A COLOR GUIDE TO DIAGNOSIS AND THERAPY

CLINICAL
DERMATOLOGY

THOMAS P. HABIF
FOURTH EDITION

Mosby

Disorders Index
Cat-scratch disease, 528
Cavernous hemangiomas, 818

Cellulitis, 273

Cement dermatitis and burns, 95

Chancroid, 327
Chapped fissured feet, 62
Cherry angioma, 824
389
Cholinergic urticaria, 145
Chondrodermatitis nodularis chronica hellicis, 716
Churg-Strauss syndrome, 640, 649
Cicatricial pemphigoid, 548
Cold urticaria, 146
Compound nevi, 774
Condyloma acuminata, 358
Congenital nevi, 777
Congenital syphilis, 320
Contact dermatitis, 81
Contact urticaria syndrome, 152
Coral poisoning, 543
Corns 374
Cowden's disease, 912
Crab lice, 506
Cradle cap, 242
Creeping eruptions, 537
CREST syndrome, 617, 832
Cutaneous horn, 706
Cutaneous larva migrans, 537
Cutaneous
lymphoma, 754
Cystic acne, 174
Delusions of parasitosis, 70
Dermal nevi, 775
Dermatitis herpetiformis, 548, 554
Dermatofibroma, 708
607
Dermatophytid reaction, 414
Dermographism, 142
Digital mucous cyst, 888
Discoid lupus erythematosus, 596,
Dissecting cellulitis, 861
Distal nail splitting, 883

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Abscesses, 284
Acanthosis nigricans, 900
Acne keloidalis, 283, 861
Acne rosacea, 198
Acne, 162
lentiginous melanoma, 796
Acrochordon, 706

Actinic cheilitis, 738

Actinic comedones, 664

Actinic keratosis, 736
Adenoma sebaceum, 909
Allergic contact dermatitis, 84
Alopecia areata, 855
Androgenetic alopecia female 844
Androgenetic alopecia men, 842
147
Angiokeratoma, 824
Angular cheilitis, 450
Animal bites, 529
Ants, 538
pruritus, 147
Aquagenic urticaria, 142
Arsenical keratoses, 753
Arterial leg ulcers, 74
Arthritis-dermatitis syndrome, 333
Asteatotic eczema (xerosis), 60
Atopic dermatitis, 105
Atypical mole syndrome, 782
Baboon syndrome, 94
Bacillary angiomatosis, 827
Basal cell carcinoma, 724
Bathing trunk nevus, 778
Beau's lines, 463, 865, 884
Becker's nevus, 780
Bee stings, 531
Benign familial chronic pemphigus, 575
Benign juvenile melanoma, 781
Berlock dermatitis, 682
Bite wounds, 530
Black heel, 374
Black widow spider bites, 512
Blepharitis, 242
Blistering distal dactylitis, 287
Blue nevus, 782
Bowenoid papulosis, 343
Bowen's disease, 748
Brown recluse spider bites, 514
Bullous impetigo, 268
Bullous pemphigoid, 567-570, 568, 569
Buschke-Lowenstein, giant condylomata of, 752
spots, 694, 905
Candidiasis, 440
Capillary hemangioma, lobular, 826
Carbuncles, 284
Cat bites, 529
Caterpillar dermatitis, 510

Dog bites, 529

Drug eruptions, 490

Dyshidrosis (pompholyx), 58
Dysplastic nevi, 782
Dystrophic epidermolysis bullosa, 576
Ecthyma gangrenosum, 298
Ecthyma, 272
Eczema craquele, 60
Eczema
388
dermatitis, 107
En coup de sabre, 622
Eosinophilic folliculitis 358
Ephelides, 691
Epidermal cyst, 717
Epidermal nevus, 713

Disorders Index
Labial melanocytic macule, 782
Lentigo (liver spots), 691
Lentigo maligna, 794
Leukocytoclastic vasculitis, 642
Leukonychia, 882
Leukoplakia, 751
Lichen planopilaris, 861
Lichen planus, 250
Lichen sclerosis et atrophicus, 257
Lichen simplex chronicus, 54, 63, 66
Linear
bullous dermatosis, 556
Lupus erythematosus, 592
Lyme disease,
Lymphangioma circumscriptum, 825
Male-pattern baldness, 842
Malignant melanoma, 786
Mastocytosis, 156
Measles, 460
299
Methotrexate 229
194
Miliaria rubra, 205
Morphea, 620
disease, 261
Muir-Torre syndrome, 914
Mycosis fungoides, 754
Myiasis, 534
Necrobiosis lipoidica, 897
Neurotic excoriations, 68
Nevoid basal cell carcinoma syndrome, 731
Nevus flammeus (port-wine stains), 819
Nevus sebaceous, 715
Nummular eczema, 54
Onycholysis, 880
Onychomycosis 875
Otitis externa, 294
Paronychia, 867
Parvovirus B-19 infection, 468
Pearly penile papules, 339
Pediculosis, 506
Pemphigoid, 567
Pemphigus, 559
Perioral dermatitis, 30, 195
Perleche, 450
Pilar cyst, 719
Pilar cysts, 719
Pitted keratolysis, 416
Pityriasis alba,
689
Pityriasis lichenoides chronica, 261
Pityriasis rosea, 246
Pityriasis rubra pilaris, 240
Plantar warts, 374
PLEVA 261
Poikiloderma vasculare atrophicans, 756
Poikiloderma, 609
Poison ivy, 85

