Dermatology in Clinical Practice

Dermatology in Clinical Practice Zohra Zaidi · Sean W. Lanigan Dermatology in Clinical Practice Authors Dr. Zohra Zaidi 7 B 9th Zamzama St. Karachi-74400 Clifton Pakistan [email protected] ISBN: 978-1-84882-861-2 Dr. Sean W. Lanigan Consultant Dermatologist, Birmingham United Kingdom e-ISBN: 978-1-84882-862-9 DOI: 10.1007/978-1-84882-862-9 Springer Dordrecht Heidelberg London New York Library of Congress Control Number: 2009938034 © Springer-Verlag London Limited 2010 This work is subject to copyright. All rights are reserved, whether the whole or part of the material is concerned, specifically the rights of translation, reprinting, reuse of illustrations, recitation, broadcasting, reproduction on microfilm or in any other way, and storage in data banks. Duplication of this publication or parts thereof is permitted only under the provisions of the German Copyright Law of September 9, 1965, in its current version, and permission for use must always be obtained from Springer. Violations are liable to prosecution under the German Copyright Law. The use of general descriptive names, registered names, trademarks, etc. in this publication does not imply, even in the absence of a specific statement, that such names are exempt from the relevant protective laws and regulations and therefore free for general use. Product liability: The publishers cannot guarantee the accuracy of any information about dosage and application contained in this book. In every individual case the user must check such information by consulting the relevant literature. Cover design: eStudio Calamar Figueres/Berlin Printed on acid-free paper Springer is part of Springer Science+Business Media (www.springer.com) ‘The book is dedicated to my late brother Syed Hasan Nasir. He tragically died at the tender age of 29 years. We loved you a lot, but God loved you still more’ Dr. Zohra Zaidi ‘This book is dedicated to my wife Hilary and my children Stuart and Eleanor for their support and encouragement’ Dr. Sean W. Lanigan Preface Books on dermatology are either focused for medical students or for students of dermatology. A general practitioner sees a lot of skin patients; about 17% of their patients are related to skin disease. We therefore decided to write a book that should meet the needs of a general practitioner. To make the book helpful for the primary care physician, we have focused more on common skin problems and have discussed the diagnosis and treatment of these disorders in depth to help the general practitioner in diagnosing and treating them. The chapter on the management of skin diseases also gives the details of topical, systemic, and the physical modalities used in treating skin disease. Uncommon skin diseases are only mentioned where required. The chapter on cutaneous manifestations of systemic diseases will help the general practitioner to correlate the cutaneous signs of the common medical problems seen by them. Emphasis is laid on the bacterial, fungal, and parasitic disorders that are prevalent in tropical countries. We have included the common diseases of other continents, as the general practitioner especially of developed countries has patients from all over the world. Congenital and hereditary disorders are discussed with the corresponding chapters, which makes it easier for the reader to remember. A number of practical points are included with each subject, and history of dermatology is included where appropriate to make the subject interesting to read. The general practitioner refers a number of cases to the dermatology clinic for dermatological procedures such as phototherapy, cryosurgery, and lasers. These procedures are vii viii Preface included in the appendix at the end of the book. This will help the practitioner to have a basic knowledge about the procedure to be performed on their patients. Skin rashes are often an enigma for beginners; a little insight into the subject with a clear understanding can make the rash so simple to diagnose. We have tried to make this book simple, practical, and easy to use. We hope that general practitioners find it helpful; it could also be of interest and benefit to medical students. Karachi, Pakistan Birmingham, UK Dr. Zohra Zaidi Dr. Sean W. Lanigan Acknowledgments The authors thank the following consultants for contributing their photographs to the book: Dr. Badr Dhanani, Consultant Dermatologist, Institute of Skin Diseases, Karachi, Pakistan, Dr. Khalid Hussain, Consultant Dermatologist, Lincoln County Hospital, Lincoln, UK, Dr. Naseema Kapadia, Consultant Dermatologist, Aga Khan University, Karachi, Pakistan, Dr. Aziz Khan, Consultant Dermatologist, Dow Institute of Health Sciences, Karachi, Pakistan, Dr. Daulat Pinjani, Consultant Dermatologist, Institute of Skin Diseases, Karachi, Pakistan, Surgeon Captain Rehanuddin, Head, Department of Dermatology, PNS Shifa, Karachi, Pakistan, Dr. Zarnaz Wahid, Professor of Dermatology, Dow Institute of Health Sciences, Karachi, Pakistan, and Dr. Shernaz Walton, Consultant Dermatologist, Hull and East Yorkshire Hospital NHS Trust, UK and Esen Rizvi for graphics. ix Contents Preface . