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Dermatoses Resulting From Physical Factors


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  • 1. Dermatoses Resulting fromDermatoses Resulting from Physical FactorsPhysical Factors Chapter 3Chapter 3 Andrew’s Diseases of the SkinAndrew’s Diseases of the Skin Ben Adams, D.O.Ben Adams, D.O. July 25th 2006July 25th 2006
  • 2. Heat InjuriesHeat Injuries  Thermal BurnsThermal Burns  Electrical BurnsElectrical Burns  MiliariaMiliaria  Miliaria Crystalline (Sudamina)Miliaria Crystalline (Sudamina)  Miliaria Rubra (Prickly Heat, Heat Rash)Miliaria Rubra (Prickly Heat, Heat Rash)  Miliaria PustulosaMiliaria Pustulosa  Miliaria ProfundaMiliaria Profunda  Occlusion MiliariaOcclusion Miliaria
  • 3. Thermal BurnsThermal Burns  First-degree burn: activeFirst-degree burn: active congestion of superficial bloodcongestion of superficial blood vesselsvessels  This causes erythema, sometimesThis causes erythema, sometimes followed by epidermalfollowed by epidermal desquamationdesquamation  Constitutional reactions occur ifConstitutional reactions occur if large area involvedlarge area involved  Pain and increased surface heatPain and increased surface heat may be severemay be severe
  • 4. Second-degree burnsSecond-degree burns  DeepDeep  Pale and anestheticPale and anesthetic  Injury to reticular dermisInjury to reticular dermis compromises blood flowcompromises blood flow and destroys appendagesand destroys appendages  Healing takes > 1 monthHealing takes > 1 month  Scarring occursScarring occurs  SuperficialSuperficial  Transudation of serumTransudation of serum causing edema ofcausing edema of superficial tissuessuperficial tissues  Vesicles and blebsVesicles and blebs  Complete recovery withoutComplete recovery without scar or blemish is usualscar or blemish is usual
  • 5. Second-degree burnSecond-degree burn  Thermal burn: This superficialThermal burn: This superficial second degree burn issecond degree burn is characterized by bullae thatcharacterized by bullae that contain serous fluidcontain serous fluid
  • 6. Second-Degree BurnsSecond-Degree Burns  Inflicted scalds: severeInflicted scalds: severe second degree burnssecond degree burns after dippingafter dipping  B: two days afterB: two days after incident-to lowerincident-to lower extremities andextremities and perineumperineum  C: foot and lower legC: foot and lower leg
  • 7. Second-Degree BurnSecond-Degree Burn  Accidental scaldAccidental scald  Splash-and-Splash-and- droplet patterndroplet pattern of an accidentalof an accidental scald from hotscald from hot cup of teacup of tea
  • 8. Third-degree burnsThird-degree burns  Full-thickness tissueFull-thickness tissue lossloss  Skin appendages areSkin appendages are destroyeddestroyed  There is no epitheliumThere is no epithelium for regenerationfor regeneration  Healing leaves a scarHealing leaves a scar
  • 9. Fourth-degree burnsFourth-degree burns  Destruction of entire skinDestruction of entire skin and subcutaneous fatand subcutaneous fat with any underlyingwith any underlying tendonstendons
  • 10.  Rule of nines:Rule of nines:  In adults, anIn adults, an estimate of burnestimate of burn extent based uponextent based upon this surface areathis surface area distribution chart.distribution chart.  Infants & childrenInfants & children have a relativelyhave a relatively increased head;increased head; trunk surface areatrunk surface area ratioratio
  • 11. Electrical BurnsElectrical Burns  ContactContact- small but deep,- small but deep, causing some necrosis ofcausing some necrosis of underlying tissuesunderlying tissues  FlashFlash-burns usually cover-burns usually cover a large area and are similara large area and are similar to a surface burn andto a surface burn and should be tx as suchshould be tx as such  Lightning is the most lethalLightning is the most lethal type of strike, cardiac arresttype of strike, cardiac arrest or other internal injuriesor other internal injuries may occurmay occur
  • 12. Electrical BurnsElectrical Burns  IndirectIndirect- burns that are- burns that are either linear in areas ateither linear in areas at which sweat was present;which sweat was present; are feathery orare feathery or aborescent pattern, whichaborescent pattern, which is believed to beis believed to be pathognomonicpathognomonic
  • 13. Electrical BurnElectrical Burn  It is characterized byIt is characterized by erythema, edema,erythema, edema, bulla formation andbulla formation and sloughing of thesloughing of the necrotic epidermisnecrotic epidermis
  • 14. Electrical Burn-pathologyElectrical Burn-pathology  Blistering and elongatedBlistering and elongated keratinocyteskeratinocytes
  • 15. MiliariaMiliaria  Retention of sweat as a result of occlusionRetention of sweat as a result of occlusion  Common in hot, humid climatesCommon in hot, humid climates  Occlusion of eccrine sweat gland obstructs delivery of sweat to theOcclusion of eccrine sweat gland obstructs delivery of sweat to the skin surfaceskin surface  Eventually backed-up pressure causes rupture of sweat gland orEventually backed-up pressure causes rupture of sweat gland or duct at different levelsduct at different levels  Escape of sweat into adjacent tissue produces miliariaEscape of sweat into adjacent tissue produces miliaria  Different forms of miliaria occur depending on the level of injury toDifferent forms of miliaria occur depending on the level of injury to the sweat glandthe sweat gland
  • 16. Miliaria CrystallinaMiliaria Crystallina  Small, clear, superficialSmall, clear, superficial vesicles without inflammationvesicles without inflammation  Appears in bedridden pts andAppears in bedridden pts and bundled childrenbundled children  Lesions are asymptomatic andLesions are asymptomatic and rupture at the slightest traumarupture at the slightest trauma  Self-limited; no tx is requiredSelf-limited; no tx is required
