Dermatoses Resulting Dermatoses Resulting from Physical Factorsfrom Physical Factors

Chapter 3Chapter 3Andrew’s Diseases of the SkinAndrew’s Diseases of the Skin

Adam Wray, D.O.Adam Wray, D.O.November 15, 2005November 15, 2005

Heat InjuriesHeat Injuries

Thermal BurnsThermal Burns Electrical BurnsElectrical Burns MiliariaMiliaria Miliaria Crystalline (Sudamina)Miliaria Crystalline (Sudamina) Miliaria Rubra (Prickly Heat, Heat Rash)Miliaria Rubra (Prickly Heat, Heat Rash) Miliaria PustulosaMiliaria Pustulosa Miliaria ProfundaMiliaria Profunda Occlusion MiliariaOcclusion Miliaria

Thermal BurnsThermal Burns

First-degree burn- active congestion of First-degree burn- active congestion of superficial blood vesselssuperficial blood vessels

This causes erythema sometimes followed This causes erythema sometimes followed by epidermal desquamationby epidermal desquamation

Constitutional reactions occur if area is Constitutional reactions occur if area is largelarge

Pain and increased surface heat may be Pain and increased surface heat may be severesevere

Second-degree burnsSecond-degree burns

DeepDeep Pale and anestheticPale and anesthetic Injury to reticular Injury to reticular

dermis compromises dermis compromises blood flow and blood flow and destroys destroys appendagesappendages

Healing takes > 1 Healing takes > 1 monthmonth

Scarring occursScarring occurs

SuperficialSuperficial Transudation of Transudation of

serum causing serum causing edema of superficial edema of superficial tissuestissues

Vesicles and blebs Vesicles and blebs Complete recovery Complete recovery

without scar or without scar or blemish is usualblemish is usual

Second-degree burnsSecond-degree burns

Thermal burn: This superficial second degree Thermal burn: This superficial second degree burn is characterized by bullae that contain burn is characterized by bullae that contain serous fluidserous fluid

Second-Degree BurnsSecond-Degree Burns Inflicted scalds: Inflicted scalds:

severe second severe second degree burns after degree burns after dipping dipping

B: two days after B: two days after incident-to lower incident-to lower extremities and extremities and perineumperineum

C: foot and lower C: foot and lower legleg

Second-Degree BurnSecond-Degree Burn

Accidental Accidental scaldscald

Splash-and-Splash-and-droplet droplet pattern of an pattern of an accidental accidental scald from hot scald from hot cup of teacup of tea

Second-Degree BurnSecond-Degree Burn

Curling iron burnCurling iron burn

Third-degree burnsThird-degree burns

Full-thickness Full-thickness tissue losstissue loss

Skin appendages Skin appendages are destroyed are destroyed There is no There is no

epithelium for epithelium for regenerationregeneration

Healing leaves a Healing leaves a scarscar

Fourth-degree burnsFourth-degree burns

Destruction of entire Destruction of entire skin and skin and subcutaneous fat with subcutaneous fat with any underlying any underlying tendonstendons

Rule of nines:Rule of nines: In adults, an In adults, an

estimate of burn estimate of burn extent based upon extent based upon this surface area this surface area distribution chart. distribution chart. Infants & children Infants & children have a relatively have a relatively increased head; increased head; trunk surface area trunk surface area ratioratio

Electrical BurnsElectrical Burns

ContactContact- small but - small but deep, causing some deep, causing some necrosis of necrosis of underlying tissuesunderlying tissues

FlashFlash-burns usually -burns usually cover a large area cover a large area and are similar to a and are similar to a surface burn and surface burn and should be tx as suchshould be tx as such

Lightening is the Lightening is the most lethal type of most lethal type of strike, cardiac arrest strike, cardiac arrest or other internal or other internal injuries may occurinjuries may occur

Electrical BurnsElectrical Burns

IndirectIndirect- burns that - burns that are either linear in are either linear in areas at which sweat areas at which sweat was present; are was present; are feathery or aborescent feathery or aborescent pattern, which is pattern, which is believed to be believed to be pathognomonic pathognomonic

Electrical BurnElectrical Burn

It is characterized It is characterized by erythema, by erythema, edema, bulla edema, bulla formation and formation and sloughing of the sloughing of the necrotic epidermisnecrotic epidermis

Electrical Burn-pathologyElectrical Burn-pathology

Blistering and Blistering and elongated elongated keratinocyteskeratinocytes

MiliariaMiliaria

Retention of sweat as a result of occlusion Retention of sweat as a result of occlusion Common in hot, humid climates Common in hot, humid climates Occlusion of eccrine sweat gland obstructs Occlusion of eccrine sweat gland obstructs

delivery of sweat to the skin surfacedelivery of sweat to the skin surface Eventually backed-up pressure causes Eventually backed-up pressure causes

rupture of sweat gland or duct at different rupture of sweat gland or duct at different levelslevels

Escape of sweat into adjacent tissue produces Escape of sweat into adjacent tissue produces miliariamiliaria

Different forms of miliaria occur depending on Different forms of miliaria occur depending on the level of injury to the sweat glandthe level of injury to the sweat gland

Miliaria CrystallineMiliaria Crystalline

Small, clear, Small, clear, superficial vesicles superficial vesicles without inflammationwithout inflammation

Appears in bedridden Appears in bedridden pts and bundled pts and bundled childrenchildren

Lesions are Lesions are asymptomatic and asymptomatic and rupture at the rupture at the slightest traumaslightest trauma