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Acknowledgments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . vii ix 1 Skin: Structure and Function . . . . . . . . . . . . . . . . . . . . 1.1 Structure. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1.1.1 Epidermis. . . . . . . . . . . . . . . . . . . . . . . . 1.1.2 Dermoepidermal Junction . . . . . . . . . . 1.1.3 Dermis . . . . . . . . . . . . . . . . . . . . . . . . . . 1.2 Functions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 1 1 5 6 14 2 Immune System of the Skin . . . . . . . . . . . . . . . . . . . . . 2.1 The Stratum Corneum . . . . . . . . . . . . . . . . . . . . 2.2 Cellular Components . . . . . . . . . . . . . . . . . . . . . 2.2.1 Langerhans Cells. . . . . . . . . . . . . . . . . . 2.2.2 Keratinocytes. . . . . . . . . . . . . . . . . . . . . 2.2.3 T Cells . . . . . . . . . . . . . . . . . . . . . . . . . . 2.2.4 Mast Cells . . . . . . . . . . . . . . . . . . . . . . . 2.2.5 Dermal Dendritic Cells . . . . . . . . . . . . 2.3 Molecular Components . . . . . . . . . . . . . . . . . . . 2.3.1 Antigens and Haptens . . . . . . . . . . . . . 2.3.2 Super-Antigens . . . . . . . . . . . . . . . . . . . 2.3.3 Histocompatability Antigens. . . . . . . . 2.3.4 Antibodies . . . . . . . . . . . . . . . . . . . . . . . 2.3.5 Cytokines . . . . . . . . . . . . . . . . . . . . . . . . 2.3.6 Eicosanoids . . . . . . . . . . . . . . . . . . . . . . 2.3.7 Cellular Adhesion Molecules (CAMs) . . . . . . . . . . . . . . . . 2.3.8 Complement . . . . . . . . . . . . . . . . . . . . . 17 18 18 18 18 19 19 19 20 20 20 20 20 21 22 22 22 xi xii Contents 2.4 Hypersensitivity Reactions . . . . . . . . . . . . . . . . 2.4.1 Type I (Immediate). . . . . . . . . . . . . . . . 2.4.2 Type II (Cytotoxic Reaction) . . . . . . . 2.4.3 Type III (Immune Complex Disease). . . . . . . . . . . . . . . . . 2.4.4 Type IV (Cell-Mediated or Delayed Hypersensitivity Reaction) . . . . . . . . . 23 23 23 23 3 Diagnosis of Skin Disease. . . . . . . . . . . . . . . . . . . . . . . 3.1 Approach to a Skin Patient . . . . . . . . . . . . . . . . 3.1.1 History Taking . . . . . . . . . . . . . . . . . . . . 3.1.2 Examination . . . . . . . . . . . . . . . . . . . . . 3.2 Primary and Secondary Lesions of the Skin . . 3.2.1 Primary Lesions . . . . . . . . . . . . . . . . . . 3.2.2 Secondary Lesions . . . . . . . . . . . . . . . . 3.2.3 Special Lesions . . . . . . . . . . . . . . . . . . . 25 25 25 26 31 31 32 34 4 Bacterial Infections . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4.1 Impetigo . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4.2 Folliculitis/Furunculosis/Carbuncle . . . . . . . . . 4.3 Recurrent Furunculosis . . . . . . . . . . . . . . . . . . . 4.4 Erysipelas/Cellulitis . . . . . . . . . . . . . . . . . . . . . . 4.5 Ecthyma . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4.6 Necrotizing Fasciitis . . . . . . . . . . . . . . . . . . . . . . 4.7 Erythrasma . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4.8 Pitted Keratolysis . . . . . . . . . . . . . . . . . . . . . . . . 4.9 Trichomycosis Axillaris . . . . . . . . . . . . . . . . . . . 4.10 Tuberculosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4.11 Leprosy (Hansen’s Disease) . . . . . . . . . . . . . . . 4.12 Pseudomonas Infections . . . . . . . . . . . . . . . . . . 4.13 Rocky Mountain Spotted Fever (RMSF) . . . . 4.14 Lymes Disease (Erythema Chronicum Migrans) . . . . . . . . . . . . . . . . . . . . . 4.15 Sexually Transmitted Diseases (Bacterial) . . . 4.15.1 Syphilis . . . . . . . . . . . . . . . . . . . . . . . . . . 4.15.2 Congenital Syphilis . . . . . . . . . . . . . . . . 4.15.3 Gonorrhea . . . . . . . . . . . . . . . . . . . . . . . 4.15.4 Chancroid (Soft Chancre) . . . . . . . . . . 37 37 39 42 42 44 45 46 47 48 48 52 57 59 23 60 62 62 67 69 71 Contents xiii Superficial Fungal Infections . . . . . . . . . . . . . . . . . . . . 5.1.1 Tinea Pedis. . . . . . . . . . . . . . . . . . . . . . . 5.1.2 Tinea Manuum . . . . . . . . . . . . . . . . . . . 5.1.3 Tinea Capitis . . . . . . . . . . . . . . . . . . . . . 5.1.4 Tinea Corporis. . . . . . . . . . . . . . . . . . . . 5.1.5 Tinea Cruris . . . . . . . . . . . . . . . . . . . . . . 