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Original article  27

Prevalence of cutaneous manifestations in chronic renal failure

patients on regular hemodialysis: a hospital-based study
Eman M. Sanada, Neveen E. Soroura, Wael M. Saudib, Afaf M. Elmasryc
a
Dermatology and Venereology Department,
Faculty of Medicine, Benha University, Benha,
b
Department of Dermatology and Venereology,
Misr University for Science and Technology, 6th
October city, cEl Mahalla Elkobra town, Egypt
Correspondence to Neveen E. Sorour, MD,
Dermatology and Venereology Department,
Faculty of Medicine, Benha University,
Benha, Egypt
Tel: 01229002044;
e-mail: neveensorour@yahoo.com
Received 1 March 2014
Accepted 16 March 2014
Egyptian Journal of Dermatology and
Venereology 2014, 34:27–35
Background
Chronic renal failure (CRF) presents with an array of cutaneous manifestations. Newer changes
are being described since the advent of hemodialysis (HD), which prolongs life expectancy,
providing time for these changes to manifest.
Objective
The aim of this study was to estimate the prevalence and pattern of cutaneous manifestations
among patients with CRF on regular HD.
Patients and methods
This case-series study included 100 patients with CRF on regular HD. They were subjected
to a full assessment of history, and general and dermatological examinations of the skin, hair,
nails, and oral mucosa.
Results
All patients included in this study had at least one cutaneous manifestation attributed
to CRF. The most prevalent finding was xerosis (72%), followed by pruritus (52%) and
hyperpigmentation (44%), whereas purpura (2%) and bullous dermatosis (1%) were the least
detected. Oral changes included xerostomia (46%), macroglossia with teeth markings (43%),
fissured tongue (17%), ulcerative stomatitis (11%), and angular cheilitis (6%). The most
common nail changes were absent lunula (61%), half and half nail (41%), and koilonychia
(29%). Hair changes included sparse scalp hair (48%), sparse body hair (41%), and brittle
and lusterless hair (39%). Hypertension and diabetes mellitus were the most common causes
of CRF (53 and 18%, respectively).
Conclusion
Every CRF patient on HD had at least one cutaneous manifestation, which may appear
before or after HD. The most common cutaneous manifestations were xerosis, pruritus,
hyperpigmentation, xerostomia, macroglossia, absent lunula, half and half nail, sparse scalp
hair, and sparse body hair.

Keywords:
chronic renal failure, cutaneous manifestations, hemodialysis

Egypt J Dermatol Venereol 34:27–35

© 2014 The Egyptian Society of Dermatology and Venereal Diseases
1110-6530

benign, a few rare skin diseases have the potential to

Introduction
Symptoms and signs in the skin and mucous membranes
can be supportive of the diagnosis of internal disease or
may even be a part of the initial presentation.Chronic renal
failure (CRF), irrespective of its cause, often produces
specific skin changes that can develop long before failure
manifests clinically [1]. It has been found that 50–100%
patients with end-stage renal disease have at least one
associated cutaneous change [2]. Hemodialysis (HD) is
one of the therapeutic modalities that can improve the
survival in these patients [3]. Skin changes can precede
or follow the initiation of HD treatment, and there are
more chances of developing newer skin changes during
the course of HD therapy [2]. Some of these cutaneous
disorders disappear following kidney transplantation,
confirming that the metabolic milieu resulting from the
malfunctioning kidney is responsible for some of these
changes [4]. Although the majority of dermatological
disorders in chronic kidney disease (CKD) are relatively
1110-6530 © 2014 The Egyptian Society of Dermatology and Venereal Diseases
cause serious morbidity and mortality. Early recognition
of these severe skin disorders and prompt initiation
of treatment can markedly alter their course and even
save a patient’s life [5]. The present study was designed
to analyze the prevalence and pattern of cutaneous
manifestations among patients with CRF on regular
HD and correlates their onset to HD.
Patients and methods
This case-series study included 100 patients with CRF
on regular HD. They were recruited from the HD center
of Benha University Hospital in the period from March
2011 to January 2012. Informed consent was obtained
from each patient after approval from research ethics
committee of the Faculty of Medicine in Benha University
before the study. Inclusion criteria included patients with
CRF on regular HD (three times weekly) with dialysis
DOI: 10.4103/1110-6530.137278
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28  Egyptian Journal of Dermatology and Venereology

