The Butterfly Sign - A Clue To Generalized Pruritus In A Patient With Chronic Obstructive Hepatobiliary Disease

Patients with chronic hepatobiliary disease are often initially seen with complaints of intense, generalized pruritus in the early stages of their disease.1Their pruritus, with subsequent excoriation, typically leads to postinflammatory hyperpigmentation. The hyperpigmentation is not limited to sunexposed areas. A characteristic butterfly area of relative hypopigmentation is frequently seen on the spared, unreachable areas of the back.2This characteristic skin finding should alert the physician to the possibility of chronic obstructive biliary disease. Report of a Case A 59-year-old woman was seen in our dermatology clinic with a two-year history of generalized pruritus that had become worse during the six months prior to examination. She had had a decreased appetite and lost 18 kg during that time. The patient denied having any change in bowel habits or in the color of her stool or urine. There was no history of alcohol abuse or liver, renal, endocrinologic, or