5.1.6 Tinea Barbae . . . . . . . . . . . . . . . . . . . . . 5.1.7 Onychomycosis (Tinea of the Nails) . 5.1.8 Tinea Incognito . . . . . . . . . . . . . . . . . . . 5.5 Pityriasis Versicolor (Furfuracea) . . . . . . . . . . . 5.6 Pityrosporum Folliculitis (Malassezia Folliculitis) . . . . . . . . . . . . . . . . . . . 5.7 Candidiasis. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5.8 Subcutaneous Fungal Infections . . . . . . . . . . . . 5.8.1 Madura Foot (Mycetoma) . . . . . . . . . . 5.8.2 Sporotrichosis . . . . . . . . . . . . . . . . . . . . 5.9 Deep Fungal Infections . . . . . . . . . . . . . . . . . . . 5.9.1 Cryptococcosis. . . . . . . . . . . . . . . . . . . . 5.9.2 Histoplasmosis. . . . . . . . . . . . . . . . . . . . 5.9.3 Blastomycosis . . . . . . . . . . . . . . . . . . . . 5.9.4 Coccidioidomycosis . . . . . . . . . . . . . . . 5.9.5 Treatment of Deep Mycosis. . . . . . . . . 73 75 75 76 79 79 79 81 81 88 6 Viral Infections . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6.1 Herpes Simplex . . . . . . . . . . . . . . . . . . . . . . . . . . 6.2 Herpes Zoster (Shingles) . . . . . . . . . . . . . . . . . . 6.3 Varicella (Chickenpox) . . . . . . . . . . . . . . . . . . . 6.4 Warts. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6.5 Molluscum Contagiosum . . . . . . . . . . . . . . . . . . 6.6 Hand Foot and Mouth Disease . . . . . . . . . . . . . 6.7 Erythema Infectiosum (Fifth Disease). . . . . . . 6.8 HIV Infection (AIDS) . . . . . . . . . . . . . . . . . . . . 6.8.3 Post Exposure Prophylaxis . . . . . . . . . 101 101 105 108 110 116 119 119 120 122 7 Parasitic Infestations and Diseases Caused by Arthropods . . . . . . . . . . . . . . . . . . . . . . . . . 7.1 Scabies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7.1.4 Norwegian Scabies . . . . . . . . . . . . . . . . 7.1.5 Animal Scabies . . . . . . . . . . . . . . . . . . . 125 125 129 130 5 90 91 95 95 97 98 98 98 98 99 99 xiv Contents 7.1.6 Other Mites . . . . . . . . . . . . . . . . . . . . . . Pediculosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7.2.1 Pediculosis Capitis . . . . . . . . . . . . . . . . 7.2.2 Peduculosis Corporis . . . . . . . . . . . . . . 7.2.3 Pediculosis Pubis. . . . . . . . . . . . . . . . . . 7.3 Leishmaniasis . . . . . . . . . . . . . . . . . . . . . . . . . . . 7.5 Myiasis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7.6 Filariasis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7.7 Onchocerciasis (River Blindness). . . . . . . . . . . 7.9 Insect Bites . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7.9.1 Prophylaxis . . . . . . . . . . . . . . . . . . . . . . 7.10 Papular Urticaria . . . . . . . . . . . . . . . . . . . . . . . . 131 131 132 133 133 136 140 142 144 145 147 148 8 Eczema . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8.1.2 Source of Injurious Agent . . . . . . . . . . 8.2.1 Acute Eczema . . . . . . . . . . . . . . . . . . . . 8.2.2 Subacute Eczema . . . . . . . . . . . . . . . . . 8.2.3 Chronic Eczema . . . . . . . . . . . . . . . . . . 8.4.1 Exogenous . . . . . . . . . . . . . . . . . . . . . . . 8.4.2 Endogenous Eczemas. . . . . . . . . . . . . . 151 152 152 153 153 157 162 9 Keratinizing and Papulosquamous Disorders . . . . . . 9.1 Psoriasis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9.1.1 Etiology . . . . . . . . . . . . . . . . . . . . . . . . . 9.1.2 Histopathology . . . . . . . . . . . . . . . . . . . 9.2 Parapsoriasis . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9.3 Lichen Planus . . . . . . . . . . . . . . . . . . . . . . . . . . . 9.3.1 Etiology . . . . . . . . . . . . . . . . . . . . . . . . . 9.3.3 Histopathology . . . . . . . . . . . . . . . . . . . 9.4 Pityriasis Rosea . . . . . . . . . . . . . . . . . . . . . . . . . . 9.5 Pityriasis Rubra Pilaris (PRP). . . . . . . . . . . . . . 9.6 Parapsoriasis . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9.7 Follicular Keratoses . . . . . . . . . . . . . . . . . . . . . . 9.7.1 Keratosis Pilaris . . . . . . . . . . . . . . . . . . 9.7.2 Lichen Spinulosis . . . . . . . . . . . . . . . . . 9.8 Hyperkeratosis of the Palms and Soles . . . . . . 9.9 Corns . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9.10 Congenital Disorders of Keratinization. . . . . . 179 179 179 180 188 189 189 194 195 197 198 198 199 200 200 201 203 7.2 Contents xv 9.10.1 Darier’s Disease . . . . . . . . . . . . . . . . . . 203 9.10.2 Ichthyosis . . . . . . . . . . . . . . . . . . . . . . . . 204 10 Diseases of Connective Tissue . . . . . . . . . . . . . . . . . . . 10.1 Lupus Erythematosus. . . . . . . . . . . . . . . . . . . . . 10.1.1 Chronic Discoid Lupus Erythematosus (CDLE). . . . . . . . . . . . 