  • 17. Miliaria CrystallinaMiliaria Crystallina  Minute, discreteMinute, discrete vesicles resultingvesicles resulting from profuse sweatingfrom profuse sweating secondary to a highsecondary to a high feverfever
  • 18. Miliaria RubraMiliaria Rubra  Discrete, extremelyDiscrete, extremely pruritic, erythematouspruritic, erythematous papulovesicles withpapulovesicles with sensation of prickling,sensation of prickling, burning, or tinglingburning, or tingling  Site of injury is prickleSite of injury is prickle cell layer wherecell layer where spongiosis is producedspongiosis is produced
  • 19. Miliaria RubraMiliaria Rubra
  • 20. Miliaria PustulosaMiliaria Pustulosa  Always preceded by someAlways preceded by some injury, destruction, orinjury, destruction, or blocking of sweat ductblocking of sweat duct  PustulesPustules independentindependent ofof hair folliclehair follicle  Seen in intertriginous areas,Seen in intertriginous areas, flexure surfaces offlexure surfaces of extremities, scrotum, andextremities, scrotum, and back of bedridden ptsback of bedridden pts  Sterile pustulesSterile pustules
  • 21. Miliaria ProfundaMiliaria Profunda  Nonpruritic, flesh-colored, deep-Nonpruritic, flesh-colored, deep- seated, whitish papulesseated, whitish papules  Asymptomatic, usually lasting onlyAsymptomatic, usually lasting only 1 hr after overheating has ended1 hr after overheating has ended  Concentrated on the trunk andConcentrated on the trunk and extremitiesextremities  Occlusion is in upper dermisOcclusion is in upper dermis  Only seen in tropics usuallyOnly seen in tropics usually following a severe bout of miliariafollowing a severe bout of miliaria rubrarubra
  • 22. Occlusion MiliariaOcclusion Miliaria  May be produced with accompanyingMay be produced with accompanying anhidrosis and increased heat stressanhidrosis and increased heat stress susceptibility after application of extensivesusceptibility after application of extensive polyethylene film occlusion for > 48 hrspolyethylene film occlusion for > 48 hrs  Tx-place pt in a cool environmentTx-place pt in a cool environment  Even a night in an air-conditioned room helpsEven a night in an air-conditioned room helps alleviate the discomfortalleviate the discomfort
  • 23. Occlusion MiliariaOcclusion Miliaria  Mild cases may respond toMild cases may respond to dusting powders, such asdusting powders, such as cornstarch or talcum powdercornstarch or talcum powder  A lotion containing 1% mentholA lotion containing 1% menthol and glycerin and 4% salicylicand glycerin and 4% salicylic acid in 95% alcohol is effectiveacid in 95% alcohol is effective  An oily “shake” lotion such asAn oily “shake” lotion such as calamine lotion, with 1% or 2%calamine lotion, with 1% or 2% phenol may be effectivephenol may be effective
  • 24. Erythema (pigmentatio) Ab IgneErythema (pigmentatio) Ab Igne  Aka “toasted skin” syndromeAka “toasted skin” syndrome  Persistent erythema or coarselyPersistent erythema or coarsely reticulated residual pigmentationreticulated residual pigmentation resulting from itresulting from it  Produced by long-continuedProduced by long-continued exposure to excessive heatexposure to excessive heat without production of a burnwithout production of a burn  It begins as a mottling caused byIt begins as a mottling caused by local hemostasis and becomes alocal hemostasis and becomes a reticulated erythema, leavingreticulated erythema, leaving pigmentationpigmentation
  • 25. Erythema Ab IgneErythema Ab Igne  ReticulatedReticulated hyperpigmentationhyperpigmentation with some epidermalwith some epidermal atrophy and scalingatrophy and scaling secondary to use ofsecondary to use of a heating pada heating pad
  • 26. Erythema Ab IgneErythema Ab Igne  Use of bland emollients isUse of bland emollients is helpfulhelpful  No effective treatmentNo effective treatment  Kligman’s combination of 5%Kligman’s combination of 5% hydroquinone in hydrophilichydroquinone in hydrophilic ointment containing 0.1%ointment containing 0.1% retinoic acid and 0.1%retinoic acid and 0.1% dexamethasone may reducedexamethasone may reduce unsightly pigmentationunsightly pigmentation
  • 27.  There is a mild superficial perivascularThere is a mild superficial perivascular inflammatory infiltrate composedinflammatory infiltrate composed predominantly of lymphocytes andpredominantly of lymphocytes and prominent pigment incontinence.prominent pigment incontinence.  HistologicallyHistologically, an, an increased amount ofincreased amount of elastic tissue in theelastic tissue in the dermis is seendermis is seen  Changes are similarChanges are similar to actinic elastosis,to actinic elastosis, and has beenand has been suggested to callsuggested to call these changesthese changes thermal elastosisthermal elastosis
  • 28. Cold InjuriesCold Injuries  ChilblainsChilblains  FrostbiteFrostbite  Immersion injuryImmersion injury
  • 29. ChilblainsChilblains  Acute chilblains is theAcute chilblains is the mildest form of cold injurymildest form of cold injury  Pts are usually unawarePts are usually unaware of injury until theyof injury until they develop burning, itching,develop burning, itching, and rednessand redness
  • 30. TreatmentTreatment  Nifedipine 20mg TIDNifedipine 20mg TID  Vasodilators (nicotinamide 100Vasodilators (nicotinamide 100 mg TID or dipyridamole 25 mgmg TID or dipyridamole 25 mg TID)TID)  Systemic corticoid tx is helpfulSystemic corticoid tx is helpful in chilblain lupusin chilblain lupus erythematosuserythematosus  Pentoxifylline may be usefulPentoxifylline may be useful  Smoking strongly discouragedSmoking strongly discouraged
