Skin problems and inflammatory bowel disease

Skin issues can affect people with inflammatory bowel disease (IBD) (such as Crohn’s disease and ulcerative colitis). A recent study¹ reported almost one third of the patients with IBD develop skin conditions related to their disease or its treatment. The most common skin condition in patients with ulcerative colitis (UC) was psoriasis, and erythema nodosum in patients with Crohn’s disease. Skin conditions were significantly more prevalent in those patients with severe UC or Crohn’s disease.

Causes

Some of the skin issues may be caused by inflammation in your body, especially during a flare, whilst some other skin issues could be linked to the medication you take to treat your IBD.  A 2015 study² concluded that ‘IBD is a systemic disease, and EIM (extra-intestinal manifestations) are the proof that IBD is not only limited to the gut’. You can experience symptoms that affect areas other than the digestive tract. In particular with Crohn’s disease EMIs may occur in up to 40% of patients, and disorders of the skin are among the most common.³   

Malnutrition, where there’s a lack of sufficient nutrients in your body and vitamin and mineral deficiencies may also have an affect on your skin.  For example: 

• Zinc deficiency - can cause red patches or plaques that may also have pustules

• Iron deficiency - can cause red, cracked patches at the corners of the mouth

• Vitamin C deficiency - can cause bleeding under the skin, which causes bruise-like spots to appear

Some skin issues may occur prior to a diagnosis of IBD. In up to one quarter of patients involved in the study ‘Skin Manifestations of Inflammatory Bowel Disease’⁴,  EIMs presented before an IBD diagnosis was established. Skin conditions may therefore instigate further investigations especially if accompanied with bowel problems. 

Other possible explanations for skin manifestations in IBD include genetic abnormalities, immune dysfunction and impairments in gut microbiota. However, more research is needed to further determine the links between IBD and skin conditions. 

Types of skin conditions

There are several skin conditions that are associated with having IBD, some common, some more rare. We’ve looked at some of those conditions here.

Erythema nodosum

Erythema nodosum is the most common skin manifestation associated with IBD. It is more common in people with Crohn’s disease than UC and is seen in more females than males. It appears as tender red nodules, usually on the skin of your arms or legs. The nodules may also look like a bruise on your skin. It can be accompanied by fever, chills, aches, and pains. This condition tends to coincide with a flare or just before a flare starts. Once your IBD is under control again, the erythema nodosum will likely go away. In the meantime, to help with erythema nodosum symptoms, treatments may include anti-inflammatory drugs and corticosteroids by mouth or local injection. 

Pyoderma gangrenosum 

Pyoderma gangrenosum is another common skin issue associated with IBD. It can often happen during a flare. It usually appears on your ankles and shins, but may also develop on your arms. It begins as a cluster of small blisters that can spread and combine to create deep, sometimes very painful ulcers. It can cause scarring. It is important to keep the ulcers clean to avoid infection. High doses of corticosteroids may be prescribed as well as pain medication for the ulcers depending on its severity.

Acne

Cystic acne is a painful type of acne that develops under your skin. It is more common in UC. These skin eruptions are more likely caused by treatments for IBD, in particular, steroids.

Hives

Hives are a red, often itchy skin rash that can occur on any part of your body. They may appear as a reaction to your IBD medication. Contact your doctor to discuss alternatives if you start a medication and you get persistent hives.

Psoriasis

Psoriasis is an autoimmune condition, which presents as red, flaky patches on the skin that form white or silver-looking scales.  It happens when the immune system goes into overdrive and causes skin cells to multiply too quickly. These extra cells build up on the skin. It is more common in Crohn’s disease. Treatment may include topical corticosteroids.

The findings from a study⁵ in 2018 suggest that psoriasis is significantly associated with IBD. Presenting with psoriasis and simultaneous bowel problems may therefore prompt investigation into an IBD diagnosis.

Skin tags

Skin tags are small flesh-coloured or brown growths that hang off the skin and look a little like warts. They're very common, are harmless and don't usually cause pain or discomfort. They usually occur on the neck, armpits, under breasts, and around the groin. They can also grow on the eyelids or under the folds of the buttocks. With Crohn’s disease it is not uncommon to have skin tags around your anus. This may be attributed to having haemorrhoids, where the skin gets thicker when the swelling goes down. These thicker areas of skin form large, hard flaps or soft, painless ones.  However, irritation can occur if faeces etc sticks to the tags.  The best way to prevent this irritation is to keep the area clean.

Mouth ulcers

Mouth ulcers, or canker sores as they’re also known, are small, painful round or oval sores that occur on the inside of your mouth, usually on the inside of the cheeks or lips.  They are thought to be more common in Crohn’s disease where the small intestine is damaged by inflammation, fistulas or strictures, making it more difficult to absorb vitamins and minerals. This may also happen if you have had surgery to remove sections of your large or small intestines, causing difficulties absorbing vitamins and minerals.

