MW_S_Rationales_files/Rash Rationale

Transcription

A RATIONALE FOR RASHES
A
RATIONALE
FOR
RASHES
Assoc. Prof. Warwick Carter
MB.BS; FRACGP; FAMA
A guide to the diagnosis of skin rashes,
patches, itches and damage.
1
CONTENTS
Introduction
SECTION ONE
Dermatological Diagnostic Flow Chart
A flow chart that leads the user through various symptoms and signs to possible diagnoses.
SECTION TWO
Diagnostic Algorithm for Rashes
Symptoms and signs involving the skin and the conditions that may be responsible
SECTION THREE
Dermatological Conditions
The symptoms, signs, investigation and treatment of medical conditions
that may cause an alteration in the skin.
Appendices
Syndromes that may cause Skin Lesions
Sun Exposure Skin Abnormalities
2
INTRODUCTION
This book is designed for both the medical student and the doctor who is not a specialist in
dermatology.
It will take the user through a logical rationale in order to diagnose, and then treat, virtually
every rash or skin condition likely to be encountered outside a specialist practice.
There are two ways to reach a diagnosis, using the flow chart in Section One, or the
Diagnostic Algorithms in Section Two.
In Section One, a flow chart will guide the user through the presenting symptoms and signs
of most rashes to a selection of possible diagnoses.
As an alternative, the algorithms in Section Two will indicate the diagnoses possible with a
variety of dermatological presenting symptoms.
Once a diagnosis has, or number of differential diagnoses have been made, a detailed
explanation of the various dermatological diagnoses can be found in the largest part of the
book, Section Three. This has been written in a style that should be easy to understand by
even junior medical students, with technical terms explained in each monograph, but should
still be useful to the non-specialist doctor. The symptoms, signs, investigations and treatment
of a very wide range of conditions are explained, along with pictures of the more common
conditions.
I trust that you will find it useful.
Warwick Carter
Brisbane
OTHER BOOKS IN THIS SERIES
A Rationale for the Brain
A Rationale for Eyes
A Rationale for the Abdomen
A Rationale for the Chest
3
Section ONE
DERMATOLOGICAL
DIAGNOSTIC FLOW
CHART
4
5
Section Two
DIAGNOSTIC
ALGORITHMS
FOR RASHES
6
Acne
DIAGNOSTIC
ALGORITHMS
FOR RASHES
Acne vulgaris (common form)
Papular acne (inflamed papules)
Comedonal acne (less inflammation)
Cystic acne (inflamed nodules, scarring)
Steroid acne (secondary to steroid therapy)
Acne medicamentosa (due to drugs or cosmetics)
Acne mechanica (due to friction from straps, etc.)
Rosacea (telangiectasia, central face papules)
Chloracne (contact with oils and chemicals)
Pseudofolliculitis barbae (ingrown hair)
Acne keloidalis (keloid scar from traumatised acne)
Pituitary tumour
Symptoms and signs
involving the skin
and the conditions that
may be responsible
Syndromes
Adrenogenital syn. (amenorrhoea, rough skin)
Cushing syn. (ecchymoses, obese, hirsute)
Polycystic ovarian syn. (late onset, persistent)
Premenstrual tension syn. (mastalgia, headache)
See also Pustules
FORMAT
Alopecia
Presenting Symptom
Loss of hair
Baldness
Male pattern baldness (genetic)
Virilisation
Testosterone secreting tumour
Alopecia totalis
Chemotherapy
(Alternate Name)
Explanation of terminology
System or other group of symptoms
Diagnoses that may present with this symptom
[alternate name of diagnosis] (other symptoms of
each diagnosis, or a discussion of the diagnosis)
Other entries to consider
Diffuse hair loss
Idiopathic (thinning of hair, either sex)
Any severe illness
Rapid weight loss
Shock or stress (eg. bereavement, surgery)
Telogen effluvium (after stress)
Hypothyroidism (fatigue, dry skin, cold intolerance)
Hyperthyroidism (sweating, heat intolerance)
SLE (butterfly rash, arthritis, nephritis)
Postpartum
Hypopituitarism
Postmenopause
Diabetes mellitus (polydipsia, polyuria)
Renal failure
Protein deficiency (eg. malnutrition, vegetarian)
Addison's disease (groin and axilla only)
Hypervitaminosis A (anorexia, weight loss, rashes)
Irradiation
Iron or zinc deficiency
Ectodermal dysplasia
Dubowitz syn. (reduced growth, ptosis)
Fröhlich syn. (thin skin, low libido, obese)
Clinical Sign
Sign (Alternate Name) [Abbreviation]
An explanation of the sign, with its
methodology described in sufficient detail to
enable the practitioner to perform the test.
Int:
The interpretation of the sign.
(+) The diseases, syndromes etc. that
should be considered if the test is positive
(++) The interpretation of an exaggerated or
grossly positive test
(–) Ditto for a negative test result
(AB) Ditto for an abnormal test result
Phys: The pathophysiology of the sign to enable
its significance to be better understood
Other entries to consider
Exp:
7
Hallermann-Streiff syn. (dwarf, cataracts)
Langer-Giedion syn. (bullous nose, exostoses)
Loose Anagen syn.
Drugs (eg. cancer therapy, anticoagulants, vitamin
A, lithium, beta-blockers, oral contraceptives)
Bleeding in Skin
See Ecchymosis; Purpura and Petechiae
Blisters
Patchy hair loss
Alopecia areata
Any severe illness
Fungal scalp infection
Discoid lupus erythematosus
Traction (hair style that pulls on one area of scalp)
Trichotillomania (recurrent trauma)
Syphilis (variable symptoms)
See Acne; Bullous Rash; Pustules; Vescicles
Bouchard's Nodes
Bony prominences at the dorsal margins of proximal
interphalangeal joints
Severe osteoarthritis
See also Heberden's Nodes
Anal Itch
Bruising, Excess
See Pruritus Ani
Thrombocytopenia (bleeding time increased)
Idiopathic purpura
Hereditary disorders of coagulation
(eg.haemophilia, von Willebrand's, Christmas
disease)
Bone marrow suppression
Ionising radiation (eg. X-rays, gamma rays)
Systemic viral infections
Leukaemia (abnormal white cell count)
Typhus (fever, malaise)
Subacute bacterial endocarditis
Insect and snake bites
Following massive blood transfusions
Renal failure
Hepatic failure
Polycythaemia (rubra) vera
Scurvy (inflamed and bleeding gums)
Cushing syn. (moon face, obese, amenorrhoea)
AIDS (splenomegaly, fever, cachexia)
Defibrination syn. (see Syndromes)
Painful bruising syn. (female, paraesthesiae)
Drugs (eg. steroids, arsenic, quinine, aspirin,
warfarin, chlorothiazide)
See also Ecchymoses
Annular Rash
Rash consisting of circular lesion(s)
Tinea cruris, corporis or capitis (red, scaly edge,
pruritis)
Pityriasis rosea (herald patch, trunk, scaly centre)
Cutaneous larva migrans (hookworm infestation,
itchy, track)
Pigmented purpuic dermatosis (venous
insufficiency, pepper spots peripheral on lesion)
Granuloma annulare (faint, flesh colour, limbs)
Cutaneous lupus (chronic relapsing, trunk,
confluent)
Areolar Pigmentation
Darkening of areola and nipple
Present or past pregnancy
Sex hormone therapy
Familial,
Racial
Auspitz's Sign
Exp:
Int:
Phys:
When white scale is removed from a plaque
of scale covered dermatitis on the shins, a
bleeding area results
(+) Psoriasis
In psoriasis, the plaque has a microcapillary
circulation that is disrupted by its removal
Bullous Rash
Large fluid filled blisters
Impetigo (crusts, vesicles, pruritic)
Herpes zoster (severe pain, dermatome
distribution)
Herpes simplex (pain)
Cellulitis (red, hot, fever)
Toxic epidermal necrolysis
Contact dermatitis (erythema, itch)
Drug eruptions
Insect and arachnid bites
Bald
See Alopecia
1
Erythema multiforme (target lesions, erythema,
extensor surfaces)
Pemphigus (normal skin surrounds, relapsing crops)
Pemphigoid (large, tense, elderly)
Dermatitis herpetiformis (vesicles, papules,
erythema)
Pompholyx (soles and palms, tense blisters)
Porphyria cutanea tarda
Epidermolysis bullosa
Lichen planus
Burns (heat or irradiation)
Circular Rash
See Annular Rash
Circumoral Pallor
Exp:
Int:
Phys:
Relatively white area around mouth
(+) Fever of any cause (eg. scarlet fever)
Dilatation of superficial blood vessels in
looser skin further away from mouth causes
darkening and reddening of that area
(rather than blanching of circumoral tissue)
Butterfly Rash
Coilonychia
Erythematous, scaly rash spreading across both
cheeks and meeting on the nasal bridge
See Koilonychia
Systemic lupus erythematosus (SLE)
Photodermatitis
Discoid lupus
Atopic dermatitis
Serum sickness
Cullen's Sign
Exp:
Int:
Café-au-Lait Spots
Phys:
Light brown spots on skin
Von Recklinghausen's disease of multiple
neurofibromata
Pityriasis versicolor
Tuberous sclerosis
See also Pigmentation of Skin, Excess
Darierʼs Sign
Exp:
Int:
Phys:
Chip Sign
Exp:
Int:
Phys:
Spontaneous umbilical bruising
(+) Ruptured ectopic pregnancy, carcinoma
of pancreas, haemorrhagic pancreatitis,
other causes of haemoperitoneum
Tracking of free intraperitoneal blood to
umbilicus
Skin blotches covered with fine,
nonadherent scabs that are easily removed
by a fingernail or blunt edge
(+) Pityriasis versicolor
Superficial fungal infection
Rubbing a finger or blunt object firmly over a
skin lesion causes oedema and erythema
around the lesion
(+) Mastocytosis
Pressure releases histamine from increased
number of mast cells in lesion
Dark Skin
See Chloasma; Face Pigmented; Pigmentation of
Mouth; Pigmentation of Skin, Excess
Chloasma
Yellow-brown spotty skin pigmentation on upper
cheeks and forehead
Depigmented Skin
Pregnancy
Oral contraceptives
Sun exposure
Syphilis
mMlaria,
Tuberculosis (TB)
Cirrhosis
Chronic trauma
Some drugs
See also Face Pigmented; Pigmentation of Skin,
Excess
Racial and familial
Pityriasis versicolor (reddish, scaling)
Pityriasis alba (eczematous, asymptomatic)
Vitiligo (dead white, well demarcated patches)
Halo naevus
Postinflammatory
Albinism
Chronic mucocutaneous candidiasis
Leprosy
Tuberous sclerosis (subnormal)
Hypopituitarism
2
Hypoparathyroidism (small muscle spasms)
Kwashiorkor (malnutrition)
Vogt-Koyanagi-Harada syn.
Phenylketonuria (mental retardation)
Scars and burns
Chemicals (eg. phenols)
Eczema (scaling)
Intertrigo (pruritus, stinging, skin folds)
Erysipelas (oedema, hot pain, malaise)
Cellulitis (hot, diffuse, deep)
Mycosis fungoides
Tinea (pruritus, ring form, scaling)
Syndromes
Red man syn. (vancomycin infusion)
Rothmund-Thomson syn. (skin atrophy,
pigmentation)
Sézary syn. (pruritus)
Stevens-Johnson syn. (conjunctivitis, stomatitis)
Dry Skin
(Xeroderma)
Fever
Seborrhoeic dermatitis (scales, erythema)
Hypothyroidism (mental retardation, reduced
growth)
Constitutional reasons (eg. genetic, familial)
Psoriasis (red, scaling, patchy)
Hypovitaminosis A (night blindness,
hyperkeratoses)
Ichthyosis (rough, scabs)
Typhoid fever (abdominal pain)
Other dermatoses
See also Ichthyosis; Scalp Dry
Other
Flush
Burn (eg. sunburn, scald)
Viral infections (eg. measles, rubella)
Allergic reaction
Scarlet fever (circumoral pallor, malaise)
Cirrhosis (palmar erythema, hepatic signs)
Erythema nodosum (nodules, female, painful rash)
Erythema multiforme (target lesions, extensor
surfaces)
Lyme disease (fever, nausea, abdominal pain)
Pellagra (red tongue, diarrhoea, abdominal pain)
Discoid lupus erythematosus (plaques, scaling,
telangiectasia)
Bilharzia (pruritus, diarrhoea or haematuria)
Diseases specific to area of erythema (eg. gout,
mastitis, arthritis)
Alcohol excess
See also Facial Erythema
Ecchymosis
Bruise, purpuric macules
Thrombocytopenia (low blood platelets)
Coagulation defects (congenital or acquired)
Meningococcal infection
Septicaemia
Subacute bacterial endocarditis
Rickettsial diseases (eg. typhus, Rocky Mountain
spotted fever)
Allergic vasculitis (arthralgia, myalgia)
Purpura fulminans (skin infarcts)
Scurvy (bleeding gums)
Basal skull fracture (mastoid ecchymosis)
Local trauma
Drug hypersensitivity
See also Bruising, Excess
Face Pigmented
Sun exposure
Freckles
Chloasma (pregnancy or oral contraceptive use)
Naevus of Ota (teenager, Asian)
Other causes of skin pigmentation elsewhere on
body
See also Chloasma; Pigmentation of Skin, Excess
Erythema
Redness of skin
Dermatological
Contact dermatitis (oedema, vesciculation, crusting)
Dermatitis, stasis (pruritus, oedema, ulceration)
Dermatitis, exfoliative (pruritus, scaling, malaise)
Photodermatitis [sunburn](pain, oedema,
vesciculation)
Rosacea (facial, exacerbated by vasodilation)
Psoriasis (plaque, scaling, nail changes, pruritus)
Seborrhoeic dermatitis (dry, scaling)
Acne (pimples; cysts; face, back and shoulders)
Urticaria (pruritus, wheals, oedema, malaise)
Facial Erythema
Excessively red face
Vasomotor instability (eg. flushing)
Rosacea
Seborrhoeic dermatitis
Superior vena caval syn.
Perioral dermatitis
Contact dermatitis
Atopic dermatitis (pruritic)
Psoriasis (scaling)
3
Excess topical steroid use
Sunburn
Light sensitivity
SLE (butterfly pattern rash)
Erysipelas
Dermatomyositis
Acne vulgaris
Sarcoidosis
Essential telangiectasia
Slapped cheek syn.
Birthmarks (eg. port wine stain)
Carcinoid syn.
See also Erythema
Heberden's Nodes
Exp:
Bony prominence at the dorsal margins of
distal interphalangeal joints
Int:
(+) Osteoarthritis, osteoarthrosis
Phys: More common in women. May be due to a
single autosomal gene
See also Bouchard's Nodes
Henoch-Schönlein Purpura
Exp:
Formication
Sensation of insects crawling on skin
Int:
Neurological sensory disorders
Psychiatric syndromes
Alcoholism withdrawl
Drugs
Phys:
Extensive elevated purpuric or ecchymotic
lesions on extensor surfaces of arms and
legs. May be recurrent and can occur on the
face, in the gut (causing haemorrhage and
colic), and in the kidney (causing
haematuria)
(+) Idiopathic, after sensitising foods,
poststreptococcal infection, drugs
Immunological reaction, more common in
children
Heliotrope Sign
Genital Itch
Exp:
See Pruritus; Pruritus Ani; Pruritus Vulvae
Int:
A reddish purple erythema involving the
eyelids
(+) Dermatomyositis
Gottron's Sign
Exp:
Int:
Scaly patches over dorsum of proximal
interphalangeal and metacarpophalangeal
joints, subungual erythema and cuticular
telangiectasiae
(+) Polymyositis, dermatomyositis
Herald Patch
Exp:
Int:
Hair Loss
Oval, discoid or annular, solitary, reddish,
slightly raised and scaly patch on the trunk.
Followed by multiple smaller lesions
(+) Pityriasis rosea, drug eruptions
Hertoghe Sign
See Alopecia
Exp:
Int:
Lack of the outer one third of the eyebrow
(+) Atopic dermatitis, neurodermatitis,
hypothyroidism and systemic sclerosis.
Exp:
A sphygmomanometer cuff inflated to 80
mmHg (10.6 kPa) around the upper arm for
five minutes causes purpuric spots to
appear below the cuff
(+) Diseases associated with purpura (eg.
thrombocytopenia, diseases of vascular
endothelium, thromboasthenia, uraemia)
Tests the resistance of capillaries to
increased venous pressure. Obsolete test
that should not be performed if more
Hanging Curtain Sign
Exp:
Int:
When the skin is stretched across the long
axis of a medallion lesion, the scale being
finer and lighter and attached at one end
tends to fold across the line of stretch.
(+) Pityriasis rosea
Hess Test
Int:
Headlight Sign
Exp:
Int:
Perinasal and periorbital pallor
(+) Atopic individuals.
Phys:
4
sophisticated tests for vascular disease
available
Purpura and Petechiae
Yellow fever (purpura, muscle pain, oliguria)
Pancreatitis (severe pain, shock)
Cytomegalovirus (neonate, purpura, haematuria)
Syphilis (variable symptoms)
Echinococcus (wheeze, urticaria)
Ichthyosis
Syndromes
Bard-Pic syn. (carcinoma of pancreas)
Crigler-Najjar syn. (kernicterus, neonate)
Dubin-Johnson syn. (neonate, asymptomatic)
Gilbert syn. (benign asymptomatic jaundice)
Lissencephaly syn. (fits, hypotonia)
Patau syn. (neonate, asymptomatic)
Generalised dryness and scaling of skin
Congenital
Ichthyosis vulgaris (widespread, inherited)
Acquired ichthyosis (precipitated by disease)
Hypothyrodisim (cold intolerance, lethragy)
Lymphomas (eg. Hodgkin's disease)
Sarcoidosis
Leprosy
Vitamin A deficiency
Harlequin syn.
Refsum syn. (deaf, ataxia, polyneuritis)
Sjögren-Larsson syn. (spastic diplegia)
Drugs (eg. cimetidine, nicotinic acid, retinoids)
See also Dry Skin; Scalp Dry
Other
Neonatal icterus
Familial causes
Hodgkin's disease (adenitis, fever, weight loss)
Sickle cell anaemia (fever, abdominal pain, negroid)
Post upper abdominal surgery
Haemolytic anaemia (fatigue, malaise, pallor)
Thalassaemia major (hepatosplenomegaly,
lethargy)
Galactosaemia (infant, vomiting)
Drugs (eg. chlorinates, chromates, sulfonamides,
halothane)
Carotenaemia (excess ingestion of orange coloured
food, headache, white conjunctivae)
Itch
See Pruritus; Pruritus Ani; Pruritus Vulvae
Janeway Lesion
Exp:
Small purplish/red nodule on palms or soles
Int:
(+) Infective endocarditis
Phys: Infected embolic lesion
See also Oslerʼs Nodes
Joint Erythema
Exp:
Int:
Jaundice
(Icterus)
Yellow skin
Hepatobiliary
Biliary tract obstruction (pain, pruritus, fever)
Cholecystitis (pain, nausea, fever)
Cirrhosis (pruritus, RUQ pain fever)
Carcinoma of head of pancreas (pain, pruritus,
cachexia)
Cholelithiasis (colic)
Primary or secondary hepatic malignancy
Alcoholic liver disease
Hepatic vein stenosis
Gaucher's disease (hepatosplenomegaly, anaemia)
Primary sclerosing cholangiitis
Redness and inflammation of tissue
overlying a joint
(+) Septic arthritis, cellulitis, gout,
pseudogout, rheumatoid arthritis, reactive
arthropathy, Reiter syn. (see Syndromes
section 6), Heberden's node, Bouchard's
node, erythema nodosum, inflammatory
osteoarthritis,rheumatic fever
Koebner Phenomenon
Exp:
Int:
Following trauma, lesions appear in the
traumatised but otherwise normal skin.
Psoriasis
Koilonychia
Exp:
Int:
Infections
Hepatitis, infectious and serum (anorexia, nausea,
fever)
Malaria (paroxysmal fevers, nausea, headache)
Clostridial gangrene (pain, foul smell, tissue
crepitations)
5
Spooning of nails
(+) Iron deficiency anaemias, PlummerVinson syn.
Lace-like Rash
Macular Rash
Lacy or net (reticular) pattern on skin
Flat, circumscribed, discoloured lesions
Erythema infectiosum (red on trunk and thighs,
slapped cheeks, Parvbovirus B19)
Livedo reticularis (bluish, worse in cold, vasculitis)
Acute meningococcaemia (purpura fulminans, dark
gray)
Cutaneous lava migrans (raised rash pattern).
Dermatological
Psoriasis (red, scaling)
Dermatomyositis (weakness, oedema, myalgia)
Vitiligo (white patches)
Tinea corporis (white centred erythematous
patches)
Pityriasis rosea (scales, erythematous, trunk)
Tinea versicolor (red patches, do not tan in sun)
Seborrhoeic dermatitis (red/brown, scaly)
Mycosis fungoides
Lichen planus (glossitis)
Leser-Trelat Sign
Exp:
Int:
Phys:
Abrupt appearance, and rapid increase in
size, of many seborrhoeic keratoses
(+) Underlying carcinoma (eg.
adenocarcinoma)
May also occur during lysis of tumour with
cytotoxics
Infections
Measles (cough, rhinitis, conjunctivitis)
Roseola infantum (high fever, adenitis, infant)
Rubella (fever, coryza, adenitis)
Rheumatic fever (erythematous margin, nodules,
arthritis)
Infectious mononucleosis (often after penicillin
therapy)
Epidemic polyarthralgia (lethargy, arthritis)
Meningococcal infection (meningism, vomiting)
Leprosy (raised edge, anaesthetic)
Pinta (itch, lymphadenopathy)
Light Sensitivity
See Photosensitive Skin
Linear Rash
Other
SLE (arthritis, malaise, anorexia)
Addison's disease (dark patches, fatigue, nausea)
Neurofibromatosis (eg. phaeochromocytoma, von
Recklinghausen's disease)
Sweet syn.
Kawasaki syn. (adenitis, fever)
Drug eruptions
Longitudinal skin rash
Lichen planus
Flat warts
Psoriasis
Epidermal naevi
Contact dermatitis (eg. perfumes)
Scabies (vesicles, `runs', finger webs involved)
Dermographia
Lichen striatus
Koebner phenomenon
Jellyfish stings
Stinging and irritating plants
Necklace of Casal
Exp:
Int:
Hyperpigmentation on the neck
Pellagra.
Lines on Skin
See Linear rash
Net Pattern
See Lace-like Rash
Lip Papules
Papules at angles of upper and lower lips
Syphilis
Nikolsky Sign
Exp:
Lumps
Int:
See Nodules; Papules
6
Gentle lateral pressure with a finger to
apparently normal skin causes epidermis to
immediately slough off leaving a raw area
(+) Pemphigus, toxic epidermal naevus
Leukaemia (fever, arthralgia, malaise)
Haemolytic anaemia (fever, nausea, abdominal
pain)
Pernicious anaemia (anorexia, sore tongue,
paraesthesiae)
Chronic renal failure (nausea, pruritus)
Aplastic anaemia (lethargy, purpura)
Shock (eg. myocardial infarct and other causes of
hypotension)
Ischaemic limb (pain, pulseless)
Racial or genetic characteristic
Nodules
Dermatological
Warts (irregular surface, varied shape, crops)
Haemangioma (blood vessel malformation)
Basal cell carcinoma (rounded, pearly,
telangiectatic vessels)
Keratoacanthoma (scaly surface, rapid growth)
Naevus (pigmented)
Lipoma (soft, diffuse)
Dermatofibroma (isolated yellow-brown nodule)
Prurigo nodularis (itchy, red, hard, scaly)
Neurofibromatosis (café-au-lait spots)
Molluscum sebaceum and contagiosum
Chilblains (red, itching, extremities)
Granuloma inguinale (ulcerates, painless, sexually
transmitted)
Melanoma (pigmented, metastasises)
Hyperlipidaemia (xanthomata) (see Signs)
Stewart-Treves syn.
Syndromes
Diencephalic syn. (cachexia, vomiting, sweating)
Dumping syn. (postgastrectomy, postprandial)
Raynaud's phenomenon (cyanosis and oedema of
fingers)
Vasovagal syn. (hypotension, syncope,
bradycardia)
Waterhouse-Friderichsen syn. (petechiae,
prostration)
Systemic
Erythema nodosum (tender, fever, legs)
Rheumatic fever (heart murmur, polyarthralgia,
rash)
Rheumatic arthritis (arthralgia, malaise,
paraesthesiae)
Heberden's nodes
Polyarteritis nodosa (arthritis, pruritus, rash)
Gout (severe pain in acute stage)
SLE (butterfly rash)
Lymphoma
Sarcoidosis (lung symptoms)
Syphilis (second stage symptom with rash)
Pallor, Circumoral
See Circumoral Pallor
Papules
Firm, raised, circumscribed lesions
Acne (comedones, cysts, erythema) (see separate
entry)
Naevi (pigmented)
Melanoma (black, irregular)
Basal cell carcinoma (pearly, telangiectasia)
Folliculitis
Xanthoma (yellow, cholesterol containing)
Molluscum contagiosum (smooth, rounded, apical
depression)
Granuloma (singular, soft)
Psoriasis (scales, erythema, nail changes)
Contact and atopic dermatitis
Lichen planus (flat topped, itchy scales)
Neurodermatitis (itch, thickened skin)
Miliaria (flexures)
Scabies
Polymorphic eruption of pregnancy
Pinta (itch, lymphadenopathy)
Cutaneous anthrax (oedema, surrounding vesicles)
Tularaemia (one papule that ulcerates, adenitis)
Gianotti-Crosti syn. (viral reaction)
Drug eruption (itchy, red)
Oslerʼs Nodes
Exp:
Small, tender, raised, red, transient patch
on tips of fingers or toes
Int:
(+) Bacterial endocarditis
Phys: Caused by infected cutaneous embolus
See also Janeway Lesion; Splinter Haemorrhages
Painful Skin
Photodermatitis [sunburn] (erythema, oedema,
vesiculation)
Herpes zoster [shingles] (dermatome distribution,
vesicular lesions, unilateral)
Cellulitis (erythema, oedema, fever)
Trauma
Pallor
Pale skin
Anaemia (lassitude, dyspnoea, palpitations)
7
Bloch-Sulzberger syn. (neonate, pigmented streaks,
incontentia pigmenti)
Blue rubber bleb syn. (multiple blue tinged rubbery
blebs, small bowel haemangiomas)
Cushing syn. (central obesity, plethora, headache)
Cronkhite syn. (pigmented hands and feet)
Dysplastic naevus syn. (multiple large moles)
Felty syn. (polyarthritis, splenomegaly)
Leopard syn. (multiple spots, cardiac changes)
Leschke syn. (spots, asthenia, hyperglycaemia)
Nelson syn. (postadrenalectomy)
Peutz-Jegher syn. (pigmented mouth, lips and
fingers)
Rothmund-Thomson syn. (erythema, telangiectasia)
Russell-Silver syn. (café-au-lait spots, dwarf)
Patches
See Macular Rash; Plaque and Patch Formation;
Port Wine Stain
Photosensitive Skin
Rashes that develop in response to sunlight
Polymorphic light eruption
Photocontact dermatitis (eg. soaps, cosmetics,
shampoo)
Systemic or discoid lupus erythematosus
Pellagra
Phenylketonuria
Hartnup disease
Xeroderma pigmentosum
Congenital photosensitivity
Bloom syn. (Jewish, reduced growth, leukaemia)
Drugs (very wide range incl. tetracycline,
phenothiazines, sulfonamides, thiazides, frusemide,
antimalarials, griseofulvin, nalidixic acid)
Other
Varicose veins (oedema, leg ache)
Renal failure (oedema)
Addisonism (fatigue, anorexia, nausea)
Neurofibromatosis (eg. von Recklinghausen's
disease, phaeochromocytoma)
Haemochromatosis (hepatomegaly, hepatic and
cardiac failure)
Scleroderma (arthritis, Raynaud's phenomenon)
Sprue (bulky foul stools, weight loss, anaemia)
Pregnancy (face, nipples and flexure lines)
Thyrotoxicosis (sweating, fatigue, weight loss)
Pituitary tumours (eg. acromegaly)
Carotenaemia (yellow palms and soles)
Porphyria (urine colour change)
Familial and racial factors
Acanthosis nigricans
Drugs (eg. chloroquine, tetracyclines, amantadine,
phenothiazines, chlorpromazine, arsenic,
busulphan, bleomycin, amiodarone, gold, psoralens,
oral contraceptives)
See also Areolar Pigmentation; Chloasma; Face
Pigmented
Pigmentation of Mouth
Addison's disease (weak, anaemia, nausea)
Melanoma (variable colouration)
Haemochromatosis (arthropathy, hepatomegaly)
Peutz-Jegher syn. (hereditary intestinal polyposis)
Kaposi's sarcoma (purple, raised, AIDS)
Racial
Pigmentation of Skin, Excess
Dermatological
Freckles
Chloasma (pregnancy or oral contraceptives)
Malignant melanoma (irregular border, varying
colour)
Naevi (benign, demarcated, hairy)
Seborrhoeic keratoses
Haemangiomas (red, benign)
Mongoloid spot (lower back, hereditary)
Lentigo (normal in most people)
Hutchison melanotic freckle (usually face)
Xeroderma pigmentosa
Café-au-lait spots (see Signs)
Kaposi's sarcoma (purple, raised, AIDS)
Mastocytosis (red/brown spots, pruritus)
Sunburn and skin trauma (eg. keloids)
Pigment Loss
See Depigmented Skin
Pimples
See Acne; Pustules; Vescicles
Plaque and Patch Formation
Red
Psoriasis vulgaris
Tinea corporis, capitis and cruris
Syndromes
Albright syn. (precocious puberty, polyostotic fibrous
dysplasia)
8
Parapsoriasis
Mycosis fungoides
Syndromes
AIDS
Sézary syn. (erythroderma)
Sjögren syn.
White
Pityriasis alba
Pityriasis versicolor
Vitiligo
Postinflammatory hypopigmentation
Other
Allergy (oedema, erythema)
Insect bites (eg. fleas)
Hepatitis (anorexia, nausea, jaundice)
Cholecystitis (RUQ pain, nausea, jaundice)
Fibreglass and other irritants
Brown
Café-au-lait patches
Postinflammatory hyperpigmentation
Congenital naevi
NO RASH USUALLY PRESENT
Hepatobiliary
Hepatomas (fever, polycythaemia, hypoglycaemia)
Cirrhosis (anorexia, jaundice, RUQ pain, alcoholic)
Obstructive hepatobiliary disease
Haemochromatosis
Port Wine Stain
Idiopathic
Klippel-Trenaunay syn. (tissue overgrowth)
Sturge-Weber syn. (convulsions, mental retardation)
Spinal cord abnormalities (eg. spina bifida)
Infections and Infestations
Pediculosis (excoriation, lice on skin and clothes)
Echinococcus (wheeze, allergies)
Other metazoal infestations (eg. hookworm,
ascariasis, hydatids)
Other intestinal parasites
Pruritus
Itching of the skin with a skin abnormality
RASH USUALLY PRESENT
Dermatological
Overcleaning of skin
Ichthyosis (dry, rough, scaly skin)
Pressure areas
Atopic eczema (exudate, skin folds, allergic history)
Seborrhoeic dermatitis (fine scale)
Contact dermatitis
Stasis dermatitis (erythema, ulceration, oedema)
Lichen simplex (pigmented lichenified lesions)
Exfoliative dermatitis (scaling, erythema, malaise)
Lichen planus (flat papules along scratches,
anxiety)
Psoriasis (red plaques, scales, nail changes)
Pityriasis rosea (herald patch, fawn scaly eruption)
Urticaria (wheals, malaise, oedema)
Intertrigo (body folds, erythema, stinging)
Miliaria [heat rash] (burning, vesicles, hot climate)
Dermatitis herpetiformis
Prurigo nodularis (nodules, red, hard, scaly)
Mastocytosis (red/brown skin spots)
Pemphigoid
Polymorphic eruption of pregnancy
Grover disease (heat stress)
Other
Diabetes mellitus (polyuria, blurred vision, fatigue)
Thyrotoxicosis (weak, weight loss, diarrhoea)
Hypothyroidism (dry skin, fatigue, cold intolerance)
Hypoparathyroidism (tetany, wheeze, abdominal
pain)
Nephritis (reaction to disease or toxins)
Uraemia (fatigue, thirst, headache)
Lymphomas & Hodgkin's disease (fever, adenitis,
fatigue)
Leukaemia (malaise, arthralgia, pallor)
Neoplastic diseases
Multiple myeloma
Polycythaemia vera (fatigue, headache)
Iron deficiency anaemia
Itchy upper arm syn. (sun damage, no rash)
Fibreglass and other irritants
Pregnancy
Ciguatera poisoning (paraesthesiae)
Emotional and psychogenic causes
Drugs of addiction (abrupt onset, malaise, fever,
headache)
Medications (eg. aspirin, dextran, narcotics,
scopolamine)
Infections and Infestations
Impetigo (pustules, crusts)
Tinea (ring, scaling, erythema)
Scabies (vesicles, `runs', finger webs involved)
Bilharzia (rash, haematuria, diarrhoea)
Pruritus Ani and Proctitis
Perianal itch
Haemorrhoids (bleeding, pain, lump)
9
Fissure-in-ano (discharge, bleeding, pain)
Perianal fistula (pain, oedema, erythema)
Leucorrhoea (physiological, any vaginal infection)
Candidiasis and other superficial fungal infections
Diarrhoea of any cause
Enterobiasis and other metazoal infections
Diabetes mellitus (polyuria, fatigue, blurred vision)
Crohn's disease (abdominal pain and mass,
diarrhoea)
Intertrigo (erythema, stinging, body folds)
Lichen simplex (pigmented lichenified lesions)
Seborrhoeic dermatitis (erythematous vesicles)
Contact dermatitis (erythema, vesicles, oedema)
Psoriasis (red plaques, nail changes, scaling)
Papillomata and skin tags
Molluscum contagiosum (umbilicated blisters)
Rectal prolapse
Condylomata accuminata
STDs (eg. syphilis, gonorrhoea)
Bowen's disease
Poor hygiene
Idiopathic thrombocytopenia (epistaxis,
ecchymoses)
Platelet or coagulation factor disorders
Vasculitis
Aplastic anaemia (lassitude, pallor, bleeding)
Acute leukaemias (malaise, arthralgia, fever)
Disseminated intravascular coagulation (secondary
to severe disease)
Other
Viral exanthema (eg. measles)
Senile purpura (ecchymoses on arms, elderly)
Allergic conditions
Cytomegalovirus (neonate, haematuria, jaundice)
Severe generalised bacterial infections
Polyarteritis nodosa (arthritis, skin disorders,
nodules)
Uraemia (fatigue, headaches, pruritus)
Yellow fever (jaundice, muscle pain, oliguria)
Scurvy (gingivitis, arthralgia, anaemia)
Amyloidosis (symptoms vary with involved organ)
Meningococcal septicaemia
Vitamin K deficit
Miliary tuberculosis
Bacterial endocarditis (murmur, fever)
Meningococcal meningitis (fever, headache,
vomiting)
Trauma
Drugs (eg. quinine, thiazides, heparin, aspirin,
trimethoprim/sulfamethoxazole)
Pruritus Vulvae
Itchy vulva
Candidiasis (rash, white vaginal discharge)
Bacterial vaginitis (pain, foul discharge)
Excessive sweating
Tight clothing (particularly nylon)
Over washing of area
Allergic reaction to soaps, material, toiletries, etc.
Atopic dermatitis
Seborrhoeic dermatitis
Psoriasis (plaques, scaling)
Urinary tract infection (frequency, dysuria)
Pediculosis (crabs seen in pubic hair)
Scabies (burrows, inflamed skin)
Human papilloma virus infection (warts)
Oestrogen deficiency (postmenopause,
postoophorectomy)
Diabetes mellitus (polyuria, polydipsia)
Depression (poor sleep pattern, loss of interest)
Lichen sclerosis (burning, fissures)
Autoimmune diseases
Lichen simplex chronicus (hyperkeratosis)
Vulval carcinoma (induration, erythema)
Trichomoniasis (yellow vaginal discharge, smell)
Genital herpes (vesicles or ulcers, pain)
Burning vulva syn.
Contraceptive foam or cream sensitivity
Syndromes
Bernard-Soulier syn. (excess bleeding)
Cushing syn. (central obesity, plethora, fatigue)
Defibrination syn. (excess bleeding)
Glanzmann syn. (mucocutaneous bleeding)
Henoch-Schoenlein syn. (abdominal pain, excess
bleeding)
Waterhouse-Friderichsen syn. (petechiae, pallor)
See also Bleeding, Excessive; Ecchymosis; Hess
Test
Pustules
Elevated lesions filled with purulent fluid
Acne (comedones, erythema)
Rosacea (face, telangiectasia, chronic)
Folliculitis (hairy areas, chronic)
Chickenpox (itch, varying stages, central
distribution)
Herpes zoster and Herpes simplex
Smallpox (historic only)
Impetigo (crusts, erythema, itch)
Melioidosis (cough, chest pain)
Chancroid (sexually transmitted, ulcerates, painful)
Generalised pustular psoriasis of pregnancy
Purpura and Petechiae
Cutaneous haemorrhages
Haematological
10
Red Skin
Sore
See Erythema; Facial Erythema
See Pustules; Ulcer
Ring Rash
Spider Naevi
See Annular Rash
Exp:
Int:
Rope Sign
Exp:
Int:
Phys:
Linear cords extending from the upper back
to the axilla
Rheumatoid arthritis
Histological granulomas
(Telangiectasia)
Skin area where several capillaries can be
seen radiating from a central point
(+) Cirrhosis of liver, thyrotoxicosis,
rheumatoid arthritis, pregnancy, sun
damaged skin, irradiation, carcinoid syn.,
CREST syn., Louis-Bar syn., Rendu-OslerWeber syn., Rothmund-Thomson syn.,
systemic sclerosis, acute alcoholic and viral
hepatitis, hereditary tendency
Rumpel-Leede Sign
Exp:
Int:
Distal shower of petechiae that occurs
immediately after the release of pressure
from a tourniquet or sphygmomanometer
applied to an arm or leg.
Sign of disorders associated with capillary
fragility.
