This surface disease causes much of the damage to the cornea and is responsible for additional inflammation. There is a female predominance, and where relevance has been found it has usually been in the context of jewellery or gold dental work [3]. The differen tial diagnosis includes angiokeratoma corporis diffusum, acquired capillary and cavernous haemangiomas, Masson tumour, glomus tumour, epithelioid haemangioma, bacillary angiomatosis, Kaposi sarcoma and epithelioid haemangioendothelioma. The significance of sentinel lymph node biopsy positivity and how to further manage the presence of nodal disease is currently unknown [215]. The patient may present because of the presence of a nodule or plaque that causes few symptoms. Introduction and general description the traumatic dermatoses induced by sports have been usefully reviewed in terms of disease processes [1] and the causative sports Part 11: ExtErnal agEnts 123. Painless, shaggy or folded white lesions typically affect the buccal mucosa bilaterally but may also involve other areas, although rarely the gingival margins [1,2]. Biochemical consequences of mechanical forces generated by distension and distortion. Unless a permanent record is kept, a number of substances will continue to be included despite a low yield of positive reactions. In papular perniosis, crops of small chilblains develop on the sides of the fingers often on a background of acrocyanosis [13]. The risk of recurrence in subsequent children is about 2% if one child has it, 6% if one parent has it, 15% if one parent and one child have it. The true incidence of sensitization is therefore difficult to establish, because even re examination of a random sample of the patients tested cannot differentiate between those sensitized by patch testing and those whose preexisting subliminal sensitivity has been boosted by further exposure from patch testing. Acrocyanosis y Definition Acrocyanosis is a persistent cyanotic or erythrocyanotic mottled discoloration of the hands and, less commonly, feet and face. Medical causes include diabetes, iatrogenic immunosuppression and systemic antibiotic treatment. In severe and longstanding staphylococcal blepharitis, trichiasis (misdirection of eyelashes towards the eye), poliosis (depigmentation of the eyelashes), madarosis (loss of eyelashes), eyelid ulceration, and eyelid and corneal scarring may occur [3]. The blepharitis should initially be classified into either anterior or posterior lid disease or both (see Table 109. This can occur as a continuation of the acute episode or may occur many years after the onset of disease. It is not possible to catalogue every complication of all these diseases but the most frequent are summarized in Table 109. Eyelash curlers and makeup applicators may contain nickel and/or rubber and cause contact allergy at this site [14,15]. Skin fragility and ulceration in the ano genital area are features of prolidase deficiency [3]. Also used in other European countries Widely used in several southern European countries as a topical antihistamine Allergic contact urticaria Definition and nomenclature the term was introduced by Fisher in 1973 [1] and defined as a weal and flare reaction following contact with an external substance, usually appearing within 30 min and completely clearing within hours, without residual signs [2]. Some patients develop persistent reactions to portions of the adhesive barrier with no demonstrable allergic component. Early lesions demonstrate oedema, haemorrhage and neutrophils within the septae, older lesions are characterized by fibrosis, periseptal granulation tissue, lymphocytes, histiocytes and multinucleated giant cells [146]. Recurrent mouth ulcers Not all recurrent mouth ulcers are aphthae, but that is the most common cause. Patients should avoid middle of the day sun (11 am to 3 pm) and wear appropriate clothing (tightly woven fabrics). Diagnosis is suggested by more pronounced findings on echocardiogram, such as extreme impairment of ejection fraction and major systolic dysfunction [60]. Characteristic, sometimes severe, involvement of the penis (circinate balanitis) occurs. Mouth cancer spreads by haematogenous dissemination only late in its natural history. The baby is small and, from the dermatological point of view, the most striking feature is the lack of subcutaneous fat, which causes the baby to look thin and wrinkled.