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Epidermolysis bullosa acquisita, 574

Epidermolysis bullosa simplex, 576
Erysipelas, 273
Erysipeloid, 287
Erythema ab
694
Erythema elevatum
653
Erythema
Erythema multiforme,
Erythema nodosum, 635
Erythema toxicum neonatorum, 582
419
psoriasis, 213
Erythroplasia of Queyrat, 749
Erythropoietic protoporphyria 680
subitum, 471
Exercise-induced anaphylaxis, 145
Exfoliative erythroderma, 491
External otitis, 294
Extramammary Paget's disease, 764
Fifth disease, 468
Fire ant stings, 538
Folliculitis decalvans, 860
Folliculitis, 279
Furuncles (boils), 284
Gardner's syndrome, 913
Genital warts, 336
German measles, 467
Gonorrhea, 330
Granuloma annulare, 898
Granuloma inguinale, 329
Guttate psoriasis, 212
Hairy leukoplakia, 363
Halo nevi,
Hand eczema, 50
Hand, foot, and mouth disease, 462
Henoch-Schonlein purpura, 645
Herpes simplex, 381
Herpes zoster, 394
Herpetic whitlow, 873
Hidradenitis suppurativa, 202
Hirsutism, 846
Hypersensitivity vasculitis, 642
Ichthyosis vulgaris, 115
Idiopathic guttate hypomelanosis, 689
Intertrigo, 418
Irritant contact dermatitis, 82
Isotretinoin, 186
Junction nevus, 774
Kaposi's sarcoma, 827
Kawasaki syndrome, 474
Keloids, 709
Keratoacanthoma,
Keratoderma blennorhagicum, 216
Keratolysis exfoliativa, 55
Keratolysis, pitted, 416
Keratosis pilaris,

Continued

Disorders Index
Sweet's syndrome, 650
Swimmer's itch, 539
Sycosis barbae, 282
Syphilis, 315
Syringoma, 721
Systemic lupus erythematosus, 600
lyphoma, cutaneous, 754
Telangiectasia macularis eruptiva perstans, 157
Telangiectasia, 830
Telogen effluvium, 841
Tendinous xanthoma, 904
Terry's nails, 885
Tick bite paralysis, 526
Tinea
243
Tinea barbae, 434
Tinea capitis, 427
Tinea corporis, 420
Tinea cruris, 417
Tinea gladiatorum, 422
Tinea incognito, 38, 417, 426
Tinea pedis, 413
Tinea unguium, 874
Tinea versicolor, 451
Toxic epidermal necrolysis, 491, 627
Toxic shock syndrome, 479
Transient neonatal pustular melanosis, 582
Trichomonas vaginalis, 440
Trichomycosis axillaris, 862
Trichotillomania, 858
Tuberous sclerosis, 909
Tuberous xanthoma, 904
Tufted folliculitis, 860
Unilateral nevoid telangiectasia syndrome, 832
Urethritis, 309
Urticaria pigmentosa, 156
Urticaria, 129
Urticarial vasculitis,
Vaginal lichen planus, erosive, 255
Vaginosis, bacterial, 313t
Varicella, 389
Venous lake, 825
Venous ulcers, 73
Verrucous carcinoma, 752
Verrucous epidermal nevus, 714
Viral exanthems, 473

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Polyarteritis nodosa, 640

Polymorphous light eruptions, 671
Pompholyx
58
Porphyria cutanea tarda, 675
Port-wine stains, 819
Postherpetic neuralgia, 400
Pressure urticaria, 144
Prurigo nodularis, 68,

Pseudofolliculitis barbae, 280

folliculitis, 290
Pseudopelade, 860
Pseudoporphyria, 679
Pseudoxanthoma elasticum, 916
Psoriasis, 209
Pustular psoriasis
Pyoderma gangrenosum, 653
Pyogenic granuloma, 826, 889
Rocky Mountain spotted fever, 524
Rosacea, 198
Roseola infantum, 471
Rubella, 467
Scabies, 497
Scarlet fever, 464
disease, 656
Scleroderma, 613
Seabather's eruption, 540
Sebaceous hyperplasia, 720
Seborrheic dermatitis, 242
Seborrheic keratosis, 698
Senile comedones, 194
Serum sickness,
Sezary syndrome, 760
Shingles, 394
Skin tags, 706
Small-vessel vasculitis,
Speckled lentiginous nevus, 778
Spider angioma, 830
Spider bites,
Spitz nevus, 781
Squamous cell carcinoma, 744
Staphylococcal scalded skin syndrome, 288
Stasis dermatitis, 72
Stasis ulcers, 14
Steroid acne, 33, 191
Steroid atrophy, 34
Steroid rosacea, 30
Stevens-Johnson syndrome, 630
Stinging insects, 531
Strawberry hemangiomas,
Striae, 15
Stucco keratosis, 705
Sturge-Weber syndrome, 822
Sunburn, 233
Superficial basal cell carcinoma, 726
Superficial spreading melanoma, 788

Virilization, 846
Vitiligo, 684

Von Recklinghausen's neurofibromatosis, 905

Warts, 368
Wegener's granulomatosis, 640, 648
White superficial onychomycosis, 876
Xanthelasma, 903
Xanthoma, 902
Xerosis, 60
Yellow nails syndrome, 884
Zoster sine herpete, 402