duration of 5 months or more and age ranging from purpura in 2% of patients. Rare skin manifestations of
15 to 65 years. Exclusion criteria included patients who CRF such as bullous dermatosis (1%) (Fig. 3) were also
had undergone HD following renal transplant, patients observed. Xerostomia (46%) was the most common
who had undergone peritoneal dialysis, and patients with
other systemic or cutaneous diseases. All patients were Figure 1
subjected to a complete assessment of history, with a
special focus on the onset of cutaneous manifestations and
their relation to HD and the etiology of CRF. Thorough
general and dermatological examinations were performed
including skin, hair, nail, and oral mucosa. Photos of
lesions were taken using a Sony Cybershot 14.1 mega
pixels camera (Sony Corp. Japan). Blood samples were
obtained to investigate the complete blood count, fasting
and postprandial blood glucose levels, liver function tests
[serum glutamic pyruvic transaminase (SGPT) serum
glutamic oxaloacetic transaminase (SGOT)], and for
kidney function tests (serum urea and creatinine). Serum
urea and creatinine levels were compared with their before
dialysis levels (obtained from the patient’s files).
Xerosis.
Statistical analysis
The data collected were analyzed using the statistical
package for social sciences (version 16; SPSS Inc., Chicago, Figure 2
Illinois, USA). Quantitative data were analyzed using
mean and SD, whereas frequency and percentage were
used to describe qualitative data. The Z-test and c2-test
were used to compare frequencies. A P value of less than
0.05 was considered statistically significant and values less
than 0.001 were considered highly statistically significant.

Results
Among the patients, there were 66 male and 34 female.
Their age ranged from 15 to 65 years (mean ± SD
50.27 ± 11.23 years). The total duration of HD ranged
from 0.5 to 16 years (mean ± SD 5.64 ± 3.45 years). The
Kyrle’s disease.
blood urea level before HD ranged from 120 to 250 mg/dl
(mean ± SD 165.59 ± 30.22 mg/dl), which decreased to
40–120 mg/dl (mean ± SD 70.79 ± 21.97 mg/dl) during Figure 3
HD. The blood creatinine level before HD ranged from
6 to 16 mg/dl (mean ± SD 9.91 ± 2.11 mg/dl), which
decreased to 4–9 mg/dl (mean ± SD 5.45 ± 1.33 mg/dl).

All the patients showed at least one cutaneous

manifestation. The most common skin manifestation
was xerosis (72%), which was predominantly
observed over the extensor surfaces of the forearms,
legs, and thighs (Fig. 1), followed by pruritus (52%),
hyperpigmentation (44%), and pallor (34%). Other skin
manifestations were fungal infections (18%) [pityriasis
versicolor (PV) in 11.1%, tinea pedis in 88.8%], Kyrle’s
disease (7%) (Fig. 2), gynecomastia (7%), bacterial
infections in 6% of patients in the form of folliculitis,
viral infections in 4% of patients (disseminated plane
Bullous dermatosis.
warts in 50% of patients, common warts in 50%), and
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Cutaneous manifestations of CRF Sanad et al.  29