Stretch marks
See Striae
Striae
(Stetch Marks)
Band, streak or strip in skin
Obesity
Pregnancy (striae gravidarum on abdomen)
Cushing syn. (obese, ecchymoses)
Nephrotic syn. (ascites, oedema)
Pituitary malfunction
Scaly Scalp
Dandruff (loose, grey scales)
Seborrhoeic dermatitis (fungal cause, inflamed
scalp)
Eczema (widespread, marked erythema, fine white
scale)
Neurodermatitis (thick crusts, erythema)
Psoriasis (erythema, firmly adherent scale, nail
changes)
Pityriasis amiantacea (very thick plaque, localised)
Tinea capitis (slightly pruritic, fractured hairs)
SLE (plaques, scarring)
Kerion (pustules, crusts)
See also Dry Skin; Ichthyosis
Target Lesions
Exp:
Int:
Phys:
Scalp Dry
Round, erythematous macule that becomes
papular, enlarges and develops concentric
rings of colour to resemble a target. Centre
of lesion may blister, erode and crust. May
become pigmented during resolution
(+) Erythema multiforme
Precursor target lesion often not identified
as erythema multiforme until widespread
lesions erupt
See Scaly Scalp
Telangiectasia
Sister Mary Joseph's Nodule
Exp:
Int:
Phys:
See Spider Naevi
Raised umbilical nodule, often
erythematous and painless
(+) Disseminated intra–abdominal
malignancy (eg. ovarian or gastric
carcinoma)
Retrograde lymphatic spread of carcinoma
to form an umbilical deposit
Thick Skin
Sun exposure
Scleroderma (arthritis, Raynaud's phenomenon)
Neurodermatitis (itch, papules)
Leprosy
Icthyosis (scales, dry)
11
Lichen sclerosis
Eosinophilia-myalgia syn. (muscle pain, cough)
Neu-Lexova syn. (nose and eyelid abnormalities)
Ichthyosiform erythroderma (infant, bullae)
Malignant melanoma (not always black)
Other malignancies
Psychiatric disturbances (self mutilation)
Coagulation disorders
TB (symptoms vary with organs involved)
Buerger's disease (smoker)
Rheumatoid arthritis
Syphilitic gummata (sexually transmitted, painless,
adenitis)
Chancroid (sexually transmitted, painful)
Tularaemia (fever, adenitis, headache)
Granuloma inguinale (large, painless, sexually
transmitted)
Lymphogranuloma venereum (adenitis, prostatitis)
Behçet syn. (uveitis, arthritis, convulsions)
Postphlebitic syn. (stasis dermatitis, leg oedema)
Gouty tophus
Sickle cell anaemia (Negro)
Hereditary spherocytosis
Leprosy
Cutaneous leishmaniasis
Tabes dorsalis
Yaws (adenitis, painless, poor hygiene)
See also Skin Lesion Associated Syndromes
Thin Skin
Aging
Cushing syn. (obese, striae, moon face)
Ehlers-Danlos syn. (joint pseudotumours)
Fröhlich syn. (late puberty, fine hair)
Goltz syn. (scalp, thighs, iliac crests)
Topical or systemic steroids
Scars
Third Eyelid of Morgan-Denny
Exp:
Int:
Phys:
Extra fold of skin above upper eyelid
(+) Atopic eczema of eyelid, allergic
conjunctivitis, other chronic irritating
conditions of eye
Caused by chronic rubbing of eye. More
common in children
Umbilical Bruising
Tin Tack Sign
Exp:
Int:
See Cullen's Sign
Appearance of small horny plugs attached
to the undersurface of the scale removed
from the affected site.
Important clinical feature in discoid lupus
erythematosus.
Vesicules
Well defined small collections of fluid
Insect and arachnid bites
Burns
Herpes zoster and Herpes simplex
Chickenpox (fever, malaise, different stages)
Contact and atopic dermatitis
Hand-foot-mouth disease (fever, irritable, child)
Molluscum contagiosum (central umbilication)
Scabies (burrows, itch)
Dermatitis herpetiformis (erythema, bullae, crops)
Vaccinia (secondary to vaccination, umbilicated
vesicles)
Drug reaction (eg. tetracyclines, cotrimoxazole)
Ramsay Hunt syn. (shingles)
Anthrax (oedema, sloughs)
Septicaemia
Porphyria
Dracunculiasis (west Africa)
See also Bullous rash; Pustules
Ugly Duckling Sign
Exp:
Int:
A naevus that doesnʼt resemble its brother
naevi.
Likely to be malignant melanoma.
Ulcer
Trauma and chronic pressure (eg. bed sore)
Stasis dermatitis (erythema, pruritus, oedema)
Decubitus ulcer (elderly or debilitated)
Squamous cell carcinoma (red, hard, scales)
Basal cell carcinoma (telangiectasia, pearly edge)
Varicose veins (pain and oedema of legs)
Diabetes mellitus (poor circulation)
Cellulitis or erysipelas
Venous thrombosis (leg, tender vein)
Venous or arterial insufficiency
Polyarteritis nodosa (nodules, arthritis, fever)
Peripheral neuropathy
Chilblains and frostbite
12
Int:
(+) Primary biliary cirrhosis, elderly,
hyperlipidaemia, cholestasis
See also Xanthomatosis
V Sign
Exp:
Int:
Photosensitivity is prominent in the ʻVʼ of the
neck and chest.
Dermatomyositis
Xanthomatosis
Exp:
Cluster of pale yellow papules on a red
patch of skin, often on buttocks
Int:
(+) Hypertriglyceridaemia, other
hyperlipidaemias, diabetes mellitus, biliary
cirrhosis, cholestasis
Phys: Deposition of excess circulating lipids in
skin
See also Arcus senilis
Vulval Itch
See Pruritus Vulvae
White Skin
See Depigmented Skin; Pallor
Xanthelasma
Exp:
Yellow Skin
(Xantheloma Palpebrarum)
Yellow-brown nodules in soft tissues around
eye
See Jaundice
13
Section Three
DERMATOLOGICAL
CONDITIONS
Many of the following images are
© DermAtlas; http://www.DermAtlas.org
and are used in this context as teaching aids as approved by their copyright.
1
DERMATOLOGICAL CONDITIONS
Common diseases that cause rashes
ACANTHOSIS NIGRICANS
Acanthosis nigricans is a skin condition of
the neck, groin, palms and armpits that appears
in four forms - true benign, benign, malignant
and pseudo. All forms cause thick, ridged skin
covered in multiple dark brown or black small
polyps, giving the skin a velvety appearance.
The diagnosis is confirmed by a skin biopsy.
True benign acanthosis nigicans is an
inherited trait that often runs in families, starts
in childhood, is more common in girls and
worsens with puberty. There is no specific
treatment, but it often settles in early adult life.
Benign acanthosis nigricans is the mildest
form and is often associated with hormonal
abnormalities in Cushing syndrome, pituitary
gland disorders or polycystic ovaries and
develops in late childhood or early adult life.
Treatment of the underlying hormonal
imbalance is necessary.
Malignant acanthosis nigricans is a reaction
to cancer in other parts of the body (eg.
stomach, breast, lung) and starts in late life. It
is the most severe form, and requires treatment
of the underlying cancer.
Pseudo acanthosis nigricans occurs in
obese women who have a dark complexion. Weight loss is the only treatment.
See also DOWLING-DEGOS DISEASE; LENTIGO
ACNE
Acne, spots, pimples, zits. It doesnʼt matter what they are called, nobody likes to have
them, or look at them. Acne can vary from the annual spot, to a severe disease that may
cause both skin and psychological scarring. It is generally a curse of teenage years, but it
may strike later in life too, particularly in women. Acne is usually more severe in teenage
males, but starts earlier in females. Acne affects Caucasians (whites) more than Negroes or
Chinese races. The face, upper chest, upper back and neck are most commonly affected.
Acne vulgaris is a severe form that almost invariably results in scarring of the face, back
and chest, while acne conglobata affects mainly the buttocks and chest and causes skin
abscesses and severe inflammation.
2
Pimples are due to a blockage in the outflow of oil (known as sebum) from the thousands of
tiny oil glands in the skin. This blockage can in turn be caused by dirt (uncommon in our
super-clean society), dead skin left behind during the normal regular regeneration of the skin
surface, or a thickening and excess production of the oil itself.
Once the opening of the oil duct becomes blocked, the gland becomes dilated with the
thick oil, then inflamed, and eventually infected. The result is a white head, with the
surrounding red area of infection. Eventually this bursts, sometimes leaving a scar.
The most common cause of acne is the thickening of sebum caused by the hormonal
changes of puberty. The severity of acne in a teenager will depend upon the degree of acne
suffered by his/her parents, as this is a strongly inherited characteristic. Pregnancy,
premenstrual syndrome (hormonal changes before a period), menopause and the oral
contraceptive pill may all cause pimples in this way.
Stress in the patient, either psychological or caused by disease, may make pimples
worsen. A simple cold, or the onset of exams may see the number of spots increase
dramatically.
Pressure from spectacles on the bridge of the nose or tight collars, increases in skin
humidity from a fringe of hair or nylon clothing, and excessive use of cosmetics that further
block the oil duct openings, can all cause deterioration in a personʼs acne. Some chemicals or
oils that a patient may encounter in the work place are also possible causes.
Treatment of asthma or other diseases with steroids (eg. prednisone) may worsen acne. A
tumour of the pituitary gland under the brain, or the adrenal glands on each kidney, may
produce higher than normal levels of steroids to mimic this problem.
The severity of acne also depends on hereditary factors. There is no evidence that diet,
chocolate, vitamins or herbs have any effect on acne.
A number of conditions can cause a rash that looks like acne, but is not. The most common
of these are rosacea and folliculitis barbae (ingrown facial hairs caused by blunt blade when
shaving or other skin damage). Rosacea is a skin disease of the face, found most commonly
in middle-aged women, that causes excessive intermittent flushing of the face, then sores
develop that are similar to a severe case of pimples.
3
There is no evidence that diet, vitamins or other herbs have any effect on pimples. A small
number of sufferers may find that one particular food causes a fresh crop of spots, but these
people usually quickly realise this and avoid the offending substance.
The first step in treatment involves keeping the skin clean with a mild soap and face cloth,
and simple oil drying, antiseptic and cleansing creams or lotions. Further treatment involves
combinations of antibiotics (eg. tetracyclines) that may be taken in the short term for acute
flare ups or in the long term to prevent acne, skin lotions or creams containing antibiotics
and/or steroids, and changing a woman's hormonal balance by putting her on the oral
contraceptive pill or using other hormones. In rare cases it is necessary to take the very
potent medication isotretinoin (which can cause birth deformities if used during pregnancy),
give steroid injections (eg. triamcinolone) into the skin around particularly bad eruptions, and
abrade away the skin around scars. The treatment of adults with maturity onset acne is more
difficult than juvenile acne.
Acne may cause both skin and psychological scarring. Picking acne spots can cause
serious secondary bacterial infections that can spread deep into the skin (cellulitis).
Although acne cannot be cured, in the majority of cases reasonable control can be
achieved. It eventually settles with age.
See also CHLORACNE
ACNE ATROPHICA
The small pits and scars left behind after an earlier time of life when the patient suffered
from severe acne is referred to as acne atrophica.
See also ACNE
ACNE CONGLOBATA
See ACNE
ACNE KELOIDALIS NUCHAE
Acne keloidalis nuchae is a skin condition of the back of the neck that occurs mainly in
curly haired Africans, particularly in the Caribbean. It is caused by the in-growth of hairs due
to dermatitis and irritation in the area. Round bumps appear from hair follicles on the hairline
at the nape of the neck, become pustular, scar and form a persistent hard lump. The scars
may form keloids and enlarge significantly to form a hard raised ridge around the hairline.
Patients should avoid any irritation of the area from clothing collars and avoid scratching.
Steroid creams and injections into the affected skin may be helpful, and antibiotic tablets can
be used for any secondary bacterial infection. In severe cases, isotretinoin tablets,
radiotherapy, and surgical excision of the affected area of skin may be used. Unfortunately it
often persists and is difficult to treat.
See also KELOID
ACNE NECROTICA MILIARIS
See SCALP FOLLICULITIS
ACNE NEONATORUM
Acne neonatorum is a temporary and benign form of acne that occurs on the face of
newborn infants due to the immaturity of the sebaceous (oil) glands in their skin. It settles
within a month or two of birth with minimal or no treatment.
4
See also SEBACEOUS GLANDS; SEBORRHOEIC ECZEMA
ACNE ROSACEA
See ROSACEA
ACNE VULGARIS
See ACNE
ACRODERMATITIS ENTEROPATHICA
Acrodermatitis enteropathica is a
disease of zinc deficiency that starts in
babies within a few days or weeks of
birth. The onset is delayed in breast
fed babies. The cause is a genetic
disorder that prevents absorption of
zinc from food.
Affected babies have dry, scaly,
irritated, red patches on the skin
around the genitals and anus,
spreading to the scalp, hands, feet
and trunk. Other symptoms include
hair loss, premature greying of hair,
the nails are ridged and may be lost, a
red tongue, mouth ulcers, light
sensitive eyes, irritable mood and failure to grow. Infection of damaged skin and mouth ulcers
with bacteria or fungi may be complications. Blood tests show the anaemia and low zinc
levels.
Zinc supplements are given by tablet or injection, and although there is no cure, it can be
well controlled by appropriate treatment.
ACRODERMATITIS PARANEOPLASTICA
See BAZEK SYNDROME
ACRODYNIA
Acrodynia is a disease of children that is associated with mercury poisoning. It causes an
itchy generalised rash, swelling of the skin, bright pink colouration of the hands, feet and
cheeks, swollen painful hands and feet, excessive sweating, diarrhoea and alternating
irritability and lethargy.
ACROKERATOSIS VERRUCIFORMIS
The inherited condition acrokeratosis verruciformis causes flat wart-like growths on the
back of the hands and the tops of the feet that sometimes spread to the forearms, shins and
knees. They are harmless but unsightly.
ACTINIC KERATOSIS
See HYPERKERATOSIS
5
ADDISON DISEASE
Addison disease is also known as adrenocortical Insufficiency and chronic
hypoadrenocorticism. It is a rare underactivity of the outer layer (cortex) of the adrenal glands
that sit on top of each kidney, and produce hormones (chemical messengers) such as
cortisone that control the levels of vital elements in the body and regulate the breakdown of
food. In most cases, the reason for adrenal gland failure is unknown, but tuberculosis is a
possible cause.
The symptoms include weakness, lack of appetite, diarrhoea and vomiting, skin
pigmentation, mental instability, low blood pressure, loss of body hair and absence of
sweating. Complications include diabetes, thyroid disease, anaemia, and eventual death. A
sudden onset of disease is known as an Addisonian or adrenal crisis, which may be rapidly
fatal.
It is diagnosed by special blood tests that measure the body's response to
stimulation of the adrenal gland (synacthen stimulation test).
Treatment involves a combination of medications (eg. steroids such as cortisone) to
replace the missing hormones, and dosages vary greatly from one patient to another.
Frequent small meals high in carbohydrate and protein are eaten, and infections must be
treated rapidly. Patients must carry an emergency supply of injectable cortisone with them at
all times. Treatment can give most patients a long and useful life, but they cannot react to
stress (both physical and mental) adequately, and additional treatment must be given in these
situations. The ultimate outcome depends greatly on the patient's ability to strictly follow all
treatment regimes.
The condition is named after the English physician Thomas Addison (1793-1860).
ALBINISM
Albinism is an uncommon condition in which there is a total lack of pigment in the skin and
eyes. The skin is white, regardless of the race of the parents, and the iris (coloured part of the
eyes) is pink. Both eyes and skin are very susceptible to damage by sunlight. Albinism is a
6
defect of genes that occurs from the moment of conception, but it is not inherited, and an
albino person will usually have normally pigmented children. There is no treatment for the
condition other than carefully protecting skin and eyes from the sun.
Albinism occurs in 1:36,000 Caucasians, 1:10,000 Negroes, and the highest incidence in
the world is 1:200 in the Hopi Indians of Arizona.
Chediak-Higashi syndrome is an inherited condition that can pass to subsequent
generations. It causes recurrent skin and lung infections, partial albinism and sometimes liver,
spleen and lung damage.
See also CHEDIAK-HIGASHI SYNDROME
ALBINO
See ALBINISM
ALOPECIA
Alopecia is a loss of hair from anywhere on the body.
See also ALOPECIA AREATA; ALOPECIA TOTALIS; BALD
ALOPECIA AREATA
Alopecia areata is a common
cause of patchy hair loss. There is a
family history in about 20% of
patients, or fungal infections and
drugs used to treat cancer may be
responsible, but in most cases no
specific cause can be found. Stress
and anxiety are not usually a cause.
Alopecia areata is different to
baldness in that it can occur at any
age, in either sex, in any race, and
more common under 25 years of
age.
Patients have a sudden loss
of hair in a well-defined patch on the
scalp or other areas of body hair (eg.
pubic area, beard, eyebrows), and a bare patch 2 cm or more across may be present before it
is noticed. The hairless area may slowly extend for several weeks before stabilising. Several
spots may occur simultaneously, and may merge together as they enlarge. If the entire body
is affected, the disease is called alopecia totalis, which is not a different disease, just a severe
case of alopecia areata. Patients need to be careful to avoid sunburn to exposed scalp skin.
Treatment involves strong steroid creams, injections of steroids into the affected area, and
irritant lotions.
In 90% of patients, regrowth of hair eventually recurs, although the new hair may be totally
white and it may take many months or years. The further the bare patch is from the top of the
scalp, the slower and less likely the regrowth of hair. It is rare to recover from total hair loss.
See also ALOPECIA TOTALIS; BALD
7
ALOPECIA TOTALIS
Alopecia totalis (or alopecia universalis) is the rare total loss of all body hair, including the
scalp, beard, eyebrows, armpit and pubic hair. The fine hair on the skin elsewhere on the
body may also disappear. The recovery rate is far lower than in alopecia areata, but treatment
is the same.
See also ALOPECIA AREATA; POLIOSIS
ALOPECIA UNIVERSALIS
See ALOPECIA TOTALIS
ANDROGENIC ALOPECIA
See BALD
ANETODERMA
A looseness of soft skin in a localised area caused by damage to the elastin fibres in the
skin is called anetoderma. Surgically removing some of the affected skin may improve the
appearance of the affected area of skin.
See also ELASTOSIS
ANGIOKERATOMA CORPORIS DIFFUSUM
See FABRY DISEASE
ANGIOKERATOMA OF FORDYCE
The angiokeratoma of Fordyce is an uncommon congenital skin condition of the genitals.
Those affected have a large number of small dark red, raised, rounded lumps on the scrotum
and penis of males and the vulva of females. It is diagnosed by a biopsy of a skin lump.
No treatment is normally necessary, but the lumps can be treated by electric diathermy,
freezing (cryotherapy), laser or excision if necessary. Although an annoying condition, it is not
serious.
See also ANGIOKERATOMA OF MIBELLI; FABRY DISEASE; HAEMANGIOMA
ANGIOKERATOMA OF MIBELLI
Angiokeratoma of Mibelli is an inherited skin condition which has two
forms. In men the elbows, knees and backs of the hands are affected. It is
much rarer in females where the genitals of young women are involved.
Pink to red raised lumps appear on the areas of affected skin. The
condition is diagnosed by a biopsy of a skin lump.
No treatment is normally necessary, but the lumps can be treated by
electric diathermy, freezing (cryotherapy), laser or excision if necessary.
Although an annoying condition, it is not serious.
See also ANGIOKERATOMA OF FORDYCE; HAEMANGIOMA; FABRY DISEASE
ANGIOKERATOSIS
An angiokeratosis is a minor unsightly skin condition that is not contagious. Dilated blood
vessels form red lumps on the skin that are then covered by a fine scale. There may be one
or two present or several dozen. They cause no specific problems other than bleeding
excessively if damaged and are easily removed by diathermy (burning under a local
8
anaesthetic), cryotherapy (freezing) or laser coagulation. They usually persist long term, but
sometimes resolve spontaneously.
See also HAEMANGIOMA; HYPERKERATOSIS
ANGULAR CHEILITIS
See CHEILITIS
ANTHRAX
Anthrax is a bacterial skin, lung or intestinal infection that usually occurs in farmers, meat
workers, veterinarians and others who come into close contact with animals. Infection of
humans is uncommon.
The bacterium Bacillus anthracis which is found in cattle, horses, sheep, goats and pigs, is
responsible. It may be caught by bacteria entering the body through scratches and grazes, or
rarely by swallowing or inhalation into the lungs. Anthrax spores may remain inactive in the
soil for decades, but it cannot be transmitted from one person to another. The natural
incidence in western countries is about one in 100 million people every year.
There are three different types of anthrax infection in humans :- Cutaneous anthrax - A sore appears at the site of entry (which may be in the mouth),
then nearby lymph nodes become inflamed, a fever develops, followed by nausea, vomiting,
headaches and collapse.
- Inhalation anthrax (woolsorterʼs disease) - After an incubation period of one to five days
the patient develops flu like symptoms with muscle aches and fever. This is followed two to
five days later by difficulty in breathing, sweating, fever, rapid pulse and blue tinged skin. The
9
patient collapses quickly with a severe form of pneumonia results. It may also spread into the
bloodstream.
- Gastrointestinal anthrax - Incubation period of one or two days, then nausea, vomiting,
fever, loss of appetite, belly pain and bloody diarrhoea develop.
The diagnosis is confirmed by microscopic examination of smears from the skin sores, or
from sputum samples. Specific blood tests may also be positive.
Treatment involves antibiotics such as ciprofloxacin or doxycycline by mouth or injection. A
vaccine is available, but is only used by those who are at high risk because of their
involvement with infected animals, and numerous boosters are required.
Treatment clears the skin and gastrointestinal forms of the disease effectively in most
cases, but anthrax pneumonia is very serious, and a significant proportion of these patients
die.
ARIBOFLAVINOSIS
Ariboflavinosis is caused by a lack of riboflavine (vitamin B2). Patients develop sores at the
corners of their mouth, on the lips and around the eyes and nostrils. If left untreated, there
may be damage to the eyes and vision and a form of seborrhoeic eczema occurs.
ASTEATOTIC ECZEMA
Asteatotic dermatitis (eczema craquelé) is a common form of dermatitis, usually affecting
older people who remain indoors in low humidity and with excess heating during cold weather.
The drying of skin from excessive bathing and soap use is also a factor.
Patients develop dry, itchy, cracked, scaling, red skin, usually on the thighs and arms, but
sometimes on the hands and trunk. If scratched excessively there may be permanent scarring
and damage to the skin. The diagnosis can be confirmed by biopsy if necessary.
Patients should avoid soap, shower instead of bath, humidify the air in the home, and use
moisturising creams and medium strength steroid creams. Resolution of the rash is slow
initially, but cure is possible with good compliance with treatment.
See also ECZEMA
ASYMMETRIC PERIFLEXURAL EXANTHEM OF CHILDHOOD
See LATEROTHORACIC EXANTHEM
ATHLETEʼS FOOT
Athleteʼs foot a fungal infection of the toes technically known
as tinea pedis. The responsible fungi can be found everywhere
in the environment in the form of hardy microscopic spores that
may survive for decades before being picked up and starting an
infection. They multiply in the moist area between the toes,
particularly in athletes who sweat and wear close fitting shoes
that lead to the ideal warm, damp environment favoured by the
fungi. A secondary bacterial infection of the damaged skin may
occur.
The infection causes sore, red, cracks in the skin under and
between the toes. Swabs may be taken to identify the
responsible fungus in resistant cases.
10
Treatment involves antifungal creams, lotions and powders, but in severe cases, antifungal
tablets may be taken. Most patients respond well to treatment, but the infection often recurs,
particularly if treatment is ceased too soon.
See also PITTED KERATOLYSIS; TINEA MANUM
ATOPIC DERMATITIS
See ATOPIC ECZEMA
ATOPIC ECZEMA
Atopic eczema or dermatitis is an abnormal reaction of skin to an irritating substance. The
rash may be triggered by changes in climate or diet, stress or fibres in clothing, and tends to
occur in areas where the skin folds in upon itself (eg. groin, arm pits, inside elbows, eyelids). It
is more common in winter and urban areas, has a peak incidence between 6 and 12 months
of age, and there is an hereditary tendency. Up to a third of the population are atopic, but only
5% of children will develop this skin condition.
Patients develop an extremely itchy rash, but any blisters that form are rapidly destroyed
by scratching which changes the normal appearance of the eczema, so that it appears as red,
scaly, grazed skin that may be weeping because of a secondary bacterial infection. With
repeated irritation, the skin may become hard, thickened, and pebbly.
In most cases, the responsible substance cannot be identified, but skin and blood tests can
be performed to tell if a person has an atopic tendency.
Soothing moisturising creams and steroid creams are prescribed to reduce inflammation
and itch, and soap substitutes are used to prevent drying the skin. In severe cases, steroid
11
and antihistamine tablets are necessary. There is no cure, but effective control can be
obtained in the most cases. The majority of children grow out of the condition.
See also ALLERGIC ECZEMA; DERMATITIS; ECZEMA; WINTER ITCH
AUTOSENSITISATION DERMATITIS
Autosensitisation dermatitis is a reaction in the skin on one part of the body (often the
trunk) in response to a form of dermatitis on another area of the body (often the limbs). The
cause is a substance (cytokine) released from the initially affected area of dermatitis that
travels through the blood and sensitises skin in other areas of the body so that a new rash or
skin irritation, that may have a totally different appearance, develops. This effect is more likely
if the initial rash is very itchy and repeatedly scratched or rubbed by the patient.
The symptoms include itchy, red, scattered, raised or flat spots on the skin, often affecting
the trunk. It usually spreads slowly and steadily. There are no specific tests and the diagnosis
is difficult, often not becoming apparent until the autosensitisation rash settles after the initial
form of dermatitis is treated. Creams or tablets containing corticosteroids are the main
treatments and the prognosis is good.
See also DERMATITIS
BAIRNSDALE ULCER
A Bairnsdale ulcer (Buruli ulcer) is an uncommon skin infection that occurs in the tropics
and affects mainly children and young adults in Australia and Africa. The cause is an infection
of the skin with the bacteria Mycobacterium ulcerans. It may develop from a prick or cut from
plants in a moist environment, but symptoms may not appear until three months after the
initial injury.
Those affected develop a small painless nodule that breaks down into a large to huge,
deep, pain free skin ulcer. Swabs or a biopsy from the ulcer will demonstrate the responsible
bacteria. A secondary bacterial or fungal infection of the ulcer is possible.
Antibiotics are often used in treatment, but the response is poor. If possible, the ulcer is
widely cut out and the wound sutured. Hot packs may speed the healing.
Untreated the ulcer persists for months or years before healing spontaneously and
significant scarring may occur.
See also FISH TANK GRANULOMA
12
BALD
By far the most common form of baldness is that caused by hereditary tendencies in men
(androgenic alopecia). If your father or grandfather was bald, you have a good chance of
developing the same problem. Baldness is a gender linked genetic condition that is very rare
in women, but passes through the female line to men in later generations. There are no cures
available, and none are likely for some time to come.
There are many other causes for patchy or diffuse hair loss including ageing, skin
diseases, stress, the menopause, lack of iron or zinc, an under active thyroid gland, drugs
(particularly those used to treat cancer) and a dozen or more rare diseases.
Some people, particularly young women, develop patches of baldness that are scattered
across their scalp. This condition is known as alopecia, and is very difficult to treat. Many
cases settle by themselves after some months or years, but most require prolonged care by a
dermatologist.
Almost always male pattern baldness commences with gradual hair loss, starting at the
front of the scalp on either side, or in a circular area on top. It is usually accompanied by
excess hair on the body due to higher levels of testosterone. The connection between
baldness and sexual potency is unproved.
Minoxidil or finasteride tablets, or minoxidil scalp lotion, may slow or stop hair loss, but the
only real treatments are hair transplants, scalp flap rotation or a wig.
See also ALOPECIA AREATA; TELOGEN EFFLUVIUM
BARBERʼS ITCH
Sycosis barbae is the technical term for barberʼs itch, an inflammation and infection of the
hair follicles on a manʼs face caused by aggressive shaving. The treatment involves
infrequent light shaves, and antibiotics tablets and cream.
See also FOLLICULITIS
BASAL CELL CARCINOMA
Also known as a rodent ulcer, these shiny, rounded lumps are a cancer of the deeper
(basal) layers of the skin. Basal cell carcinomas (BCC) are caused by prolonged exposure to
sunlight, and occur most commonly on the face and back. They are not as serious as the
more superficial squamous cell carcinomas (SCC), but occur at an earlier age than SCCs,
although rarely before 25 years.
BCCs often change in size and colour, or they may present as an ulcer that fails to heal.
The ulcer often has a pearly, rounded edge.
13
Whenever a BCC is suspected, it should be removed surgically. The specimen is then sent
to a pathologist for examination to ensure that the diagnosis is correct, and that all the tumour
has been removed. Alternate treatments in more difficult areas include anticancer creams,
irradiation and diathermy.
If correctly treated, they can be completely healed, but if left until large, significant plastic
surgery may be necessary as they will slowly invade deeper tissues, and after many years
may cause death.
See also GORLIN GOLTZ SYNDROME; SKIN CANCER
BASAL CELL CARCINOMA NAEVUS SYNDROME
See GORLIN GOLTZ SYNDROME
BASAL CELL PAPILLOMAS
See SEBORRHOEIC KERATOSES
BAZEK SYNDROME
Bazek syndrome (acrodermatitis paraneoplastica or paraneoplastic acrokeratosis) is a rare
complication of cancer in the mouth, throat or intestine. Patients develop finger and toenail
destruction and eczema on the ears, hands, cheeks and knees. The worsening eczema and
nail damage does not respond to treatment or recurs rapidly after treatment. The diagnosis is
not usually made until the symptoms of cancer become apparent. Treatment involves control
of tissue damage with steroid and antibiotic cream while treating the underlying cancer
appropriately. The prognosis depends on the cancer.
BAZIN DISEASE
See ERYTHEMA INDURATUM
BCC
See BASAL CELL CARCINOMA
BECKER NAEVUS
See NAEVUS
BED SORE
A bed sore (pressure ulcer) forms in
skin on which the body rests and so
most commonly affects areas the heels,
buttocks, back of the head and the skin
over the lower part of the backbone.
If the blood supply to the skin is
significantly reduced, the affected skin
dies. When pressure is applied to the skin for many hours without relief, the area will break
down into an ulcer. Elderly, infirm, paralysed or unconscious patients who spend long periods
in bed, or sitting, may not have the ability to move themselves or the sensation necessary to
prompt movement, so that a particular area of skin may carry a great deal of the body's
weight for a prolonged period of time.
14
Prevention involves moving patient regularly so that no area bears pressure for a
prolonged period of time. Sheep skins, ripple mattresses, water beds and other devices are
placed under affected patients to spread their weight as much as possible.
Once present they are often difficult to heal, but may be cured by avoidance of any further
pressure to the area, antibiotic dressings, special absorbent bandages or dressings, and, in
resistant cases, surgical treatment to cover the area with a skin graft. These sores may
become infected very easily and require antibiotic treatment. Once affected, the same area is
very susceptible to future damage, and extra precautions must be taken to avoid their
recurrence.
See also TROPHIC ULCER
BEJEL
Bejel is a form of syphilis caused by the spirochete bacteria Treponema pallidum that is
transmitted by close personal contact, but without sexual contact, in the same way as yaws
and pinta. It tends to occur in children with very poor hygiene in the Middle East and is
characterised by sores around the mouth, followed by a pimply rash on the rest of the body.
Rarely the condition can develop a third stage similar to syphilis. Penicillin cures the infection.
See also PINTA; SYPHILIS; YAWS
BENIGN FAMILIAL CHRONIC PEMPHIGUS
See HAILEY-HAILEY DISEASE
BENIGN JUVENILE MELANOMA
See SPITZ NAEVUS
BENIGN LYMPHOEPITHELIAL CONDITION
See MIKULICZ DISEASE
BERNARD-SOULIER SYNDROME
The Bernard-Soulier syndrome is an inherited defect of platelets (blood cells essential for
clotting), which fail to stick together to form a clot. Excessive bleeding occurs, particularly from
mouth and nose. Bruises and red spots and patches under skin, particularly on feet. The
condition is aggravated by aspirin.
Blood tests on platelet function and bleeding time are diagnostic.
Blood transfusions on a regular basis are the only treatment for this lifelong defect that may
cause significant disability.
BIRT-HOGG-DUBE SYNDROME
The Birt-Hogg-Dube syndrome is a rare skin disorder that is inherited from one parent. The
symptoms include multiple lumps in the skin arising from hair follicles on the head, chest,
back and arms that develop in adult life. It is often accompanied by kidney cancer (Wilms
tumour) and other associated features may include lung cysts, kidney cysts and
pneumothorax. A biopsy of a skin lump is diagnostic.
The disfiguring skin lumps can be excised and appropriate treatment is given for the kidney
cancer, but there is no cure, and the prognosis depends on the management of kidney cancer
and other complications.
15
BLOCH-SULZBERGER SYNDROME
The Bloch-Sulzberger syndrome (incontinentia pigmenti) is a rare, congenital skin disease
of newborn infants that affects females only as males die as a foetus and are passed as a
miscarriage. It is characterised by lines of grouped blisters on the skin that become warty then
subside to leave pigmented streaks. It may also cause brain, dental and eye abnormalities. It
is incurable and no treatment is available.
BLOOD BLISTER
A blood blister is merely a blister formed by another process (eg. friction on the skin) that
has filled with blood due to damage to the blood vessels at the base of the blister. It is no
more sinister than a normal blister, but has merely damaged deeper layers of tissue. The
blister should be lanced with a sterile blade or a needle that has been sterilised in a flame, so
that the blood can be squeezed out as this will allow it to heal faster.
Blood blisters are more likely to become infected than a normal blister, and if this occurs
antibiotics will be necessary.
BLOOM SYNDROME
Bloom syndrome is an extremely rare familial
genetic abnormality that occurs in Jews. These
children are small at birth, have light sensitive skin,
underdeveloped cheeks, leukaemia and other
malignant diseases. Some have spider naevi (blood
vessels) on the facial skin. People who are carriers of
the gene, but do not suffer from the syndrome, are
more likely to develop cancers. No treatment is
available and death in adolescence is common.
See also RILEY-DAY SYNDROME
BLUE NAEVUS
A blue naevus is a benign (noncancerous) blue coloured mole that
may be found anywhere on the
body, and usually appears on older
children and teenagers, but may
develop at any age. They are
caused
by
overproduction
of
pigment in the deeper layers of the
skin by melanocytes (skin cells that
are
responsible
for
pigment
production).
No treatment is necessary
unless the mole is cosmetically
unacceptable, when it can be
surgically excised.
See also BLUE RUBBER
BLEB NAEVUS SYNDROME
16
BLUE RUBBER BLEB NAEVUS SYNDROME
Strange as it may sound, the blue rubber bleb naevus syndrome is a real medical
condition. It is a rare disorder of small blood vessels in skin and bowel caused by the
congenital overgrowth of capillaries.
Patients have multiple blue tinged rubbery growths (blebs or haemangiomas) in the
skin and small bowel that bleed easily. Blebs may also develop in the liver, spleen and brain.
Blood can be found in the faeces, and blood tests show anaemia and low levels of iron.
Surgical removal of the affected gut and skin blebs, iron supplements and blood
transfusions are the only treatments as there is no cure.
See also BLUE NAEVUS; HAEMANGIOMA
BOIL
A boil (or furuncle) is a small superficial abscess that develops when a hair follicle
becomes infected by bacteria. As a result, people who are very hairy will develop more boils.
Commonly affected areas are the armpits, buttocks and groin.
Patients develop an acutely painful, red and tender lump, which gradually enlarges,
causing more and more pain until it ruptures, discharging pus.
Treatment involves antibiotic tablets, applying antiseptic or antibiotic ointment to the boil,
and when pus is obviously present, lancing the boil with a scalpel or needle. Repeated attacks
may require long-term antibiotic treatment, antiseptic soaps and antiseptic lotions applied
regularly.
In some cases infection can spread to cause boils in other areas, or in severe cases, the
infection may enter the blood stream to cause septicaemia. Boils should never be squeezed,
as the pus they contain may rupture internally, and spread through the blood stream to the
brain and other vital organs.
A carbuncle is several boils in a limited area that join together to form an interconnecting
infected mass. It usually degenerates into an abscess.
See also FURUNCULOSIS; HIDRADENITIS SUPPRAVITA
BOUCHARD NODES
Bouchard nodes are bony lumps on the top of the finger joints between the first and second
finger bones (proximal interphalangeal joints). They are a sign of severe rheumatoid arthritis.
BRACHIORADIALIS PRURITUS
See ITCHY UPPER ARM SYNDROME
BULLOUS IMPETIGO
See SCALDED SKIN SYNDROME
BULLOUS PEMPHIGOID
See PEMPHIGOID
BUNION
Hallux valgus is the technical term for a common bunion.
If the big toe is constantly pushed across towards the smaller toes by tight shoes, it may
become semi-permanently deformed in this direction. The end of the long bone in the foot
behind the toe bones is then able to push against the skin. A protective, fluid-filled sac (a
17
bursa) forms between the bone end and the skin and
slowly enlarges to form a tender and painful bunion.
They usually start in childhood but may not cause
significant discomfort until adult life.
A number of surgical procedures are available to
correct the deformity, but in elderly people it may be
preferable for a protective pad to be worn inside soft or
especially made shoes.
BURULI ULCER
See BAIRNSDALE ULCER
CAFÉ-AU-LAIT SPOTS
Café-au-lait (white coffee) spots are multiple light brown spots on the skin. They occur with
von Recklinghausen's disease of multiple neurofibromata, pityriasis versicolor, tuberous
sclerosis and ageing.
CALCIFYING EPITHELIOMA OF MALHERBE
See PILOMATRIXOMA
CALLUS
A callus (callosity or keratoma) is an abnormal thickening of skin keratin caused by
recurrent injury to, or rubbing. The patient should remove any pressure to the area if possible
(eg. correct footwear, protective pads), and can then carefully peel away the layers of keratin
with a scalpel or apply salicylic acid ointment. A callus may become painful, and rarely
infected, if trimmed excessively.
See also CORN
CAMPBELL de MORGAN SPOTS
18
Campbell de Morgan spots are also known as cherry angiomas and senile haemangiomas.
They are a common skin disorder affecting the trunk of older people caused by overgrowth of
blood vessels in the skin. There is a genetic tendency to develop them.
Patients develop red to maroon, raised, dome shaped growths on the skin a few
millimetres across that steadily increase in number with age. Normally no treatment is
necessary, but cautery, laser treatment or surgical excision can be used if cosmetically
unacceptable.
See also HAEMANGIOMA; VENOUS LAKE
CAPILLARITIS
Capillaritis (lichen aureus, Schamberg disease, Majocchiʼs purpura or purpura annularis
telangiectodes) is a harmless skin condition caused by leaky capillaries under the skin that
become inflamed. Blood passes through small gaps between the cells that make up the
capillary walls and tiny red dots appear on the skin. These join together to form a flat red
patch, which becomes brown and then slowly fades away over weeks to months.
