Other Skin Conditions

Actinic keratoses are rough, red, lesions usually found on the light exposed areas of the body particularly the face and upper extremities in fair complexioned people which are precursors of squamous cell carcinoma. They can occur as solitary lesions or can be found in considerable numbers. They are the direct result of excessive sun exposure in the patients' early childhood and young adult life. Once they start to appear, there is a propensity for them to increase in number even if sun exposure is significantly curtailed. The rough spots can often be felt before actually seen. As the lesions develop, they enlarge, the surface becomes rougher and more elevated.

A cutaneous horn is an old actinic keratosis with a hard horny projection overlying the lesion. The horn can be quite large. As these lesions continue to mature, a nodule not infrequently develops under the horn and pain or tenderness become apparent. These lesions have become squamous cell carcinoma in situ (limited to the epidermis). With more time, invasive squamous carcinoma develops.

Many forms of destructive therapy are available to deal with these lesions and are extremely effective. Maintenance therapy at regular intervals is often recommended since new lesions continue to develop. These same patients are much more likely to develop basal cell carcinomas as well. Detecting these cancers when they are small, and before they exhibit tissue destruction, is certainly in the patient's best interest. If you think you might have any of these lesions, please see a dermatologist.

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Alopecia Areata

Alopecia areata is the sudden and complete loss of hair in coin shaped areas on a hair bearing area of the skin, most commonly the scalp. It is most common in children but can appear up to the age of forty. It is felt to be evidence of autoimmunity but can also be influenced by the increased pressures of everyday life (stress). An area, once it occurs, will normally slowly enlarge for 4 to 6 weeks, just sit there for 4-6 weeks and then gradually fill in within the next six weeks. The older the patient, this process can be stretched out to six months.

Unfortunately, as one area grows in, another one can fall out. These bald spots can continue to develop resulting in significant hair loss. Therapy is quite effective for any one spot but the condition can be recurrent. The sooner therapy is instituted; the more successful it's likely to be.

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Bacterial Infections

Bacterial infections of the skin are very common among skin problems. Impetigo is often encountered. It is common in children, but no age group is exempt. It is contagious particularly within the family. There are two types. First, impetigo contagiosa which presents with honey colored crusts (scabs) and superficial erosions often on the face but can be found on any part of the body. The second, but less common, is bullous impetigo presenting with solitary fragile blisters which rupture easily leaving raw, weeping, denuded areas which spread peripherally. New blisters sprout in the surrounding area. Prompt antibiotic therapy is rapidly curative.

Bacterial infections involving hair follicles are extremely common particularly in shaved areas such as the beard, scalp and legs but can occur in any hairy area. They may present as folliculitis, superficial pustules (whitehead with a hair in the center), a furuncle green-black necrotic plug (core) that is tenaciously embedded. Little pus is present. When the infection is deep in the follicle at the hair bulb level, the surrounding subcutaneous tissue is involved usually opening in one draining sinus exuding pus. This is a boil. When a much larger area is involved with multiple draining openings, we refer to it as a carbuncle. If pus is localized, it should be drained surgically and then appropriate antibiotic therapy instituted. Antibiotic therapy without surgical draining will often be ineffective.

Bacterial paronychial (around the cuticle) infections are common particularly in nail biters, nurses, and after a manicure. These are exquisitely painful and present redness, swelling and acuminated pus under the cuticle or lateral nail fold of a finger. It is very important these be treated early with drainage and antibiotics. If neglected, a felon may develop (a deep bacterial infection in the tendon spaces of the hand) which can prove extremely destructive with significant morbidity and loss of function.

Most bacterial infections are pustules, but this is more of a guideline than a rule. The picture on the left may look like a bacterial infection, but it is actually fire ant bites.

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Contact Dermatitis

Contact dermatitis is certainly one of the more common skin problems dermatologists encounter. The cause may be something the patient is allergic to or something that is a primary irritant.