oral mucosal manifestation, followed by macroglossia
with teeth markings (43%) (Fig. 4), fissured tongue
(17%), uremic breath (17%), ulcerative stomatitis
(11%), and angular cheilitis (6%). The relation between
the onset of skin and oral mucosal manifestations with
HD showed that xerosis (65.3%), pruritus (69.2), and
pallor (91.2%) statistically significantly manifested
before HD (P = 0.006, 0.002, and <0.001, respectively),
whereas hyperpigmentation (86.4%), wrinkles (93.9%),
ecchymosis (90.6%), macroglossia (83.4%), fissured
tongue (94.1%), and ulcerative stomatitis (81.8%)
statistically significantly manifested after HD (P <
0.001 for all except ulcerative stomatitis, P = 0.006)
(Table 1). Nail changes were absent lunula (AL) (61%),
Figure 4
half and half nail (41%) (Fig. 5), koilonychia (29%),
splinter hemorrhages (15%), subungual hyperkeratosis
(12%), onycholysis (10%), onychomycosis (7%),
Muehrcke’s lines (7%) (Fig. 6), Mees’ lines (6%), and
Beau’s lines (1%) (Fig. 7). Hair manifestations included
sparse scalp hair (48%), sparse body hair (41%), and
brittle and lusterless hair (39%). The relation between
the onset of nail and hair manifestations with HD
showed that AL (96.7%) was the only manifestation
that statistically significantly manifested before HD (P
< 0.001), whereas half and half nail (95.1%), onycholysis
(90%), and Muehrcke’s lines (85.7%) statistically
significantly manifested after HD (P < 0.001, <0.001,
and 0.007, respectively) (Table 2).
Figure 5

Macroglossia and teeth markings. Half and half nails.

Table 1 Skin and oral mucosal manifestations and the relation between their onset and hemodialysis
Onset [n (%)]
Variables N Before HD After HD Z P
Skin
Xerosis 72 47 (65.3) 25 (34.7) 2.7 0.006*
Pruritus 52 36 (69.2) 16 (30.8) 3.0 0.002*
Hyperpigmentation 44 6 (13.6) 38 (86.4) 7.0 <0.001*
Pallor 34 31 (91.2) 3 (8.8) 10.1 <0.001*
Skin wrinkles 33 2 (6.1) 31 (93.9) 6.2 <0.001*
Ecchymosis 32 3 (9.4) 29 (90.6) 7.4 <0.001*
Fungal infection 18 9 (50.0) 9 (50.0) 0.0 1.0
Bacterial infection 6 3 (50.0) 3 (50.0) 0.0 1.0
Viral infection 4 2 (50.0) 2 (50.0) 0.0 1.0
Kyrle’s disease 7 2 (28.6) 5 (71.4) 1.3 0.21
Gynecomastia 7 4 (57.1) 3 (42.9) 0.38 0.7
Purpura 2 0 (0.0) 2 (100.0) – –
Bullous dermatosis 1 0 (0.0) 1 (100.0) – –
Oral mucosa
Xerostomia 46 29 (63.0) 17 (37.0) 1.83 0.07
Macroglossia with teeth marking 43 7 (16.3) 36 (83.7) 5.99 <0.001*
Fissured tongue 17 1 (5.9) 16 (94.1) 7.7 <0.001*
Ulcerative stomatitis 11 2 (18.2) 9 (81.8) 2.74 0.006*
Angular cheilitis 6 2 (33.3) 4 (66.7) 0.87 0.39
HD, hemodialysis; *P < 0.05 was considered statistically significant and P < 0.001 was considered statistically highly significant.
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30  Egyptian Journal of Dermatology and Venereology

Figure 6 Figure 7

Muehrcke’s lines. Beau’s line.

