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Dermatoses Resulting from Physical Factors. Chapter 3 Andrew’s Diseases of the Skin Ben Adams, D.O. July 25th 2006 . Heat Injuries. Thermal Burns Electrical Burns Miliaria Miliaria Crystalline (Sudamina) Miliaria Rubra (Prickly Heat, Heat Rash) Miliaria Pustulosa Miliaria Profunda

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dermatoses resulting from physical factors

Dermatoses Resulting from Physical Factors

Chapter 3

Andrew’s Diseases of the Skin

Ben Adams, D.O.

July 25th 2006

heat injuries
Heat Injuries
  • Thermal Burns
  • Electrical Burns
  • Miliaria
  • Miliaria Crystalline (Sudamina)
  • Miliaria Rubra (Prickly Heat, Heat Rash)
  • Miliaria Pustulosa
  • Miliaria Profunda
  • Occlusion Miliaria
thermal burns
Thermal Burns
  • First-degree burn: active congestion of superficial blood vessels
  • This causes erythema, sometimes followed by epidermal desquamation
  • Constitutional reactions occur if large area involved
  • Pain and increased surface heat may be severe
second degree burns
Deep

Pale and anesthetic

Injury to reticular dermis compromises blood flow and destroys appendages

Healing takes > 1 month

Scarring occurs

Superficial

Transudation of serum causing edema of superficial tissues

Vesicles and blebs

Complete recovery without scar or blemish is usual

Second-degree burns
second degree burn
Second-degree burn
  • Thermal burn: This superficial second degree burn is characterized by bullae that contain serous fluid
second degree burns6
Second-Degree Burns
  • Inflicted scalds: severe second degree burns after dipping
  • B: two days after incident-to lower extremities and perineum
  • C: foot and lower leg
second degree burn7
Second-Degree Burn
  • Accidental scald
  • Splash-and-droplet pattern of an accidental scald from hot cup of tea
third degree burns
Full-thickness tissue loss

Skin appendages are destroyed

There is no epithelium for regeneration

Healing leaves a scar

Third-degree burns
fourth degree burns
Fourth-degree burns
  • Destruction of entire skin and subcutaneous fat with any underlying tendons
slide10
Rule of nines:
  • In adults, an estimate of burn extent based upon this surface area distribution chart.
  • Infants & children have a relatively increased head; trunk surface area ratio
electrical burns
Electrical Burns
  • Contact- small but deep, causing some necrosis of underlying tissues
  • Flash-burns usually cover a large area and are similar to a surface burn and should be tx as such
  • Lightning is the most lethal type of strike, cardiac arrest or other internal injuries may occur
electrical burns12
Electrical Burns
  • Indirect- burns that are either linear in areas at which sweat was present; are feathery or aborescent pattern, which is believed to be pathognomonic
electrical burn
Electrical Burn
  • It is characterized by erythema, edema, bulla formation and sloughing of the necrotic epidermis
electrical burn pathology
Electrical Burn-pathology
  • Blistering and elongated keratinocytes
miliaria
Miliaria
  • Retention of sweat as a result of occlusion
  • Common in hot, humid climates
  • Occlusion of eccrine sweat gland obstructs delivery of sweat to the skin surface
  • Eventually backed-up pressure causes rupture of sweat gland or duct at different levels
  • Escape of sweat into adjacent tissue produces miliaria
  • Different forms of miliaria occur depending on the level of injury to the sweat gland
miliaria crystallina
Miliaria Crystallina
  • Small, clear, superficial vesicles without inflammation
  • Appears in bedridden pts and bundled children
  • Lesions are asymptomatic and rupture at the slightest trauma
  • Self-limited; no tx is required
miliaria crystallina17
Miliaria Crystallina
  • Minute, discrete vesicles resulting from profuse sweating secondary to a high fever
miliaria rubra
Miliaria Rubra
  • Discrete, extremely pruritic, erythematous papulovesicles with sensation of prickling, burning, or tingling
  • Site of injury is prickle cell layer where spongiosis is produced
miliaria pustulosa
Miliaria Pustulosa
  • Always preceded by some injury, destruction, or blocking of sweat duct
  • Pustules independent of hair follicle
  • Seen in intertriginous areas, flexure surfaces of extremities, scrotum, and back of bedridden pts
  • Sterile pustules
miliaria profunda
Miliaria Profunda
  • Nonpruritic, flesh-colored, deep-seated, whitish papules
  • Asymptomatic, usually lasting only 1 hr after overheating has ended
  • Concentrated on the trunk and extremities
  • Occlusion is in upper dermis
  • Only seen in tropics usually following a severe bout of miliaria rubra
occlusion miliaria
Occlusion Miliaria
  • May be produced with accompanying anhidrosis and increased heat stress susceptibility after application of extensive polyethylene film occlusion for > 48 hrs
  • Tx-place pt in a cool environment
  • Even a night in an air-conditioned room helps alleviate the discomfort
occlusion miliaria23
Occlusion Miliaria
  • Mild cases may respond to dusting powders, such as cornstarch or talcum powder
  • A lotion containing 1% menthol and glycerin and 4% salicylic acid in 95% alcohol is effective
  • An oily “shake” lotion such as calamine lotion, with 1% or 2% phenol may be effective
erythema pigmentatio ab igne
Erythema (pigmentatio) Ab Igne
  • Aka “toasted skin” syndrome
  • Persistent erythema or coarsely reticulated residual pigmentation resulting from it
  • Produced by long-continued exposure to excessive heat without production of a burn
  • It begins as a mottling caused by local hemostasis and becomes a reticulated erythema, leaving pigmentation
erythema ab igne
Erythema Ab Igne
  • Reticulated hyperpigmentation with some epidermal atrophy and scaling secondary to use of a heating pad
erythema ab igne26
Use of bland emollients is helpful