A brand new edition

...in a brand new way!
A COLOR GUIDE TO DIAGNOS

CLINICAL
DERMATOLOGY

Accessing unparalleled clinical guidance on

the identification, diagnosis, and treatment
of virtually every common skin disorder is
now easier than ever!
A variety of formats delivers unprecedented
reference power!
Clinical Dermatology: A Color Guide
to Diagnosis and Therapy (Edition

THOMAS P. HABlF

Clinical Dermatology: A Color

Guide to Diagnosis and Therapy,
4th edition
By Thomas R Habif, MD

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Mosby
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At www.clinderm.com, you can search the
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or laptop. You'll also access...
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Clinical Dermatology
A COLOR GUIDE TO DIAGNOSIS AND THERAPY

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Clinical Dermatology
A COLOR GUIDE TO DIAGNOSIS AND THERAPY
Thomas Habif MD

Adjunct Professor of Medicine (Dermatology)

Dartmouth Medical School
Hanover, NH, USA

Commissioning Editor: Sue Hodgson

Project Development Editor: Louise Cook
Publishing Services Manager: Melissa Lastarria
Layout Design: Jeanne Genz
Design Coordinator: Jayne Jones
Illustration Coordinator: Michael Ruddy

Project Organization: Laura A. McCann

Medical Photography: Alan N. Binnick, MD, and
Thomas P. Habif, MD

Photographs: Barry M. Austin, MD, Richard D. Baughman,

MD, Daniel W. Collison, MD, Warren M. Pringle, MD,
Cameron L. Smith, MD, and Steven K. Spencer, MD

Technical Advice: David V. Habif, Jr, MD

Moral Support: Dorothy, Tommy, and David

Mosby

Edinburgh

London New York Oxford Philadelphia St Louis Sydney Toronto 2004

Mosby
An Affiliate of Elsevier

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The Curtis Center

Independence Square West
Philadelphia, Pennsylvania 19106

CLINICAL DERMATOLOGY: A COLOR GUIDE TO

DIAGNOSIS AND THERAPY

Mosby,

All rights reserved.

No part of this publication may be reproduced or transmitted

form
or by any means, electronic or mechanical, including photocopying,
recording, or any information storage and retrieval system, without
permission in writing from the publisher. Permissions may be sought
directly from Elsevier's Rights Department in Philadelphia, PA, USA: phone:
(11) 215 238 7869, fax: (11)
238 2239, e-mail:
You may also complete your request on-line via the Elsevier
homepage
by selecting 'Customer Support' and
then
Permissions'.

ronicor
Dermatology is an ever-changing field. Standard safety precautions must be
followed, but as new research and clinical experience broaden our knowledge, changes in treatment and
therapy may become necessary or apReaders are advised to check the most current product information provided by the manufacturer of each
to be administered to verify
the recommended dose, the method and duration of administration, and
contraindications. It is the responsibility of the licensed prescriber, relying
on experience and knowledge of the patient, to determine dosages and the
best treatment
each individual patient. Neither the publisher nor the author assumes any liability for any injury
damage to persons or property arising from this publication.

Previous editions copyrighted

International Standard Book Number 0-323-01319-8

Printed in Chile

Last digit i s t h e print n u m b e r :

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Preface

Clinical Dermatology is intended to be a practical resource for

the busy clinician. Over 1000 illustrations are combined with
disease descriptions and current and comprehensive therapeutic information. Bold headings are used to facilitate rapid
access to information. Diseases can be accessed in many ways.
The classic method of organizing skin diseases is used.
Common diseases are covered in depth. Illustrations of classic examples of these disorders and photographs of variations
seen at different stages are included. Basic dermatologic surgical techniques are covered in detail. Specialized techniques
such as Mohs'
surgery are described so that the
physician can be better prepared to suggest referral.
Theoretical information, disease mechanisms, and rare disease are found in comprehensive textbooks.

Rapid Access to the Text

1. List of disorders with page

front cover.
2. List of common topical
disorders pages.
3. List of diseases by region with page
back cover.
4. List of diseases by lesion type with page
3.
5. Formulary is located on pages 945 to 973.

How to Use This Book

Students in the classroom

Students should learn the primary and secondary lesions and

the distribution of diseases in Chapter 1 and study the differential diagnosis of each lesion. Select a few familiar diseases
from each list and read about them. Study the close-up pictures carefully. Obtain an overview of the text. Turn the
pages, look at the pictures, and read the captions.

Students in the clinic

You see skin abnormalities every day in the clinic. Try to

identify these diseases, or ask for assistance. Study all
eases, especially tumors, with a magnifying glass or ocular
lens. Read about what you see and you will rapidly gain a
broad fund of knowledge.

Study Chapters 20 (Benign Skin Tumors), 21 (Premalignant

and Malignant Nonmelanoma Skin Tumors), and 22 (Nevi
and Malignant Melanoma). Skin growths are common, and it
is important to recognize their features.
House officers are responsible for patient management.
Read Chapter 2
and study all aspects of the use of
topical steroids. These valuable agents are used to treat a
great variety of inflammatory skin conditions. It is tempting
to use these agents as a therapeutic trial and ask for a consultation only if therapy fails. Topical steroids mask some diseases, make some diseases worse, and create other diseases.
Do not develop bad habits; if you do not know what a disease
is, do not treat it.
The diagnosis of skin disease is deceptively easy. Do not
make hasty diagnoses. Take a history, study primary lesions
and the distribution, and be deliberate and methodical. Ask
for help. With time and experience you will feel comfortable
managing many common skin diseases.