Self-limited; no tx is Self-limited; no tx is requiredrequired

Miliaria CrystallinaMiliaria Crystallina Minute, discrete Minute, discrete

vesicles resulting vesicles resulting from profuse from profuse sweating sweating secondary to a secondary to a high feverhigh fever

Miliaria CrystallinaMiliaria Crystallina

Miliaria Rubra Miliaria Rubra

Discrete, extremely Discrete, extremely pruritic, pruritic, erythematous erythematous papulovesicles with papulovesicles with sensation of sensation of prickling, burning, or prickling, burning, or tinglingtingling

Site of injury is Site of injury is prickle cell layer prickle cell layer where spongiosis is where spongiosis is producedproduced

Miliaria RubraMiliaria Rubra

Miliaria PustulosaMiliaria Pustulosa

Always preceded by Always preceded by some injury, some injury, destruction, or destruction, or blocking of sweat ductblocking of sweat duct

Pustules independent Pustules independent of hair follicleof hair follicle

Seen in intertriginous Seen in intertriginous areas, flexure areas, flexure surfaces of extrmities, surfaces of extrmities, sctrotum, and back of sctrotum, and back of bedridden ptsbedridden pts

Sterile pustulesSterile pustules

Miliaria ProfundaMiliaria Profunda

Nonpruritic, flesh-colored, Nonpruritic, flesh-colored, deep-seated, whitish deep-seated, whitish papulespapules

Asymptomatic, usually Asymptomatic, usually lasting only 1 hr after lasting only 1 hr after overheating has endedoverheating has ended

Concentrated on the trunk Concentrated on the trunk and extremitiesand extremities

Occlusion is in upper Occlusion is in upper dermisdermis

Only seen in tropics usually Only seen in tropics usually following a severe bout of following a severe bout of miliaria rubramiliaria rubra

Occlusion MiliariaOcclusion Miliaria

May be produced with accompanying May be produced with accompanying anhidrosis and increased heat stress anhidrosis and increased heat stress susceptibility after application of susceptibility after application of extensive polyethylene film occlusion extensive polyethylene film occlusion for > 48 hrsfor > 48 hrs

Tx-place pt in a cool environmentTx-place pt in a cool environment Even a night in an air-conditioned room Even a night in an air-conditioned room

helps alleviate the discomforthelps alleviate the discomfort

Occlusion MiliariaOcclusion Miliaria

Mild cases may respond to dusting Mild cases may respond to dusting powders, such as cornstarch or baby powders, such as cornstarch or baby talcum powdertalcum powder

A lotion containing 1% menthol and A lotion containing 1% menthol and glycerin and 4% salicylic acid in 95% glycerin and 4% salicylic acid in 95% alcohol is effectivealcohol is effective

An oily “shake” lotion such as calamine An oily “shake” lotion such as calamine lotion, with 1% or 2% phenol may be lotion, with 1% or 2% phenol may be effectiveeffective

Erythema (pigmentatio) Erythema (pigmentatio) Ab IgneAb Igne Aka “toasted skin” Aka “toasted skin”

syndromesyndrome Persistent erythema or Persistent erythema or

coarsely reticulated coarsely reticulated residual pigmentation residual pigmentation resulting from itresulting from it

Produced by long-Produced by long-continued exposure to continued exposure to excessive heat without excessive heat without production of a burnproduction of a burn

It begins as a mottling It begins as a mottling caused by local hemostasis caused by local hemostasis and becomes a reticulated and becomes a reticulated erythema, leaving erythema, leaving pigmentationpigmentation

Erythema Ab IgneErythema Ab Igne

Reticulated Reticulated hyperpigmentatiohyperpigmentation with some n with some epidermal epidermal atrophy and atrophy and scaling secondary scaling secondary to use of a to use of a heating padheating pad

Erythema ag igneErythema ag igne

Use of bland Use of bland emollients is helpfulemollients is helpful

No effective treatmentNo effective treatment Kligman’s combination Kligman’s combination

of 5% hydroquinone in of 5% hydroquinone in hydrophilic ointment hydrophilic ointment containing 0.1% containing 0.1% retinoic acid and 0.1% retinoic acid and 0.1% dexamethasone may dexamethasone may reduce unsightly reduce unsightly pigmentationpigmentation

Histologically, an Histologically, an increased amount increased amount of elastic tissue in of elastic tissue in the dermis is seenthe dermis is seen

Changes are Changes are similar to actinic similar to actinic elastosis, and has elastosis, and has been suggested to been suggested to call these changes call these changes thermal elastosisthermal elastosis

Cold InjuriesCold Injuries

ChilblainChilblain FrostbiteFrostbite Immersion injuryImmersion injury

ChilblainsChilblains

Acute chilblains is the mildest form of cold Acute chilblains is the mildest form of cold injuryinjury

Pts are usually unaware of injury until they Pts are usually unaware of injury until they develop burning, itching, and rednessdevelop burning, itching, and redness

Chilblains (pernio)Chilblains (pernio)

TreatmentTreatment

Nifedipine 20mg TIDNifedipine 20mg TID Vasodilators (nicotinaVasodilators (nicotina amide 100 mg TID or dipyridamole amide 100 mg TID or dipyridamole

25 mg TID)25 mg TID) Systemic corticoid tx is helpful in Systemic corticoid tx is helpful in

chilblain lupus erythematosuschilblain lupus erythematosus Pentoxifylline may be usefulPentoxifylline may be useful Smoking strongly discouragedSmoking strongly discouraged