No effective treatment

Kligman’s combination of 5% hydroquinone in hydrophilic ointment containing 0.1% retinoic acid and 0.1% dexamethasone may reduce unsightly pigmentation

Erythema Ab Igne
slide27
There is a mild superficial perivascular inflammatory infiltrate composed predominantly of lymphocytes and prominent pigment incontinence.
  • Histologically, an increased amount of elastic tissue in the dermis is seen
  • Changes are similar to actinic elastosis, and has been suggested to call these changes thermal elastosis
cold injuries
Cold Injuries
  • Chilblains
  • Frostbite
  • Immersion injury
chilblains
Chilblains
  • Acute chilblains is the mildest form of cold injury
  • Pts are usually unaware of injury until they develop burning, itching, and redness
treatment
Treatment
  • Nifedipine 20mg TID
  • Vasodilators (nicotinamide 100 mg TID or dipyridamole 25 mg TID)
  • Systemic corticoid tx is helpful in chilblain lupus erythematosus
  • Pentoxifylline may be useful
  • Smoking strongly discouraged
frostbite
Frostbite
  • When soft tissue is frozen and locally deprived of blood supply
  • Frozen part is painless and becomes pale and waxy
  • Four stages:
  • I- Frost-nip erythema, edema,cutaneous anesthesia & transient pain
  • II- second degree: hyperemia, edema & blistering, with clear fluid in bullae
  • III- third-degree: full-thickness dermal loss with hemorrhagic bullae formation or waxy, dry, mummified skin
  • IV- full-thickness loss of entire part
immersion foot syndromes
Immersion Foot Syndromes
  • Trench Foot
  • Warm Water Immersion Foot
trench foot
Trench Foot
  • Term derived from trench warfare in World War I, when soldiers stood, sometimes for hours, in trenches with a few inches of cold water in them
  • Results from prolonged exposure to cold, wet conditions without immersion or actual freezing
  • Tx-removal from environment
tropical immersion foot
Tropical Immersion Foot
  • AKA “paddy foot” in Vietnam
  • Seen after continuous immersion of the feet in water or mud of temperatures above 71.6 degrees F (22 degrees C) for 2-10 days
  • Erythema, edema, and pain of the dorsal feet
  • Also fever and adenopathy
  • Resolution occurs 3 to 7 days after the feet have been

dried

dermatoses with cold hypersensitivity
Dermatoses with Cold Hypersensitivity
  • Erythrocyanosis Crurum
  • Acrocyanosis
  • Cold Panniculitis
erythrocyanosis crurum
Slight swelling and a bluish pink tint of the skin of the legs and thighs of young girls and women