  • 31. FrostbiteFrostbite  When soft tissue is frozen andWhen soft tissue is frozen and locally deprived of blood supplylocally deprived of blood supply  Frozen part is painless andFrozen part is painless and becomes pale and waxybecomes pale and waxy  Four stages:Four stages:  I- Frost-nip erythema,I- Frost-nip erythema, edema,cutaneous anesthesia &edema,cutaneous anesthesia & transient paintransient pain  II- second degree: hyperemia,II- second degree: hyperemia, edema & blistering, with clear fluidedema & blistering, with clear fluid in bullaein bullae  III- third-degree: full-thicknessIII- third-degree: full-thickness dermal loss with hemorrhagicdermal loss with hemorrhagic bullae formation or waxy, dry,bullae formation or waxy, dry, mummified skinmummified skin  IV- full-thickness loss of entire partIV- full-thickness loss of entire part
  • 32. First-Degree FrostbiteFirst-Degree Frostbite
  • 33. Immersion Foot SyndromesImmersion Foot Syndromes  Trench FootTrench Foot  Warm Water Immersion FootWarm Water Immersion Foot
  • 34. Trench FootTrench Foot  Term derived from trenchTerm derived from trench warfare in World War I, whenwarfare in World War I, when soldiers stood, sometimes forsoldiers stood, sometimes for hours, in trenches with a fewhours, in trenches with a few inches of cold water in theminches of cold water in them  Results from prolongedResults from prolonged exposure to cold, wetexposure to cold, wet conditions without immersionconditions without immersion or actual freezingor actual freezing  Tx-removal from environmentTx-removal from environment
  • 35. TropicalTropical Immersion FootImmersion Foot  AKA “paddy foot” in VietnamAKA “paddy foot” in Vietnam  Seen after continuous immersion of the feet in water or mud ofSeen after continuous immersion of the feet in water or mud of temperatures above 71.6 degrees F (22 degrees C) for 2-10 daystemperatures above 71.6 degrees F (22 degrees C) for 2-10 days  Erythema, edema, and pain of the dorsal feetErythema, edema, and pain of the dorsal feet  Also fever and adenopathyAlso fever and adenopathy  Resolution occurs 3 to 7 days after the feet have beenResolution occurs 3 to 7 days after the feet have been drieddried
  • 36. Dermatoses with ColdDermatoses with Cold HypersensitivityHypersensitivity  Erythrocyanosis CrurumErythrocyanosis Crurum  AcrocyanosisAcrocyanosis  Cold PanniculitisCold Panniculitis
  • 37. Erythrocyanosis CrurumErythrocyanosis Crurum  Slight swelling and aSlight swelling and a bluish pink tint of thebluish pink tint of the skin of the legs andskin of the legs and thighs of young girlsthighs of young girls and womenand women  May be unilateralMay be unilateral  May have cramps in theMay have cramps in the legs at nightlegs at night  Small tender nodulesSmall tender nodules may be found onmay be found on palpationpalpation  Nodules may break downNodules may break down and form small, multipleand form small, multiple ulcersulcers  Seen in northernSeen in northern countries and probablycountries and probably due to an abnormaldue to an abnormal reaction of bloodreaction of blood vessels to prolongedvessels to prolonged coldcold
  • 38. AcrocyanosisAcrocyanosis  A persistent cyanosis with coldnessA persistent cyanosis with coldness and hyperhidrosis of hands and feetand hyperhidrosis of hands and feet  Chiefly occurs in young womenChiefly occurs in young women  At times, on cold exposure, a digitAt times, on cold exposure, a digit becomes stark white and insensitivebecomes stark white and insensitive (acroasphyxia)(acroasphyxia)  Cyanosis increases as theCyanosis increases as the temperature decreases and changestemperature decreases and changes to erythema with elevation ofto erythema with elevation of dependent partdependent part  Cause is unknownCause is unknown  Smoking, coffee, and tea should beSmoking, coffee, and tea should be avoidedavoided
  • 39. AcrocyanosisAcrocyanosis
  • 40. Cold PanniculitisCold Panniculitis  After exposure to severe cold, well-After exposure to severe cold, well- demarcated erythematous warmdemarcated erythematous warm plaques may develop, particularly onplaques may develop, particularly on the cheeks of young childrenthe cheeks of young children  Lesions usually develop within a fewLesions usually develop within a few days after exposure, and resolvedays after exposure, and resolve spontaneously in 2 weeks (approx)spontaneously in 2 weeks (approx)  No tx is indicatedNo tx is indicated  Popsicle dermatitis is a temporaryPopsicle dermatitis is a temporary redness and induration of the cheek inredness and induration of the cheek in children resulting from suckingchildren resulting from sucking PopsiclesPopsicles
  • 41. Sunburn and Solar ErythemaSunburn and Solar Erythema  Parts of solar spectrumParts of solar spectrum important to photomedicine:important to photomedicine:  Visible light 400 to 760 nmVisible light 400 to 760 nm  Infrared radiation beyondInfrared radiation beyond 760 nm760 nm  Visible light has little biologicVisible light has little biologic activity, except foractivity, except for stimulating the retinastimulating the retina  Infrared radiation isInfrared radiation is experienced as radiant heatexperienced as radiant heat  Below 400 nm is theBelow 400 nm is the ultraviolet spectrum,ultraviolet spectrum, divided into threedivided into three bands:bands:  UVA, 320 to 400 nmUVA, 320 to 400 nm  UVB, 290 to 320 nmUVB, 290 to 320 nm  UVC, 200 to 290 nmUVC, 200 to 290 nm  Virtually no UVCVirtually no UVC reaches the earth’sreaches the earth’s surface, because it issurface, because it is absorbed by the ozoneabsorbed by the ozone layerlayer  Exception: Australia,Exception: Australia, welderswelders