FrostbiteFrostbite When soft tissue is frozen When soft tissue is frozen

and locally deprived of and locally deprived of blood supplyblood supply

Frozen part is painless Frozen part is painless and becomes pale and and becomes pale and waxywaxy

Four stages: Four stages: I- Frost-nip erythema, I- Frost-nip erythema,

edema,cutaneous edema,cutaneous anesthesia & transient anesthesia & transient painpain

II- second degree: II- second degree: hyperemia, edema & hyperemia, edema & blistering, with clear fluid blistering, with clear fluid in bullaein bullae

III- third-degree: full-III- third-degree: full-thickness dermal loss with thickness dermal loss with hemorrhagic bullae hemorrhagic bullae formation or waxy, dry, formation or waxy, dry, mummified skinmummified skin

IV- full-thickness loss of IV- full-thickness loss of entire partentire part

First-Degree FrostbiteFirst-Degree Frostbite

Immersion Foot SyndromesImmersion Foot Syndromes

Trench FootTrench Foot Warm Water Immersion FootWarm Water Immersion Foot

Trench FootTrench Foot

Results from prolonged Results from prolonged exposure to cold, wet exposure to cold, wet conditions without conditions without immersion or actual immersion or actual freezingfreezing

Term derived from trench Term derived from trench warfare in World War 1, warfare in World War 1, when soldiers stood, when soldiers stood, sometimes for hours, in sometimes for hours, in trenches with a few inches trenches with a few inches of cold water in themof cold water in them

Tx-removal from causal Tx-removal from causal environmentenvironment

Tropical Tropical immersion Foot immersion Foot

Seen after continuous immersion of the feet Seen after continuous immersion of the feet in water or mud of temperatures above 71.6 in water or mud of temperatures above 71.6 degrees F (22 degrees C) for 2-10 daysdegrees F (22 degrees C) for 2-10 days

AKA “paddy foot” in VietnamAKA “paddy foot” in Vietnam Erythema, edema, and pain of the dorsal feetErythema, edema, and pain of the dorsal feet Also fever and adenopathyAlso fever and adenopathy Resolution occurs 3 to 7 days after the feet Resolution occurs 3 to 7 days after the feet

have been driedhave been dried

Dermatoses with Cold Dermatoses with Cold HypersensitivityHypersensitivity

Erythrocyanosis CrurumErythrocyanosis Crurum AcrocyanosisAcrocyanosis Cold PanniculitisCold Panniculitis

Erythrocyanosis CrurumErythrocyanosis Crurum

Slight swelling and a Slight swelling and a bluish pink tint of the bluish pink tint of the skin of the legs and skin of the legs and thighs of young girls thighs of young girls and womenand women

May be unilateralMay be unilateral May have cramps in May have cramps in

the legs at nightthe legs at night

Small tender nodules Small tender nodules may be found on may be found on palpationpalpation Nodules may break Nodules may break

down and form small, down and form small, multiple ulcersmultiple ulcers

Seen in northern Seen in northern countries and countries and probably due to an probably due to an abnormal reaction of abnormal reaction of blood vessels to blood vessels to prolonged coldprolonged cold

AcrocyanosisAcrocyanosis

A persistent cyanosis with coldness and A persistent cyanosis with coldness and hyperhidrosis of hands and feethyperhidrosis of hands and feet

Chiefly occurs in young womenChiefly occurs in young women At times, on cold exposure, a digit becomes At times, on cold exposure, a digit becomes

stark white and insensitive (acroasphyxia)stark white and insensitive (acroasphyxia) Cyanosis increases as the temperature Cyanosis increases as the temperature

decreases and changes to erythema with decreases and changes to erythema with elevation of dependent partelevation of dependent part

Cause is unknownCause is unknown Smoking, coffee, and tea should be avoidedSmoking, coffee, and tea should be avoided

AcrocyanosisAcrocyanosis

Cold PanniculitisCold Panniculitis

After exposure to severe cold, well-After exposure to severe cold, well-demarcated erythematous warm plaques demarcated erythematous warm plaques may develop, particularly on the cheeks of may develop, particularly on the cheeks of young childrenyoung children

Lesions usually develop within a few days Lesions usually develop within a few days after exposure, and resolve spontaneously after exposure, and resolve spontaneously in 2 weeks(approx)in 2 weeks(approx)

No tx is indicatedNo tx is indicated Popsicle dermatitis is a temporary redness Popsicle dermatitis is a temporary redness

and induration of the cheek in children and induration of the cheek in children resulting from sucking Popsiclesresulting from sucking Popsicles

Sunburn and Solar Sunburn and Solar ErythemaErythema

Parts of solar spectrum Parts of solar spectrum important to important to photomedicine:photomedicine:

Visible light 400 to 760 Visible light 400 to 760 nmnm

Infrared radiation Infrared radiation beyond 760 nmbeyond 760 nm

Visible light has little Visible light has little biologic activity, except biologic activity, except for stimulating the retinafor stimulating the retina

Infrared radiation is Infrared radiation is experienced as radiant experienced as radiant heatheat

Below 400 nm is the Below 400 nm is the ultraviolet spectrum, ultraviolet spectrum, divided into three bands:divided into three bands:

UVA, 320 to 400 nmUVA, 320 to 400 nm UVB, 290 to 320 nmUVB, 290 to 320 nm UVC, 200 to 290 nmUVC, 200 to 290 nm Virtually no UVC reaches Virtually no UVC reaches

the earth’s surface, the earth’s surface, because it is absorbed because it is absorbed by the ozone layerby the ozone layer Exception: Australia, Exception: Australia,

welderswelders

UVB is 1000 times UVB is 1000 times more erythemogenic more erythemogenic than UVAthan UVA

