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Dermatoses Resulting from Physical Factors. Chapter 3 Andrew’s Diseases of the Skin JoAnne M. LaRow, D.O. Heat Injuries. Thermal Burns Electrical Burns Hot Tar 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

JoAnne M. LaRow, D.O.

heat injuries
Heat Injuries
  • Thermal Burns
  • Electrical Burns
  • Hot Tar Burns
  • Miliaria
  • Miliaria Crystalline (Sudamina)
  • Miliaria Rubra (Prickly Heat, Heat Rash)
  • Miliaria Pustulosa
  • Miliaria Profunda
  • Postmiliarial Hypohidrosis
  • Tropical Anhidrotic Asthenia
  • Occlusion Miliaria
thermal burns
Thermal Burns
  • First-degree burn- active congestion of superficial blood vessels
  • This causes erythema sometimes followed by epidermal desquamation
  • Sunburn
  • Constitutional reactions occur if area is large
  • Pain and increased surface heat may be severe
second degree burns
Deep –is pale and anesthetic

Injury to reticular dermis compromises blood flow and destroys appendages

Healing takes > 1 month

Scarring occurs

Two types-superficial and deep

Superficial-transudation of serum from capillaries, causing edema of superficial tissues

Vesicles and blebs form from serum gathering beneath the outer layers of the dermis

Complete recovery without scar or blemish is usual

Second-degree burns
second degree burns5
Thermal burn: This superficial second degree burn is characterized by bullae that contain serous fluidSecond-degree burns
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 burn
Second-Degree Burn
  • Accidental scald
  • Splash-and-droplet pattern of an accidental scald from hot cup of tea
second degree burn8
Second-Degree Burn
  • Curling iron burn
third degree burns
Third-degree burns
  • Full-thickness tissue loss
  • Often loss of subcutaneous tissue occurs
  • Since skin appendages are destroyed there is no epithelium for regeneration
  • An ulcerating wound occurs
  • Healing leaves a scar
  • Followed by constitutional symptoms
fourth degree burns
Fourth-degree burns
  • Destruction of entire skin and subcutaneous fat with any underlying tendons
  • Requires grafting for closure
  • Constitutional symptoms occurs
  • Constitutional symptoms depend on size of area involved, depth, and especially location
  • The more vascular the involved area, the more severe the symptoms
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
thermal burns12
Symptoms of shock may appear within 24-hrs

Next, symptoms of toxemia from the absorption of destroyed tissue on wound surface

Symptoms of wound infection may then occur as a result of contamination with pyogenic organisms

Symptoms of all three may merge making differentiation difficult

Prognosis is poor when large surfaces are involved

Particularly when > two thirds of body surface is burned

Infection of the wound

Cellulitis, sepsis, with seeding of internal organs (ie meninges, lungs, kidneys)

Irregularities in electrolytes and fluid balance, loss or serum proteins

Thermal Burns
complications of thermal burns
Excessive scarring with keloid-like scars or flat scars with contractures of joints

Chronic ulcerations because of local impaired circulation

Burn scars may be the site of carcinoma or sarcoma

Complications of thermal burns
For minor thermal burns-prompt cold applications until pain has resolved

Do not open vesicles or blebs, they provide a natural barrier

If tense and painful evacuate fluid under strict aseptic conditions via puncture of the wall to allow blister to collapse

Apply topical antibiotic

Severe deep wounds silver sulfadiazine ointment is indicated

Antibiotics, fluid, and electrolyte support, supplemental vitamins

Collagen-synthetic bi-laminate membranes may be used

In many centers, cultured epidermal grafts, both autologous and allogeneic, are being utilized

Morbidity and mortality following severe burns is often due to bacterial and fungal infection

Definitive tx consists of antishock measures, debridement of loose skin and dirt, and application of silver sulfadiazine ointment

Expedient primary excision of deep dermal and full-thickness burn wounds with subsequent grafting is standard of care

Severe second- and third degree burns require specialized teams of physicians working together to provide most effective tx

electrical burns
Electrical Burns
  • Two varieties:
  • Contact and flash
  • 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
  • Lightening may cause burns after direct strike, where an exist and an entrance wound are visible
  • Lightening is the most lethal type of strike, cardiac arrest or other internal injuries may occur
electrical burns17
Electrical Burns
  • Other types of strikes are indirect and result in linear 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
hot tar burns
Hot Tar Burns
  • Demling has reported that the polyoxyethylene sorbitan in Neosporin ointment is an excellent dispersing agent that facilitates the removal of hot tar from burns
  • Retention of sweat as a result of occlusion of eccrine sweat ducts and pores
  • Produces an eruption that is common in hot, humid climates such as the tropics and during the hot summer months in temperate 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 crystalline
Miliaria Crystalline
  • Characterized by small, clear, superficial vesicles without inflammation
  • Appears in bedridden pts in whom fever produces increased perspiration or when clothing prevents dissipation of heat and moisture, as in bundled children
  • Lesions are asymptomatic and rupture at the slightest trauma
  • Self-limited; no tx is required
miliaria crystallina
Miliaria Crystallina
  • Minute, discrete vesicles resulting from profuse sweating secondary to a high fever
miliaria rubra
Miliaria Rubra
  • Lesions are descrete, extremely pruritic, erythematous papulovesicles with sensation of prickling, burning, or tingling
  • Tingling may become confluent on a bed of erythema
  • Most frequently affected sites: antecubital and popliteal fossae, trunk, inframammary areas, abdomen
  • Site of injury is prickle cell layer where spongiosis is produced
miliaria pustulosa
Miliaria Pustulosa
  • Always preceded by some other dermatitis that has produced injury, destruction, or blocking of sweat duct
  • Pustules are distinct, superficial, and independent of hair follicle
  • Pruritic pustules occur most frequently on intertriginous areas, flexure surfaces of extrmities, sctrotum, and back of bedridden pts
  • Usually pustules contain sterile material, but may contain nonpathogenic cocci
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

Except for face, axillae, hands, and feet(where there may be a compensatory hyperhydrosis), all sweat glands are nonfunctional