One effective, additional measure for early chronic papillomatous dermatitis is to apply 20% domestic vinegar (diluted in tap water) to the skin, using soaked gauze, for 10 min each day after cleaning [8]. Oral swelling and soreness after eating lettuce has been reported in sensitized persons [13]. Nylon dyes, especially in tights, may also produce allergic contact dermatitis largely confined to this area. The young age group includes many patients with irritant and atopic eczema of the hands. The prognosis of dermatitis due to nickel in jewellery and clothing is excellent if further use of nickelplated objects is avoided. Meibomian gland disease may be diagnosed in isolation, or more commonly in association with dry eye or ocular surface damage. Systemic disease typically comprises solid organs, most commonly the liver, though renal, lung, intestinal, myocardial, pericardial, splenic, pancreatic, thyroid and central nervous system involvement have also been described. Differential diagnosis this includes the causes of pruritus ani, anal fissures, fistulae and perianal ulceration. Using a device for the propagation of low amplitude shear disturbances it has been shown that there is a progressive increase in viscosity of the skin with age [6]. A number of cases of persistent leukoderma following allergic contact dermatitis have been reported. Nickel sensitivity is common in women and, unless allowance is made for this, false occupational associations may be inferred. Apart from allergy associated with clothing, shoes and nail varnish, formaldehyde resin allergy is uncommon. Selected population studies Most other epidemiological studies have been based on patients already attending dermatology clinics, or have involved either specific occupational or other population groups. Cosmetics and work creams that contain it can usually be identified from the full ingredient label or data sheet. Other potentially allergenic sources may require specific enquiry as to the nature of the biocide/preservative used. Symptoms are due to release of histamine and other inflammatory agents by mast cells which lead to dilatated blood vessels, irritated nerve endings and increased secretion of tears. Resources Patient resources International Society for the Study of Vulvovaginal Disease information sheet: issvd. Management of irritant dermatitis follows lines similar to those for pruritus ani. A nummular pattern of eczema is commonly constitutional but may be a feature of irritant and allergic contact dermatitis, particularly from chromate in cement. Systemic sepsis can quickly follow skin infection and lead to multiorgan failure [4]. Localized perianal involvement [14], a solitary plaque on the penis [15] and response to treatment with imiqui mod have been described [15,16]. Systemic treatment with corticosteroids may cause serous chorioretinopathy or diffuse retinal pigment epitheliopathy. Both preventative and treatment measures need to take place simultaneously for optimum management of these complex patients. Intralesional triamcinolone acetonide in combination with topical pimecrolimus 1% has also been used. Lesions are usually asymmetrical, typically on a limb, less often involving the torso or head. Defining pseudofolliculitis barbae in 2001: a review of the literature and current trends.
Langerhans cells stain positively with S100 and characteristic Birkbeck granules are seen on electron microscopy. There is a great need for efficient and accurate assessment, transportation and emergency care for these patients in order to improve their overall outcome. A yellow colour is produced in the presence of formaldehyde, due to the formation of 3,5diacetyl1,4dihydrolutidine. Clinical signs are usually confined to localized mucosal swelling, although anaphylaxis is rarely reported. Another major advance is the recent initiative by burn care providers to hold consensus conferences and implement specific definitions of disease processes in severely burned patients, allowing for the conduct of appropriate multicentre trials [6] and comparative studies. Miliaria profunda is very uncommon in neonates as it usually occurs in adults where there have been repeated episodes of miliaria rubra. Also very rare is depigmented extramammary Paget disease of the genitalia, evoking the differential diagnosis of vitiligo, hypopig mented mycosis fungoides and lichen sclerosus. In Europe, their presence can be determined by identifying the relevant E number on the ingredient label of the foodstuff packaging. Examination should include digital rectal examination to exclude the presence of a mass and proctocopy to evaluate if there is any other anorectal pathology. Pathology Features include follicular hyperplasia, ductal hyperkeratosis, chronic inflammation, fibrosis and sinus tract formation. There may be intercurrent attacks of cellulitis and/or erysipelas with systemic upset. Textile dyes and resins will occasionally cause purpuric eruptions