Panhypopituitarism
Cutaneous signs include:
• Smooth facial skin with fine wrinkles, loss of facial hair, reduced body hair.
• Decreased ability to tan and pale yellowish skin (deficiency of ACTH, which has a role
in regulating melanin pigmentation).
Addison disease
Primary adrenal failure is commonly caused by autoimmune adrenalitis or infection (TB,
fungal, CMV, AIDS). High levels of circulating pituitary peptides, e.g. pro
opiomelanocortin, ACTH β-lipotropin, and melanocyte- stimulating hormone, induce
melanocyte activity. Look for:
• Hyperpigmentation of sun-exposed skin.
• Hyperpigmentation in palmar creases, axillae, nipples, old scars, and sites of pressure or
friction such as knuckles and waistline.
• Pigmented mucous membranes—lips (can occur up to 10 years before diagnosis, may
be diffuse, speckled, or streaks), gums, buccal, vaginal, vulval, and anal.
• Darkening of melanocytic naevi and hair.
• If caused by autoimmune adrenalitis, you may find vitiligo.
Note: hyperpigmentation does not occur if adrenal failure is secondary to ACTH
deficiency, e.g. after withdrawing oral glucocorticoids.
Cushing syndrome
Cushing syndrome is associated with inappropriately elevated free plasma glucocorticoid.
Skin signs include:
• Central obesity with thin arms and legs. Dorsal neck and supraclavicular fat pads.
Plethoric telangiectatic round ‘moon’ face.
• Hirsutism with fine hair on the cheeks.
• Atrophic skin with purple striae on the trunk, upper thighs, and arms.
• Easy bruising.
• Cutaneous fungal infections: pityriasis versicolor, widespread Trichophyton rubrum
(nails, trunk, buttocks), nail candidiasis.
• Acne: pustules and peri follicular papules, but no comedones.
• Signs of virilism if adrenal tumour produces androgens.
• Hyperpigmentation if associated with high ACTH levels, e.g. in ectopic ACTH
syndrome, Addison disease, and Nelson syndrome.
• Signs of Carney syndrome/McCune–Albright syndrome.
Acromegaly
Excess secretion of growth hormone by pituitary tumours.
Look for:
• Thick greasy, coarse, furrowed skin on the face and neck.
• Frontal bossing, thick lips, and broad nose; doughy hands.
• Cutis verticis gyrata (thick ridges and furrows on the scalp).
• Hyperhidrosis (common). Hyperpigmentation: 40% of patients. Hirsutism: 50% of
patients.