Occlusion is in upper dermis

Only seen in tropics usually following a severe bout of miliaria rubra

Miliaria Profunda
postmiliarial hypohidrosis
Postmiliarial Hypohidrosis
  • Results from occlusion of sweat ducts and pores and may be severe enough to impair one’s ability to perform sustained work in a hot environment
  • Affected pts may show decreasing efficiency, irritability, anorexia, drowsiness, vertigo, and headache; they may wander in a daze
  • Hypohidrosis invariably follows miliaria
  • The duration and severity of hypohidrosis are related to severity and duration of miliaria
  • Sweating may be depressed to half the normal amount for as long as 3 weeks
tropical anhidrotic asthenia
Tropical Anhidrotic Asthenia
  • Rare form of miliaria with long-lasting pore occlusion, producing anhidrosis and heat retention
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
  • Anhydrous lanolin resolves occlusion of pores and may help restore normal sweat secretions
  • Hydrophilic ointment helps dissolve keratinous plugs facilitating sweat flow
  • Soothing, cooling baths containing Aveeno colloidal oatmeal or cornstarch in moderation
occlusion miliaria32
Occlusion Miliaria
  • Mild cases may respond to dusting powders, such as cornstarch or baby talcum powder
  • A lotion containing 1% menthol and glycerin and 4% salicylic acid in 95% alcohol is effective
  • This should be dabbed on affected areas several times daily until desquamation sets in
  • 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
All the various phases usually are present simultaneously in a patch, the color varying from pale pink to old rose or dark purplish brown

After cause is removed the color tends to disappear gradually, but sometimes pigment is permanent

Most common on the legs of women as a result of warming in open fireplaces, radiators, or heaters

Similar changes may be produced with a hot water bag or electric heating pad

Also occurs in cooks, stokers, invalids, and others exposed to long periods of moderate heat

Epithelial atypia and Bowen’s disease has been reported

Erythema Ab Igne
erythema ab igne35
Erythema Ab Igne
  • Reticulated hyperpigmentation with some epidermal atrophy and scaling secondary to use of a heating pad
heat sources causing eai
Steam radiators

Car heaters

Heated reclining chairs

Heating blankets

Hot bricks

Infrared lamps

Heating pads

Hot water bottles

Electric stove/heater

Open fires

Coal stoves

Peat fires

Wood stoves

Heat sources causing EAI
key features
Localized areas of reticulated erythema and hyperpigmentation

Due to chronic exposure to a non-burning heat source

Common locations: lumbosacral region and shins

Key pathologic finding is squamous atypia

There is a risk of cutaneous malignancy, in particular squamous cell carcinoma

Also Merkel cell carcinoma risk

Latent period of 30 years or more with carcinoma

Key Features
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

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
  • Local cold injuries are divided into chilblain, frostbite, and immersion injury
  • Immersion foot is encountered almost entirely in the armed forces
  • Intense vasoconstriction resulting from local action of cold and reflex vasoconstrictor stimulation is reinforced by the passage of cold blood through the vasomotor center
  • Vasoconstriction evokes tissue anoxia
  • Decreased muscular activity further diminishes blood supply
  • Ice crystal formation in blood vessels usually does not occur, but when it does necrosis occurs
Recurrent, localized erythema and swelling caused by exposure to cold

Blistering and ulcerations may develop in severe cases

In pts predisposed by poor circulation even moderate exposure to cold may produce chilblains

Acute chilblains is the mildest form of cold injury

Occurs chiefly on hands, feet,ears, and face, especially in children

Onset is enhanced by dampness

Pts are usually unaware of injury until they develop burning, itching, and redness

Areas are bluish red, the color partial or totally blanches with pressure, and are cool to touch

Chronic chilblains occurs repeatedly during cold weather and disappears during warm weather

Nifedipine 20mg TID

Vasodilators (nicotina

amide 100 mg TID or dipyridamole 25 mg TID)

Systemic corticoid tx is helpful in chilblain lupus erythematosus

Pentoxifylline may be useful

Affected areas should be cleansed with water and massaged gently with warm oil each day and should be protected against further injury and exposure to cold or dampness

If feet are affected, woolen socks should be worn at night during cold months

Careful use of electric pads may be used

Smoking strongly discouraged

frostbite congelation
When soft tissue is frozen and locally deprived of blood supply

Ears, nose, cheeks,fingers,and toes most common sites

Frozen part is painless and becomes pale and waxy

Various degrees of tissue destruction similar to those of burns are seen

Erythema and edema, vesicles and bullae, superficial gangrene, deep gangrene

Injury to muscles, tendons, periosteum, and nerves

Arolla index-formula linking duration of exposure (defined by temperature and wind chill index) with frostbite

Frostbite (Congelation)
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

With skin, muscle, tendon & bone damage; may lead to amputation

Tx of all: rapid rewarming, preventing further cold exposure & restoration of circulation

In hypothermia important to complete fluid resuscitation & core rewarming before limb rewarming to prevent sudden hypotension & shock

Early- (before swelling develops) covering body with clothing or a warm hand or other body surface to maintain a warm temperature to maintain adequate blood circulation

Rapid rewarming in bath water between 100 degrees and 110 F

Analgesics(because rewarming is painful)

Slow rewarming, rubbing frozen extremity with ice, using dry heat all CI

When the skin flushes and is pliable, thawing is complete

Supportive measures: bed rest, high protein/high calorie diet, wound care, avoidance of trauma, avoid rubbing of affected parts

After swelling and hyperemia have developed, bed rest with limb slightly flexed, elevated and at rest

Room temperature relieves pain and helps prevent tissue damage

  • Protection by a heat cradle may be helpful
  • Anticoagulants to prevent thrombosis and gangrene
  • Papaverine and nicotinic acid may reduce vasospasm
  • Antibiotics for prophylactic measures and an updated tetanus immunization is recommended
  • Recovery may take months
immersion foot syndromes
Immersion Foot Syndromes
  • Trench Foot
  • Warm Water Immersion Foot
trench foot
Trench Foot
  • Results from prolonged exposure to cold, wet conditions without immersion or actual freezing
  • Term derived from trench warfare in World War 1, when soldiers stood, sometimes for hours, in trenches with a few inches of cold water in them
  • Lack of circulation produces edema, paresthesias, and damage to blood vessels
  • Gangrene may occur in severe cases
  • Tx-removal from causal environment, bed rest, and circulatory restoration
  • Measures underlined on tx for frostbite should be performed
warm water immersion foot
Exposure of feet to warm, wet conditions for 48 hrs or more may produce a syndrome of maceration, blanching, and skin wrinkling of soles and sides of feet