  • 42.  UVB is 1000 times moreUVB is 1000 times more erythemogenic than UVAerythemogenic than UVA  UVA is 100 times greaterUVA is 100 times greater than UVB radiation duringthan UVB radiation during the midday hoursthe midday hours  Most solar erythema isMost solar erythema is cause by UVBcause by UVB  Sunlight early and late in theSunlight early and late in the day contains more UVAday contains more UVA  UVA is reflected from sand,UVA is reflected from sand, snow, or ice to a greatersnow, or ice to a greater degree than UVBdegree than UVB  Amount of ultravioletAmount of ultraviolet exposure increases at higherexposure increases at higher altitudes, is greater inaltitudes, is greater in tropical regions, andtropical regions, and temperate climates intemperate climates in summersummer Sunburn and Solar ErythemaSunburn and Solar Erythema
  • 43. Clinical signs and symptomsClinical signs and symptoms  Sunburn is normal cutaneousSunburn is normal cutaneous reaction to sunlight in excessreaction to sunlight in excess of an erythema dose (theof an erythema dose (the amount that will induceamount that will induce reddening)reddening)  UVB erythema peaks at 12 toUVB erythema peaks at 12 to 24 hrs after exposure24 hrs after exposure  Desquamation is commonDesquamation is common about a week after sunburnabout a week after sunburn even in non-blistering areaseven in non-blistering areas
  • 44. Sunburn treatmentSunburn treatment  Cool compressesCool compresses  Topical steroidsTopical steroids  Topical remedy:Topical remedy: Indomethacin 100 mgIndomethacin 100 mg Absolute ethanol 57 mlAbsolute ethanol 57 ml Propylene glycol 57 mlPropylene glycol 57 ml spread widely over burned areaspread widely over burned area with palms and let drywith palms and let dry
  • 45. Skin TypesSkin Types
  • 46. Second-degree sunburnSecond-degree sunburn
  • 47. ProphylaxisProphylaxis  Avoid sun exposureAvoid sun exposure between 10 am and 2 pmbetween 10 am and 2 pm  Barrier protection withBarrier protection with hats and clothinghats and clothing  Sunscreen agents includeSunscreen agents include UV-absorbing chemicals,UV-absorbing chemicals, and UV-scattering orand UV-scattering or blocking agents (physicalblocking agents (physical sunscreens)sunscreens)
  • 48. SunscreensSunscreens  Chemical sunscreens: para-Chemical sunscreens: para- aminobenzoic acid(PABA),aminobenzoic acid(PABA), PABA esters, cinnamates,PABA esters, cinnamates, salicylates, anthranilates,salicylates, anthranilates, benzophenoes)benzophenoes)  Physical agents: titanium/zincPhysical agents: titanium/zinc dioxidedioxide  Combinations of bothCombinations of both  Water resistant: maintainingWater resistant: maintaining their SPF after 40 minutes oftheir SPF after 40 minutes of water immersionwater immersion  Water proof: maintaining theirWater proof: maintaining their SPF after 80 mins of waterSPF after 80 mins of water immersionimmersion  UVA protection: sunscreensUVA protection: sunscreens containing benzophenones orcontaining benzophenones or dibenzoylmethanesdibenzoylmethanes  Apply sunscreen at leastApply sunscreen at least 20mins before sun exposure20mins before sun exposure
  • 49. Photoaging (Dermatohelioisis)Photoaging (Dermatohelioisis)  Characteristic changesCharacteristic changes induced by chronic suninduced by chronic sun exposureexposure  Risk of developing theseRisk of developing these changes correlated withchanges correlated with baseline pigmentationbaseline pigmentation (constitutive(constitutive pigmentation) and abilitypigmentation) and ability to resist burning and tanto resist burning and tan following sun exposurefollowing sun exposure (facultative pigmentation)(facultative pigmentation)
  • 50. DermatoheliosisDermatoheliosis  Poikiloderma of CivattePoikiloderma of Civatte :: refers to reticulaterefers to reticulate hyperpigmentation withhyperpigmentation with telangiectasia, and slighttelangiectasia, and slight atrophy of sides of the neck,atrophy of sides of the neck, lower anterior neck and V oflower anterior neck and V of chestchest  Submental area is sparedSubmental area is spared  Frequently presents in fair-Frequently presents in fair- skinned men and women inskinned men and women in their middle to late thirties ortheir middle to late thirties or early fortiesearly forties
  • 51. DermatoelastosisDermatoelastosis  Cutis rhomboidalisCutis rhomboidalis nuchaenuchae (sailor’s neck or(sailor’s neck or farmer’s neck) isfarmer’s neck) is characteristic of long-characteristic of long- term, chronic sunterm, chronic sun exposureexposure  Skin on back of neckSkin on back of neck becomes thickened,becomes thickened, tough, and leathery andtough, and leathery and normal skin markingnormal skin marking become exaggeratedbecome exaggerated
  • 52. DermatoheliosisDermatoheliosis  Favre-RacouchotFavre-Racouchot syndromesyndrome  Thickened yellow plaquesThickened yellow plaques studded with comedomesstudded with comedomes and cystic lesionsand cystic lesions  Tx-removal , retinoic acidTx-removal , retinoic acid cream, surgical removalcream, surgical removal of cysts and redundantof cysts and redundant skinskin
  • 53. Solar ElastosisSolar Elastosis  Homogenization and aHomogenization and a faint blue color offaint blue color of connective tissue of theconnective tissue of the upper reticular dermis,upper reticular dermis, so-calledso-called solar elastosissolar elastosis  Characteristically there isCharacteristically there is a zone of normala zone of normal connective tissue belowconnective tissue below the epidermisthe epidermis
