Cutaneous manifestations of cardiovascular disease

Central cyanosis is one of the important manifestations to look for in congenital heart disease. Central cyanosis means cyanosis of skin and mucous membranes. If the bluish discoloration is seen only in the lower part of the body and not in the upper part, it is known as differential cyanosis. That can occur in patent ductus arteriosus with reversal of shunt due to to pulmonary hypertension. As the right to left shunt in PDA Eisenmenger reaches the lower part of the body selectively, upper limbs and tongue will not be cyanosed. The opposite pattern known as reverse differential cyanosis can occur in certain complex congenital heart diseases. Cyanosis is usually associated with clubbing of fingers or toes or both. Peripheral cyanosis can occur when the circulation is sluggish as in congestive heart failure.

Telangiectasia of lips, tongue and mucous membranes can occur in Rendu-Weber-Osler syndrome. Telangiectasia can cause bleeding from the involved sites. When present in the lungs, it can cause right to left shunting of blood and central cyanosis. Iron overload in hemochromatosis can cause a tanned or bronze skin. Hemochromatosis can cause cardiomyopathy, heart failure and complete heart block.

Ecchymoses can be a manifestation of infective endocarditis or vasculitis. But it is more likely to be due to antiplatelet agents or anticoagulants taken for various cardiovascular conditions. Of course, other causes should be considered and ruled out before attributing ecchymoses solely to medications. Xanthomas are an important indication of lipid disorders. Subcutaneous nodules of rheumatic fever is now a rarity, with decreasing prevalence of rheumatic fever. ‘Plucked chicken appearance’ of skin, especially over the neck, is characteristic of pseudoxanthoma elasticum, a connective tissue disorder. It can be associated with premature atherosclerosis involving coronary, renal and peripheral arteries, which could be associated with arterial calcification.

Multiple lentigines which are freckle like brown spots can be associated with familial myxomas and other cardiovascular syndromes like LAMB, LEOPARD and Carney’s complex. Erythema marginatum seen on the trunk in acute rheumatic fever is difficult to appreciate in dark skinned individuals. Moreover, it is extremely uncommon with decreased prevalence of rheumatic fever. Erythema nodosum may be noted in association with cardiac sarcoidosis. Pulsating collateral arteries in the back may be felt in coarctation of aorta.