May be unilateral

May have cramps in the legs at night

Small tender nodules may be found on palpation

Nodules may break down and form small, multiple ulcers

Seen in northern countries and probably due to an abnormal reaction of blood vessels to prolonged cold

Erythrocyanosis Crurum
acrocyanosis
Acrocyanosis
  • A persistent cyanosis with coldness and hyperhidrosis of hands and feet
  • Chiefly occurs in young women
  • At times, on cold exposure, a digit becomes stark white and insensitive (acroasphyxia)
  • Cyanosis increases as the temperature decreases and changes to erythema with elevation of dependent part
  • Cause is unknown
  • Smoking, coffee, and tea should be avoided
cold panniculitis
Cold Panniculitis
  • After exposure to severe cold, well-demarcated erythematous warm plaques may develop, particularly on the cheeks of young children
  • Lesions usually develop within a few days after exposure, and resolve spontaneously in 2 weeks (approx)
  • No tx is indicated
  • Popsicle dermatitis is a temporary redness and induration of the cheek in children resulting from sucking Popsicles
sunburn and solar erythema
Parts of solar spectrum important to photomedicine:

Visible light 400 to 760 nm

Infrared radiation beyond 760 nm

Visible light has little biologic activity, except for stimulating the retina

Infrared radiation is experienced as radiant heat

Below 400 nm is the ultraviolet spectrum, divided into three bands:

UVA, 320 to 400 nm

UVB, 290 to 320 nm

UVC, 200 to 290 nm

Virtually no UVC reaches the earth’s surface, because it is absorbed by the ozone layer

Exception: Australia, welders

Sunburn and Solar Erythema
sunburn and solar erythema42
UVB is 1000 times more erythemogenic than UVA

UVA is 100 times greater than UVB radiation during the midday hours

Most solar erythema is cause by UVB

Sunlight early and late in the day contains more UVA

UVA is reflected from sand, snow, or ice to a greater degree than UVB

Amount of ultraviolet exposure increases at higher altitudes, is greater in tropical regions, and temperate climates in summer

Sunburn and Solar Erythema
clinical signs and symptoms
Clinical signs and symptoms
  • Sunburn is normal cutaneous reaction to sunlight in excess of an erythema dose (the amount that will induce reddening)
  • UVB erythema peaks at 12 to 24 hrs after exposure
  • Desquamation is common about a week after sunburn even in non-blistering areas
sunburn treatment
Sunburn treatment
  • Cool compresses
  • Topical steroids
  • Topical remedy:

Indomethacin 100 mg

Absolute ethanol 57 ml

Propylene glycol 57 ml

spread widely over burned area with palms and let dry

prophylaxis
Prophylaxis
  • Avoid sun exposure between 10 am and 2 pm
  • Barrier protection with hats and clothing
  • Sunscreen agents include UV-absorbing chemicals, and UV-scattering or blocking agents (physical sunscreens)
sunscreens
Chemical sunscreens: para-aminobenzoic acid(PABA), PABA esters, cinnamates, salicylates, anthranilates, benzophenoes)

Physical agents: titanium/zinc dioxide

Combinations of both

Water resistant: maintaining their SPF after 40 minutes of water immersion

Water proof: maintaining their SPF after 80 mins of water immersion

UVA protection: sunscreens containing benzophenones or dibenzoylmethanes

Apply sunscreen at least 20mins before sun exposure

Sunscreens
photoaging dermatohelioisis
Photoaging (Dermatohelioisis)
  • Characteristic changes induced by chronic sun exposure
  • Risk of developing these changes correlated with baseline pigmentation (constitutive pigmentation) and ability to resist burning and tan following sun exposure (facultative pigmentation)
dermatoheliosis
Dermatoheliosis
  • Poikiloderma of Civatte: refers to reticulate hyperpigmentation with telangiectasia, and slight atrophy of sides of the neck, lower anterior neck and V of chest
  • Submental area is spared
  • Frequently presents in fair-skinned men and women in their middle to late thirties or early forties
dermatoelastosis
Dermatoelastosis
  • Cutis rhomboidalis nuchae (sailor’s neck or farmer’s neck) is characteristic of long-term, chronic sun exposure
  • Skin on back of neck becomes thickened, tough, and leathery and normal skin marking become exaggerated
dermatoheliosis52
Dermatoheliosis
  • Favre-Racouchot syndrome
  • Thickened yellow plaques studded with comedomes and cystic lesions
  • Tx-removal , retinoic acid cream, surgical removal of cysts and redundant skin
solar elastosis
Solar Elastosis
  • Homogenization and a faint blue color of connective tissue of the upper reticular dermis, so-called solar elastosis
  • Characteristically there is a zone of normal connective tissue below the epidermis
photosensitivity
Photosensitizers may induce an abnormal reaction in skin exposed to sunlight or its equivalent

