Skin Signs Of Liver Damage: What Is The Connection?

The skin is a vital organ that can tell us a lot about our health. 

Changes in skin color or the development of spots can indicate liver damage and disease, even in the absence of other symptoms. 

Common skin manifestations of liver diseases 

Common skin manifestations of liver disease include vascular changes which affect the skin, skin rashes, discoloration, and dry skin. 

How are skin problems related to liver diseases?

Skin problems are common in people with acute and chronic liver disease. They can be one of the first signs that something is wrong with the liver. 

Skin problems can develop when any of the following functions of the liver are impaired:

• Synthesizing proteins such as clotting factors, complements (proteins that are part of the immune system), and albumin

• Neutralizing toxins

• Metabolizing lipids and carbohydrates

• Appropriate bile secretion and flow 

Usually, these skin problems are non-specific to liver disease. 

Liver diseases that can contribute to skin problems include:

• Alcoholic liver disease: 43% of people with alcoholic cirrhosis develop cutaneous lesions 

• Primary biliary cirrhosis

• Viral hepatitis infections 

Vascular signs on the skin caused by liver diseases

Liver diseases can cause several vascular signs on the skin. These include:

Spider angioma 

Spider angioma also called spider nevi, is a superficial vascular problem that occurs when dilated blood vessels develop near the surface of the skin. 

One reason why this is thought to happen is that spider angiomas occur in response to high estrogen levels, and high estrogen levels are associated with liver fibrosis. However, spider angiomas can also occur during pregnancy and severe malnutrition. Typically, the severity of the liver disease correlates with the amount and size of the lesions.

Spider angiomas get their name because they look like a spider. They have central, raised, red spots that resemble the body and capillaries that radiate outwards and look like the legs. 

Spider angiomas are most commonly found on the face, neck, upper chest, and arms. They disappear when pressure is applied to them but reappear as soon as the pressure is released. 

Around a third of people with liver cirrhosis experience spider angioma.¹

After liver function improves, spider angioma can spontaneously resolve. 

Palmar erythema

Palmar erythema describes the exaggeration of the normal speckled mottling of the palms of the hands and is again thought to be secondary to altered sex hormone metabolism. This occurs when surface capillaries dilate. 

Palmar erythema commonly occurs in liver cirrhosis, where it’s experienced in 23% of people. But it is not specific to liver disease and can be seen with pregnancy, rheumatoid arthritis, or hyperthyroidism.²

Palmar erythema is generally not painful but, in some cases, may throb and feel tingly. 

Paper money skin

Paper money skin is a superficial vascular problem that occurs when thin capillaries become scattered across the upper trunk of the body. 

Paper money skin gets its name because the skin looks like the silk threads of the United States dollar bills. 

It’s usually seen in cirrhosis that’s related to chronic alcohol use.  

Bier spots

Bier spots are irregularly shaped, small, white mottling on the skin that usually develop on the arms and legs. They, too, are superficial vascular problems. 

There are different ways to help identify Bier spots:

• Although the spots are hypopigmented, lifting the affected limb causes the spots to disappear.

• Applying pressure to the spot causes it to disappear. 

• Placing a tourniquet around the affected limb causes the spots to accentuate.

Other vascular changes

Some other vascular changes that may be related to the liver disease include: 

• Ascites are the buildup of fluid in the peritoneal cavity due to high blood pressure in the liver’s blood vessels/portal hypertension. Ascites are a potential complication of cirrhosis.³

• Dupuytren’s contracture is a condition linked to alcohol misuse. It’s when the connective tissue under the skin of the fingers gradually becomes thicker and tighter, causing the fingers to bend towards the palm.⁴

• Porphyria cutanea tarda is a blistering condition that causes blisters to form in response to sunlight. PCT is caused by acquired inhibition of an important enzyme in the liver. Alcohol, hepatitis C, etc., can contribute to the development of PCT, but they’re never the sole cause.⁵

• Finger clubbing is defined as a greater than a 180-degree angle between the nail plate and the proximal nail fold, leading to a “drumstick” appearance. Clubbing is not specific to liver disease but can be seen particularly in biliary causes of cirrhosis.

Pruritus

Pruritus means itch in medical jargon. 

Hepatic pruritus is also often resistant to therapy if associated with cholestasis (backup of bile flow), but treatments such as cholestyramine, colesevelam, and naltrexone may help. 

It’s more likely to be experienced in primary biliary cirrhosis and biliary obstructive diseases rather than alcoholic liver diseases and non-alcoholic fatty liver disease. 

The exact pathogenesis of pruritus in cholestasis is unknown, but it is thought to be secondary to either bile acid accumulation, increased opioidergic tone, or elevations in lysophosphatidic acid levels.