UVA is 100 times UVA is 100 times greater than UVB greater than UVB radiation during the radiation during the midday hoursmidday hours

Most solar erythema Most solar erythema is cause by UVBis cause by UVB

Sunlight early and Sunlight early and late in the day late in the day contains more UVAcontains more UVA

UVA is reflected from UVA is reflected from sand, snow, or ice to sand, snow, or ice to a greater degree a greater degree than UVBthan UVB

Amount of ultraviolet Amount of ultraviolet exposure increases exposure increases at higher altitudes, is at higher altitudes, is greater in tropical greater in tropical regions, and regions, and temperate climates temperate climates in summerin summer

Sunburn and Solar Sunburn and Solar ErythemaErythema

Clinical signs and symptomsClinical signs and symptoms

Sunburn is normal cutaneous reaction to Sunburn is normal cutaneous reaction to sunlight in excess of an erythema dose sunlight in excess of an erythema dose (the amount that will induce reddening)(the amount that will induce reddening)

UVB erythema peaks at 12 to 24 hrs after UVB erythema peaks at 12 to 24 hrs after exposureexposure

Desquamation is common about a week Desquamation is common about a week after sunburn even in non-blistering after sunburn even in non-blistering areasareas

Sunburn treatmentSunburn treatment

Cool compressesCool compresses Topical steroidsTopical steroids Topical remedy:Topical remedy:Indomethacin 100 mgIndomethacin 100 mgAbsolute ethanol 57 mlAbsolute ethanol 57 mlPropylene glycol 57 mlPropylene glycol 57 ml spread widely over burned area with palms spread widely over burned area with palms

and let dryand let dry

Skin TypesSkin Types

Second-degree sunburnSecond-degree sunburn

ProphylaxisProphylaxis

Avoid sun exposure between 10 am and 2 Avoid sun exposure between 10 am and 2 pmpm

Barrier protection with hats and clothingBarrier protection with hats and clothing Suncreen agents include UV-absorbing Suncreen agents include UV-absorbing

chemicals and UV-scattering or –blocking chemicals and UV-scattering or –blocking agents(physical sunscreens)agents(physical sunscreens)

SunscreensSunscreens

Chemical suncreens-Chemical suncreens-para-aminobenzoic para-aminobenzoic acid(PABA), PABA acid(PABA), PABA esters, esters, cinnamates,salicylatescinnamates,salicylates, anthranilates, , anthranilates, benzophenoes)benzophenoes)

Physical agents-Physical agents-titanium dioxidetitanium dioxide

Combinations of the Combinations of the twotwo

Water resistant-Water resistant-maintaining their SPF after maintaining their SPF after 40 minutes of water 40 minutes of water immersionimmersion

Water proof-maintaining Water proof-maintaining their SPF after 80 mins of their SPF after 80 mins of water immersionwater immersion

UVA protection- UVA protection- sunscreens containing sunscreens containing benzophenones or benzophenones or dibenzoylmethanesdibenzoylmethanes

Apply sunscreen at least Apply sunscreen at least 20mins before sun 20mins before sun exposureexposure

Photoaging(DermatohelioisiPhotoaging(Dermatohelioisis) s)

Characteristic changes induced by chronic Characteristic changes induced by chronic sun exposuresun exposure

Risk of developing these changes Risk of developing these changes correlated with baseline correlated with baseline pigmentation(constitutive pigmentation) pigmentation(constitutive pigmentation) and abilitiy to resist burning and tan and abilitiy to resist burning and tan following sun exposure(facultative following sun exposure(facultative pigmentation)pigmentation)

DermatoheliosisDermatoheliosis

Poikiloderma of Civatte-Poikiloderma of Civatte-refers to reticulate refers to reticulate hyperpigmentation with hyperpigmentation with telangiectasia, and slight telangiectasia, and slight atrophy of sides of the atrophy of sides of the neck, lower anterior neck neck, lower anterior neck and V of neck, and V of and V of neck, and V of chestchest

Submental area is sparedSubmental area is spared frequently presents in frequently presents in

fair-skinned men and fair-skinned men and women in their middle to women in their middle to late thirties or early late thirties or early fortiesforties

DermatoelastosisDermatoelastosis

Cutis rhomboidalis Cutis rhomboidalis nuchaenuchae (sailor’s neck (sailor’s neck or farmer’s neck) is or farmer’s neck) is characteristic of characteristic of long-term, chronic long-term, chronic sun exposuresun exposure

Skin on back of neck Skin on back of neck becomes thickened, becomes thickened, tough, and leathery tough, and leathery and normal skin and normal skin marking become marking become exaggeratedexaggerated

DermatoheliosisDermatoheliosis

Favre-Racouchot Favre-Racouchot syndrome syndrome

Thickened yellow Thickened yellow plaques studded with plaques studded with comedomes and comedomes and cystic lesionscystic lesions

Tx-removal , retinoic Tx-removal , retinoic acid cream, surgical acid cream, surgical removal of cysts and removal of cysts and redundant skinredundant skin

Solar ElastosisSolar Elastosis

Homogenization and a Homogenization and a faint blue color of faint blue color of connective tissue of connective tissue of the upper reticular the upper reticular dermis, so-called dermis, so-called solar solar elastosiselastosis

Characteristically Characteristically there is a zone of there is a zone of normal connective normal connective tissue below the tissue below the epidermisepidermis