Mouth ulcers can occur during a flare or as a side effect of your IBD medication. Though painful, they are usually harmless and will clear up by themselves within a week or two.  There are over-the-counter medications available to help ease the discomfort whilst they heal. It is advisable to see your doctor, however, if an ulcer gets worse or lasts for longer than three weeks, or if you develop ulcers regularly.

Sweet’s syndrome

A much rarer skin manifestation is Sweet’s syndrome, which is linked to active IBD flares. It starts as small, tender, red or purple bumps that spread into painful clusters, usually on your upper body, neck or face. It may be accompanied by headaches, body pain, and a general feeling of being unwell. The bumps may appear black or brown on darker skin tones and red on lighter skin. The bumps may go away on their own but recurrence is common and may leave scars. The main treatment for Sweet’s syndrome is corticosteroids, either injected or in tablet form. 

Vitiligo

Though a rarer skin condition, the prevalence of vitiligo is thought to be higher in people with IBD than in the general population⁶.  Vitiligo occurs when the cells (melanocytes) that are responsible for your skin colour are destroyed. These cells no longer produce skin pigment, or melanin, causing areas of your skin to lose colour or turn white and can occur anywhere on your body. It is thought to be an immune disorder. 

Pyodermatitis-pyostomatitis vegetans (PPV)

PPV refers to two skin conditions; pyodermatitis vegetans - a rash of red pustules, which can rupture and form raised scaly patches of skin and occurs in the skin folds of your armpit or groin; and pyostomatitis vegetans - where the pustules form in your mouth. These linked conditions are associated with UC.  As with some other skin conditions, it may pre-date the onset of UC, which may alert your doctor to consider the possibility of an IBD diagnosis.  PPV has been identified as having a correlation with underlying bowel disease activity⁶.  Oral corticosteroids are thought to be the best treatment option.

Leukocytoclastic vasculitis

With leukocytoclastic vasculitis, inflammation causes small blood vessels to burst and blood to pool under your skin. This leads to purple-coloured spots on lighter skin or black or brown spots on darker skin, known as purpura. The spots can cluster in small or large patches and are usually found on your legs or ankles.

In most mild cases of leukocytoclastic vasculitis, supportive measures can be effective to treat it e.g leg elevation, rest, compression stockings, and antihistamines. In more severe cases a 4-6 week dose of corticosteroids may be prescribed.

Acrodermatitis enteropathica

Acrodermatitis enteropathica appears as a flaky skin rash or blisters usually found on your hands, face, feet or genitals and is caused by a zinc deficiency. If you experience ongoing diarrhoea with your IBD, you may be losing zinc through your poo. Taking a zinc supplement should help alleviate the rash.  Always speak to your doctor before taking any supplements. 

Treatment overview

Most skin issues associated with IBD are best treated by managing the IBD as much as possible, as many of these issues can coincide with being in a  flare. If you do develop a rash or skin condition you may be prescribed corticosteroids to help with the inflammation that often causes the skin issues. For the rash itself, antibiotic ointment or pain medication may be prescribed to help alleviate the symptoms. Topical corticosteroids may also be prescribed.

Depending on the type of skin condition you have will determine the course of treatment.  Potential treatments include:

• Corticosteroids - oral, injected or topical

• Immunosuppressive drugs, such as methotrexate or azathioprine

• Anti-inflammatory medications, such as sulfasalazine

• Anti-TNF biologics, such as infliximab or adalimumab

• Antibiotics

If a particular medication is thought to be causing the skin condition, you may be advised to discontinue taking it. If a vitamin or mineral deficiency is thought to be the cause, your doctor may suggest you take vitamin or mineral supplements.

If you do experience an IBD associated skin condition, keep the area clean to prevent infections and see your doctor or IBD nurse or team for further advice or treatment, particularly if it covers a large area, has spread quickly, is painful, occurs with a fever or you have blisters or fluid drainage.

Tips

Here are some general tips for dealing with skin conditions, for more specific advice, please contact your doctor:

• Patch test before using new cosmetics and hair products to check for irritation. Apply a small amount of the product to your skin and leave it on to see if a reaction develops. The American Academy of Dermatology (AAD) has advice on performing patch tests at home

• Do not apply cosmetics to open sores

• Avoid irritants such as soaps, bubble bath, detergents and any fabrics that seem to irritate. Cotton clothing is usually comfortable for people with skin conditions

• If your skin condition is itchy, try not to scratch it (easier said than done!). Keep your nails short to limit any damage done to the skin by scratching

• Try  not to pick at a rash or scabs - it can make the condition worse, cause more discomfort and itching and lead to infections 

Support

The Psoriasis Association has information, advice and support for those affected by psoriasis.

The British Association of Dermatologists has a patient hub with impartial information and advice on living with a skin condition including treatments and finding a dermatologist and getting involved in research.

The American Academy of Dermatology  has information on skin conditions, everyday care and finding a dermatologist.