Itching and burning with swelling may persist a few days after removal of the cause, but disability is temporary

Commonly seen in military service members in Vietnam

Also seen in persons wearing insulated boots, the so-called moon-boot syndrome

Tx-by allowing feet to dry for a few hrs out of 24 hrs

Or by greasing soles with a silicone grease once/day

Recovery is usually rapid and complete if dried thoroughly for a few hrs

Warm Water Immersion Foot
tropical immersion foot
Tropical immersion Foot
  • 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
  • AKA “paddy foot” in Vietnam
  • Erythema, edema, and pain of the dorsal feet
  • Also fever and adenopathy
  • Resolution occurs 3 to 7 days after the feet have been dried
warm water immersion foot52
Warm Water Immersion Foot
  • This was known as “paddy foot” in Vietnam
  • It involves erythema, edema, and pain of the dorsal feet, and fever and adenopathy
  • Resolution occurs 3-7 days after the feet have been dried
  • Can be prevented by allowing the feet to dry for a few hrs out of every 24 or by greasing the soles with a silicone grease once daily
  • Recovery is usually rapid if feet are thoroughly dried for a few hrs
dermatoses with cold hypersensitivity
Dermatoses with Cold Hypersensitivity
  • Erythrocyanosis Crurum
  • Acrocyanosis
  • Cold Panniculitis
  • Exposure to cold produces abnormal reactions in several disease states
  • These reactions are mediated through globulins ie cryoglobulin and cryofibrinogen
  • Also histamine, serotonin, leukotrienes, protaglandins, kinins, and cold hemolysins may be involved
erythrocyanosis crurum
Characterized by slight swelling and a bluish pink tint of the skin of the legs and thighs of young girls and women

May be unilateral

Atypical varieties are common, some presenting cinnabar red spots, bullae, indurations, and lichenoid papules

May be a history of cramps in the legs at night

Small tender nodules may be found on palpation

Nodules may break down and form small, multiple ulcers

Affected limbs are cold to touch

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

Erythrocyanosis Crurum
  • A persistent cyanosis with coldness and hyperhidrosis of fingers and hands
  • May also be present on toes and feet
  • Chiefly occurs in young women, but not rare in young men
  • 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
  • Remitting necrotizing acrocyanosis is a term applied to functional vascular spasm or organic occlusion that produces pain in hands and feet, with ateas of coldness, cyanosis, andnecrosis of the tops of fingers and toes
  • This has been reported to occur without prodromal or constitutional symptoms
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)
Lesions are readily reproducible by placing an ice cube on the volar aspect of the forearm for 2 minutes
  • This type of panniculitis is seen mostly in young children whose fat contains more high saturated fatty acids, which have a higher melting point and a lower solidification point than an adult’s less saturated fat
  • Pts outgrow this susceptibility
  • 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:

Ultraviolet radiation , 400nm

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

UVA is divided into two subcategories: UVA I(340 to 400 nm) and UVA II(320 to 340 nm)

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

Sunburn and Solar Erythema
Minimal erythema dose (MED) is the minimal amount of a particular wavelength of light capable of inducing erythema on an individual’s skin

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

A large portion of UVA and UVB may be reflected from sand, snow, ice, and water

Cloud cover is a poor UV absorber

Mercury-vapor lamp or sunlamp bulb produces mostly UVB( stronger inducer of erythema)

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, but onset is sooner and severity greater with increased exposure

Erythema is followed by tenderness, blistering, which may become confluent

Edema commonly occurs in extremities and face; chills, fever, nausea, tachycardia, and hypotension may be present

Sever cases symptoms may last as long as a week

Desquamation is common about a week after sunburn even in non-blistering areas

Clinical signs and symptoms
After UV exposure, skin pigment undergoes two changes: immediate pigment darkening (IPD, Meirowsky phenomenon) and delayed melanogenesis

IPD is maximal immediately after sun exposure(it results from changes in melanin already in the skin)

IPD occurs after exposure to long-wave UVB, UVA, and visible light

Large doses of UVA produce initial prolonged darkening

Delayed tanning is induced by UVB and UVC wavelengths and begin 2 to 3 days after exposure and last 10-14 days

Delayed tanning does produce some protection from further solar injury , it is at the expense of damage to the dermis and epidermis

Tanning is not recommended for sun protection

An individual’s inherent ability to tan and the ease with which they burn are described as their “skin type”

“Skin type” is useful to determine the starting dose of phototherapy, sun-creen recommendations, and reflects the risk of skin cancer

Exposure to UVB and UVA causes an increase in epidermal thickness, especially of the stratum corneum, leading to increased tolerance to further solar radiation


Prostaglandins are important mediators of sunburn (ASA or Indomethacin)

Cool compresses

Sunburn victim experiences at least 1-2 days of discomfort and even pain before much relief occurs

Topical remedy:

Indomethacin 100 mg

Absolute ethanol 57 ml

Propylene glycol 57 ml

spread widely over burned area with palms and let dry

Avoid sun exposure between 10 am and 2 pm

Barrier protection with hats and clothing

Avoidance plus physical barriers can virtually always prevent sunburn

Suncreen agents include UV-absorbing chemicals and UV-scattering or –blocking agents(physical sunscreens)

Use of the UV index, published daily by the National Weather Service for many US cities

Sun protection factor-the ratio of the number of MEDs of radiation required to induce erythema through a thin film of sunscreen, compared with unprotected skin

Chemical suncreens-para-aminobenzoic acid(PABA), PABA esters, cinnamates,salicylates, anthranilates, benzophenoes)

Physical agents-titanium dioxide

Combinations of the two

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

ephelis freckle
Small (<0.5cm) brown macules occurring on sun-exposed skin of face, neck,shoulders,backs of hands