The practicing clinician

Most skin diseases are treated by practitioners other than

dermatologists. This includes primary care physicians, nurse
practitioners and physician assistants. Clinicians involved in
direct patient care should read the above guidelines for using
this book. Learn a few topical steroids in each potency group.
There are a great number of agents in the Formulary. Many
in each table contain similar ingredients and have the same
therapeutic effect. Develop an armamentarium of agents and
gain experience in their use.
Inflammatory conditions are often confusing, and sometimes biopsies are of limited value in their diagnosis. Eczema
is common, read Chapters 2 and 3. Acne is seen everyday,
read Chapter 7. Managing acne effectively will provide a great
service to many young patients who are very uncomfortable
with their appearance. The clinical diagnosis of pigmented lesions is complicated. A dermatologist can often make a specific diagnosis without the need for a biopsy.

The dermatologist

Many dermatologists use the pictures as an aid to reassure

patients. Examine the patient, make a diagnosis, and then

Clinical Dermatology
show them an illustration of their disease. Many patients see
the similarity and are reassured.
This book is designed to be a practical resource. All of the
most current descriptive and therapeutic information that is
practical and relevant has been included. All topics are researched on Medline. Details about basic science and complex mechanisms of disease can be found elsewhere. Rare diseases are found in larger textbooks.

Production
The author writes the manuscript. The publishing company
makes the book. Manufacturing a book is a complicated
process. The key people involved in this effort are listed on
the title page. As my first editor said 20 years ago, "if people
ever realized what was involved in making a book, they
would not believe that it could ever get done."
The layout and design of each page in this book is done the
"old fashion way," by cutting and pasting images and strips
of text by the layout artist. Page layout design is a science and
an art. Jeanne Genz has designed all four editions of this
book. This older, slower, noncomputerized technique created by an expert produces pages that are balanced and of
maximum clarity. Computer layout programs are not capable of this art. The final "pasted" book is then converted to a
digital file and printed on high-grade glossy paper on a
sheetfed press. Glossy paper retains ink at the surface to enhance definition. Sheetfed presses print slowly and allow ink
to be laid down precisely so that exceptional sharpness and
color balance are achieved.

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viii

Photography

The photographs were taken with medium format cameras,

35-mm macro cameras, and digital macro cameras. The digital images for this edition were taken by me with a Nikon
digital camera fitted with a 60 mm macro lens and a
Canfield TwinFlash. The macro camera takes pictures that
simulate the view through a hand lens. Therefore the distribution of the disease and the primary lesion can be accurately illustrated. Over 4000 new digital images were acquired in preparation for this edition. Alan N.
Adjunct Assistant Professor of Medicine (Dermatology),
Dartmouth Medical School, provided all of the new images
taken with transparency film. He has 25 years of experience
as a clinician, teacher, and expert photographer. His entire
collection was available for this edition.

Thomas P. Habif
2003

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1 Principles of Diagnosis and Anatomy 1

Skin anatomy 1
Epidermis 1
Dermis 1
Dermal nerves and vasculature 1
Diagnosis of skin disease 2
A methodical approach 2
Examination technique 2
Approach to treatment 2
Primary lesions 2
Secondary lesions 2
Special skin lesions 16
Regional differential diagnoses 18

2 Topical Therapy and Topical Corticosteroids 23

Topical therapy 23
Emollient creams and lotions 23
Severe dry skin (xerosis) 23
Wet dressings 24
Topical corticosteroids 25
Strength 25
Vehicle 26
Steroid-antibiotic mixtures 27
Amount of cream to dispense 27
Application 28
Adverse reactions 30

3 Eczema and Hand Dermatitis

41

Stages of eczematous inflammation 43

Acute eczematous inflammation 43
Subacute eczematous inflammation 44
Chronic eczematous inflammation 48
Hand eczema 50
Irritant contact dermatitis 51
Atopic hand dermatitis 53
Allergic contact dermatitis 54
Nummular eczema 54
Lichen simplex chronicus 54
Recurrent focal palmar peeling 55
Hyperkeratotic eczema 55
Fingertip eczema 57
Pompholyx 59
Id reaction 59

Eczema: various presentations 60

Asteatotic eczema 60
Nummular eczema 61
Chapped fissured feet 62
Self-inflicted dermatoses 63
Lichen simplex chronicus 63
Prurigo nodularis 68
Neurotic excoriations 68
Psychogenic parasitosis 70
Stasis dermatitis and venous ulceration: postphlebitic
syndromes 72
Stasis dermatitis 72
Types of eczematous inflammation 72
Venous leg ulcers 74

4 Contact Dermatitis and Patch Testing

Irritant contact dermatitis 82
Allergic contact dermatitis 84

81

Systemically induced allergic contact dermatitis 84

Clinical presentation 84
Rhus dermatitis 88
Natural rubber latex allergy 90
Shoe allergy 92
Metal dermatitis 93
Cement dermatitis and burns 95
Further examples of allergic contact dermatitis 95
Patients with leg ulcers 97
Cosmetic and fragrance allergy 97
Diagnosis of contact dermatitis 98
Patch testing 98

