A RATIONALE FOR RASHES

A RATIONALE FOR

RASHES

Assoc. Prof. Warwick Carter MB.BS; FRACGP; FAMA

A guide to the diagnosis of skin rashes, patches, itches and damage.

1 A RATIONALE FOR RASHES

CONTENTS

Introduction

SECTION ONE Dermatological Diagnostic Flow Chart A flow chart that leads the user through various symptoms and signs to possible diagnoses.

SECTION TWO Diagnostic Algorithm for Rashes Symptoms and signs involving the skin and the conditions that may be responsible

SECTION THREE Dermatological Conditions The symptoms, signs, investigation and treatment of medical conditions that may cause an alteration in the skin.

Appendices Syndromes that may cause Skin Lesions Sun Exposure Skin Abnormalities

2 A RATIONALE FOR RASHES

INTRODUCTION

This book is designed for both the medical student and the doctor who is not a specialist in dermatology. It will take the user through a logical rationale in order to diagnose, and then treat, virtually every rash or likely to be encountered outside a specialist practice. There are two ways to reach a diagnosis, using the flow chart in Section One, or the Diagnostic Algorithms in Section Two. In Section One, a flow chart will guide the user through the presenting symptoms and signs of most rashes to a selection of possible diagnoses. As an alternative, the algorithms in Section Two will indicate the diagnoses possible with a variety of dermatological presenting symptoms. Once a diagnosis has, or number of differential diagnoses have been made, a detailed explanation of the various dermatological diagnoses can be found in the largest part of the book, Section Three. This has been written in a style that should be easy to understand by even junior medical students, with technical terms explained in each monograph, but should still be useful to the non-specialist doctor. The symptoms, signs, investigations and treatment of a very wide range of conditions are explained, along with pictures of the more common conditions. I trust that you will find it useful.

Warwick Carter Brisbane

OTHER BOOKS IN THIS SERIES

A Rationale for the Brain A Rationale for Eyes A Rationale for the Abdomen A Rationale for the Chest

3 A RATIONALE FOR RASHES

Section ONE

DERMATOLOGICAL DIAGNOSTIC FLOW CHART

4 A RATIONALE FOR RASHES

5 A RATIONALE FOR RASHES

Section Two

DIAGNOSTIC ALGORITHMS FOR RASHES

6 A RATIONALE FOR RASHES

Acne DIAGNOSTIC vulgaris (common form) Papular acne (inflamed papules) ALGORITHMS Comedonal acne (less ) Cystic acne (inflamed nodules, scarring) (secondary to steroid therapy) FOR RASHES Acne medicamentosa (due to drugs or cosmetics) (due to friction from straps, etc.) (telangiectasia, central face papules) Symptoms and signs (contact with oils and chemicals) Pseudofolliculitis barbae (ingrown hair) involving the skin Acne keloidalis (keloid scar from traumatised acne) and the conditions that Pituitary tumour may be responsible Syndromes Adrenogenital syn. (amenorrhoea, rough skin) Cushing syn. (ecchymoses, obese, hirsute) Polycystic ovarian syn. (late onset, persistent) Premenstrual tension syn. (mastalgia, headache) See also Pustules FORMAT

Alopecia Presenting Symptom Loss of hair (Alternate Name) Baldness Explanation of terminology Male pattern baldness (genetic) System or other group of symptoms Virilisation Diagnoses that may present with this symptom Testosterone secreting tumour [alternate name of diagnosis] (other symptoms of each diagnosis, or a discussion of the diagnosis) Chemotherapy Other entries to consider Diffuse Idiopathic (thinning of hair, either sex) Clinical Sign Any severe illness Sign (Alternate Name) [Abbreviation] Rapid weight loss Exp: An explanation of the sign, with its Shock or stress (eg. bereavement, surgery) methodology described in sufficient detail to (after stress) enable the practitioner to perform the test. Hypothyroidism (fatigue, dry skin, cold intolerance) Int: The interpretation of the sign. Hyperthyroidism (sweating, heat intolerance) (+) The diseases, syndromes etc. that SLE (butterfly rash, arthritis, nephritis) should be considered if the test is positive Postpartum (++) The interpretation of an exaggerated or Hypopituitarism grossly positive test Postmenopause (–) Ditto for a negative test result Diabetes mellitus (polydipsia, polyuria) (AB) Ditto for an abnormal test result Renal failure Phys: The pathophysiology of the sign to enable Protein deficiency (eg. malnutrition, vegetarian) its significance to be better understood Addison's disease (groin and axilla only) Other entries to consider Hypervitaminosis A (anorexia, weight loss, rashes) Irradiation Iron or zinc deficiency Ectodermal dysplasia Dubowitz syn. (reduced growth, ptosis) Fröhlich syn. (thin skin, low libido, obese)