Become prominent during summer when exposed to sunlight and subside in winter

Blondes and redheads, with blue eyes, of Celtic origin (skin types I or II) are especially susceptible

May be genetically determined

May occur in successive generations in similar locations and patterns

Usually appear around age five

Must be differentiated from lentigo simplex

LS- a benign discrete hyperpigmented macule appearing at any age and on any part of the body, including mucosa

Intensity of color is independent of sun exposure

Ephelis (Freckle)
Solar lentigo (frequently misnamed “liver spot”) appears at at a later age, mostly in persons with long-term sun exposure

Favored sites are backs of hands and face

Histologically, the ephelis shows increased production of melanin pigment by a normal number of melanocytes

Otherwise epidermis is normal

Lentigo has elongated rete ridges that appear club shaped

photoaging dermatohelioisis
  • Characteristic changes induced by chronic sun exposure
  • AKA photoaging or dermatoheliosis
  • Risk of developing these changes correlated with baseline pigmentation(constitutive pigmentation) and abilitiy to resist burning and tan following sun exposure(facultative pigmentation)
  • Individuals can be divided into six skin types(or phototypes)
  • Risk for melanoma and nonmelanoma is also related to these skin types
Most susceptible to effects of sunlight are those of skin type I-blue-eyed, fair-complexioned persons who do not tan

These pts require more frequent and careful skin exams

Many of the changes of chronic sun exposure were formerly ascribed to chronic aging

Primary sites involved are:

V area of neck and chest, back, and sides of neck,face, backs of hands and extensor arms

Skin becomes atrophic, scaly, wrinled, inelastic. Or leathery with a yellow hue (Milian’s citrine skin)

In some pts of Celtic ancestry, dermatoheliosiis produces profound atrophy without wrinkling, resulting in an almost translucent appearance of skin through which hyperplastic sebaceous glands and prominent telangiectasias are seen

These people are at high risk for nonmelanoma cancer

Solar elastosis(actinic)

Caused by alterations in upper dermal elastic tissue and collagen

Imparts a yellow color to skin

A textural and tinctorial change in sun-damaged skin

Striated beaded lines- are small yellowish papules and plaques developing along the sides of the neck

These are a result of sebaceous hyperplasia

Fibroelastolytic papulosis – of the neck(psuedoxanthoma elasticum-like papillary dermal elastolysis

  • On the face or chest a macroscopic, translucent papule with a pearly color resembling a basal cell carcinoma may occur
  • This is Dubreuilh’s elastoma, actinic elastic plaque
  • Similar plaques may occur on the helix or antihelix of ear
  • Poikiloderma of Civatte-refers to reticulate hyperpigmentation with telangiectasia, and slight atrophy of sides of the neck, lower anterior neck and V of 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
  • 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
  • Nodular elastoidosis with cysts and comedomes occurs on the inferior periorbital and malar skin-Favre-Racouchot syndrome or on the forearms (actinic comedonal plaque)
  • Both consist of thickened yellow plaques studded with comedomes and cystic lesions
  • Tx-removal , retinoic acid cream, surgical removal of cysts and redundant skin
Telangiectasias over cheeks, ears, and sides of neck may develop

Due to damage to connective tissue of dermis, skin fragility is prominent, and pts note skin tearing with minimal trauma

Especially to extensor surface of arms leading to an ecchymosis, called actinic purpura

As ecchymoses resolve, dusky brown macules remain for months, increasing mottled appearance of skin

White stellate pseudoscars on forearms are a frequent complication of this enhanced skin fragility

Some pts develop soft, flesh-colored to yellow papules and nodules that coalesce on the forearms to form cordlike bands extending from the dorsal to the flexural surfaces- solar elastotic bands

solar elastosis
Solar Elastosis
  • Histologically, chronically sun-exposed skin demonstrates homogenization and a faint blue color of connective tissue of the upper reticular dermis, so-called solar elastosis
  • The elastotic material is derived from elastic fibers mainly
  • Characteristically there is a zone of normal connective tissue below the epidermis
adult onset colloid milium
Adult –Onset Colloid Milium
  • Translucent, flesh-colored, or slightly yellow 1- to 2-mm papules on sun exposed areas of hands, face, neck, ears in middle-aged adults
  • Refinery workers and persons using high-concentration hydroquinone creams may also develop colloid degeneration
  • Histologically, homogenous, fissured masses occupy the upper dermis, resembling amyloid
Chemically induced – many substances known as photosensitizers may induce an abnormal reaction in skin exposed to sunlight or its equivalent

Substances may be delivered externally (by contact) or internally by enteral or parenteral administration

Resulting in a markedly increased sunburn response without prior allergic sensitization 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)

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

Chemicals known to cause photosensitivity (photosensitizers) are usually resonating compounds with a molecular weight of < 500

Absorption of radiant energy (sunlight) by the photosensitizer produces an excited state

When returning from returning from an excited state to a lower energy state gives off energy through fluorescence, phosphorescence, charge transfer, heat, or formation of free radicals

Each photosensitizing substance absorbs only a specific wavelengths of light called its absorption spectrum

Action spectrum-specific wavelength of light that evokes a photosensitive reaction

Action potential for photoallergy is mostly in the long ultraviolet (UVA) region and may extend into the visible light region (320 to 425 nm)

Photosensitivity reactions occur only when there is sufficient concentrations of the photosensitizer in skin, and the skin is exposed to a sufficient intensity and duration of light in the action spectrum of that photosensitizer

The intensity of the photosensitivity reaction is dose dependent and is worse with a greater dose of photosensitizer and greater light exposure

Drug-induced photosensivity-photoallergic dermatitis on sun-exposed areas of an infant following topical use of hexachlorophenePhotosensitivity
photoallergic dermatits
Photoallergic dermatits
  • Papulovesicular lesions of photoallergic dermatitis due to hexachlorophene
  • Plant-induced photosensitivity-linear hyperpigmentation on the face of a child following exposure to limes and sunlight
  • Hyperpigmentation on the dorsal aspect of the hands following the use of limes and sunlight exposure
phototoxic reactions
A nonimmunologic reaction developing after exposure to a specific wavelength and intensity of light in the presence of a photosensitizing substance