  • 54. PhotosensitivityPhotosensitivity  Photosensitizers mayPhotosensitizers may induce an abnormalinduce an abnormal reaction in skin exposedreaction in skin exposed to sunlight or itsto sunlight or its equivalentequivalent  Substances may beSubstances may be delivered externally ordelivered externally or internallyinternally  Increased sunburnIncreased sunburn response without priorresponse without prior allergic sensitization isallergic sensitization is calledcalled phototoxicityphototoxicity  Phototoxicity may occurPhototoxicity may occur from both externallyfrom both externally appliedapplied (phytophotodermatitis(phytophotodermatitis and berloque dermatitis)and berloque dermatitis) or internallyor internally administered chemicalsadministered chemicals (phototoxic drug(phototoxic drug reaction)reaction)  Or by external contact-Or by external contact- (photoallergic contact(photoallergic contact dermatitis)dermatitis)
  • 55. Phototoxicity vs photoallergyPhototoxicity vs photoallergy  In the case of external contactants –phototoxicityIn the case of external contactants –phototoxicity occurs on initial exposure, has onset < 48 hrs,occurs on initial exposure, has onset < 48 hrs, occurs in most people exposed to the phototoxicoccurs in most people exposed to the phototoxic substance and sunlightsubstance and sunlight  Photoallergy, in contrast, occurs only inPhotoallergy, in contrast, occurs only in sensitized persons, may have delayed onset, upsensitized persons, may have delayed onset, up to 14 days (a period of sensitization), and showsto 14 days (a period of sensitization), and shows histologic features of contact dermatitishistologic features of contact dermatitis
  • 56. PhotosensitivityPhotosensitivity  Drug-inducedDrug-induced photosensivity-photosensivity- photoallergicphotoallergic dermatitis on sun-dermatitis on sun- exposed areas ofexposed areas of an infant followingan infant following topical use oftopical use of hexachlorophenehexachlorophene
  • 57. Photoallergic dermatitisPhotoallergic dermatitis  PapulovesicularPapulovesicular lesions oflesions of photoallergicphotoallergic dermatitis due todermatitis due to hexachlorophenehexachlorophene
  • 58. PhytophotosensitivityPhytophotosensitivity  Plant-inducedPlant-induced photosensitivity-linearphotosensitivity-linear hyperpigmentation onhyperpigmentation on the face followingthe face following exposure to limes andexposure to limes and sunlightsunlight
  • 59. PhytophotosensitivityPhytophotosensitivity  Hyperpigmentation onHyperpigmentation on the dorsal aspect ofthe dorsal aspect of the hands followingthe hands following the use of limes andthe use of limes and sunlight exposuresunlight exposure
  • 60. Photosensitivity inPhotosensitivity in TattoosTattoos  Yellow cadmium sulfide mayYellow cadmium sulfide may be used as a yellow dye orbe used as a yellow dye or may be incorporated into redmay be incorporated into red mercuric sulfide pigment tomercuric sulfide pigment to produce a brighter red colorproduce a brighter red color for tattooingfor tattooing  When exposed to 380, 400,When exposed to 380, 400, and 450 nm wavelengths ofand 450 nm wavelengths of light, these areas in tattooslight, these areas in tattoos may swell, developmay swell, develop erythema, and becomeerythema, and become verrucoseverrucose
  • 61. Phototoxic Drug ReactionsPhototoxic Drug Reactions  Most occur fromMost occur from tetracyclines, nonsteroidaltetracyclines, nonsteroidal antiinflammatory drugs,antiinflammatory drugs, amiodarone, andamiodarone, and phenothiazinesphenothiazines  Action spectrum for all is inAction spectrum for all is in the UVA rangethe UVA range  In the case of amiodaroneIn the case of amiodarone and chlorpromazine,and chlorpromazine, hyperpigmentation is ahyperpigmentation is a well-recognized pattern ofwell-recognized pattern of phototoxicityphototoxicity  It causes slate blueIt causes slate blue (amiodarone) or slate gray(amiodarone) or slate gray (chlorpromazine)(chlorpromazine) coloration, resulting fromcoloration, resulting from drug deposition in thedrug deposition in the tissuestissues
  • 62. AmiodaroneAmiodarone
  • 63. Drug induced photosensitivityDrug induced photosensitivity  The erythema is lessThe erythema is less apparent in blackapparent in black skin, but theskin, but the involvement of theinvolvement of the nose in this patientnose in this patient suggestssuggests phototoxicity, in thisphototoxicity, in this case caused bycase caused by thiazidethiazide
  • 64. Drug-induced photosensitivityDrug-induced photosensitivity  Not only the noseNot only the nose was but also the “V”was but also the “V” of the neck whichof the neck which was highlywas highly suggestive ofsuggestive of phototoxicityphototoxicity  Same ptSame pt
  • 65. Drug induced photosensitivityDrug induced photosensitivity  The backs of theThe backs of the hands are the classichands are the classic sites to be involved insites to be involved in light induced eruptionlight induced eruption
  • 66.  Phototoxic reaction toPhototoxic reaction to a nonsteroidala nonsteroidal antiinflammatory drugantiinflammatory drug
  • 67.  PhotoallergicPhotoallergic dermatitis on sun-dermatitis on sun- exposed areasexposed areas
  • 68. Polymorphous Light EruptionPolymorphous Light Eruption  Most common form ofMost common form of sensitivitysensitivity  All races and skin typesAll races and skin types affectedaffected  Typically in first three decadesTypically in first three decades  Females outnumber malesFemales outnumber males  Unknown pathogenesisUnknown pathogenesis  Positive family history in 10-Positive family history in 10- 50% of pts50% of pts  Different morphologies seen,Different morphologies seen, although in the individual thealthough in the individual the morphology is constantmorphology is constant