10.1.2 Subacute Cutaneous Lupus Erythematosus (SCLE) . . . . . . . . . . . . 10.1.3 Systemic Lupus Erythematosus . . . . . 10.2 Dermatomyositis (DM) . . . . . . . . . . . . . . . . . . . 10.2.1 Adult Dermatomyositis . . . . . . . . . . . . 10.2.2 Childhood Dermatomyositis . . . . . . . . 10.3 Scleroderma. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10.3.1 Morphea. . . . . . . . . . . . . . . . . . . . . . . . . 10.3.2 CREST Syndrome . . . . . . . . . . . . . . . . 10.3.3 Systemic Sclerosis . . . . . . . . . . . . . . . . . 10.3.5 Mixed Connective Tissue Disorder. . . 10.4 Miscellaneous Disorders of Connective Tissue. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10.4.1 Keloids . . . . . . . . . . . . . . . . . . . . . . . . . . 10.4.2 Knuckle Pads (Holoderma). . . . . . . . . 10.5 Hereditary Disorders of Connective Tissue . . 10.5.1 Pseudoxanthoma Elasticum . . . . . . . . 10.5.2 Cutis Laxa . . . . . . . . . . . . . . . . . . . . . . . 10.5.3 Ehler Danlos Syndrome. . . . . . . . . . . . 11 Bullous Disorders: Autoimmune and Childhood Bullous Dermatoses . . . . . . . . . . . . . . 11.1 Pemphigus . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11.2 Pemphigoid . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11.3 Dermatitis Herpetiformis (DH): Duhring Brocq Disease . . . . . . . . . . . . . . . . . . . 11.4 Acquired Epidermolysis Bullosa (Epidermolysis Bullosa Acquisita) . . . . . . . . . . 11.5 Congenital Bullous Disorders . . . . . . . . . . . . . . 11.5.1 Epidermolysis Bullosa . . . . . . . . . . . . . 211 211 211 213 213 218 219 220 221 221 223 223 226 226 226 228 229 229 230 231 233 234 239 242 245 246 246 xvi Contents 11.5.3 Chronic Bullous Disease of Childhood (Childhood Linear IgA Disease) . . . . 249 11.5.4 Acrodermatitis Enteropathica (AE) . 250 12 Vasculitis, Common Erythemas, and Lymphatic Disorders . . . . . . . . . . . . . . . . . . . . . . . 12.1 Approach to a Patient with Vasculitis . . . . . . . 12.4 Leucocytoclastic Vasculitis. . . . . . . . . . . . . . . . . 12.4.1 Cuteneous Manifestations . . . . . . . . . . 12.4.2 Systemic Manifestations. . . . . . . . . . . . 12.5 Henoch–Schonlein Purpura (HSP). . . . . . . . . . 12.6 Polyarteritis Nodosa . . . . . . . . . . . . . . . . . . . . . . 12.7 Pyoderma Gangrenosum . . . . . . . . . . . . . . . . . . 12.8 Giant Cell Arteritis. . . . . . . . . . . . . . . . . . . . . . . 12.9 Erythema Multiforme . . . . . . . . . . . . . . . . . . . . 12.10 Erythema Nodosum (EN) . . . . . . . . . . . . . . . . . 12.11 Common Localized Erythemas. . . . . . . . . . . . . 12.11.1 Flushing and Blushing . . . . . . . . . . . . . 12.11.2 Erythema Palmare . . . . . . . . . . . . . . . . 12.12 Generalized Nonspecific Erythemas . . . . . . . . 12.12.1 Scarlatiniform Erythema . . . . . . . . . . . 12.12.2 Morbilliform Erythema . . . . . . . . . . . . 12.13 Pigmented Purpuric Dermatosis (PPD). . . . . . 12.13.1 Schamberg’s Disease . . . . . . . . . . . . . . 12.14 Lymphatic Disorders . . . . . . . . . . . . . . . . . . . . . 12.14.1 Lymphangitis . . . . . . . . . . . . . . . . . . . . . 12.14.2 Lymphoedema. . . . . . . . . . . . . . . . . . . . 13 Exanthems and Hypersensitivity Syndromes. . . . . . . 13.1 Exanthems . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13.1.1 Measles (Rubeola, Morbilli) . . . . . . . . 13.1.2 Rubella (German Measles) . . . . . . . . . 13.1.3 Scarlet Fever . . . . . . . . . . . . . . . . . . . . . 13.1.4 Hand, Foot and Mouth Disease . . . . . 13.2 Hypersensitivity Syndromes (Toxic Erythemas) . . . . . . . . . . . . . . . . . . . . . . . 13.2.3 Kawasaki’s Disease. . . . . . . . . . . . . . . . 13.2.4 Toxic Shock Syndrome. . . . . . . . . . . . . 253 254 255 255 255 256 258 259 260 260 263 265 265 266 266 266 266 266 267 268 268 269 271 271 271 273 274 275 275 277 277 Contents xvii 13.2.5 Staphylococcal Scalded Skin Syndrome (Ritter’s Disease) . . . . . . . . 277 13.2.6 Toxic Epidermal Necrolysis (TEN) . . 278 14 Urticaria . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 281 14.3 Mastocytosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . 286 15 Pruritus . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15.1 Etiology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15.2 Evaluation of the Itching Patient . . . . . . . . . . . 15.5 General Guidelines . . . . . . . . . . . . . . . . . . . . . . . . 287 287 289 293 16 Leg Ulcers. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16.1 Venous Ulcers . . . . . . . . . . . . . . . . . . . . . . . . . . . 16.2 Arterial Ulcers . . . . . . . . . . . . . . . . . . . . . . . . . . 16.3 Decubitis Ulcers (Bedsore) . . . . . . . . . . . . . . . . 16.4 Neuropathic Ulcers. . . . . . . . . . . . . . . . . . . . . . . 