7 A RATIONALE FOR RASHES Hallermann-Streiff syn. (dwarf, cataracts) Bleeding in Skin Langer-Giedion syn. (bullous nose, exostoses) See Ecchymosis; Purpura and Petechiae Loose Anagen syn. Drugs (eg. cancer therapy, anticoagulants, vitamin A, lithium, beta-blockers, oral contraceptives)

Patchy hair loss Blisters See Acne; Bullous Rash; Pustules; Vescicles Any severe illness Fungal scalp infection Discoid lupus erythematosus Bouchard's Nodes Traction (hair style that pulls on one area of scalp) Bony prominences at the dorsal margins of proximal Trichotillomania (recurrent trauma) interphalangeal joints Syphilis (variable symptoms) Severe osteoarthritis See also Heberden's Nodes

Anal Itch See Pruritus Ani Bruising, Excess Thrombocytopenia (bleeding time increased) Idiopathic purpura Annular Rash Hereditary disorders of coagulation Rash consisting of circular lesion(s) (eg.haemophilia, von Willebrand's, Christmas Tinea cruris, corporis or capitis (red, scaly edge, disease) pruritis) Bone marrow suppression Pityriasis rosea (herald patch, trunk, scaly centre) Ionising radiation (eg. X-rays, gamma rays) Cutaneous larva migrans (hookworm infestation, Systemic viral infections itchy, track) Leukaemia (abnormal white cell count) Pigmented purpuic dermatosis (venous Typhus (fever, malaise) insufficiency, pepper spots peripheral on lesion) Subacute bacterial endocarditis Granuloma annulare (faint, flesh colour, limbs) Insect and snake bites Cutaneous lupus (chronic relapsing, trunk, Following massive blood transfusions confluent) Renal failure Hepatic failure Polycythaemia (rubra) vera Scurvy (inflamed and bleeding gums) Areolar Pigmentation Cushing syn. (moon face, obese, amenorrhoea) Darkening of areola and nipple AIDS (splenomegaly, fever, cachexia) Present or past pregnancy Defibrination syn. (see Syndromes) Sex hormone therapy Painful bruising syn. (female, paraesthesiae) Familial, Drugs (eg. steroids, arsenic, quinine, aspirin, Racial warfarin, chlorothiazide) See also Ecchymoses

Auspitz's Sign Exp: When white scale is removed from a plaque Bullous Rash of scale covered dermatitis on the shins, a Large fluid filled blisters bleeding area results Impetigo (crusts, vesicles, pruritic) Int: (+) Psoriasis Herpes zoster (severe pain, dermatome Phys: In psoriasis, the plaque has a microcapillary distribution) circulation that is disrupted by its removal Herpes simplex (pain) Cellulitis (red, hot, fever) Toxic epidermal necrolysis Bald Contact dermatitis (erythema, itch) See Alopecia Drug eruptions Insect and arachnid bites

1 A RATIONALE FOR RASHES Erythema multiforme (target lesions, erythema, Circular Rash extensor surfaces) See Annular Rash Pemphigus (normal skin surrounds, relapsing crops) Pemphigoid (large, tense, elderly) Dermatitis herpetiformis (vesicles, papules, erythema) Circumoral Pallor Pompholyx (soles and palms, tense blisters) Exp: Relatively white area around mouth Porphyria cutanea tarda Int: (+) Fever of any cause (eg. scarlet fever) Epidermolysis bullosa Phys: Dilatation of superficial blood vessels in looser skin further away from mouth causes Burns (heat or irradiation) darkening and reddening of that area (rather than blanching of circumoral tissue)