Substances may be delivered externally or internally

Increased sunburn response without prior allergic sensitization is called phototoxicity

Phototoxicity may occur from both externally applied (phytophotodermatitis and berloque dermatitis) or internally administered chemicals (phototoxic drug reaction)

Or by external contact- (photoallergic contact dermatitis)

Photosensitivity
phototoxicity vs photoallergy
Phototoxicity vs photoallergy
  • In the case of external contactants –phototoxicity occurs on initial exposure, has onset < 48 hrs, occurs in most people exposed to the phototoxic substance and sunlight
  • Photoallergy, in contrast, occurs only in sensitized persons, may have delayed onset, up to 14 days (a period of sensitization), and shows histologic features of contact dermatitis
photosensitivity56
Drug-induced photosensivity-photoallergic dermatitis on sun-exposed areas of an infant following topical use of hexachlorophenePhotosensitivity
photoallergic dermatitis
Photoallergic dermatitis
  • Papulovesicular lesions of photoallergic dermatitis due to hexachlorophene
phytophotosensitivity
Phytophotosensitivity
  • Plant-induced photosensitivity-linear hyperpigmentation on the face following exposure to limes and sunlight
phytophotosensitivity59
Phytophotosensitivity
  • Hyperpigmentation on the dorsal aspect of the hands following the use of limes and sunlight exposure
photosensitivity in tattoos
Photosensitivity in Tattoos
  • Yellow cadmium sulfide may be used as a yellow dye or may be incorporated into red mercuric sulfide pigment to produce a brighter red color for tattooing
  • When exposed to 380, 400, and 450 nm wavelengths of light, these areas in tattoos may swell, develop erythema, and become verrucose
phototoxic drug reactions
Most occur from tetracyclines, nonsteroidal antiinflammatory drugs, amiodarone, and phenothiazines

Action spectrum for all is in the UVA range

In the case of amiodarone and chlorpromazine, hyperpigmentation is a well-recognized pattern of phototoxicity

It causes slate blue (amiodarone) or slate gray (chlorpromazine) coloration, resulting from drug deposition in the tissues

Phototoxic Drug Reactions
drug induced photosensitivity
Drug induced photosensitivity
  • The erythema is less apparent in black skin, but the involvement of the nose in this patient suggests phototoxicity, in this case caused by thiazide
drug induced photosensitivity64
Drug-induced photosensitivity
  • Not only the nose was but also the “V” of the neck which was highly suggestive of phototoxicity
  • Same pt
drug induced photosensitivity65
Drug induced photosensitivity
  • The backs of the hands are the classic sites to be involved in light induced eruption
polymorphous light eruption
Polymorphous Light Eruption
  • Most common form of sensitivity
  • All races and skin types affected
  • Typically in first three decades
  • Females outnumber males
  • Unknown pathogenesis
  • Positive family history in 10-50% of pts
  • Different morphologies seen, although in the individual the morphology is constant
slide69
PMLE
  • Exposed areas such as the backs of the hands and forearms are affected. Ultraviolet A is mainly responsible and may penetrate window glass
slide70
PMLE
  • The patchiness of the edematous papules and plaques is characteristic
slide71
PMLE
  • The eruption is less red and confluent than a sunburn (left)
  • Lesions are typically papular & clustered (right)
pmle pathology
PMLE-pathology
  • Characteristic perivascular mononuclear cell infiltration
slide73
PMLE
  • Very itchy, red, edematous papules, which may coalesce into plaques, occur 1 or 2 days after exposure to light
slide74
PMLE
  • Polymorphous light eruption:

erythematous papulovesicular and plaque-like lesions with characteristic distribution on the sun-exposed areas of the cheek

