Skin markers of coronary artery disease

You might be wondering why I am writing about coronary artery disease when I am a dermatologist and aesthetic surgeon.  Well, that’s because the skin is very much like a canvas where you can paint a picture of what else is happening or about to happen inside the body. 

Coronary artery disease (CAD) is rapidly increasing in prevalence across the world, particularly among South Asians at a relatively younger age.  As atherosclerosis starts in early childhood, the process of risk evaluation must start quite early.  A diligent search for skin manifestations or lesions — namely,  xanthelasma, xanthoma, arcus juvenilis, acanthosis nigricans, skin tags, ear lobe crease, nicotine stains, premature graying and balding in smokers, hyperpigmented hands, central obesity, and signs of peripheral vascular disease — may prove to be a rewarding exercise in identifying asymptomatic coronary artery disease in high-risk individuals.  

One of the more common cutaneous markers of CAD is xanthelasma/xanthoma.  These are yellow elevations that occur near the inner eyelid, more often on the upper eyelid.  It can be soft, semisolid or calcareus, frequently symmetrical with all the eyelids involved.  They have a tendency to progress, coalesce (groupe together), and become permanent.  Most studies have found increased concentrations of plasma total cholesterol or low-density lipoprotein cholesterol in people with xanthelasma.  It has been known to be associated with atherosclerosis, coronary artery disease, insulin resistance, diabetes mellitus, hypertension, stroke, dyslipidemia, obesity, and hyperuricemia.

Cholesterol or fatty particles cannot dissolve in the blood.  They are carried to and from the body’s cells by carriers called lipoproteins.  High-density lipoprotein (HDL) is regarded as the good cholesterol as it protects the body against heart attacks.  That is because HDL is able to carry the “bad” cholesterol stored in the arteries back to the liver, where it is processed and expelled from the body.  So, the higher the HDL cholesterol level, the less likelihood of heart disease.  On the other hand, low-density lipoprotein (LDL)  is considered bad as it can slowly accumulate on the inner walls of the arteries when too much of it circulates in the blood.  Together with other substances, it forms a plaque — a thick, hard deposit that can eventually narrow the arteries and disrupt blood circulation leading to atherosclerosis, which puts the body at risk of a heart attack or stroke. In particular, small and dense LDL particles are said to increase the risk of atherosclerosis, as their small size and density may allow them to travel through the walls of blood vessels more easily, thus becoming deposited in them.

Xanthelasma is fairly prevalent in our population.  However, people tend to complain about it only for aesthetic reasons.  Studies found associations with hypertension, dyslipidemia (a disorder of lipoprotein metabolism), central obesity, and diabetes.  Jain et al found 42.4 % of patients had associated hypertension, CAD, diabetes, and cholelithiasis.

Others to look for are:

• Arcus juvenilis — extracellular deposit of lipids at the corneoscleral limbus (boundary of cornea and sclera) that represents the most common peripheral corneal opacity.  Associated with alcohol, cigarette smoking, hypertension, hypercholesterolemia, diabetes, CAD, and xanthelasma.  Its presence in a younger person should prompt a search for lipid abnormalities.  Its presence also suggests a more aggressive lipid therapy. 

• Acanthosis nigricans (AN) — a skin disorder characterized by darkening (hyperpigmentation) and thickening (hyperkeratosis) of the skin, occurring mainly in the folds of the skin, back of the neck, the axilla, and/or groin.  Rarely is it observed in some regions of the face.  AN is not a skin disease per se but is a cutaneous sign indicating insulin resistance, diabetes, metabolic syndrome, Cushing’s syndrome, internal malignancy, polycystic ovarian syndrome, etc.

• Skin tags  are thought to be relatively common skin lesions.  However, it has been reported that they might reflect insulin resistance states.  In a large study of patients with skin tags, over 25% had DM and a further 8% had impaired glucose tolerance.  There are also reports of an association between tags and an atherogenic lipid profile.  In a study by Erdogan et al, it was concluded that skin tags may not be innocent tumoral proliferations and instead, patients with this need a followup with regard to the development of diseases associated with atherosclerosis.  Skin tags associated with AN carry a more sinister significance than any of them alone.

• Premature graying and balding. It has been observed that young CAD patients who are heavy smokers develop premature graying and balding.  Thus, the presence of premature graying in chronic smokers  and the early onset of androgenetic alopecia indicate a higher-than-normal risk of CAD.  A case control study examined the association of dermatological signs such as baldness, thoracic hairiness, hair graying, and a diagonal ear lobe crease with the risk of myocardial infarction (MI) in male subjects less than 60 years and concluded that these signs indicate an additional risk of myocardial infarction in men under the age of 60 years.

• Ear lobe crease (ELC).  Ear lobes of children and young adults are normally smooth.  The presence of ELC and its association with CAD was first described in 1973.  Blodget, et all found that 75% of CAD cases had an ELC as compared to 35% of the controls; afterwards many studies presented ELC as a marker for CAD.

• Nicotine staining. The most evident and enduring signs of smoking are the tar and nicotine stains found on hands, fingers, lips, and on the skin, in addition to the teeth.  The discoloration, more often than not, develops on the lips and on the fingernails.  Nicotine is most commonly absorbed from cigarette smoke, with each puff containing approximately 50ug of nicotine. The adverse effects of smoking on the cardiovascular system are known to all.

• Central obesity. Excess belly is not just an aesthetic issue, it is also a risk factor with regard to health.  This is due to an increased amount of visceral fat, which lies deeper in the abdomen beneath the muscles and the surrounding internal organs.  Central obesity increases the risk of diabetes, heart disease, hypertension, stroke, sleep apnea, cancer, and other degenerative diseases.

• Peripheral vascular disease (PVD)  — also known as arterosclerosis obliterans, primarily the result of atherosclerosis. The atheroma consists of a core of cholesterol attached to proteins with a fibrous intravascular (inside the vein) covering.  The atherosclerotic process gradually progresses to complete occlusion of medium and large arteries, which presents with the following:  pulselessness (no pulse), paralysis, paresthesia (abnormal sensation), pain, and pallor.

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