295 295 299 302 302 17 Disorders of Pigmentation . . . . . . . . . . . . . . . . . . . . . . 17.1 Albinism. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17.2 Vitiligo . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17.3 Melasma (Chloasma) . . . . . . . . . . . . . . . . . . . . . 17.4 Freckles . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17.5 Acanthosis Nigricans (AN) . . . . . . . . . . . . . . . . 17.6 Periocular Hyperpigmentataion . . . . . . . . . . . . 305 305 307 311 313 314 315 18 Disorders of Ultraviolet Radiation and Injuries Due to Cold . . . . . . . . . . . . . . . . . . . . . . . 18.2 Direct Effect of Sunlight on the Skin . . . . . . . . 18.2.1 Sunburn . . . . . . . . . . . . . . . . . . . . . . . . . 18.2.2 Tanning. . . . . . . . . . . . . . . . . . . . . . . . . . 18.2.3 Epidermal Thickening . . . . . . . . . . . . . 18.2.4 Vitamin D Production . . . . . . . . . . . . . 18.2.5 Immunological Effects . . . . . . . . . . . . . 18.2.6 Chronic Effects of Ultraviolet Radiation. . . . . . . . . . . . 18.2.7 Protection Against Ultraviolet Radiation . . . . . . . . . . . . . . 317 320 320 320 320 321 321 321 324 xviii Contents 18.3 Photosensitive Skin Reactions . . . . . . . . . . . . . 18.4 Skin Diseases Affected by Sunlight . . . . . . . . . 18.5 Congenital Disorders Leading to Increased Photosensitivity . . . . . . . . . . . . . . . . . . . . . . . . . . 18.5.1 Porphyrias . . . . . . . . . . . . . . . . . . . . . . . 18.5.2 Xeroderma Pigmentosum . . . . . . . . . . 18.6 Injuries Due to Cold. . . . . . . . . . . . . . . . . . . . . . 18.6.1 Asteatosis (Eczema Craquele) . . . . . . 18.6.2 Chilblain (Perniosis). . . . . . . . . . . . . . . 18.6.3 Frostbite . . . . . . . . . . . . . . . . . . . . . . . . . 18.6.4 Raynaud’s Phenomenon . . . . . . . . . . . 326 326 327 327 330 332 332 332 333 334 19 Diseases of the Sebaceous, Sweat, and Apocrine Glands . . . . . . . . . . . . . . . . . . . . . . . . . . 19.1 Acne Vulgaris . . . . . . . . . . . . . . . . . . . . . . . . . . . 19.2 Rosacea . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19.3 Perioral Dermatitis . . . . . . . . . . . . . . . . . . . . . . . 19.4 Hyperhidrosis of the Hands, Feet, and Axilla . . 19.5 Miliaria (Prickly Heat) . . . . . . . . . . . . . . . . . . . . 19.6 Congenital Disorders of the Sweat Glands . . . 19.6.1 Anhidrotic Ectodermal Dysplasia . . . 19.7 Intertrigo . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19.8 Hidradenitis Suppurativa (HS) . . . . . . . . . . . . . 19.9 Bromhidrosis (Fetid Sweat). . . . . . . . . . . . . . . . 19.10 Tumors of the Sweat Glands . . . . . . . . . . . . . . . 19.10.1 Syringomas. . . . . . . . . . . . . . . . . . . . . . . 19.10.2 Cylindroma (Turban Tumor) . . . . . . . . 337 337 345 347 348 350 351 351 353 354 355 355 355 356 20 Hair Disorders . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20.1 Excessive Hair. . . . . . . . . . . . . . . . . . . . . . . . . . . 20.1.1 Hirsutism . . . . . . . . . . . . . . . . . . . . . . . . 20.2 Loss of Hair (Alopecia) . . . . . . . . . . . . . . . . . . . 20.2.1 Nonscarring Alopecia. . . . . . . . . . . . . . 20.2.2 Scarring Alopecia . . . . . . . . . . . . . . . . . 20.3 Disorders of Color and Texture. . . . . . . . . . . . . 20.3.1 Premature Graying of the Hair . . . . . . 20.3.2 Dryness of the Hair . . . . . . . . . . . . . . . 20.4 Tumor of the Hair Follicles . . . . . . . . . . . . . . . . 20.4.1 Pilomatricoma . . . . . . . . . . . . . . . . . . . . 359 360 361 364 364 372 373 374 374 374 374 Contents xix 20.4.2 Trichoepithelioma . . . . . . . . . . . . . . . . . 20.5 Miscellaneous Disorders . . . . . . . . . . . . . . . . . . 20.5.1 Pityriasis Amiantacea . . . . . . . . . . . . . . 20.5.2 Pseudofolliculitis Barbae . . . . . . . . . . . 20.5.3 Acne Keloidalis. . . . . . . . . . . . . . . . . . . 20.5.4 Dissecting Cellulitis of the Scalp (Perifolliculitis Capitis Abscedens et Suffodiens) . . . . . . . . . . . . . . . . . . . . 375 376 376 377 378 21 Nail Disorders . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21.1 Paronychial Disorders . . . . . . . . . . . . . . . . . . . . 21.2 Common Nail Dystrophies . . . . . . . . . . . . . . . . 21.3 Discoloration . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21.4 Tumors Adjacent to and Under the Nails . . . . 381 381 386 389 390 22 Diseases of the Subcutaneous Tissue . . . . . . . . . . . . . 22.1 Panniculitis. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22.1.1 Evaluation of Panniculitis . . . . . . . . . . 22.2 Fat Dystrophies . . . . . . . . . . . . . . . . . . . . . . . . . . 22.3 Dercums Disease (Adipose Dolorosa) . . . . . . 22.4 Sclerema Neonatorum . . . . . . . . . . . . . . . . . . . . 