actinic prurigo
Actinic Prurigo
  • The clinical features are somewhat suggestive of PML, but the lesions are persistent and the HLA type was DR4 (occurs in 80-90% of AP pts)
slide76
AP
  • Severe actinic prurigo shows spread to buttocks (left)
  • Arms show crusted papules that are denser distally; they are also worse in summer
actinic prurigo77
Actinic prurigo
  • Actinic prurigo in Native American brothers
actinic prurigo78
Actinic prurigo
  • Actinic prurigo in Native American boy
ap pathology
AP Pathology
  • Early lesions have variable acanthosis and spongiosis of the epidermis with an underlying perivascular mononuclear cell infiltrate with edema
  • Later lesions show crusts, increasing acanthosis and variable lichenification plus a heavy infiltrate of mononuclear cells, leading to a non-specific picture (as seen here)
hydroa vacciniforme
Hydroa Vacciniforme
  • Photodermatosis with onset in childhood
  • Lesions appear in crops with disease free intervals
  • Attacks may be preceded by fever and malaise
  • Ears, nose, cheeks, and extensor arms and hands are affected
  • Within 6 hrs of exposure stinging may occur
hydroa vacciniforme81
Hydroa Vacciniforme
  • There is an early, PML-like eruption, but with vesicles around the mouth and umbilicated lesions on the nose
hydroa vacciniforme82
Hydroa Vacciniforme
  • A later, more severe example shows vesiculation with umbilication, but also marked hemorrhagic crusting
hydroa vacciniforme83
Hydroa Vacciniforme
  • A severe example of the typical vacciniform facial scarring that may develop following repeated acute attacks
acute radiodermatitis
Acute Radiodermatitis
  • With an “erythema dose” of ionizing radiation there is a latent period of up to 24 hrs before visible erythema develops
  • Initial erythema lasts 2-3 days but may be followed by a second phase beginning up to 1 week after the exposure and lasting up to 1 month
chronic radiodermatitis
Chronic Radiodermatitis
  • Chronic exposure to “sub erythema” doses of ionizing radiation over a prolonged period will produce varying amounts of damage to skin and underlying skin after a variable latent period of several months to several decades
  • Telangiectasia, atrophy, and hypopigmentation with residual focal increased pigment (freckling) may appear
radiation cancer
Radiation Cancer
  • After a latent period averaging 20 –30 yrs, various malignancies may develop
  • Most frequent are basal cell carcinomas
  • Next frequent are squamous cell carcinomas
  • These may occur in sites of prior radiation even without evidence of chronic radiation damage
  • SCCs arising in sites of radiation therapy metastasize more frequently than purely sun-induced SCCs
  • Other cancers induced by radiation: angiosarcoma, malignant fibrous histiocytoma, sarcomas, and thyroid carcinoma
radiation cancer88
Radiation Cancer
  • SCC developing in a chronic radiation ulcer on the chest
callus
Nonpenetrating, circumscribed hyperkeratosis produced by pressure

Occurs on parts subject to intermittent pressure (palms, soles, bony prominences of the joints)

Callus differs from clavus in that a callus has no penetrating central core and is a more diffuse thickening

Calluses tend to disappear spontaneously when pressure is removed

Callus
clavus corns
Clavus (Corns)
  • Circumscribed, horny, conical thickenings with the base on the surface and the apex pointing inward and pressing on adjacent structures
  • Two types:hard and soft
  • Hard: occur on dorsa of toes or on soles
  • Soft: occur between toes, softened by macerating action of sweat
corns
Corns
  • Plantar corns can be differentiated from plantar warts by paring off the surface keratin until either the pathognomonic elongated dermal papillae of the wart with its blood vessels, or the clear horny core of the corn can be visualized
  • Ddx: also includes porokeratosis plantaris discreta- a sharply marginated, cone-shaped, rubbery lesion common beneath the metetarsal heads
porokeratosis plantaris discreta
Porokeratosis Plantaris Discreta
  • Multiple lesions can occur
  • Females are affected 3 times as frequently than men
  • It is painful
  • Frequently confused with a plantar wart or corn
  • Keratosis punctata of the palmar creases may be seen in the creases of the digits of the feet where it may be mistaken for a corn
surfer s nodules
Surfer’s Nodules
  • Nodules 1 to 3 cm (rarely as much as 5 or 6 cm)
  • Sometimes eroded or ulcerated
  • Develop on tops of feet or over tibial tubercles of surfboard riders who paddle their boards in a kneeling position, as is customary in cold water off the California coast
  • Nodules seldom occur in surfers in warmer waters like Hawaii, because a prone position is used
  • Nodules involute over months when there is no surfing
pressure ulcers decubitus
Pressure Ulcers (Decubitus)
  • The bedsore is a pressure ulcer produced anywhere on the body by prolonged pressure
  • Caused by ischemia of underlying structures of skin, fat, and muscles resulting from sustained and constant pressure
  • Usually in chronically debilitated persons unable to change position
  • Bony prominences of body are most frequently involved
care tx
Ulcer care is critical

