Postgraduate Medicine

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Recognizing Alcoholism Early By Physical Signs Peter M. Silberfarb To cite this article: Peter M. Silberfarb (1976) Recognizing Alcoholism Early By Physical Signs, Postgraduate Medicine, 59:4, 79-81, DOI: 10.1080/00325481.1976.11714324 To link to this article:

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• Alcoholics are thought to visit their physicians more often than other people. Frequently these visits are not for treatment of the alcoholism but for other problems th at may or may not be related to it. The physician then bas an opportunity to identify alcoholism as a real problem and to direct the patient toward a treatment plan. However, while we may have subliminal knowledge of certain early signs of alcoholism in our patients, physicians still hesitate to identify alcoholism as a problem and instead tend to wait until a catastrophic event forces the problem into the open. This event may be a physical disorder, such as hematemesis, or sorne type of social disruption, such as loss of job or divorce. Delay in identifying the real problem seldom serves the patient's best interest. By being more confident in our awareness of the early physical signs of alcoholism, we may be able to broach the problem sooner. The intent and hope of this discussion is to contribute toward such confidence. Generally, there are no physical signs consistent! y diagnostic of earl y alcoholism. In the earl y stage, alcoholism is frequently definable only by its behavioral characteristics. There are, however, clinical indications of hidden heavy drinking. Even though these indications are not always specifie to alcoholism, they are easily discernible and may be the first clue to hidden alcoholism. Since most alcoholics attempt to bide their habit, we must be alert to what we see and hear.

recognizing alcoholism early by physical signs Peter M. Sllberfarb, MD Dartmouth Medical School Hanover, New Hampshire

Many clinicians are subliminally aware of the possibility of alcoholism in their patients but seldom openly identify the problem as soon as they could. They may be able to guide the alcoholic to treatment early if they are familiar with the easily noticed physical signs that point to hidden heavy drin king.

Changes in Speech and Facial Appearance

The patient's speech is often the first clue to alcoholism. Edema of the nasal mucosa, posterior pharynx, larynx, and vocal cords gives sorne alcoholics a characteristically hoarse voice that may be one of the earliest physical signs of the surreptitious drinker. Next we usually observe the patient's facial appearance. The characteristic physiognomy of earl y alcoholism is a puffy, edematous appearance of the skin and subcutaneous tissues. It is only later that subcutaneous fat is lost and atrophy of the dermis occurs. Cirrhosis of the liver usually occurs during this later stage of dermal wasting. In addition to the edematous facies, conjunctival vessels become engorged and general dilatation of the facial vessels occurs, causing a flushed appearance. This flushing should not be confused with the chronic dermatologie disorder rosacea,

Vol. 59 • No. 4 • April1976 • POSTORADUATE MEDICINE


Peter M. Sllberfarb

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Dr. Silberfarb is assistant professor of psychiatry, Dartmouth Medical School, Hanover, New Hampshire.

which affects the flushing areas of the face and which leads to permanent hyperemia, acne-type lesions often with pitting and scarring, and hypertrophie changes in the face and nose. The last sometimes lead to rhinophyma, or so-called whiskey nose-an unfortunate term, since people with this disorder are frequently accused of alcoholism when they really have an advanced form of rosacea. An unusual concomitant of alcoholism that is readily visible on simple inspection is bilateral parotid hyperplasia, or so-called chipmunk facies, in which Joss of the normal angle of the jaw is apparent. This is a painless condition without associated fever that occurs only in malnutrition, cirrhosis, or alcoholism. Changes ln Skln and Halr

Hidden drinking is probably most evident in the appearance of the skin. Cigarette burns on the bands and chest or heavy nicotine stains on the fin gers and persistent or repeated ecchymoses, abrasions, lacerations, or puncture wounds on shins, knees, face, or head from repeated falls should alert the physician. A pronounced ecchymotic area at the site of venipuncture may also be a clue to an alcohol-associated bleeding disorder. In addition to a relationship with anemia (such as folate deficiency), alcohol seems to have a direct bone-marrow suppressant effect that causes thrombocytopenia and leukopenia, with an increase in susceptibility to infection. Fungal infections of the nails and slowhealing abrasions are just two of the nonspecific lesions that can occur with alcobol abuse. ln northern climates, repeated occurrences of frostbite also should make the ciinician suspicious. A form of melanosis is especially corn mon if alcohol abuse bas proceeded to the point of


