o Violaceous, indurated plaques on nose, cheeks, lips, ears
o Strongly associated with upper respiratory tract involvement
o Often on face and extremities
o Tender, erythematous nodules on shins
o Suggests acute, self-limiting disease, usually good prognosis
• Non-caseating granulomas on biopsy
• ACE level often raised; consider pulmonary involvement
• Hyperpigmentation, hypertrichosis (especially face)
• Skin fragility, milia formation
• Exacerbated by alcohol, oestrogens, hepatitis C, iron overload
• Urine: pink or orange fluorescence under Wood's lamp (uroporphyrins)
• Phlebotomy (reduce iron stores)
• Low-dose hydroxychloroquine
o Yellow-brown, atrophic plaques with telangiectasia
o Commonly on shins
o Ulceration possible
o Intertriginous areas (axillae, groin, under breasts)
o Vulvovaginal candidiasis frequent in women
o Hyperpigmented, velvety thickening
o Neck, axillae
o Insulin resistance marker; in rare cases, may indicate gastric adenocarcinoma
o "Shin spots": brown, atrophic macules
• Waxy papules and plaques
o Periorbital, anogenital
• Pinch purpura
o Easy bruising from minimal trauma (especially around eyes)
• Macroglossia (seen in systemic amyloidosis)
• AL amyloidosis often associated with plasma cell dyscrasias (e.g., myeloma)
o Localised, firm, non-pitting oedema
o Shins most common
• Dry, coarse skin
• Hair thinning, loss of lateral eyebrows
• Myxoedema (generalised skin thickening)
o Very common in advanced CKD
o May be due to secondary hyperparathyroidism, uraemic toxins
o Painful, purpuric skin lesions → ulceration, necrosis
o High mortality; often in dialysis patients
o Risk factors: hyperphosphataemia, hypercalcaemia, warfarin use
o Yellowish or brownish due to carotene accumulation and hyperpigmentation
• Lupus pernio → specific for sarcoidosis
• Acanthosis nigricans → think insulin resistance first; if sudden and widespread, rule out internal malignancy
• PCT + hepatitis C + alcohol → classic exam trio
• Calciphylaxis → do not biopsy ulcer edge → risk of worsening necrosis
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Author & Educational Disclaimer
Author:
Dr Phillip Cockrell BM FRCP DipClinEd
Dr Phillip Cockrell is a UK Consultant Physician in Internal Medicine, currently working at Queen Alexandra Hospital, Portsmouth University Hospitals NHS Trust. He has previously worked as a registrar across Intensive Care Medicine, Gastroenterology, Cardiology, Stroke Medicine, Acute Medicine, and Respiratory Medicine.
He has held senior leadership roles including Associate Clinical Director of the Acute Medical Unit, Clinical Director of Internal Medicine, and Chief of Medicine. Dr Cockrell has over 15 years’ experience in postgraduate medical education, having lectured extensively across the MRCP syllabus and contributed to MRCP revision teaching and course development.
Dr Cockrell holds a Bachelor of Medicine (BM), Fellowship of the Royal College of Physicians (FRCP), and a Diploma in Clinical Education (DipClinEd). His teaching approach is based on structured consolidation of complex medical topics to support efficient and effective revision for postgraduate examinations.
Purpose of this content:
The material on this page is intended solely for educational purposes to support revision for the MRCP (UK) Part 1 examination. It reflects examination-relevant principles of internal medicine and is designed to aid learning and pattern recognition.
Medical disclaimer:
This content is designed for postgraduate medical examination revision and does not constitute medical advice, diagnosis, or treatment guidance and must not be used as a substitute for professional clinical judgement, local guidelines, or specialist consultation. Clinical decisions should always be made in the context of individual patient circumstances and current national guidance.