associated with contact allergy [11]. Management Management of both tuberculosis and leprosy requires specialist input from infectious disease specialists. Systemic antibacterial therapy is usually required for furunculosis based, if possible, on the results of culture. Clinical features Facial skin and lips are involved in twothirds of cases with an intensely itchy, excoriated papular and nodular skin eruption, and lip pruritus, oedema, scales, fissures, crusts and ulceration. However, depending on the degree of sensitivity, penetration and other factors, this may vary from a few hours to many days. The acute irritation reaction results in a pruriginous dermatitis; as clothing may trap the fibreglass, this may occur on covered parts of the body. The commonest allergens were rubber chemicals (including those in gloves), nickel and resins. It is suggested that the patient`s back is positioned 15 cm from the front panel of the lamps. It was therefore suggested that either amniotic bands or some undetermined prenatal insult was the cause. More discrete, deeply pigmented macules are also common on the vulva and sometimes on the glans penis, where they are usually referred to as genital melanotic macules, or mucosal melanosis. The histology may show features compatible with lichen planus or a nonspecific, chronic, superficial perivascular dermatitis. In sports shoes, the sole is usually moulded to fit into the instep and the dermatitis may affect the whole sole [5]. In cases where systemic involvement such as renal impairment or liver function disturbance is noted, appropriate supportive care such as intravenous fluids and careful haemodynamic monitoring should be employed.
Extensive vegetating masses can cover the vulva and perianal area, particularly in diabetes, pregnancy and immunocompromised patients. However, histological examination has shown them to comprise foci of dermal erythropoiesis [3,6]. Investigations the diagnosis is usually made by direct microscopy and the culture of skin scrapings. The patient may not attach importance to a drug which they deem to have been taken too long ago to be relevant, and thus this aspect of the history must be explored thoroughly. Molybdenum has been implicated in orthopaedic implants, resulting in systemic sensitization. Clinical features History There may be prodromal symptoms of tingling or tender, enlarged inguinal nodes. The histology is of an intraepithelial carcinoma [23] and the his tological subtypes have been described earlier: it is not possible reliably to separate them macroscopically [6]. Allergy to nickel, chromate and ptertiarybutylphenol formaldehyde resin may develop at the wrists from sensitivity to the metal, leather and glue, respectively, in watchstraps containing these allergens. The nodules tend to be symmetrically distributed and show a predilection for the buttocks, thighs, shoulders, back, cheeks and arms. There is sometimes a long interval between exposure and development of the skin cancer. Peeling of citrus fruit in the domestic environment may also induce allergic hand dermatitis. A new approach to patch testing patients with paraphenylenediamine allergy secondary to temporary black henna tattoos. The most common location is the lower lip, Management If in clinical doubt, an incisional biopsy of an appropriately representative area is necessary to exclude melanoma. If systemic antihistamines are needed during pregnancy, the first generation antihistamine chlorphenamine is preferable due to the greater experience with its use. In practice a few skin diseases warrant special mention either because they are more common than expected or because they can present atypically. Papillary hyperplasia may require treatment with antifungals, excision or laser removal. All the species of this genus possess a venom apparatus, and several species have caused human Part 11: ExtErnal agEnts the dermatosis caused by A. Cold usually exacerbates the cyanotic discoloration, while leg elevation tends to decrease the intensity of the colour changes. The authors concluded that patients who paid attention to their allergy had statistically significantly fewer eruptions than those who did not [17]. A positive reaction consists of an urticarial weal, which is usually apparent after 15 min, although it may take as long as 45 min to develop. An apparent worsening of venous eczema may be related to allergy to rubber in elastic bandaging, and such patients are prone to develop a secondary generalized eczema. Differential diagnosis Viral infection is the most important differential diagnosis. Presentation the lesions occur on the vulva, perineum and perianal skin and extend onto the thighs and lower abdomen. Immunological memory is not involved and dermatitis occurs without prior sensitization. It is most commonly associated with Coxsackie A viral infection, most usually A16 [1], but infection with A6 [2], Coxsackie B [1] and enterovirus 71 [1] have also been described.
