Alcohol consumption is a major public health issue worldwide, with its misuse contributing significantly to both systemic and dermatological morbidity. Chronic alcohol dependence is known to produce a wide array of cutaneous manifestations, either as a direct toxic effect of ethanol on the skin, through its systemic consequences such as liver dysfunction and malnutrition, or due to neglect of personal hygiene and high-risk behaviours (1). Despite these associations, the skin remains an underutilized diagnostic window in the early identification of alcohol misuse, especially in primary care and dermatological settings.

The skin changes associated with chronic alcoholism include vascular anomalies such as spider nevi and palmar erythema, pigmentary disorders, nail changes like Terry’s nails and Muehrcke’s lines, infectious dermatoses, nutritional deficiencies (e.g., pellagra, scurvy), and exacerbation of pre-existing dermatoses like psoriasis and seborrheic dermatitis (2). In a seminal study by Rosset and Oki, a high prevalence of skin conditions was reported in alcoholics, with 43% of males and 33% of females affected by various dermatoses (3). Higgins and colleagues also noted a significant association between alcohol use and seborrheic dermatitis, onychomycosis, and tinea infections in their observational research (4). However, most of these studies have originated from Western populations with minimal representation from Indian cohorts.

In the Indian context, alcohol use is rising, with national prevalence estimates ranging between 14% and 30% among adult males (5). Yet, data on the dermatological burden associated with chronic alcohol use in Indian settings, particularly rural populations, remains sparse. Some regional studies have noted cutaneous indicators like pellagra, rosacea, and oral pigmentation in alcoholics, but have lacked comprehensive categorization or correlation with alcohol dependence parameters (6). This research gap is significant, considering the unique socio-demographic, dietary, and health-seeking behaviours in rural India that may influence the type and presentation of dermatoses.

Furthermore, there is a lack of structured studies that correlate dermatological findings with measurable parameters such as duration of drinking, quantity of alcohol consumed, and severity of dependence using validated tools like the Severity of Alcohol Dependence Questionnaire (SADQ). This limits the potential of using skin manifestations as early markers for detecting problem drinking, which could be particularly valuable in dermatology clinics and rural primary care settings where psychiatric screening tools are not routinely employed.

The present study was conducted to determine the prevalence and spectrum of cutaneous manifestations among chronic alcohol-dependent patients attending a rural tertiary care hospital in India. The objective was also to provide a structured classification of these manifestations and contribute Indian data to the global literature on alcohol-related dermatoses.

Study Design and Setting: This was a descriptive cross-sectional study conducted at the Psychiatry and Dermatology departments (both inpatient and outpatient services) of Kamineni Institute of Medical Sciences, Narketpally, Telangana. The study was carried out over a period of two years, from October 2017 to September 2019.

Study Population: A total of 205 patients diagnosed with alcohol dependence were included in the study. Diagnosis was confirmed by a psychiatrist using the International Classification of Diseases, 10th revision (ICD-10) criteria. Among these, 199 were males and 6 were females. Due to the small number of female patients, only male patients were included in the final analysis.

Inclusion Criteria

• Male patients aged 18 years and above
• Diagnosed with Alcohol Dependence Syndrome (ADS) based on ICD-10 criteria
• Provided written informed consent for participation

Exclusion Criteria

• Patients below 18 years of age
• Patients with comorbid psychiatric illnesses that could interfere with assessment
• Individuals unwilling to participate

Sampling Method: A consecutive sampling method was adopted. Every eligible alcohol-dependent patient presenting to the Psychiatry or Dermatology departments during the study period was evaluated and recruited.

Data Collection Procedure: After obtaining informed consent, a detailed history including alcohol use parameters (age of onset, duration, quantity, type of alcohol consumed) was collected. The severity of alcohol dependence was measured using the Severity of Alcohol

Dependence Questionnaire (SADQ).

All participants underwent a complete general and dermatological examination, including assessment of the skin, hair, nails, oral cavity, and genital mucosa. Relevant investigations were carried out when required to support clinical diagnosis, including:

• Hematological investigations
• Liver function tests (LFTs)
• Tzanck smear
• KOH mount
• Acid-fast bacilli (AFB) smear
• Skin biopsy
• Abdominal ultrasonography and upper GI endoscopy (when indicated)

Diagnosis of Alcoholic Liver Disease (ALD) was based on clinical findings supported by imaging and liver function tests, using established criteria referenced from Sheila Sherlock’s Diseases of the Liver and Biliary System.