5 Atopic Dermatitis

105

Pathogenesis and immunology 106

Clinical aspects 107
Infant phase (birth to 2 years) 108
Childhood phase (2 to 12 years) 111
Adult phase (12 years to adult) 114
Associated features 115
Dry skin and xerosis 115
Ichthyosis vulgaris 115
Keratosis pilaris 116
Hyperlinear palmar creases 118
Pityriasis alba 118

Overview of diagnosis and treatment 163

Etiology and pathogenesis 169
Approach to acne therapy 170
Acne treatment 171
Therapeutic agents for treatment of acne 178
Acne surgery 190
Other types of acne 190
Perioral dermatitis 195
Treatment 197
Rosacea (acne rosacea) 198
Skin manifestations 198
Ocular rosacea 200
Treatment 200
Hidradenitis suppurativa 202
Clinical presentation 202
Pathogenesis 202
Management 203
Miliaria 205
Miliaria crystalline 205
Miliaria rubra 205
Miliaria profunda 205

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Atopic pleats 118

Cataracts and keratoconus 118
Triggering factors 120
Temperature change and sweating 120
Decreased humidity 120
Excessive washing 120
Contact with irritating substances 120
Contact allergy 120
Aeroallergens 120
Microbic agents 120
Food 120
Aeroal lergens 120
Treatment 120
Dry skin 122
Inflammation and infection 122
Infants 123
Children and adults 123
Tar 124
Hospitalization for severely resistant cases 125
Lubrication 125
Sedation and antihistamines 125
Phototherapy 126
Diet restriction and breast-feeding 126

6 Urticaria and Angioedema 129

Clinical aspects 130

Pathophysiology 133
Initial evaluation of all patients with urticaria 134
Acute urticaria 134
Chronic urticaria 136
Treatment of urticaria 139
Antihistamines 140
Epinephrine 141
Oral corticosteroids 141
Immunotherapy 141
Physical urticarias 142
Dermographism 142
Pressure urticaria 144
Cholinergic urticaria 145
Exercise-induced anaphylaxis 145
Cold urticaria 146
Solar urticaria 147
Heat, water, and vibration urticarias 147
Aquagenic pruritus 147
Angioedema 147
Acquired forms of angioedema 148
Hereditary angioedema 151
Contact urticaria syndrome 152
Pruritic urticarial papules and plaques
of pregnancy 152
Urticarial vasculitis 154
Serum sickness 155
Mastocytosis 156

Acne, Rosacea, and Related Disorders 162

Acne 162
Classification 163

Psoriasis and Other Papulosquamous

Diseases 209
Psoriasis 209
Clinical manifestations 210
Histology 211
Clinical presentations 211
Chronic plaque psoriasis 212
Guttate psoriasis 212
Generalized pustular psoriasis 213
Erythrodermic psoriasis 213
Light-sensitive psoriasis 214
Psoriasis of the scalp 214
Psoriasis of the palms and soles 214
Pustular psoriasis of the palms and soles 214
Keratoderma blennorrhagicum (Reiter's syndrome) 216
Psoriasis of the penis and Reiter's syndrome 216
Pustular psoriasis of the digits 216
Psoriasis inversus (psoriasis of the flexural or intertriginous
areas) 217
Human immunodeficiency virus (HlV)-induced psoriasis 217
Psoriasis of the nails 218
Psoriatic arthritis 220
Treatment of psoriasis 222
Topical therapy 224
Systemic therapy 228
Biologic therapy for psoriasis 238
Pityriasis rubra pilaris 240
Seborrheic dermatitis 242
Infants (cradle cap) 242
Young children (tinea amiantacea and blepharitis) 242
Adolescents and adults (classic seborrheic dermatitis) 245
Acquired immunodeficiency syndrome 245
Pityriasis rosea 246
Lichen planus 250
Localized papules 250

