My dear patients !
And why not continue with the extraintestinal manifestations of the skin ?
Also the skin and the mucosa (the oral mucosa to be more precise) can be affected from inflammation in case of inflammatory bowel disease, Crohn`s disease or ulcerative colitis. The pathomechanisms of EIM (extraintestinal manifestation)of the skin are supposed to be very similar to the ones in other extraintestinal manifestations with affection of the joints, the eyes or the bile duct system.
Certain features on the surface of the skin-cells are recognized similar to features on the intestinal mucosal cells by the immune system. And they make the immune system react in a certain way, which is initiating inflammation – same as in the intestine.
Micro particles, described widely as antigens, from the intestinal lumen also seem to play a certain role by migrating into the blood circulation and into another organ ( – the skin). And there they also get recognized by the cells of the immune system. And even though the antigens are not in the designated enviroment of the intestine – the immune system reacts in the same way – by initiating inflammation.
And even though there is some proof for the described mechanisms above, we still don`t know exactly, how this works. But again it is the immune system and the basic principle: too much inflammation. And to say it right away: that is important when thinking about the therapy. Zinc ointment, arnica ointment or “healing” ointment won`t work for the kind of inflammation you deal with in case of EIM of the skin. It needs a special anti-inflammatory therapy, that suppresses inflammation (same principle as in the gut).
Skin manifestations in case of IBD, inflammatory bowel disease, Crohn`s disease or ulcerative colitis also have a genetical component. Which means there needs to be a certain genetic constellation for developing EIM of the skin. People who develop an extraintestinal manifestation (EIM) of the skin are more likely to have other EIM, for example of the joints and the other way around.
And there is a clear positive correlation to smoking.
Smoking….
Do you know what ? Actually I feel convinced: whoever reads this blog – at least on a regular basis – is a non-smoker ! Does not smoke. Because the whole I.M. information-matters idea is about knowing what is going on with your condition, your inflammatory bowel disease, may it be Crohn`s disease or ulcerative colitis. In order to be able to take individual responsibility and not exclusively depend on information your doctor shares (or doesn`t share) and decisions your doctor makes (in the worst case without even discussing different opportunities with you).
Smoking for me by the way is the exact opposite of individual responsibility.
Skin manifestations are more common in Crohn`s disease than in ulcerative colitis. They are more frequent than affection of the eyes but less frequent than affection of the bile duct system the PSC.
Up to 15% of patient with inflammatory bowel disease, IBD, Crohn`s disease or ulcerative colitis are supposed to develop EIM (extraintestinal manifestation) of the skin.
And regarding the broader issue of skin affections in case of IBD another important thing is (and some of you might have made experience on that) that some of the therapies, the medication you receive for Crohn`s disease or ulcerative colitis can cause affections of the skin as well. TNF alpha antiboy therapies for example can cause skin affections – not that seldom.
(And just to mention it peripherally: it was not that easy to choose a picture for this article. Illustrating this blog by myself – you go ahead and try to draw or sketch “skin” !
In general: when you have an IBD, inflammatory bowel disease, Crohn`s disease or ulcerative colitis and recognize skin lesions – go see a specialist (dermatologist) right away or at least let any doctor know or even better have a look at it.
I wrote it above, it is a certain inflammation, that causes the skin lesions and it needs a certain therapie. (no zinc ointment, not any healing ointment, no arnica ointment either. You have recognized by now, this point is important).
And as I also mentioned earlier: skin lesions can have all kinds of reasons. Wether they develop due to the inflammatory bowel disease or due to the therapy does of course make a difference. And it`s sometimes not that easy to discriminate.
And there is acutally a not so small chance that these lesions in case of extraintestinal manifestation (EIM) of the skin stay unrecognized for a longer time. In the sense of “not noticed”, in the sense of “unseen”.
Not from you of course ! You as a patient are the first to notice and recognize everything. Always.
Some of these extraintestinal manifestations (EIM) of the skin lead to changes, that will make you consulat a doctor rather sooner than later since it is obvious that something needs to be done.
But in case of certain, in the beginning rather small lesions you might think: “Well let`s wait how this will evolve. It might improve on its own “. And than nobody sees it except you and maybe your partner.
As a matters of fact some of the extraintestinal manifestations of the skin are localized in areas of the body, that may very well be covered by clothing most of the time. Armpits, groin area, the butt, at the shin. At the trunk of the body, the back, the belly (which you not even as a gastroenterologist look at in every consultation hour).
And some of these EIM of the skin won`t even lead to a major impairment, except a sort of cosmetic impairment.
Extraintestinal manifestations (EIM) of the skin won`t heal of by themselves. Zinc ointment, any kind of “healing ointment” won`t help either. arnica ointment as well. (…did I mention that already ?) Erythema nodosum may be the only exception. With regard to: heal of by themselves, not with regard to treatment response to zinc ointment, healing ointment and arnica ointment.