The cause is usually unknown but the condition occasionally arises as a reaction to a
medication, a food additive, a viral infection or it may flare after exercise.
There are several different types of capillaritis:
- Schamberg's disease (progressive pigmented purpura) - most common type. Crops
of red-brown flat patches with tiny red spots on their borders appear on the lower legs and
other parts of the body.
- Gourgerot-Blum disease (pigmented purpuric lichenoid dermatosis) - less common.
The patches are thickened and itchy, rather like eczema.
- Majocchiʼs purpura (purpura annularis telangiectodes) - dilated capillaries as well as
brown patches and red spots. The patches gradually spread outwards.
- Lichen aureus - a solitary brown-yellow patch that is very persistent and often overlies
a varicose vein.
Those affected should discontinue any medication for several months if possible to see if
the condition improves, and avoid food preservatives and artificial colouring agents. Steroid
creams help itching but rarely clear the capillaritis. If the lower leg is affected, consider
wearing compression elastic stockings.
There is no cure, but it can disappear within a few weeks, recur from time to time, or persist
for years.
CAPILLARY HAEMANGIOMA
See STRAWBERRY NAEVUS
CAROTENAEMIA
Vitamin A is found in leafy green vegetables, dairy products, liver and yellow coloured
foods such as carrots, pumpkin, mangoes, paw paws, oranges and apricots that contain large
quantities of a yellow substance known as carotene. Excess levels of carotene and vitamin A
(hypervitaminosis A) therefore occur simultaneously in most cases.
Carotenaemia is caused by taking excessive amounts of vitamin A tablets or eating large
quantities of yellow fruit and vegetables. Huge quantities must be consumed, but patients who
develop a craving for one particular type of food can consume sufficient for the symptoms to
appear in a few weeks.
19
The symptoms may include loss of appetite and weight, yellow colouring of the skin
(particularly the palms and soles, but unlike liver diseases, not the whites of the eyes), brittle
nails, dry and cracked skin, sore gums, headaches and other more bizarre symptoms. It can
cause deformities to the foetus of a pregnant woman, and therefore large doses of vitamin A
should be avoided during pregnancy.
All liver blood tests remain normal, but yellow palms and soles are diagnostic features. The
amount of carotene present in the blood can be measured. The normal range is 0.93 to 3.7
µmol/L. and higher levels are characteristic of carotenaemia. High carotene levels can also
occur in patients with an under active thyroid gland (hypothyroidism) or excess fat in blood
(hyperlipidaemia), while low levels are possible with tropical sprue or a poor absorption of fat.
The only treatment is not eating the offending foods and vitamin supplements. Almost
invariably the condition resolves slowly over a few weeks without long-term damage.
CAT SCRATCH DISEASE
Cat scratch disease is a curious condition caused by a scratch from a cat claw, often to the
face. The bacterium Bartonella henselae, that may be present on cat paws, is responsible.
When a person is scratched by a cat, the bacteria enter the damaged tissue.
A few days after being scratched, about one third of patients develop a scab-covered sore
at the site of the scratch. Between one and three weeks later, a fever and headache occur,
and are accompanied by enlarged lymph nodes in the groin and the side of the neck or armpit
nearest the scratch. Occasionally the infected nodes develop into an abscess. No specific
tests are available to confirm the diagnosis, and blood tests merely show that an infection is
present, but not what has caused the infection.
No treatment is available or necessary, but sometimes it is necessary to surgically drain an
abscess. It usually settles spontaneously within a week or two, but very rarely a form of
encephalitis (brain inflammation) and skin rashes may occur.
CAVERNOUS HAEMANGIOMA
A cavernous haemangioma is a benign growth that
consists of greatly dilated veins that can vary in size from
a pinhead to several centimetres across.
They most commonly occur on the face, scalp and neck
skin of babies, but may also develop internally and not be
discovered until they bleed or they are incidentally found
during surgery. Cavernous haemangiomas are delicate
and bleed very easily if damaged. They may be treated by
surgical excision, irradiation, cautery or injecting
sclerosing substances to destroy the blood vessels.
See also HAEMANGIOMA
CELLULITIS
Cellulitis is a bacterial infection of the tissue immediately under the skin that may start from
a bite or wound, but sometimes occurs for no apparent reason.
The area affected is hot, red, tender, swollen and painful. The infected area slowly
spreads, and once the lymphatic system becomes involved, red streaks may run towards the
nearest lymph nodes (adenitis), and the patient will develop a fever and become quite ill.
20
A swab may be taken from any sore to determine the type of bacteria responsible, and the
appropriate antibiotic to treat it is then prescribed. An abscess may develop in the tissue if
treatment is delayed, and rarely, the infection may spread to the blood to cause septicaemia.
Most cases respond rapidly to antibiotics.
See also ERYSIPELAS
CERCARIAL DERMATITIS
Cercarial dermatitis (swimmerʼs itch or clam diggerʼs itch) is caused by an infestation of the
skin by the larval form (cercaria) of the parasite Schistosoma cercariae, which normally lives
in birds and small mammals. It occurs world-wide in salt and fresh water. The parasiteʼs eggs
are shed with animal faeces into water, where they hatch, then infect snails, from which they
emerge as larvae. The larvae penetrate the skin of humans or other animals.
Victims experience a sudden onset of itchy red lumps on the skin at the site(s) of
penetration by the larvae. In very sensitive patients, an allergy reaction (hives) can occur on
the skin around the lump, or in severe cases may be generalised. The microscopic larvae
cannot survive in humans and die just under the skin.
Antihistamine tablets and steroid creams may ease itch and skin reaction, but the lumps
and sores settle within a week.
See also HIVES
CHAGAS DISEASE
Chagas disease (American trypanosomiasis) is an infestation by the protozoan (single
celled) parasite Trypanosoma cruzi that is widespread in tropical America from Texas to
Bolivia. It is transmitted from wild animals to humans by bug bites to the skin or bug faeces in
the eye.
The disease goes through three stages - acute, latent and chronic. Initially a sore develops
on skin at the site of a bite or in the eye, and in many patients, no other symptoms ever occur
until after a latent stage lasting 10 to 30 years when a chronic stage with heart disease occurs
causing irregular heart rhythm, congestive heart failure, and pulmonary thromboses (blood
clots in lung). A minority of patients go through an acute illness, which causes enlarged lymph
nodes near the bite, fever, tiredness, headache, and enlarged liver and spleen. Acute heart or
brain infection may be rapidly fatal. Long-term infection may cause severe heart disease. The
disease is diagnosed by specific blood tests, but may be undetectable in the latent stage.
Treatment is generally unsatisfactory. Medications may be tried in the acute stage, but are
of no use in the chronic stage.
Chagas disease is fatal in 10% of acute illnesses, and death from heart disease may occur
in the chronic stage.
The condition is named after the Brazilian physician Carlos Chagas (1879-1934).
CHANCRE
A chancre is a sore that starts as a small lump (papule) and breaks down into a painless
ulcer. The most common cause of a chancre is syphilis, in which the chancre heals after a
few weeks without treatment or leaving a scar, but the underlying syphilitic infection
progresses in other parts of the body.
21
CHANCROID
Chancroid is a sexually transmitted infection caused by the bacteria Haemophilus ducreyi,
that is rare in developed countries, and more common in the tropics and Asia.
Three to five days after sexual contact with a carrier, a
sore develops on the penis or vulva, which rapidly breaks
down to form a painful ulcer. Several sores and ulcers may
be present at the same time. Lymph nodes in the groin then
swell up into hard, painful lumps, that may degenerate into
an abscess and discharge pus. The patient is feverish and
feels ill. Some patients develop a mild form with minimal
symptoms, but they can transmit the disease. This is
particularly common in women, where the sores may be
hidden internally in the vagina. The condition is diagnosed by
taking swabs from the sores and identifying the bacteria
present in the pus, or skin tests that often remain positive for
life.
Antibiotics (eg. azithromycin, ciprofloxacin) cure the
infection, but balanitis (infection of penis head) and phimosis
(contracture of foreskin) are possible complications.
CHÉDIAK-HIGASHI SYNDROME
The Chédiak-Higashi syndrome is a familial (runs through families) failure of white blood
cells to function or develop. Patients have recurrent skin infections, partial albinism (loss of
skin pigment) and a lack of white blood cells. Some patients have a large liver and spleen,
and severe respiratory infections. Blood tests show abnormal and low number of white cells.
Antibiotics can be used for bacterial infections, and steroids, bone marrow transplants and
vitamin C supplements may also be helpful. The prognosis is poor.
See also ALBINISM
CHEILITIS
Angular cheilitis or perlèche) is inflammation
at the corner of the lips. The cause is drying of
the lips for various reasons including mouth
breathing, loss of teeth in the elderly (upper lip
overhangs lower one), dribbling, repeated
nervous licking of lips, dry skin, lack of vitamin B
or iron, and the uncommon disease Sjögren
syndrome.
Red, sore, cracked and sometimes bleeding
occurs at the outer corners of the lips. Fungal or
bacterial infection of the damaged tissue may
occur.
It is necessary to exclude any serious causes, but normally no investigations are
necessary. Patients should use a moisturising or mild steroid cream and any secondary
fungal or bacterial infection must also be treated. It is usually easily managed, but may be
chronic in the elderly.
See also RHAGADES
22
CHERRY ANGIOMA
See CAMPBELL de MORGAN SPOTS
CHICKENPOX
Chickenpox (varicella) is a generalised infection caused by the virus Herpes zoster.
Infection occurs when the virus passes to another person from the fluid-filled blisters that
cover the body of patients, or in their breath and saliva. Patients are infectious for a day or
two before the spots appear, and remain infectious for about eight days. The incubation
period is 10 to 21 days.
Early symptoms are similar to those of a cold, with a vague feeling of being unwell,
headache, fever and sore throat. The rash usually starts on the head or chest as red pimples,
then spreads onto the legs and arms, and develops into blisters before drying up and
scabbing over. New spots may develop for three to five days, and it may be two weeks or
more before the last spot disappears. The diagnosis can be confirmed by varicella antibody
blood tests, but none are usually necessary.
Treatment involves bed and home rest until the patient feels well, and medications to
relieve the itch (eg. calamine lotion, antihistamines), fever and headache. Children must be
excluded from school for at least five days from the appearance of the first blisters and until all
blisters have developed a dry scab.
There is a vaccine has been available since 2000 to prevent the disease. One injection is
necessary if given between 12 months and 12 years of age, but two injections six weeks apart
in older children and adults.
23
Complications are more common in adults, and include chest infections and a type of
meningitis. It is unusual for the pockmarks to scar unless a secondary bacterial infection
occurs.
Complete recovery within ten days is normal. Once a person has had chickenpox, it is
unlikely (but not impossible) that they will ever catch it again.
Once a patient has had chickenpox, the virus never leaves their body but migrates to the
nerves along the spinal cord where it remains forever. The virus may be reactivated years
later at times of stress to give the patient the painful rash of shingles.
See also SHINGLES
CHICLERO ULCER
See CUTANEOUS LEISCHMANIASIS
CHIGGER
Chiiger is skin irritation and itching caused by the larva of the mite Trombicula which is
found in long grass in Europe and North America and sticks to the skin.
CHIGOE
Chigoe (jigger or tungiasis) is an infestation by the female flea Tunga penetrans which
burrows into the skin of the foot, particularly around the base of a small toe where it lays its
eggs. The infestation causes damage to the tissue, an ulcer, and may result in gangrene of a
toe.
CHIKUNGUNYA
The arboviral infection chikungunya is transmitted from one person to another by a
mosquito bite and is found mainly in tropical Africa. The cause is an Togavirus. It causes a
fever, rash, joint and muscle pain, but usually settles after a few weeks with no treatment. In
severe cases it causes bleeding into the skin and a form of viral encephalitis, which may be
fatal.
CHILBLAINS
Chilblains are a mild form of frostbite
caused by exposure to extreme cold.
Itchy, red skin spots develop on the
fingers, toes and other exposed areas such as
the nose. The spot may form a blister, and the
itching is aggravated by warmth.
Treatment involves gradual warming in a
warm room. The fingers or toes should NOT be
immersed in hot water or placed near a heater
or fire, nor should the area be rubbed or
massaged as this may cause further damage.
Sometimes damaged skin may become infected and require antibiotics. Recurrent chilblains
can lead to a permanent scar forming at the site, but if not exposed to further cold, the skin
will heal in a day or two.
See also FROSTBITE
24
CHLOASMA
Chloasma (melasma) is a pigmentation disorder of the skin that
occurs almost invariably in women, and more commonly in those
with a dark complexion. The deposits of pigment on the forehead,
cheeks, upper lip, nose and nipples are often triggered by
pregnancy or starting the oral contraceptive pill.
Treatment is unsatisfactory. Numerous blanching agents have
been tried with minimal success, but the pigmentation usually
fades slowly over several years.
CHLORACNE
This rare skin condition chloracne, occurs as a reaction to toxic chemicals (eg. dioxin,
chlorbenzene, polychlorbiphenyls, chlorophenol, pyrazole) found in insecticides, herbicides
and wood preservatives. The chemicals may be touched, inhaled or swallowed.
Whiteheads and blackheads similar to acne (pimples) that are not inflamed (red), develop
on the skin of the cheeks, neck, armpits and groins. Because the chemicals are stored in
body fat, more pimples may develop for some time after exposure to the chemicals has
ceased.
The source of exposure must be identified and further exposure prevented. Antibiotics and
isotretinoin are used to slowly clear pimples.
After an attack the palms and soles may be excessively sweaty, the liver may be damaged,
excess fat is found in the blood, impotence may occur, patients may become tired and
nervous, and porphyria cutanea tarda may develop. Provided there is no more exposure to
the responsible chemicals, the pimples usually clear within two years.
See also ACNE; PORPHYRIA CUTANEA TARDA
CHOLINERGIC URTICARIA
A skin reaction that occurs in some individuals, cholinergic urticaria is characterised by
multiple small itchy lumps surrounded by a reddened area of skin. It is caused by a
contraction of blood vessels from excessive nerve sensitivity at times of stress, exertion, heat
or sweating. It is not an allergy reaction, but may be
treated by antihistamines and cooling the affected
skin.
CHONDRODERMATITIS NODULARIS
CHRONICA HELICIS
Chondrodermatitis nodularis chronica helicis is a
painful inflammatory condition affecting the ear of
middle-aged and elderly men. It is caused by
pressure on the ear between the head and pillow at
night. It occurs in people who usually sleep on only
one side, and may also be due to a minor injury (eg.
tight headgear or telephone headset), or by
exposure to cold. Reduction in the blood supply to
the ear with ageing prevents healing of minor
damage to the ear cartilage.
A benign exquisitely tender lump a few millimetres
25
across develops in the cartilaginous part of the ear. There is often a tiny central core, which
may discharge a small amount of scaly material. An ulcer may form on the ear if left
untreated.
Patients should avoid sleeping on the affected ear, use a soft pillow with a hole in it if
necessary, and wear a warm hat over the ears when outside in the cold and wind. It may be
treated with a cortisone injection, frozen with liquid nitrogen or surgically removed. If
ulcerated, antibiotic ointment may be applied.
The condition is annoying but not serious and there is a 10% recurrence rate after surgery.
CHROMOMYCOSIS
Chromomycosis or chromoblastomycosis is a persistent fungal infection of the skin caused
by various fungi that normally live in the soil and decaying wood in tropical climates. It enters
the skin through a graze or cut.
An ulcer or sore develops that will not heal and forms a crust, while slowly enlarging over
many years. Secondary infection by a bacteria and spread of the fungus to deeper tissues
may occur with time.
The diagnosis is confirmed by a biopsy that is examined under a microscope, and culture
of a wound swab for fungi. A complete cure usual with prolonged treatment with antifungal
medications (eg. itraconazole).
CICATRIX
A cicatrix is abnormally thickened, hard, white scar tissue.
CIRCUMSCRIBED DERMATITIS
See LICHEN SIMPLEX
CIRCUMSCRIBED SCLERODERMA
See MORPHEA
CLAM DIGGERʼS ITCH
See CERCARIAL DERMATITIS
CLEAVAGE LINES
See LANGERʼS LINES
COFFIN-SIRIS SYNDROME
The Coffin-Siris syndrome is a familial (runs in families) developmental abnormality in
which both parents must be carriers. Patients have poorly developed toenails, are very hairy
at birth but have sparse hair in later life, suffer intellectual disability and coarse facial features.
There are no specific diagnostic tests, and no treatment is available, but life expectancy is
reasonable.
COMEDO
A comedo is a black or white headed pimple on the skin filled with sebum (oil) as in acne.
See also ACNE
26
COMEDONE NAEVUS
A comedone naevus is an unusual type of
birthmark that may occur anywhere on the body.
It is caused by the localised overgrowth of oil and
sweat glands in the skin and appears as a tightly
clumped patch of pimples on the skin that is
present from birth. It may become inflamed and
infected.
Surgical removal of the patch is performed if
possible as it persists long term unless removed.
See also ACNE; NAEVUS
CONDYLOMA ACCUMINATA
See GENITAL WARTS
CONGENITAL POIKILODERMA
See ROTHMUND-THOMSON SYNDROME
CONTACT DERMATITIS
Contact dermatitis (housewifeʼs dermatitis or irritant eczema) is one of the most common
forms of dermatitis. It is particularly troublesome in some occupations including hairdressers,
painters, kitchen workers, mechanics and those working with chemicals.
Soaps, medicated creams, detergents, chemicals, solvents, cosmetics, perfume, jewellery,
metals, rubber, animals and plants are the most common substances causing contact
dermatitis. Substances that a person has used or touched regularly for many years without
any adverse effect may suddenly cause a reaction. This is particularly common with solvents,
dyes, rubber, inks and cosmetics. The rash is more common on exposed parts of the body,
but may occur on other areas if, for example, underclothes are washed in a detergent to
which the patient reacts.
The affected area of skin is red, itchy, swollen, burns and may blister. After a few days, it
may become crusted and weep. The dermatitis may become secondarily infected by bacteria,
and then antibiotics are required.
A person's reaction to suspect agents may be investigated, but these tests, in which a
patch of skin is exposed to a substance to test its response, are often inconclusive.
27
If the substance causing the dermatitis can be identified and avoided, the problem is
solved. Gloves can be used to avoid detergents, soap substitutes used for washing, and
changes in occupation to avoid solvents. If the irritating substance can be tracked down, it
may be possible to desensitise the patient. The main treatment is a steroid cream, lotion or
ointment. Placing a plastic dressing over the dermatitis and cream increases the effectiveness
of the treatment. In severe cases, steroids may need to be given in tablet form, or even by
injection.
Provided the causative agent is not touched again, the dermatitis should settle with
treatment, and not recur.
See also DERMATITIS
CORN
A corn is a hard mass made of dead skin cells that overlies a bony prominence on the foot
or hand. They are caused by persistent friction and pressure between the skin and a shoe or
other hard surface. They are treated by preventing further friction and pressure by modifying
footwear, altering work practices and using a protective adhesive ring (corn pad) around the
corn. The corn can then be softened with acidic creams and the excess callus can be
carefully cut away.
CORYNEBACTERIUM MINUTISSIUM
See ERYTHRASMA
COWPOX
Cowpox is a mild viral infection that can be transmitted from cattle to man by close contact.
It causes blisters on the affected part of the skin, which settle without treatment after a couple
of weeks. It is usually the hands that are affected as it can be caught by manual milking.
Cowpox was found to give immunity against smallpox as it is caused by a related virus, and
this was the basis of the first vaccine against smallpox.
COXSACKIE VIRUS INFECTION
There are two main types of Coxsackie virus (A and B), but these are further broken down
into more than 50 subtypes.
The symptoms depend on where the infection occurs. It may cause viral meningitis, cold
like symptoms, fevers, ulceration of the mouth and throat (herpangina), inflammation of the
pleura around the lungs (Bornholm disease), hand foot mouth disease, myositis (inflammation
of muscles), and inflammation of the heart or the pericardium that surrounds the heart. Rarely,
if the heart is infected, it may be permanently damaged.
There is no cure other than time and rest, but symptoms may be eased by appropriate
medication when necessary. Most patients recover uneventfully unless the heart is involved.
See also HAND FOOT MOUTH DISEASE
CRABS
Crabs (pubic pediculosis) is an infestation of the pubic hair with the lice (parasitic insect)
Phthirus pubis, that lives by sucking blood from the soft pubic skin. Caught by being in close
bodily contact with someone who already has an infestation (eg. during sex), but as the lice
can survive away from humans for a time, they can also be caught from borrowed clothing,
towels or bedding.
28
Often there are no symptoms and many people are unaware
of the presence of lice. In others the lice cause an itchy rash in
the pubic area, which may be raw and bleeding from constant
scratching. Secondary skin infections may develop in these
sores, and this infection can cause further symptoms including
a fever and enlarged glands in the groin. Lice may be seen by
examining the pubic hair through a magnifying glass.
A number of lotions are available to kill the crabs. The
affected individual, and all sex partners, must be treated
simultaneously to prevent reinfestations occurring. All clothing
and bedding must be thoroughly washed in hot water. A repeat
treatment after 24 hours and again after seven days is
advisable in order to kill any lice that have hatched in the
interim. Antibiotics may be required to treat secondary
infections.
Correct treatment should result in a complete cure.
CRADLE CAP
See SEBORRHOEIC ECZEMA
CREEPING ERUPTION
See CUTANEOUS LARVA MIGRANS
CREST SYNDROME
The name of this syndrome is an acronym for its symptoms :- Calcinosis (the formation of hard calcium containing nodules under the skin)
- Raynaudʼs phenomenon (fingers and toes to become cold and blue)
- Oesophageal (Esophageal - American spelling) inflammation causing difficulty in
swallowing
- Sclerodactyly (thickening and hardening of the skin on the fingers and toes)
- Telangiectasia (multiple dilated blood vessels in the skin).
It is known as CRST syndrome if the oesophagus is not involved.
The cause is unknown, but it can be diagnosed by a biopsy of affected tissue and detecting
the presence of centromere autoantibodies in the blood.
There is no cure, and the condition is usually slowly progressive, but medications can be
given to ease symptoms. Scleroderma may be a complication.
See also SCLERODERMA
CRONKHITE-CANADA SYNDROME
The rare Cronkhite-Canada syndrome is the thickening of the lining of the stomach, small
bowel and colon to form non-cancerous polyp-like lumps. The cause is unknown. The
symptoms include abdominal discomfort, irregular bowel habits and bleeding from the bowel
to give dark or black motions. Other symptoms may include abnormal skin pigmentation
(particularly of the palms and soles), poorly developed finger and toenails, hair loss and
diarrhoea. It is diagnosed by gastroscopy and/or colonoscopy. No treatment is available.
29
“CROTCH ROT”
See TINEA CRURIS
CUTANEOUS LARVA MIGRANS
Cutaneous larva migrans, or creeping
eruption, is a skin infestation by a larval
nematode worm. The rash is caused by
the burrowing of hookworm larvae
through the skin. The larvae hatch from
dog or cat faeces, mature in the soil and
then penetrate human skin.
Patients develop several centimetre
long red, very itchy, twisting tracks in
and under the skin. Large blisters may
form later. Secondary bacterial infection
of skin may occur due to damage by
both the larvae and scratching.
A skin biopsy is sometimes used to
make the diagnosis. Treatment involves medication by mouth and ointment to kill the larvae,
and other creams to ease the skin irritation.
The larvae cannot mature in humans, and die after several weeks, and then the skin tracks
slowly heal.
CUTANEOUS LEISCHMANIASIS
Cutaneous leischmaniasis has numerous local names in different parts of the world
including Chicleroʼs ulcers, oriental sore and uta. It is an ulcerating skin infection caused by
the protozoan (single celled animal) Leischmania tropica, Leischmania aethiopica,
Leischmania mexicana, or Leischmania peruviana depending upon the geographic location.
It is transmitted from one person to another by sand flies. Occurs throughout the tropics in
Asia, Africa and particularly America.
The symptoms depend upon which protozoan
is causing the disease, and vary from a self healing
ulcer (Oriental sore), to persistent multiple mutilating
sores and ulcers (Chicleroʼs ulcers), or widespread
non-ulcerating plaques on the skin. Secondary
bacterial infection of sores can allow rapid spread of
the protozoa and gross disfigurement.
Smears taken from ulcer edge show the
protozoan under a microscope, and specific blood
tests may be positive.
Single ulcers are treated with heat packs,
cryotherapy (freezing), radiotherapy or specific ointments. Widespread disease is difficult to
treat but numerous medications may be tried. Antibiotics are given for secondary infections.
The prognosis depends on the infecting organism and form of disease. Single ulcers often
heal after a few months, but widespread disease may be steadily progressive without
treatment.
See also KALA-AZAR
30
CUTANEOUS NEUROENDOCRINE TUMOUR
See MERKEL CARCINOMA
CUTANEOUS PAPILLOMA
See SKIN TAG
CUTIS HYPERELASTICA
See EHLERS-DANLOS SYNDROME
CUTIS LAXA
Cutis laxa is an inherited condition in which there is a lack, or reduced number, of elastic
fibres in the skin resulting in abnormally slack, loose, folded, wrinkled skin, particularly around
the neck. Particularly disfigured areas may be helped by plastic surgery.
DANDRUFF
Dandruff is A very common form of scalp irritation. It is actually a disease in itself, but most
people describe a scalp that is shedding copious quantities of skin scale as dandruff.
Over a period of a few weeks, the skin totally replaces itself. New cells are produced deep
in the skin, slowly move out as new cells are produced beneath them, thin out to form a hard
scaly layer, and eventually slough off. Dandruff is an acceleration of this natural process in
which the rate at which cells are produced on the scalp is increased, so that the excess cells
produced form a scale on the skin. The underlying skin may become inflamed and itchy. It is
thought that a mild fungal infection of the scalp causes this increased rate of cell loss.
Emotional stress, overworking, hot climates and a poor diet all aggravate dandruff.
Dandruff must be differentiated from other skin diseases such as psoriasis, dermatitis,
eczema, neurodermatitis and other fungal infections. A biopsy is sometimes necessary to
make the diagnosis.
Seborrhoeic dermatitis is an inflammation of the scalp that is more common in babies,
when it is known as cradle cap.
Good scalp hygiene, and an antidandruff lotion or shampoo containing pyrithione zinc are
the main treatments, but excessive use of shampoos or soap may aggravate the problem by
further drying and irritating the scalp. Resistant cases may be helped by steroid scalp lotions,
and antifungal lotions (eg. selenium sulfide) or gels.
Most patients have recurrences, with bad and good periods, often for no apparent reason,
but reasonable control is normally possible.
See also PSORIASIS; SEBORRHOEIC ECZEMA; TINEA CAPITIS
DARIER DISEASE
A rare skin condition that usually starts between 8 and
15 years of age, Darier disease (keratosis follicularis)
affects the face, back, scalp, groin and armpits. It is an
inherited disorder causing the production of abnormal
keratin (hardening substance in skin) that may worsen
with heat and sweating.
Patients develop small, brown, firm lumps on the skin
that slowly enlarge and become covered in greasy
31
scales. They may appear as small pits on the soles and palms. The diagnosis can be
confirmed by a skin biopsy.
Salicylic acid and retinoic acid ointments are used in treatment.
In serious cases the lumps in the skin may merge together to form a hard crusted plaque,
and the nails become brittle, ridged and discoloured in persistent cases. Secondary bacterial
infections may also occur. The syndrome may be associated with subnormal mentality and
reduced height in some patients.
In the early stages, the disease may settle spontaneously, but if it becomes prolonged the
disease is difficult to control.
DERCUM DISEASE
Dercum disease (adipositas dolorosa) is a familial (runs in families) condition that causes
the development of tender lumps under the skin in middle aged and elderly. It is much more
common in women.
Multiple, tender, soft, fatty lumps (lipomas) form under the skin. The condition is often
associated with emotional instability and weakness in women. A biopsy is usually necessary
to confirm the diagnosis.
Excision of lipomas that are particularly painful or disfiguring is the only treatment. The
condition persists, but there is a good response to the treatment of individual lumps.
DERMATITIS
Any inflammation of the skin can be called dermatitis, so there are many different types of
dermatitis.
It is often very difficult to determine any cause, for although the skin is the most visible of
our organs, its diseases are very diverse and often difficult to diagnose.
In most cases simple steroid anti-inflammatory creams will control dermatitis, but it may
become persistent and widespread.
For further information see the specific types of dermatitis.
See also ATOPIC ECZEMA; AUTOSENSITISATION DERMATITIS; CONTACT
DERMATITIS; DERMATITIS ARTEFACTA; DERMATITIS ARTEFACTA; DERMATITIS
HERPETIFORMIS;
DERMATITIS
MEDICAMENTOSA;
ECZEMA;
EXFOLIATIVE
DERMATITIS; NEURODERMATITIS; PERIORAL DERMATITIS; PHOTODERMATITIS;
POMPHOLYX; PSORIASIS; SCALDED SKIN SYNDROME; STASIS DERMATITIS
DERMATITIS ARTEFACTA
Dermatitis artefacta is a rash that is deliberately self-inflicted to attract attention or obtain
special treatment. Patients may be disturbed psychiatrically, prisoners, deprived of affection
or attention, senile or confused. They may use heat, sharp instruments, sandpaper, chemicals
or their fingernails to create the rash. Women are five times more likely to have the condition
than men.
The rash can be extraordinarily varied in its form, and quite bizarre in its presentation. It
usually does not respond to treatment, and occurs on unusual parts of the body. Treatment
involves psychiatric counselling and medication, and dressings that cannot be easily removed
by the patient. Plaster casts may occasionally be necessary to stop a patient constantly
picking at an ulcer that will not heal. Sometimes the rash may become infected or
gangrenous, but if effective psychiatric care given, treatment is usually successful.
See also DERMATITIS
32
DERMATITIS, ATOPIC
See ATOPIC ECZEMA
DERMATITIS EXFOLIATIVA NEONATORUM
DERMATITIS HERPETIFORMIS
This is an uncommon blistering itch that occurs on the elbows, knees and backside. There
are several different causes, including gluten, which is found in many cereals.
Patients develop small, intensely itchy, fluid-filled blisters on red, inflamed skin. Often
appears scratched and bleeding because of the almost irresistible itching. The diagnosis can
be confirmed by a biopsy of a skin blister.
Treatment requires avoiding gluten containing cereals, and using very potent steroid
creams or tablets, or rarely dapsone.
The rash can be cured by avoiding any cause that can be discovered, otherwise control
may be difficult.
See also DERMATITIS
DERMATITIS MEDICAMENTOSA
Dermatitis medicamentosa (a drug eruption or toxic erythema) is an abnormal reaction to a
medication that causes skin inflammation. There is the sudden onset of a bright red, itchy
rash. Some patients have a fever, tiredness, joint pains, headache and nausea. Blood cell
damage, severe allergy reactions (anaphylaxis), kidney and liver damage may also occur.
The diagnosis is often difficult, as there is usually no specific test.
Patients should stop the use of responsible medication, and antihistamines are taken for
the itch. Steroid creams or tablets may also be used.
The rash usually settles with cessation of the responsible medication, but if complications
occur, the condition may be serious.
See also DERMATITIS; ERYTHEMA MULTIFORME; FIXED DRUG ERUPTION
DERMATOFIBROMA
Dermatofibromas (histiocytomas) are common
non-cancerous fibrous skin lumps that usually
occur on the legs and arms. Their cause is
unknown, but they may arise at the site of a
minor injury such as an insect bite or thorn prick.
Patients develop firm yellow-brown nodule in
the skin, that if squeezed forms a dimple
because the skin is tethered to the nodule. No
treatment is necessary unless the lumps are
cosmetically unacceptable, when they can be
removed surgically, frozen (cryotherapy) with
liquid nitrogen or injected with a steroid. They
usually persist for years unless surgically
removed.
33
DERMATOGRAPHIA
See DERMOGRAPHISM
DERMATOHELIOSIS
Dermatoheliosis (photoaging) is a form of skin damage from prolonged exposure to
sunlight. Ultraviolet B in the sunʼs rays causes damage to the skin. It affects older people,
particularly males with fair skin who have worked outdoors for years. It is far more common in
Caucasians than in darker skinned races.
Those affected have highly wrinkled, leathery, dry skin on sun-exposed areas such as the
face and forearms. Hyperkeratoses are almost invariably present and there is a significantly
increased risk of developing skin cancer.
The condition is better prevented than treated by using sun protection creams and shading
hats. Tretinoin cream may reduce severity of wrinkles. Although disfiguring, dermatoheliosis is
not otherwise serious unless skin cancers develop.
See also HYPERKERATOSIS
DERMATOMYCOSIS
A dermatomycosis is any superficial fungal infection of the skin. Examples include tinea
and pityriasis versicolor.
See also PITYRIASIS VERSICOLOR; TINEA
DERMATOMYOSITIS
Dermatomyositis is a rare disease
that combines a persistent rash with
muscle weakness. When it occurs
without the rash (which is present in
only 40% of cases) it is called
polymyositis. The cause is unknown,
but it commonly attacks those in late
middle-age.
Patients experience a gradually
progressive weakness and pain of the
muscles in the neck, upper arms,
shoulder, buttocks and thighs. Patients
may also develop a dusky red rash on
the cheeks and nose, shoulders and
upper chest and back. The eyelids are
often swollen and appear bruised. Unusual symptoms include redness and bleeding under the
nails, cold hands, and a scaly rash over the knuckles.
The condition is diagnosed by blood tests, muscle biopsy and by measuring the muscle's
electrical activity.
Drugs such as steroids, methotrexate and azathioprine are commonly used in treatment.
Para-amino benzoic acid is sometimes used on the skin.
One in ten patients risk developing cancer, but there is no cure. Most patients can lead a
relatively normal life, although a minority are disabled by muscle weakness.
34
DERMATOSIS PAPULOSA NIGRA
The presence of multiple benign dark pigmented raised spots on the skin of dark-skinned
people is called dermatosis papulosa nigra. It is an inherited characteristic, the spots are most
common on the face and neck and the number of spots increases with age.
DERMOGRAPHISM
Dermographism is an exaggerated skin response that usually occurs in young adults when
the skin is rubbed. It is caused by the excessive release of histamine into the skin from mast
cells. In severe cases, pressure from
clothing (eg. belts, bra straps), chairs,
clapping hands, tools or even kissing
may start the reaction.
In normal skin, firmly rubbing a blunt
rounded object over the skin produces a
white line for a few seconds. In about
one third of people, the white line is
followed by a red line and slight swelling
of the underlying skin which subsides
quickly. In the approximately 4% of the
population
who
suffer
from
dermographism this response is exaggerated and pressure results in an itchy, red, raised
weal that follows the course of a firm blunt pressure on the skin. Any part of the body can be
affected, and although the welts develop in a few minutes, they may take many hours or days
to fade away. The response is often worse when the patient is anxious, after a hot bath or in
warm weather.
Dermographism may be a temporary phenomenon that lasts for a few months, or may
persist life long.
It is a condition that can develop at any age, but is far more common in women than men.
The cause of dermographism is unknown and there is no permanent cure, but patients who
have serious problems with the condition can take antihistamine tablets on a regular basis to
reduce the severity of attacks. Most victims find that the condition is severe at some times,
and less severe at others. There is a tendency for the severity of the reaction to slowly
subside over many years.
DESMOPLASTIC TRICHOEPITHELIOMA
See TRICHOEPITHELIOMA
DESQUAMATION
Desquamation is the natural continuous loss of the outer surface of the skin which
comprises dead epithelial cells. Excessive desquamation may occur with skin inflammation
and irritation and result in a scaly appearance to the skin and trapped skin cells in surface
hairs (eg. dandruff).
See also DANDRUFF
DIAPER RASH
See NAPPY RASH
35
DISCOID ECZEMA
Discoid or nummular eczema is a persistent
rash that is often confused with a fungal infection.
the cause is unknown, but it usually occurs in
young adults.
The rash appears as discs of scaling, red,
thickened skin on the back of the forearms and
elbows, back of the hands, front of the legs and
the tops of the feet. The affected areas can vary
in size from a few millimetres to three
centimetres or more. The diagnosis can be
confirmed by biopsy.
Steroid creams and tablets are effective, but
antihistamine tablets are sometimes needed for
the itch.
The rash heals rapidly with correct treatment,
but unfortunately, there is a tendency for
recurrences. Attacks usually cease after 6 to 12 months.
See also ECZEMA
DISCOID LUPUS ERYTHEMATOSUS
Discoid lupus erythematosus is an uncommon disfiguring inflammatory skin disease. Its
cause is an autoimmune condition in which the body inappropriately reject patches of skin for
no known reason.
Patients develop distinct red plaques on the face (particularly the cheeks), scalp and ears
that worsen with sun exposure. Permanent facial hair loss and loss of pigmentation in dark
skinned races may also occur. The diagnosis is confirmed by a skin biopsy and some specific
blood tests may be abnormal. Treatment involves protecting the affected skin from the sun,
strong steroid creams, injections of steroids into the spots and medications such as
chloroquine, dapsone and retinoic acid. All these must be used with great care as they have
significant side effects.
The condition is often persistent, and only 60% of patients adequately controlled.
DISSEMINATED SUPERFICIAL ACTINIC POROKERATOSIS
Disseminated superficial actinic porokeratosis (DSAP) is an unusual inherited condition that
increases the risk of sun damage to the skin in people of European descent.
Half the children of an affected parent will have
the condition, but only if they have excessive sun
exposure will it be a problem. New spots may also be
caused by ultraviolet light in sun lamps. The average
age of onset is about 40, and severity increases steadily
with age. It does not occur in childhood.
Spots begin as a 1-3 mm cone shaped lump,
brownish red or brown in colour and usually around a
hair follicle. The spot expands and a slightly raised dark
brown ring develops and spreads out to a diameter of
10 mm or more. The skin within the ring is thin and
36
mildly reddened or slightly brown, and sometimes may ulcerate and crust. Sweating is absent
in affected areas and sun exposure may cause itching. The condition becomes more
prominent in the summer and may improve in winter. Affects sun exposed areas, appearing
mainly on the cheeks, forearms and lower legs and occurs more frequently in women than
men. The diagnosis can be confirmed by a skin biopsy.
There is no satisfactory treatment, but cryotherapy (freezing) and creams containing 5
fluorouracil, tretinoin or alpha hydroxy acid may be tried. It is important to reduce sun
exposure by wearing long sleeves shirts and slacks and using sunscreens.
