The skin can serve as a mirror of underlying diseases. Changes in skin color and texture or the presence of lesions may be indicators of disease affecting internal organs. Skin manifestations may tell us about the severity of a disease, as well as its potential course and prognosis. It is also useful in directing management and may determine whether further evaluation is warranted. 

In particular, several conditions can affect both the skin and lungs. It is important to recognize these signs and symptoms, so early diagnosis and treatment can be initiated. Let's look at the connection between respiratory health and skin.

Skin Signs of Pulmonary Disorders

Respiratory disease affects the airways and lungs, as well as the muscles and nerves involved in breathing. Some of these conditions may manifest through the skin ¹. Below are some of the skin changes that you may see if there is an underlying respiratory condition. Knowledge of these signs and symptoms will aid in early diagnosis and prompt treatment.

Cyanosis

This is a bluish discoloration of the skin due to low oxygen². Cyanosis affecting the lips and tongue is often associated with poor blood oxygenation in the lungs. In contrast, cyanosis of the extremities may point to inadequate oxygenation in the smaller and farther blood vessels.

Nail Clubbing

This is a condition marked by thickening of the fingernails with them becoming more convex, and is associated with a soft, boggy texture. Clubbing is seen in numerous diseases, such as lung cancer, interstitial lung disease, tuberculosis, and cystic fibrosis³.

 Nodules

About two⁴ to eight⁵ percent of people with lung cancer develop nodules on the skin of the chest, abdomen, neck, and scalp. These nodules usually grow rapidly, and are noted to be hard, painless, and movable. Monitoring the character, size, shape, and growth of these nodules is key in assessing a person’s response to chemotherapy.

Dilated Veins

Superior vena cava syndrome⁶ is a result of obstruction of the superior vena cava, the vein that transports deoxygenated blood from the upper body to the heart. It manifests with bulging and dilated veins in the neck and upper chest. Cancers are usually the main culprit, including non-small-cell lung cancer, lymphoma, and metastatic tumors. 

Purpura

Purpura is also called blood spots or skin hemorrhages, appearing over parts of the skin as purple-red colored spots that do not become pale under pressure. They, alsong with ulcers, raised dark spots, and nodules on the lower extremities, are usually seen when someone has granulomatosis with polyangitis in the lungs or other parts of the body⁷. Granulomatosis with polyangitis (previously known as Wegener's granulomatosis) is a chronic condition where someone’s blood vessels become inflamed and their immune system’s response to this causes red or white lumps around the inflammation. It is likely genetic and cannot be caught from others. When this occurs in the lungs, mouth ulcers, gingivitis, shortness of breath and coughing up blood ⁸ are also apparent. 

Raised Lesions

Fat embolism syndrome occurs due to fractures or trauma to bones ⁹. Fat particles can then cause respiratory distress and affect mental status. Additionally, on the skin, you might note raised lesions two to three mm in size on the upper chest, neck, and armpit.

Common Pulmonary Disorders with Skin Manifestations

Skin conditions¹⁰ that arise from pulmonary disease can be caused by a variety of conditions:

• Congenital or developmental in nature, which means you were born with the condition 
• Primarily dermatological disease that proceeded to manifest with lung symptoms 
• A pulmonary disease that manifests with skin symptoms 
• Lastly, skin changes may arise from drugs that are used to treat respiratory conditions 

Let us go over these diseases more thoroughly.

1.     Congenital Disorders With Skin and Lung Manifestations

a. Neurofibromatosis¹¹ – In this condition, cysts develop in the upper lobes of the lungs. There are also visible birthmarks on the skin known as café-au-lait spots.

b. Ehlers-Danlos syndrome¹² – People with this condition often have loose joints, stretchy skin, and abnormal scar formation. Depending on the subtype, there can be the risk of lung collapse or holes in the lungs.

c. Marfan’s syndrome¹³ – This condition results in abnormalities in the cartilage connecting the ribs to the breast bone. People with Marfan’s syndrome may have chest abnormalities such as pectus excavatum, a depression of the chest wall, as well as kyphoscoliosis (unusual curvature of the spine both front-to-back and left-to-right), which leads to restriction of the lungs.

2.     Dermatologic Conditions With Lung Symptoms

a. Staphylococcus aureus infection¹⁴ – A skin infection with this bacteria, usually manifesting as boils, impetigo, and cellulitis, can lead to pneumonia. 

b. Malignant melanoma¹⁵ – This skin cancer can metastasize to the lung, leading to malignant pleural effusion (the collection of fluid between the lung and the chest), which causes shortness of breath due to reduced lung capacity.

c. HIV infection¹⁶ – Persons with HIV may have various infective or non-infective skin conditions. Because of their compromised immune system, they are prone to numerous lung diseases. This is not exactly a skin condition leading to a lung condition, but both being due to the same underlying condition.

3.     Lung Disease With Skin Manifestations

a. Tuberculosis¹⁷ – Tuberculosis manifesting with skin symptoms is not common but can happen. Diagnosis can be difficult as these lesions may mimic other dermatologic conditions. A skin biopsy and tests using special staining techniques are needed for proper identification. 

b. Bacterial pneumonia¹⁸ – Caused by bacteria of the Pseudomonas genus, bacterial pneumonia may manifest on the skin as cellulitis, inflamed hair follicles, necrosis,, and pus-filled swellings. These bacteria are particularly troublesome for immunocompromised patients, as they are more prone to infections that otherwise healthy individuals could easily fight off.

c. Lung cancer¹⁹ – There are numerous skin changes in lung cancer. In some instances, the dermatologic symptoms may appear even before obvious signs of lung cancer. Nail clubbing, superior vena cava syndrome (symptoms include facial swelling in the morning, coughing, and swelling of the upper arms and neck), and acanthosis nigricans (blackening of the skin at the nape of the neck) are common manifestations of lung cancer. Certain cancers of the chest wall and ribs can even grow outwards, causing the chest skin to swell.

4.     Skin Changes Due to Drugs for Lung Diseases

a.     Antibiotics²⁰ – An allergic reaction to antibiotics used to treat a lung infection, the most common being penicillin, may manifest with skin rashes as an allergic response. 

b.     Anti-TB drugs²¹ – Skin rashes, purpura, and other hypersensitivity reactions are common reactions to anti-tubercular drugs.

c.     Immuno-suppressants²² – Drugs used to treat auto-immune diseases stemming from overactive immune systems, as well as cancer and certain other conditions, can lead to fungal or bacterial skin infections due to the immune system being rendered less effective by the drugs. 

Conclusion

Clearly, a variety of pulmonary conditions can present with skin symptoms. Knowing the dermatologic manifestations of common lung disease can serve as the impetus to consult your doctor as soon as possible. The earlier the diagnosis, the sooner prompt management can be initiated.

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Mikaela Millan

Mikaela is a dentistry clinician at the University of the Philippines.