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Clinical manifestations 299

Hypertrophic lichen planus 252
Diagnosis 301
Generalized lichen planus and lichenoid drug eruptions 252
Differential diagnosis 301
Lichen planus of the palms and soles 252
Management 301
Follicular lichen planus 252
Nontuberculous mycobacteria 304
Oral mucous membrane lichen planus 254
. ulcerans, . fortuitum, . chelonei, and M. avium
Follic ular lichen planus 252
intracellulare 304
Nails 255
Diagnosis 255
10 Sexually Transmitted Bacterial Infections 307
Treatment 256
Sexually transmitted disease presentations 307
Lichen sclerosus et atrophicus 257
Genital ulcers 307
Lichen sclerosus et atrophicus of the penis 258
Syphilis 315
Pityriasis lichenoides 261
Incidence 315
Bacterial Infections
267
Stages 315
Skin infections 267
Risk of transmission 317
Impetigo 267
T. pallidum 317
Primary syphilis 317
Ecthyma 272
Secondary syphilis 318
Cellulitis and erysipelas 273
Cellulitis of specific areas 274
Latent syphilis 320
Necrotizing fasciitis 278
Tertiary syphilis 320
Syphilis and human immunodeficiency virus 320
Folliculitis 279
Staphylococcal folliculitis 279
Congenital syphilis 320
Syphilis serology 321
Keratosis pilaris 280
Pseudofolliculitis barbae (razor bumps) 280
Treatment of syphilis 323
Posttreatment evaluation of syphilis 324
Sycosis barbae 282
Acne keloidalis 283
Rare sexually transmitted diseases 325
Furuncles and carbuncles 284
Lymphogranuloma venereum 325
Location 284
Chancroid 327
Granuloma inguinale (donovanosis) 329
Bacteria 284
Predisposing conditions 284
Diseases characterized by urethritis and cervicitis 330
Clinical manifestations 284
Gonorrhea 330
Neisseria gonorrhoeae 330
Differential diagnosis 285
Treatment of furuncles 285
Nongonococcal urethritis 334
Recurrent furunculosis 286
11 Sexually Transmitted Viral Infections 336
Erysipeloid 287
Genital warts 336
Clinical manifestation 287
Human papillomavirus 336
Diagnosis 287
Incidence 336
Treatment 287
Transmission 336
Blistering distal dactylitis 287
Clinical presentation 337
Staphylococcal scalded skin syndrome 288
Diagnosis 340
Epidermolytic toxin 288
Treatment 340
Incidence 288
Bowenoid papulosis 343
Clinical manifestations 288
Molluscum contagiosum 344
Pathophysiology 289
Clinical manifestations 344
Diagnosis 289
Diagnosis 344
Treatment 289
Treatment 345
Pseudomonas aeruginosa infection 290
Genital herpes simplex 346
Pseudomonas folliculitis 290
Prevalence 346
Pseudomonas hotfoot syndrome 290
Risk factors 346
Pseudomonas cellulitis 292
Rate of transmission 348
External otitis 294
Primary and recurrent infections 348
Malignant external otitis 297
Prevention 350
Toe web infection 298
Laboratory diagnosis 350
Ecthyma gangrenosum 298
Serology 351
Meningococcemia 299
Psychosocial implications 352
Transmission 299
Treatment of genital herpes (Centers for Disease Control
Incidence 299
Guidelines) 352
Pathophysiology 299

Chronic mucocutaneous candidiasis 450

Tinea versicolor 451
Pityrosporum folliculitis 454

Exanthems and Drug Eruptions 457

Exanthems 460
Measles 460
Hand, foot, and mouth disease 462
Scarlet fever 464
Rubella 467
Erythema infectiosum (parvovirus B19 infection) 468
Roseola infantum (human herpes virus 6 and 7 infection) 471
Enteroviruses: echovirus and coxsackievirus exanthems 473
Kawasaki syndrome 474
Superantigen toxin-mediated illnesses 478
Toxic shock syndrome 479
Cutaneous drug reactions 482
Drug eruptions: clinical patterns and most frequently
causal drugs 485
Exanthems (maculopapular) 485
Urticaria 488
Pruritus 489
Drug eruptions 490
Acute generalized exanthemous pustulosis 490
Acneiform (pustular) eruptions 490
Eczema 490
Blistering drug eruptions 491
Erythema multiforme and toxic epidermal necrolysis 491
Exfoliative erythroderma 491
Fixed drug eruptions 492
Lichenoid (lichen planus-like drug eruptions) 493
Lupus erythematosus-like drug eruptions 493
Photosensitivity 493
Pigmentation 494
Vasculitis 494
Lymphomatoid drug eruptions 494
Chemotherapy-induced acral erythema 494
Skin eruptions associated with specific drugs 494

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Genital herpes simplex during pregnancy 354

Genital herpes simplex dur infection 355
Acquired immunodeficiency syndrome 356
Human immunodeficiency virus pathogenesis 356
14
Diagnosis 356
Viral burden 356
Assessment of immune status (CD4 + T-cell determinations)
357
Revised Centers for Disease Control and Prevention classification and management 357
Dermatologic diseases associated with human immunodeficiency virus infection 358

12 Warts, Herpes Simplex, and Other Viral

Infections 368

Warts 368
Common warts 371
Filiform and digitate warts 372
Flat warts 373
Plantar warts 374
Subungual and periungual warts 378
Genital warts 378
Molluscum contagiosum 379
Herpes simplex 381
Oral-labial herpes simplex 384
Cutaneous herpes simplex 386
Eczema herpeticum 388
Varicella 389
Chickenpox in the immunocompromised patient 391
Chickenpox and HIV infection 391
Chickenpox during pregnancy 391
Congenital and neonatal chickenpox 392
Herpes zoster 394
Herpes zoster after varicella immunization 398
Herpes zoster and HIV infection 398
Herpes zoster during pregnancy 398
Syndromes 398
Prevention of postherpetic neuralgia: early combined antiviral
drugs and antidepressants 404
15 Infestations and Bites 497
Treatment of postherpetic neuralgia 404
Scabies 497
Anatomic features, life cycle, and immunology 499
13 Superficial Fungal Infections 409
Clinical manifestations 500
Dermatophyte fungal infections 409
Diagnosis 503
Tinea 413
Treatment and management 504
Tinea of the foot 413
Scabies in long-term care facilities 505
Pitted keratolysis 416
Pediculosis 506
Tinea of the groin 417
Tinea of the body and face 420
Biology and life cycle 506
Clinical manifestations 507
Tinea of the hand 425
Diagnosis 508
Tinea incognito 426
Treatment 509
Treatment of the scalp 427
Caterpillar dermatitis 510
Tinea of the beard 434
Clinical manifestations 510
Treatment of Fungal Infections 434
Diagnosis 512
Candidiasis (Moniliasis) 440
Treatment 512
Candidiasis of normally moist areas 440
Spiders 512
Candidiasis of large skin folds 446
Black widow spider 512
Candidiasis of small skin folds 449