A sunburn-type reaction(erythema, tenderness, and blistering)

Can occur in pts without prior history of exposure to that particular substance

Erythema begins (like sunburn) after 2-6 hrs and worsens for 48-96 hrs before beginning to subside

Exposure of the nail bed may lead to onycholysis, called photo-onycholysis

Phototoxic reactions may cause hyperpigmentation, even without preceding erythema

The action spectrum for most phototoxic reactions is in the UVA range

Phototoxic Reactions
phototoxic tar dermatitis
Coal tar, creosote, crude coal tar, or pitch, in conjunction with sunlight exposure, may induce a sunburn reaction associated with a severe burning sensation

Direct contact may not be needed, since these hydrocarbons are airborn

Burning and erythema may continue for 1 –3 days

Persons with type V and VI skin are protected from this

Up to 70% of whites exposed to such combinations will develop this

Hyperpigmentation occurs, and may persist for years

Coal tar or its derivatives may be found in cosmetics, drugs, dyes, insecticides, and disinfectants

Phototoxic Tar Dermatitis
Phytophotodermatits from squeezing limes

When furocoumarins in many plants may cause a phototoxic reaction when these plants come in contact with moist skin exposed to UVA light

Several hrs after exposure, a burning erythema occurs, followed by edema and development of vesicles or bullae

Intense hyperpigmenation occurs that may persist for weeks or months

Tx-similar to tx of sunburn; hyperpigmentation-time

berloque dermatitis
Berloque Dermatitis
  • Characterized by lavaliere(hanging drop)-shaped pigmented patches
  • Word for pendant in French is berloque, and in German is berlocke
  • Seen most frequently on sides of neck, and retroauricular area in women
  • In men usually beard area caused by aftershave lotion
  • Chief cause-oil of bergamount, containing a furocoumarin (bergapten)
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
  • If occurs, either the tattooed person must avoid sunlight exposure
phototoxic drug reactions
Most occur from tetracyclines, nonsteroidal antiinflammatory drugs, amiodarone, and phenothiazines

Action spectrum for all is in the UVA range

Among the NSAIDs, piroxicam is the most potent photosensitizer

Among the tetracycline group, demthylchlortetracycline and doxycycline are most phototoxic

In the case of amiodarone and chlorpromazine, while typical phototoxic reactions (resembling sunburn) may occur, 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 photosensitivity94
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 photosensitivity95
Drug-induced photosensitivity
  • There is erythema and edema on the exposed sites, the “V” of the neck .
  • This distribution would suggest the diagnosis
drug induced photosensitivity96
Drug induced photosensitivity
  • The backs of the hands are the classic sites to be involved in light induced eruption
  • Same pt
Photoallergic dermatitis is caused by a photosensitizing substance plus sunlight exposure in a sensitized person

If photosensitizer is delivered internally, it is called a photoallergic drug reaction

If it comes to the skin externally, is is called a photoallergic contact dermatitis

Clinically the pt develops a pruritic eruption, initially on sun-exposed areas

Over time lichenification develops, leading to thick plaques

Face, hands, neck, forearms are most frequently involved

Over time the dermatitis develops to sunprotected skin

Removal of offending agent may not lead to complete resolution of the photoallergic reaction-referred to as a persistent light reaction

Clinical and path findings are similar to those of allergic contact dermatitis

photoallergy testing
Practical office procedure is that each of the suspected photosensitizers is applied in duplicate to two symmetrical sites on the back that have not been exposed to sunlight

Usual concentration used for the patch test is 1& petrolatum

After 48 hrs, one set is removed and examined for reactions as a contactant without exposure to light

Then the site is exposed to UVA

After another 48 hrs, the irradiated site is compared with the other patch test site (unexposed site)

When both sides are positive, there is a contact sensitivity or photoallergy

When the irradiated site alone is positive ther is only photoallergy

When the irradiated site is more positive than the unirradiated site, ther is both allergic contact and phototcontact dermatitis

Photoallergy Testing
  • Both acute and chronic photosensitivity are treated similarly to any other inflammatory dermatitis, with topical corticosteroids
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

The papular (or erythmatopapular) variant is the most common, but papulovesicular, eczematous, erythematous and plaquelike lesions also occur

Lesions occur 1-4 days after exposure to sunlight

Pts report itching and erythema within the first 24 hrs

A change in the amount of radiation is important

Polymorphous Light Eruption
Pts living in the tropics are free of eruption but may develop disease when they move to temperate zones

Most commonly involved areas are chest, face, neck, and arms

Typically areas protected during the winter, as the extensor surface of the forearms, are particularly affected, whereas areas exposed all year (face and dorsa of hands) may be relatively spared

Eruption appears in springtime commonly

PLE is induced by UV light, but the wavelengths responsible varies

Visible light does not induce PLE

Standard phototesting usually does not induce an abnormal response in pts

If an abnormal response occurs it is only erythema

Provocation testing with repeated exposures may be required

Two unusual variants of PLE are juvenile spring eruption of the ears and solar purpura

  • Exposed areas such as the backs of the hands and forearms are affected. Ultraviolet A is mainly responsible and may penetrate window glass
  • The patchiness of the edematous papules and plaques is characteristic
  • The eruption is less red and confluent than a sunburn (left)
  • Lesions are typically papular & clustered (right)
pmle pathology
  • Characteristic perivascular mononuclear cell infiltration
  • Very itchy, red,edematous papules, which may coalesce into plaques, occur 1 or 2 days after exposure to light
  • This young women developed a widespread pruritic, papular eruption after using a sunbed, which emitted ultraviolet A
juvenile spring eruption
Solar purpura-rare variant of PLE, presenting as macular or palpable purpura on the legs

It is also UVA induced, but its distribution suggests other factors such as high hydrostatic pressure are required

Therapeutically:sunscreen, avoiding sun, topical steroids for itch and clearing eruption, antihistamines, systemic steroids, hydroxychloroquine sulfate, chloroquine, PUVA, thalidomide, Azathioprine