Dry skin and a predisposition to blushing/ flushing were factors associated with a sensitive skin. Infiltration of the skin with neoplastic cells produces the clinical appearance of cellulitis or erysipelas. It is suggested that the increased allergy is caused by, rather than being responsible for, the loosening. However of the 13 cases described, nine were in term children with no documented evidence of amniotic bands or limb constriction/defects. Workers should be informed of the hazards of their occupation, and should wear warm antivibratory gloves, avoid smoking and undergo regular medical surveillance. In addition, lamellar thickening of the papillary dermis and perineural fibrosis can be seen. These components of disease are present to variable degrees in different diseases. Cheilitis granulomatosa: overview of 13 patients with longterm followupresults of management. Investigations Diagnosis of recurrent aphthous stomatitis is based on the history and clinical features; no specific tests are available. Irrespective of subtype or depth, most infantile haemangiomas reach 80% of their final size by 3 months of age [9]. Comedones and cysts behind the ears have been attributed to paraffin products in shaving soap inadequately rinsed from this region [30]. The earlyonset form results from the development of miliary granulomas following bloodborne dissemination of infection. The pathogenesis of idiopathic pruritus ani is thought to be primarily the consequence of faecal contamination or possibly the intake of certain food or drinks. Patients should also be evaluated for the need of rabies postexposure immunoprophylaxis. Oral squamous cell carcinoma predominantly metastasizes locally and to draining regional lymph nodes, primarily in the anterior neck. Resources Patient resources International Society for the Study of Vulvovaginal Disease information sheets: issvd. Patients initially complain of a tingling or burning sensation that precedes the eruption. Firm leaflike painless swellings are seen, usually in the buccal or labial vestibule. Histologically it shows hyperpigmentation of the basal layer, mild acanthosis, elongation of the rete ridges and numerous melanophages in the upper dermis. A review of published research mainly originating from North America and western Europe in the general population identified that the median prevalence of contact allergy to at least one allergen was 21. The results of therapy with corticosteroids, alkylating agents and interferon have been poor. In addition, the Health and Safety Executive have a statutory right to investigate skin problems at work through the Employment and Medical Advisory Service, provided they are reported [31]. In one study, it identified twice the number of sensitized persons detected by sesquiterpene lactone mix, and by testing with both allergens 76% of all allergic subjects were identified. Among occupations, foundry workers and bakers and the various tasks that involve carrying heated coals are sometimes relevant. A similar pattern may be seen in occupations where employees are repeatedly exposed to solvents, friction or irritating food components. Some of the histological variants of blue naevi may also present with distinct clinical features. Coldinduced vasoconstriction is a heatpreserving, protective mechanism but prolonged vasospasm may jeopardize the vitality of the skin.
