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
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
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
thyronine, with increased conversion to the inactive
isomer reverse triiodothyronine.44 The hypothyroid-
Self-inflicted dermatoses in AN,33 eg, dermatitis artefacta,
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
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
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)
Soft-Tissue Infections Caused by Mycobacterium fortuitum Complex Following
E. Kanta Subbarao, MBBS; Martha M. Tarpay, MD; Melvin I. Marks, MD (AJDC
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