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Author: Dr Delwyn Dyall-Smith FACD, Dermatologist, 2015.
There are two main forms of inflammatory bowel disease – ulcerative colitis and Crohn disease. Both are characterised by abdominal pain and diarrhoea, sometimes with bleeding.
Although the two diseases are quite separate, accurate diagnosis can sometimes be difficult especially in the early stages. Therefore involvement of other organs can help to make the distinction.
Both forms of inflammatory bowel disease can develop symptoms and signs in addition to the bowel disease. Changes in the skin and oral mucosa can develop with both, but are more commonly seen with Crohn disease. Sometimes these develop before the diagnosis of inflammatory bowel disease, leading the doctor to investigate for bowel problems. In some patients they may appear with flares of the bowel inflammation. Where the association is specific with diagnostic histology, it can be valuable in making the diagnosis.
The changes of the face and oral mucosa associated with inflammatory bowel disease can be divided into four main categories:
The first three of these categories may be useful in directing the doctor to the bowel problem and making the specific diagnosis.
The oral mucosa is commonly affected in Crohn disease with up to one third of patients reported to have oral changes, and even higher in children. In some studies, the oral changes preceded the diagnosis of Crohn disease in 60%. There may be a male predominance.
1. Specific oral mucosal changes: orofacial Crohn disease
In children with Crohn disease, orofacial Crohn disease can be an important presentation preceding the bowel diagnosis.
2. Nonspecific changes in the mouth and surrounding facial skin associated with Crohn disease:
Mucosal changes have been reported in some patients with ulcerative colitis.
1. Specific orofacial changes of ulcerative colitis: pyostomatitis vegetans
2. Nonspecific changes of the mouth and surrounding skin associated with ulcerative colitis:
In children with ulcerative colitis, only nonspecific changes were seen in one large study.
Malabsorption may be due to the chronic diarrhoea, reduced food intake, overgrowth of bacteria in the bowel, bowel surgery, the disease itself, or the drugs used to treat the bowel disease.
Many different medications may be used to treat various aspects of inflammatory bowel diseases including antibiotics, biologic agents, immunosuppressants, anti-diarrhoeal agents and for pain. An alphabetical listing of some of the more common treatments follows, with their oral side effects.
|adalimumab (biologic)||infections, angioedema|
|Budesonide (oral steroid)||glossitis, swelling of the tongue, dry mouth|
|Certolizumab (biologic)||Stevens-Johnson syndrome / toxic epidermal necrolysis, angioedema|
|Cholestyramine (anion exchange resin)||irritation of the tongue, sour taste, dental bleeding, dental caries, erosion of tooth enamel, tooth discoloration|
|Ciclosporin (calcineurin inhibitor)||gum hyperplasia|
|Ciprofloxacin (antibiotic)||oral candidiasis, angioedema, Stevens-Johnson syndrome / toxic epidermal necrolysis, loss of taste|
|Colestipol (anion exchange resin)||difficulty swallowing|
|Diphenoxylate and atropine (antispasmodics)||dry mouth, lip swelling, taste changes or loss|
|Infliximab (biologic)||infections, angioedema|
|Loperamide (antidiarrhoeal)||dry mouth, Stevens-Johnson syndrome / toxic epidermal necrolysis, angioedema|
|Mesalazine (anti-inflammatory)||sore throat, oral candidiasis, dry mouth, stomatitis, altered taste|
|Methotrexate (folic acid antagonist)||stomatitis, gingivitis, pharyngitis|
|Metronidazole (antibiotic)||unpleasant metallic taste, furry tongue, glossitis, stomatitis, oral candidiasis, dry mouth|
|Prednis(ol)one (oral steroid)||oral candidiasis (thrush)|
|Propantheline (antispasmodic)||dry mouth, angioedema, loss of taste|
|Sulphasalazine (anti-inflammatory)||stomatitis, Stevens-Johnson syndrome / toxic epidermal necrolysis, altered taste, impaired folic acid absorption|
|Tacrolimus (calcineurin inhibitor)||oral candidiasis, aphthous mouth ulcers, Stevens-Johnson syndrome / toxic epidermal necrolysis, angioedema|
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