Butterfly Rash Coilonychia Erythematous, scaly rash spreading across both See cheeks and meeting on the nasal bridge Systemic lupus erythematosus (SLE) Photodermatitis Discoid lupus Cullen's Sign Atopic dermatitis Exp: Spontaneous umbilical bruising Serum sickness Int: (+) Ruptured ectopic pregnancy, carcinoma of pancreas, haemorrhagic pancreatitis, other causes of haemoperitoneum Café-au-Lait Spots Phys: Tracking of free intraperitoneal blood to Light brown spots on skin umbilicus Von Recklinghausen's disease of multiple neurofibromata Pityriasis versicolor Tuberous sclerosis Darierʼs Sign See also Pigmentation of Skin, Excess Exp: Rubbing a finger or blunt object firmly over a skin lesion causes oedema and erythema around the lesion Int: (+) Mastocytosis Chip Sign Phys: Pressure releases histamine from increased Exp: Skin blotches covered with fine, number of mast cells in lesion nonadherent scabs that are easily removed by a fingernail or blunt edge Int: (+) Pityriasis versicolor Phys: Superficial fungal infection Dark Skin See Chloasma; Face Pigmented; Pigmentation of Mouth; Pigmentation of Skin, Excess Chloasma Yellow-brown spotty skin pigmentation on upper cheeks and forehead Pregnancy Depigmented Skin Oral contraceptives Racial and familial Sun exposure Pityriasis versicolor (reddish, scaling) Syphilis Pityriasis alba (eczematous, asymptomatic) mMlaria, Vitiligo (dead white, well demarcated patches) Tuberculosis (TB) Halo naevus Cirrhosis Postinflammatory Chronic trauma Albinism Some drugs Chronic mucocutaneous candidiasis See also Face Pigmented; Pigmentation of Skin, Leprosy Excess Tuberous sclerosis (subnormal) Hypopituitarism

2 A RATIONALE FOR RASHES Hypoparathyroidism (small muscle spasms) Eczema (scaling) Kwashiorkor (malnutrition) Intertrigo (pruritus, stinging, skin folds) Vogt-Koyanagi-Harada syn. Erysipelas (oedema, hot pain, malaise) Phenylketonuria (mental retardation) Cellulitis (hot, diffuse, deep) Scars and burns Mycosis fungoides Chemicals (eg. phenols) Tinea (pruritus, ring form, scaling)

Syndromes Dry Skin Red man syn. (vancomycin infusion) (Xeroderma) Rothmund-Thomson syn. (skin atrophy, Fever pigmentation) Seborrhoeic dermatitis (scales, erythema) Sézary syn. (pruritus) Hypothyroidism (mental retardation, reduced Stevens-Johnson syn. (conjunctivitis, stomatitis) growth) Constitutional reasons (eg. genetic, familial) Other Psoriasis (red, scaling, patchy) Flush Hypovitaminosis A (night blindness, Burn (eg. sunburn, scald) hyperkeratoses) Viral infections (eg. measles, rubella) Ichthyosis (rough, scabs) Allergic reaction Typhoid fever (abdominal pain) Scarlet fever (circumoral pallor, malaise) Other dermatoses Cirrhosis (palmar erythema, hepatic signs) See also Ichthyosis; Scalp Dry Erythema nodosum (nodules, female, painful rash) Erythema multiforme (target lesions, extensor surfaces) Lyme disease (fever, nausea, abdominal pain) Ecchymosis Pellagra (red tongue, diarrhoea, abdominal pain) Bruise, purpuric macules Discoid lupus erythematosus (plaques, scaling, Thrombocytopenia (low blood platelets) telangiectasia) Coagulation defects (congenital or acquired) Bilharzia (pruritus, diarrhoea or haematuria) Meningococcal infection Diseases specific to area of erythema (eg. gout, Septicaemia mastitis, arthritis) Subacute bacterial endocarditis Alcohol excess Rickettsial diseases (eg. typhus, Rocky Mountain See also Facial Erythema spotted fever) Allergic vasculitis (arthralgia, myalgia) Purpura fulminans (skin infarcts) Scurvy (bleeding gums) Face Pigmented Basal skull fracture (mastoid ecchymosis) Sun exposure Local trauma Freckles Drug hypersensitivity Chloasma (pregnancy or oral contraceptive use) See also Bruising, Excess Naevus of Ota (teenager, Asian) Other causes of skin pigmentation elsewhere on body See also Chloasma; Pigmentation of Skin, Excess Erythema Redness of skin Dermatological Contact dermatitis (oedema, vesciculation, crusting) Facial Erythema Dermatitis, stasis (pruritus, oedema, ulceration) Excessively red face Dermatitis, exfoliative (pruritus, scaling, malaise) Vasomotor instability (eg. flushing) Photodermatitis [sunburn](pain, oedema, Rosacea vesciculation) Seborrhoeic dermatitis Rosacea (facial, exacerbated by vasodilation) Superior vena caval syn. Psoriasis (plaque, scaling, nail changes, pruritus) Seborrhoeic dermatitis (dry, scaling) Contact dermatitis Acne (pimples; ; face, back and shoulders) Atopic dermatitis (pruritic) Urticaria (pruritus, wheals, oedema, malaise) Psoriasis (scaling)