Poison ivy is a common culprit. Findings on the skin characteristically are linear vesicular (blistering) streaks of a very pruritic (itchy) dermatitis anywhere on the body where exposed to the plant or its juice. Once started, it can crescendo rapidly covering extensive surface areas with considerable to the quality of life. The sooner therapy is instituted, the quicker the response. The problem is recurrent with re-exposure to the plant. Effective desensitization is not available at this time.

With other contact dermatitis, look for uncommon geometric shapes such as straight lines, right angles, tear drops and other lesion configurations seen as unnaturally occurring conditions. When your suspicion is arisen, take a good history.

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Erythema Nodosum

Erythema nodosum refers to the development of multiple painful nodules in recurrent crops on the pretibial areas bilaterally. Sixty percent of cases are idiopathic (without apparent cause). In the other forty percent, the skin lesions are simply the cutaneous manifestations of a systemic disease. What other diseases are associated with erythema nodosum depend on the geographic area you are in. In the Midwest, streptococcal infections predominate. In Scandinavia, tuberculosis should be looked for. In the Philippines, leprosy is likely. Southwest of this country, coccidiomycosis is likely and in the Southeast, North American blastomycosis is likely. Drug eruptions to iodides, bromides, penicillin, sulfa drugs and birth control pills may be associated with erythema nodosum. This is an important disease to recognize. With appropriate therapy, the problem clears quickly.

Fungal Infections: Tineas

Fungus infections are extremely common in clinical practice. Fungi are plants and like all plants they like to grow in a warm, moist place. Like flowers, there are many different fungi. In practice, fungal infections are categorized according to the area of the body involved.

1. Tinea capitis (scalp)
2. Tinea corporis or ringworm (body)
3. Tinea cruris or jock itch (groin)
4. Tinea pedis or athletes feet (feet)
5. Tinea manuum (hand)
6. Tinea facei (face)
7. Onychomycosis (nails)

The key to diagnosis for all of these fungal infections is the KOH exam. This is the ability to find the plants under the microscope when scrapings of scale, hair or nail are soaked in KOH (potassium Hydroxide solution). If the clinical lesion has no scaling and you can't do a KOH, it's not a fungus infection anyway. If the KOH is positive, the diagnosis is correct and the therapy will work. If it's negative, therapy for a fungus infection will not work. If a KOH is not done, the diagnosis is an educated guess. Embarking on an expensive course of therapy without doing a KOH exposes the patient to the risk of side effects without the likelihood of clinical benefits. This is particular true in treating nail disease.

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Hand Dermatitis

Hand dermatitis is among the most common conditions dermatologists are asked to deal with. It consists of a spectrum of diseases from very mild annoyances with dryness and irritation, to a severe disabling condition. Dermatitis by itself means inflammation of the skin. This is an all-encompassing category of disease. We need some modifiers to better classify these problems. Eczema refers to a red, denuded and weepy dermatitis normally with considerable complaints of severe itching. This would then be an eczematous dermatitis. Many occur in isolated patches separated by normal appearing skin. When found with the above, it would be called a patchy eczematous dermatitis.

Since these areas are often denuded of the epidermis, body fluid (serum) leaks from these areas. This is a great culture media for bacteria, which are always present on the skin.

Impetigo (superficial bacterial infection of the skin) is the result. When combined with the above characteristic, we have an impetiginized, patchy eczematous dermatitis.

The palms and soles have great numbers of sweat glands. With increasing inflammation in the skin, the sweat ducts which carry sweat to the surface of the skin is compressed like standing on a garden hose. The sweat distends the duct below the obstruction producing deep-seated blisters at varying depths. In its common form, this is referred to as dyshidrosis and in its more severe form, it is called pomphylox. The blister fluid is clear with the composition of sweat.

There are times when the palms and soles are covered with deep-seated pustules which occur with pustular psoriasis and its various subtypes. Therapy for these problems is quite effective and can usually limit disability and improve the quality of life.

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Kaposi's Sarcoma

Kaposi's sarcoma is the result of infection with the Human Herpes Virus type 8. In the pre 1980's, Kaposi's was an uncommon disease of elderly white males of a northern Mediterranean origin. Although considered a cancer, it evolved slowly over a number of years with low morbidity and mortality.