Systemic noneczematous reactions Extensive allergic contact dermatitis is not uncommonly associated with systemic upset from the metabolic effects of the disorder itself and secondary infection, particularly in those who are erythrodermic. Auricular haematoma may affect athletes in close contact, for example in wrestling, boxing and judo. Patch test concentrations the choice of a suitable concentration is of fundamental importance. Clinical characteristics, etiologic associations, laboratory findings, treatment, and proposal of diagnostic criteria of pernio (chilblains) in a series of 104 patients at Mayo Clinic, 2000 to 2011. Storage in small jars has the drawbacks of oxidation, drying and evaporation of volatile test substances. Management Erysipelas is a serious skin infection that needs to be treated urgently with appropriate systemic antibiotics. Contact with pine and other coniferous trees, and probably Cupressocyparis leylandii, should be avoided; in those with extreme sensitivity, felling and removing the offending trees may be necessary. It may cause pain and bleeding; however, this method can encourage a stalled wound to begin healing as a reaction to the now acute wound. People who both smoke and drink heavily over several years have the highest risk of developing head and neck cancers. Epidemiology Differential diagnosis Incidence and prevalence It is unknown but very rare. A recent murine study showed that pregnancy appeared to promote melanoma metastasis through enhanced lymphangiogenesis [7]. In boys, complete circumcision is the treatment of choice because all affected tissue is removed and any secon dary involvement of the glans probably regresses or resolves [16]; it is the unproven impression that this phenomenon also occurs in most adult patients. Leucocytosis, lymphopenia, lymphocytosis, thrombocytosis and thrombocytopenia are also described. In the older male, persistent primary phimosis or the secondary development of phimosis in a previously retractable foreskin may be related to lichen sclerosus [9]. The latter are mushroomshaped red structures covered by nonkeratinized epithelium. Following envenomation, several syndromes must be distinguished: neurotoxicity, systemic toxicity, coagulopathy, rhabdomyolysis and renal failure. Circumcision is important in the management of disorders of the penis and the foreskin, including dermatological disease. Patch tests are positive either to aluminium chloride 2% aqueous or an empty Finn chamber. Third line Given the rarity of the condition, the evidence base for therapeutic options is limited to case reports and case series. This class contains several thousand species, including the sea anemones, the soft corals and the stony or true corals. Part 12: NeoPlasia A labial melanotic macule is a benign, hyperpigmented macule of the lip, quite similar to a freckle or simple lentigo. The skin may be broken by excoriations and become secondarily impetiginized or colonized by Candida. Other reviews did not find that available studies were adequate enough to recommend one risk assessment scale over another or even over clinical judgement [29,30]. Allergy can never be completely excluded, nor is any pattern of hand dermatitis Part 11: ExtErnal agEnts 129. There is no current evidence to indicate that a different disease mechanism underlies the contrasting conditions. The manner in which they are used will vary, and optimum regimens have yet to be established [2].
The mechanisms of sun induced skin cancers are discussed elsewhere (see Chapter 9). Stinging of an aquarium shopworker by a stony coral, Euphyllia picteti, has been reported [43]. Even when there is no eruption on the hands, allergens on the fingertips may cause dermatitis elsewhere, for example the genital area, eyes, or face and neck. A wide variety of drugs and chemicals, both systemically and topically administered, may cause photosensitivity [21,22]. Local and systemic reactions to puncture injuries by the sea urchin spine and the date palm thorn. Although cinchocaine is an aminoalkylamide and lidocaine (lignocaine) is an aminoacylamide, most individuals do not crossreact. Phenothiazines can produce allergic contact dermatitis, photoal lergic reactions and eczematous contacttype dermatitis, and may crossreact with certain antihistamines. Differential diagnosis Malignant blue naevi should be differentiated from blue naevi and the socalled atypical blue naevi. Ini tial treatment of chemical burns [6,7] requires irrigation with large volumes of lukewarm water and removal of contaminated cloth ing. Painful extensive stomatitis, painful paronychia and lichenoid papules may be seen, and histology may show lichenoid changes, acantholytic blister formation and apoptotic keratinocytes. When practicable (taking into account the needs of other family members), avoid unnecessary environmental exposure, such as holidays in sunnier climes. However, the majority of patients will require systemic corticosteroid therapy, either via the oral route or the intravenous route, as guided by clinical state. Introduction and general description Cutaneous features in cryoglobulinaemia occur as a consequence of intravascular precipitation of cryoglobulins in the small vessels of the skin or as an immune complex disease (see Chapter 102). Management Appropriate antibiotic therapy and supportive care is needed in severe infections. Phototherapy is contraindicated because of the risk of Part 10: sites, sex, age 111. More prolonged courses of corticosteroid or more potent corticosteroids may be needed under specialist ophthalmological supervision. However, in our experience most reactions are in the red areas, and patch testing with mercurials is negative, suggesting another cause. Pathophysiology Darier disease e Definition Darier disease is an acantholytic disorder of keratinization, usually with autosomal dominant inheritance (see also Chapter 66). The histological features suggest that they arise from ectopic urethral tissue during embryological development [7]. Associated diseases There is often underlying immunosuppression, the aetiology of which may include malignancy, dermatomyositis [1], lupus erythematosus, rheumatoid arthritis and organ transplantation [2]. In addition, wet skin has an increased frictional coefficient and higher microbial content (5). As well as simplifying terminology, this designation embraces the overlapping clinical and histopathological features that occur in the chemotherapyinduced erythemas. Exposure time the mere touch of a Primula leaf may provoke a subsequent bullous response in a sensitive person, but with some materials. Many clothing resins will release formaldehyde [6], and free formaldehyde may be found on treated garments and will induce dermatitis in its own right. Herbal teas, medicines and cosmetics may all contain Compositae plants or extracts. Taking a small scrape from the edge of the corneal epithelial defect and sending it for microbiology will help confirm that an infection is present and whether it is likely to respond to the empirical treatment instituted.