Debridement-except stable heel ulcers (do not need debridement if only a dry eschar is present)

Clean wounds initially and at each dressing change via nontraumatic technique

Normal saline is best

Dressing selection should maintain moist environment

Occlusive dressings like film and hydrocolloid are often utilized

Surgical debridement with reconstructive procedures may be needed

Electrical stimulation of refractory ulcers may be beneficial

Care-Tx
friction blisters
Friction Blisters
  • Formation of vesicles or bullae occurring at sites of combined pressure and friction
  • Enhanced by heat and moisture
  • Examples: feet of military recruits in training, palms of oarsmen not having developed protective calluses, beginning drummers (“drummer’s digits”)
sclerosing lymphangiitis
Sclerosing Lymphangiitis
  • Cordlike structure encircling the coronal sulcus of the penis, or running the length of the shaft
  • Attributed to trauma
  • Produced by a sclerosing lymphangiitis
  • No tx is needed
  • Follows a benign, self-limiting course
black heel
Black Heel
  • Also called talon noir, calcaneal petechiae, and chromidrose plantaire
  • A sudden shower of minute macules occurs most often on the posterior edge of the plantar surface of one or both heels
  • Sometimes occurs distally on one or more toes
  • Black heel is seen in basketball, volleyball, tennis, or lacrosse players
painful fat herniation
AKA painful piezogenic pedal papules

Rare cause of painful feet representing fat herniations through thin fascial layers of weight-bearing parts of the heel

These dermatoceles become apparent when wt is placed on the heel

These disappear when pressure is removed

Extrusion of fat tissue together with its blood vessels and nerves initiates pain on prolonged standing

Avoidance of prolonged standing is the only way to provide relief

Majority of people experience no symptoms

Painful Fat Herniation
narcotic dermopathy
Narcotic Dermopathy
  • Heroin(diacetylmorphine) is a narcotic prepared by dissolving the heroin powder in boiling water and then injecting it
  • Favored route is IV
  • Resulting in thrombosed, cordlike, thickened veins
narcotic dermopathy103
Narcotic Dermopathy
  • Subcutaeous injection (“skin popping”) can result in multiple, scattered ulcerations, which heal with discrete atrophic scars
tattooing
Tattooing
  • Photosensitivity can occur from pigments used (cadmium sulfide-used for yellow color or to brighten up cinnabar red)
  • Unsanitary tattooing has resulted in inoculation of syphilis, infectious hepatitis, tuberculosis, HIV, and leprosy
  • Occasionally keloid formation occurs
  • Accidental tattoo marks may be induced by narcotic addicts who sterilize needles for injection by flaming needle with a lighted match
tattooing105
Tattooing
  • Discoid lupus has been reported to occur in red-pigmented portions of tattoos
  • Sarcoid nodules and granuloma annulare-like lesions have also been seen
  • Dermatitis in areas of red (mercury), green (chromium), or blue (cobalt) have been described in pts patch-test positive to these metals
  • Tx:Q-switched laser allows removal without scarring
  • One report of five pts who developed darkening after tx due to ferrous oxide formation
paraffinoma
Paraffinoma
  • AKA-sclerosing lipogranuloma
  • Injection of paraffin into skin for cosmetic purposes
  • Smoothing of wrinkles and breast augmentation
  • Oils like paraffin, camphorated oil, cottonseed or sesame oil, beeswax were used
  • These can produce plaque-like indurations with ulcerations after time