Table 2 Nail and hair manifestations and the relation between

their onset and hemodialysis which was in agreement with the results of Pico
Onset [n (%)] et al. [6] and Sultan et al. [7], whereas Bencini et al. [8]
Variables N Before HD After HD Z P observed cutaneous changes in 79% of patients of CRF
Nail on regular HD.
Absent lunula 61 59 (96.7) 2 (3.3) 20.5 <0.001*
Half and half nail 41 2 (4.9) 39 (95.1) 13.4 <0.001* In this study, xerosis was the most common cutaneous
Koilonychias 29 18 (62.1) 11 (37.9) 1.34 0.18 abnormality detected. Its prevalence was found in 72%
Splinter 15 4 (26.7) 11 (73.3) 2.05 0.04
hemorrhage
of the patients studied, which was in agreement with
Subungual 12 0 (0.0) 12 (100.0) – – Udayakumar et al. [2] and Falodun et al. [4], who reported
hyperkeratosis xerosis in 79 and 60% of CRF patients, respectively.
Onycholysis 10 1 (10.0) 9 (90.0) 4.2 <0.001* However, Hajheydari et al. [3] reported xerosis only
Muehrcke’s line 7 1 (14.3) 6 (85.7) 2.7 0.007* in 23% of Iranian patients and they attributed this to
Onychomycosis 7 2 (28.6) 5 (71.4) 1.26 0.2 geographic distribution. The onset of xerosis statistically
Mees’ line 6 0 (0.0) 6 (100.0) – –
significantly manifested before HD (65.3%).
Beau’s line 1 0 (0.0) 1 (100.0) – –
Hair
The possible etiological factors for xerosis include
Sparse scalp hair 48 26 (54.2) 22 (45.8) 0.58 0.57
atrophy of sebaceous glands as well as the secretory and
Sparse body hair 41 25 (61.0) 16 (39.0) 1.44 0.14
Brittle 39 25 (64.1) 14 (35.9) 1.84 0.06
ductal portions of the eccrine sweat glands, resulting
lusterless hair in lower levels of surface lipids of the skin. Loss of
HD, hemodialysis; P < 0.05 was considered statistically significant integrity of the water content in the stratum corneum
and *P < 0.001 was considered statistically highly significant. by skin barrier dysfunction may also be important in
the pathogenesis of xerosis [9].
The current study showed that hypertension and Pruritus is one of the most characteristic and annoying
diabetes mellitus were the most common causes of cutaneous symptoms of CRF. Its prevalence among HD
CRF (53 and 18%, respectively), followed by urinary patients ranges from 19 to 90% [10]. In this study, pruritus
tract obstruction (9%), postanalgesic renal failure (6%), was the second most common skin manifestation, found
unknown (5%), systemic lupus erythematosus (4%), in 52% of the patients studied. Pruritus statistically
urinary tract infection (3%), and polycystic kidney significantly manifested before HD (69.2%).
(2%). Skin and oral mucosal manifestations in relation
to the etiology of CRF are shown in Table 3, whereas The etiology of pruritus in CRF is unknown;
nail and hair manifestations are shown in Table 4. however, several hypotheses have been suggested.
Immunohypothesis considers uremic pruritus (UP) as
an inflammatory systemic disease rather than a local
skin disorder. This idea is supported by the beneficial
Discussion effects of ultraviolet B radiation exposure on UP, and
The results of the present study showed that all patients the amelioration of UP with thalidomide treatment
with CRF had one or more cutaneous manifestations, or calcineurin inhibitors such as tacrolimus [3]. The
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Cutaneous manifestations of CRF Sanad et al.  31

Table 3 Skin and oral mucosal manifestations and their relations to the etiology of chronic renal failure
Cause of CRF [n (%)]
Manifestations DM (18) HTN (53) PK (2) Analgesic (6) RUTI (3) SLE (4) Urinary tract Unknown (5) Total
obstruction (9) number (N)
Skin
Xerosis 13 (18) 34 (47.2) 2 (2.7) 6 (8.3) 2 (2.7) 4 (5.5) 9 (12.5) 2 (2.7) 72
Pruritus 14 (26.9) 22 (42.3) – 6 (11.5) 3 (5.7) 2 (3.8) 4 (7.6) 1 (1.9) 52
Hyperpigmentation 7 (15.9) 25 (56.8) 1 (2.2) 4 (9) 2 (4.5) 1 (2.3) 2 (4.5) 2 (4.5) 44
Pallor 3 (8.8) 18 (52.9) 2 (5.8) 1 (2.9) – 3 (8.8) 5 (14.7) 2 (5.8) 34
Skin wrinkle 5 (15.1) 16 (48.4) 1 (3) 2 (6) 2 (6) 2 (6) 3 (9) 2 (6) 33
Ecchymosis 5 (15.6) 13 (40.6) – 2 (6.2) 1 (3.1) 1 (3.1) 7 (21.8) 3 (9.3) 32
Fungal infections 8 (44.4) 5 (27.7) 1 (5.5) – – 2 (11.1) 1 (5.5) 1 (5.5) 18
Kyrel’s disease 5 (71.4) – – – – – 2 (28.5) – 7
Bacterial infections 2 (33.3) 1 (16.6) – 2 (33.3) 1 (16.6) – – – 6
Viral infections 2 (50) 2 (50) – – – – – – 4
Purpura 1 (50) 1 (50) – – – – – – 2
Bullous dermatosis – 1 (100) – – – – – – 1
Oral mucosa
Xerostomia 8 (17.3) 17 (36.9) 1 (2.1) 3 (6.5) 2 (4.3) 4 (8.6) 9 (19.5) 2 (4.3) 46
Macroglossia 7 (16.2) 25 (58.1) 1 (2.3) 4 (9.3) 3 (6.9) – 2 (4.6) 4 (9.3) 43
Fissured tongue 2 (11.7) 8 (47) 1 (5.8) 1 (5.8) – – 3 (17.6) 2 (11.7) 17
Ulcerative 1 (9) 6 (54.5) 1 (9) – – – 1 (9) 2 (18.1) 11
stomatitis
Angular cheilitis 2 (33.3) 2 (33.3) – 2 (33.3) – – – – 6
CRF, chronic renal failure; DM, diabetes mellitus; HTN, hypertension; PK, polycystic kidney; RUTI, recurrent urinary tract infections; SLE,
systemic lupus erythematosis.