Most common in boys ages 5-12 yrs

Presents in spring with grouped s,all papules or papulovesicles on the helices

It is self-limited and does not scar

UVA is the inducing spectrum and some pts have PLE lesions elsewhere

Juvenile springeruption
  • Polymorphous light eruption: erythematous papulovesicular and plaque-like lesions with characteristic distribution on the sun-exposed areas of the cheek
actinic prurigo
In children the cheeks, distal nose, ears, and lower lip are involved

Cheilitis may be the initial and only feature for years

Conjunctivitis is seen in 10-20% of pts

Lesions of arms and legs are also common but usually exhibit a prurigo nodule configuration

May extend and involve sun-protected areas, especially buttocks

In adults dry papules and plaques are typical, cheilitis and crusting occur less frequently

Variant of PLE

Most common in Native Americans of North and Central America and Colombia

More common in females

Begins before age 10 in 45% of cases and before age 20 in 72% of Native Americans

Up to 75% have a family history

In childhood begins as small papules or papulovesicles that crust and become impetiginized

Intensely pruritic

Actinic Prurigo
actinic prurigo113
In temperate and high-latitude regions, lesions occur from March through the summer and remit in winter

In tropics lesions tend to last all yr

Hardening as seen with PLE does not occur

Up to 60% of pts with actinic prurigo that present before age 20 have resolution within 5 yrs

Adults, however continue with disease all through life

IgE levels may be elevated

Pts are more commonly positive for HLA-A24 and Cw4 and neg for A3 than are control pts

Tx same as PLE

Thalidomide has been used extensively with excellent results

Actinic Prurigo
actinic prurigo114
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)
  • Severe actinic prurigo shows spread to buttocks (left)
  • Arms show crusted papules that are denser distally; they are also worse in summer
actinic prurigo116
Actinic prurigo
  • Actinic prurigo in Native American brothers
actinic prurigo117
Actinic prurigo
  • Actinic prurigo in Native American boy
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)
solar urticaria
Most common in females aged 20-40

Within seconds to mins after light exposure, typical urticarial lesions appear and resolve in 1-2 hrs

Delayed reactions may rarely occur

In severe attacks syncope, bronchospasm, and anaphylaxis may occur

Pts with SU are sensitive to wavwlenghs of light from UVB-visible light

Wavelengths of sensitivity may vary with anatomic location and over time with same pt

Leenutaphong et al divided SU into two types:Type I the photoallergen precursor is an abnormal endogenous substance; in type II it is a normal skin component

Type I SU has an action spectrum in visible range; type II has a variable action spectrum


Solar Urticaria
solar urticaria120
Solar Urticaria
  • Sunlight-induced whealing with surrounding erythema of the abdomen
Phototesting is useful in SU to determine the wavelengths of sensitivity

Lasers and natural sunlight may be used to elicit positive reactions

Many pts have a sensitivity in the UVA or even visible range, standard sunscreens are of limited benefit

Antihistamines and sun avoidance are first line tx

Doxepin may be added if these are not effective

Antimalarials can help in some pts

PUVA or increasing UVA exposures are effective in more difficult cases

Plasmapheresis may be used to remove the circulating photoallergen, allowing PUVA to be given leading to remission

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

At 24 hrs or sooner erythema and edema appear, followed by vesicles

Over a few days the lesions rupture, becoming centrally necrotic, and heal with a smallpox-like scar

Lesions may become confluent, forming bullae, and recurrent disease may lead to contractures of digits

Conjunctivitis with photophobia may occur and corneal ulcers and opacities may result

Natural history is improvement by second decade often complete resolution

Hydroa Vacciniforme
  • Hydroa vacciniforme-the face was also involved
hydroa vacciniforme124
Hydroa Vacciniforme
  • There is an early, PML-like eruption, but with vesicles around the mouth and umbilicated lesions on the nose
hydroa vacciniforme125
Hydroa Vacciniforme
  • A later, more severe example shows vesiculation with umbilication, but also marked hemorrhagic crusting
hydroa vacciniforme126
Hydroa Vacciniforme
  • A severe example of the typical vacciniform facial scarring that may develop following repeated acute attacks
Tx-avoid sunlight exposure, use broad-spectrum or barrier sunscreens that block UVA range

Hydroxychloroquine and prophylactic PUVA may be partially effective

Ddx-PLE, actinic prurigo, and erythropoietic protoporphyria (EPP)

Porphyrin levels are normal in hydroa vacciniforme

In EPP the burning typically begins within mins of sun exposure, and healing is diffuse, thickened, wax-like scarring, rather than the smallpox-like scars of hydroa vacciniforme

Histology is helpful in differentiating between the two

chronic actinic dermatitis
A disease concept in evolution

Previously known as persistent light reactivity, actinic reticuloid, photosensitive eczema and chronic photosensitivity dermatitis

Basic components are:a persistent, chronic, eczematous eruption in absence of exposure to known photo-sensitizers; decreased MED to UVA, and/or UVB, and visible light

Disease affects middle-aged or elderly men

In US skin types V and VI more affected

Skin lesions are edematous, scaling, thickened patches and plaques that become confluent

Lesions occur on most sun-exposed skin

Chronic Actinic Dermatitis
Cutaneous signs of sig. Photoaging:
  • Top: cutis rhomboidalis nuchae with deep furrowing of posterior neck
  • Middle: multiple open comedomes of malar region in Favre-Racouchot syndrome
  • Bottom: erosive pustular dermatosis of the bald scalp
Danazol 600mg daily was effective in one pt

Hydroxychloroquine may be added to systemic steroids or azathioprine

Low-dose PUVA is beneficial but may not be tolerated

Cyclosporine is tx of last resort but is effective in severe cases (it is associated with acute and chronic toxicity and relapse occurs rapidly after discontinuation

Difficult-possible topical photosensitizers should be identified via photopatch testing

Maximum sun avoidance and broad-spectrum sunscreens

Topical and systemic steroids are effective in some cases

Azathioprine, 50 to 200 mg/day(most reproducibly effective tx), may be required annually during periods of increased sun exposure

dermatoses with photoexacerbation or photosensitivity
Pts with lupus erythematosus and dermatomyositis, among other connective tissue diseases, often exhibit photosensitivity