Over the past 25 years, latent viral infection was discovered in a much larger segment of the population. It only became clinically significant when the immune system was suppressed by the AIDS virus or chemotherapy. It appears more as a tissue reaction pattern than a true malignancy. Interestingly, wide spread disease can regress completely when chemotherapy is discontinued and the immune system is allowed to recover.

Today, its recognition is very helpful in identifying patients with HIV infections. It may actually be the first clinical clue suggesting the correct underlying diagnosis.

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Leg Ulcers

Leg ulcers are a significant problem leading to major inconvenience, discomfort and inability to work or function. Most leg ulcers occur about the ankles and are secondary to varicosities (varicose veins). This propensity runs in the family and is associated with being over weight in the majority of cases. Leg ulcers often develop after the age of forty in patients who spend a lot of their time on their feet. Phlebitis (blood clots) in these legs is common. These ulcers are called stasis dermatitis secondary to chronic edema (fluid in the legs) and venous insufficiency. Therapy is very effective for these ulcers. The sooner they are attended to, the easier it is for the patient.

The second most common cause of leg ulcers is leukocytoclastic vasculitis. This produces deep, punched out, very painful ulcers with surrounding white scar tissue (atrophe blanche) which is pathognomonic of this condition. These ulcers are tough to heal and are often recurrent. You should pick the most experienced dermatologist to handle these problems.

Arterial ulcers are the third and most difficult ulcers to manage. They result from inflammatory vasculitis of many varied etiologies. Embolization (blocks the flow of blood) can be caused by a blood clot, cholesterol, tumor or arteriosclerosis (thickening and hardening of the arterial walls). An obstructive block (total occlusion) can lead to gangrene (death of tissue). Without sufficient blood supply, tissue dies and the body is unable to heal these ulcers. Peripheral vascular surgeons are usually required to deal with these problems.

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Lichen Planus

Lichen planus is a relatively common skin disease which often goes undiagnosed. Usually found in middle aged adults (30 to 60), it is commonly located on the wrists and ankles but can occur anywhere on the body including the scalp, in the mouth or on the genitals. The lesions are often grouped and consist of flat topped, shiny, polygonal papules with a distinct violaceous color and a lacy whiteness over the surface. The eruption can be extremely itchy. When the scalp is involved, permanent scarring with hair loss can be appreciable.

When the mucous membranes of the mouth or genital areas are involved, annular or circular lesions are found, often without symptoms. White opalescence reticulated patterns are commonly found which are quite diagnostic.

Several forms of the disease can be very difficult to manage. Erosive (ulcerations) lichen planus of the mouth often requires aggressive therapy. It can be an extremely painful condition. Hypertrophic lichen planus consists of large, thickened, scaly plaques on the pretibial areas (shins) which produce severe itching and without effective therapy, can go on for twenty years or more.

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Molluscum Contagiosum

Molluscum contagiosum is a very common viral infection which is often seen in children, tanning bed users, wrestlers and as a sexually transmitted disease of the genital areas of young adults. Multiple lesions are usually found and have a very typical clinical pattern. They are well demarcated, smooth, dome-shaped, firm lesions with a central dimple, pit or crater in its center. They can be transferred to others by close skin to skin contact. Patients may have hundreds of individual lesions especially in immuno-compromised patients (patients with HIV infection, on chemotherapy, transplant patients, etc.).

Therapy is very effective. The sooner people are treated, the better. The lesions can spontaneously disappear but because we cannot predicate when, how many will develop, how much it will interfere with the quality of life or how many others will acquire the problem from the patient, no time should be wasted in treating them.

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Paget's Disease

Paget's disease is a relatively uncommon condition usually involving the nipple and areolar area of the breast. It is almost invariably found in association with papillary intraductal carcinoma (breast cancer) in the same breast. Early diagnosis and treatment is imperative if the problem is to be treated effectively. Any breast lesion involving the nipple should be properly evaluated by a dermatologist.

Occasionally, Paget's disease can occur in extramammary locations usually in the groin or perirectal area, in either males or females. These are often associated with a cancer in a nearby organ. These lesions often go undiagnosed for a long period of time. Any skin problem that is not resolved within 4-6 weeks could benefit from a dermatology consult.