Table 4 Nail and hair manifestations and their relations to the etiology of chronic renal failure
Cause of CRF
Manifestations DM (18) HTN (53) PK (2) Analgesic (6) RUTI (3) SLE (4) Obstruction (9) Unknown (5) Total number
Nail
Absent lunula 13 (21.3) 29 (47.5) 2 (3.2) 6 (9.8) 1 (1.6) 4 (6.5) 5 (8.1) 1 (1.6) 61
Half and half 8 (19.5) 20 (48.7) – 2 (4.8) 2 (4.8) 2 (4.8) 4 (9.7) 3 (7.3) 41
Koilonychia 6 (20.6) 8 (27.5) 2 (6.8) 2 (6.8) 2 (6.8) 3 (10.3) 6 (20.6) – 29
Splinter 2 (13.3) 9 (60) – 1 (6.6) 1 (6.6) – 2 (13.3) – 15
hemorrhage
Subungual 1 (8.3) 5 (41.6) 1 (8.3) – – – 3 (25) 2 (16.6) 12
hyperkeratosis
Onycholysis 1 (10) 5 (50) – 2 (20) – – 2 (20) – 10
Muehrcke’s line 4 (57.1) 1 (14.2) 1 (14.2) – – – 1 (14.2) – 7
Onychomycosis 2 (28.5) 3 (42.8) – – – – 1 (14.2) 1 (14.2) 7
Beau’s line – 1 (100) – – – – – – 1
Hair
Sparse scalp hair 8 (16.6) 25 (52) – 4 (8.3) 3 (6.2) 3 (6.2) 1 (6.2) 4 (8.3) 48
Sparse body hair 12 (29.2) 27 (65.8) – – – – 2 (4.8) – 41
Brittle, 5 (12.8) 17 (43.5) 1 (2.5) 6 (15.3) 2 (5.1) 2 (5.1) 4 (10.2) 2 (5.1) 39
lusterless hair
CRF, chronic renal failure; DM, diabetes mellitus; HTN, hypertension; PK, polycystic kidney; RUTI, recurrent urinary tract infections; SLE,
systemic lupus erythematosis.