Moa may be UV alteration of cellular cytoplasmic or nuclear antigen expression, allowing antigens to interact with circulating autoantibodies

Pts with diseases characterized by a deficiency of protective pigmentation are photosensitive(albinism, vitiligo)

Heritable disorders with increased sensitivity to ultraviolet cellular or DNA damage such as xeroderma pigmentosum, Bloom syndrome, and Cockayne’s disease

Disease where ultraviolet light seems to act by a Koebner’s phenomenon- Darier’s, and perhaps pemphigus foliaceus

Dermatoses with Photoexacerbation or Photosensitivity
Major target within the cell is DNA

Effects depend on the amount, its intensity(exposure rate), and characteristics of the individual cells

Rapidly reproducing cells and anaplastic cells have increased photosensitivity compared to normal tissue

When radiation is delivered it is fractionated-divided into small doses called fractions-allowing normal cells to recover between doses

In small amounts effects are insidious and cumulative

When dose is large, cell death occurs

With sublethal doses many changes occur-mitosis is arrested temporarily, with subsequent growth arrest

Exposure rate affects the number of chromosome breaks

The more rapid the delivery the greater the number of chromosome breaks

acute radiodermatitis
When exposed to a large amount of ionizing radiation, an acute reaction develops, the extent of which depends on amount, quality, and duration of exposure

Such reaction is used in tx of malignancy and in accidental overexposure

Reaction is manifested by initial erythema, followed by a second phase of erythema at 3-6 days

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

Acute Radiodermatitis
acute radiodermatitis135
Skin develops a dark color that may be mistaken for hyperpigmentation, but that desquamates

This my subside in several weeks to months(depending on amount of radiation)

Skin which recieves a large amount or radiation will never return to normal

It will lack adnexal structure, be dry, atrophic, and smooth, and be hypopigmented or deoigmented

Acute Radiodermatitis
chronic radiodermatitis
Chronic Radiodermatitis
  • Chronic exposure to “suberythema” 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
chronic radiodermatitis137
Skin becomes dry, thin, smooth, and shiny

Subcutaneous fibrosis, thickening and binding of the surface layers to deep tissues may present as tenser, erythematous plaques 6-12 months after

It may resemble erysipelas or inflammatory mets

Nails may become striated, brittle, and fragmented

Capacity to repair is greatly reduced

This results in ulceration from minor trauma

Hair becomes brittle and sparse

In more severe cases these chronic changes are followed by radiation keratoses and carcinoma

Chronic Radiodermatitis
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

Sun damage may be additive

SCCs arising in sites of radiation therapy metastasize more frequently than purely sun-induced SCCs

In some pts either type of tumor may predominate

Location plays some role-SCCs are more common on the arms and hands, whereas BCCs are seen on lumbosacral area

Other cancers induced by radiation :angiosarcoma, malignant fibrous histiocytoma, sarcomas, and thyroid carcinoma

Radiation Cancer
radiation cancer139
Radiation Cancer
  • SCC developing in a chronic radiation ulcer on the chest
Nonpenetrating, circumscribed hyperkeratosis produced by pressure

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

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

Calluses tend to disappear spontaneously when pressure is removed

Most problems with calluses is on the soles

Ill-fitting shoes and orthopedic problems of the foot caused by aging are some of the etiologies

Padding to relieve pressure, paring of thickened callus, and the use of keratolytics(40% salicylic acid plasters)

Lac-Hydrin 12%

Calluses may be softened by moistening them nightly with 2 parts propylene glycol:1 water

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

Hard corns have shiny and polished surface

When upper layers are shaved off, a core is seen in densest part of lesion

The core causes the dull/boring or sharp/lancinating pain by pressing on underlying sensory nerves

Corns arise on sites of friction and pressure, when these factors are removed they may resolve

  • Frequently, a bony spur or exostosis is present beneath both hard and soft corns of long duration
  • Soft interdigital corns usually occur in the fourth interdigital space of the foot
  • Many times there is an exostosis at the metatarsal-phalangeal joint causing pressure on the adjacent toe these are soft, soggy, and macerated so that they appear white
  • Tx by simple excision may be effective
  • 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
corns tx
Primary-relief of pressure by corrective footwear

Salicylic acid and dichloroacetic acid

Careful paring in particular remove central core

40% salicylic acid application, remove after 48hrs, remove white macerated skin, and apply new plaster

Continue until corn is removed

Sometimes more feasible to use a salicylic acid-lactic acid in collodion rather than plaster

Collodion medication is painted on and allowed to dry each day until cure

Soaking prior to application enhances effect-this tx especially effective for interdigital soft corns

Soaking feet in hot water and paring the surface by means of a scalpel blade or pumice stone helps

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
coal cuts
Coal Cuts
  • Sever type of skin injury may occur from the cuts of coral skeletons
  • Abrasions and cuts are painful, and local therapy may sometimes provide little or no relief
  • Healing may take months
  • Watch for secondary infection
  • Possibilities include-Mycobacterium marinum in persistent lesions
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 stage II and stage IV ulcers may be beneficial

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”)

Size of bullae depends on site of trauma

If skin is tense and uncomfortable, the blister should be drained, not removing the roof because it may act as its own dressing

Studies in long distance runners and soldiers and acrylic fiber socks (Thor-lo) was found to prevent blisters

The drying action and differential sock thickness of this brand were felt to be important in its success

Friction Blisters
fracture blisters
Occur overlying sites of closed fractures, especially the ankle

Appear a few days to 3 weeks after injury

Caused by vascular compromise nd may create complications such as infection

Generally heal spontaneously in 5 14 days, but may result in delay of surgical reduction of the fracture

Fracture Blisters
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
Seeming confluence may lead to think of melanoma

Bleeding is caused by shearing stress of sports activities

Paring with a No. 15 blade and performing a guaiac test will confirm diagnosis

Tx-none needed

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

Black Heel
subcutaeous emphysema
Free air occurring in subcutaneous tissues is detected by cutaneous crepitations