22.5 Subcutaneous Fat Necrosis of the Newborn . . 22.6 Cellulite . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 395 395 396 397 397 398 398 399 23 Tumors of the Skin . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23.1 Benign Tumors . . . . . . . . . . . . . . . . . . . . . . . . . . 23.1.1 Skin Tags . . . . . . . . . . . . . . . . . . . . . . . . 23.1.2 Pyogenic Granuloma (Acquired Hemangioma) . . . . . . . . . . . . . . . . . . . . 23.1.3 Milia . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23.1.4 Dermatosa Papulosa Nigra . . . . . . . . . 23.1.5 Seborrhoeic Keratosis . . . . . . . . . . . . . 23.1.6 Sebaceous Cyst (Epidermoid Cyst) . . 23.1.7 Trichilemmal Cyst . . . . . . . . . . . . . . . . . 23.1.8 Dermatofibroma . . . . . . . . . . . . . . . . . . 23.1.9 Lipoma . . . . . . . . . . . . . . . . . . . . . . . . . . 23.1.10 Keratoacanthoma . . . . . . . . . . . . . . . . . 23.2 Premalignant Tumors . . . . . . . . . . . . . . . . . . . . . 23.2.1 Bowen’s Disease . . . . . . . . . . . . . . . . . . 401 401 401 379 402 402 403 405 406 407 407 408 408 410 410 xx Contents 23.2.2 Solar Keratosis . . . . . . . . . . . . . . . . . . . 23.3 Malignant Tumors . . . . . . . . . . . . . . . . . . . . . . . . 23.3.1 Basal Cell Carcinoma (BCC) . . . . . . . 23.3.2 Squamous Cell Carcinoma (SCC) . . . 23.3.3 Malignant Melanoma . . . . . . . . . . . . . . 23.3.4 Cutaneous Lymphoma (Mycosis Fungoides). . . . . . . . . . . . . . . 23.3.5 Kaposi’s Sarcoma . . . . . . . . . . . . . . . . . 23.3.6 Paget’s Disease of the Nipple . . . . . . . 411 413 413 416 418 24 Naevi and Hereditary Disorders of the Skin . . . . . . . 24.1 Naevi. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24.1.1 Epidermal Naevi . . . . . . . . . . . . . . . . . . 24.1.2 Vascular Naevi. . . . . . . . . . . . . . . . . . . . 24.1.3 Pigmented Naevi (Moles) . . . . . . . . . . 24.1.4 Naevus Achromicus . . . . . . . . . . . . . . . 24.1.5 Lymphangioma . . . . . . . . . . . . . . . . . . . 24.1.6 Connective Tissue Naevus . . . . . . . . . . 24.2 Neurofibromatosis . . . . . . . . . . . . . . . . . . . . . . . 24.3 Adenoma Sebaceum (Tuberous Sclerosis) . . . 431 431 431 432 434 440 440 441 442 444 423 426 427 25 Skin and Malnutrition . . . . . . . . . . . . . . . . . . . . . . . . . . 447 25.1 Vitamin and Mineral Deficiency and Their Effects on the Skin . . . . . . . . . . . . . . 449 26 Skin and Systemic Disease . . . . . . . . . . . . . . . . . . . . . . 26.1 Diabetes Mellitus . . . . . . . . . . . . . . . . . . . . . . . . 26.1.1 Vascular Manifestations . . . . . . . . . . . . 26.1.2 Diabetic Neuropathy . . . . . . . . . . . . . . 26.2 Liver Disease. . . . . . . . . . . . . . . . . . . . . . . . . . . . 26.2.1 Pigmentary Abnormalities. . . . . . . . . . 26.2.2 Vascular Abnormalities . . . . . . . . . . . . 26.2.3 Hair and Nail . . . . . . . . . . . . . . . . . . . . . 26.2.4 Miscellaneous Changes . . . . . . . . . . . . 26.3 Kidney Disease . . . . . . . . . . . . . . . . . . . . . . . . . . 26.4 Rheumatoid Arthritis . . . . . . . . . . . . . . . . . . . . . 26.4.1 Rheumatic Nodules . . . . . . . . . . . . . . . 26.4.2 Vascular Lesions . . . . . . . . . . . . . . . . . . 451 451 451 452 453 454 454 455 455 456 457 457 458 Contents xxi 26.4.3 Atrophic Skin in Rheumatoid Arthritis . . . . . . . . . . . . . . 26.4.4 Rheumatoid Neutrophilic Dermatosis. . . . . . . . . . . . . . . . . . . . . . . Hyperthyroidism . . . . . . . . . . . . . . . . . . . . . . . . . Hypothyroidism . . . . . . . . . . . . . . . . . . . . . . . . . Cushing’s Syndrome . . . . . . . . . . . . . . . . . . . . . . Addison’s Disease. . . . . . . . . . . . . . . . . . . . . . . . Acromegaly . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Hyperlipidemias . . . . . . . . . . . . . . . . . . . . . . . . . Phenylketonuria . . . . . . . . . . . . . . . . . . . . . . . . . Sarcoidosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26.12.1 Cutaneous Manifestations . . . . . . . . . . 26.12.2 Pulmonary Manifestations. . . . . . . . . . 26.12.3 Ocular Manifestations . . . . . . . . . . . . . Skin and Immunodeficiency . . . . . . . . . . . . . . . Skin and Internal Malignancy . . . . . . . . . . . . . . 26.14.1 Invasion of the Skin by Malignant Cells . . . . . . . . . . . . . . . . . . 26.14.2 Exposure to the Carcinogen . . . . . . . . 26.14.3 Physiological . . . . . . . . . . . . . . . . . . . . . 26.14.4 Genetic Disease Predisposing to Malignancy . . . . . . . . . . . . . . . . . . . . 26.14.5 Miscellaneous . . . . . . . . . . . . . . . . . . . . 468 469 27 Skin and the Psyche. . . . . . . . . . . . . . . . . . . . . . . . . . . . 27.1 The Effect of Skin Disease on Psyche . . . . . . . 