neurophysiological hypothesis is considered to play an
important role in CRF-associated pruritus [10].
The prevalence of hyperpigmentation in this study was
44% and presented as localized or diffuse brownish-black
pigmentations on sun-exposed areas. Abdelbaqi-Salhab
et al. [11] reported that pigmentary alteration occurs in
25–70% of the dialysis population and increases over
the duration of renal disease. Our results were different
from those obtained by Falodun et al. [4], who detected
hyperpigmentations in 7.5% of the Nigerian CRF patients
studied. This could be attributed their dark skin color as
hyperpigmentation in black skin may be masked unless it
is extensive. The onset of hyperpigmentation in our study
statistically significantly manifested after HD in 86.4%.
Hyperpigmentation can be attributed to the retention of
chromogens and deposition of melanin in the basal layer
and superficial dermis because of failure of the kidneys to
excrete b-melanocyte-stimulating hormone [12].
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32  Egyptian Journal of Dermatology and Venereology
Pallor was observed in 34% of patients in this study. This
is in agreement with Attia et al. [13], who observed pallor
in 42.2%, but not in agreement with Udayakumar et al.
[2], who observed pallor in 60% of Indian patients, which
may be attributed to nutritional factors. The onset of pallor
in our study statistically significantly manifested before
HD (91.2%). Patients with CKD are at risk of blood loss
because of platelet dysfunction. Erythropoietin deficiency
is considered the most important cause of anemia in
CKD [14]. Other contributory factors included absolute
iron deficiency as HD patients may lose 3–5 g of iron
per year [15]; the survival of red blood cells is reduced by
approximately one-third in HD patients and vitamin B12
deficiency [16].
The prevalence of early wrinkling and exaggerated
skin markings was observed in 33% of the patients in
this study. These results are in agreement with those of
Sultan et al. [7], who observed early wrinkles in 40% of
patients. The onset was because of the early occurrence
of actinic elastosis in patients undergoing long-term
HD [12]. The onset of appearance of wrinkles in our
study statistically significantly manifested after HD
(93.9%).
Ecchymosis was detected in 32% of the studied
patients. It was observed around the arteriovenous
fistula, which is in agreement with Hajheydari et al. [3]
and Sultan et al. [7], who observed ecchymosis in 30
and 27% of their patients, respectively. In contrast,
Attia et al. [13] observed ecchymosis in 1.8% of their
dialysis patients. Defects in primary hemostasis such as
increased vascular fragility, abnormal platelet function,
and the use of heparin during dialysis are the main
causes of ecchymosis in CKD patients on HD [17]. In
this study, ecchymosis appeared in 90.6% of patients
after HD, and this was statistically significant. This
may be because of the repeated venopuncture necessary
for HD in addition to the lack of connective tissue-
supporting blood vessels that occur with aging and
debilitating conditions.
Skin infections was observed in 28% of the patients
studied: fungal infections in 18% (PV in 11.1% and
tinea pedis in 88.8%), bacterial infections in 6% (in
the form of folliculitis), and viral infections in 4%
(disseminated plane warts in 50% of patients and
common warts in 50%). Sultan et al. [7] reported skin
infections in 40% of patients in their study (fungal
infections, bacterial infections, and viral infections
in 33, 5, and 2%, respectively). Udayakumar et al. [2]
reported skin infections in 67% of their HD Indian
patients (fungal infections, bacterial infections, and
viral infections in 30, 13, and 12%, respectively). The
lower percentage of skin infections in the present
study may be because of the lower percentage of DM
associated with CRF patients (18%), whereas it was
38% in the Indian patients; also, onychomycosis (19%)
was also observed in addition to the skin infection,
whereas onychomycosis was a nail manifestation in
the present study. Excessive use of antibiotics in our
community may be the reason for this lower incidence.
In terms of fungal infections, we believe that the lower
percentage of PV infection in comparison with tinea
pedis resulted from the reduction in the function of
the pilo sebaceous and eccrine sweat glands in patients
with CRF as the sebum is one of the important factors
in the development of PV. There was no statistically
significant difference between the onset of skin
infection and HD.
Kyrle’s disease was detected in 7% of the patients
in the present study. This was in agreement with
Sultan et  al.  [7], who reported Kyrle’s disease in 3%
of the CRF patients on HD. However, Deshmukh