  • 69. PMLEPMLE  Exposed areas suchExposed areas such as the backs of theas the backs of the hands and forearmshands and forearms are affected.are affected. Ultraviolet AUltraviolet A isis mainly responsiblemainly responsible and may penetrateand may penetrate window glasswindow glass
  • 70. PMLEPMLE  The patchiness of theThe patchiness of the edematous papules andedematous papules and plaques is characteristicplaques is characteristic
  • 71. PMLEPMLE  The eruption is less red and confluent than aThe eruption is less red and confluent than a sunburn (left)sunburn (left)  Lesions are typically papular & clustered (right)Lesions are typically papular & clustered (right)
  • 72. PMLE-pathologyPMLE-pathology  CharacteristicCharacteristic perivascularperivascular mononuclear cellmononuclear cell infiltrationinfiltration
  • 73. PMLEPMLE  Very itchy, red, edematous papules, whichVery itchy, red, edematous papules, which may coalesce into plaques, occur 1 or 2may coalesce into plaques, occur 1 or 2 days after exposure to lightdays after exposure to light
  • 74. PMLEPMLE  Polymorphous lightPolymorphous light eruption:eruption: erythematouserythematous papulovesicular and plaque-papulovesicular and plaque- like lesions withlike lesions with characteristic distribution oncharacteristic distribution on the sun-exposed areas ofthe sun-exposed areas of the cheekthe cheek
  • 75. Actinic PrurigoActinic Prurigo  The clinical featuresThe clinical features are somewhatare somewhat suggestive of PML,suggestive of PML, but the lesions arebut the lesions are persistent and thepersistent and the HLA type was DR4HLA type was DR4 (occurs in 80-90% of(occurs in 80-90% of AP pts)AP pts)
  • 76. APAP  Severe actinic prurigo shows spread to buttocks (left)Severe actinic prurigo shows spread to buttocks (left)  Arms show crusted papules that are denser distally;Arms show crusted papules that are denser distally; they are also worse in summerthey are also worse in summer
  • 77. Actinic prurigoActinic prurigo  Actinic prurigo in NativeActinic prurigo in Native American brothersAmerican brothers
  • 78. Actinic prurigoActinic prurigo  Actinic prurigo inActinic prurigo in Native American boyNative American boy
  • 79. AP PathologyAP Pathology  Early lesions have variableEarly lesions have variable acanthosis and spongiosis ofacanthosis and spongiosis of the epidermis with anthe epidermis with an underlying perivascularunderlying perivascular mononuclear cell infiltratemononuclear cell infiltrate with edemawith edema  Later lesions show crusts,Later lesions show crusts, increasing acanthosis andincreasing acanthosis and variable lichenification plus avariable lichenification plus a heavy infiltrate ofheavy infiltrate of mononuclear cells, leadingmononuclear cells, leading to a non-specific picture (asto a non-specific picture (as seen here)seen here)
  • 80. Hydroa VacciniformeHydroa Vacciniforme  Photodermatosis with onset inPhotodermatosis with onset in childhoodchildhood  Lesions appear in crops withLesions appear in crops with disease free intervalsdisease free intervals  Attacks may be preceded by feverAttacks may be preceded by fever and malaiseand malaise  Ears, nose, cheeks, and extensorEars, nose, cheeks, and extensor arms and hands are affectedarms and hands are affected  Within 6 hrs of exposure stingingWithin 6 hrs of exposure stinging may occurmay occur
  • 81. Hydroa VacciniformeHydroa Vacciniforme  There is an early,There is an early, PML-like eruption,PML-like eruption, but with vesiclesbut with vesicles around the moutharound the mouth and umbilicatedand umbilicated lesions on the noselesions on the nose
  • 82. Hydroa VacciniformeHydroa Vacciniforme  A later, more severeA later, more severe example showsexample shows vesiculation withvesiculation with umbilication, butumbilication, but also markedalso marked hemorrhagichemorrhagic crustingcrusting
  • 83. Hydroa VacciniformeHydroa Vacciniforme  A severe exampleA severe example of the typicalof the typical vacciniform facialvacciniform facial scarring that mayscarring that may develop followingdevelop following repeated acuterepeated acute attacksattacks
  • 84. Acute RadiodermatitisAcute Radiodermatitis  With an “erythema dose” of ionizing radiationWith an “erythema dose” of ionizing radiation there is a latent period of up to 24 hrs beforethere is a latent period of up to 24 hrs before visible erythema developsvisible erythema develops  Initial erythema lasts 2-3 days but may beInitial erythema lasts 2-3 days but may be followed by a second phase beginning up to 1followed by a second phase beginning up to 1 week after the exposure and lasting up to 1week after the exposure and lasting up to 1 monthmonth
  • 85. Acute RadiodermatitisAcute Radiodermatitis (fluoroscopic induced)(fluoroscopic induced)
  • 86. Chronic RadiodermatitisChronic Radiodermatitis  Chronic exposure to “subChronic exposure to “sub erythema” doses of ionizingerythema” doses of ionizing radiation over a prolongedradiation over a prolonged period will produce varyingperiod will produce varying amounts of damage to skinamounts of damage to skin and underlying skin after aand underlying skin after a variable latent period ofvariable latent period of several months to severalseveral months to several decadesdecades  Telangiectasia, atrophy, andTelangiectasia, atrophy, and hypopigmentation with residualhypopigmentation with residual focal increased pigmentfocal increased pigment (freckling) may appear(freckling) may appear