affecting liver function. This hyperpigmentation is usually manifested as a dirty tan hue that is most noticeable in skin exposed to the sun or in skin subject to chronic irritation, eg, in the axilla. It often is a poorly defined blotchy area sim il ar to the chloasma normal in pregnant women. The mechanism is somewhat obscure but is most likely related to an increase in melanocyte-stimulating hormone, possibly resulting from failure of the liver to destroy this hormone. Four other manifestations are sometimes seen in alcoholics: vascular spiders, telangiectatic nets, palmar erythema, and corkscrew scierai vesse! s. Ail of these visible manifestations generally reflect advanced liver disease, but sometimes they are the first indication of hidden chronic alcoholism. The vascular spiders, also called spider angiomas or arteriole spiders, are circular, stellate, bright red, highly branched lesions that are faintly pulsatile and that blanch on pressure. In alcoholics, they are almost always found in the upper half of the body, sornetimes in groups or crops. However, they also occur in other conditions, such as thyrotoxicosis, and in pregnancy. The vascular spiders of alcoholism can usually be differentiated from the spiders of Rendu-Osier-Weber syndrome in that the latter are flat and discrete, tend to bleed, and have a different distribution. Telangiectatic nets or mats are patches of small finely intermeshed vessels. They are the "paper-money" skin that bas been described in alcoholics. Palmar erythema, a red flush of the thenar and hypothenar eminences, occasionally occurs in alcoholics. This flush can also be seen on the fingertips and, as with vascular spiders, can be a sign of other illnesses, such as thyrotoxicosis or rheumatoid arthritis. The corkscrew scierai vessels are merely extensively tortuous arteries visible in the margins of the sciera of the eye. While not pathognomonic of alcoholism, their appearance should raise the ciinician 's suspicion. Changes in hair and skin texture are also common in alcoholics, especially if drinking bas proceeded to the point of cirrhosis. Initially, however, these changes are subtle and may go unnoticed. In the male alcoholic, there is a definite thinning and softening of

POSTGRADUATE MEDICINE o April1976 o Vol. 59 o No. 4

skin and scalp hair; also, a decrease in facial hair and loss of chest, axillary, and pu bic hair result in a typically female escutcheon. The reverse, increased roughening of the skin and hair, often develops in the female alcoholic. These changes most likely are secondary to an androgen-estrogen imbalance affecting hair follicles.

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Changes in Nails and Fingers

Changes in the characteristics of the patient's nails also occur in alcoholism and usually accompany liver damage and serum protein changes. However, these nail changes may give the clinician sorne important elues to identifying hidden alcoholism. In addition to the increased occurrence of fungal infections and paronychia, four signs of chronic alcohol abuse may be manifested in the nailbed or fingertips. First, clubbing of the fingers can occur and may be secondary to liver disease rather than to pulmonary disease. Second, transverse white bands, sornetimes called Muehrcke's lines, can occur and generally reflect a decrease in serum albumin level. Third, transverse furrows, or Beau's


lines, are characteristic of the cirrhotic individual and may be one of the first clinical signs. Finally, the typical white or opaque nail called Terry's nail is usually seen in the alcoholic in whom cirrhosis has already begun. Another curious entity that is sometimes associated with alcoholism but is also found in nonalcoholics is Dupuytren 's contracture. This is a thickening and contracture of the palmar aponeurosis with resultant flexion deformities of the fingers. The third, fourth, and fifth fingers are commonly affected. Summary

lt is hoped that by being alert to elues easily seen on simple inspection, physicians will be more confident in uncovering hidden alcoholism or at least will pursue further any indications in the patient's behavior or history that might lead to earl y diagnosis and bence to treatment. • Address reprint requests to Peter M. Silberfarb, MD, Department of Psychiatry, Dartmouth Medical School, Hanover, NH 03755.





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Vol. 59 • No. 4 • April 1976 • POSTGRADUATE MEDICINE


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Recognizing alcoholism early by physical signs.

It is hoped that by being alert to clues easily seen on simple inspection, physicians will be more confident in uncovering hidden alcoholism or at lea...
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