Data Analysis: Descriptive statistics were used to summarize the spectrum and frequency of dermatological findings. Independent sample t-tests were employed to compare means of variables (e.g., alcohol quantity, SADQ score) between groups with and without skin disease. A chi-square test was applied to assess the association between skin disease and presence of ALD. A p-value < 0.05 was considered statistically significant.

Ethical Considerations: The study was approved by the Institutional Ethical Committee. All procedures followed the ethical standards of the responsible committee and with the Helsinki Declaration of 1975, as revised in 2000. Informed consent was obtained from all individual participants included in the study.

Table 1: Age Distribution of Study Participants

The majority of alcohol-dependent patients in the study were middle-aged, with the highest numbers in the 41–45 (40 patients), 46–50 (38), and 36–40 (35) year groups. This suggests that chronic alcohol-related health issues are most prominent in the fourth and fifth decades of life, highlighting the need for focused intervention in this age group (Table 1).

The figure 1 shows that 86.8% of alcohol-dependent patients exhibited at least one significant skin disease, while only 13.2% had no dermatological findings. This high prevalence highlights the strong association between chronic alcohol use and cutaneous manifestations, reinforcing the value of skin examination as a clinical indicator of alcohol dependence.

Among the alcohol-dependent patients studied, 45.2% had mild dependence, 41.7% had moderate dependence, and 13.1% had severe dependence based on the Severity of Alcohol Dependence Questionnaire (SADQ). This distribution indicates that most patients fell into the mild-to-moderate range, suggesting an opportunity for early intervention before progression to severe dependency

The figure 3 shows that Alcoholic Liver Disease was present in 50.3% of alcohol-dependent patients, while 49.7% did not exhibit ALD. This near-equal distribution highlights that although ALD is a common consequence of chronic alcohol use, a significant proportion of alcoholics may still present without liver involvement, reinforcing the need to assess extra-hepatic indicators such as skin changes for early identification of alcohol-related morbidity.

The figure 3 illustrates the prevalence of key dermatological signs linked to chronic alcohol use. Jaundice was the most common finding (15%), followed by palmar erythema (12.5%), Terry’s nails (9.5%), and spider nevi/telangiectasia (9%). Less common manifestations included clubbing (5%), red lunula (1.5%), and diffuse pigmentation (2.5%). These findings reflect the systemic impact of alcohol, particularly on liver function and vascular health, and emphasize the diagnostic value of skin examination in identifying chronic alcohol abuse.

Table 2: Prevalence of Alcohol-Induced Skin Diseases

Among alcohol-dependent individuals, a wide range of skin conditions were observed as direct or indirect consequences of alcohol use. Xerosis was the most prevalent (25.6%), followed by fungal infections (21.6%) and seborrheic dermatitis (19%). Hyperhidrosis (16%) and bacterial infections (11.5%) were also common. Nutritional dermatoses such as pellagra (7%), along with urticaria and scabies (2% each), were less frequent. These findings reflect the impact of alcohol on immune function, skin barrier integrity, and nutritional status, highlighting the diagnostic value of dermatological evaluation in chronic alcohol users (Table 2).

Table 3: Miscellaneous Cutaneous Findings in Alcohol-Dependent Patients

A diverse range of non-specific but frequently observed skin and adnexal findings were noted among alcohol-dependent individuals. Oral pigmentation was the most prevalent (52.2%), followed by Idiopathic Guttate Hypomelanosis (IGH) (25.6%), melanonychia (25.1%), and vertical nail ridging (20.6%). Cherry angiomas (18.5%) and androgenetic alopecia (19.5%) were also common. Additional findings included melasma (7.5%), road traffic accident (RTA) scars (15.5%), and tattoos (17.5%). Though these may not be directly caused by alcohol, their frequent presence may reflect lifestyle factors, chronic systemic effects, or coexisting habits in individuals with alcohol dependence (Table 3).

Table 4: Types and Prevalence of Infectious Dermatoses in Alcohol-Dependent Patients

Among alcohol-dependent individuals, infectious skin diseases were notably common. Bacterial infections were dominated by trichomycosis axillaris (65.2%), with lesser contributions from impetigo, erythrasma, paronychia, and pitted keratolysis. Fungal infections were also prominent, especially pityriasis versicolor (42.5%) and onychomycosis (23.4%), followed by candidiasis and dermatophytosis. Viral infections included warts (66.7% of viral cases) and herpes (33.3%). These infections reflect alcohol-related immune compromise, poor hygiene, and nutritional deficiencies, emphasizing the need for regular skin screening in this vulnerable population (Table 4).