3 A RATIONALE FOR RASHES Excess topical steroid use Heberden's Nodes Sunburn Exp: Bony prominence at the dorsal margins of Light sensitivity distal interphalangeal joints SLE (butterfly pattern rash) Int: (+) Osteoarthritis, osteoarthrosis Erysipelas Phys: More common in women. May be due to a Dermatomyositis single autosomal gene Acne vulgaris See also Bouchard's Nodes Sarcoidosis Essential telangiectasia Slapped cheek syn. Birthmarks (eg. port wine stain) Henoch-Schönlein Purpura Carcinoid syn. Exp: Extensive elevated purpuric or ecchymotic See also Erythema lesions on extensor surfaces of arms and legs. May be recurrent and can occur on the face, in the gut (causing haemorrhage and colic), and in the kidney (causing Formication haematuria) Sensation of insects crawling on skin Int: (+) Idiopathic, after sensitising foods, Neurological sensory disorders poststreptococcal infection, drugs Psychiatric syndromes Phys: Immunological reaction, more common in Alcoholism withdrawl children Drugs

Genital Itch Heliotrope Sign Exp: A reddish purple erythema involving the See Pruritus; Pruritus Ani; Pruritus Vulvae eyelids

Int: (+) Dermatomyositis

Gottron's Sign Exp: Scaly patches over dorsum of proximal Herald Patch interphalangeal and metacarpophalangeal Exp: Oval, discoid or annular, solitary, reddish, joints, subungual erythema and cuticular slightly raised and scaly patch on the trunk. telangiectasiae Followed by multiple smaller lesions Int: (+) Polymyositis, dermatomyositis Int: (+) Pityriasis rosea, drug eruptions

Hair Loss Hertoghe Sign See Alopecia Exp: Lack of the outer one third of the eyebrow Int: (+) Atopic dermatitis, neurodermatitis, hypothyroidism and systemic sclerosis. Hanging Curtain Sign Exp: When the skin is stretched across the long axis of a medallion lesion, the scale being Hess Test finer and lighter and attached at one end Exp: A sphygmomanometer cuff inflated to 80 tends to fold across the line of stretch. mmHg (10.6 kPa) around the upper arm for Int: (+) Pityriasis rosea five minutes causes purpuric spots to appear below the cuff Int: (+) Diseases associated with purpura (eg. Headlight Sign thrombocytopenia, diseases of vascular Exp: Perinasal and periorbital pallor endothelium, thromboasthenia, uraemia) Int: (+) Atopic individuals. Phys: Tests the resistance of capillaries to increased venous pressure. Obsolete test that should not be performed if more