27.2 The Effect of Psyche on the Skin . . . . . . . . . . . 27.2.1 Dermatitis Artifacta . . . . . . . . . . . . . . . 27.2.2 Trichotillomania . . . . . . . . . . . . . . . . . . 27.2.3 Delusion of Parasitosis . . . . . . . . . . . . . 27.2.4 Acne Excoriee. . . . . . . . . . . . . . . . . . . . 27.2.5 Dermatological Non-disease . . . . . . . . 471 471 472 472 472 473 474 474 26.5 26.6 26.7 26.8 26.9 26.10 26.11 26.12 26.13 26.14 459 459 459 459 460 460 461 461 463 464 464 465 466 466 467 467 468 468 28 Erythroderma. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 477 29 Ages of Man and Their Dermatoses . . . . . . . . . . . . . . 481 29.1 Neonates and Infants . . . . . . . . . . . . . . . . . . . . . 481 xxii Contents 29.1.1 Erythema Toxicum Neonatorum (ETN) . . . . . . . . . . . . . . . 29.1.2 Transient Neonatal Pustular Melanosis . . . . . . . . . . . . . . . . 29.1.3 Miliaria . . . . . . . . . . . . . . . . . . . . . . . . . . 29.1.4 Neonatal Acne. . . . . . . . . . . . . . . . . . . . Skin and Pregnancy . . . . . . . . . . . . . . . . . . . . . . Dermatoses of Pregnancy . . . . . . . . . . . . . . . . . 29.3.1 Pruritus. . . . . . . . . . . . . . . . . . . . . . . . . . 29.3.2 Polymorphous Eruption of Pregnancy (Pruritic Urticarial Papules and Plaques of Pregnancy, PUPP) . . . 29.3.3 Impetigo Herpetiformis . . . . . . . . . . . . 29.3.4 Herpes Gestationis . . . . . . . . . . . . . . . . Skin and the Menopause . . . . . . . . . . . . . . . . . . Cutaneous Disease at the Menopause . . . . . . . 29.5.1 Menopausal Flushing . . . . . . . . . . . . . . 29.5.2 Keratoderma Climacterum . . . . . . . . . Aging Skin . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Dermatoses of Old Age . . . . . . . . . . . . . . . . . . . Looking Younger . . . . . . . . . . . . . . . . . . . . . . . . 29.8.1 Nonsurgical Cosmetic Procedures . . . 484 485 485 486 486 486 486 487 488 488 488 30 Diseases of the Oral Cavity . . . . . . . . . . . . . . . . . . . . . 30.1 Apthous Ulcer. . . . . . . . . . . . . . . . . . . . . . . . . . . 30.2 Oral Candidiasis (Trush) . . . . . . . . . . . . . . . . . . 30.3 Leukoplakia. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30.4 White Hairy Leukoplakia . . . . . . . . . . . . . . . . . 30.5 Submucous Fibrosis . . . . . . . . . . . . . . . . . . . . . . 30.6 Lichen Planus . . . . . . . . . . . . . . . . . . . . . . . . . . . 30.7 Betel Leaf Stomatitis . . . . . . . . . . . . . . . . . . . . . 30.8 Lesions on the Tongue . . . . . . . . . . . . . . . . . . . . 30.9 Lesions on the Lips. . . . . . . . . . . . . . . . . . . . . . . 30.9.1 Actinic Cheilitis. . . . . . . . . . . . . . . . . . . 30.9.2 Angular Cheilitis. . . . . . . . . . . . . . . . . . 30.9.3 Cheilitis Exfoliativa . . . . . . . . . . . . . . . 491 491 493 494 495 496 497 498 499 499 500 500 501 29.2 29.3 29.4 29.5 29.6 29.7 29.8 482 482 483 483 484 484 484 31 Diseases of the External Genitalia . . . . . . . . . . . . . . . 503 31.1 Vulval Intraepithelial Dysplasia (VIN) . . . . . . 503 31.2 Paget’s Disease . . . . . . . . . . . . . . . . . . . . . . . . . . 504 Contents xxiii 31.3 Lichen Sclerosus (LS). . . . . . . . . . . . . . . . . . . . . 504 31.4 Erythroplasia of Queyrat . . . . . . . . . . . . . . . . . . 505 32 Miscellaneous Disorders. . . . . . . . . . . . . . . . . . . . . . . . 32.1 Amyloidosis. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32.2 Mucinosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32.3 Langerhan’s Cell Histiocytosis . . . . . . . . . . . . . 32.4 Benign Lymphocytic Cutaneous Infiltrations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32.5 Kyrle’s Disease . . . . . . . . . . . . . . . . . . . . . . . . . . 32.6 Granuloma Annulare . . . . . . . . . . . . . . . . . . . . . 32.7 Reiter’s Disease . . . . . . . . . . . . . . . . . . . . . . . . . 32.8 Poikiloderma . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32.9 Cutis Verticis Gyrata . . . . . . . . . . . . . . . . . . . . . 507 507 509 510 33 Drug Reactions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33.1 Classification of Drug Reactions. . . . . . . . . . . . 33.1.1 Non-immunological Reactions . . . . . . 33.1.2 Immunological Reactions . . . . . . . . . . 33.2 Approach to a Patient with a Suspected Drug Reaction. . . . . . . . . . . . . . . . . . . . . . . . . . . 33.2.1 Fixed Drug Eruption . . . . . . . . . . . . . . 33.2.2 Exfoliative Dermatitis . . . . . . . . . . . . . 517 517 518 518 34 Management of Skin Diseases . . . . . . . . . . . . . . . . . . . 34.1 Principles of Topical Therapy . . . . . . . . . . . . . . 34.2 Drugs Commonly Used in the Management of Skin Disorders . . . . . . . 