Localized pemphigoid 571

Benign chronic bullous dermatosis of childhood 572
Herpes gestationis (pemphigoid gestationis) 573
Pemphigoid-like disease 574
Epidermolysis bullosa acquisita 574
Benign familial chronic pemphigus 575
Epidermolysis bullosa 576
The newborn with blisters, pustules, erosions, and
ulcerations 577

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Brown recluse spider 514

Ticks 516
Lyme disease and erythema migrans 517
Rocky mountain spotted and spotless fever 524
Tick bite paralysis 526
Removing ticks 527
Cat-scratch and related diseases 528
Clinical manifestations 528
Neurologic complications 528
Bacillary angiomatosis 528
Diagnosis of cat-scratch disease 529
Treatment 529
Animal and human bites 529
Management 529
Stinging insects 531
Toxic reactions 531
Allergic reactions 531
Diagnosis 532
Indications for venom skin testing and immunotherapy 532
Treatment 532
Biting insects 533
Papular urticaria 533
Fleas 533
Myiasis 534
Mosquitoes 536
Creeping eruption 537
Management 537
Ants 538
Fire ants 538
Dermatitis associated with swimming 539
Swimmer's itch (fresh water) 539
Nematocyst stings 539
Florida, Caribbean, Bahamas 541
Echinoderms (sea urchins and starfish) 543

16 Vesicular and Bullous Diseases 547

Blisters 547
Autoimmune blistering diseases 547
Major blistering diseases 547
Classification 550
Diagnosis of bullous disorders 551
Dermatitis herpetiformis and linear IgA bullous
dermatosis 554
Gluten-sensitive enteropathy 556
Lymphoma 556
Diagnosis of dermatitis herpetiformis 556
Bullae in diabetic persons 559
Pemphigus 559
Pathophysiology 561
Pemphigus vulgaris 561
Pemphigus foliaceus, IgA pemphigus, and pemphigus
erythematosus 562
Diagnosis of pemphigus 564
Treatment 565
Pemphigus in association with other diseases 566
The pemphigoid group of diseases 567
Bullous pemphigoid 567

17 Connective Tissue Diseases 587

Diagnosis 587
Antinuclear antibody testing 587
Lupus erythematosus 592
Clinical classification 592
Subsets of cutaneous lupus erythematosus 593
Chronic cutaneous lupus erythematosus 596
Subacute cutaneous lupus erythematosus 598
Systemic lupus erythematosus 600
Other cutaneous signs of lupus erythematosus 602
Drug-induced lupus erythematosus 603
Neonatal lupus erythematosus 604
Diagnosis and management of cutaneous lupus
erythematosus 605
Treatment 605
Dermatomyositis and Polymyositis 607
Polymyositis 607
Dermatomyositis 607
Scleroderma 613
Systemic sclerosis 613
Chemically induced scleroderma 613
CREST syndrome 617
Localized scleroderma 620

18 Hypersensitivity Syndromes and Vasculitis 626

Hypersensitivity syndromes 626

Erythema multiforme 626
The Stevens-Johnson syndrome/toxic epidermal
necrolysis spectrum of disease 630
Stevens-Johnson syndrome 630
Toxic epidermal necrolysis 632
Erythema nodosum 635
Vasculitis 637
Vasculitis of small vessels 642
Hypersensitivity vasculitis 642
Henoch-Schonlein purpura 645
Antinuclear cytoplasmic antibody-associated
small-vessel vasculitis 648
Wegener's granulomatosis 648
Churg-Strauss syndrome 649
Microscopic polyangiitis 649
Antinuclear cytoplasmic antibody-negative
small-vessel vasculitis 649
Neutrophilic dermatoses 650
Sweet's syndrome (acute febrile neutrophilic dermatosis) 650
Erythema elevatum diutinum 653
Pyoderma gangrenosum 653
Schamberg's disease 656

19 Light-Related Diseases and Disorders of

Pigmentation 661

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Photobiology 661
Sun-damaged skin 662
Suntan and sunburn 668
Sun protection 668
Polymorphous light eruption 671
Hydroa aestivale and hydroa vacciniforme 674
Porphyrias 675
Porphyria cutanea tarda 675
Pseudoporphyria 679
Erythropoietic protoporphyria 680
Phototoxic reactions 681
Photoallergy 683
Disorders of hypopigmentation 684
Vitiligo 684
Idiopathic guttate hypomelanosis 689
Pityriasis alba 689
Nevus anemicus 690
Tuberous sclerosis 690
Disorders of hyperpigmentation 691
Freckles 691
Lentigo in children 691
Lentigo in adults 691
Melasma 692
Cafe-au-lait spots 694
Diabetic dermopathy 694
Erythema ab igne 694

Bowen's disease 748

Erythroplasia of Queyrat 750
Leukoplakia 751
Verrucous carcinoma 753
Arsenical keratoses and other arsenic-related skin
diseases 753
Cutaneous T-cell lymphoma 754
Paget's disease of the breast 763
Extramammary Paget's disease 764
Cutaneous metastasis 765