Table 5: Nutritional and Hair Dermatoses in Alcohol-Dependent Patients

Among the nutritional dermatoses, pellagra or pellagroid dermatoses were the most frequent (8 cases), followed by glossitis (5) and angular cheilitis (1), indicating B-complex and niacin deficiencies common in chronic alcohol use. Regarding hair-related findings, androgenetic alopecia was predominant (39 cases), with occasional findings of alopecia areata (3) and pediculosis (2). These conditions reflect the cumulative impact of alcohol on nutritional status, hormonal balance, immune function, and hygiene (Table 5).

Table 6: Oral Mucosal and Pigmentary Changes in Alcohol-Dependent Patients

Oral mucosal changes were highly prevalent, with dental caries (128 cases) and bluish pigmentation (101) being the most common, reflecting poor oral hygiene and possible systemic effects of chronic alcohol use. Less frequent findings included oral candidiasis and glossitis (4 cases each). Among pigmentary disorders, Idiopathic Guttate Hypomelanosis (IGH) was the most common (51 cases), followed by melasma (15), macular amyloidosis (8), and knuckle pigmentation (7). Diffuse pigmentation and vitiligo were less common. These findings point to both nutritional deficiencies and systemic effects of long-term alcohol abuse on the skin and mucosa (Table 6).

Table 7: Nail and Eczematous Dermatoses in Alcohol-Dependent Patients

Nail changes were commonly observed in alcohol-dependent patients, with melanonychia (28 cases) and vertical ridging (23 cases) being the most frequent. Classic signs of systemic disease such as Terry’s nails (11), Muehrcke’s lines (8), clubbing (5.7%), and red lunula (1.7%) were also noted. Miscellaneous nail findings accounted for 9 cases. In terms of eczematous dermatoses, nummular eczema (4 cases) and contact dermatitis (3) were the main conditions, with asteatotic eczema seen in one patient. These findings reflect nutritional deficiencies, liver dysfunction, and irritant exposure often associated with chronic alcohol use (Table 7).

Among the alcohol-dependent patients who presented with sexually transmitted diseases (STDs), Candidal balanoposthitis was the most common (40%), followed by herpes progenitalis and genital warts, each accounting for 30% of cases. The occurrence of these infections reflects high-risk sexual behavior, immunosuppression, and neglect of personal hygiene often associated with chronic alcohol abuse

The present study, conducted at a rural tertiary care hospital in South India, evaluated 199 male patients diagnosed with alcohol dependence to determine the prevalence and variety of cutaneous manifestations associated with chronic alcohol use. A striking 87.4% of the study population demonstrated at least one significant dermatological finding, underscoring the skin as a sensitive marker of systemic substance abuse.

The most frequently observed findings were xerosis (25.6%), oral pigmentation (52.2%), seborrheic dermatitis (19%), onychomycosis (23.4%), melanonychia (25.1%), and androgenetic alopecia (19.5%). These are largely consistent with previous literature, affirming alcohol's multifaceted impact on skin health.

Infections were common, particularly fungal infections (21.6%), with Pityriasis versicolor being the most prevalent. This aligns with the findings by Padma et al., who also noted increased incidence of Malassezia-related conditions in alcoholics due to immunosuppression and poor hygiene (7). Trichomycosis axillaris, a bacterial infection, accounted for 65% of all bacterial cases, indicating sweat gland involvement in this population a finding similar to reports by Buttler et al., (8).

Nutritional dermatoses like pellagra, glossitis, and angular cheilitis were noted in 7% of patients, reflecting the role of chronic alcohol use in inducing vitamin B complex deficiencies. These findings are in line with observations made by Jain and colleagues, who reported that chronic alcohol abuse disrupts niacin metabolism, leading to pellagroid presentations (9).

Nail changes, including Terry’s nails, red lunulae, and Muehrcke’s lines, were observed in 63.7% of patients often regarded as stigmata of liver dysfunction and malnutrition. Spider nevi and palmar erythema, classical signs of alcoholic liver disease (ALD), were observed in 9% and 12.5% of patients respectively. However, not all patients with these signs had biochemical or radiological confirmation of ALD, suggesting that these may precede overt hepatic damage or appear independently (10).

Psoriasis (5.5%), rosacea (3%), and nummular eczema (2.5%) were among the dermatoses known to be exacerbated by alcohol use, corroborating prior studies where alcohol was implicated as a trigger for persistent or treatment-resistant dermatoses (11).

