immune function.                                                 pills," and diuretics surreptitiously, and only suspi¬
   In a case report, an association was made between                              cion and careful inquiry on the part of the clinician
anorexia nervosa and oculocutaneous albinism of the                               will disclose a history of their use. A wide range of
yellow mutant type, a disorder associated with obesi¬                             drugs may be consumed. Phenolphthalein-containing
ty.50 The predisposition to develop obesity may lead                              laxatives are frequently abused because their stimu¬
to an increased incidence of restrictive dietary pat¬                             lant properties rapidly relieve the abdominal bloat¬
terns and predispose these patients to development                                ing associated with eating disorders.




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           COMPLICATIONS ASSOCIATED WITH
         CONCOMITANT PSYCHIATRIC DISORDERS
                                                                          attending school even after her eating disorder was
                                                                          under control, attributing this primarily to the mod¬
   The psychiatric determinants of eating disorders                       erate disfigurement resulting from the scarred, self-
are  heterogeneous and multifactorial.52 In many                          inflicted lesions on her face. Her acne excoriée and
patients, attempts at weight control and the resul¬                       bulimia nervosa would typically be exacerbated
tant eating disorder indicate an attempt to gain a                        when she was faced with a significant task, eg, going
sense of effectiveness in the face of developmental                       for a job interview, and she would defer the task.
and maturational tasks of adolescence and young                              Anorexia nervosa has also been associated with
adulthood,752 such as choice of career, separation                        obsessive-compulsive symptoms,1034 and bulimia ner¬
from the family, and assumption of an independent                         vosa is sometimes a repetitive, compulsive phenome¬
adult role. These patients often demonstrate vulner¬                      non. We observed an obese, 19-year-old woman with
abilities of personality and immature coping mecha¬                       trichotillomania who also developed bulimia nervo¬
nisms, sometimes in association with abnormalities                        sa. The bulimia nervosa and trichotillomania devel¬
in the family dynamics. Anorexia nervosa and the                          oped when she felt rejected in a romantic relation¬
subsequent development of the "sick role" may                             ship and attempted to lose weight (M.A.G., H.F.H.,
enable the patient to avoid these developmental                           unpublished data, 1986). A recent report36 suggested
tasks. Sometimes anorexia nervosa becomes the                             that patients refusing to eat various foods because
focus of the family's concern and their main reason                       they claim to have multiple food allergies that
for staying together. Sneddon and Sneddon33 fol¬                          cannot be objectively confirmed may also have an
lowed up a cohort of patients with dermatitis arte-                       underlying eating disorder. Some of these patients
facta for 22 years and observed that 5% of these                          may see a dermatologist for a skin condition, such as
individuals also developed anorexia nervosa. Self-                        acne, that they attribute to their food "allergies."36
inflicted dermatoses sometimes occur in patients                          Patients presenting with dermatologie complaints
with immature and inadequate coping mechanisms                            where there is minimal or no physical basis for the
in the face of a difficult life situation.3335 Since some                 complaint frequently have a disturbed body image.37
patients with eating disorders demonstrate imma¬                          Suspicion of an underlying eating disorder may be
ture defense mechanisms, they may be predisposed                          justified in these patients, as their disturbed body
to developing self-inflicted dermatoses when faced                        image may be further associated with concerns about
with a crisis. We observed a 20-year-old woman with                       body weight and also predispose them to develop¬
immature personality traits who had a four-year                           ment of an eating disorder.
history of severe acne excoriée and anorexia nervosa
with bulimia nervosa, which first started when she
had trouble coping with the social and academic                             We thank J. E. Rasmussen,    MD, and C. N. Ellis, MD, Depart¬
                                                                          ment of  Dermatology, University of Michigan, Ann Arbor, for
pressures in high school (M.A.G., H.F.H., unpub¬                          their help and J. B. Kopstein, MD, Department of Dermatology,
lished data, 1986). She withdrew socially and stopped                     Windsor (Ontario) Western Hospital, for his clinical comments.

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                                                       In Other AMA Journals

                        AMERICAN JOURNAL OF DISEASES OF CHILDREN (AJDC)
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                           E. Kanta   Subbarao, MBBS; Martha M. Tarpay, MD; Melvin I. Marks, MD (AJDC
                           1987;141:1018-1020)




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