4 A RATIONALE FOR RASHES sophisticated tests for vascular disease Yellow fever (purpura, muscle pain, oliguria) available Pancreatitis (severe pain, shock) Purpura and Petechiae Cytomegalovirus (neonate, purpura, haematuria) Syphilis (variable symptoms) Echinococcus (wheeze, urticaria) Ichthyosis Generalised dryness and scaling of skin Syndromes Congenital Bard-Pic syn. (carcinoma of pancreas) Ichthyosis vulgaris (widespread, inherited) Crigler-Najjar syn. (kernicterus, neonate) Acquired ichthyosis (precipitated by disease) Dubin-Johnson syn. (neonate, asymptomatic) Hypothyrodisim (cold intolerance, lethragy) Gilbert syn. (benign asymptomatic jaundice) Lymphomas (eg. Hodgkin's disease) Lissencephaly syn. (fits, hypotonia) Sarcoidosis Patau syn. (neonate, asymptomatic) Leprosy Vitamin A deficiency Other Harlequin syn. Neonatal icterus Refsum syn. (deaf, ataxia, polyneuritis) Familial causes Sjögren-Larsson syn. (spastic diplegia) Hodgkin's disease (adenitis, fever, weight loss) Drugs (eg. cimetidine, nicotinic acid, retinoids) Sickle cell anaemia (fever, abdominal pain, negroid) See also Dry Skin; Scalp Dry Post upper abdominal surgery Haemolytic anaemia (fatigue, malaise, pallor) Thalassaemia major (hepatosplenomegaly, lethargy) Itch Galactosaemia (infant, vomiting) See Pruritus; Pruritus Ani; Pruritus Vulvae Drugs (eg. chlorinates, chromates, sulfonamides, halothane) Carotenaemia (excess ingestion of orange coloured Janeway Lesion food, headache, white conjunctivae) Exp: Small purplish/red nodule on palms or soles Int: (+) Infective endocarditis Phys: Infected embolic lesion Joint Erythema See also Oslerʼs Nodes Exp: Redness and inflammation of tissue overlying a joint Int: (+) Septic arthritis, cellulitis, gout, Jaundice pseudogout, rheumatoid arthritis, reactive (Icterus) arthropathy, Reiter syn. (see Syndromes Yellow skin section 6), Heberden's node, Bouchard's Hepatobiliary node, erythema nodosum, inflammatory Biliary tract obstruction (pain, pruritus, fever) osteoarthritis,rheumatic fever Cholecystitis (pain, nausea, fever) Cirrhosis (pruritus, RUQ pain fever) Carcinoma of head of pancreas (pain, pruritus, Koebner Phenomenon cachexia) Exp: Following trauma, lesions appear in the Cholelithiasis (colic) traumatised but otherwise normal skin. Primary or secondary hepatic malignancy Int: Psoriasis Alcoholic liver disease Hepatic vein stenosis Gaucher's disease (hepatosplenomegaly, anaemia) Primary sclerosing cholangiitis Koilonychia Exp: Spooning of nails Infections Int: (+) Iron deficiency anaemias, Plummer- Hepatitis, infectious and serum (anorexia, nausea, Vinson syn. fever) Malaria (paroxysmal fevers, nausea, headache) Clostridial gangrene (pain, foul smell, tissue crepitations)

5 A RATIONALE FOR RASHES Lace-like Rash Macular Rash Lacy or net (reticular) pattern on skin Flat, circumscribed, discoloured lesions Erythema infectiosum (red on trunk and thighs, Dermatological slapped cheeks, Parvbovirus B19) Psoriasis (red, scaling) Livedo reticularis (bluish, worse in cold, vasculitis) Dermatomyositis (weakness, oedema, myalgia) Acute meningococcaemia (purpura fulminans, dark Vitiligo (white patches) gray) Tinea corporis (white centred erythematous Cutaneous lava migrans (raised rash pattern). patches) Pityriasis rosea (scales, erythematous, trunk) Tinea versicolor (red patches, do not tan in sun) Seborrhoeic dermatitis (red/brown, scaly) Leser-Trelat Sign Mycosis fungoides Exp: Abrupt appearance, and rapid increase in Lichen planus (glossitis) size, of many seborrhoeic keratoses Int: (+) Underlying carcinoma (eg. Infections adenocarcinoma) Measles (cough, rhinitis, conjunctivitis) Phys: May also occur during lysis of tumour with Roseola infantum (high fever, adenitis, infant) cytotoxics Rubella (fever, coryza, adenitis) Rheumatic fever (erythematous margin, nodules, arthritis) Infectious mononucleosis (often after penicillin Light Sensitivity therapy) See Photosensitive Skin Epidemic polyarthralgia (lethargy, arthritis) Meningococcal infection (meningism, vomiting) Leprosy (raised edge, anaesthetic) Pinta (itch, lymphadenopathy)