20 Benign Skin Tumors 698

Seborrheic keratoses 698

Stucco keratoses 705
Dermatosis papulosa nigra 706
Cutaneous horn 706
Skin tags (acrochordon) and polyps 706
Dermatofibroma 708
Hypertrophic scars and keloids 709
Keratoacanthoma 711
Epidermal nevus 713
Nevus sebaceous 715
Chondrodermatitis nodularis chronica helicis 716
Epidermal cyst 717
Pilar cyst (wen) 719
Senile sebaceous hyperplasia 720
Syringoma 721

21

Premalignant and Malignant Nonmelanoma

Skin Tumors 724

Basal cell carcinoma 724

Pathophysiology 725
Histologic characteristics 726
Clinical types 726
Management and risk of recurrence 732
Actinic keratosis 736
Squamous cell carcinoma 744
Squamous cell carcinoma of the extremities
(Marjolin's ulcer) 747

22 Nevi and Malignant Melanoma 773

Melanocytic nevi 773

Common moles 774
Special forms 776
Atypical nevi 782
Malignant melanoma 786
Superficial spreading melanoma 789
Nodular melanoma 792
Lentigo maligna melanoma 794
Acral lentiginous melanoma 796
Benign lesions that resemble melanoma 797
Dermoscopy 798
Classification of atypical melanocytic nevi 799
Pregnancy, oral contraceptives, prognosis, and risk 806
Management 806
Biopsy 806
Initial diagnostic workup 808
Follow-up examinations 808
Staging and prognosis 810
Melanoma staging system 810
Medical treatment 810
Treatment of lentigo maligna 811

23 Vascular Tumors and Malformations 814

Congenital vascular lesions 814

Hemangiomas of infancy 815
Malformations 819
Acquired vascular lesions 824
Cherry angioma 824
Angiokeratomas 824
Venous lake 825
Lymphangioma circumscriptum 825
Pyogenic granuloma (lobular capillary hemangioma) 826
Kaposi's sarcoma 827
Telangiectasias 830
Spider angioma 830
Hereditary hemorrhagic telangiectasia 831
Unilateral nevoid telangiectasia syndrome 832
Scleroderma 832
Generalized essential telangiectasia 832

24 Hair Diseases 834

Anatomy 834
Physiology 836
Evaluation of hair loss 838
Generalized hair loss 841

Pseudoxanthoma elasticum 916

Guide to information for families with inherited skin
disorders 917

27 Dermatologic Surgical Procedures 921

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Localized hair loss 842

Androgenic alopecia in men (male-pattern baldness) 842
Adrenal androgenic female-pattern alopecia 844
Hirsutism 846
Alopecia areata 855
Trichotillomania 858
Traction (cosmetic) alopecia 859
Scarring alopecia 860
Trichomycosis 862

25 Nail Diseases 864

Anatomy and physiology 864

Normal variations 868
Nail disorders associated with skin disease 869
Acquired disorders 871
Bacterial and viral infections 871
Fungal nail infections 874
Trauma 880
The nail and internal disease 884
Congenital anomalies 886
Color and drug-induced changes 886
Tumors 888

26 Cutaneous Manifestations of Internal

Disease 893

Internal cancer and skin disease 893

Cutaneous paraneoplastic syndromes 893
Cutaneous manifestations of diabetes mellitus 896
Necrobiosis lipoidica 896
Granuloma annulare 898
Acanthosis nigricans 900
Xanthomas and dyslipoproteinemia 902
Neurofibromatosis 905
Tuberous sclerosis 909
Cancer-associated genodermatoses 912
Cowden's disease (multiple hamartoma syndrome) 912
Muir-Torre syndrome 914
Gardner's syndrome 915

Local anesthesia 922

Hemostasis 922
Wound healing 923
Postoperative wound care 925
Skin biopsy 926
Punch biopsy 926
Shave biopsy and shave excision 926
Simple scissor excision 928
Electrodesiccation and curettage 929
Techniques 929
Curettage 930
Techniquescurettage 930
Techniqueselectrodesiccation and curettage of basal cell
carcinoma 930
Blunt dissection 931
Technique 931
Cryosurgery 931
Technique 932
Extraction of cysts 933
Technique 933
Mohs' micrographic surgery 934
Technique 934
Chemical peels 936
Filling materials 936
Liposuction 936
Lasers 937
Botulinum toxin 938

Appendix 940

Dermatologic Formulary 945

Index 975

SKIN ANATOMY

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shaft

Melanocyte

Huxley's layer

Hair
follicle

Sebaceous gland

layer

muscle

External sheath

corpuscle

Glassy membrane

Connective
layer

Free nerve endings

Pore of sweat gland

Stratum

-Stratum

Stratum

Stratum spinosum
Stratum basale

Sweat gland

Hair matrix

Papilla of
follicle

Hair cuticle

Motor (autonomic)
nerve

Sensory nerve

Elastic fibers

Vater-Pacini
corpuscle

(Copyright 1967, CIBA Pharmaceutical Company, Division of CIBA-GEIGY Corporation. Reprinted

with permission from Clinical Symposia. Illustrated by Frank H. Netter,
All rights reserved.)

Vein