See also DERMATITIS
DONOVANOSIS
See GRANULOMA INGUINALE
DOWLING-DEGOS DISEASE
Abnormal pigmentation of the armpits and groin may be due to Dowling-Degos disease,
which is also known as the reticular pigmentation anomaly of the flexures. This is a familial
(runs in families) condition, which causes dark, mottled to solid, brown to black pigmentation
in the armpits, groin, under the breasts and in other areas of skin infolding. There may be
small raised lumps in the pigmented area. Sometimes pigmentation also occurs on the back
of the hands and at the base of nails. Uncommonly, pitted scars may occur around the mouth
and acne-like sores on the face and upper back. There is an increased incidence of skin
cancer (squamous cell carcinoma) in the areas of worst pigmentation. A skin biopsy confirms
the diagnosis.
Laser therapy may reduce intensity of pigmentation but there is no cure for this annoying
but relatively harmless condition.
See also ACANTHOSIS NIGICANS; LENTIGO; MELANOMA
DYSPLASTIC NAEVUS
A dysplastic naevus is a brown coloured skin mark that usually develops in middle age or
later, often on sun affected areas of skin. It may have varied colouration from light brown to
almost black, and an indistinct and irregular edge. A small percentage may progress to
become a malignant melanoma, and as a result they probably should be excised.
See also DYSPLASTIC NAEVUS SYNDROME; MELANOMA
DYSPLASTIC NAEVUS SYNDROME
Malignant melanomas are becoming more common because of excessive sun exposure,
particularly in childhood, but there is a small group of people who are born with an excessive
number of brown and black moles on their body that have the increased propensity to become
malignant melanomas. These people have the dysplastic naevus syndrome.
They have scores or hundreds of small, irregularly pigmented and irregularly shaped moles
with poorly defined borders scattered across their skin. Once diagnosed, regular detailed
photographs of their body are taken and compared every few months. Any moles that alter in
shape, size, colour or regularity are excised and examined by a pathologist. Because of their
large number, excision of all moles is impractical.
See also MELANOMA; NAEVUS
37
ECCHYMOSIS
Ecchymosis is a term used in medicine for a bruise.
ECZEMA
The term eczema describes a large number of skin diseases that cause itching and burning
of the skin. The many different forms of eczema also have innumerable causes, both from
within the body (eg. stress) and outside (eg. allergies, chemicals).
The appearance of eczema depends more on its position on the body, duration, severity
and degree of scratching than the actual cause. Typically it appears as red, swollen, itchy skin
that is initially covered with small fluid-filled blisters that quickly break down to a scale or crust.
No investigations are usually necessary, but a biopsy is can be diagnostic.
Treatment depends upon cause of eczema, but steroid creams and tablets are commonly
used.
The main complication is a secondary bacterial infection of the skin
See also ALLERGIC ECZEMA; ASTEATOTOC ECZEMA; ATOPIC ECZEMA; BAZEK
SYNDROME; CONTACT DERMATITIS; DISCOID ECZEMA; ECZEMA HERPETICUM;
GRAVITATIONAL
ECZEMA;
LICHEN
SIMPLEX;
PHOTOSENSITIVE
ECZEMA;
SEBORRHOEIC ECZEMA; VARICOSE ECZEMA
ECZEMA CRAQUELÉ
See ASTEATOTIC ECZEMA
ECZEMA HERPETICUM
A widespread viral skin infection with the Herpes simplex virus (which is also responsible
for cold sores) may be referred to as eczema herpeticum. It usually occurs in people with
reduced immunity and pre-existing eczema.
The symptoms are widespread itchy crusting skin blisters mainly affecting the face, fever,
tiredness and irritability. Effectively, these people have hundreds of cold sores spread all over
their face and body. The sores may be infected by bacteria, and the Herpes infection may
involve the eyes causing damage to the cornea (eye surface). The diagnosis is confirmed by
testing swabs from a skin sore for the virus.
Aciclovir or similar antiviral medications should be started immediately the diagnosis is
suspected. The underlying eczema must also be treated as well as any secondary bacterial
infections. Untreated the condition may persist for six weeks or so. If antiviral treatment is
started soon enough, the duration of the viral infection will be dramatically reduced.
See also COLD SORES; ECZEMA
EHLERS-DANLOS SYNDROME
Ehlers-Danlos syndrome (cutis hyperelastica or the elastic skin syndrome) is a congenital
abnormality of skin development with eight clinically and genetically different variants.
Patients have over extendable joints, excessively elastic and fragile skin, scarring of skin and
growths on their knees and elbows, and premature arthritis may occur. It is diagnosed by a
skin biopsy. There is no treatment or cure available, but life expectancy is normal.
The syndrome is named after Danish dermatologist Edvard Ehlers (1863-1937) and French
dermatologist Henri Danlos (1844-1912).
38
See also PSEUDOXANTHOMA ELASTICUM
ELASTIC SKIN
See EHLERS-DANLOS SYNDROME; PSEUDOXANTHOMA ELASTICUM; RHAGADES
ELASTOSIS
Elastosis is the degeneration of elastic tissue in the skin, particularly in elderly people, so
that it wrinkles around a joins rather than springing back into shape with movement of a joint.
See also ANETODERMA; CUTIS LAXA
ELEPHANT MAN DEFORMITY
See PROTEUS SYNDROME
EPIDERMAL CYST
See SEBACEOUS CYST
EPIDERMOLYSIS BULLOSA
Epidermolysis bullosa is a rare familial (runs in
families) skin disease of which there are several
subtypes. The slightest injury to the skin causes
large, firm blisters and so these children may be
referred to as cotton wool babies. In infants blisters
develop on knees and hands as the child starts to
crawl, but later may occur anywhere. In severe
forms the disease continues throughout life, the
fingers may become bound together by scar
tissue, the mouth and throat may be involved, and
nails and teeth may be damaged. On healing,
39
blisters leave behind a scar that causes significant disfigurement and cancer may develop in
the affected tissue. The diagnosis is confirmed by a skin biopsy.
Steroids are the only treatment available, but are not particularly effective, so avoiding
injury to the skin is imperative. There is no cure, and the subtypes vary in severity from an
inconvenience to life-threatening.
See also BLISTERS
EPIDERMOPHYTON
See TINEA CAPITIS; TINEA CORPORIS; TINEA CRURIS
ERYSIPELAS
Erysipelas (St. Anthonyʼs fire) is an infection of the skin, caused by any one of a large
number of bacteria, but usually Streptococci, and most commonly involving the cheek, but any
area of the body may be affected. It may start at the site of a scratch, crack or bite, but often
there is no apparent cause.
The skin is red, swollen, painful and hot, and the patient may be feverish, shiver and feel
very ill. Fluid-filled blisters sometimes develop on the infected area. Swabs may be taken to
identify the responsible bacteria, then an antibiotic (eg. penicillin, erythromycin) capsule or
tablet is prescribed. It was a very serious disease and often killed children before effective
antibiotics were available, but now recovery is rapid once antibiotics are started, and it usually
heals without scarring.
See also CELLULITIS; ERYTHRASMA
ERYTHEMA INDURATUM
Erythema induratum (Bazin disease) is a skin disease that usually affects the calves and
back of the upper arms of young and middle aged adults. The cause is unknown, but it has
been associated with tuberculosis in the past.
Painful, soft, purplish lumps (nodules) develop on the skin and then gradually join together
and ulcerate. It is sometimes necessary to biopsy a lump to make the diagnosis.
40
No treatment is necessary in most cases, but steroids may be given in persistent cases.
Most ulcers heal without treatment in a few months, but leave a permanent scar.
ERYTHEMA INFECTIOSUM
See FIFTH DISEASE
ERYTHEMA MULTIFORME
Erythema multiforme (which can be loosely translated as “red spots of many shapes”) is an
acute inflammation (redness) of the skin and moist (mucus) membranes lining body cavities.
It may be triggered by drugs, bacterial or viral infections, cold sores and other Herpes
infections, or may appear for no apparent reason. 75% occur after a Herpes or cold sore
infection, and half of the remainder are caused by drugs - particularly sulfa antibiotics. Attacks
caused by cold sores and other infections tend to be mild, but those that occur as a result of
drug sensitivity can be very severe.
Patients experience the sudden development of several types of rash simultaneously. The
easiest rash to identify appears as multiple red, sore rings on the skin with a pale centre that
vary in diameter from a few millimetres to 2 or 3 cm. Other forms include red patches, swollen
lumps, fluid-filled blisters, itchy red stripes, and painful hard dome-shaped bumps. The insides
of the mouth and the vagina, and the eye surface, may be involved with ulcers developing in
some cases. The rash may occur anywhere, but is more common on the front of the leg, over
the shoulders, above and below the elbow on the outside of the arm, and on the soles and
palms. Most patients have only a mild fever, but those severely affected may be acutely ill
with a very high fever and generalised weakness, and rarely it may progress to the StevensJohnson syndrome. No blood or other tests can confirm the diagnosis.
If a drug is suspected as the cause, it is immediately ceased; but if an infection is thought
responsible, this is treated appropriately. The discomfort can be minimised with painkillers
such as paracetamol and aspirin, and with creams, lotions and dressings to ease the skin
irritation. Steroid tablets are taken in severe cases.
There is no cure, but the vast majority of cases are mild and settle in two to four weeks, but
severe cases may persist for up to six weeks, and in rare cases, with lung involvement
41
(Stevens-Johnson syndrome) in the elderly or chronically ill, death may occur. Recurrent
attacks are quite common.
See also COLD SORE
ERYTHEMA NODOSUM
Erythema nodosum is an unusual skin inflammation for which the cause is often unknown,
but it may be a reaction to certain bacterial infections, medications (eg. penicillin) or more
serious underlying diseases (eg. leukaemia, tuberculosis, syphilis, hepatitis B or ulcerative
colitis).
Very tender, painful red lumps develop on the front of the leg, usually below the knees,
while less commonly affected areas include the arms, face and chest. Patients also have a
fever, joint pains and general tiredness, and skin ulcers may be a complication. The diagnosis
is confirmed by a skin lump biopsy, and other tests are done to find any underlying cause.
If a cause can be found, this is treated (eg. infection) or removed (eg. medication), but
there is no specific treatment, although steroids and painkillers may ease the symptoms. The
condition lasts about six weeks before slowly disappearing with no serious after-effects, but
recurrences are common.
ERYTHRASMA
Erythrasma is a common superficial infection of the outermost layer of the skin caused by
the bacteria Corynebacterium minutissium that usually affects the groin, armpit and under the
breasts. It causes well defined, red-brown, scaling, slightly itchy patches that slowly enlarge
and become wrinkled. A culture of skin scrapings can identify the responsible bacteria, and
antibiotic tablets (eg. tetracycline, erythromycin) and ointments (eg. fusidic acid) are used to
cure the infection.
See also ERYSIPELAS
ERYTHRAEMIA
See POLYCYTHAEMIA RUBRA VERA
ERYTHRODERMA
See EXFOLIATIVE DERMATITIS; LEINER DISEASE
42
ERYTHROPLASIA OF QUEYRAT
The erythroplasia of Queyrat is a form of skin cancer (Bowenʼs disease) on the penis. The
cause is unknown, but it is much rarer in circumcised males. It appears as a raised, velvety,
red patch on the head of the penis, and is diagnosed by a biopsy. Anticancer cream
containing 5-fluorouracil gives good results, but if left untreated, the cancer may spread onto
the foreskin and break down into an ulcer.
See also BOWENʼS DISEASE; SQUAMOUS CELL CARCINOMA OF THE SKIN
ERYTHROPOIETIC PROTOPORPHYRIA
Erythropoietic protoporphyria is sometimes
called “sunlight allergy”. It is a distressing
inherited excessive skin reaction to sun exposure
that normally starts in childhood, has an
incidence of one in 100,000 people and affects
both sexes equally. Red, swollen, crusted,
irritated, painful, raised patches develop on sun
exposed areas of the body, particularly the face.
The rash starts minutes to hours after sun
exposure, and slowly settles after hours or days.
Milder attacks may involve skin pain with minimal
rash, but areas of skin frequently affected by
attacks may develop scars, skin thickening and
wrinkling, and there is a higher than normal
incidence of gall stones and liver damage
(cirrhosis).
Specific blood tests can detect abnormalities
that aid in diagnosis, and a skin biopsy is also
abnormal.
Sun avoidance is essential, and beta-carotene
used regularly reduces the severity of the
reaction. Although it is a life long condition, its
severity slowly decreases with age.
See also PORPHYRIA CUTANEA TARDA
ESPUNDIA
See MUCOCUTANEOUS LEISCHMANIASIS
EXANTHEMA
A rash of any form is medically known as an exanthema.
See VIRAL EXANTHEMA
EXANTHEMA SUBITUM
See ROSEOLA INFANTUM
43
EXFOLIATIVE DERMATITIS
Exfoliative
dermatitis
(generalised
erythroderma) is a form of dermatitis in which
there is extensive peeling of skin. It is often
associated with drugs or foods, such as gold
injections (used for rheumatoid arthritis), sulfa
antibiotics, some diabetes tablets and some antiinflammatory medications, and exposure to
heavy metals (eg. lead in battery factories) may
also be responsible.
There is widespread scaling, peeling and
redness of the skin, and patch testing of the skin
may be undertaken to determine the cause.
Removal of the substance that the causes the rash is the obvious treatment, and steroid
creams can be used to ease the inflammation. Rarely the condition may become very severe
and debilitating, but in most cases the outcome is good, particularly if the trigger substance
can be found, but may still take many months to settle.
FABRY DISEASE
Fabry disease (angiokeratoma corporis diffusum) is a rare inherited inborn error in body
chemistry that affects the skin and internal organs of males. Tiny dark red raised spots appear
on the lower abdomen, buttocks, penis and scrotum. The heart and brain are also affected to
cause transient ischaemic attacks, strokes, angina, heart attacks (myocardial infarction) and
excruciating attacks of body pain.
44
Women who carry the gene but who do not actually develop the disease may develop
cataracts in their eyes. It is diagnosed by a biopsy of skin spots and family history. No specific
treatment is available, but the symptoms may be eased.
See also ANGIOKERATOMA OF FORDYCE; HAEMANGIOMA
FAVUS
Favus (witkop in southern Africa) is an infection of the scalp by the fungus Trichophyton
schoenleinii, which causes redness of the scalp followed by matting of the hair and gradual
formation of a thick off-white crust on the skin. Permanent skin damage and hair loss occurs
with severe infections. Examination of the skin under a microscope shows characteristic
changes. Griseofulvin or other antifungal tablets are taken for several weeks to cure the
infection.
FIBREGLASS RASH
Insulating batts are usually made of fibreglass that is loosely spun. Tiny slivers of glass
fibre can easily break off and penetrate the skin to cause pain, irritation and inflammation.
While the glass remains, the rash will persist. With time, the body will reject the tiny pieces of
glass, but until then, irritation may be intense.
Secondary infections may develop in some areas, and these require antibiotic treatment.
Various anti-itch and anti-inflammatory creams can be prescribed, but unfortunately time is
the usual cure. Anyone dealing with uncoated fibreglass should wear protective clothing, and
eye protection, to prevent this problem. Coated and sealed fibreglass as used in boats and
car bodies is quite safe unless it is cut or sawed, when the dust produced may cause irritation.
FIBROEPITHELIAL POLYP
See SKIN TAG
FIFTH DISEASE
Fifth disease (erythema infectiosum) is a
common childhood viral disease caused by the
Parvovirus that last from two to five days, but
occasionally may persist for weeks.
It occurs in epidemics every few years, and
virtually every child will eventually develop the
infection before their teenage years.
The infection is characterised by red flushed
cheeks (slapped cheeks appearance), paleness
around the mouth and a red patchy rash on the
arms and legs. Many children will have very mild
symptoms that may be overlooked, or confused
with German measles. Rarely joints may become
sore and inflamed. Complete recovery is normal
and no treatment is necessary.
Six diseases that caused a rash were known by
numbers. They were first disease (measles), second disease (scarlet fever), third disease
(German measles - rubella), fourth disease (Dukeʼs disease - Coxsackie virus infection) and
45
sixth disease (exanthema subitum - roseola infantum). Only the fifth disease nomenclature is
commonly used today.
See also GERMAN MEASLES
FISH TANK GRANULOMA
Fish tank (or swimming pool) granuloma is a skin infection that occurs in contaminated
water. It is common in exotic fish fanciers. The cause is the bacteria Mycobacterium marinum,
which infects a tiny skin abrasion that is immersed in water. The main symptom, that may
develop months after initial infection, is a red, inflamed, crusted, raised patch on the skin,
often on fingers and hands, knees and elbows that may be itchy and slightly painful. Usually
only a single patch occurs, from 1 to 3 cm. in diameter, but it may break down into an ulcer. A
skin biopsy is usually necessary to confirm the diagnosis.
Antibiotics over a prolonged period are used in treatment. Sometimes quite potent
antibiotics, normally used to treat tuberculosis, may be required. The sore may persist for
months or years before disappearing spontaneously without treatment, but it settles far
sooner with antibiotics.
See also BAIRNSDALE ULCER; GRANULOMA
FIXED DRUG ERUPTION
A fixed drug eruption is a persistent skin rash caused by a reaction to a drug (eg: blood
pressure medications, antibiotic, arthritis drugs, oral contraceptives, food colouring, thiazide
diuretics - fluid tablets) that may have been taken for years without previous reaction.
Patients develop a widespread, itchy, red, patchy, raised rash, and a biopsy is sometimes
necessary to confirm the diagnosis. It is necessary to stop taking the suspected drug, then
use steroid creams and antihistamine tablets. In severe cases steroid tablets may be
necessary. The rash may persist for months or years after causative drug ceased, but most
eventually subside.
See also DERMATITIS MEDICAMENTOSA
46
FLINDERS ISLAND SPOTTED FEVER
See TYPHUS
FOCAL DERMAL HYPOPLASIA
See GOLTZ SYNDROME
FOLLICULITIS
Folliculitis is a bacterial (most common) or
fungal (yeast) infection of hair follicles, which
occurs mainly on the neck, armpits, upper lip and
groins, and is more common in men than women.
Numerous different bacteria and fungi may be
responsible. Staphylococcus aureus is the most
common bacteria, while Pityrosporum is the most
common fungus. Infection is more likely in
diabetics, obesity, at times of stress, those with
poor hygiene, and with oily skin.
A sore, tender, and sometimes itchy pus-filled
blister appears on the skin surrounded by red
skin. A boil or abscess may form, and the latter will need to be cut open and drained.
Antibiotic or antifungal ointments are applied to the sores, and in severe cases antibiotic
tablets are taken. A swab may be taken from a blister in resistant cases to identify the
bacteria or fungus responsible for the infection and the correct antibiotic or antifungal to treat
it. Personal hygiene must be scrupulous, and the long-term use of antibiotics and antiseptic
soaps may be required. The infection is often difficult to cure, and attacks may recur for
several months or years, and any underlying cause (eg. diabetes) must be cured or
controlled.
See also BARBERʼS ITCH; SCALP FOLLICULITIS
FOX-FORDYCE DISEASE
Fox-Fordyce disease (hidrosadenome or lichen axillaris) is a rare skin disease that occurs
in women between 15 and 50 years of age. The cause is unknown, but it is possibly due to a
hormonal imbalance that causes blockage of the sweat glands in the affected areas.
Patients develop extremely itchy groups of small, firm skin coloured lumps in the armpits,
groin and on the nipples. The itch worsens during a menstrual period. Scratching may
damage the skin and allow a secondary bacterial infection.
Treatments include steroid creams, and taking the oral contraceptive pill to reduce
hormone fluctuations.
The problem often persists long term, but may be cured by pregnancy.
FRÖHLICH SYNDROME
Fröhlich syndrome (dystrophia adiposgenitalis or adiposogenital dystrophy) is a rare
condition that has its onset after puberty when there is a loss of sexual function and libido due
to a lack of sex hormones, which in turn may be due to a tumour of the pituitary gland in the
centre of the brain.
47
The symptoms are a lack of sexual development and activity, the skin becomes thin and
wrinkles prematurely, body hair is scanty, scalp hair becomes very fine, and fat may deposit
around the buttocks and genitals. All hormones must be checked by blood tests, and a CT or
MRI scan of the pituitary gland is performed. There is no cure, but long-term control possible
by sex hormone supplements and surgery for any pituitary tumour.
FROSTBITE
Frostbite is the freezing of living tissue due to exposure of flesh to very cold conditions that
occurs most commonly in the toes, but the fingers, ears and nose may also be affected. The
severity of the frostbite depends on the depth to which the freezing has penetrated. Early
symptoms are numbness, itching and a pricking sensation. As the freezing penetrates
deeper, stiffness and shooting pains will occur, the skin is white or yellow, and the toe or
finger becomes immobile. Freezing of the skin itself is not particularly serious, but if the
freezing penetrates to the bone, the tissue will die, and the finger or toe requires amputation.
Late stages of frostbite are characterised by blistering, swelling, black colouration and
gangrene.
Treatment involves slow and gradual thawing of frozen tissue in warm water. Rapid
rewarming or overheating further damages the tissue. Never warm an area affected by
frostbite by rubbing or massage. If two people are present, thawing each otherʼs toes by
placing them in the other person's armpit is an ideal method. After thawing, the tissue should
be kept protected and warm. No dressings should be applied, but the affected areas should
be left exposed in a warm room. Antiseptics may be applied to blisters and antibiotics given
for infection. Only after several days or weeks, is amputation of affected fingers or toes
considered, as recovery may occur from an apparently hopeless situation. Moist gangrene is
an indication for immediate amputation. Any area that has been frostbitten will be more
susceptible to frostbite in future.
See also CHILBLAINS
GANGLION CYST
A ganglion of a tendon is a benign thin-walled cyst filled with a thick, clear fluid that
develops on a tendon of the wrist, hand or foot. It has nothing to do with a nerve ganglion,
Tendons slide within fibrous sheaths lined with a smooth synovial membrane, which
prevent the tendon from slipping out of position around a joint. Within the sheath, the tendon
is surrounded by a thin film of lubricating synovial fluid. A tiny puncture in the sheath allows
some of the synovial fluid around the tendon to escape and form a disfiguring hard lump on
the back of the hand, wrist or less commonly on the top of the foot. Painful bleeding may
occur into the ganglion, or pressure on a nerve may cause also cause pain. Rarely the
ganglion may become infected.
48
Treatments available are either a minor operation, in which the ganglion is cut away from
the tendon, or a needle is inserted into the ganglion to withdraw the thick fluid within, and a
small amount of a steroid solution is then injected. Many settle spontaneously, but they may
recur after injection, while most are permanently cured by surgery.
GENERALISED ACUTE PUSTULAR PSORIASIS
Generalised acute pustular psoriasis (also known as von Zumbusch psoriasis) is a severe,
rare form of psoriasis affecting adults. The cause is unknown, and the patient may or may not
have previously had another form of psoriasis.
The symptoms are a sudden onset of burning red skin that rapidly spreads within hours
across a large area of the body. Pustules then form on the red skin and enlarge to form large
pus filled blisters. The patient is weak, feverish, has a headache and is obviously very ill.
Blood tests show a very high white cell count, but skin and blood cultures for infection are
negative.
Treatment is in hospital, and in the same way as a patient with severe burns. Fluids are
given through a drip, antibiotics are given to prevent infection, and potent medications are
given to reverse the skin inflammation.
There may be one or a series of attacks. Dehydration from fluid loss through the damaged
skin is a major concern.
The disease is life threatening, but most people recover completely with correct treatment.
See also GUTTATE PSORIASIS; PSORIASIS
GENERALISED ERYTHRODERMA
See EXFOLIATIVE DERMATITIS
GENITAL HERPES
Genital herpes is a contagious viral infection of the genitals caused by the Herpes simplex
type 2 virus, which is caught by sexual contact with someone who already has the disease. It
is possible, but unlikely, for the virus to be caught in hot spa baths and from a shared wet
towel. If sores are present, there is a good chance of passing the disease on, but a patient is
also infectious for several days before a new crop of sores develop.
Condoms can give limited protection against spreading the disease. If a condom is worn, a
woman can more easily pass the infection to a man than vice versa, and the overall risk is
reduced by 75%. Normally it is easier for men to pass
the infection to women.
Once a person is infected with the virus, it
settles in the nerve endings around the vulva or penis,
and remains there for the rest of that person's life. With
stress, illness or reduced resistance, the virus starts
reproducing and causes painful blisters and ulcers on
the penis or scrotum (sac) in the male; and on the
vulva (vaginal lips), and in the vagina and cervix
(opening into the womb) of the female. The first attack
may occur only a week, or up to some years, after the
initial infection. An attack will last for two to four weeks
and then subside, but after weeks, months or years, a
further attack may occur. Women are affected more
49
severely and frequently than men. The incidence of gynaecological cancer is increased in
women with the infection and in rare cases it can cause encephalitis (brain infection).
If a baby catches the infection from the mother during delivery, it can cause severe brain
damage in the child. For this reason, if a woman has a history of repeated herpes infections,
she may be delivered by caesarean section.
The infection is diagnosed by taking a swab from the ulcer or a blood test.
Antiviral tablets (eg. valaciclovir, aciclovir, famciclovir) will control an attack, but must be
started within 72 hours of its onset, or they can be taken for months or years to prevent further
attacks. Good control is possible with modern medications.
A person taking antiviral medication long term to prevent attacks of genital herpes can still
pass the infection on to a sexual partner, but the overall risk is reduced by 50%.
Without any treatment, the average time for attacks to stop coming is four years, but
recurrences may still occur decades later at a time when the patient is stressed or has
another illness that reduces overall resistance to infections.
GENITAL WARTS
Genital or venereal warts (condyloma accuminata) are a sexually transmitted viral infection
caused by the human papilloma virus (HPV), which is transmitted from one person to another
only by sexual intercourse or other intimate contact, but condoms can give some protection
against the infection. It is not possible to catch it from toilet seats or spa baths. The incubation
period varies from one to six months.
Warts, sometimes of a large size, grow on the penis in men and in the genital area of
women. They initially appear as flat, pale areas on the skin, or as dark-coloured, irregularly
shaped lumps. Both men and women can be carriers without being aware they are infected,
and in women genital warts may develop internally where they are difficult to detect. A
significant proportion of women with this infection will develop cancer of the cervix, which can
only be detected at an early stage by
regular Pap smears. Anyone with
genital warts should also have tests
performed to check for the presence
of other venereal disease.
Small warts can be more easily
seen if a special stain is applied to
the skin, then treatment can be given
with antiviral imiquimod cream
applied three times a week for up to
four months, acid paints (eg.
trichloroacetic
acid)
or
acid
ointments, freezing with liquid
nitrogen, or burning with electric
diathermy or laser. The treatment is
often prolonged, and warts tend to
recur, but with careful watching and
rapid treatment of any recurrence
the infection will eventually settle.
See also WART
50
GERMAN MEASLES
German measles (rubella) is a contagious viral
infection caused by a Togavirus, which is
widespread in the community, and causes
epidemics every few years. It spreads from one
person to another with coughs and sneezes, but
can be caught only once in a lifetime, although
an infection in a child may be so mild that it is
completely overlooked. The incubation period is
two to three weeks.
Infection occurs most commonly in children,
and produces a fine rash over the body that lasts
only two or three days, is not itchy, and is not
accompanied by the sore eyes and cold
symptoms associated with common measles.
There are often some enlarged lymph nodes at
the back of the neck, and in severe cases there
may be a fever, runny nose and joint pains.
If a pregnant woman catches the disease
between the sixth and twelfth weeks of
pregnancy, infection may cause blindness,
deafness, heart damage and other serious
defects to her child. As a result, an antibody
blood test is sometimes done to confirm the
disease or determine the immune status of a
pregnant woman.
Paracetamol for fever and discomfort is all the treatment that is necessary. Children must
be excluded from school for four days after the rash first appears.
An effective vaccine is available, and all children are now given mumps, measles and
rubella as a combined vaccine at one and four years of age. Once infected with, or vaccinated
against rubella, antibody levels rise permanently and reinfection is not possible.
See also FIFTH DISEASE; MEASLES; ROSEOLA INFANTUM
GIANOTTI CROSTI SYNDROME
The Gianotti Crosti syndrome is a skin rash that usually affects children between the ages
of 6 months and 12 years. It often occurs in clusters, with multiple children who are in contact
being affected, and usually follows an upper respiratory tract infection. the cause is an
abnormal skin response to a viral infection (eg. Hepatitis B, Epstein Barr virus, Coxsackie
viruses, Echo viruses, respiratory syncitial virus).
Over 3 or 4 days multiple slightly raised dull red spots develop on the thighs and buttocks,
then spread to the arms and face. Later spots often look purple, especially on the legs, due to
leakage of blood into them from capillaries. The patient may feel quite well or have a mild
fever, there may be a mild itch, slightly enlarged lymph nodes in the armpits and groins, and
an enlarged liver.
There is no specific treatment, but a mild steroid cream may be used for the itch. The rash
fades in 2-8 weeks with mild scaling. Recurrence is unlikely but has been reported.
51
GLOMUS TUMOUR
A glomus tumour (or glomangioma) is a painful, but benign, skin discolouration caused by a
developmental defect of nerve tissue in the skin. Patients develop one or more painful, pink to
purplish lumps (nodules) on the skin of the hands or feet. They may occur under the nails.
The pain is worse with heat or pressure. Examination of the removed nodule under a
microscope is diagnostic.
Surgical removal is the only, and a very successful, form of treatment.
GOLTZ SYNDROME
Goltz syndrome (also known as focal dermal hypoplasia) is a rare condition of abnormal
skin development due to a partial or complete absence of normal skin in affected areas. Scarlike areas of very thin skin are found on the scalp, thighs and sides of pelvis. There may also
be a lack of body and scalp hair, and nail abnormalities. A biopsy of an affected area of skin
examined under a microscope can make definite diagnosis.
There is no cure, but some areas may be improved by plastic surgery.
GORLIN GOLTZ SYNDROME
The Gorlin-Goltz syndrome (or basal cell carcinoma naevus syndrome) is a rare inherited
condition of children characterised by the development of multiple basal cell carcinoma
(BCC), skin cancers and other abnormalities including calcification of areas of the brain,
abnormal vertebrae and ribs, multiple cysts in the jaw and pitting of the palm. Other
characteristics that may be present include a large head, skin cysts, depressed breast bone,
lumps of fibrous tissue in the heart, cleft lip, and extra fingers and toes. X-rays of jaw,
vertebrae and ribs can help make the diagnosis. Excision of jaw cysts and basal cell
carcinomas is the only treatment, but recurrence of skin cancers and jaw cysts after excision
is common.
See also BASAL CELL CARCINOMA
GOURGEROT-BLUM SYNDROME
See CAPILLARITIS
GRAFT VERSUS HOST DISEASE
Graft versus host disease (GvHD) is an uncommon but severe immune reaction affecting
the whole body due to a reaction between tissue donated by one person and the body of the
recipient of the tissue. It is most common after bone marrow transplantation for diseases such
as leukaemia and aplastic anaemia, where it occurs mildly in 8% of transplants, and seriously
in about 1%. There are two forms of the disease, acute and chronic. Symptoms start two to
twelve weeks after the transplant in acute cases, and more than three months later in chronic
cases.
The symptoms of acute GvHD are very variable depending on organs affected. Mild
symptoms include itchy skin, skin pain and soreness, and tender soles and palms. With more
severe cases, symptoms may include nausea, vomiting, red patches or lumps in and on the
skin, fever, jaundice (yellow skin) from liver damage, mouth and nostril sores, belly pain,
diarrhoea, eye ulceration, blistering and shedding of inflamed skin, ulcers in the oesophagus,
bleeding into the lung and coughing of blood, and massive loss of skin similar to severe burn.
The acute form may be a life threatening condition, as patient has little or no immunity to any
52
form of infection, and severe bacterial, viral or fungal infections may start in skin or lungs, and
spread to blood to cause septicaemia.
Chronic GvHD causes weight loss, flat-topped red raised small skin lumps, and in more
severe cases hair loss, skin pigment loss (white patches) or gain (dark patches or areas), liver
damage and jaundice.
Numerous blood tests may be abnormal, but there is no specific diagnostic test.
Prednisone by mouth is the main treatment, while creams containing steroids are used in
milder cases. Ultraviolet light with associated medication may also be useful, but severe
cases require a drip with steroids and other potent medications.
Most acute forms respond well to treatment, but if secondary infections occur, the outlook
is poor. Chronic GvHD settles slowly with time and treatment.
GRANULOMA
A granuloma is a nodule of abnormal tissue that may develop on the surface of an organ or
the skin. It usually occurs as a result of persistent inflammation or irritation of a tissue. A
granuloma may develop around a splinter in the skin or an area that is constantly scratched.
See also FISH TANK GRANULOMA; GRANULOMA ANNULARE; GRANULOMA
INGUINALE
GRANULOMA ANNULARE
Granuloma annulare causes one or more
ring shaped lumps of 1-3 cm. diameter to
develop on the back of the hands, elbows or
top of the feet. The lumps are covered with
normal skin but vary in colour from red to
white. They are harmless, but slightly
disfiguring. The cause is unknown although
the may be associated with diabetes, and
they are more common in teenagers and
young adults. The diagnosis is confirmed by
a skin biopsy.
No ideal treatment exists. Application of
potent steroid creams, or injections of
steroids into the skin lesion are sometimes
successful, while cryotherapy (freezing),
ultraviolet light and medications used to treat cancer are other options. Spontaneous
regression is possible over years.
See also SKIN LUMPS
GRANULOMA INGUINALE
Granuloma inguinale (donovanosis or granuloma venereum) is caused by the bacteria
Donovania or Calymmatobacterium granulomatis, which pass from one person to another
during sexual intercourse. The incubation period is one to twelve weeks and it causes
painless nodules on or around the genitals that break down to shallow ulcers, and may join
together into progressively larger ulcers that spread up onto the lower abdomen. Infection of
the ulcers with other bacteria will cause them to fill with pus and become foul smelling.
53
Microscopic examination of a biopsy or swab smear from the edge of an ulcer reveals the
responsible bacteria and confirms the diagnosis.
Treatment is difficult, and it may be necessary to take antibiotics such as tetracycline for
several months. Relapses are common unless full antibiotic course completed.
See also GENITAL ULCER
GRANULOMA VENEREUM
See GRANULOMA INGUINALE
GRAVITATIONAL ECZEMA
Gravitational eczema occurs mainly in older women due to poor drainage of veins in the
legs from varicose veins, thromboses or other circulatory problems. Excessive blood pressure
in the veins increases the fluid pressure in the tissue to create the rash.
The symptoms are an itchy red blotchy rash
affecting the lower legs, a firm swollen leg that is
worse after standing and eased by raising the leg (eg.
after resting overnight in bed), and hot weather
aggravates the problem. The rash may ooze and
become infected by bacteria, and scratching may
break down the skin resulting in thickening and
permanent pigmentation due to scar formation. In
severe cases, ulcers may form. An ultrasound scans
may be used to check circulation.
Patients should avoid prolonged standing, and
when seated, should place their leg on a footstool and
elevate the foot of the bed slightly at night. Steroid creams will ease the itch and irritation, and
moisturising creams should be used regularly to keep the skin soft and supple. Condyʼs
solution compresses may be used to dry up oozing, and antibiotics are prescribed for any
infection that may develop. Patients must never scratch the affected skin. In severe cases,
elastic pressure stockings may be used to reduce the collection of blood in the leg, or surgery
to remove varicose veins may be considered.
The condition is usually chronic, with frequent relapses.
See also ECZEMA
GRÖNDBLAD-STRANDBERG SYNDROME
See PSEUDOXANTHOMA ELASTICUM
GROVER DISEASE
Grover disease (transient acantholytic dermatosis) is an itchy skin condition of the chest
and back that usually affects men over 50, and much less commonly women or younger
people. It frequently follows sweating or some unexpected heat stress to cause the sudden
onset of very itchy spots on the central back, mid chest and occasionally elsewhere. A skin
biopsy can be used to confirm diagnosis.
Treatment is unsatisfactory as it is necessary for patients to remain cool and avoid
sweating. A mild steroid lotion can be applied frequently to give temporary relief. Most cases
settle in six to twelve months, but occasionally it may last longer.
54
GUINEA WORM
Dracunculiasis (Guinea worm disease) is a worm infestation that occurs only in west and
central Africa, although it used to occur in south Asia and Arabia. It is being actively
eradicated from its remaining areas of infestation in Africa and may be totally eradicated by
2010.
The worm Dracunculus medinensis is caught by swallowing water contaminated by
microscopic crustaceans (copepods - water fleas) that contain the worm larva. In the stomach
these are released, burrow through the stomach wall into the bloodstream, and migrate to the
fat under the skin where they mature. After mating the male worm dies, but the mature female
worm, which may be 60 to 80 cm. long, moves to the skin surface where it forms a sore, and
through this discharges eggs every time the skin comes into contact with water. The eggs are
then swallowed by the copepods where the cycle starts again. The worms eventually die and
emerge through the skin sore, or occasionally remain under the skin. The full cycle takes 9 to
14 months.
Patients experience generalised itching, fever, shortness of breath and nausea when
larvae are in the blood. Redness, burning and itching occurs at the site of skin sores, usually
on the foot or leg. After the worm dies a red, tender ulcer forms.
Smears from skin sores show eggs when examined under a microscope to confirm the
diagnosis.
The patient should rest with affected leg elevated. Worms can be individually removed by
exposing one end and then slowly drawing them out a centimetre at a time over several days.
Medications (eg. thiabendazole) cannot kill worms, but may encourage them to be expelled
through a sore. Secondary bacterial infection of an ulcer can spread to the surrounding skin
(cellulitis). Abscesses can form under the skin (particularly if a worm is broken during
removal), in joints or rarely in other organs that are reached by worms.
The ulcers heal after a month or two and most patients recover eventually after a prolonged
period of disability.
GUMMA
A gumma is a rubbery sore that contains dead
(necrotic) tissue and is usually caused by syphilis.
They are most commonly seen in the skin of
patients with third stage syphilis.
See also SYPHILIS
GUTTATE PSORIASIS
Guttate psoriasis is a very active form of the skin
disease psoriasis that is more common in
teenagers and young adults and may follow a
Streptococcal
bacterial
infection.
Patients
experience the sudden appearance of multiple
small, red, scale covered patches on the arms, leg
and trunk that may gradually enlarge and merge,
and it may progress to normal psoriasis. Usually no
investigations are necessary, but if the diagnosis is
in doubt it may be confirmed by a skin biopsy.
55
One or more of numerous skin preparations including coal tar, dithranol, calcipotriol and
steroid creams are used in treatment. It may disappear spontaneously after a few weeks, or
persist for many years, and is controlled, but not cured, by medication.
See also PITYRIASIS LICHENOIDES; PSORIASIS
GvHD
See GRAFT VERSUS HOST DISEASE
HAEMANGIOMA
An haemangioma (angioma) is a localised over growth of arteries and veins in the skin,
intestine, spinal cord, brain or inside other organs. They appear as a red lump that blanches
(turns white) with pressure. Haemangiomas may bleed dramatically if injured, and in the gut
be responsible for steady blood loss and anaemia. They may also put pressure on nerves
(eg. in spine) to cause pain or loss of nerve function.