PhotosensitivitPhotosensitivityy Photosensitizers may Photosensitizers may

induce an abnormal induce an abnormal reaction in skin reaction in skin exposed to sunlight or exposed to sunlight or its equivalentits equivalent

Substances may be Substances may be delivered externally delivered externally or internallyor internally

Increased sunburn Increased sunburn response without prior response without prior allergic sensitization allergic sensitization called called phototoxicityphototoxicity

Phototoxicity may Phototoxicity may occur from both occur from both externally applied externally applied (phytophotodermatitis (phytophotodermatitis and berloque and berloque dermatitis) or dermatitis) or internally internally administered administered chemicals (phototoxic chemicals (phototoxic drug reaction)drug reaction)

Or by external Or by external contact- (photoallergic contact- (photoallergic contact dermatitis)contact dermatitis)

Phototoxicity vs Phototoxicity vs photoallergyphotoallergy

In the case of external contactants –In the case of external contactants –phototoxicity occurs on initial exposure, has phototoxicity occurs on initial exposure, has onset < 48 hrs, occurs in most people onset < 48 hrs, occurs in most people exposed to the phototoxic substance and exposed to the phototoxic substance and sunlightsunlight

Photoallergy, in contrast, occurs only in Photoallergy, in contrast, occurs only in sensitized persons, may have delayed onset, sensitized persons, may have delayed onset, up to 14 days( a period of sensitization), and up to 14 days( a period of sensitization), and shows histologic features of contact shows histologic features of contact dermatitisdermatitis

PhotosensitivityPhotosensitivity

Drug-induced Drug-induced photosensivity-photosensivity-photoallergic photoallergic dermatitis on dermatitis on sun-exposed sun-exposed areas of an infant areas of an infant following topical following topical use of use of hexachlorophenehexachlorophene

Photoallergic dermatitsPhotoallergic dermatits

Papulovesicular Papulovesicular lesions of lesions of photoallergic photoallergic dermatitis due to dermatitis due to hexachlorophenehexachlorophene

PhytophotosensitivityPhytophotosensitivity

Plant-induced Plant-induced photosensitivity-photosensitivity-linear linear hyperpigmentation hyperpigmentation on the face of a on the face of a child following child following exposure to limes exposure to limes and sunlightand sunlight

PhytophotosensitivityPhytophotosensitivity

Hyperpigmentation on the dorsal Hyperpigmentation on the dorsal aspect of the hands following the use aspect of the hands following the use of limes and sunlight exposureof limes and sunlight exposure

Photosensitivity in Photosensitivity in TattoosTattoos

Yellow cadmium sulfide Yellow cadmium sulfide may be used as a yellow may be used as a yellow dye or may be dye or may be incorporated into red incorporated into red mercuric sulfide pigment mercuric sulfide pigment to produce a brighter red to produce a brighter red color for tattooingcolor for tattooing

When exposed to 380, When exposed to 380, 400, and 450 nm 400, and 450 nm wavelengths of light, wavelengths of light, these areas in tattoos these areas in tattoos may swell, develop may swell, develop erythema, and become erythema, and become verrucoseverrucose

Phototoxic Drug ReactionsPhototoxic Drug Reactions

Most occur from Most occur from tetracyclines, tetracyclines, nonsteroidal nonsteroidal antiinflammatory antiinflammatory drugs, amiodarone, drugs, amiodarone, and phenothiazinesand phenothiazines

Action spectrum for Action spectrum for all is in the UVA all is in the UVA rangerange

In the case of In the case of amiodarone and amiodarone and chlorpromazine, chlorpromazine, hyperpigmentation is a hyperpigmentation is a well-recognized pattern well-recognized pattern of phototoxicityof phototoxicity

It causes slate It causes slate blue(amiodarone) or blue(amiodarone) or slate gray slate gray (chlorpromazine) (chlorpromazine) coloration, resulting coloration, resulting from drug deposition in from drug deposition in the tissuesthe tissues

Drug induced Drug induced photosensitivityphotosensitivity

The erythema is The erythema is less apparent in less apparent in black skin, but the black skin, but the involvement of the involvement of the nose in this patient nose in this patient suggests suggests phototoxicity, in phototoxicity, in this case caused by this case caused by thiazidethiazide

Drug-induced Drug-induced photosensitivityphotosensitivity

Not only the nose Not only the nose was but also the was but also the “V” of the neck “V” of the neck which was highly which was highly suggestive of suggestive of phototoxicityphototoxicity

Same ptSame pt

Drug-induced Drug-induced photosensitivityphotosensitivity

There is erythema There is erythema and edema on the and edema on the exposed sites, the exposed sites, the “V” of the neck .“V” of the neck .

This distribution This distribution would suggest the would suggest the diagnosisdiagnosis

Drug induced Drug induced photosensitivityphotosensitivity

The backs of the The backs of the hands are the hands are the classic sites to be classic sites to be involved in light involved in light induced eruptioninduced eruption

Same ptSame pt

Phototoxic reaction Phototoxic reaction to a nonsteroidal to a nonsteroidal antiinflammatory antiinflammatory drugdrug

Photoallergic Photoallergic dermatitis on sun-dermatitis on sun-exposed areasexposed areas

Polymorphous Light Polymorphous Light EruptionEruption

Most common form of sensitivityMost common form of sensitivity All races and skin types affectedAll races and skin types affected Typically in first three decadesTypically in first three decades Females outnumber malesFemales outnumber males Unknown pathogenesisUnknown pathogenesis Positive family history in 10-50% of ptsPositive family history in 10-50% of pts Different morphologies seen, although in Different morphologies seen, although in

the individual the morphology is constantthe individual the morphology is constant