Pruritus can range from mild to severe and from temporary to permanent. In severe cases, pruritus can be distressing and lower the quality of life. 

It usually affects the limbs, palms of the hands, and soles of the feet of the body, but it can also be more generalized. Typically, pruritus is worse in the evening, and contact with excessive heat or some fabrics like wool makes it worse. 

Unconjugated jaundice

Unconjugated jaundice in the context of chronic liver disease happens when the liver cannot process hemoglobin breakdown products adequately and unconjugated bilirubin accumulates.

The build-up of bilirubin above 2.5 or 3.0 mg/dL in the blood causes yellow skin and eyes. 

If jaundice is due to cholestasis (issues with bile flow, such as due to blocked bile ducts), there will be a presence of conjugated bilirubinemia (a pathologic elevation of conjugated bilirubin). 

Xanthelasma

Xanthelasma (plane xanthoma) are painless, yellow plaques that develop in the skin on or near the eyelids. They may be flat or slightly raised. They can be soft, chalky, or semi-solid. 

Xanthelasma is lipid deposits in the skin. Although they’re associated with cholestasis-related hypercholesterolemia in PBC or biliary atresia, the relationship between xanthelasma and dyslipidemia is controversial.

If desired, xanthelasma can be removed through surgery. 

Other changes in pigmentation and skin color identifying liver damage

In addition to the above vascular skin conditions that can happen as a result of liver disorders, some other changes that can occur include:

• Easy bleeding and bruising of the skin

• Hyperpigmentation of the skin, which can occur in alcoholic liver disease or cirrhosis  

• Leukonychia, whitening of the nails 

How can you protect your liver?

You can protect your liver from damage and help to prevent the further progression of existing liver disease in several ways. Treating the underlying liver disorder should be the focus. 

For example:

Dietary changes

For those with cirrhosis or alcoholic hepatitis, protein-calorie malnutrition is common. Nutritional support is recommended alongside a registered dietitian. It’s recommended to:

• Increase the intake of vitamin D and calcium to keep bones strong. This is because osteoporosis is common in individuals with liver disease. 

• Reduce the intake of salt. This can help reduce swelling in the body and control ascites. 

• Eat at least two to three servings of protein at each meal.

A Mediterranean-style diet can be beneficial for meeting these recommendations. 

Physical activity: According to the American Heart Association, you should aim to get at least 150 minutes of moderate-intensity aerobic activity every week. Moderate-intensity aerobic activities include brisk walking, water aerobics, or gardening. 

Reduce alcohol intake: It’s recommended that you abstain from alcohol or at least decrease your intake as much as possible.

A good guide is one standard drink a day for women and two standard drinks a day for men. A standard drink is 12 ounces of regular beer, 5 ounces of wine, or 1.5 ounces of distilled spirits. 

Weight control: It’s important to maintain a healthy weight and lose weight if you’re overweight. The American Heart Association recommends that adults who are overweight or obese lose weight through lifestyle interventions, like calorie restriction. 

Practice safe sex by using a condom to help prevent hepatitis, which can be chronic, depending on the type. You can also get vaccinated against some types of hepatitis. 

Avoid sharing needles to help prevent hepatitis. 

Take caution with medications: It’s important to be careful with any prescription and over-the-counter medications you take because overconsumption can injure the liver. Acetaminophen is the leading cause of acute liver failure in the US. Always follow the instructions on the packet and the advice given by your doctor.

The lowdown

Liver disorders affect many areas of the body, including the skin. 

If you develop any skin abnormalities, such as itching, color changes, rashes, or new flat or elevated bumps, it’s a good idea to see your doctor so that they can test your liver function. 

Getting an early diagnosis of liver disease can improve the overall outcome and symptom management of the skin problems and your liver disorder.

People also ask 

Can you see liver damage on your skin?

Liver damage often presents itself on the skin, with signs and symptoms including the following: 

• Cutaneous lesions usually accompany alcoholic cirrhosis.

• The combination of vascular problems (such as spider angioma and palmar erythema) has been linked to alcoholic cirrhosis. 

• Jaundice (a yellowish or brownish tinge of the skin and eyes) is exhibited when serum bilirubin levels exceed 2.5 or 3.0 mg/dL. Mild cases tend to show a yellow tinge, while severe cases tend to show a brown tinge. 

What skin color indicates a liver disorder?

Yellow or brown skin can indicate jaundice, a skin condition that can stem from a liver disorder. You should also look out for new flat or elevated spots on the skin, which range from being hypopigmented to red. 

Where do you itch when you have liver damage?

Chronic liver diseases are associated with an itch that usually affects the palms of the hands and soles of the feet.