  • 87. Radiation CancerRadiation Cancer  After a latent period averaging 20 –30 yrs, variousAfter a latent period averaging 20 –30 yrs, various malignancies may developmalignancies may develop  Most frequent are basal cell carcinomasMost frequent are basal cell carcinomas  Next frequent are squamous cell carcinomasNext frequent are squamous cell carcinomas  These may occur in sites of prior radiation even withoutThese may occur in sites of prior radiation even without evidence of chronic radiation damageevidence of chronic radiation damage  SCCs arising in sites of radiation therapy metastasizeSCCs arising in sites of radiation therapy metastasize more frequently than purely sun-induced SCCsmore frequently than purely sun-induced SCCs  Other cancers induced by radiation: angiosarcoma,Other cancers induced by radiation: angiosarcoma, malignant fibrous histiocytoma, sarcomas, and thyroidmalignant fibrous histiocytoma, sarcomas, and thyroid carcinomacarcinoma
  • 88. Radiation CancerRadiation Cancer  SCC developing in a chronicSCC developing in a chronic radiation ulcer on the chestradiation ulcer on the chest
  • 89. CallusCallus  Nonpenetrating,Nonpenetrating, circumscribedcircumscribed hyperkeratosis produced byhyperkeratosis produced by pressurepressure  Occurs on parts subject toOccurs on parts subject to intermittent pressure (palms,intermittent pressure (palms, soles, bony prominences ofsoles, bony prominences of the joints)the joints)  Callus differs from clavus inCallus differs from clavus in that a callus has nothat a callus has no penetrating central core andpenetrating central core and is a more diffuse thickeningis a more diffuse thickening  Calluses tend to disappearCalluses tend to disappear spontaneously whenspontaneously when pressure is removedpressure is removed
  • 90. Clavus (Corns)Clavus (Corns)  Circumscribed, horny, conicalCircumscribed, horny, conical thickenings with the base onthickenings with the base on the surface and the apexthe surface and the apex pointing inward and pressingpointing inward and pressing on adjacent structureson adjacent structures  Two types:hard and softTwo types:hard and soft  HardHard: occur on dorsa of toes: occur on dorsa of toes or on solesor on soles  SoftSoft: occur between toes,: occur between toes, softened by macerating actionsoftened by macerating action of sweatof sweat
  • 91. CornsCorns  Plantar corns can bePlantar corns can be differentiated from plantardifferentiated from plantar warts by paring off thewarts by paring off the surface keratin until eithersurface keratin until either the pathognomonicthe pathognomonic elongated dermal papillae ofelongated dermal papillae of the wart with its bloodthe wart with its blood vessels, or the clear hornyvessels, or the clear horny core of the corn can becore of the corn can be visualizedvisualized  Ddx: also includesDdx: also includes porokeratosis plantarisporokeratosis plantaris discreta- a sharplydiscreta- a sharply marginated, cone-shaped,marginated, cone-shaped, rubbery lesion commonrubbery lesion common beneath the metetarsalbeneath the metetarsal headsheads
  • 92. Porokeratosis Plantaris DiscretaPorokeratosis Plantaris Discreta  Multiple lesions can occurMultiple lesions can occur  Females are affected 3 timesFemales are affected 3 times as frequently than menas frequently than men  It is painfulIt is painful  Frequently confused with aFrequently confused with a plantar wart or cornplantar wart or corn  Keratosis punctata of theKeratosis punctata of the palmar creases may be seenpalmar creases may be seen in the creases of the digits ofin the creases of the digits of the feet where it may bethe feet where it may be mistaken for a cornmistaken for a corn
  • 93. Surfer’sSurfer’s NodulesNodules  Nodules 1 to 3 cm (rarely asNodules 1 to 3 cm (rarely as much as 5 or 6 cm)much as 5 or 6 cm)  Sometimes eroded or ulceratedSometimes eroded or ulcerated  Develop on tops of feet or overDevelop on tops of feet or over tibial tubercles of surfboardtibial tubercles of surfboard riders who paddle their boardsriders who paddle their boards in a kneeling position, as isin a kneeling position, as is customary in cold water off thecustomary in cold water off the California coastCalifornia coast  Nodules seldom occur in surfersNodules seldom occur in surfers in warmer waters like Hawaii,in warmer waters like Hawaii, because a prone position isbecause a prone position is usedused  Nodules involute over monthsNodules involute over months when there is no surfingwhen there is no surfing
  • 94. Pressure Ulcers (Decubitus)Pressure Ulcers (Decubitus)  The bedsore is a pressure ulcer produced anywhere onThe bedsore is a pressure ulcer produced anywhere on the body by prolonged pressurethe body by prolonged pressure  Caused by ischemia of underlying structures of skin, fat,Caused by ischemia of underlying structures of skin, fat, and muscles resulting from sustained and constantand muscles resulting from sustained and constant pressurepressure  Usually in chronically debilitated persons unable toUsually in chronically debilitated persons unable to change positionchange position  Bony prominences of body are most frequently involvedBony prominences of body are most frequently involved
  • 95. Care-TxCare-Tx  Ulcer care is criticalUlcer care is critical  Debridement-except stableDebridement-except stable heel ulcers (do not needheel ulcers (do not need debridement if only a drydebridement if only a dry eschar is present)eschar is present)  Clean wounds initially and atClean wounds initially and at each dressing change viaeach dressing change via nontraumatic techniquenontraumatic technique  Normal saline is bestNormal saline is best  Dressing selection shouldDressing selection should maintain moist environmentmaintain moist environment  Occlusive dressings like filmOcclusive dressings like film and hydrocolloid are oftenand hydrocolloid are often utilizedutilized  Surgical debridement withSurgical debridement with reconstructive procedures mayreconstructive procedures may be neededbe needed  Electrical stimulation ofElectrical stimulation of refractory ulcers may berefractory ulcers may be beneficialbeneficial