34.2.1 Corticosteroids . . . . . . . . . . . . . . . . . . . 34.2.3 Methotrexate . . . . . . . . . . . . . . . . . . . . . 34.2.4 Azathioprine . . . . . . . . . . . . . . . . . . . . . 34.2.5 Cyclosporin . . . . . . . . . . . . . . . . . . . . . . 34.2.6 Dapsone . . . . . . . . . . . . . . . . . . . . . . . . . 34.2.7 Psoralens . . . . . . . . . . . . . . . . . . . . . . . . 34.2.8 Retinoids . . . . . . . . . . . . . . . . . . . . . . . . 34.2.9 Griseofulvin . . . . . . . . . . . . . . . . . . . . . . 34.2.10 Polyenes . . . . . . . . . . . . . . . . . . . . . . . . . 34.2.11 Azole Antifungals . . . . . . . . . . . . . . . . . 34.2.12 Allylamines . . . . . . . . . . . . . . . . . . . . . . 34.2.13 Acyclovir . . . . . . . . . . . . . . . . . . . . . . . . 523 523 511 512 512 513 514 515 518 519 520 525 525 530 531 532 532 533 533 535 535 536 537 537 xxiv Contents 34.3 Immunobiologicals . . . . . . . . . . . . . . . . . . . . . . . 34.3.1 Alefacept . . . . . . . . . . . . . . . . . . . . . . . . 34.3.2 Efalizumab. . . . . . . . . . . . . . . . . . . . . . . 34.3.3 Etanercept . . . . . . . . . . . . . . . . . . . . . . . 34.3.4 Infliximab . . . . . . . . . . . . . . . . . . . . . . . . 34.3.5 Denileukin Difitox . . . . . . . . . . . . . . . . 34.3.6 Interferons (IFN) . . . . . . . . . . . . . . . . . 34.3.7 Intravenous Immunoglobulins . . . . . . 34.4 Topical Immunomodulators . . . . . . . . . . . . . . . 34.4.1 Macrolactams . . . . . . . . . . . . . . . . . . . . 34.4.2 Contact Sensitizers . . . . . . . . . . . . . . . . 34.4.3 Immunostimulants . . . . . . . . . . . . . . . . 34.4.4 Miscellaneous . . . . . . . . . . . . . . . . . . . . 34.5 Physical Modalities Used in the Management of Skin Disorders . . . . . . . 34.5.1 Cryotherapy. . . . . . . . . . . . . . . . . . . . . . 34.5.2 Phototherapy with Psoralens (PUVA) . . . . . . . . . . . . . . . . 34.5.3 Narrow Band UVB Radiation (311 nm). . . . . . . . . . . . . . . . 34.5.4 Photodynamic Therapy . . . . . . . . . . . . 34.5.5 Lasers . . . . . . . . . . . . . . . . . . . . . . . . . . . 34.5.6 Electrocautery/Electrosurgery . . . . . . 34.5.7 Electrolysis. . . . . . . . . . . . . . . . . . . . . . . 34.5.8 Iontophoresis. . . . . . . . . . . . . . . . . . . . . 34.5.9 Surgical Excision. . . . . . . . . . . . . . . . . . 538 539 539 539 539 540 540 540 541 541 541 542 542 Appendix . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Compression Bandaging for Venous Ulcers . . . . . . . . . . Patch Testing and Prick Testing . . . . . . . . . . . . . . . . . . . . Removal of the Nail by Urea . . . . . . . . . . . . . . . . . . . . . . Ultraviolet Radiation and Photochemotherapy . . . . . . . . Lasers Therapy. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Cryotherapy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Management and Care of Wounds . . . . . . . . . . . . . . . . . . 551 551 555 561 563 569 573 577 543 543 543 544 544 545 546 547 547 548 Bibliography. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 581 Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 583 Morning Prayer of Maimonides O God let my mind be clear and enlightened. By the bedside of the patient let no alien thought deflect it. Let everything that experience and scholarships have taught me, be present in me, and my mind hinders not in my tranquil work. For great and noble are those scientific judgments, that serve the purpose of preserving health and lives of thy creatures. Keep far from me the delusions that I can accomplish all things. Give me the strength, the will and the opportunity to amplify my knowledge more and more. Today I can disclose things in my knowledge, which yesterday I would have not dreamt of; for the art is great, but the human mind presses on untiringly. In the patient let me see only the man. Thou, All-Bountiful One, have chosen me to watch over life and death of thy creatures. I prepare myself now for my calling. Stand Thou by me in this great task, so that it may prosper. For without Thine aid man prospers not even in the smallest things. xxv xxvi Morning Prayer of Maimonides Maimonides (1135–1204) Moses Maimonides was one of the greatest Jewish scholars of all times. He was a rabbi, physician and philosopher. Maimonides was the first person to write the systematic review of all Jewish law. Maimonides was trained as a physician in Spain. He wrote a number of books on medicine, ethics and on aphorisms. His treatises became influential for generation of physicians. Maimonides was a physician to Sultan Saladin, after his death he continued to be a physician to the royal family. When Almohades from Africa conquered Cordoba and threatened the Jewish community, Maimonides’ family choose exile