No investigations are necessary for haemangiomas in the skin. Internal haemangiomas
may be detected by angiography (injecting dye into a blood vessel and taking an x-ray), CT or
MRI scans, gastroscopy or colonoscopy. Surgical removal is performed if the spot is
cosmetically unacceptable or causing symptoms.
See also ANGIOKERATOSIS; BLUE RUBBER BLEB NAEVUS SYNDROME; CAMPBELL
de MORGAN SPOTS; CAVERNOUS HAEMANGIOMA; FABRY DISEASE; SPIDER NAEVI;
STRAWBERRY NAEVUS; VENOUS LAKE
HAILEY-HAILEY DISEASE
Hailey-Hailey disease (also known as benign familial chronic pemphigus) is a rare,
inherited skin condition that starts in middle age and involves the armpits, groin and under the
breasts. It is characterised by small blisters that break down into a red, moist or crusted sore
with tiny cracks across it. The diagnosis is confirmed by a skin biopsy. Secondary fungal and
bacterial infections are common.
Drying agents may be applied to affected areas, while small areas may be surgically
excised, but there is no cure, although it usually settles in old age.
See also PEMPHIGUS
56
HALO NAEVUS
A halo naevus is an area of
depigmentation
around
a
benign
pigmented spot (naevus) that is common
in Caucasian children and young adults. It
is an autoimmune response to the
presence of the naevus that appears as a
dark brown spot surrounded by an area of
abnormally white skin. The naevus often
disappear over a few years.
See also NAEVUS
HAND FOOT MOUTH DISEASE
Hand foot mouth disease is an infection that
virtually every child will eventually catch caused
by a Coxsackie virus. The infection is usually so
mild that it causes no symptoms, but in severe
cases a child will develop blisters on the soles
and palms, and mouth ulcers. It may be
accompanied by a mild intermittent fever,
headache and irritability.
Paracetamol is the only treatment necessary. The rash persists for three to five days
before settling without any problems.
See also COXSACKIE VIRUS INFECTION
HANSENʼS DISEASE
See LEPROSY
HARLEQUIN SYNDROME
The harlequin syndrome is a rare, congenital, disfiguring disease due to abnormal skin
formation. The child is born with very thick hard plates of skin separated by deep cracks, and
there may also be absence of the ears, and out turning of the lips and eyelids to give a
grotesque appearance. There is an inability to move joints freely due to skin hardening.
The diagnosis is confirmed by skin biopsy and treated with moisturising cream in large
quantities, but death within days or weeks of birth is usual, and many die before birth.
HEBERDEN NODES
Heberden nodes are bony lumps on the back of the outermost finger joints (distal
interphalangeal joints). They are a sign of osteoarthritis, are more common in women and
57
may be due to an inherited tendency. They are named after the English physician William
Heberden (1710-1801).
See also BOUCHARD NODES
HENOCH-SCHÖNLEIN SYNDROME
The Henoch-Schönlein syndrome (anaphylactoid
purpura) is a generalised inflammation of small blood
vessels resulting in the formation of small red spots in
the skin (Henoch-Schönlein purpura). It may be a
complication of a number of different diseases (eg.
after a Streptococcal bacteria infection), but its cause
is often unknown, although it is more common in
children.
Small, slightly raised dilated blood vessels
(purpura) appear on the skin as red or purple patches
about five to ten millimetres across. There may also
be bleeding into the intestine, lungs, kidneys and
joints to cause belly pain, coughing of blood, blood in
the urine and arthritis.
It is diagnosed by biopsy of one of the purpura in
the skin, but no treatment is normally necessary as
the condition is self-limiting and usually settles
without serious long-term problems in one to six
weeks. If the kidneys become involved medical
treatment is necessary, as long-term kidney damage
may occur.
Eduard Henoch (182-1910) and Johannes
Schönlein (1793-1864) were German physicians.
HEREDITARY HAEMORRHAGIC TELANGIECTASIA
See OSLER-RENDU-WEBER DISEASE
HERPES GESTATIONIS
Herpes gestationis (pemphigoid gestationis) is a rare, generalised blistering rash that
occurs in pregnancy between the fourth and seventh months, and sometimes after delivery. It
occurs in less than one in ten thousand pregnancies, and is an autoimmune reaction that may
be aggravated by oestrogen. It is not an infection, and not related to genital herpes.
Patients develop extremely itchy, fluid filled, scattered small lumps on the body, particularly
the belly, sides of the trunk, palms and soles. These may enlarge to form large fluid filled
blisters, before bursting and forming crusts. A biopsy of one spot is normally necessary before
the diagnosis can be confirmed.
Prednisone tablets, starting at a high dose and gradually reducing are the usual treatment.
The prognosis is good and the condition usually does not affect the baby, but it tends to
recur in subsequent pregnancies.
HERPES SIMPLEX TYPE ONE
See COLD SORE; ERYTHEMA MULTIFORME; WHITLOW
58
HERPES SIMPLEX TYPE TWO
See GENITAL HERPES
HERPES ZOSTER VIRUS
See CHICKENPOX; RAMSAY-HUNT SYNDROME; SHINGLES
HIDRADENITIS SUPPRAVITA
Hidradenitis suppurativa is an uncommon skin
disorder caused by hair follicles blocked by
keratin, in which painful boil-like lumps develop in
the groin, armpits and under the breasts and
around the anus and vulva. It is more common in
women.
Abscesses may develop due to secondary
bacterial infection and fistulas (channels) may
form into the anus and vagina. Treatment is
unsatisfactory. Patients should wash with
antiseptics to reduce skin bacteria, use
antibiotics
(eg.
tetracycline,
clindamycin,
metronidazole) long term, and doctors may
surgically remove persistent lumps. Some
women benefit by taking the oral contraceptive
pill. Roaccutane tablets and radical surgery to
excise the entire affected area are used in very severe cases. Unfortunately, the condition
often persists long term.
HIDRADENOMA
A hidradenoma is a benign tumour of sweat glands that appears as a small firm lump on
the skin.
HISTIOCYTOMA
See DERMATOFIBROMA
HIVES
See URTICARIA
HOUSEWIFEʼS DERMATITIS
See CONTACT DERMATITIS
HPV
See HUMAN PAPILLOMAVIRUS
HUMAN PAPILLOMAVIRUS
The human papillomavirus (HPV) is the virus responsible for the development of all types
of warts. More than 50 different types of papillomavirus are known to affect humans. If the
59
female cervix is affected, these viruses predispose to the development of cancer of the cervix.
They may also aggravate the formation of squamous cell carcinomas (skin cancer).
See also CONDYLOMA ACCUMINATA; GENITAL WARTS; PLANE WARTS; PLANTAR
WARTS; WART
HUTCHISON MELANOTIC FRECKLE
A Hutchison melanotic freckle (melanoma in situ or
lentigo maligna) is an irregular flat black-blue pigmented
spot, usually on the face of the middle aged or elderly, that
slowly enlarges. It is diagnosed by biopsy, and small spots
may be frozen (cryotherapy), but larger spots are surgically
excised.
Rarely they develop into a malignant melanoma. Without
treatment, they slowly enlarge and thicken.
See also MELANOMA
HUTCHISON PRURIGO
See PHOTODERMATITIS
HYPERCAROTENAEMIA
See CAROTENAEMIA
HYPERKERATOSIS
A hyperkeratosis (actinic or solar keratosis) is a common form of sun damage to exposed
areas of skin. Skin damage is more common during childhood and on fair skinned people. It
appears as a patch of rough, raised and scaling skin, but it is not red or itchy. One quarter of
all hyperkeratoses disappear spontaneously every year, while one in a thousand may
progress to become a squamous cell carcinoma (SCC) every year.
It may be treated when suspected by acid ointments, anticancer cream (5-Fluorouracil),
freezing (cryosurgery), burning (diathermy) or surgical excision. In some elderly patients with
very large affected areas it may not be practical to remove all the spots, but they should be
checked regularly so that any
spots that change can be
treated. The prognosis is very
good, but new spots tend to
arise in nearby areas.
See
also
DERMATOHELIOSIS;
SEBORRHOEIC
KERATOSES; SQUAMOUS
CELL CARCINOMA OF THE
SKIN
ICHTHYOSIS
Ichthyosis is an uncommon
congenital
(present
since
birth) skin condition due to a
60
lack of oil glands in the skin. Numerous subtypes are known (eg. ichthyosis vulgaris - most
common type; X-linked ichthyosis - affects males only; ichthyosis linearis circumflexa - affects
babies). Widespread scaling, dryness and thickening of the skin occurs, and the diagnosis is
confirmed by a skin biopsy.
Massive quantities of moisturising creams and oils must be applied to the skin, but the skin
is more susceptible to other skin diseases, sun damage and poor healing. No cure is
possible.
IDIOPATHIC THROMBOCYTOPENIC PURPURA
See THROMBOCYTOPENIA
IMMATURE HAEMANGIOMA
See STRAWBERRY NAEVUS
IMPETIGO
Impetigo or school sores, is a very common skin infection that virtually every child will
catch, but it may also occur in adults. Several different bacteria may be responsible, but the
most common is Staphylococcus aureus (“golden staph”). This is a serious infection inside
the body, but relatively mild on the skin. Impetigo spreads from one person to another by
close contact, and sometimes an infected animal may act as a source. Once one sore
develops on the skin, scratching with fingers can rapidly spread the infection to other parts of
the body. It is more common in warm climates and in summer.
An itchy, red, raised, weeping or crusting sore appears. If there are a many sores, the
patient may feel generally unwell, but normally there are no other symptoms. In new-born
babies, impetigo may spread rapidly and become serious, so for this reason, infected children
should be kept away from infants.
If necessary, swabs can be taken from the sores to confirm the diagnosis, determine the
infecting bacteria, and select the correct antibiotic.
Treatment involves antibiotic mixtures or tablets, and an antibiotic or antiseptic cream (eg.
mupirocin). Antiseptic soaps, not sharing towels and bedding, and careful personal hygiene
can be used to prevent the spread of infection, and a child must be excluded from school until
61
the sores start to heal. With correct treatment, the sores will heal without scarring in a few
days.
See also BOIL; SCALDED SKIN SYNDROME
INCONTINENTIA PIGMENTI
See BLOCH-SULZBERGER SYNDROME
INFECTIOUS EXANTHEMA
See VIRAL EXANTHEMA
INTERTRIGO
Intertrigo is an inflammatory skin
condition caused by heat, sweat and
friction in those who are overweight,
have poor personal hygiene, live in the
tropics, or suffer from diabetes.
Red, damaged, moist, itchy and
burning skin occurs in places where the
skin folds back upon itself, such as
under the breasts, in the groin and
armpit, and in skin folds of the abdomen
and neck in obese people. In advanced
cases, the skin may crack, bleed,
become painful and fungal and/or
bacterial infections may develop on the
damaged skin.
Treatment
involves
scrupulous
hygiene, controlling diabetes, using antibiotics and antifungals to remove infection, losing
weight, and applying drying powders to the affected areas. A piece of soft cloth placed under
bulky breasts, and a well fitted bra may help. Plastic surgery to reduce large breasts or
excessive skin on the belly may be appropriate. Unfortunately most patients remain
overweight, are not consistent in their hygiene, and the problem persists or recurs.
INTRAEPITHELIAL CARCINOMA
An intraepithelial carcinoma (IEC) is a common cancer in the outer layers of skin, similar to,
but deeper in the skin than, a squamous cell carcinoma. They usually occur in patients who
are over 50 years of age and are caused by prolonged exposure to sunlight. The rims of the
ears, the face, scalp, arms and hands are commonly affected.
The cancer appears as an unsightly red spot covered in fine white scales that may be itchy
or sore. Small IECs are easily removed by burning with a diathermy machine or freezing with
liquid nitrogen. If larger, or if the diagnosis is not certain, it is necessary to excise the spot and
surrounding tissue. Any IEC that recurs after freezing or burning must be surgically excised.
Rarely they may spread by blood or lymphatics to other parts of the body.
Treatment is very effective in early stages of the disease.
See also BOWENʼS DISEASE; HYPERKERATOSIS; KERATOACANTHOMA;
SQUAMOUS CELL CARCINOMA OF SKIN
62
IRRITANT ECZEMA
See CONTACT DERMATITIS
ISRAELI SPOTTED FEVER
See TYPHUS
ITCHY UPPER ARM SYNDROME
The itchy upper arm syndrome (brachioradialis pruritus) is a real disease despite its
descriptive name, and is an abnormal response of the skin to long term sun damage and the
constant release of the irritating substance histamine from allergy (mast) cells in the affected
skin.
Patients with chronic sun damage to their skin may develop intense itching and burning on
outer surface of arm that is worse in summer, but have no apparent rash. A skin biopsy
shows the presence of excessive numbers of mast cells.
Very strong steroid creams or ointments can be tried, but the condition is generally
resistant to treatment.
JANEWAY LESION
A Janeway lesion is a small
purplish to red nodule on the palm
or sole. It is characteristic of
infective endocarditis and is caused
by the spread (embolism) of an
infected lesion from the heart to the
capillaries in the palm or sole.
JUNCTION NAEVUS
A junction naevus is a common,
benign, hairless, brown, flat or slightly raised spot that may
occur anywhere on the skin. They rarely become malignant,
but when they do so they change in colour, shape, size and
thickness and may bleed. Junction naevi that are constantly
irritated (eg. on a collar line, or under a large breast) are
more likely to become malignant.
See also MELANOMA; NAEVUS
JUVENILE PLANTAR DERMATOSIS
Juvenile plantar dermatosis is a skin disease affecting
the feet of children, usually boys between four and eight
years of age. The cause is excessive friction between the
foot and shoe, particularly synthetic shoes in which
sweating is greater. It is more common in children who have
asthma, eczema, hay fever or other allergy problems.
The sole at the front of the foot becomes shiny, glazed in
appearance, covered in a fine scale and sensitive. Tender
cracks occur under the toes and sometimes on the ball of
the foot. The tops of the feet may sometimes be affected, and the condition is more severe in
63
hot weather. In some children, the hands are also affected. Skin scrapings may be taken to
exclude a fungal infection.
Treatment involves wearing well-fitted leather shoes with two pairs of socks (ideally cotton
inside wool), using lubricants on dry skin (eg. paraffin) and barrier creams (eg. dimethicone)
over the lubricant. Steroid ointments are used in severe cases. The problem improves
spontaneously with age.
KA
See KERATOACANTHOMA
KELOID
Some people have an inherited tendency in which there is excessive healing of a scar that
results in a keloid. In some cases it may occur at the site of an acne scar. It is more common
in Negroes, and on the chest, back and neck. A red or brown, raised, thick scar that may
become painful or itchy, forms at the site of skin injury. It may be improved by injection, or
application under a plastic dressing, of powerful steroids. Most keloids stop enlarging after a
few months, and then persist for many years, before very slowly subsiding in some cases.
See also CICATRIX
KERATOACANTHOMA
A keratoacanthoma (KA) is a
rapidly enlarging skin growth that is
often confused with a skin cancer.
They are more common in the elderly
and on the face, hands and other sunexposed areas of the body, but rare in
dark-skinned races.
They initially appear as a small,
scale-covered lump, but over a couple
of months they enlarge rapidly to
become a red, shiny, firm blister
topped with a plug of hard scaly
material that may be 2 cm. or more in
diameter. Over the next few months or
years it will slowly disappear, and eventually little or no trace of their presence remains, but
they take about twice as long to resolve as they take to develop. No treatment is required but
as most KAs are very disfiguring and unsightly they are usually removed surgically. If there is
any doubt at all about the diagnosis a biopsy must be taken. Except for the disfigurement they
cause, they are quite harmless.
See also SQUAMOUS CELL CARCINOMA OF THE SKIN
KERATODERMA
Keratoderma is an abnormal thickening of skin that may be inherited, or due to psoriasis,
eczema, lichen planus or other skin diseases. Patients have very thick, rough, cracked skin
on the palms and/or soles. Salicylic acid ointment or urea cream are used in treatment, but
the condition often persists long term.
See also ECZEMA; LICHEN PLANUS; PSORIASIS
64
KERATOLYSIS
See PITTED KERATOLYSIS
KERATOMA
See CALLUS
KERATOSIS
See HYPERKERATOSIS; KERATOSIS PILARIS; SEBORRHOEIC KERATOSES
KERATOSIS FOLLICULARIS
See DARIER DISEASE
KERATOSIS PILARIS
Keratosis pilaris is a very common skin condition that affects women twice as often as
men, tends to run in families, and starts in the teenage years. It occurs most commonly on the
back of the upper arms, front of the thighs and buttocks. The cause is excess keratin (scale)
formation at the opening of hair follicles.
Small rough polyps appear on the skin and salicylic acid or urea cream and other scale
removing (keratolytic) agents can be used to remove the excess keratin. The condition tends
to settle in mid-life.
See also KERATOLYTICS
KERION
A kerion is an abscess of the scalp caused by the fungi Trichophyton, Microsporum and
other fungi that normally cause tinea (ringworm). A sore, boggy, raised abscess develops on
the scalp and there may be spread of the fungal infection to other areas of the skin. A swab
can be taken to identify the responsible fungus, then potent antifungal tablets and creams are
used to cure the infection.
See also TINEA CAPITIS
KLIPPEL-TRENAUNAY SYNDROME
The Klippel-Trenaunay syndrome is a condition in which there is massive overgrowth of
blood vessels within the skin and other tissues. The cause is unknown.
65
The symptoms include artery and vein malformations on the limbs, portwine naevi (large
red skin marks), local overgrowth of soft tissue, and sometimes local overgrowth of bone and
abnormal connections between arteries and veins elsewhere in the body. Severe bleeding
may occur from an abnormal blood vessel. Surgery and compression bandages are the only
treatments.
See also PORTWINE NAEVUS
LANGERʼS LINES
Langerʼs lines (cleavage lines) are the faint lines in the skin, rather like fingerprint lines, that
are found on all skin surfaces. They tend to rotate length wise down the arms and legs, and
run diagonally across the trunk, but in other areas (eg. the face) there may be complex
interconnecting patterns of lines. The lines indicate tensions in the underlying layers of skin
and fibrous tissue and are generally along the line that there is least elasticity in the skin.
Often skin moles and growths have a long axis in the direction of the Langerʼs lines. A
surgical incision made along these lines will leave less scarring after healing than an incision
made across the lines.
LARVA MIGRANS
See CUTANEOUS LARVA MIGRANS
LEINER DISEASE
Leiner disease (erythroderma desquamativum) is a rare disease of infants characterised by
generalised dermatitis with red scaling skin all over the body, and seborrhoeic eczema of the
scalp.
See also SEBORRHOEIC ECZEMA
LEIOMYOMA CUTIS
A leiomyoma is a benign, painful skin tumour that usually occurs on the arms and legs. The
cause is unknown, but is due to overgrowth of tiny muscles in the skin. Groups of multiple,
small, red-brown, painful lumps (nodules) appear under the skin. The condition is diagnosed
by biopsy of a lump, and cured by surgical removal of each spot, otherwise it persists life long
otherwise.
LENTIGO
Lentigo is a skin pigmentation condition that starts in childhood and affects mainly
Caucasians. There is an inherited tendency that is aggravated by sun exposure.
Small, permanent, pigmented spots appear on the skin. Rarely it is necessary to biopsy a
spot to confirm the diagnosis. No treatment is normally necessary but plastic surgery can be
performed to remove disfiguring spots.
See also ACANTHOSIS NIGICANS; DOWLING-DEGOS DISEASE; HUTCHINSON
MELANOTIC FRECKLE
LENTIGO MALIGNA
See HUTCHINSON MELANOTIC FRECKLE
66
LEOPARD SYNDROME
Leopard syndrome is a congenital heart and skin
pigmentation disorder that passes through families
from one generation to the next. The characteristics
are multiple brown spots on the skin, excessive skin
pigmentation, narrowing of the valve in the artery
leading from the heart to the lungs (pulmonary valve),
enlarged heart and other organs, and sometimes
deafness. Heart failure and attacks may occur.
It is diagnosed by an abnormal ECG (cardiograph)
and echocardiogram (ultrasound scan of heart). There
is no cure, but it is controlled reasonably by heart
valve surgery.
LEPROSY
Leprosy (Hansenʼs disease) is a very slowly progressive infection caused by the bacterium
Mycobacterium leprae that damages the skin and nerves (neuropathy). It is spread from one
person to another by prolonged close contact, most commonly in childhood.
Pale, thick patches of skin on the hands and feet are the first sign, followed by slowly
enlarging nodules, then nerves supplying the affected areas of skin become involved and
sensation is lost. The cooler parts of the body, furthest from the heart, are affected first. As
the disease progresses, a pins and needles sensation may be felt, ulcers form, and bones in
the fingers and toes begin to disintegrate. There is rarely any pain. Damage and deformity is
due to unintentional burns and injuries to totally numb tissue. In severe cases, fingers and
toes do fall off, but this is very rare. The diagnosis can be confirmed by microscopic
examination of a skin biopsy.
A number of antileprotic drugs (eg. dapsone, clofazimine, rifampicin, ethionamide) are
available that will slowly cure leprosy over several years. Any existing deformities must be
treated with plastic surgery. With good management, cure is possible and patients can live
normally in the community. Untreated, the disease progresses to death over 10 to 20 years.
Curiously, the armadillo is the only animal other than humans that can catch leprosy.
LICHEN AUREUS
See CAPILLARITIS
LICHEN AXILLARIS
See FOX-FORDYCE DISEASE
LICHENIFICATION
Lichenification is a medical term for thickening and hardening of the skin or a membrane.
Repeated scratching of the skin will lead to lichenification.
See also DERMATOSCLEROSIS
67
LICHEN PLANUS
Lichen planus is an uncommon skin condition which normally affects people in their
twenties to forties. It may start where the skin has been injured, may be a chronic viral
infection of the skin, or may be triggered by drugs, but the actual cause is unknown.
Small, red to pink, shiny, flat topped,
itchy skin growths develop and may enlarge
and join together to form a plaque. Multiple
paques may develop. They are more
common in skin creases such as the inside
of the wrists and elbows, but can occur
anywhere on the body, including the insides
of the mouth, nose, ears, vagina and anus.
It is diagnosed by a skin biopsy.
Mild cases are often not treated, but
more serious cases are treated with steroid
creams and occlusive plastic dressings.
Further treatments include steroid tablets or
injections under a plaque, ultraviolet light, excision of the plaque and the use of potent
medications such as retinoic acid and dapsone.
The long-term course is very variable. Some patients recover in a few months, while others
may suffer for years, but eventually complete recovery does occur. Some pigmentation of the
skin may remain after the rash has cleared.
See also LICHEN SCLEROSIS; LICHEN SIMPLEX
LICHEN SCLEROSIS
Lichen sclerosis et atrophicus (to give its full name) causes scarring of the tissue on the
genitals and affects women more than men. The cause is unknown, but infection or injury to
the genitals may be a factor.
In men a thickened area of skin develops on one side of the penis, which causes a
sideways curve to the penis that may be painful during an erection, and sexual intercourse
may be difficult. In women, a shiny white itchy area with a red margin appears on the vulva. It
may also occur in skin on other parts of the body. Biopsy of affected skin is sometimes
necessary to make a diagnosis.
Minor surgery can be performed to stretch the scarred penis tissue, and steroid creams are
prescribed for the itch.
See also LICHEN PLANUS; LICHEN SIMPLEX
LICHEN SIMPLEX
Lichen simplex chronicus (circumscribed dermatitis) is a type of persistent dermatitis that is
thought to be a form of nerve rash, and patients who are anxious, tense, nervous or
aggressive are more likely to develop it. In some cases, mild stimulants such as tea or coffee
may aggravate the condition.
Intensely itchy, dry, scaling, thick plaques develop on the skin. They may appear
anywhere, but usually occur in areas, which are easy to scratch, such as the wrist, neck, thigh
and groin. Permanent skin scarring may occur from scratching. A skin biopsy may help with
the diagnosis.
68
Stopping tea and coffee may dramatically improve the itch, and it is important for patients
to avoid any further damage to the skin from scratching by bandages or applying a plaster.
Steroid creams and injections into the affected areas of skin may be beneficial. Avoiding
stressful situations is helpful, but often not practical.
If the patient can stop scratching the skin, the disease will cure itself.
See also ECZEMA; LICHEN PLANUS; LICHEN SCLEROSIS
LICHEN URTICARIUS
See PRURIGO
LINEAR IgA DERMATOSIS
Linear IgA dermatosis is a rare skin disease that affects teenagers. It is a congenital
abnormality of the immune system due to excess immunoglobulin A (IgA) under the skin.
Patients develop very itchy, severe skin blistering that occurs in groups or lines over the outer
surfaces of joints (eg. knees, elbows) and on the buttocks and neck. Ulcers may form in the
mouth. Secondary infection of blisters is possible, with resultant scarring. Specific blood tests
are abnormal, and a skin biopsy can confirm the diagnosis. Medications such as dapsone,
prednisone and specific sulfas are used in treatment. These medications are usually
successful in controlling, but not curing, the disease.
See also DERMATITIS HERPETIFORMIS
LINEA NIGRA
Literally, linea nigra translates from the Latin as black line. It is a line of pigment that forms
on the skin of some pregnant women, running from the top front of the pelvis (pubic
symphysis) to the umbilicus, and sometimes up as far as the sternum. It is harmless, and
tends to fade after the pregnancy.
LIVEDO RETICULARIS
Livedo reticularis is a skin reaction indicating an underlying disease or generalised
reaction. A maroon to red, net like or starburst pattern rash appears on the skin, particularly
on the buttocks and thighs. The rash becomes more pronounced if skin exposed to cold. The
cause is damage to veins in the skin from any one of many different diseases such as
69
arteriosclerosis (hardening of arteries), embolism (blood clots), polyarteritis nodosa, systemic
lupus erythematosus, Sneddon syndrome and leukaemia, or may be a reaction to a drug such
as quinidine or amantadine.
The cause of problem and any underlying disease or drug reaction needs to be identified
by appropriate tests before treatment can be commenced. Low dose aspirin, pentoxifylline
tablets and skin warming may help the rash.
LÖFGREN SYNDROME
Löfgren syndrome is a complication of acute stage sarcoidosis that tends to occur in
women of Scandinavian or Irish heritage. Erythema nodosum (skin condition) occurs, and
enlarged lymph nodes in the chest seen on chest X-ray, in a patient with sarcoidosis. Antiinflammatory medications control leg and skin symptoms, while the sarcoidosis is also
treated. There is an 80% chance of spontaneous recovery
See also ERYTHEMA NODOSUM
LOUIS-BAR SYNDROME
The Louis-Bar syndrome is a rare form of rapidly progressive brain deterioration due to
degeneration of the cerebellum (lower back portion of brain) and spinal cord. The symptoms
include dilated capillaries on the whites of the eyes, the face and areas of skin flexion (eg.
arm pit, behind knee); intellectual disability; recurrent infections of lungs and ears, and poor
coordination that steadily worsens. Late symptoms include twitching movements of the eyes
and abnormal writhing movements of the arms and legs. There is an above average incidence
of cancer.
Numerous blood tests are abnormal, including very low immunoglobulin levels.
No treatment is available and death in teenage years is usual.
LYME DISEASE
Lyme disease is a relatively common blood infection caused by the bacterium Borrelia
burgdorferi that occurs in the northeast United States. It is spread by the bite of the tick Ixodes
70
from infected mice or deer to humans. The tic may lie dormant for up to a year before passing
on the infection with a bite.
The disease has three stages:- in stage one the patient has a flat or slightly raised red patchy rash, fever, muscle
aches and headache.
- stage two comes two to four weeks later with a stiff neck, severe headache,
meningitis (inflammation of the membrane around the brain) and possibly Bellʼs
palsy.
- in stage three, which may come three to twelve months later, the patient has
muscle pains, and most seriously a long lasting severe form of arthritis that may
move from joint to joint. Persistent crippling arthritis sometimes occurs.
The diagnosis is confirmed by specific immunoglobulin blood tests, then a prolonged
course of antibiotics is prescribed.
Long term, one third of patients may suffer from continuing muscle and joint pains, while a
smaller percentage have after effects of the meningitis.
LYMPHANGIOMA
A lymphangioma (lymphangiomata) is a benign, soft, yellow to tan coloured lump that
forms on the skin. It consists of a mass of dilated lymph vessels. Cysts may form in the
lymphangioma and swell to an enormous size, but they can be drained to allow treatment.
They can be removed by excision or diathermy.
LYMPHOEPITHELIAL CONDITION, BENIGN
See MIKULICZ DISEASE
LYMPHOGRANULOMA VENEREUM
Lymphogranuloma venereum (LGV) is a
sexually transmitted disease that is rare in
developed countries but common in Africa and
Asia. It is caused by the Chlamydia organism
which is a bacteria-like germ that lives inside cells
and destroys them. The incubation period after
sexual contact is one to three weeks.
A sore develops on the penis or vulva, then the
lymph nodes in the groin become infected,
swollen, soften and suppurate (drain pus) onto the
skin. The infection may spread to cause joint, skin,
brain and eye infections. If anal intercourse has
occurred, sores and pus discharging lymph nodes
may form in and around the anus. The initial sore
and pus discharging lymph nodes are not painful,
and only if the disease spreads does a fever develop. It is diagnosed by special skin and
blood tests.
Antibiotics such as tetracyclines are prescribed and surgical procedures to drain pus from
lymph nodes may be necessary. If left untreated disfiguring scarring will occur in the groin at
the site of the infected lymph nodes, and the genitals may become permanently swollen, and
71
if the infection spreads to other organs, they may be seriously damaged. The majority of
cases are cured by appropriate treatment.
MAJOCCHI GRANULOMA
A Majocchi granuloma is a fungal infection of hairy areas of the body. A fungus infects the
deepest part of a hair follicle, usually after an injury (eg. deep graze or burn) to the affected
area of skin. It causes irritation, inflammation and hair loss on the scalp or other hairy area.
Severe infections may result in skin thickening, pustules on the skin and tender nearby lymph
nodes. A secondary bacterial infection is possible, as is spread of the fungus to other areas of
the skin.
Plucked hairs from affected areas may grow the responsible fungus when cultured, but a
biopsy of the area may be required to make a final diagnosis. The infection usually responds
well to antifungal creams or lotions, and antifungal tablets.
MEASLES
Measles (technically called morbilli or rubeola) is a
highly contagious Morbilli virus infection that is contagious
from five days before the rash appears until it disappears.
The incubation period is 10 to 14 days. It was originally a
disease of cattle that was only passed to humans after
these animals were domesticated many thousands of
years ago.
It starts with the cold-like symptoms of a snuffly nose,
cough and red eyes. A rash develops about four days
later, starting in the mouth where tiny white spots appear
on the lining of the cheeks. Dark red blotches then
develop on the face and gradually spread across the
body, remaining for a week or more before gradually
fading. Other symptoms include a high fever and eye
discomfort with bright lights. The patient often starts to
feel better once the rash has reached its maximum
spread.
The diagnosis can be confirmed by blood tests if
necessary, and previous exposure to the measles virus or
vaccine can also be confirmed by specific antibody blood tests.
There is no specific treatment. Rest, paracetamol and medication are used to relieve the
cold symptoms, and vitamin A supplements appear to reduce the severity of an attack.
Children must be excluded from school for at least four days after the appearance of the rash.
Measles may be prevented by a vaccination, which is usually given at one and four years
of age in combination with the mumps and rubella (German measles) vaccine, and with
widespread vaccination, it is becoming a rare infection in developed countries, and may be
totally eradicated by 2020.
Complications include encephalitis (a serious brain infection), pneumonia, ear infections
and damage, and possibly the increased risk of developing multiple sclerosis later in life.
Immediately after an attack patients are susceptible to other infections, and a significant
number will develop tonsillitis, ear and lymph node infections.
72
The prognosis is usually very good, but significant complications occur in one in every 200
cases, and death occurs in one in every 5000 cases in developed countries, while in thirdworld countries one in ten children or adults who catch measles will die.
See also GERMAN MEASLES; ROSEOLA INFANTUM
MEASLES, BABY
MEASLES, GERMAN
See GERMAN MEASLES
MEDITERRANEAN SPOTTED FEVER
See TYPHUS
MEDULLARY CARCINOMA
A medullary carcinoma is an uncommon, soft, cancer of the skin that contains virtually no
fibrous tissue, and arises from the epithelial cells of the skin.
MELANOCYTIC NAEVUS
See MOLE
MELANOMA
A melanoma is the most serious form of skin cancer, and it starts in the skin cells that
create pigment. In Europeans (Caucasians), these cells are relatively inactive, giving a pale
colour to the skin, but in Asians (Mongols) they are moderately active, and in Africans
(Negroes) they are very active, giving a darker skin colour.
The actual cause is unknown, but exposure to sunlight, particularly in childhood and teen
years, dramatically increases the
risk. Ultraviolet radiation, most of
which is filtered out of sunlight by
the ozone layer in the upper
atmosphere, is the part of the
spectrum that causes the damage.
Fair-skinned people have a higher
incidence than those with dark
complexions, and it is rare in
children, slightly more common in
women than men, and most
common between 30 and 50 years
of age and on the legs and back.
One in every 150 people in
Australia will develop a melanoma
at some time.
It appears as a skin spot that
may be black, brown, pink or blue, and the colours may be found individually or mixed. They
usually have an irregularly edge, enlarge steadily, have an uneven and bumpy surface, and
the pigment can be seen advancing into the surrounding skin, and in advanced cases the
73
spot will bleed, scab and ulcerate. They have a tendency to grow deep into the body and
migrate to other organs, particularly the liver, lungs and lymph nodes in the armpit and groin.
Melanomas can occur under the nail (where they may be mistaken for a bruise), in the mouth,
under the eyelids, on the retina inside the eye, and in the anus, but the sun-exposed parts of
the skin are the most commonly affected.
It is diagnosed by biopsy or excision of the suspected mole, then the melanoma and a
large area of skin around and under it, must be cut out. The lymph nodes around the
melanoma may also need to be removed. If there is evidence that it has spread to other
areas, the patient will also be treated with irradiation and injected medications to control its
further growth.
In the very early stages there is a 97% cure rate, but as the cancer enlarges, the cure rate
drops dramatically. The thicker the melanoma the worse the prognosis, and ulceration of the
melanoma at the time it is excised also worsens the long-term outcome. Unfortunately,
sometimes the cancer may appear to be cured but can flare up decades later.
See also DYSPLASTIC NAEVUS SYNDROME; HUTCHISON MELANOTIC FRECKLE
MELANOMA IN SITU
See HUTCHINSON MELANOTIC FRECKLE
MERKEL CARCINOMA
A Merkel carcinoma (also known as a
Merkel tumour, primary neuroendocrine
carcinoma of the skin or a trabecular
carcinoma) is a rare form of skin cancer that
usually affects the elderly. It develops from
nerve cells in the deeper layers of the skin
that respond to the movement of hairs, is
caused by excess sun exposure over many
years, and is often associated with other
forms of skin cancer.
The cancer appears as firm, raised,
painless lumps that may be red, pink or
rarely blue in colour on sun exposed skin of
the face, hands and neck. In advanced
cases, the overlying skin ulcerates. They
may spread to nearby lymph nodes and other organs such as liver and bone. It is diagnosed
by biopsy or excision of the lump.
Treatment involves excision of the tumour with a wide margin of skin, usually followed by
irradiation of the area and any nearby lymph nodes. Chemotherapy (potent anticancer drugs)
may also be prescribed. Lymph nodes may be removed surgically if necessary. Radiotherapy
is often used as an added treatment.
About one-third spread to other organs, and one half recur in the skin or nearby lymph
nodes. It may not be possible to effectively treat the disease once it has spread.
See also MELANOMA
74
MILIA
Milia (keratin cysts) is a problem of excess keratin (scale) production by oil glands in the
skin, commonly in areas of skin damage. Tiny, firm, creamy lumps (papules) appear on the
skin, usually of the face. They can be removed for cosmetic reasons by piercing with a needle
or cryosurgery (freezing). They persist long term unless removed.
See also TRICHOEPITHELIOMA
MILIARIA
In conditions of high humidity and heat, an active person will sweat profusely. If the sweat
ducts may become blocked, particularly if the person has been involved in dirty work, the
blocked sweat glands will appear as small lumps (papules). Itching and redness may occur as
the sweat escapes from the blocked glands into the surrounding tissue. This condition is
called miliaria (heat rash or prickly heat). Treatment involves a cool, dry environment (eg. air
conditioning) or a cool bath.
MOLLUSCUM CONTAGIOSUM
Molluscum contagiosum is a mild contagious viral skin infection spread from one person to
another by close contact. If the blisters occur on the genitals, it has probably been caught by
sexual contact. Multiple small (2-4 mm.), dome-shaped, white blisters with a central dimple
appear on scattered parts of their body. The abdomen, chest and face are the most
commonly affected areas.
No treatment is normally required. Unsightly or persistent blisters can be removed by a
doctor scraping out their contents, or heating them with an electrical cautery needle.
Secondary bacterial infection of a scratched blister can occur. The rash disappears
spontaneously after three to twelve months. It is not necessary to exclude a child from school.
MONGOLIAN SPOT
The Mongolian spot is a diffuse dark bluish patch at the lower end of the spine over the
sacrum. It is characteristic of those with Mongolian heritage, tends to run in families, and has
been seen in children from eastern Europe to SE Asia, as well as in China and its surrounding
areas. It tends to fade with age.
75
MORPHEA
Morphea (circumscribed scleroderma) is a skin condition that occurs more commonly in
women and starts in early adulthood. It may occur on the forehead when it is called en Coup
de Sabre (sabre cut), and on the scalp,
limbs and chest. The cause is unknown.
It may appear as patches or thick lines
on the skin that are initially purplish in
colour, then become crusted, thick and
shiny. Hairs are lost from affected skin
and permanent scarring may occur. It is
diagnosed by a skin biopsy.
Treatment is unsatisfactory. Plastic
surgery is sometimes performed, and
while some cases settle spontaneously
over many years, most persist long term.
See also SCLERODERMA
MUCOCUTANEOUS LEISCHMANIASIS
Mucocutaneous leischmaniasis (espundia or naso-oral leischmaniasis) is a protozoan
(single celled animal) infection of the nose, mouth and surrounding skin, caused by
Leishmania braziliensis, which is transmitted from person to person by direct contact (eg.
kissing) or sand flies. Dogs and rats also carry the protozoan. It occurs only in tropical central
and South America.