  • 96. Friction BlistersFriction Blisters  Formation of vesicles or bullaeFormation of vesicles or bullae occurring at sites of combinedoccurring at sites of combined pressure and frictionpressure and friction  Enhanced by heat andEnhanced by heat and moisturemoisture  Examples: feet of militaryExamples: feet of military recruits in training, palms ofrecruits in training, palms of oarsmen not having developedoarsmen not having developed protective calluses, beginningprotective calluses, beginning drummers (“drummer’s digits”)drummers (“drummer’s digits”)
  • 97. Sclerosing LymphangiitisSclerosing Lymphangiitis  Cordlike structure encirclingCordlike structure encircling the coronal sulcus of thethe coronal sulcus of the penis, or running the lengthpenis, or running the length of the shaftof the shaft  Attributed to traumaAttributed to trauma  Produced by a sclerosingProduced by a sclerosing lymphangiitislymphangiitis  No tx is neededNo tx is needed  Follows a benign, self-Follows a benign, self- limiting courselimiting course
  • 98. Black HeelBlack Heel  Also calledAlso called talon noirtalon noir,, calcanealcalcaneal petechiae,petechiae, andand chromidrosechromidrose plantaireplantaire  A sudden shower of minuteA sudden shower of minute macules occurs most often on themacules occurs most often on the posterior edge of the plantarposterior edge of the plantar surface of one or both heelssurface of one or both heels  Sometimes occurs distally on oneSometimes occurs distally on one or more toesor more toes  Black heel is seen in basketball,Black heel is seen in basketball, volleyball, tennis, or lacrossevolleyball, tennis, or lacrosse playersplayers
  • 99. Painful FatPainful Fat HerniationHerniation  AKA painful piezogenicAKA painful piezogenic pedal papulespedal papules  Rare cause of painful feetRare cause of painful feet representing fat herniationsrepresenting fat herniations through thin fascial layers ofthrough thin fascial layers of weight-bearing parts of theweight-bearing parts of the heelheel  These dermatoceles becomeThese dermatoceles become apparent when wt is placedapparent when wt is placed on the heelon the heel  These disappear whenThese disappear when pressure is removedpressure is removed  Extrusion of fat tissueExtrusion of fat tissue together with its bloodtogether with its blood vessels and nerves initiatesvessels and nerves initiates pain on prolonged standingpain on prolonged standing  Avoidance of prolongedAvoidance of prolonged standing is the only way tostanding is the only way to provide reliefprovide relief  Majority of people experienceMajority of people experience no symptomsno symptoms
  • 100. Painful Fat HerniationPainful Fat Herniation
  • 101. Narcotic DermopathyNarcotic Dermopathy  Heroin(diacetylmorphine)Heroin(diacetylmorphine) is a narcotic prepared byis a narcotic prepared by dissolving the heroindissolving the heroin powder in boiling waterpowder in boiling water and then injecting itand then injecting it  Favored route is IVFavored route is IV  Resulting in thrombosed,Resulting in thrombosed, cordlike, thickened veinscordlike, thickened veins
  • 102. Narcotic DermopathyNarcotic Dermopathy  Subcutaeous injection (“skin popping”) canSubcutaeous injection (“skin popping”) can result in multiple, scattered ulcerations, whichresult in multiple, scattered ulcerations, which heal with discrete atrophic scarsheal with discrete atrophic scars
  • 103. TattooingTattooing  Photosensitivity can occur fromPhotosensitivity can occur from pigments used (cadmium sulfide-usedpigments used (cadmium sulfide-used for yellow color or to brighten upfor yellow color or to brighten up cinnabar red)cinnabar red)  Unsanitary tattooing has resulted inUnsanitary tattooing has resulted in inoculation of syphilis, infectiousinoculation of syphilis, infectious hepatitis, tuberculosis, HIV, andhepatitis, tuberculosis, HIV, and leprosyleprosy  Occasionally keloid formation occursOccasionally keloid formation occurs  Accidental tattoo marks may beAccidental tattoo marks may be induced by narcotic addicts whoinduced by narcotic addicts who sterilize needles for injection bysterilize needles for injection by flaming needle with a lighted matchflaming needle with a lighted match
  • 104. TattooingTattooing  Discoid lupus has been reported toDiscoid lupus has been reported to occur in red-pigmented portions ofoccur in red-pigmented portions of tattoostattoos  Sarcoid nodules and granulomaSarcoid nodules and granuloma annulare-like lesions have also beenannulare-like lesions have also been seenseen  Dermatitis in areas of red (mercury),Dermatitis in areas of red (mercury), green (chromium), or blue (cobalt)green (chromium), or blue (cobalt) have been described in pts patch-testhave been described in pts patch-test positive to these metalspositive to these metals  Tx:Q-switched laser allows removalTx:Q-switched laser allows removal without scarringwithout scarring  One report of five pts who developedOne report of five pts who developed darkening after tx due to ferrous oxidedarkening after tx due to ferrous oxide formationformation
  • 105. ParaffinomaParaffinoma  AKA-sclerosingAKA-sclerosing lipogranulomalipogranuloma  Injection of paraffin into skinInjection of paraffin into skin for cosmetic purposesfor cosmetic purposes  Smoothing of wrinkles andSmoothing of wrinkles and breast augmentationbreast augmentation  Oils like paraffin,Oils like paraffin, camphorated oil, cottonseedcamphorated oil, cottonseed or sesame oil, beeswax wereor sesame oil, beeswax were usedused  These can produce plaque-These can produce plaque- like indurations withlike indurations with ulcerations after timeulcerations after time