The erythema nodosum is describing one or more red to blue or livid discolored lumps, mostly localized at the shin. In the occurence it shows a correlation to the activity of the IBD, which means – they respond to the therapy of the intestine in case of Crohn`s or colitis activity.
Which again means: it doesn`t actually heal of by itself, it needs therapy – of the intestinal inflammation.
What are the extraintestinal manifestaions, the EIM of the skin anyway ? (which won`t get better on zinc ointment, healing ointment and arnica ointment). How do you recognize extraintestinal manifestations (EIM) of the skin ? (except you recognize that they don´t respond to zinc ointment, healing ointment or arnica ointment)
I already mentioned one EIM of the skin, the erythema nodosum. Livid knots at the shin, sometimes painfull, They do not hurt a lot though and are probably the less damaging of the EIM of the skin. Also because they have the tendency to heal of – as metiones above – when the activity of the intestinal inflammation is decreasing.
Another important extraintestinal manifestation of the skin is the pyoderma gangraenosum. And that one belongs to a complete different category. To be more precise to the category of skin lesions, that really need to be treated quickly, since the skin lesions worsen rapidly and can really lead to large ulcers. In the beginning it starts with maybe rather small secreting wounds or ulcers, which turn bigger very quickly. They can develop from small lesions at any site of the body also the site of an ileostoma. The pyoderma gangraenosum needs a specialist and it needs special therapy right away. Again the heavy inflammation is the problem, the therapy needs strong and effective enhancement of inflammation, it needs immunospppresssion, often the therapy you receive for IBD must be intensified. Whoever is confronted with pyoderma gangraenosum understands very quickly, that it is not just a “bad healing wound”.
Psoriasis is another EIM of te skin. It is manifesting with scaly skin on generally reddened skin areas on the head, the feet, the hands, pretty much every part of the body can be affected. Psoriasis can occur as an extraintestinal manifestation EIM of the skin on the one side. But on the other side (and that is probably even more frequent from my experience) it can be a side effect from biological therapy, namely TNF alpha antibody therapy. Psoriasis also needs to be assessed by your gastroenterologist and a dermatologist. It needs special therapy, sometimes irradiation of the affected skin regions.
Another EIM of the skin is the acne inversa (or hidradenitis suppurativa). As the name suggests, acneiforme lesions of the skin, not in the face but mostly in the armpits, the groin area and the gluteal region (buttom). These are exactly the skin manifestations nobody sees except you allow somebody to see it. And these are lesions that won`t approve by themselves either and espscially won`t improve when you are manipulating on it yourself. In case of acne inversa large abcesses can develop out of small abscesses or build tunnel-like connections beneath the skin surface with eachother. And there are treatment options. So if you recognize abscesses or boils in the mentioned areas of your body – even when it feels uncomfortable to talk about it, please do not wait for weeks and months but go see to your doctor instead. The earlier an adequate therapy is started the better for you.
Not only the skin but also the oral mucosa can be involved. Mostly small vesicals, that erupt, it is called vesicular stomatitis. Finidings of the oral mucosa are also hard to detect for a doctor. So in case you recognize something, let your doctor know, so that she or he can have a look and decide what to do. And another thing is, that the described lesions might be extraintestinal manifestations (EIM) of the oral mucosa, but at the same time it is possible, that in case of Crohn`s disease the lesions represents an oral manifestation of Crohn`s disease. In any case there is a need for therapy.
So I hope I was able to explain that inflammation of the intestine can also take over parts of the skin. And I hope that it is clear, that lesions of the skin in case of IBD are not just “something”, that will heal of and dissapear by itself.
It does need a specialist (dermatologist) and needs special therapy, either topic application of certain antiinflammatory medication or even systemic therapy. It does not need zinc ointment, healing ointment, arnica ointment, (even when that worked very well for a friend or your neighbor)
And I do like to stress the influence of nutrition, stress or better: ways to deal with stress here. I do that since there is proof, that these factors stabilize your IBD,wether it is Crohn`s disease or ulcerative colitis. But what about the influence of these factors in case of extraintestinal manifestation (EIM) of the skin ?
There is not a lot of concrete resaearch to that, as a matter of fact I didn`t find any at all. But the one lifestyle factor that is mentioned everywhere and that is known to increase the risk for developing EIM of the skin: smoking,
What you can and should do – always by the way – is: DO NOT smoke ! Smoking really is the one factor that seems to increase the likelyhood that you develop EIM of the skin.
I wrote above, that I think the INFORMATION MATTERS blog is a nonsmoker blog.
And with that take care everybody and best regards,
yours,
Dr. Susanne Weyrauch
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