et al. [18] and Udayakumar et al. [2] reported Kyrle’s
disease in 17.14 and 21%, respectively, in their
patients. This difference could be explained by the
higher frequency of diabetic patients (51 and 38%,
respectively) compared with 18% in our patients. The
onset of Kyrle’s disease manifestations in our study
was not statistically significantly related to HD. The
pathogenesis of the disease is not known, but it may
occur as a result of dermal connective tissue dysplasia
and decay. Suspected causes include an inflammatory
skin reaction secondary to the presence of uremic
toxins, uric acid deposits, or scratching-induced
trauma [19]. Microvascular deposition of calcium may
interrupt blood flow to connective tissue in the dermal
layer, causing death and necrosis [20].
Gynecomastia was observed in the present study in 7%
of patients, whereas Udayakumar et al. [2] reported it
in 1% of patients. This difference may be because of
associated schistosomiasis in our patients.
In this study, bullous lesions in the form of
pseudoporphyria (PP) were noted in 1% of patients,
which matched with the reported percentage of
bullous disease range of 1–18% in patients with CRF
on HD [11]. Usually, this PP is equivalent to porphyria
cutanea tarda, showing blistering and mechanical
fragility of skin subjected to sunlight and incidental
trauma. It typically begins only after several months or
years of dialysis therapy. Hypertrichosis is less common
and plasma porphyrin levels are usually normal [21].
The etiology of PP remains unclear; however, CRF
patients with PP show abnormal porphyrin profiles
because of impaired excretion, rather than a deficiency
in the enzyme uroporphyrinogen decarboxylase, in
contrast to true porphyria cutanea tarda [22].
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AL was the most common nail change observed in the
present study (61% of patients). This is in agreement
with Martinez et al. [23], who reported AL in 62.9%
of CRF patients on HD. However, Saray et al. [24]
and Salem et al. [25] observed AL in 31.9 and 17%
of patients, respectively. Visible lunula is a good sign
in healthy cases of CRF on HD [25] and the lower
percentage in their reports may be because of the
better general health of their patients. The onset of
AL was the only nail manifestation that statistically
significantly appeared before HD.
In total, 41% of the patients in this study had nail
manifestation in the form of half and half nail (HHN),
which is in agreement with Lubach et al. [26] and
Pico et al. [6], who reported HHN in 50.6 and 40%
of their patients, respectively. In contrast, Deshmukh
et al. [18] and Salem et al. [25] reported HHN in 19.04
and 20% of their patients, respectively. Malnutrition is
an important cause for HHN [27] and its presence
in some patients may be the reason for the higher
percentage in this study. The pathophysiology of this
phenomenon is related to the proximal half of the nail
appearing white because of edema associated with a
dilated capillary network and the other half of the nail
bed appearing normal [28].
Koilonychia was observed in 29% of CRF patients in
this study. Our results were in agreement with those of
Sultan et al. [7], who reported koilonychia in 39% of
their patients. However, Onelmis et al. [29] reported
koilonychia in 19% of their CRF patients on HD.
This difference may be because of the fact that the
prevalence of koilonychia increased with increasing
HD duration [3].
Splinter hemorrhage was present in 15% of the patients
in this study, which is in agreement with Sultan
et al. [7], who observed it in 16% of their patients. In
contrast, Martinez et al. [23] and Udayakumar et al. [2]
reported splinter hemorrhage in 7 and 5% of their
patients, respectively. Splinter hemorrhage was widely
considered to result from microtrauma [30].
Subungual hyperkeratosis was found in 12% of
patients in this study, which is in agreement with
Udayakumar et al. [2] and Tercedor et al. [31], who
reported subungual hyperkeratosis in 12% of their
studied patients. In contrast, Salem et al. [25] observed
subungual hyperkeratosis in 3% of their patients.
Onycholysis was observed in 10% of the included
patients, which is in agreement with Salem et al. [25]
and Onelmis et al. [29], who reported onycholysis in
10 and 9% of their patients, respectively, whereas both
Sultan et al. [7] and Hajheydari et al. [3] reported
Cutaneous manifestations of CRF Sanad et al.  33
onycholysis in 3% only of their patients. Certain
medications that cause photosensitivity can induce
photo onycholysis as reported in HD patients who
receive large doses of cephalordine or cloxacillin [25].
Onychomycosis was observed in 7% of the patients
in this study, is in agreement matched with Bencini
et al. [8], who reported onychomycosis in 6.2% of