Nodules, warty growths or ulcers develop on the nose and lips, and ulcers occur inside the
nostrils and mouth. Death may occur from massive ulceration and facial tissue destruction,
and it may spread to affect the throat. Disfiguring scars and facial deformities may be left after
healing. Secondary bacterial infection of sores is common.
Scrapings from ulcers show characteristic changes under a microscope, and other specific
diagnostic tests are available.
Regular injections of medications to destroy the protozoan are necessary for several
weeks, although in most patients sores heal spontaneously in six to 24 months.
See also CUTANEOUS LEISCHMANIASIS
MUIR-TORRE SYNDROME
The Muir-Torre (or Torre-Muir) syndrome is an inherited trait in which patients have multiple
cancers of glands in the skin and internal organs. Unusual skin cancers involving glands
develop, and further cancers involving internal organs (eg. colon, kidneys) are found. The skin
cancers are unusual and may initially be mistaken for less severe forms of skin cancer.
Excision and analysis treats skin cancers, but extensive investigations (eg. colonoscopy, CT
scan) are necessary to detect, and then remove, internal cancers. The prognosis depends on
the number of cancers found, their location and severity.
MURINE TYPHUS
The most common form of typhus is murine typhus, which is spread from mice to man by a
flea bite. It is caused by the bacteria Rickettsia typhi, and is common almost worldwide in
urban areas with poor hygiene. The symptoms include headache, fever, muscle pains, chills
76
and a rash. The incubation period is 8 to 16 days, and the illness lasts about 12 days.
Recovery is normal, but death may occur in the elderly and debilitated. The antibiotic
tetracycline can be used in treatment.
See also TYPHUS
MYCOSIS FUNGOIDES
Mycosis fungoides is a rare form of
cancer involving the lymphatic tissue in the
skin. It may be caused by spread from other
lymphatic cancers (eg. Hodgkinʼs disease)
elsewhere in the body, or may arise in the
skin.
Red circular patches appear on the skin,
that initially may be confused with a fungal
skin infection (thus the disease name), and
gradually spread across the body, and may
spread from the skin to other organs.
It is diagnosed by taking a biopsy
(surgical sample) of the rash, then applications of anticancer medications are applied directly
to the skin, and ultraviolet light therapy, irradiation of the affected areas of skin, and in more
severe cases, anticancer tablets and injections are used. From when first diagnosed, average
life expectancy is seven years.
See also PARAPSORIASIS EN PLAQUE
MYXOID CYST
A myxoid or mucous cyst is a common annoying but harmless cyst that forms on fingers
due to degeneration of tissue under the skin on the back of the last segment of a finger. A
small, smooth, shiny cyst forms under the skin on the back of a finger between the base of
the nail and the last joint. The cyst contains a thick jelly-like substance and the nail may
develop a lengthways groove. Uncommonly, they may become infected.
They can be removed by freezing or injection if small, but larger cysts must be removed
surgically under local anaesthetic. The surgical result is good, but recurrence is common.
NAEVUS
A naevus (nevus in the USA) is a small area of abnormal, but benign, rough raised
pigmented skin that may be single or multiple. Many different forms including blue naevus
(benign blue coloured and smooth), Becker naevus (hairy, male, shoulders), junction naevus
(flat, hairless, brown), sebaceous naevus (yellow, bumpy, on scalp), epidermal naevus (very
common, may be extensive), halo naevus, portwine naevus, strawberry naevus, telangiectatic
naevus (dark pink patches on head of infants) and spider naevus. The plural of naevus is
naevi.
If there is any suspicion that the spot may be malignant, it should be biopsied or cut out,
otherwise they usually remain life long.
See also BLUE NAEVUS; BLUE RUBBER BLEB NAEVUS SYNDROME; COMEDONE
NAEVUS; DYSPLASTIC NAEVUS SYNDROME; HALO NAEVUS; JUNCTION NAEVUS;
NAEVUS ANAEMICUS; NAEVUS OF OTA; PORTWINE NAEVUS; SPIDER NAEVI; SPITZ
NAEVUS; STRAWBERRY NAEVUS; TELANGIECTATIC NAEVUS
77
NAEVUS ANAEMICUS
Naevus anaemicus is a congenital abnormality of blood vessels in the skin that causes one
or more irregularly shaped white patches in the skin. The condition is harmless and caused by
a persistent poor blood supply to the affected area. Staining of the skin is the only available
treatment.
See also NAEVUS
NAEVUS OF OTA
A naevus of Ota is a congenital (but not inherited)
skin pigment disorder affecting Asians (particularly
Japanese) and less commonly Negroes. They are rare
in Caucasians. The condition usually starts in
childhood or teenage years to cause a mottled, dusky
blue/brown, disfiguring pigmentation of the face that
may involve the inside the mouth and the whites of the
eyes. Patients have an increased risk of malignant
melanoma. The diagnosis can be confirmed by biopsy.
Laser treatment of the affected skin sometimes
beneficial, but treatment is not particularly effective and
there is no specific cure.
See also MELANOMA
NAPPY ECZEMA
See NAPPY RASH; SEBORRHOEIC ECZEMA
NAPPY RASH
A nappy (diaper) rash is not a reflection on the mother or a sign of neglect, but a very
common problem. The baby develops an angry red area of skin under the nappy due to
excess moisture on the skin from wet nappies, pilchers and plastic over-pants that can cause
skin damage, eczema and fungal infections (tinea cruris). Over-bathing, soap and detergents
left in nappies may also irritate the skin.
Red, pealing, irritated skin appears on the buttocks. If the skin folds are spared, it is
probably a pure dermatitis, but if the rash extends to the skin folds and there are red satellite
lesions beyond the edge of the rash, it probably has a fungal component. Uncommonly
bacterial infections may occur.
Zinc cream, lanolin or petroleum jelly applied to the bottom will protect it against moisture,
and fungal infections will settle with antifungal creams, but eczema may require a mild steroid
cream. The results of treatment are good, and even the most resistant cases settle once the
child is toilet trained.
See also SEBORRHOEIC ECZEMA; TINEA CRURIS
NECROBIOSIS LIPOIDICA
Necrobiosis lipoidica is a rare skin condition affecting the shin of the leg. It is often a
complication of insulin dependent (type one) diabetes mellitus, but may also occur in nondiabetics. The absolute cause is unknown.
78
One or more tender, yellow to brown patches develop slowly over many months on the shin
of the lower leg. The patches may be round or oval, and as they mature, the centre becomes
thin and shiny with prominent small blood vessels. The central area may degenerate into an
ulcer, which is painless.
The diagnosis can be confirmed by biopsy of the patch. Steroid creams or injections may
be useful in treatment, and sometimes pentoxyfylline tablets are prescribed, but many cases
require no treatment. The patches usually persist for many years before slowly disappearing.
NETTLE RASH
Nettle rash is a very itchy rash that appears as multiple tiny red dots on areas that have
come into contact with a stinging nettle, a weed common in the Americas. The rash last for
several hours before settling, but may be eased by antihistamines.
See also URTICARIA
NEURODERMATITIS
Neurodermatitis, a nerve rash, is a rapidly developing form of dermatitis associated with
stress such as an exam, job interview, marriage or any other event. It does not mean that the
patient is neurotic or in need of psychiatric care, the rash is merely an outward manifestation
of a sometimes minor stress in an otherwise normal person.
Multiple very itchy, small red raised lumps develop on the skin and they may fluctuate quite
rapidly in their intensity. The front of the wrist, inside of the elbow and backs of the knees are
the most commonly affected areas, but it may occur anywhere.
A mild steroid cream is used to reduce inflammation in the skin, and if the cream is applied
as soon as the rash appears, it should settle almost immediately.
See also DERMATITIS; LICHEN SIMPLEX
NEVUS
See NAEVUS
79
NODULE
A nodule is any small, hard lump in or (more commonly) on the body. The term is derived
from the Latin word for knot, nodus. Nodules may form in many organs (eg. thyroid), tissues
(eg. muscle, fat) or in the skin. A nodular melanoma is normally more sinister than one without
nodules.
See also SURFERʼS NODULE; TRICHOEPITHELIOMA
NORWEGIAN SCABIES
Norwegian scabies is a very severe form of scabies that causes thickening and scaling of
the skin (particularly the palms and soles) from huge numbers of scabies mites.
See also SCABIES
NOTALGIA PARAESTHETICA
Notalgia paraesthetica is a condition caused by nerve and skin damage on the upper back.
The nerves that supply sensation to the upper back emerge from the spinal cord and run a
long course through thick muscles in the back before making a right-angled turn and reaching
the skin. They are easily damaged by an injury to the area, shingles or even sunburn. The
skin is then further damaged by rubbing and scratching the affected area.
Patients develop an itch and/or changed sensation in the area of skin just below the
shoulder blade on either side of the back. There may be no visible change in the skin or there
may be a brown pigmentation, patchy loss of skin colour or thickening due to rubbing. The
changed sensation can be tested for by pinprick, cotton wool or heat and cold.
Treatment is not always successful. Measures that may be tried include cooling lotions (eg.
camphor and menthol), capsaicin cream, local anaesthetic creams and amitriptyline tablets at
night. The condition is not serious but often persistent.
NUMMULAR ECZEMA
See DISCOID ECZEMA
OCHRONOSIS
Ochronosis is an inherited biochemical abnormality in which homogentisic acid
accumulates to a high level in the body to cause arthritis, and bluish patches in the mouth, on
the whites of the eyes, nose, ears, fingers, genitals and in the armpits. These blue to black
patches may also be found within the body, and the urine is a darker than normal colour.
There is no cure, but the arthritis can be controlled by appropriate medication.
ORF
Orf is an unusual viral infection of sheep and goats that can infect the skin on the fingers
and hands of people (eg. shearers, abattoir workers, veterinarians) who come into close
contact with infected animals, when the Parapoxvirus can enter a minor injury to the skin.
A sore develops at the site of infection after about ten days later, and this enlarges to
become a large, fluid-filled, ulcerating and scabbing lump that may be one to three
centimetres across. The lymph nodes in the armpit or other areas may become tender and a
secondary bacterial infection of the sore may occur. The lump becomes soft, breaks down,
and heals completely after four to eight weeks, leaving no scar.
80
ORIENTAL SORE
See CUTANEOUS LEISCHMANIASIS
ORIENTAL SPOTTED FEVER
See TYPHUS
OSLERʼS NODES
Oslerʼs nodes are small, tender, raised, red, transient patch on the tips of the fingers or
toes that are caused by infected skin emboli (blood clots). It is a sign of bacterial endocarditis.
OSLER-RENDU-WEBER DISEASE
Also known as hereditary haemorrhagic telangiectasia (HHT), this inherited blood vessel
disorder starts in childhood, but only becomes serious in adult life. It is more common in
Mormons but generally rare, occurring in one in every 10,000 people.
The symptoms include widespread red dots and lumps caused by dilated small blood
vessels (telangiectasia) just under and in the skin of the face, forearms, lips, tongue, palms
and toes. The moist membranes lining body cavities (eg. nose, mouth, gut, lungs, vagina)
may also be affected, resulting in serious internal bleeding and blood noses. Uncommonly the
brain may also be affected.
The disease is diagnosed by a skin biopsy, but the only treatment is surgical removal of
bleeding internal or large skin telangiectasia. Liver involvement may occur, causing damage
to the organʼs blood supply and replacement of normal liver tissue with scar tissue. Blood loss
may lead to anaemia.
There is no cure, but provided bleeding is not serious, life expectancy is normal.
81
See also ROTHMUND-THOMSON SYNDROME
PACHYDERMA
Pachyderma is the medical term used to describe excessive thickening of the skin and the
underlying tissues.
See also DERMATOSCLEROSIS
PAINFUL BRUISING SYNDROME
The painful bruising syndrome is abnormal bruising that occurs in young women for no
known cause, but it may follow emotional or physical stress. A pins and needles sensation is
felt in the limbs and trunk followed by crops of bruises without injury. All blood and other tests
are normal. No treatment is necessary as it is a self-limiting condition.
PALMOPLANTAR PUSTULOSIS
Palmoplantar pustulosis is a persistent rash affecting the palms and soles of the hands and
feet. The cause is unknown, but it is more common in smokers, there is a family tendency and
it is often associated with psoriasis. It is not caused by a bacterial infection but it may become
secondarily infected with a fungus or bacteria.
Crops of grouped blisters full of fluid occur on thick, red, irritated, scaly skin of the palms
and soles. Painful cracks may develop in the affected skin, and it is aggravated by walking on
affected feet. A biopsy may be taken to confirm the diagnosis.
Patients should avoid loose footwear and friction. Treatment involves copious amounts of
moisturising cream, soaking in warm water with emulsifying ointments and applying strong
steroid creams to the worst affected areas. Wrapping the affected areas in cling wrap or
wearing plastic gloves increases the effectiveness of steroid creams. Other treatments
82
sometimes used include coal tar, calcipotriol ointment, ultraviolet light with psoralens (PUVA),
tetracycline antibiotics, dapsone, methotrexate and acetretin tablets.
There is no cure and the condition recurs intermittently for many years before subsiding.
See also PSORIASIS
PANNICULITIS
Panniculitis (Weber-Christian panniculitis) is an
inflammation of the fat layer under the skin that
usually affects young women. Numerous subtypes
are known. The cause has not been identified, but it
is due to inflammation of the small arteries
(vasculitis) supplying the fat, and a reduced blood
supply to the fat layer. Weber-Christian pannicultis is
the most severe form and may rarely lead to death
from reduced blood supply to internal organs.
Tender lumps (nodules) develop under the
reddened skin. It is diagnosed by biopsy of fatty
lump. No treatment is normally necessary except for
severe forms, when steroids are given to settle
inflammation. It usually settles without treatment
over many months to leave a dent in the skin due to
lack of underlying fat.
PAPULAR URTICARIA
Papular urticaria is a skin condition of children that is more common in Spring and Autumn.
The cause is an allergy reaction to insects (eg. fleas, mites) in the childʼs environment, but the
insect does not have to bite the child. The insects may live on household pets and not the
child.
Multiple, small, very itchy, red lumps that may blister are the main symptom. Crops occur
every few days, usually on the legs, forearms and face, before slowly subsiding and leaving a
scar that may persist for months. Scratched spots become crusted and may become infected.
Steroid creams ease the irritation, as do antihistamine mixtures or tablets. Parents should
fumigate the house, treat pets vigourously for fleas and keep pets outside. The problem is
often recurrent but eventually disappears, often after moving to a new house.
See also URTICARIA
PAPULE
A papule is a small solid lump on the skin that is less than one centimetre across. There
are many reasons for the presence of papules ranging from insignificant to sinister.
Acne is the most common cause of a papular rash.
A xanthoma is a yellowish swelling in the skin resulting from a deposit of fat. It may indicate
a raised blood cholesterol level.
A basal cell carcinoma, or rodent ulcer, is a slow growing malignant tumour, often at the
edge of the eyelids, lips or nostrils, or on the ears. These take a long time to spread but
ultimately can be very destructive of nearby tissues and should be removed.
The appearance of a dark coloured papule may be a malignant melanoma and should be
investigated promptly.
83
Molluscum contagiosum is a common viral infection of the skin that causes multiple small
papules to appear.
PARAPSORIASIS EN PLAQUE
Parapsoriasis en plaque is an uncommon skin
disease of no known cause that is divided into
two types, small and large plaque. The condition
is characterised by the slow development over
many months of multiple, oval to cigar shaped,
red, slightly raised, scaly, non-itchy patches.
They tend to avoid the forearms and lower legs
and head, and to follow nerve pathways in skin.
Large plaques (patches over 10 cm. in diameter)
may progress to mycosis fungoides. A skin
biopsy can confirm the diagnosis.
Steroid creams and ultraviolet therapy control
the condition, but there is no cure.
See
also
MYCOSIS
FUNGOIDES;
PITYRIASIS LICHENOIDES; PSORIASIS
PEAU DʼORANGE
In some forms of advanced breast cancer, the skin over the cancer takes on a dimpled
appearance similar to that of an orange known as peau dʼorange (orange peel in French).
PEMPHIGOID
Bullous pemphigoid is an uncommon but serious autoimmune skin disease that usually
affects elderly women. There is an inappropriate immune reaction within the body that
causes the skin to be rejected in the same way as a transplanted kidney is rejected by the
body. The actual cause of the autoimmune reaction is unknown.
Patients develop red, scaling, itchy patches, which after a few days break down into large,
fluid-filled blisters on widespread areas of the body. These huge, soft bubbles develop on the
arms and legs initially, but soon spread to the trunk. The face and head are rarely affected.
Severe fluid loss from the body through the blisters may cause dehydration and heart rhythm
irregularities.
84
The diagnosis is confirmed by a skin biopsy (taking a sample of the affected skin, and
examining it under a microscope) and a specific blood test (basement membrane
autoantibodies). Treatment involves high doses of prednisone, a steroid that reduces the
immune response and allows the skin to repair itself. Once the disease is under control, the
dosage is slowly reduced over a period of many months, but some patients need to remain on
a low dose for years. Cytotoxic drugs may also be used. Without treatment, pemphigoid is
fatal in one third of patients. With treatment, deaths are very rare, and one third of patients will
require no treatment after two years.
See also PEMPHIGUS
PEMPHIGOID GESTATIONIS
See HERPES GESTATIONIS
PEMPHIGUS
Pemphigus is a rare but severe autoimmune skin disease that occurs in all age groups and
both sexes, but is very uncommon in children. There is an inappropriate immune reaction
within the body that causes the skin to be
rejected in the same way as a transplanted
kidney is rejected by the body. The actual
cause of the autoimmune reaction is
unknown.
The rash varies dramatically in its form
from shallow ulcers, to multiple blisters, red
scaling patches or massive peeling of skin.
Any part of the body, including the face and
the inside of the mouth, may be affected.
A biopsy (sample) of the affected skin is
examined to confirm the diagnosis, then
large doses of prednisone or other steroids,
immunosuppressive and cytotoxic drugs, all
of which may have significant side effects,
must be used long-term. Para-amino
benzoic acid is sometimes used on the skin.
Without treatment, pemphigus is invariably fatal. With adequate treatment, the mortality rate is
below 25%.
See also HAILEY-HAILEY DISEASE; PEMPHIGOID; SCALDED SKIN SYNDROME
PEMPHIGUS AUTOANTIBODIES
See INTERCELLULAR CEMENT CELL SUBSTANCE AUTOANTIBODIES
PEMPHIGUS NEONATORUM
PENIS WART
See GENITAL WARTS
85
PERIORAL DERMATITIS
Perioral dermatitis is a common facial skin problem that tends to occur more in women who
have oily skin, do not wash their face thoroughly, and use face creams, foundation and
cosmetics that clog skin pores. The overuse of strong steroid creams on delicate facial skin
may also be responsible.
Clumps of small, red, itchy, tender spots develop on the skin around the mouth, but not on
the lips. The rash may also occur around the nose and eyes. Tetracycline antibiotics clear the
rash, but patients should avoid all face creams, sunscreens, cosmetics and steroid creams,
and wash their face regularly with warm water without soap. The rash settles well with
treatment, but sometimes recurs.
PETECHIAE
Petechiae are tiny flat red spots that are scattered across the skin. They are caused by
bleeding from capillaries in the skin, which occurs in diseases such as generalised viral
infections, bleeding disorders (eg. thrombocytopenia), meningococcal infections, capillaritis
and advanced typhoid fever.
PHOTODERMATITIS
Photodermatitis is a congenital (present since birth) abnormal allergy type reaction of skin
to sunlight. There are several different forms including Hutchison prurigo, polymorphic light
eruption and solar urticaria. The victim develops a red, raised itchy rash on sun-exposed skin
that may result in permanent skin damage and scarring.
There is no cure, and the only treatment is to use clothing that covers all sun exposed skin
and broad brimmed hats.
See also DERMATITIS; PHOTOSENSITIVE ECZEMA
PHOTOSENSITIVE ECZEMA
Photosensitive eczema is an uncommon type of eczema that usually occurs in middle-aged
and elderly men and affects areas of skin that are exposed to light. It is due to a reaction in
the skin to the ultraviolet wavelengths in sunlight. Fluorescent lights also give off ultraviolet
radiation and can cause this reaction.
A red rash covered with scales that is intensely itchy develops on the face, forearms and
hands, but other areas exposed to sunlight may also be affected. In rare cases, the reaction
may be so severe that the patient cannot go outside during the day, and they must reverse
their lifestyle - sleeping during the day and being active at night - in order to avoid the sun. A
skin biopsy may assist in the diagnosis.
Wearing long-sleeved shirts and hats, and applying UV sun screen creams and very strong
steroid creams are the main treatment. Occasionally steroid tablets are also required. Once
established, the condition persists for life.
See also ECZEMA; LIGHT SENSITIVE SKIN; PHOTODERMATITIS
PIGMENTED PURPURA
See CAPILLARITIS
PIGMENTED PURPURIC LICHENOID DERMATOSIS
See CAPILLARITIS
86
PILOMATRIXOMA
A pilomatrixoma (calcifying epithelioma of
Malherbe or Malherbe tumour) is a benign
tumour of a hair follicle that is usually found in the
arm pit or other hairy areas of skin that are
subject to friction damage. It may be from a
couple of millimetres to two centimetres across
and grows slowly over many years.
Patients notice a slowly enlarging firm solitary
lump under the skin that is often attached to the
skin. It usually causes little or no trouble but may
be annoying and unsightly, and sometimes may
become inflamed, tender and infected. It is
diagnosed after surgical excision by examination
under a microscope.
PINTA
Pinta is a bacterial skin infection by Treponema carateum that occurs in children and young
adults who are malnourished and living in conditions of poor hygiene. It is more common on
the forearms and lower legs and the incubation period is one to three months. It starts with a
small, pink scaly lump (papule), which gradually enlarges to form a scale-covered plaque with
raised edges. Further spots appear around the original one, and then elsewhere on the body.
In a second stage of the disease, the plaques become extensive, thicken, enlarge and merge
together, and pigment is lost or gained to change the skin colour.
It is diagnosed by a biopsy of affected skin and blood tests for syphilis, which is caused by
similar bacteria, are positive. Treatment involves the use of antibiotics such as penicillin or
tetracycline. There is a very good response to treatment, but pigment changes in second
stage disease are permanent.
See also SYPHILIS; YAWS
PITTED KERATOLYSIS
Pitted keratolysis is a bacterial
infection of the thick skin on the
sole that is more common in young
males, and those who wear tight
shoes. It is caused by the bacteria
Micrococcus
sedentarius
or
Corynebacterium due to excessive
sweating from the soles, and is
aggravated by hot weather and
synthetic shoes. A secondary
fungal infection may develop, and
rarely, the palm sides of the fingers
may also be affected.
The skin on the forefeet and/or
heels becomes covered with
87
hundreds or thousands of tiny pits, which may be smelly and slightly itchy. The affected area
of the sole looks dark red to brown. Skin scrapings can be cultured in a laboratory to identify
the responsible bacteria.
Treatment involves the use of antibiotic creams (eg. fusidic acid) and tablets (eg.
erythromycin). The feet must be kept dry by wearing double socks (ideally cotton inside wool),
and antiseptic soaps should be used twice a day.
The condition usually settles well if treatment program followed carefully, but recurs
frequently.
See also ATHLETEʼS FOOT
PITYRIASIS
Pityriasis is a term used in skin diseases to indicate the presence of a fine scale
resembling natural bran flakes.
See also PITYRIASIS ALBA; PITYRIASIS LICHENOIDES; PITYRIASIS ROSEA;
PITYRIASIS VERSICOLOR
PITYRIASIS ALBA
Pityriasis alba is a common skin condition of children and teenagers. Several round or oval,
scaly, pale pink patches occur on the skin, and there is usually no irritation or itchiness. The
patches are more apparent on tanned skin, as the condition prevents tanning. It settles
spontaneously without treatment after a few months, although moisturising creams may
remove scale, and mild steroid creams reduce redness.
See also PITYRIASIS VERSICOLOR
PITYRIASIS LICHENOIDES
Pityriasis lichenoides, or guttate parapsoriasis,
is an uncommon skin rash that is more common
in males and usually affects teenagers and
young adults. A mild form is known as pityriasis
lichenoides chronica, while the more severe
rapidly developing form is pityriasis lichenoides
et varioliformis acuta (PLEVA). The cause is
unknown, but it may be a reaction to a bacteria or
virus in the skin, although it is not contagious.
Small, firm, raised, non-irritating, red to brown
spots develop on sun-protected areas such as
the trunk, thighs and inside the upper arms. A
fine scale covers the spots that are 2 to 15 mm.
across, and slowly flatten out over several weeks
to leave a brown mark, which disappears after
several months. PLEVA may be accompanied by
a headache and fever. A biopsy of a spot
confirms the diagnosis.
Treatment is usually not necessary, but in severe cases steroid creams, sun exposure and
antibiotics (erythromycin or tetracycline) may help. Severe cases of PLEVA are treated with
methotrexate or oral steroids. The condition always settles without treatment eventually, but
this may take many months or years.
88
See also PARAPSORIASIS EN PLAQUE; PITYRIASIS; PSORIASIS
PITYRIASIS ROSEA
Pityriasis rosea is a skin disease of no known cause that occurs in older children and
adults up to middle age. Dark red, scaling, slightly raised, oval-shaped patches appear on the
chest, upper arms, thighs, neck, abdomen and back. Usually a large patch (“herald patch”)
precedes other smaller patches by a week or two. There is only very slight itching or irritation,
and minimal discomfort, and the forearms, lower legs and face are not usually affected.
Antihistamine tablets may be taken at night for itching, and steroid creams can be applied,
but the condition settles without treatment in six to eight weeks.
See also PITYRIASIS
PITYRIASIS VERSICOLOR
Pityriasis versicolor (tinea versicolor) is a relatively common skin disease caused by the
fungus Mallassezia furfur (previously called Pityrosporum oviculare) that occurs in the tropics.
It is more common in young adults than the elderly and children, and the chest, upper arms,
neck, upper back and armpits are the most commonly affected areas.
Pink/brown patches develop on the skin, which may have a very faint scale upon them.
After a few weeks, the skin underlying the rash has less pigment, so the rash appears as
white patches, which are due to sunlight being unable to tan the skin underlying the fungus.
Areas not exposed to sunlight (eg. armpits, breasts) may retain the pink/brown patch
appearance. This effect does not occur on Aborigines, Chinese, Negroes and other darkskinned races. There are no other symptoms other than an occasional very mild itch.
89
The diagnosis can be proved by examining skin scrapings under a microscope, and then it
is treated by regular use of antifungal lotions, rinses or creams. An antifungal tablet
(ketoconazole) is used in persistent and widespread cases. The white patches will remain for
some time after the fungus has been destroyed, until the sun tans the area again.
Episodes of infection are quite easy to clear, but they often recur in the next summer.
See also DERMATOMYCOSIS
PLANE WARTS
Plane or flat warts are mildly disfiguring growths on the face caused by a human papilloma
virus (HPV) infection of the skin. Small (1 to 5 mm.), round or oval, smooth, flat topped,
slightly elevated, skin coloured or grey/cream raised areas of skin occur. They tend to follow
the line of a scratch or graze and may become red, swollen and itchy. Tretinoin cream or
other irritants can be applied to warts, but they disappear spontaneously in one to six months,
although they do resolve faster with treatment.
See also PLANTAR WART; WART
PLANTAR WART
A plantar wart is known as a verruca in
England. It is a type of wart that grows on
the soles of the feet, and they tend to grow
inwards rather than out. The cause is a very
slow
developing
virus
(human
papillomavirus) that attacks softened skin. A
hard, slightly raised, scar like growth forms
on the sole of the foot, and becomes painful
with walking. Verrucae are like icebergs,
with only a small part showing on the
surface and a much larger area affected
deeper in the sole. They may become so
large, widespread and painful that walking
is very difficult.
There are numerous treatments available
including
diathermy
(burning),
acid
ointments, freezing, cutting out, or injecting
under the wart. After surgery, a far larger hole than expected is usually left in the sole that
may take some weeks to heal. Unfortunately. Recurrence is common despite the best
treatment.
See also WART
PLICA POLONICA
Pica Polonica (Polish plait) is an extreme disease of the hair and scalp in which long hair
becomes so dirty and matted that is sticks together in a solid concrete-like mass and
becomes infested with lice and other insects. The scalp becomes inflamed and sore. Rare in
the 21st. century, it was not uncommon in Medieval times when long hair and not washing
hair were common. King Christian IV of Denmark (who died in 1648) suffered from the
condition. Total removal of all head hair is the only treatment, but normal hair will regrow on
the shaved scalp.
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POIKILODERMA ATROPHICANS VASCULARE
Poikiloderma atrophicus vasculare is a rare
skin condition with varied patches of excess or
reduced pigmentation, skin thinning and
bleeding into the skin (telangiectasia). It may
be localised or widespread, and once present it
is usually permanent.
POIKILODERMA OF CIVATTE
The poikiloderma of Civatte is a common
weathering effect on the skin at the sides and
front of the neck, that spares the shaded area
under the chin. The exact cause unknown, but
contributing factors include fair skin, long term
sun exposure, cosmetics, perfumes and
hormonal changes. The affected skin is thin, red-brown with prominent hair follicles and
dilated small blood vessels (telangiectasia).
Treatment is difficult and involves sun protection with hats and sunscreen, avoiding
perfumes and soaps on affected area, preparations to help fade the pigmentation, lotions
containing tretinoin and laser treatment to reduce the telangiectasia
POLYARTERITIS NODOSA
Polyarteritis nodosa (PAN or periarteritis nodosa) is an inflammation of small to mediumsized arteries.
The damaged artery may become weakened and balloon out to several times its normal
diameter, it may scar and shrink down, or the blood passing through the inflamed section of
artery may clot and completely block the artery (a thrombosis). The arteries affected may be
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anywhere in the body, but the gut, liver, heart, testes, kidney, and muscles are most
commonly involved.
The cause is unknown, but it is more common in drug abusers and in patients with hepatitis
B. Rarely it may be a side effect of medication. Men are three times more likely to develop the
disease than women, and it is most common in young adults.
The symptoms are very varied, depending on which arteries and organs are involved. The
patient is usually feverish, and has pain in the area involved. Specific complaints may include
muscle pain, palpitations, arthritis, skin ulcers, spots in the vision, abdominal pain, nausea,
vomiting, diarrhoea and high blood pressure.
There are no diagnostic blood tests, and the diagnosis must be confirmed by a biopsy
(sample) taken from an involved artery. Taking steroids (eg. prednisone) in high doses for a
long period of time is the main treatment, and immunosuppressive drugs may also be used.
The prognosis varies markedly from one patient to another, depending upon the areas and
arteries involved. Some patients do recover, but the majority slowly deteriorate to die within a
few months or years.
POLYMORPHIC LIGHT ERUPTION
See PHOTODERMATITIS
POLYMORPHOUS ERUPTION OF PREGNANCY
See PUPPP
POLYMORPHOUS LIGHT ERUPTION
Some people develop a varied form of rash called a polymorphous light eruption a day or
two after exposure to sunlight. The rash may take the form of blisters or papules (small lumps)
and is usually itchy. The rash usually settles after a week or two.
POROKERATOSIS
See DISSEMINATED SUPERFICIAL ACTINIC POROKERATOSIS
PORPHYRIA CUTANEA TARDA
Porphyria cutanea tarda (latent hepatic porphyria) is the most common form of porphyria,
which are a group of liver diseases. It is usually inherited, but may be triggered by some
poisons (eg. dioxin), and occurs in all races but is more common amongst the Bantu tribes of
Africa.
Patients have skin that is very sensitive to sunlight, with skin thickening and pigmentation
occurring in sun exposed areas such as the face and forearms. The urine has a strange
characteristic in that it turns a dark purple colour, then brown, if left standing. Liver damage
may occur, and may progress to liver failure or liver cancer (hepatoma). It occurs in varying
degrees of severity from so mild that it is undetected to a rapidly fatal form.
It is diagnosed by special blood tests, and treatment involves careful genetic counselling of
families and the use of a complex drug regime. It may be controlled, but not cured, and is
rarely fatal.
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PORTWINE NAEVUS
A portwine or mature capillary naevus is a
congenital, disfiguring skin condition due to
overdilated blood vessels. Patients have a flat
or slightly raised, pale pink to red or dark purple
stain on the skin, usually on the face or upper
chest, and on only one side of the body. Plastic
surgery is sometimes possible to remove the
naevus, depending on its site, otherwise these
harmless marks persist life long.
See also NAEVUS
PRESSURE ULCER
See BED SORE; TROPHIC ULCER
PRICKLY HEAT
See MILIARIA
PRIMARY NEUROENDROCRINE CARCINOMA OF THE SKIN
See MERKEL CARCINOMA
PROUD FLESH
Proud flesh is an overgrowth of granulation tissue on the skin to form a red lump at the site
of a healing wound. It tends to occur when there is excessive irritation, inflammation or
infection of the wound, and may consolidate into a keloid scar.
See also KELOID
PRURIGO
Prurigo (lichen urticarius) is a very itchy skin reaction that is more common in middle-aged
women and poorly cared for children. It usually occurs on the back of the arms, front of the
legs, buttocks, face and neck. The cause is an allergy reaction, possibly to food, insect bites
or medications.
Patients develop multiple, pink, dome shaped, intensely itchy lumps (papules) topped with
a tiny blister (vescicle). The vescicle is soon scratched off and replaced by a brown crust.
Antihistamine tablets and creams containing a steroid are used in treatment. The attacks
eventually settle spontaneously, sometimes taking only a few days, or may they persist for
months.
PRURIGO NODULARIS
Prurigo nodularis is an intensely irritating and persistent
rash that may be due to excessive scratching of another itchy
rash (eg. scabies). It is more common in middle age females
and those with coeliac disease (a sensitivity to gluten - wheat
starch).
Hard, scale covered, extremely itchy nodules (small
lumps) develop in the skin. They may vary in diameter from 5
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to 20 mm. and may occur almost anywhere, but the outside of the arms, front of the thighs,
upper back, chest and belly are the most common areas affected. The surrounding skin may
be damaged by scratching. A biopsy can confirm the diagnosis.
Treatment involves powerful steroid creams or cryotherapy (freezing with liquid nitrogen). A
gluten free diet is given if this is shown to be the cause. Most cases settle with appropriate
treatment, but a small number persist long term.
PRURITIC URTICATED PAPULES AND PLAQUES OF PREGNANCY
See PUPPP
PSEUDOFOLLICULITIS BARBAE
See RAZOR RASH
PSEUDOXANTHOMA ELASTICUM
Pseudoxanthoma
elasticum
(GrönbladStrandberg syndrome) is a rare inherited
condition (one in 100,000) disorder of elastic
tissue involving the skin, eyes and blood vessels,
that starts in young adults.
The symptoms are yellowish small lumps or
slightly raised patches on skin (particularly the
neck, armpits, groin and belly) that are arranged
along skin lines. Affected skin hangs loosely in
folds, yellowish small lumps form inside the
mouth and vagina, and decreasing vision leading
to blindness from macular degeneration.
Additionally there are often poor pulses, high
blood pressure and heart valve damage
(particularly the mitral valve). Complications
include severe internal bleeding, strokes and
heart attacks from damaged arteries and high
blood pressure. It is diagnosed by a skin biopsy
and x-rays show calcium deposits in arteries.
Treatment is unsatisfactory. Cosmetic surgery may help skin problems, and lasers may
slow degeneration of the retina in the eye, but there is no cure. Premature death due to
complications is usual.
PSORIASIS
Psoriasis vulgaris (to use the full name) is an annoying, distressing, persistent and difficult
to treat skin disease that affects 2% of the population. It is an autoimmune disease in which
the bodyʼs immune system is inappropriately triggered to reject tissue as though it was a
foreign material. In psoriasis, varying parts of the skin are rejected. It is unusual in children but
becomes more common as age increases.
The rash appears as a small patch of red skin covered with fine scales that gradually
enlarges, roughens and thickens the skin, and other spots may start over a period of months.
The elbows, knees and scalp are the most common sites, while on the scalp it may appear to
be a bad case of dandruff. The nails may also be affected, and become rough and pitted.
94
The severity of psoriasis is assessed using three criteria - the area affected, the degree of
inflammation and scale present and the impact the disease has on a personʼs lifestyle.
The Koebner phenomenon occurs when psoriasis develops on areas of skin that have
been injured, and may appear as a line of inflamed skin along a healed cut or surgical
incision, or a patch at the site of a previous graze.
In severe cases the joints may be attacked to cause a type of arthritis.
Psoriasis has many subtypes, and it is often necessary to perform a biopsy to confirm the
exact diagnosis.
Treatment involves one or more of a number of keratolytic creams or ointments that are
used regularly on the skin. Coal tar is the mainstay of treatment, but calcipotriol and steroid
creams are also very effective. Other skin preparations include dithranol, salicylic acid,
psoralen and tacalcitol. Ultraviolet light may be used in conjunction with psoralen to promote
healing. In very severe cases, steroid tablets or injections, or acitretin tablets, may be given.
In the first few years of this millennium new biological treatments using monoclonal antibodies
(eg. efalizumab) and other natural proteins (eg. alefacept, etanercept) became available. On
the other hand the rash may come and go without any treatment.
There is no cure for psoriasis, but it can usually be successfully controlled.
See also DERMATITIS; GENERALISED ACUTE PUSTULAR PSORIASIS; GUTTATE
PSORIASIS; PARAPSORIASIS EN PLAQUE; PITYRIASIS LICHENOIDES;
PUPPP
For fairly obvious reasons, the skin condition known as pruritic urticated papules and
plaques of pregnancy or the polymorphous eruption of pregnancy is normally known by its
acronym, PUPPP. It is a skin condition that develops in the last three months of pregnancy
and is more commonly in a first pregnancy. It is a reaction within the stretch marks on the
abdomen as a result of the damage within the skin. it is also more common in women who put
on an excessive amount of weight during pregnancy.
Small, very itchy, pink bumps develop in the stretch marks on the abdomen, buttocks and
thighs. There may be a pale halo around the bump and several bumps may merge into a
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raised patch. Steroid creams, moisturisers
and antihistamine tablets control the itch but
do not cure the rash. PUPPP does not
cause any problems in the baby and always
clears shortly after delivery of the baby.
PURPURA
Purpura are small red or dark blue marks
made in the skin by abnormal bleeding from
capillaries. The most common cause is a
low level of platelets in the blood
(thrombocytopenia).
PUSTULAR ACUTE GENERALISED
PSORIASIS
See GENERALISED ACUTE PUSTULAR
PSORIASIS
PYODERMA FACIALE
Pyoderma faciale is a rare skin condition involving the face of young women. Men are not
affected. The cause is unknown, but it is not an infection and is not contagious.