When correlating skin disease with alcohol dependence parameters, the study found a statistically significant association between the quantity of alcohol consumed and presence of skin disease (p = 0.05), whereas duration and severity scores (SADQ) did not show significant differences. This suggests a dose-dependent threshold effect in the manifestation of alcohol-induced skin conditions, consistent with findings by Al-Jefri et al. who showed higher prevalence of androgenetic alopecia in heavy drinkers regardless of duration (12).

Comparative studies such as one by Sengottuvel et al. in Tamil Nadu reported similar patterns of infectious and nutritional dermatoses in chronic alcoholics, although the overall prevalence of skin manifestations in our study was slightly higher, possibly due to differences in geographic and nutritional factors or better screening practices in the current study setting (13).

This study highlights that cutaneous manifestations are extremely common in patients with chronic alcohol dependence and encompass a wide range of conditions, from infections and nutritional deficiencies to pigmentary and vascular changes. Importantly, many of these skin conditions can serve as early clinical clues to underlying alcohol misuse, especially in resource-limited rural settings where detailed psychiatric evaluation may not be feasible.

Our findings reinforce the need for dermatologists and primary care physicians to maintain a high index of suspicion for alcohol abuse when encountering patients with unusual, persistent, or recurrent dermatoses. Integrating dermatological signs into routine screening protocols could facilitate early diagnosis and timely intervention, ultimately improving both dermatological and systemic outcomes for individuals with alcohol dependence.

1. Smith KE, Fenske NA. Cutaneous manifestations of alcohol abuse. J Am Acad Dermatol. 2000;43(1 Pt 1):1-18. doi:10.1067/mjd.2000.104512
2. Liu SW, Lien MH, Fenske NA. The effects of alcohol and drug abuse on the skin. Clin Dermatol. 2010;28(4):391-399. doi:10.1016/j.clindermatol.2010.03.024
3. Rosset M, Oki G. Skin diseases in alcoholics. Quarterly journal of studies on alcohol. 1971 Dec 1;32(4):1017-24.
4. Higgins EM, Vivier AD. Cutaneous disease and alcohol misuse. British medical bulletin. 1994 Jan 1;50(1):85-98.
5. Rastogi A, Manthey J, Wiemker V, Probst C. Alcohol consumption in India: a systematic review and modelling study for sub‐national estimates of drinking patterns. Addiction. 2022 Jul;117(7):1871-86.
6. Rao SK, Srinivas RT, Reddy M, Ashraf A. Study of Cutaneous Manifestations in Alcohol Dependence Syndrome Patients in a Rural Tertiary Care Center in India. Addict Health. 2023 Jan;15(1):45-52. doi: 10.34172/ahj.2023.1340. Epub 2023 Jan 2PMID: 37560076; PMCID: PMC10408745.
7. Padma K, Hegde S, Yadihal AG, Shetty S. Dermatological Disorders in Patients with Alcohol Dependence Syndrome: An Observational Clinical Study. Indian Journal of Private Psychiatry. 2019 Jan;13(1):5.
8. Buttler L, Stange J, Pyrsopoulos N, Hassanein T, Wedemeyer H, Maasoumy B, Busch M; VTL‐308 study group. Bacterial Infections in Patients With Severe Alcohol-Associated Hepatitis: Drivers of Organ Failure and Mortality. Liver Int. 2025 Jun;45(6):e70111. doi: 10.1111/liv.70111. PMID: 40332100; PMCID: PMC12057653.
9. Jain NP, Shao K, Stewart C, Grant-Kels JM. The effects of alcohol and illicit drug use on the skin. Clinics in Dermatology. 2021 Sep 1;39(5):772-83.
10. Witkowska AB, Jasterzbski TJ, Schwartz RA. Terry's Nails: A Sign of Systemic Disease. Indian J Dermatol. 2017 May-Jun;62(3):309-311. doi: 10.4103/ijd.IJD_98_17. PMID: 28584375; PMCID: PMC5448267.
11. Szentkereszty-Kovács Z, Gáspár K, Szegedi A, Kemény L, Kovács D, Törőcsik D. Alcohol in Psoriasis-From Bench to Bedside. Int J Mol Sci. 2021May 7;22(9):4987. doi: 10.3390/ijms22094987. PMID: 34067223; PMCID: PMC8125812.
12. Al-Jefri K, Newbury-Birch D, Muirhead CR, et al. High prevalence of alcohol use disorders in patients with inflammatory skin diseases. Br J Dermatol.2017;177(3):837-844. doi:10.1111/bjd.15497
13. Sengotuven KL, Murugaiyan R, Kaliaperumal K. Cutaneous manifestations of chronic alcoholism: a cross sectional study in a tertiary care centre in South India. Int J Res Dermatol. 2016 Oct;2(4):55-63.