PMLEPMLE

Exposed areas Exposed areas such as the backs such as the backs of the hands and of the hands and forearms are forearms are affected. affected. Ultraviolet A is Ultraviolet A is mainly responsible mainly responsible and may penetrate and may penetrate window glasswindow glass

PMLEPMLE

The patchiness of The patchiness of the edematous the edematous papules and plaques papules and plaques is characteristicis characteristic

PMLEPMLE

The eruption is less red and confluent than a The eruption is less red and confluent than a sunburn (left)sunburn (left)

Lesions are typically papular & clustered Lesions are typically papular & clustered (right)(right)

PMLE-pathologyPMLE-pathology

Characteristic Characteristic perivascular mononuclear perivascular mononuclear cell infiltrationcell infiltration

PMLEPMLE

Very itchy, Very itchy, red,edematous red,edematous papules, which may papules, which may coalesce into plaques, coalesce into plaques, occur 1 or 2 days occur 1 or 2 days after exposure to lightafter exposure to light

PMLEPMLE

This young women developed a This young women developed a widespread pruritic, papular eruption after widespread pruritic, papular eruption after using a sunbed, which emitted ultraviolet using a sunbed, which emitted ultraviolet AA

PMLEPMLE

Polymorphous light Polymorphous light eruption: eruption: erythematous erythematous papulovesicular papulovesicular and plaque-like and plaque-like lesions with lesions with characteristic characteristic distribution on the distribution on the sun-exposed areas sun-exposed areas of the cheekof the cheek

Actinic PrurigoActinic Prurigo

The clinical The clinical features are features are somewhat somewhat suggestive of PML, suggestive of PML, but the lesions are but the lesions are persistent and the persistent and the HLA type was DR4( HLA type was DR4( occurs in 80-90% occurs in 80-90% of AP pts)of AP pts)

APAP

Severe actinic prurigo shows spread to buttocks (left)Severe actinic prurigo shows spread to buttocks (left) Arms show crusted papules that are denser distally; Arms show crusted papules that are denser distally;

they are also worse in summerthey are also worse in summer

Actinic prurigoActinic prurigo

Actinic prurigo in Native Actinic prurigo in Native American brothersAmerican brothers

Actinic prurigoActinic prurigo

Actinic prurigo in Actinic prurigo in Native American Native American boyboy

AP-pathologyAP-pathology Early lesions have Early lesions have

variable acanthosis and variable acanthosis and spongiosis of the spongiosis of the epidermis with an epidermis with an underlying perivascular underlying perivascular mononuclear cell mononuclear cell infiltrate with edemainfiltrate with edema

Later lesions show crusts, Later lesions show crusts, increasing acanthosis and increasing acanthosis and variable lichenification variable lichenification plus a heavy infiltrate of plus a heavy infiltrate of mononuclear cells, mononuclear cells, leading to a non-specific leading to a non-specific picture(as seen here)picture(as seen here)

Hydroa VacciniformeHydroa Vacciniforme

Photodermatosis with Photodermatosis with onset in childhoodonset in childhood

Lesions appear in crops Lesions appear in crops with disease free with disease free intervalsintervals

Attacks may be preceded Attacks may be preceded by fever and malaiseby fever and malaise

Ears, nose, cheeks, and Ears, nose, cheeks, and extensor arms and hands extensor arms and hands are affectedare affected

Within 6 hrs of exposure Within 6 hrs of exposure stinging may occurstinging may occur

Hydroa VacciniformeHydroa Vacciniforme

There is an early, There is an early, PML-like eruption, PML-like eruption, but with vesicles but with vesicles around the mouth around the mouth and umbilicated and umbilicated lesions on the lesions on the nosenose

Hydroa VacciniformeHydroa Vacciniforme

A later, more A later, more severe example severe example shows shows vesiculation with vesiculation with umbilication, but umbilication, but also marked also marked hemorrhagic hemorrhagic crustingcrusting

Hydroa VacciniformeHydroa Vacciniforme

A severe A severe example of the example of the typical typical vacciniform facial vacciniform facial scarring that may scarring that may develop following develop following repeated acute repeated acute attacksattacks

Acute RadiodermatitisAcute Radiodermatitis

With an “erythema dose” of ionizing With an “erythema dose” of ionizing radiation there is a latent period of up to radiation there is a latent period of up to 24 hrs before visible erythema develops24 hrs before visible erythema develops

Initial erythema lasts 2-3 days but may be Initial erythema lasts 2-3 days but may be followed by a second phase beginning up followed by a second phase beginning up to 1 week after the exposure and lasting to 1 week after the exposure and lasting up to 1 monthup to 1 month

Acute RadiodermatitisAcute Radiodermatitis(fluoroscopic induced)(fluoroscopic induced)

Chronic RadiodermatitisChronic Radiodermatitis Chronic exposure to Chronic exposure to

“suberythema” doses of “suberythema” doses of ionizing radiation over a ionizing radiation over a prolonged period will prolonged period will produce varying amounts produce varying amounts of damage to skin and of damage to skin and underlying skin after a underlying skin after a variable latent period of variable latent period of several months to several several months to several decadesdecades

Telangiectasia, atrophy, Telangiectasia, atrophy, and hypopigmentation and hypopigmentation with residual focal with residual focal increased pigment increased pigment (freckling) may appear(freckling) may appear

Radiation CancerRadiation Cancer

After a latent period averaging 20 –30 yrs, various After a latent period averaging 20 –30 yrs, various malignancies may developmalignancies may develop