Infantile haemangiomas can also occur with or without associated lesions (Table 117. Often this is nonspecific and harmless [1], but some viral infections have very characteristic features that allow a diagnosis to be made. The reaction is substantially reduced in the absence of sweating and is commoner in the summer. Noncaseating granulomas and lymphoedema may be seen but the granulomas tend to be sparse and deep, close to the muscle. The use of ethical tests in human volunteers may be considered where testing in vivo is considered essential [1]. The mouth may be involved as part of a wider disease, though in many patients only oral lesions are seen [9]. First line Topical 5% imiquimod or 5fluorouracil cream are therapeutic options for perianal or intraanal disease and can be selfapplied [6]. It is particularly common after sports where there are sudden stops, such as basketball. Sex Oral hair Oral hair is a rare innocuous anomaly [1,2], not to be confused with hairy tongue or the hair on skin flaps used intraorally in reconstructions as, for example, after cancer resections. Various drugs have been associated with acneform eruptions and the common drugs are summarized in Box 118. Azo dyes will normally be incorporated into a larger series of allergens for the investigation of textile dermatitis (see the section on clothing). In some cases, distinction between solar lentigo and lentigo maligna or melanoma in situ is very difficult when classic pathology is used. No active therapy is required although topical or systemic glucocorticoids may hasten recovery [38]. Pathophysiology Part 11: ExtErnal agEnts Black heel occurs when the repeated shearing force of the epidermis sliding over the dermal papillae results in damage to the papillary dermal capillaries, resulting in intraepidermal haemorrhage. The proportion of patients with ocular involvement alone varies from 18 to 50%; these differences are likely to reflect differences in the referral base for each series. Dandelion allergy, in particular, may be missed by the sesquiterpene lactone mix patch test, and supplementary testing with extract has increased the number of Compositaeallergic subjects identified [29]. However, due to the lack of appropriate comparison trials, it is not clear if there is a specific protein supplementation regimen which is most beneficial. Haematological diseases Deficiency states Low iron, folate or vitamin B12 levels may predispose to mouth ulcers. Some patients bring foods in the mistaken belief that the test will diagnose ingested food allergy. In those with linear IgA disease, 50% of adults and 80% of children will have vulval lesions. Unfortunately, the weed has spread over much of the subcontinent, including urban areas. The recent resurgence in the incidence of syphilis in many countries may lead to an increase in cases of congenital disease, especially where antenatal care is poor [2,3,4]. Patients should not be treated with more than the maximum daily dosage (hydroxychloroquine at a maximum dosage of 6. Patterns also change with fashion, as shown by the virtual disappearance of suspender dermatitis from nickel, which was replaced by an increase in dermatitis from earrings, watches and jeans studs. Epidemiology Incidence and prevalence Acneform eruptions represent 1% of all druginduced skin reac tions [165]. Lips are more frequently cleft bilaterally (approximately 25%) when combined with cleft palate.
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