There is a sudden onset of large, painful, ugly, red lumps and sores on facial skin that also
becomes red. The skin immediately around the eyes is not involved. There are no diagnostic
tests, and all skin swabs are negative. Treatment involves the long-term use of isotretinoin
and steroid tablets, but after healing the lumps may leave long lasting scars. Although there is
a poor response to treatment the condition rarely persists for more than a year.
PYODERMA GANGRENOSUM
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Pyoderma gangrenosum is an uncommon cause of skin ulceration that usually affects the
lower legs. It may be an autoimmune disorder, in which the body inappropriately rejects its
own tissue. It occurs more frequently in patients with rheumatoid arthritis, colitis, Crohnʼs
disease and other autoimmune conditions.
The condition starts as a small pustule or blood blister at the site of a minor injury, then
rapidly breaks down into a painful ulcer with an undermined edge that deepens and widens
quite quickly. Several ulcers may develop simultaneously. Bacterial or fungal infection of the
ulcer can be a complication. It may be diagnosed by biopsy, and swabs may be taken to
identify any bacteria or fungi that have infected the ulcer.
Treatment involves the use of steroid creams around the ulcer edges, and steroid injections
under and around the ulcer. Antibiotic or antifungal tablets or creams are used for any
secondary infection. Special healing gels may be applied under a dressing. Rarely, oral
steroids or methotrexate tablets are prescribed. The ulcers heal very slowly over many
months with intensive treatment and almost invariably leave a significant scar.
RAZOR RASH
Doctors seem to insist that even the simplest medical conditions have technical names,
and in the case of razor rash it is pseudofolliculitis barbae. This is a skin irritation of face and
neck caused by minor damage to facial hair follicles from the scraping of a razor, and the
ingrowing of hairs. It occurs more commonly in people who have curly hair.
An ugly, raised, red, itchy rash develops on the neck and face. Initially, affected men
should let the beard grow for a month to eliminate ingrown hairs, then use a polyester skincleansing pad twice a day or a moisturising shaving foam, a single blade razor, or shave
frequently and as lightly as possible with an electric razor. They should not stretch the skin
when shaving. Astringents and alcohol rubs may harden the skin to prevent the problem, and
a mild steroid cream will settle the rash when it flares. As a last resort, they can grow a beard!
RENDU-OSLER-WEBER SYNDROME
The Rendu-Osler-Weber syndrome is abnormal overgrowth of small blood vessels
throughout the body. It is an inherited condition and passes from one generation to the next in
families. Patients develop polyp-like outgrowths of dilated small blood vessels on the skin,
tongue and throughout the gastrointestinal tract,
that bleed easily to cause severe anaemia. Large
connections that develop between arteries and
veins may short circuit the blood supply to an
organ or tissue and place strain on the heart. A
biopsy of a skin or intestinal polyp is diagnostic,
and blood is often found in the faeces. Treatment
involves surgical removal of as many bleeding
points as possible, iron supplements and blood
transfusion, but there is no cure.
RHINOPHYMA
Rhinophyma is a severe form of rosacea
affecting the nose that usually occurs in men.
There is an increase in size of the nose due to a
dramatic enlargement of the oil glands in the skin
97
and excessive deposition of fat and other tissue under the skin. In advanced cases it
becomes very disfiguring and gives the appearance of a large growth on the nose.
A skin biopsy is sometimes necessary to confirm diagnosis, then plastic surgery can be
performed to remove the excess tissue. Patients obtain reasonable results from surgery.
See also ROSACEA
RICKETSIALPOX
Rickettsialpox is an uncommon mild infection caused by the primitive bacteria Rickettsia
akar that has widespread effects. It passes from mice to humans through a mite bite in over
crowded unhygienic conditions. The incubation period is seven to twelve days.
The symptoms are a sudden onset of fever, chills, a single red lump on the skin at the site
of the mite bite, headache and widespread muscular and joint pains. Two to four days later
swelling of skin occurs with chickenpox-like blisters on the affected skin. It can be diagnosed
by specific blood tests, and treated by tetracycline antibiotic tablets. Complete recovery is
normal.
ROCKY MOUNTAIN SPOTTED FEVER
Rocky Mountain spotted fever is a serious widespread infection that occurs throughout the
Americas, but most commonly in the western United States. It is caused by the primitive
bacteria Rickettsia rickettsii, which is transmitted from numerous small wild mammals and
dogs to man by a tick bite. The infection has an incubation period of three to twelve days.
The symptoms include a sudden onset of severe headache, shaking, very high fever,
muscle pains, nausea, restlessness, delirium and collapse. The belly muscles may become
very sore and pain occurs in numerous joints. A faint pink large spotted rash appears on the
arms and legs about four days after other symptoms. The rash steadily darkens to a deep
red, tends to be more severe over bony prominences (eg. sides of ankles), and bleeding may
occur into the spots which may then degenerate into ulcers. A rapid pulse and low blood
pressure develop when the heart becomes affected. Complications may include pneumonia,
ear and salivary gland infections, dehydration, an enlarged spleen, and blood clots
(thrombosis) in limbs, which may lead to gangrene. Permanent effects rarely occur after
recovery, but may include permanent paralysis and epilepsy.
The infection may be diagnosed by specific blood tests and treated with potent antibiotics
(eg. chloramphenicol, tetracycline) by a drip into a vein. Up to 20% of patients die, even with
good medical care, but the mortality rate is higher in the elderly.
RODENT ULCER
See BASAL CELL CARCINOMA
ROSACEA
Acne rosacea is a skin disease of the face, of no known cause, found most commonly in
middle-aged women. Patients develop intermittent flushing of the face that becomes a
permanent redness of the facial skin. After a few days or weeks, sores similar to a severe
case of acne develop. In advanced cases, the surface of the eyes may be involved in a form
of conjunctivitis.
Treatment involves antibiotic tablets (eg. tetracycline, erythromycin) and/or metronidazole
gel applied to the affected skin. Both must be continued for two or three months. Relapses are
98
common for years afterwards, but if medication is used immediately, it suppresses each
attack effectively, and eventual a cure can be expected with good treatment.
See also RHINOPHYMA
ROSEA
See PITYRIASIS ROSEA
ROSEOLA INFANTUM
Roseola infantum (baby measles, sixth
disease or exanthema subitum) is a
contagious viral infection that is caught by
virtually every child in the first two or three
years of life. It has an incubation period
from 7 to 17 days, and most children will
have such a mild attack that it will be
passed off as a slight cold. Those with a
severe attack will develop a fever and a
measles-like rash on the trunk and neck,
which usually appears after the fever has
gone.
No treatment is necessary other than
paracetamol for the fever, and the child recovers completely within two or three days.
See also GERMAN MEASLES; MEASLES
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ROSE SPOTS
Rose spots are small red patches on the skin of the lower chest and upper abdomen that
may occur in the early stages of typhoid fever. They fade after a few days while the infection
may worsen.
See also TYPHOID FEVER
ROTHMUND-THOMSON SYNDROME
The Rothmund-Thomson syndrome (congenital poikiloderma) is a congenital abnormality
of skin development. The skin is thin, red and pigmented, with red dots caused by dilated
small blood vessels (telangiectasia) just under the skin. Patients are short, have under
developed genitals, and the skin is very sensitive to sunburn. There may be scarring of the
skin from sunburn and serious bleeding may occur from the telangiectasia. It is diagnosed by
a skin biopsy, but there is no treatment or cure available.
See also OSLU-RENDU-WEBER DISEASE; TELANGIECTASIA
SARCOPTES SCABIEI
See SCABIES
SCABIES
Scabies is an infestation (not an infection) by a tiny insect that burrows for 1 cm. or more
through the outer layers of the skin. Most common areas affected are the fingers, palms,
heels, groin and wrists, but it can spread across the entire body, although it is unusual for the
head and neck to be involved. The scabies mite, Sarcoptes scabiei, is just visible to the naked
eye, appearing like a spot of dust on a piece of black paper, but it cannot be seen on the skin.
It spreads by close contact (eg. shaking hands) with someone who already has the disease,
and can occur despite scrupulous personal cleanliness. In many third-world countries, the
disease is in epidemic proportions, but it is relatively uncommon in developed countries.
The main symptom is incessant itching caused by the burrowing mite, as the tissue around
them becomes red, itchy and inflamed. Scratching often damages the skin, making diagnose
difficult, and allowing a secondary bacterial infection to enter the skin. Norwegian scabies is a
100
very severe form of infestation that causes thickening and scaling of the skin (particularly the
palms and soles) from huge numbers of mites.
The diagnosis can be confirmed when a skin scraping is examined under a microscope
and the mites and their eggs can be seen.
Treatment involves covering the entire body with a lotion or cream (eg. benzyl benzoate,
malathion, permethrin, crotamiton) that kills the mites. All other members of the family, and
anyone else closely connected with the patient, should be treated at the same time. It is
advisable to change all the bed linen, and to repeat the treatment after a week, so that any
mites that hatch from the remaining eggs after the initial treatment will be killed. The itch may
continue for 10-20 days after treatment due to an allergy to the scabies bodies or their
products (eggs, droppings, etc.).
There is a good response to treatment, but recurrences are common. Children may return
to school a day after appropriate treatment has been given.
SCALDED SKIN SYNDROME
The scalded skin syndrome is a severe superficial bacterial skin infection known as Ritter
disease or dermatitis exfoliativa neonatorum in newborn infants, and toxic epidermal
necrolysis in older children. Milder forms are known as pemphigus neonatorum or bullous
impetigo. Scalded skin syndrome and Lyell syndrome are terms that cover all forms.
It is caused by the bacterium Staphylococcus
aureus (golden Staph) that spreads from nose, eyes,
mouth or umbilicus to areas of skin damaged by
eczema or injury. It may be a complication of the
Stevens-Johnson syndrome.
The infant or child has severe peeling of skin that
commences on the face and genitals and spreads
across body. The skin appears similar to very severe
sunburn. Death from fluid loss through damaged skin
or internal spread of infection is possible.
A culture of swabs from the nose, eyes, throat and
umbilicus will confirm responsible bacteria and the
appropriate antibiotic (eg. penicillin or erythromycin).
The infection responds slowly to antibiotics, but most
children recover.
See also IMPETIGO; STEVENS-JOHNSON SYNDROME
SCALP FOLLICULITIS
Folliculitis of the scalp is technically called acne necrotica miliaris. It is an inflammation of
the hair follicles in the scalp caused by a bacterial infection.
Multiple, small, very itchy, pus filled lumps form on the scalp, particularly on the hairline
above the forehead. They often become sore and crust covered due to scratching. Swabs
may be taken to identify the responsible bacteria, and blood tests may be performed to
exclude any underlying disease that makes the patient more susceptible to infection (eg.
diabetes).
Treatment involves washing the hair regularly with antidandruff shampoo, and applying
antibiotic and steroid lotions or gels to the scalp. Antibiotic tablets (eg. tetracyclines) may be
101
prescribed to settle flare ups, or may be taken long term to keep the condition under control.
Antihistamine tablets may ease the itching.
The problem often flares when treatment is ceased, but eventually settles permanently.
See also FOLLICULITIS
SCC
See SQUAMOUS CELL CARCINOMA OF THE SKIN
SCHAMBERG DISEASE
See CAPILLARITIS
SCHISTOSOMIASIS
Schistosomiasis (bilharzia) is a fluke infestation transmitted by a species of snail that is
found in fresh water streams, rivers and lakes in Egypt, tropical Africa as far south as
Zimbabwe, the Caribbean and eastern South America. It is often caught by bathing or
washing in fresh water.
The cause is a microscopic animal (trematode fluke) that enters the body by burrowing
through the skin, often of the foot. Three different flukes - Schistosoma mansoni, Schistosoma
japonicum, and Schistosoma mekongi - may be responsible. Once in the blood it travels to
the veins around the large intestine, where eggs are laid. These pass out with the faeces or
urine to infect water supplies. Once in fresh water, the eggs hatch, and the larvae seek out
and burrow into the flesh of specific species of fresh water snail. They mature in the snail, and
emerge from it ready to enter and infect another human. Patients do not pass out all the eggs
that are laid by the fluke, and they may spread to the liver, lungs or spinal cord to cause
further symptoms. Damage caused to organs by the fluke may be permanent.
The first symptom is an itchy patch at the site of skin penetration. Varying symptoms then
follow, depending on the areas affected by the fluke as it moves through the body, and the
individual's reaction to those changes. Long-term symptoms include diarrhoea, abdominal
pain and bloody urine. A particularly severe and rapidly progressive form of the disease is
known as Katayama Fever.
The diagnosis involves blood, urine and skin tests, and liver and gut biopsies.
102
Treatment is difficult, particularly late in the disease, although a number of drugs (eg.
praziquantel) can be used to kill the fluke inside the body. Untreated it may cause a low-grade
chronic illness, or may progress to death in a matter of months. The results of treatment are
good if commenced early in the course of the disease, but advanced disease may be
incurable.
See also CERCARIAL DERMATITIS
SCHÖNLEIN-HENOCH SYNDROME
See HENOCH-SCHÖNLEIN SYNDROME
SCHOOL SORES
See IMPETIGO
SCLERODERMA
Scleroderma (progressive systemic sclerosis) is an inflammatory condition most commonly
affecting the skin and gut, then the oesophagus (gullet), lungs, heart and other internal
organs. It is an autoimmune disease, in which the body inappropriately rejects its own tissue,
and usually starts between 30 and 50 years of age, with women being more commonly
affected.
Symptoms vary widely but include thickening of the skin, arthritis that moves between
joints, patchy changes in skin colouration,
poor circulation to the hands, difficulty in
swallowing, lung infections, fevers and
diarrhoea. Damage to vital organs such as
the heart may occur.
Blood tests show abnormalities but are
not diagnostic, and a biopsy (sample) of
skin or other affected tissue must be taken
to confirm the diagnosis.
Medications can relieve the symptoms,
but there is no cure, and the disease is
slowly progressive over many years. Men
and the elderly deteriorate more rapidly.
See also MORPHEA
SCRUB TYPHUS
Scrub typhus (tsutsugamushi disease) is an infection caused by the bacteria Rickettsia
tsutsugamushi (also known as Orientia tsutsugamushi). It is transmitted from rats and other
rodents to man by the bite of a mite and causes a black spot and lump at the site of the mite
bite, a fever, severe headache, tender lymph nodes, eye pain, widespread rash and muscle
pain. In severe cases the heart and brain may be infected and cause death. A specific
antibody can be identified in the blood to confirm the diagnosis.
Treatment with antibiotics such as doxycycline and azithromycin is usually effective.
The condition is found in the western Pacific, northern Australia and southern Asia.
See also TYPHUS
SEABATHERʼS ERUPTION
103
Seabatherʼs eruption is a skin reaction that occurs under the clothing of swimmers in the
Caribbean Sea and along the Atlantic coast of the United States. It is caused by exposure of
skin to the larvae of jellyfish or sea anemone.
Victims develop an itchy, red rash consisting of very small lumps on the buttocks, breast
and groin. Slight stinging is felt initially while swimming but the skin reaction starts three to 24
hours later. Patients may develop a crust on top of the small lumps, while sensitive individuals
may develop a significant allergy reaction and urticaria (hives).
Steroid creams and antihistamine tablets ease itch, but it settles with or without treatment
after one or two weeks.
See also URTICARIA
SEBACEOUS CYST
A sebaceous cyst (epidermal cyst or
pilar cyst) is full of sebum (the oil that
keeps the skin moist and supple), which is
produced in sebaceous glands beneath
the skin all over the body, and is
discharged through small ducts. In areas
that become sweaty, dirty or injured it is
possible to block the duct draining the
sebaceous gland. The sebum continues to
be produced, and a cyst slowly forms
under the skin.
Cysts usually appear on the back, chest and neck, are slightly soft and often have a tiny
dimple at the point where the original duct opened onto the skin. Sometimes pressure in the
cyst is sufficient for its contents to be discharged through the previously blocked duct, but the
cyst usually reforms. Cysts may become infected, and if antibiotics are not given soon
enough, an abscess may form.
Any cyst that is unsightly may be cut out, while infected cysts are treated with antibiotic
tablets.
SEBACEOUS HYPERPLASIA
Sebaceous hyperplasia is a harmless skin condition of the face that occurs in the elderly
due to enlarged sebaceous (oil) glands in the skin. Small yellow lumps develop on the
forehead and cheeks, often with a central hair. They may become infected if scratched. No
treatment is n necessary unless the bumps are unsightly when they can be removed by
excision, diathermy or laser. Severe widespread spots may be helped by isotretinoin tablets,
but the condition persists long term.
SEBORRHOEA
Seborrhoea is the medical term for oily skin due to overactivity of the oil producing
sebaceous glands in the skin. It is a congenital (present from birth) condition. There is often a
family tendency, and rarely it may be due to some underlying disease (eg. acromegaly). Any
possible underlying cause may be excluded by blood tests.
Patients have excessively oily skin that appears shiny, becomes dirty quickly and feels
slippery. The face is more affected than other areas. These people also have an increased
incidence of dermatitis, acne and skin infections.
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Treatment involves washing regularly with soap and water, applying retinoid lotions and in
women taking antiandrogen (hormone) tablets. In severe cases, isotretinoin tablets may be
prescribed. The problem slowly eases with increasing age.
SEBORRHOEIC ECZEMA
Seborrhoeic eczema or dermatitis is a widespread, common form of eczema that can occur
at any age.
It is caused by inflammation of the oil producing sebaceous glands in the skin, but the
cause of the inflammation is unknown.
In infants, seborrhoeic eczema frequently affects the scalp to cause cradle cap or the
buttocks to cause nappy eczema. Other frequently affected areas are the cheeks, neck,
armpits, groin and folds behind the knees and elbows and under the breasts. In adults, it is
responsible for some forms of dandruff. On the scalp, it appears as a red, scaly, greasy rash.
In skin folds, the skin is red, moist and breaks down into tiny ulcers. On exposed areas such
as the face, the rash is red, scaling and may contain tiny blisters.
The scalp is treated with a lotion or cream to remove the oil and scale, and regular
shampooing. Tar solutions are applied in resistant cases. In other areas, mild steroid lotions
or creams are used. Soap should be avoided and substitutes used.
A complication may be the development of a secondary fungal infection.
Seborrhoeic eczema tends to be chronic and recurrent. Children often grow out of it in the
early teens, but in adults it may persist intermittently for years.
See also ACNE NEONATORUM; DANDRUFF; ECZEMA
SEBORRHOEIC KERATOSES
Seborrhoeic keratoses (basal cell papillomas or senile warts) are very common harmless
skin growths that increase in number with age and may occur anywhere on the body, but
particularly on the trunk. There is an inherited tendency to develop them, and they are more
common in patients who have had any form of dermatitis.
These keratoses appear as raised, light brown, greasy surfaced spots that slowly enlarge
and thicken to the point where they appear to be stuck onto the skin. The surface eventually
105
becomes rough and cracked, and the colour darkens. If damaged, they bleed easily, and they
persist long term.
They may be removed by diathermy, laser or shaving off the skin under a local anaesthetic.
Smaller ones may be removed by freezing with liquid nitrogen, but they are harmless and only
removed if unsightly or irritating as a significant scar may be left after removal.
See also HYPERKERATOSIS
SENILE HAEMANGIOMAS
See CAMPBELL de MORGAN SPOTS
SENILE WARTS
See SEBORRHOEIC KERATOSES
SERUM SICKNESS
Serum sickness is an uncommon reaction to a blood or serum (liquid part of blood without
the cells) transfusion, or use of a blood product (eg. globulin or proteins). Uncommonly it may
be caused by the use of a drug. The reaction may be immediate, or delayed for up to two
weeks after a transfusion.
The patient feels unwell, tired, nauseated and feverish; lymph nodes in the neck, armpit
and groin become enlarged, an itchy rash develops, cramps occur in the belly, and joints may
become painful.
No tests are diagnostic, but blood tests show generalised abnormalities characteristic of an
allergy.
Antihistamines are given to counteract the allergy reaction, and steroids or adrenaline are
prescribed to treat the results of the reaction. The reaction can vary widely in severity from
being so mild that it passes almost unnoticed, to a very severe condition that can lead to
death in a few hours.
SÉZARY SYNDROME
Sézary syndrome is a form of cancer that is a variant of mycosis fungoides and starts in
middle age.
Patients develop persistently itchy patches of thick red skin, overlying hair loss on affected
skin, and enlarged lymph nodes in neck, groin, armpits and elsewhere. It may spread to other
areas of the body, and the nails may be damaged. Eventually the syndrome progresses to
leukaemia or a type of sarcoma.
Skin and lymph node biopsy are diagnostic, and a blood test reveals abnormal white blood
cells.
Low-grade irradiation of skin, and cytotoxic drugs (chemotherapy) are the main treatments,
but despite these the condition is usually very slowly progressive.
See also MYCOSIS FUNGOIDES
SHAVING RASH
See RAZOR RASH
SHINGLES
Shingles (varicella) is an infection of nerves and skin by the Herpes zoster virus, which is
the same virus that causes chickenpox, and is usually caught as a child. The virus never
106
leaves the body, but migrates to the roots of nerves along the spinal cord, where it remains
inactive lifelong. At times of stress, the virus may reactivate and move along the nerve to
cause the skin and other tissues to become very painful. Shingles is far more common in
older people, and uncommon in children. You cannot catch shingles from another person, but
a child who has not had chickenpox may catch this from a person who has active shingles.
An acutely tender blistering rash develops, often in a belt-like line on one side of the body,
and even the slightest touch causes severe shooting pain. Any nerve may be affected, and it
can occur on the abdomen or chest (most common sites), or on the face or legs. Occasionally
the rash leaves permanent scars, particularly on the face. A small number of elderly people
can develop chronic inflammation in the nerve, and pain that persists for years (post-herpetic
neuralgia). The worst complication occurs if nerves around the eye and ear are involved,
when dizziness, ear noises and rarely blindness may occur (Ramsay-Hunt syndrome).
No investigations are normally necessary, but if required the diagnosis can be confirmed by
taking special swabs from a sore.
Shingles can be cured by specific antiviral tablets, but only if treatment is started within 72
hours of the rash first appearing. If treatment is neglected until after three days from the onset
of the rash, the only treatment is painkillers, drying antiseptic lotions and mild sedatives.
Steroids may be used in severe cases.
The rash dries out slowly and disappears over several weeks, usually healing completely.
The pain is slower to disappear, and may last a month longer than the rash, but the vast
majority of patients make an excellent recovery.
See also CHICKENPOX
SIBERIAN TICK TYPHUS
See TYPHUS
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SISTER MARY JOSEPH NODULE
A Sister Mary Joseph nodule is a raised nodule in the umbilicus. It is often red and painless
and may be a sign of widespread cancer in the abdomen (eg. ovarian or stomach cancer).
The nodule is caused by spread of the cancer through the lymph channels to form an
umbilical growth.
SIXTH DISEASE
SJÖGREN-LARSSON SYNDROME
The Sjögren-Larsson syndrome is a rare inherited disease of the skin and brain, but both
parents must be carriers for the condition to occur. These patients have widespread thick dry
scaly skin and muscle spasms. There is no cure.
SKIN CANCER
The various forms of skin cancer vary from the relatively innocuous, to those that can
spread rapidly enough to eventually kill. Most are caused by sun exposure, primarily in
childhood, but some chemicals may also be responsible and there is sometimes a familial
tendency. Tropical countries with a predominantly white-skinned population have a far higher
incidence.
Skin cancers fall into several different categories - squamous cell carcinomas (SCC),
intraepithelial carcinoma (IEC), basal cell carcinomas (BCC), Bowenʼs disease and
melanomas are the most common and are dealt with separately. Signs to watch for in a spot
or sore that may indicate that it is a skin cancer are any irregularity in colour, shape or outline;
soreness or itchiness; bleeding or weeping. A biopsy can give a definitive diagnosis, but it
may be more practical to excise whole growth.
Prevention involves protecting the skin from the sun.
They may be treated by freezing with liquid nitrogen, diathermy (burning), cutting out the
growth, injecting anticancer drugs in and under it, or applying acid or anticancer ointments.
See also BASAL CELL CARCINOMA; BOWENʼS DISEASE; DERMATOHELIOSIS;
GORLIN GOLTZ SYNDROME; INTRAEPITHELIAL CARCINOMA; KAPOSI DISEASE;
MELANOMA; MERKEL CARCINOMA; MUIR-TORRE SYNDROME; SQUAMOUS CELL
CARCINOMA OF THE SKIN
SKIN TAG
A skin tag (cutaneous papilloma or fibroepithelial polyp are the technical names) is a
protuberant lump on the skin that has a narrow attachment to the body. They are more
common in women and obese people, and appear more frequently after middle age. The
108
cause is friction to the skin from skin folds (eg. in armpits, under breasts, between buttocks)
or rubbing of clothing (eg. around waist or neck).
They are a small soft, rounded lump of fat surrounded by skin and connected to the body
by a narrow stalk. They may be skin or brown in colour. Occasionally they are irritated, injured
and bleed, or become inflamed and infected.
These harmless growths persist long term but may be surgically removed, diathermied
(burnt away) or tied off at their base by a thin thread.
SLAPPED CHEEK DISEASE
See FIFTH DISEASE
SNEDDON SYNDROME
The Sneddon syndrome is a severe, rare disorder of blood vessels affecting the skin, heart
and brain. The cause is unknown. Patients develop livedo reticularis (maroon to red, net like
or starburst pattern on the skin) and severe high blood pressure (hypertension) resulting in
transient ischaemic attacks and strokes. Ulcers sometimes develop around ankles. Blood
tests are performed to exclude any other underlying disease or cause, but a biopsy of the
affected skin is diagnostic. Medication is prescribed to lower blood pressure and prevent
strokes (eg. low dose heparin or aspirin). It cannot be cured, but the response to treatment is
reasonable.
See also LIVEDO RETICULARIS
SOLAR KERATOSIS
See HYPERKERATOSIS
SOLAR URTICARIA
See PHOTODERMATITIS
SORE
See BOIL; IMPETIGO
SPARGANOSIS
Sparganosis is an infestation caused by the larvae of the fish tapeworm that enters the
body by being swallowed in contaminated water or frog flesh. It causes painful swellings
under the skin, but sometimes enters the eye, which it destroys. The only treatment is cutting
out the lump and the larva within it.
SPIDER ANGIOMA
See SPIDER NAEVI
SPIDER NAEVI
Spider naevi (spider angioma or
telangiectasia) are an over dilation of a
capillary that becomes visible on the
skin. They are commonly caused by sun
damage to the skin, but pregnancy and a
number of diseases may also be
109
responsible including liver failure, an overactive thyroid gland, alcoholism and rheumatoid
arthritis.
The dilated blood vessels usually appear on the nose and cheeks and look like tiny red
spiders. The small blood vessels can be seen diverging from a central point.
Each individual naevus can be treated by cryotherapy (freezing), laser or diathermy
(electrical heat) to the central blood vessel, which destroys it. A small white spot will remain at
the site.
These naevi may bleed excessively if damaged.
SPITZ NAEVUS
A Spitz naevus (benign juvenile melanoma) is an
uncommon skin growth that occurs on the head, neck
and sometimes other skin areas of children and young
adults.
The cause is unknown. A small (under one
centimetre), dome shaped, rapidly growing, benign,
hairless lump forms on the skin. It may be pink, brown
or black. The treatment is surgical excision, after
which the diagnosis can be confirmed by examination
of the specimen under a microscope. An inadequate
excision will result in a rapid recurrence, but otherwise
the prognosis is good and the growth is harmless.
See also NAEVUS
SPOROTRICHOSIS
Sporotrichosis is an unusual tropical and temperate climate skin infection that is more
common in gardeners, farmers and florists. The cause is contamination of a puncture wound
from a plant with the fungus Sporothrix schenckii, which is found in soil and on plants. The
fungus is also found on the spines of the armadillo.
Patients develop a pain free lump under skin that occurs several weeks after a skin injury.
The lump slowly breaks down to form an ulcer and nearby lymph nodes become enlarged.
The infection may spread through the lymphatic system to the lungs, joints, eyes and brain.
Specific tests on swabs and smears taken from ulcer can be used to confirm diagnosis.
Antifungal tablets and injections are used to treat the infection, which responds well to
treatment, but sometimes recurs when treatment ceased. There is a poor outcome if the
disease spreads to internal organs.
SQUAMOUS CELL CARCINOMA OF THE SKIN
A squamous cell carcinoma (SCC) is a cancer of the outermost layer of skin that occurs on
sun-exposed parts of the body, usually in patients who are over 50 years of age. They are
caused by prolonged exposure to sunlight or irritant chemicals. The rims of the ears, the face,
scalp, arms and hands are commonly affected, but the cancer may also occur on the penis.
SCC can also occur in the moist mucous membrane lining the nose, mouth and throat.
SCCs look like a red spot covered in fine white scales. They may be itchy or sore but often
attract attention because they are unsightly. In severe cases they can spread by blood or
lymphatics to distant parts of the body.
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If suspected, excision or biopsy is necessary to make the diagnosis. Small SCCs are easily
removed by burning with a diathermy machine or freezing with liquid nitrogen. If it is larger, or
if the diagnosis is not certain, it is necessary to excise the spot and surrounding tissue. Any
SCC that recurs after freezing or burning must be surgically excised.
Treatment IS very effective in early stages of the disease.
See also BOWENʼS DISEASE; HYPERKERATOSIS; INTRAEPITHELIAL CARCINOMA;
KERATOACANTHOMA
STAPHYLOCOCCAL SCALDED SKIN SYNDROME
STASIS DERMATITIS
If there is poor return of blood from the feet and lower legs due to damage to the valves
within the veins of the leg, the long term pooling of blood results in swelling of the ankles and
feet and pigmentation of the overlying skin from the haemoglobin and iron in the blood. The
skin also becomes thin, damaged and petechiae (blood spots) may form. Eventually the
damaged skin may break down into ulcers with minimal injury.
111
Treatment involves elevation of the legs, elastic stockings and surgical correction of any
varicose veins. Creams and ointments are ineffectual.
See also VARICOSE ECZEMA
STASIS ULCER
See VENOUS ULCER
STEATOCYSTOMA MULIPLEX
Steatocystoma multiplex is a rare skin disorder that starts at puberty and affects both
sexes. It is an inherited abnormality of the sebaceous (oil) glands in the skin. Numerous soft
cysts up to 2cm across develop on the chest and upper arms. They are full of yellow oily liquid
and may have hairs growing from them, but only rarely is the face affected. The cysts may
become inflamed and leave raised scars when they heal.
The diagnosis is confirmed by excising one of the cysts and examining it under a
microscope.
The cysts may be excised if disfiguring or irritating, and isotretinoin tablets may reduce
severity of cyst inflammation. Individual cysts eventually rupture and heal, but new cysts
develop throughout life, although the incidence reduces with age.
See also ACNE
STEVENS-JOHNSON SYNDROME
The Stevens-Johnson syndrome is a severe complication of erythema multiforme that may
be triggered by drugs or infection.
The characteristics of the syndrome include
erythema multiforme; severe purulent ulcerating
conjunctivitis; high fever; inflamed mouth
(stomatitis); blisters or ulcers in nose, vagina,
urethra, and anal canal; and ulceration, pain and
swelling extending down the throat and into the
lungs to give a form of bronchitis. The heart and
lungs may become involved, and the scalded
skin syndrome may develop. There is no specific
diagnostic test.
Treatment involves intensive steroid therapy,
and if possible, removing the cause of the
erythema multiforme. Most patients recover
slowly, but death is possible in the elderly and
debilitated.
See also ERYTHEMA MULTIFORME; SCALDED SKIN SYNDROME
STRACHAN SYNDROME
Strachan syndrome (also known as Jamaican neuritis) causes widespread nerve and skin
damage due to poor nutrition, particularly a lack of vitamin B. It often occurs in alcoholics and
with starvation, and is worse in smokers.
The symptoms include amblyopia (dim vision), dermatitis around the mouth and
genitals, and painful and excessively sensitive areas of skin. Some patients have muscle
weakness or spasms and permanent vision damage occurs if the syndrome is left untreated
112
for a prolonged period. Abnormalities of the retina (light sensitive area at back of eye) can be
seen when examined through an ophthalmoscope (magnifying light), and there are blood test
abnormalities, and over active reflexes.
Vitamin supplements and a good diet cure the condition.
STRAWBERRY NAEVUS
A strawberry naevus (immature or capillary haemangioma)
is a temporarily disfiguring skin blemish of children caused by
the overgrowth of small blood vessels. A bright red, raised,
irregular, rapidly enlarging spot appears shortly after birth, but
growth ceases by nine months of age. Virtually all disappear
spontaneously, completely and without a scar by the age of
five years. Surgery to remove naevus leaves a permanent
scar, and is never considered until at least the age of six
years.
See also HAEMANGIOMA; TELANGIECTATIC NAEVUS
STRETCH MARKS
Stretch marks (striae or stria gravidarum) are the curse of
pregnant women, when they develop on their belly and
breasts, and overweight people whose stretch marks persist after they have lost weight. The
tendency to develop striae is one that may be inherited.
They are caused by a break down and
stretching of the elastic fibres in the skin by
changes in the bodyʼs hormone levels as well
as direct stretching of the skin. Once they form
they usually remain permanently unless
removed by plastic surgery or reduced by
creams containing retinoic acids.
Cushing syndrome is caused by an over
production of steroids such as cortisone in the
body, or taking large doses of cortisone.
Headache, obesity, thirst, easy bruising,
impotence, menstrual period irregularities,
stretch marks, acne, high blood pressure, bone
pain and muscle weakness are common
symptoms of this syndrome.
STRIAE
See STRETCH MARKS
STURGE-WEBER SYNDROME
The Sturge-Weber syndrome is a congenital developmental disorder of the brain and skin
that causes intellectual disability, a red stain across part of the face, convulsions, paralysis
down one side of the body and eye abnormalities.
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Medication can control the convulsions, surgery can correct the cosmetic deformities, and a
combination of drugs and surgery are used for the eye abnormalities. Although there is no
cure, reasonable control of symptoms is possible.
SUNBURN
The sun is extremely hot and will burn in the same way as fire, except that the sun is so far
away we are not aware of the burning sensation that makes us draw back from fire. Obviously
people with fair complexions are most susceptible to sunburn and should take extra
precautions, especially in the middle of the day when the sun is at its height.
When the skin is burnt by the sun, it becomes red, painful and hot to the touch. If the
burning is severe, the skin will blister. After a few days the skin dries and a layer peels off.
Long-term effects of overexposure to the sun are permanent freckling, blotching and
premature ageing of the skin.
Most cases of sunburn can be dealt with by taking a cool bath or shower, and apply cool
compresses (although not iced since these may chill the victim) to the most affected parts.
Calamine lotion or one of the commercial anti- sunburn moisturising creams will usually help.
Paracetamol may reduce the pain, but if the sunburn is severe, the victim may develop cold
shivers and a temperature, and if a child is the sufferer, medical advice may be necessary.
Do not allow the victim of sunburn back in the sun without light-protective clothing until the
burns have healed.
SURFERʼS NODULES
Surferʼs nodules are hard calluses on the skin of the knees, feet and toes of surfboard
riders caused by constant friction on these areas by the surfboard.
Knee pads and fitted rubber boots can be worn to reduce their incidence and severity. They
slowly subside with time if surfboard riding is ceased. If they become painful, steroid injections
under the nodule ease the discomfort.
SWEET SYNDROME
Sweet syndrome (acute febrile neutrophilic dermatosis) is a generalised skin disease of no
known cause that is more common in women. Multiple tender red or purple skin plaques
develop on the neck and limbs, and are associated with muscle pains, fever, and joint pains
and swelling. Acute myeloid leukaemia develops in 20% of patients, and rarely ulcerative
colitis occurs.
Blood tests show excess white cells (neutrophils), and skin plaque biopsy is diagnostic.
Prednisone is used in treatment. The plaques heal spontaneously over 2 or more months, but
recurrences common.
SWIMMERʼS ITCH
See CERCARIAL DERMATITIS
SWIMMING POOL GRANULOMA
See FISH TANK GRANULOMA
SYCOSIS BARBAE
See BARBERʼS ITCH
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SYPHILIS
In the 18th. and 19th. Centuries, syphilis was called the French pox by the English, and the
English pox by the French.
Syphilis is an infection that is usually sexually transmitted, and which passes through three
main stages over many months or years. It is relatively uncommon in developed countries, but
still widespread in poorer societies. The cause is the spirochete bacterium Treponema
pallidum, which is transmitted by heterosexual or homosexual contact, sharing injecting
needles, blood transfusions, or from a mother to her child during pregnancy (congenital
syphilis). The same bacteria also cause yaws and bejel, which are transmitted by close body
contact, but not necessarily sexual contact.
The symptoms are totally different in each of the three stages:- First stage syphilis causes a painless sore (chancre) on the penis, the female
genitals, or around the anus of homosexuals, which heals after three to six weeks.
There may be painless enlarged lymph nodes in the armpit and groin that also
disappear.
- Second stage syphilis starts a few weeks or months later with a widespread rash,
mouth and vaginal ulcers, and a slight fever. The patient is highly infectious but will
usually recover and enter a latent period that may last many years.
- Third (tertiary) stage syphilis develops years later with tumours (gumma) in the
liver, major arteries, bones, brain, spinal cord (tabes dorsalis), skin and other
organs. Symptoms vary depending on organs involved but may include arthritis,
bone weakness, severe bone pain, paralysis, strokes, heart attacks, internal
bleeding from aneurysms, blindness, headaches, jaundice (liver failure), muscle
spasms, skin ulcers, scars, nodules in the larynx and lungs, vomiting, confusion,
insanity and death.
- Congenital syphilis occurs in newborn infant who have teeth abnormalities,
deafness, misshapen bones, deformed saddle nose, pneumonia, and intellectual
disability.
It can be diagnosed at all stages by
specific blood tests (eg. fluorescent
treponemal antibodies, syphilis IgG
enzyme immunoassay), or by finding
the responsible bacteria on a swab
taken from a genital sore in the first
stage of the disease. All pregnant
women should be routinely tested.
The first stage and second stages
are treated by antibiotics such as
penicillin (often as an injection),
tetracycline or erythromycin. In the
third (tertiary) stage antibiotics are also
used, but can merely prevent further
deterioration, as organ damage is
irreversible. A child suffering from
congenital syphilis is infectious when born and is treated with antibiotics.
There are many complications associated with a syphilis infection. In the first stage there
are usually none, but in second stage syphilis there may be spread of the infection to involve
115
the joints, brain, liver and kidney which may be severely damaged. In the third (tertiary) stage
almost any organ can be seriously damaged. Infants with congenital syphilis may develop
more serious problems if the condition is not treated aggressively.
A course of antibiotics for a few weeks almost invariably cures the disease in its first two
stages, but there is no cure for tertiary or congenital syphilis. Plastic surgery may correct the
more obvious congenital deformities.