Most frequent are basal cell carcinomasMost frequent are basal cell carcinomas Next frequent are squamous cell carcinomasNext frequent are squamous cell carcinomas These may occur in sites of prior radiation even These may occur in sites of prior radiation even

without evidence of chronic radiation damagewithout evidence of chronic radiation damage SCCs arising in sites of radiation therapy SCCs arising in sites of radiation therapy

metastasize more frequently than purely sun-metastasize more frequently than purely sun-induced SCCsinduced SCCs

Other cancers induced by radiation :angiosarcoma, Other cancers induced by radiation :angiosarcoma, malignant fibrous histiocytoma, sarcomas, and malignant fibrous histiocytoma, sarcomas, and thyroid carcinomathyroid carcinoma

Radiation CancerRadiation Cancer

SCC developing in a chronic SCC developing in a chronic radiation ulcer on the chestradiation ulcer on the chest

CallusCallus Nonpenetrating, Nonpenetrating,

circumscribed circumscribed hyperkeratosis produced by hyperkeratosis produced by pressurepressure

Occurs on parts subject to Occurs on parts subject to intermittent pressure(palms, intermittent pressure(palms, soles, bony prominences of soles, bony prominences of the joints)the joints)

Callus differs from clavus in Callus differs from clavus in that a callus has no that a callus has no penetrating central core and penetrating central core and is a more diffuse thickeningis a more diffuse thickening

Calluses tend to disappear Calluses tend to disappear spontaneously when spontaneously when pressure is removedpressure is removed

Clavus(Corns)Clavus(Corns)

Circumscribed, horny, Circumscribed, horny, conical thickenings with conical thickenings with the base on the surface the base on the surface and the apex pointing and the apex pointing inward and pressing on inward and pressing on adjacent structuresadjacent structures

Two types:hard and softTwo types:hard and soft Hard:occur on dorsa of Hard:occur on dorsa of

toes or on solestoes or on soles Soft:occur between toes, Soft:occur between toes,

softened by macerating softened by macerating action of sweataction of sweat

Hard CornHard Corn

CornsCorns Plantar corns can be Plantar corns can be differentiated from plantar differentiated from plantar warts by paring off the warts by paring off the surface keratin until either surface keratin until either the pathognomonic the pathognomonic elongated dermal papillae of elongated dermal papillae of the wart with its blood the wart with its blood vessels, or the clear horny vessels, or the clear horny core of the corn can be core of the corn can be visualizedvisualized

Ddx: also includes Ddx: also includes porokeratosis plantaris porokeratosis plantaris discreta- a sharply discreta- a sharply marginated, cone-shaped, marginated, cone-shaped, rubbery lesion common rubbery lesion common beneath the metetarsal beneath the metetarsal headsheads

Porokeratosis Plantaris Porokeratosis Plantaris DiscretaDiscreta

Multiple lesions can Multiple lesions can occuroccur

Females are affected 3 Females are affected 3 times as frequently than times as frequently than menmen

It is painfulIt is painful Frequently confused with Frequently confused with

a plantar wart or corna plantar wart or corn Keratosis punctata of the Keratosis punctata of the

palmar creases may be palmar creases may be seen in the creases of seen in the creases of the digits of the feet the digits of the feet where it may be where it may be mistaken for a cornmistaken for a corn

Surfer’s Surfer’s NodulesNodules

Nodules 1 to 3 cm (rarely as Nodules 1 to 3 cm (rarely as much as 5 or 6 cm)much as 5 or 6 cm)

Sometimes eroded or Sometimes eroded or ulceratedulcerated

Develop on tops of feet or over Develop on tops of feet or over tibial tubercles of surfboard tibial tubercles of surfboard riders who paddle their boards riders who paddle their boards in a kneeling position, as is in a kneeling position, as is customary in cold water off the customary in cold water off the California coastCalifornia coast

Nodules seldom occur in Nodules seldom occur in surfers in warmer waters like surfers in warmer waters like Hawaii,because a prone Hawaii,because a prone position is usedposition is used

Nodules involute over months Nodules involute over months when there is no surfingwhen there is no surfing

Pressure Ulcers (Decubitus)Pressure Ulcers (Decubitus)

The bedsore is a pressure ulcer produced The bedsore is a pressure ulcer produced anywhere on the body by prolonged pressureanywhere on the body by prolonged pressure

Caused by ischemia of underlying structures Caused by ischemia of underlying structures of skin, fat, and muscles resulting from of skin, fat, and muscles resulting from sustained and constant pressuresustained and constant pressure

Usually in chronically debilitated persons Usually in chronically debilitated persons unable to change positionunable to change position

Bony prominences of body are most Bony prominences of body are most frequently involvedfrequently involved

http://www.ldhpmed.com/DU_wheelchair_image.htm

Care-TxCare-Tx

Ulcer care is criticalUlcer care is critical Debridement-except Debridement-except

stable heel ulcers(do not stable heel ulcers(do not need debridement if only need debridement if only a dry eschar is present)a dry eschar is present)

Clean wounds initially Clean wounds initially and at each dressing and at each dressing change via nontraumatic change via nontraumatic techniquetechnique

Normal saline is bestNormal saline is best Dressing selection Dressing selection

should maintain moist should maintain moist environmentenvironment

Occlusive dressings Occlusive dressings like film and like film and hydrocolloid are often hydrocolloid are often utilizedutilized

Surgical debridement Surgical debridement with reconstructive with reconstructive procedures may be procedures may be neededneeded

Electrical stimulation Electrical stimulation of refractory ulcers of refractory ulcers may be beneficialmay be beneficial