This raises a concern of infection with gas-producing organisms, especially gas gangrene, or leakage of free air from lungs of GI tract

Various causes include:

Penetrating and nonpenetrating injuries, iatrogenic causes including a spontaneous pneumomediastinum such as may occur with violent cough, childbirth, asthma, Boerhaave’s syndrome(esophageal rupture after vomiting), or the Heimlich maneuver, intraabdominal causes, inflammatory bowel disease, cancer, perirectal abscess, pancreatitis, cystitis, and factitial disease

Subcutaeous Emphysema
traumatic asphyxia
Traumatic Asphyxia
  • Prolonged crushing injuries of the thorax or upper abdomen that reverses blood flow in the superior vena cava or its tributaries
  • Characterized by cerviofacial cyanosis and edema, multiple petechiae of face, neck, and upper chest, and bilateral subconjunctival hemorrhage
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 dermopathy160
Narcotic Dermopathy
  • Subcutaeous injection (“skin popping”) can result in multiple, scattered ulcerations, which heal with discrete atrophic scars
narcotic dermopathy161
Amphetamines, cocaine, and other drugs may be injected

Subcutaneous injection may result in infections, complications of bacterial abscess and cellulitis or sterile nodules(acute foreign body reactions to injected drug or adulterants mixed with it)

These lesions may ulcerate

Chronic persistent , firm nodules, combination of scar and foreign body reaction, may occur

If cocaine is being injected it may cause ulcers because of its direct vasospastic effect

Addicts will continue to inject into the chronic ulcer bed

Narcotic Dermopathy
narcotic dermopathy162
Narcotic Dermopathy
  • Ulcer from extravascular injection of “speed” (amphetamine)
narcotic dermopathy163
Cutaneous manifestations of injection of heroin and other drugs also include camptodactylia, edema of eyelids, persistent nonpitting edema of hands, urticaria, abscesses, atrophic scars, and hyperpimentation

IM pentazocine abuse leads to a typical tense, woody fibrosis, irregular punched-out ulcerations, and a rim of hyperpigmentation at sites of injection

Narcotic Dermopathy
foreign body reactions
Foreign body Reactions
  • Tattoo-introduction of insoluble pigments into the skin producing permanent inscriptions and figures
  • Pigment is applied to skin and then needles pierce skin to force material into dermis
  • Pigments inserted may be carmine, indigo, vermillion, India ink, chrome green, manganese, Venetian Red, aluminum, titanium or zinc oxide, lead carbonate, logwood, cobalt blue, cinnabar (mercuric sulfide), and cadmium sulfide
  • 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
  • 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 re (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
  • 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
Another reaction may be inflammatory, with mild erysipeloid attacks and tenderness

Human adjuvant disease with usually presents with scleroderma-like findings may occur

Present tx is unsatisfactory

When these tumors are surgically excised they need to be excised widely and completely

  • Silicone granuloma
  • Mercury granuloma
  • Beryllium granuloma
  • Zirconium granuloma
  • Silica granuloma
silicone granuloma
Liquid silicones, composed of long chains of dimethyl siloxy groups, are biologically inert

These have been used for correction of wrinkles, reduction of scars, and for building up atrophic depressed areas of skin

For breast augmentation, it was also used as silastic implants

Human adjuvant disease and sclerodermatous reactions after have been reported after such events

However, large reviews have failed to establish an etiologic link to silicone and CTD’s

They are no longer available in the U.S>

Bioplasque consists of polymerized silicone particles dispensed in a gel carrier when used for lip augmentation, nodules may develop

Silicone granuloma
mercury granuloma
Mercury granuloma
  • Occur as foreign-body giant cell granulomas
  • Systemic toxicity may develop from cutaneous injury and may result in death
beryllium granuloma
Beryllium granuloma
  • Seen in chronic, persistent, granulomatous inflammation of skin with ulceration which may follow accidental laceration by an old-fashioned broken fluorescent light-bulb coated with zinc beryllium silicate
  • Modern bulbs do not contain beryllium
zirconium granuloma
Zirconium granuloma
  • Papular eruption involving the axillae sometimes seen as a allergic reaction in those shaving their armpits and using a deodorant containing zirconium lactate
  • Zirconium was eliminated from aerosol-type deodorants in 1978
  • It may also be seen following application of various poison ivy lotions containing zirconium compounds
  • Lesions are brownish red, dome-shaped, shiny papules suggestive of sarcoidosis
  • This is an acquired, delayed-type, allergic reaction resulting in a granuloma of sarcoid type; lesions spontaneously involute
silica granuloma
Automobile and other types of accidents produce tattooing of dirt(silicon dioxide) into skin, inducing silica granulomas

Usually black or blue papules or macules arranged in a linear fashion

At times granulomatous reactions to silica may be delayed for many years, until sensitization develops

They may be caused by amorphous or crystalline silicon dioxide(quartz), by magnesium silicate(talcum) or by complex polysilicates(asbestos)

Talcum granulomas of skin and peritoneum may develop after surgical operations from talcum powder used on surgical gloves

Best method of cure is immediate and complete removal

Silica Granuloma
carbon stain
Discoloration of skin from embedded carbon usually occurs in children from careless use of firearms or firecrackers or from a puncture wound by a pencil, which may leave a permanent black mark of embedded graphite, easily mistaken for a metastatic melanoma

Carbon is deposited at various depths to produce a connective tissue reaction and even keloids

Carbon particles may be removed immediately after deposition by using a tooth brush and a forceps

This provides best cosmetic outcome

If left for a long time can be removed by the Q-switched neodymium-YAG laser

Dermabrasion may be effective

Carbon Stain
injectable collagen reactions
May occur with bovine collagen solution

Major histologic differential diagnosis is granuloma annulare

One report of abscess formation and local necrosis of glabella region after Zyderm or Zyplast collagen injections

Both were rare-4-9 per 10,000 pts

Artecoll consists of polymethylmethacrylate microspheres suspended in bovine collagen

Palpable thickening and nodules may occur when it is used for lip augmentation

Pathology reveals granulomas

Injectable Collagen Reactions
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