See also PINTA; YAWS
SYSTEMIC LUPUS ERYTHEMATOSUS
Systemic (or disseminated) lupus erythematosus (SLE) is a relatively common
inflammatory condition affecting joints, skin, liver, and kidney most commonly, but almost any
tissue in the body may be involved. 85% of cases occur in women (usually young), and it is
more common in Negroes than Caucasians.
Lupus is an autoimmune disorder in which the body inappropriately rejects normal tissue
for no known reason. Attacks may be precipitated by stress, some medications or chemicals.
There is also a familial tendency.
Common symptoms are arthritis of several
joints, a red scaly rash across both cheeks and
the bridge of the nose (“butterfly rash”), rashes on
other areas that are exposed to sunlight, mouth
ulcers, poorly functioning kidneys and anaemia.
Additional symptoms may include a fever, loss of
appetite, tiredness, weight loss, damaged nails,
loss of hair and painfully cold fingers. Less
common complaints include conjunctivitis, blurred
vision, chest pain, pneumonia, heart failure, belly
pain, constipation, depression and convulsions.
The symptoms vary significantly from one patient
to another, and none will have them all. Many
patients are free of symptoms for months before
a recurrence. After each attack, there is slightly
more permanent liver, kidney or heart damage,
and eventually these problems accumulate to the
point where the disease becomes life threatening.
In rare cases it proceeds relentlessly to death
within a relatively short time.
Specific blood tests can diagnose the condition
(eg. lupus anticoagulant antibody, ANCA, antiSmith antibodies, anti-DNA, anti-dsDNA).
Treatment depends upon the severity of the disease, and with mild symptoms, no
treatment is required. Sun exposure should be avoided, and all non-essential medications
ceased. In severe cases, a wide range of drugs, including steroids, cytotoxics,
immunosuppressives and antimalarials may all be used. Regular blood tests follow the course
of the condition, which is very variable, from a mild arthritic complaint to a rapidly progressive
disease. There is no cure, but with careful management, compliance with treatment, and
regular check-ups, 90% of patients are alive more than ten years after the diagnosis is made.
See also DISCOID LUPUS ERYTHEMATOSUS
116
SYSTEMIC MASTOCYTOSIS
See URTICARIA PIGMENTOSA
SYSTEMIC SCLEROSIS
See SCLERODERMA
TAG
See SKIN TAG
TAN
Suntans may look attractive, but remember that it can take ten or twenty years for skin
cancer to develop. Have a look at the skin on some of the older beachside residents. Most
people do not want leathery skin covered in red, scaling, lumpy cancers when middle aged. It
is therefore better to limit tanning as much as possible, particularly in fair skinned and red
haired people. Beach bumming now may cause a person to spend many hours under a
doctorʼs scalpel later.
Ultraviolet (UV) rays cause tanning of the skin, and it does not matter whether these rays
come from the sun or an artificial source (eg. a solarium), the results are the same.
If excessive amounts of UV rays hit the skin it will burn, and the more the skin is exposed,
the higher the risk of skin cancer. A tan will not protect the skin from further burning or skin
cancer.
Chemical tans can give the brown colour desired by many people without any risk (except
allergy to the preparation) but will not protect the skin in any way.
It is sensible to avoid both the solarium and the sunʼs rays. Go on a beach holiday but
follow the rules and “slip, slop, slap” (slip on a shirt, slop on sunscreen, slap on a hat) to
avoid burning, excessive tanning and skin cancer.
See also SKIN CANCER
TANAPOX
Tanapox is a rare viral infection found in Kenya, Zaire and neighbouring countries of
central Africa. The cause is a pox virus infection of a minor break in the skin that may spread
from chimpanzees. Patients have a few days of fever followed by one or two, red, raised,
blistering lumps on the arms or legs. A biopsy can be used to confirm the diagnosis. No
treatment is necessary or available as full recovery occurs without treatment in a few weeks.
TELANGIECTASIA
ERUPTIVA
MACULARIS
PERSTANS
Telangiectasia eruptiva macularis perstans is a
mouthful of a disease that has no simpler name. It is a
rare form of the skin disease urticaria pigmentosa.
Patients develop diffuse red skin patches that have
overlying dilated capillaries (telangiectasia). The skin
patches are made of abnormal collections of mast
cells. These contain histamine and when the cell is
disturbed, the histamine is released into the skin.
Histamine makes blood vessels leak, resulting in
117
localised itching, swelling and redness. A skin biopsy confirms the diagnosis.
Potent steroid creams, antihistamines and PUVA (ultraviolet radiation) two or three times a
week for several months are used in treatment, but the condition is usually persistent.
See also URTICARIA PIGMENTOSA
TELANGIECTATIC NAEVUS
Telangiectatic naevi (stork bites) are a common skin condition of infants. They form dark
pink patches on the head and neck that are made from dilated skin capillaries. They fade and
disappear by two years of age.
See also NAEVUS; STRAWBERRY NAEVUS
TELOGEN EFFLUVIUM
Telogen effluvium is a form of diffuse hair loss. Both men and
women have fewer hairs as they grow older, but excessive
generalised hair loss from the scalp, and sometimes other hairy
areas of the body (eg. eyebrows, pubic area, chest) may be a
symptom of disease such as sex hormone disturbances (eg.
pregnancy, menopause), an over or underactive thyroid gland,
pituitary gland diseases, many other serious illness, drugs used
to treat cancer, radiation therapy, too much vitamin A, and
sudden and excessive loss of weight (eg. anorexia nervosa).
Extreme mental or physical stress may also be responsible. Blood and other tests may be
done to exclude specific causes but are often normal.
If a cause can be found this should be treated. When the cause is medication, the hair
usually grows back when it is ceased.
See also ALOPECIA AREATA; BALD; LOOSE ANAGEN SYNDROME
THROMBOCYTOPENIA
Thrombocytopenia (idiopathic thrombocytopenic purpura) is a complex uncommon
condition due to a lack of platelets (also known as thrombocytes), the blood cells that are
responsible for controlling the rate at which blood clots. In children the condition often follows
a viral illness and settles quickly, but in adults it is usually an autoimmune condition (body
rejects its own cells) in which platelets are inappropriately destroyed by the spleen for no
apparent reason. It can also occur as a result of adverse drug reactions, infections and other
rare disorders.
Patients are unable to clot their blood as quickly as normal, and they bleed excessively.
They develop purpura (red dots under the skin caused by microscopic bleeding) across a
wide area, bleed internally to cause black motions, have nosebleeds that are difficult to stop,
may vomit and cough blood, bruise very easily, bleed around their teeth after eating and may
bleed very heavily during a menstrual period. Bleeding into the brain may cause a stroke, or
very rarely, death. The diagnosis is confirmed by a simple blood test.
In some children, rest and time are the only necessary treatments. In all adults and most
children, high doses of prednisone (a steroid) are given to settle the condition and allow more
platelets to be made in the bone marrow. Immunoglobulin injections may also be used. As the
spleen is the organ destroying the platelets, surgical removal of this can cure the disease in
resistant cases. Other exotic medications may be used in severe cases.
118
The disease may last for a long time in adults, but the vast majority of patients respond well
to treatment, although there are significant dangers before the patient presents to a doctor
and in the first few days of treatment. It may occasionally recur in adults, but rarely in children.
TICKS
Ticks are from the same family as
spiders (arachnids) but are modified so
much that they look nothing like their
distant cousins. They have a large black
body from which mouth parts protrude
and grasp the skin. The tick does not
have a head as such. A tube-like mouth
part pierces the victim's skin to suck up
blood. When the tick is full of blood, it
drops off and waits for its next victim,
which may be almost any warm-blooded
animal,
although
some
species
preferentially attack certain animals. A full
feed of blood may last the tick for a year
or more.
Ticks are most active in the spring and summer. Bush ticks, which are the only dangerous
form of tick, live on the eastern coastal strip of Australia. The most common victims of ticks
are children playing in the bush, and golfers, as ticks shelter in foliage and drop on a victim
and burrow in as they engorge themselves on blood. Ticks are usually found on the head,
burrowing in amongst the hair, or in body crevices.
Ticks generally cause painful irritation and a raised lump on the skin. Uncommonly they
may lead to paralysis if left untreated, especially in children.
Symptoms of tick bite are irritation and pins and needles at the site of the bite, nausea,
double vision, unsteadiness, and eventually weakness and difficulty in moving first the lower
limbs, then the upper limbs, and finally the face and breathing apparatus.
Do NOT attempt to pull the tick off or cut it out or squeeze it - this forces more venom into
the system.
To remove a tick, wash it and the surrounding skin with an alcohol solution, such as
methylated spirits. Place a pair of tweezers flat on the skin so that the jaws are on either side
of the tick. Grasp the tick firmly, as close to the skin as possible, twist through 90 degrees,
and then lift off. The tick will come away easily with minimal pain. Some tiny black marks, the
mouth parts, may be left behind, but these rarely cause any trouble. Place some antiseptic
cream or lotion on the bite and leave it alone to heal over the next couple of days. If the area
becomes red and angry, it may have become infected, and a doctor should be consulted.
Ticks are responsible for the transmission of a wide range of infections including Lyme
disease, typhus and Dutton relapsing fever.
TICK TYPHUS
See TYPHUS
119
TINEA
Tinea is a term used to describe any fungal infection of the skin, hair or nails. The technical
term is dermatomycosis. Ringworm is a lay term that may be used for a fungal infection
involving skin only.
See also ATHLETEʼS FOOT; PITYRIASIS VERSICOLOR; TINEA CAPITIS; TINEA
CORPORIS; TINEA CRURIS; TINEA MANUM; TINEA NIGRA
TINEA CAPITIS
Tinea capitis is a fungal infection of the
skin on the scalp that usually occurs in
children. The fungi usually come from the
Trichophyton,
Microsporum
and
Epidermophyton families. It is caught by
close contact with another infected human
or animal (eg. cat, dog).
The child develops an irregular, relatively
bald patch on the scalp covered in a fine
scale and broken hair stubble (the fungi
invades the hairs and causes them to
become fragile and break). A severely
affected patch may develop a thick build-up
of scale and form a fungal abscess (kerion).
The diagnosis can be proved by taking a skin scraping or hair sample, and examining it
under a microscope for fungal spores. Ultraviolet light (Woodʼs light) in an otherwise dark
room will cause a bright green fluorescence of hair and skin affected by a fungus.
Antifungal ointments, lotions, tinctures and shampoos are all very effective treatments.
See also DANDRUFF; KERION; TINEA
TINEA CORPORIS
Tinea corporis (ringworm) is a fungal
infection of the skin that is not caused by a
worm. The fungi usually come from the
Trichophyton,
Microsporum
and
Epidermophyton families, and are caught by
or animal (eg. cat, dog). The fungi prefer
areas of the body where there is heat
(under clothing, in shoes), friction (from tight
clothes or skin folds rubbing together) and
moisture (from sweat), and more common
in the tropics. It affects both sexes and all
ages equally.
The fungus settles in one spot on the skin, where a red dot may be seen. This slowly
enlarges as the fungus spreads, and after a few days the centre of the red patch becomes
pale again and similar to normal skin, because the infection is no longer active at this point.
The infection continues to spread and forms an enlarging red ring on the skin. Multiple ringshaped spots with a pale centre are seen on the chest, abdomen and back. It usually does
120
not cause an itch or discomfort. The diagnosis is proved by taking a skin scraping and
examining it under a microscope for fungal spores.
Antifungal creams, ointments, lotions and tinctures are usually effective. Antifungal tablets
are available for more serious infections, but sometimes they are very slow to work, and may
need to be taken for up to six months. Without treatment, the ringworm may persist for many
months.
The prognosis is very good with proper treatment, but the infection tends to recur if
treatment ceased prematurely. Children may return to school a day after appropriate
treatment has been commenced.
See also TINEA; TINEA MANUM
TINEA CRURIS
Tinea cruris (“crotch rot”) is a fungal infection of the skin
in the groin. The fungi usually come from the Trichophyton,
Microsporum and Epidermophyton families and are caught
by close contact (eg. sexual) with an infected person, or in
babies may be due to wet nappies or sweaty skin. Infection
is more common in men than women, has a peak incidence
in the 20s and 30s, and tends to occur more in summer
and with exercise.
A red, scaly rash spreads out from the skin folds in the
groin to cover the inside of the thighs, the lower abdomen
and the buttocks. It is often itchy and feels constantly
uncomfortable. A secondary bacterial infection of damaged
skin is possible. The diagnosis proved by taking a skin scraping and examining it under a
microscope for fungal spores.
Antifungal creams, ointments, lotions and tinctures are usually effective. Antifungal tablets
are available for more serious infections, but sometimes they are very slow to work, and may
need to be taken for up to six months.
The prognosis is good with proper treatment, but recurrences are common.
See also TINEA; TINEA CORPORIS
TINEA MANUM
Tinea manum is a fungal infection of the
palm of the hand. The fungi usually come
from the Trichophyton, Microsporum and
Epidermophyton families, and are caught by
or animal (eg. cat, dog). This form of tinea is
uncommon in children.
Patients develop a fine scale with a faint
red edge that affects the palms and palm
side of the fingers. The diagnosis proved by
taking a skin scraping and examining it
under a microscope for fungal spores.
Treatment involves antifungal tablets
taken for a month or more, rather than
121
cream, because the thick skin of the palm makes it difficult for creams to penetrate. Results
are good with proper treatment.
See also ATHLETEʼS FOOT; TINEA; TINEA CRURIS
TINEA NIGRA
Tinea nigra is a fungal infection of
the palms and soles of the hands and feet
caused by the brown fungus (mould)
Exophiala phaeoannellomyces, which is
found in soil. It is more common in tropical
areas and in people who sweat excessively.
Slowly growing, dark brown or black,
lightly scaled patches develop on the soles
and palms. There is no itching or pain. Skin
scrapings can identify the mould and it is
treated with antifungal creams. It usually
clears within a few weeks with appropriate
treatment.
See also FUNGI; TINEA
TINEA PEDIS
See ATHLETEʼS FOOT
TINEA VERSICOLOR
See PITYRIASIS VERSICOLOR
TOPHI
Patients with severe, recurrent gout can develop hard lumps (tophi) filled with sodium urate
under the skin near their finger joints and over the ear cartilage. These tophi may ulcerate and
discharge. They can be surgically removed if necessary, and once the gout is controlled, no
more will form. Tophi are now rare as virtually all patients have their gout adequately
managed.
TOXIC EPIDERMAL NECROLYSIS
TOXIC ERYTHEMA
See DERMATITIS MEDICAMENTOSA
TRANSIENT ACANTHOLYTIC DERMATOSIS
See GROVER DISEASE
TRENCH FEVER
Trench fever (quintana fever) is a generalised bacterial infection caused by the rickettsial
organism Bartonella. It causes a fever, rash, overwhelming weakness and aching legs. It
settles with no treatment after about five days. It was a common cause of temporary disability
in World War One front line troops, but is now almost unknown.
122
TRICHOEPITHELIOMA
Trichoepithelioma is an uncommon inherited
skin condition arising from poorly developed hair
follicles that is more common in women.
One or more small, shiny, firm, round
nodules form on the face after puberty. Their
colour varies from yellow to pink or blue.
Desmoplastic trichoepitheliomas are a variant
that form a ring shaped nodule. A
trichofolliculoma is a similarly formed solitary
nodule that occurs on the face of elderly people.
The condition is diagnosed by biopsy or
excision.
They can be excised if unsightly or annoying,
but the number of nodules slowly increases with
age and they persist long term if not removed.
See also MILIA
TRICHOFOLLICULOMA
See TRICHOEPITHELIOMA
TRICHOTILLOMANIA
Trichotillomania is a self induced cause of hair loss that often starts in childhood or the teen
years. Females are far more commonly affected than males, and any body hair, including
pubic and eyebrows, may be involved.
Patients pull and twist the hair until it breaks, usually as a subconscious habit, but
sometimes in association with a psychiatric disturbance, resulting in patchy hair loss, with hair
of varying lengths in the affected area.
Strangely, shaving the head or pubic area (but not the eyebrows) may break the habit, but
sometimes psychiatric medications are required, although most patients grow out of the habit.
TSUTSUGAMUSHI DISEASE
See SCRUB TYPHUS
TUBEROUS SCLEROSIS
Tuberous sclerosis (epiloia) is an uncommon nodule formation in organs of young children.
It is a congenital condition (present since birth) that may occur in successive generations in
the one family or develop randomly.
Repeated convulsions occur in infancy due to the presence of brain nodules. Later in
childhood, intellectual disability is noted and a rash consisting of red nodules (small lumps)
appears on the face and neck. Other unusual rashes may develop elsewhere on the body,
and lumps may form under the nails. Eye damage, cysts in the heart, bone and lungs, and
nodules in the bowel, may also develop.
No curative treatment is available, but medication is given to control convulsions, and
surgery is performed to remove some of the more serious nodules. Mental retardation usually
steadily worsens with age.
123
TYPHOID FEVER
Typhoid fever (enteric fever or intestinal Salmonellosis) is a widespread bacterial infection
of the gut and surrounding lymph nodes, including the spleen, that occurs throughout Asia,
Africa and South America.
AREAS OF THE WORLD AFFECTED BY TYPHOID FEVER
The infection is caught by eating food contaminated with the bacterium Salmonella typhi,
which pass out in the faeces and urine of those who have the infection, or are symptom-free
carriers of the bacteria. The incubation period is 5-14 days.
Symptoms include fever, headache, tiredness, cough, sore throat, abdominal pain, red
spots on the trunk (rose spots) and constipation. After a day or two, the constipation suddenly
gives way to copious diarrhoea. Complications may include massive bleeding into the gut and
perforation of the gut, which usually cause the death of the patient. In severe cases, it is
possible for the infection to spread to the lungs, brain, kidneys and gall bladder.
The diagnosis confirmed by specific blood tests (Widal test), urine and faeces tests.
Antibiotics are prescribed to destroy invading bacteria, steroids are given to reduce
inflammation, and a low-residue diet and intravenous fluids prevent gut irritation and
dehydration. The bacteria may be almost impossible to eradicate from people who become
symptom-free carriers of the disease. Preventive vaccines are available as three tablets taken
over five days that give at least six months protection, or injections that give three years
protection.
Death occurs in up to 30% of untreated cases, but only in 2%
of those who are treated in good facilities. With no treatment,
survivors slowly improve after about ten days, but relapses may
occur for the next two or three weeks.
TYPHUS
Typhus is a worldwide infection caused by various types of
the primitive bacteria Rickettsia, that causes a significant
generalised illness. The bacteria pass to humans from rats and
mice through a lice, tick or flea bite, and the incubation period is
124
3 days to two weeks.
It is more common around the Mediterranean Sea, in the Middle East and in East Africa,
and different names are given to the infection in different parts of the world, and to infections
caused by different species of Rickettsia. These include:- Rickettsia typhi - Almost world wide, but often in urban areas - Murine typhus.
- Rickettsia conorrii - Mediterranean Sea and East Africa - Mediterranean
Spotted Fever, Fievre Boutonneuse, Astrakhan Spotted Fever, Indian Tick
Typhus, Kenya Tick Typhus, Israeli Spotted Fever.
- Rickettsia sibirica - North Asia - Siberian Tick Typhus.
- Rickettsia africae - East and Southern Africa - African Tick Bite Fever.
- Rickettsia australis - Tropical Australia - Queensland Tick Typhus.
- Rickettsia japonica - Japan - Oriental Spotted Fever.
- Rickettsia honei - Flinders Island, Tasmania - Flinders Island Spotted Fever.
All forms have similar symptoms and treatment, but some are milder (eg. Siberian tick
typhus) than others.
Symptoms include a black spot on the skin at the site of the tick bite, swelling of skin, a
widespread red large spot rash, fever, generalised aches and pains, tiredness, headache,
joint pains, loss of appetite and enlarged lymph nodes. Liver damage and skin ulceration may
be complications.
It is diagnosed by specific blood tests (eg. Weil-Felix test) and/or a skin biopsy.
Treatment involves antibiotics such as tetracycline and ciprofloxacin, which settle the
infection in a few days. Without treatment, and with no complications, symptoms settle in
three or four weeks.
The prognosis is usually good in western countries with appropriate treatment, but up to
10% of patients die from liver damage without medical attention.
The disease name comes from the Greek word for fever, typhos.
See also SCRUB TYPHUS
ULCER
An ulcer is any persistent break in a body surface that exposes underlying tissue, be it the
skin or lining of a hollow organ (eg. mouth, intestine).
See also BED SORE; ORF; TROPHIC ULCER; VENOUS ULCER
URAEMIC FROST
In patients with chronic kidney failure and very high levels of blood urea over a prolonged
time, a pale frost-like deposit of white urea crystals may become visible on the skin as the
high levels of urea in sweat deposit out on the skin as the sweat evaporates.
URTICARIA
Hives or urticaria (angioedema) is an allergic reaction in the skin. Angioedema is a term
used more commonly when the lips or eyelid is involved and becomes severely swollen, with
only slight itchiness and redness. Common causes include brushing against plants that may
have stinging nettles on their surface, insect bites and chemicals (in creams, cosmetics,
soaps) that are applied to the skin. Urticaria may also occur in a non-allergic form, which may
be a response to stress or a viral infection. Some patients with long-term and recurrent forms
of urticaria may be reacting to medications or salicylates and tartrazine, chemicals that occur
naturally in a wide range of foods.
125
Patients develop red, raised, itchy wheals that may be limited to a small area, or spread
widely over the skin. The rash develops rapidly over a few minutes or a couple of hours, and
may persist for up to two weeks, although two or three days is average. Some rarer forms
may become chronic and last for months or years.
Skin and blood tests can be undertaken in an attempt to identify the substance responsible
for the reaction, but these are often unsuccessful.
Antihistamines or steroids by mouth or injection are the main treatments. Tricyclic
antidepressants also seem to benefit some patients with persistent hives. Soothing creams,
lotions and baths can give relief to patients during the worst stages of an attack, and a diet
which is free of salicylates and tartrazine may be of benefit.
See also NETTLE RASH; PAPULAR URTICARIA; URTICARIA MEDICAMENTOSA;
URTICARIA PIGMENTOSA
URTICARIA MEDICAMENTOSA
The overuse of medications orally (eg. quinine) or on the skin (eg. steroids) may result in
an itchy rash as a complication of the medication or its excessive use. This is urticaria
medicamentosa.
See also URTICARIA
URTICARIA PIGMENTOSA
Urticaria pigmentosa (mastocytosis) is an allergy-like patch reaction in skin that most often
affects infants. The patches are made of abnormal collections of mast cells that contain
histamine, and when the cell is disturbed, the histamine is released into the skin. Histamine
makes blood vessels leak, resulting in localised itching, swelling and redness.
126
Brown patches develop on the skin of young children that steadily increase in number over
several months or years and blister when rubbed. If many patches are activated at the same
time the skin becomes itchy and the infant may become irritable, but it is uncommon for
severe symptoms to arise. A severe attack can result in flushing and faintness. Rarely it
occurs in adults, when the condition is usually worse, spots are itchier, and may spread to
involve internal organs (systemic mastocytosis).
Rubbing a patch causes redness, swelling and itching within a few minutes (Darier sign).
Occasionally a skin biopsy is needed to confirm the diagnosis.
No treatment is normally necessary. Exercise, heat, alcohol and some medications (eg.
aspirin, narcotics - codeine and morphine) can aggravate the condition. If symptoms are
significant antihistamine mixture or tablets, and steroid creams can be used. Over the a few
years the skin becomes less irritable and eventually the patches fade away. By the teenage
years, most patches will have gone.
See also TELANGIECTASIA ERUPTIVA MACULARIS PERSTANS
VACCINIA
Vaccinia was a complication of smallpox vaccination. This vaccination is now unavailable
and unnecessary as smallpox has been eliminated worldwide.
Smallpox vaccination was given by scratching the vaccine into the skin. If the patient had
eczema, dermatitis, significant burns or other skin damage the vaccination reaction could
spread across the skin to cause varying rashes, ulceration and rarely spread internally to vital
organs such as the brain to cause encephalitis. Patients with vaccinia can spread the reaction
to close contacts. No treatment was available.
127
VARICOSE ECZEMA
Varicose or hypostatic eczema is a chronic skin
deterioration that affects women more than men, and is
far more common in the elderly. The cause is a poor
return of blood through the veins from the feet to the
heart, and as a result blood pools in the feet, causing
pressure on the skin. It is more common if varicose veins
are present.
The affected skin is itchy, red, shiny, swollen, dry and
covered with scales. It is easily injured and very slow to
heal. The inside of the shin, just above the ankle, is the
area usually affected. Ulcers are a common complication,
as are bacterial skin infections, and allergy reactions.
Treatment involves elevating the leg as much as
possible, using support stockings or pressure bandages,
and raising the foot of the bed slightly. If varicose veins
are present, it may be appropriate to remove them
surgically. Mild steroid creams and coal tar solutions are
used on the eczema. Unfortunately the eczema is usually
persistent, and the results of treatment are often poor
unless the patient is very compliant.
See also ECZEMA; STASIS DERMATITIS; VENOUS ULCER
VENEREAL WARTS
See GENITAL WARTS
VENOUS LAKE
A venous lake is a common disfiguring
problem affecting older people, and usually
develops on the face and ears. They are
caused by sun exposure that damages
veins under the skin, or a direct injury to the
skin. The damaged vein dilates to form a
dark blue to black, painless, raised, smooth,
soft, blood filled blister under the skin. They
bleed profusely if injured.
Electric cautery, laser or excision can be
used to remove the spot if it is cosmetically
unacceptable.
See also CAMPBELL de MORGAN SPOTS; HAEMANGIOMA
VENOUS ULCER
A venous, stasis or varicose ulcer may occur on the shin and ankle in middle-aged and
elderly people due to a poor return of blood from the ankles and feet to the heart. The ankles
may be swollen, and the skin may be thin and discoloured by eczema. A slight injury to a leg
affected by varicose veins may cause an ulcer, and because of the high pressure from the
swollen veins in the area, the poor quality of the skin, and the poor blood supply, healing may
128
be very slow. Women are affected far more often than men, and they are more common in
diabetics. Secondary bacterial infection of the ulcer is the only significant complication.
Treatment involves prolonged elevation of the leg to reduce the pressure in the veins,
wearing compression bandages or stockings when walking, avoiding standing still for
prolonged periods, and careful dressing of the ulcer with antiseptics and specialised pastes,
pads or powders. In persistent cases, surgery to the swollen veins to relieve the pressure may
be necessary before healing can occur. Recovery is often very slow, but most heal with
persistence.
See also VARICOSE ECZEMA
VIRAL EXANTHEMA
A viral exanthema is any rash caused by a viral infection. These are much more common
in children than adults and common examples include measles, roseola infantum (baby
measles), chickenpox and German measles (rubella), but a wide range of other viral
infections may be responsible.
The rashes that may occur are extremely variable in their appearance. Usually there is a
red or maroon, flat, widely scattered, slightly itchy rash in a child with a mild fever who is
vaguely unwell, but the rash may also be a raised, crusting and highly itchy as in chickenpox.
No tests are normally necessary, but blood tests and swabs of sores may be necessary to
make definite diagnosis.
The rash settles spontaneously within hours or days without treatment. Paracetamol and
medication for the itch may be necessary.
VITILIGO
Vitiligo is a skin pigmentation disorder that can occur in all races, in both sexes, and at all
ages, but onset is uncommon over 50 years of age. The cause is unknown, but it is probably
an autoimmune disease, in which the body's defence mechanisms inappropriately attack
129
normal cells and tissue, in this case destroying pigment producing melanin cells
(melanocytes) in the skin.
The loss of skin pigmentation in
multiple patches that are sharply
defined, may appear anywhere on the
body, in any size and number, and
overlying hair is usually white or grey.
The affected skin is very sensitive to
sunlight, and burns easily.
In pale-skinned northern Europeans
the patches may be barely noticed, but
in southern Europeans, Arabs, Negroes
and Chinese the resultant large white
patches are quite disfiguring. There are
no other side effects or complications of
the disease
Cosmetic stains or dyes (eg.
dihydroxyacetone) are used to disguise
the affected areas of skin, and may be
quite effective. A number of other
treatments are available, but require
long-term use of tablets and/or ultraviolet
light exposure, and have only moderate
success. The affected area of skin usually slowly extends to involve larger areas but
eventually stabilises after several years. Spontaneous recovery is uncommon.
von RECKLINGHAUSENʼS DISEASE OF MULTIPLE NEUROFIBROMATOSIS
Besides having the longest disease name
in
any
medical
textbook,
von
Recklinghausen's
disease
of
multiple
neurofibromatosis has the characteristics of
multiple light brown marks on the skin, soft
fatty lumps under the skin, and, in some
patients, nerves may be damaged. It is
named after Friedrich von Recklinghausen
(1833-1910), who was a pathologist in
Strasbourg, Germany, and first described the
condition in 1881.
One in every 3000 people in Australia are
affected by the condition. The lumps and
spots are most commonly found on the trunk,
pelvis and in the armpits. They also increase
in size and number with age. The lumps grow
from cells that form the soft sheath around
every nerve in the body. The nerve damage is
due to these soft lumps developing in the
130
spinal canal, and in other areas (e.g. the auditory nerve that is responsible for hearing) where
they can cause pressure on nerves to the point where the nerve is no longer able to function.
Deafness, blindness and paralysis may be the long-term result in a small number of cases.
The disease passes from one generation to the next, but has a very variable result. About
one third of patients merely have a couple of brown spots that never concern them, while
about 10% are severely disfigured and disabled by large soft lumps under the skin, nerve
weakness and multiple brown patches. Complications include scoliosis (curvature of the
spine), bone cysts, uneven growth of the limbs (one arm or leg larger than the other) and
arthritis. Sometimes mild mental retardation occurs, and rarely the lumps may become
cancerous.
The diagnosis is confirmed by examining a sample (biopsy) of the patches or lumps under
a microscope, where characteristic abnormal cells can be seen.
There is no treatment other than plastic surgery for any particularly bad lumps and patches.
There is also no way in which you can determine whether a future child will have the
condition, or how badly affected that child will be.
As the disease is transmitted genetically, anyone from an affected family should not marry
someone who also has this condition in their background. Any family with members affected
by this disease should seek further advice from a paediatrician, neurologist or geneticist.
See also NEUROFIBROMA
WART
A wart is an unsightly, hard, rough, raised growth on the skin caused by a very slowgrowing virus (papillomavirus), which take months or years to cause a wart. Only about a
quarter of the population is susceptible to the wart virus, the rest have natural immunity. They
are most common in children from 8 to 16 years of age, but people with warts should not be
isolated for fear of spreading the disease, as the virus is widespread in the community. The
most common sites affected are the knees, elbows, hands and feet.
131
Treatments that may be tried include acid paints (eg. keratolytics, podophyllum) applied
regularly to eat away the wart tissue, freezing (cryotherapy) with liquid nitrogen which causes
the wart to fall off after a few days, burning the wart tissue away with a high voltage electric
current (diathermy) or laser, injecting a cell destroying substance (bleomycin) under the wart,
immunotherapy (inducing a skin reaction under and around the wart), or rarely cutting the wart
out surgically. Warts may recur after all forms of treatment, and only warts that are causing
disfigurement or discomfort should be treated, as a scar may remain after any form of
surgery, diathermy or cryotherapy.
Warts usually go away by themselves without any treatment, but this may take many
months or years. The average life span of a wart is about 18 months, but some may last
several years.
See also GENITAL WARTS; PLANTAR WART; SEBORRHOEIC KERATOSES
WELLS SYNDROME
Wells syndrome (eosinophilic cellulitis) is a form of skin inflammation associated with skin
redness, blistering and swelling. The patient has a mild fever and flame-like redness of the
skin may extend away from the affected area. A blood test shows the presence of an
excessive number of eosinophils (a type of white blood cell). Attacks last two to six weeks but
may recur.
See also CELLULITIS
WINTER ITCH
Winter itch is a skin irritation caused by dry cold air in people with dry skin and atopic
eczema. Using copious amounts of skin moisturiser (emollient eg. Sorbolene) is the main
treatment unless a trip to a warmer more humid climate is possible.
See also ATOPIC ECZEMA
WISKOTT-ALDRICH SYNDROME
Wiskott-Aldrich syndrome is an inherited X-linked (passes from mothers to sons) abnormal
destruction of the cells (platelets), which are responsible for blood clotting, and a lack of the
cells necessary to protect the body from infection.
Patients have widespread eczema, recurrent severe infections, and excessive bleeding
and bruising because of a lack of platelets in the blood. Severe life threatening infections may
occur. It can be diagnosed by blood tests and bone marrow biopsy.
Vigourous treatment of infections is necessary, as are blood transfusions, bone marrow
transplants and sometimes removal of the spleen (which is responsible for destroying the
platelets), but despite the best treatment, few of these children survive into their teen years.
WITKOP
See FAVUS
XANTHELASMA
Xanthelasma are yellow-brown nodules in the soft skin around the eye. They are common
in the elderly but may be a sign of high cholesterol or triglyceride levels, liver cirrhosis and
other liver disease.
132
XANTHOGRANULOMA
A xanthogranuloma is a small lump (papule) on
the skin. They vary in size from 1 to 10 mm across
and are more common in children. Their cause is
unknown. they appear as one or more red papules
with a yellowish hue on the skin. The papules are
not itchy or sore but they may catch on clothing or
become scratched, irritated and infected.
Treatment is not normally necessary, but if the
diagnosis is in doubt or the papule is annoying they
may be excised or biopsied. They slowly disappear
without treatment over many years.
XANTHOMATOSIS
Xanthomatosis
is
a
complication
of
excess
cholesterol in the blood that
settles in the skin. Small, fatty,
yellow lumps appear that are
almost on top of the skin. They
most commonly develop around
the eyes, on the knees, elbows
and buttocks. Diet and medication
can lower blood cholesterol
levels, but skin lumps must be
destroyed by cautery (burning) or
removed surgically as they persist
after cholesterol levels are
controlled.
See also XANTHELASMA
XERODERMA PIGMENTOSUM
Xeroderma pigmentosa is a rare familial
(inherited) disorder of skin and nerves
resulting in an inability to repair damage to
the skin, brain and other tissues. Sun
exposure causes skin damage.
Affected children have skin sores,
inflammation and abnormal pigmentation
associated with small heads, mental
deterioration, poor coordination (ataxia),
muscle spasms (spasticity), abnormal
movements of the limbs (athetosis) and
under developed testes or ovaries. Other
abnormalities may include deafness,
133
seizures, abnormal sensations and abnormal heart nerves. They also have a high incidence
of cancer. There is no specific diagnostic test.
Affected children should avoid the sun but otherwise no treatment is available and the
prognosis is poor.
YAWS
Yaws is a bacterial infection that occurs
in some third-world countries with very poor
hygiene. Treponema pallidum is the
responsible bacterium, and this is the same
bacterium that causes syphilis. It is
transmitted from one person to another by
close
contact
and
poor
personal
cleanliness.
Sores develop on the skin (particularly
the legs) and in the nose and mouth, and
inflamed lymph nodes appear in the armpits
and groin. The sores may become large,
ulcerate, penetrate to the bone and cause
permanent disfigurement. The diagnosis
can be confirmed by taking swabs from the
sores.
Treatment involves antibiotics (eg.
penicillin) and improved personal hygiene,
which cure the infection.
See also BEJEL; PINTA; SYPHILIS
134
APPENDICES
Syndromes That May Cause Skin Lesions
AIDS (fever, high risk group, splenomegaly)
Bloch-Sulzberger syn. (vesicles fade to pigmented streaks)
Bloom syn. (photosensitive skin, Jewish)
Carney's complex (spotty pigmentation, atrial myxoma)
Chediak-Higashi syn. (skin infections, albinism)
Cogan syn. (interstitial keratitis, tinnitus)
Conradi-Hunermann syn. (large skin pores, cardiac lesions)
Dubowitz syn. (ptosis, micrognathia)
Ehlers-Danlos syn. (fragile skin, joint pseudotumours)
Felty syn. (leg ulcers, polyarthritis)
Fröhlich syn. (thin skin, scanty hair, obese)
Gardner syn. (sebaceous cysts, melaena)
Goltz syn. (scar-like skin atrophy)
Gorlin-Goltz syn. (multiple BCC, jaw keratocysts)
Hand-Schuller-Christian syn. (diabetes insipidus)
Harlequin syn. (severe ichthyosis)
Johanson-Blizzard syn. (aplasia cutis, anal atresia)
Kawasaki syn. (polymorphous rash, fever, red hands and feet)
Koebner phenomenon (linear psoriasis)
Leschke syn. (brown spots, hyperglycaemia, asthenia)
Letterer-Siwe syn. (pruritic, papular rash)
Nephrotic syn. (striae, ascites, oedema)
Neu-Lexova syn. (collodion skin, face abnormal)
Nezelof syn. (infant, diarrhoea, rashes, infections)
Postphlebitic syn. (stasis dermatitis, leg ulcers)
Proteus syn. (gross disfigurement)
Ramsay Hunt syn. (herpetic vesicles, earache)
Reiter syn. (arthritis, conjunctivitis, urethritis)
Richner-Hanhart syn. (keratoderma, uveitis)
Rothmund-Thomson syn. (skin pigmentation and atrophy)
Scalded skin syn. (infant, Staphylococcal infection)
Sjögren-Larsson syn. (ichthyosis, spastic)
Stevens-Johnson syn. (mucous membrane vesicles)
Sweet syn. (tender plaques, myalgia)
Toxic shock syn. (fever, vomiting, diarrhoea)
Vogt-Koyanagi-Harada syn. (vitiligo, blind)
Wiskott-Aldrich syn. (eczema, thrombocytopenia)
135
Sun Exposure Skin Abnormalities
SKIN CONDITIONS THAT MAY BE AGGRAVATED BY SUN EXPOSURE
Albinism
Alopecia
Bloom syn. (photosensitive skin, Jewish)
Cockayne syn. (deaf, blind, retarded)
Dermatoheliosis
Disseminated superficial actinic porokeratosis
Erythropoietic protoporphyria
Hyperkeratoses
Itchy upper arm syn. (no rash, intense pruritus)
Icthyosis
Inta-epithelial carcinoma
Lentigo
Melanoma
Merkel carcinoma
Photodermatitis
Photosensitive eczema
Poikiloderma of Civatte
Polymorphous light eruption
Rothmund-Thomson syndrome
Spider naevi
Squamous cell carcinoma
Systemic lupus erythematosus
Venous lake
Vitiligo
Xeroderma pigmentosa
Tetracycline antibiotics (burn easily)
© Warwick Carter
www.medwords.com.au
136

MW_S_Rationales_files/Rash Rationale

Transcription

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