Friction BlistersFriction Blisters

Formation of vesicles or Formation of vesicles or bullae occurring at sites bullae occurring at sites of combined pressure of combined pressure and frictionand friction

Enhanced by heat and Enhanced by heat and moisturemoisture

Examples: feet of military Examples: feet of military recruits in training,palms recruits in training,palms of oarsmen not having of oarsmen not having developed protective developed protective calluses, beginning calluses, beginning drummers (“drummer’s drummers (“drummer’s digits”) digits”)

Sclerosing LymphangiitisSclerosing Lymphangiitis

Cordlike structure Cordlike structure encircling the coronal encircling the coronal sulcus of the penis, or sulcus of the penis, or running the length of running the length of the shaftthe shaft

Attributed to trauma Attributed to trauma Produced by a Produced by a

sclerosing sclerosing lymphangiitislymphangiitis

No tx is neededNo tx is needed Follows a benign, Follows a benign,

self-limiting courseself-limiting course

Black HeelBlack Heel

Also called Also called talon noirtalon noir, , calcaneal petechiae,calcaneal petechiae, and and chromidrose plantairechromidrose plantaire

A sudden shower of A sudden shower of minute macules occurs minute macules occurs most often on the most often on the posterior edge of the posterior edge of the plantar surface of one or plantar surface of one or both heelsboth heels

Sometimes occurs distally Sometimes occurs distally on one or more toeson one or more toes

Black heel is seen in Black heel is seen in basketball, volleyball, basketball, volleyball, tennis, or lacrosse playerstennis, or lacrosse players

Painful Fat Painful Fat HerniationHerniation

AKA painful piezogenic pedal AKA painful piezogenic pedal papulespapules

Rare cause of painful feet Rare cause of painful feet representing fat herniations representing fat herniations through thin fascial layers of through thin fascial layers of weight-bearing parts of the weight-bearing parts of the heelheel

These dermatoceles become These dermatoceles become apparent when wt is placed apparent when wt is placed on the heelon the heel

These disappear when These disappear when pressure is removedpressure is removed

Extrusion of fat tissue Extrusion of fat tissue together with its blood together with its blood vessels and nerves initiates vessels and nerves initiates pain on prolonged standing pain on prolonged standing

Avoidance of Avoidance of prolonged standing prolonged standing is the only way to is the only way to provide reliefprovide relief

Majority of people Majority of people experience no experience no symptomssymptoms

Painful Fat HerniationPainful Fat Herniation

Narcotic DermopathyNarcotic Dermopathy

Heroin(diacetylmorphiHeroin(diacetylmorphine) is a narcotic ne) is a narcotic prepared by dissolving prepared by dissolving the heroin powder in the heroin powder in boiling water and then boiling water and then injecting itinjecting it

Favored route is IVFavored route is IV Resulting in Resulting in

thrombosed, cordlike, thrombosed, cordlike, thickened veins thickened veins

Narcotic DermopathyNarcotic Dermopathy

Subcutaeous injection (“skin popping”) can result in multiple, Subcutaeous injection (“skin popping”) can result in multiple, scattered ulcerations, which heal with discrete atrophic scarsscattered ulcerations, which heal with discrete atrophic scars

Narcotic DermopathyNarcotic Dermopathy

Ulcer from Ulcer from extravascular injection extravascular injection of “speed” of “speed” (amphetamine)(amphetamine)

TatooingTatooing

Photosensitivity can occur from pigments Photosensitivity can occur from pigments used (cadmium sulfide-used for yellow used (cadmium sulfide-used for yellow color or to brighten up cinnabar red)color or to brighten up cinnabar red)

Unsanitary tattooing has resulted in Unsanitary tattooing has resulted in inoculation of syphilis, infectious hepatitis, inoculation of syphilis, infectious hepatitis, tuberculosis, HIV, and leprosytuberculosis, HIV, and leprosy

Occasionally keloid formation occursOccasionally keloid formation occurs Accidental tattoo marks may be induced Accidental tattoo marks may be induced

by narcotic addicts who sterilize needles by narcotic addicts who sterilize needles for injection by flaming needle with a for injection by flaming needle with a lighted matchlighted match

TattooingTattooing Discoid lupus has been reported to occur in red-Discoid lupus has been reported to occur in red-

pigmented portions of tattoospigmented portions of tattoos Sarcoid nodules and granuloma annulare-like Sarcoid nodules and granuloma annulare-like

lesions have also been seenlesions have also been seen Dermatitis in areas of re (mercury), green Dermatitis in areas of re (mercury), green

(chromium), or blue (cobalt) have been (chromium), or blue (cobalt) have been described in pts patch-test positive to these described in pts patch-test positive to these metalsmetals

Tx:Q-switched laser allows removal without Tx:Q-switched laser allows removal without scarringscarring

One report of five pts who developed darkening One report of five pts who developed darkening after tx due to ferrous oxide formationafter tx due to ferrous oxide formation

ParaffinomaParaffinoma AKA-sclerosing AKA-sclerosing

lipogranulomalipogranuloma Injection of paraffin into Injection of paraffin into

skin for cosmetic purposesskin for cosmetic purposes Smoothing of wrinkles and Smoothing of wrinkles and

breast augmentationbreast augmentation Oils like paraffin, Oils like paraffin,

camphorated oil, camphorated oil, cottonseed or sesame oil, cottonseed or sesame oil, beeswax were usedbeeswax were used

These can produce plaque-These can produce plaque-like indurations with like indurations with ulcerations after timeulcerations after time