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Perioral Dermatitis

Perioral dermatitis is a common complexion problem of young adults, particularly women 21 to 36 which involve the areas around the mouth and chin. It presents with small, red, itchy bumps which come and go. It is often misdiagnosed as a dermatitis and treated with steroid creams which may control the itching but usually makes the problem worse. Effective therapy is readily available to control this annoying problem Recurrences are common if therapy is discontinued to quickly.

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Porokeratosis

Porokeratosis is an uncommon tumor which occurs in two forms. Disseminated superficial actinic porokeratosis is seen most often. It consists of extensive flat, slightly scaling discrete lesions. They may be solitary or literally hundreds of lesions primarily located on the light exposed areas of the arms and legs. Adult patients who have a fair complexion are the norm. Each of the individual lesions are surrounded by a thickened wall of kurtosis which identify the diagnostic hallmark. These lesions may develop into squamous cell carcinomas.

Porokeratosis of Mibelli is rarely seen but quite characteristic clinically. It presents with a plaque normally enlarging centrically with atrophy or thinning in the center and an elevated, warty border around the entire lesion often referred to as the great wall of china. Less commonly, porokeratosis type lesions can occur as a solitary lesion on the palms and soles or in a linear pattern. Therapy for extensive lesions can be frustrating.

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Sarcoidosis

Sarcoidosis is a complicated disease that can mimic many others. Skin involvement is often a central feature of this condition, although any organ of the body can be affected. The cause is unknown to date. The reaction pattern simulates tuberculosis and similar diseases.

The skin lesions are quite suggestive of the diagnosis. Multiple flesh-colored or hyper- pigmented, firm papules around the central part of the face are seen. Annular configurations about the mouth and nose are likely to occur. Lupus pernio consisting of large infiltrated reddish or purplish plaques on the nose or surrounding area associated with punch out osteolytic lesions on X- ray of the hand is quite specific. Mortality is more often determined by the extent of pulmonary, renal and liver involvement than skin and joint involvement.

Early recognition of this disease is essential for effective therapy. Consultation with a dermatologist can be very helpful in making the diagnosis as well as managing the cutaneous manifestations of this condition.

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Scabies

Scabies is a common problem in society. It is caused by an itch mite acquired through intimate contact with someone who has the disease. It is common among school children, nursing homes, hospital personnel, hospitalized patients and those with multiple sexual partners.

Once acquired, symptoms of a rash and severe itching develop within thirty days. The itching becomes progressively worse particularly at night and the rash spreads to involve the hands, between the fingers, wrists, elbows, axillae, genitals in men, knees, ankles and toes. This is one of the few diseases where itching of the nipples occurs in women.

The key to diagnosis is the characteristic history and the fact that others in the family, sexual partners, associates at work, friends or other associates are also itching. Diagnosis is confirmed by identifying the burrows of the active mites in the skin. It takes an experienced clinician to find these lesions. Scabies is often diagnosed when not actually present and not diagnosed when it's obviously present.

Therapy is very effective. All people exposed must be treated at the same time or recurrences are common. This is usually the cause of treatment failure.

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Venereal Warts

Venereal warts (genital warts) also known as condyloma acuminata or bowenoid papulosis are transmitted from person to person during sexual intercourse with someone who is infected with them. They normally occur in the genital or rectal area in both men and women. They are caused by several phenotypes of the human papilloma virus. Infection with this virus on the cervix of women is directly correlated with the subsequent development of cervical cancer.

It is extremely important to treat this problem as quickly as possible before others are exposed. Men should be very considerate of their receptive partners so they too can be evaluated. Many forms of therapy are available. The choice is determined by the extensiveness of the problem.

Two recent advances have occurred with this disease. One, when women get their PAP smears for cervical cancer, they have an immunofluorescent stain that will identify the human papilloma virus infections before they become a problem.

The second major advance is the development of a new vaccine that can immunize young women 8-15 to the four human papilloma virus types that cause cervical cancer. It is currently available and should be seriously considered for young women before their periods start.

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