their patients. However, Saray et al. [24] reported
it in 19.2% of their patients. This may be because of
the difference in the number of study patients; they
included 182 patients in their study.
In this study, sparse scalp hair was the most common
hair disorder. Its prevalence was 48%, followed by sparse
body hair in 41% and brittle and lusterless hair in 39%
of the patients studied. These results were in agreement
with those of Sultan et al. [7], who found sparse scalp
hair in 46%, sparse body hair in 27%, and lusterless
hair in 47% of their patients. Our results were different
from those observed by Udayakumar et al. [2], who
reported sparse scalp hair in 11%, sparse body hair in
30%, and lusterless hair in 16% of their Indian patients.
Also, Hajheydari et al. [3] reported sparse scalp hair in
10%, sparse body hair in 9%, and lusterless hair in 2%
of their Iranian patients. The higher percentage of hair
changes in the Egyptian patients detected in this study
in comparison with Indian and Iranian patients may be
because of the racial variation in hair density [7].
This study detected no statistically significant relation
between the onset of hair manifestations in patients
with CRF on regular HD.
The most common oral mucosal manifestation in
this study was xerostomia, found in 46% of patients.
This is in agreement with Malekmakan et al. [32] and
Onelmis et al. [29], who reported it in 48.6 and 40%
of their patients, respectively. However, Udayakumar
et al. [2] found xerostomia in 31% of their patients and
the lower percentage may be because of the inclusion of
fewer hypertensive patients (18%) and administration
of antihypertensive drugs. Dry mouth in HD patients
is a multifactorial phenomenon that may be because of
water restriction, excessive water intake may increase
the risk of elevated blood pressure and heart failure,
and low saliva flow, minor salivary glands parenchymal
fibrosis and atrophy, medication use (fundamentally
antihypertensive agents), and oral breathing secondary
to lung perfusion problems [33].
Macroglossia and teeth markings were detected in 43%
of the patients in this study. This result is in agreement
with that of Sultan et al. [7], who found it in 42% of the
patients studied, but it was different from the results
detected by Udayakumar et al. [2], who reported it in
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34  Egyptian Journal of Dermatology and Venereology
35% of their patients. In many patients, the abnormality
of the tongue was found to disappear gradually and the
tongue regained its normal color, size, and shape with
the clinical and histopathological correlations soon
after renal transplantation. This original observation
in uremic patients should be designated as the ‘tongue
sign of uremia’ [34].
Ulcerative stomatitis was detected in 11% of the
patients in this study. This is in agreement with Sultan
et al. [7], who found ulcerative stomatitis in 9%, but
not in agreement with Udayakumar et al. [2], who
reported ulcerative stomatitis in 29% of patients. This
may be because of their patients’ intake of alcohol,
spices, hot food, and tobacco smoking, which are the
precipitating factors of ulcerative stomatitis. It has
been suggested that stomatitis appears when blood
urea levels exceed 300 mg/ml, although there have
been reports of mucosal changes at urea levels of less
than 200 mg/ml [35].
In this study, angular cheilitis was found in 6% of the
patients. This result was in agreement with that of
King et al. [36], who found angular cheilitis in 4% of
their HD patients. However, Udayakumar et al. [2]
and Sultan et al. [7] reported angular cheilitis in 12
and 15% of their patients, respectively. Their higher
percentage may be related to the larger numbers of
diabetic patients (38%) in their study. Angular cheilitis
appears with nutritional deficiencies, namely riboflavin
(vitamin B2), iron-deficiency anemia, or zinc deficiency.
Angular cheilitis occurred most commonly with fungal
infections and can be caused by bacteria.
In terms of the etiology of CRF patients on HD, this
study estimated that hypertension (53%) and diabetes
mellitus (18%) were the most common causes of CRF.
This was in agreement with Sultan et al. [7], who
confirmed that hypertension and DM were the most
common causes for CRF (60 and 14%, respectively).
Conclusion
Every CRF patient on HD had at least one cutaneous
manifestation, which may appear before or after HD.
The most common cutaneous manifestations were
xerosis, pruritus, hyperpigmentation, xerostomia,
macroglossia, AL, half and half nail, sparse scalp hair,
and sparse body hair. Hypertension and diabetes
mellitus were the most common causes of CRF.
Acknowledgements
Conflicts of interest
None declared.
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