Linear Rash Other Longitudinal skin rash SLE (arthritis, malaise, anorexia) Lichen planus Addison's disease (dark patches, fatigue, nausea) Flat warts Neurofibromatosis (eg. phaeochromocytoma, von Psoriasis Recklinghausen's disease) Epidermal naevi Sweet syn. Contact dermatitis (eg. perfumes) Kawasaki syn. (adenitis, fever) Scabies (vesicles, `runs', finger webs involved) Drug eruptions Dermographia

Lichen striatus

Koebner phenomenon Jellyfish stings Necklace of Casal Stinging and irritating plants Exp: Hyperpigmentation on the neck Int: Pellagra. Lines on Skin See Linear rash Net Pattern See Lace-like Rash Lip Papules Papules at angles of upper and lower lips Syphilis Nikolsky Sign Exp: Gentle lateral pressure with a finger to apparently normal skin causes epidermis to Lumps immediately slough off leaving a raw area See Nodules; Papules Int: (+) Pemphigus, toxic epidermal naevus

6 A RATIONALE FOR RASHES Nodules Leukaemia (fever, arthralgia, malaise) Dermatological Haemolytic anaemia (fever, nausea, abdominal Warts (irregular surface, varied shape, crops) pain) Haemangioma (blood vessel malformation) Pernicious anaemia (anorexia, sore tongue, Basal cell carcinoma (rounded, pearly, paraesthesiae) telangiectatic vessels) Chronic renal failure (nausea, pruritus) Keratoacanthoma (scaly surface, rapid growth) Aplastic anaemia (lethargy, purpura) Naevus (pigmented) Shock (eg. myocardial infarct and other causes of Lipoma (soft, diffuse) hypotension) Dermatofibroma (isolated yellow-brown nodule) Ischaemic limb (pain, pulseless) Prurigo nodularis (itchy, red, hard, scaly) Racial or genetic characteristic Neurofibromatosis (café-au-lait spots) Molluscum sebaceum and contagiosum Syndromes Chilblains (red, itching, extremities) Diencephalic syn. (cachexia, vomiting, sweating) Granuloma inguinale (ulcerates, painless, sexually Dumping syn. (postgastrectomy, postprandial) transmitted) Raynaud's phenomenon (cyanosis and oedema of Melanoma (pigmented, metastasises) fingers) Hyperlipidaemia (xanthomata) (see Signs) Vasovagal syn. (hypotension, syncope, Stewart-Treves syn. bradycardia) Waterhouse-Friderichsen syn. (petechiae, Systemic prostration) Erythema nodosum (tender, fever, legs) Rheumatic fever (heart murmur, polyarthralgia, rash) Pallor, Circumoral Rheumatic arthritis (arthralgia, malaise, See Circumoral Pallor paraesthesiae) Heberden's nodes Polyarteritis nodosa (arthritis, pruritus, rash) Papules Gout (severe pain in acute stage) Firm, raised, circumscribed lesions SLE (butterfly rash) Acne (comedones, cysts, erythema) (see separate Lymphoma entry) Sarcoidosis (lung symptoms) Naevi (pigmented) Syphilis (second stage symptom with rash) Melanoma (black, irregular) Basal cell carcinoma (pearly, telangiectasia) Oslerʼs Nodes Xanthoma (yellow, cholesterol containing) Exp: Small, tender, raised, red, transient patch Molluscum contagiosum (smooth, rounded, apical on tips of fingers or toes depression) Int: (+) Bacterial endocarditis Granuloma (singular, soft) Phys: Caused by infected cutaneous embolus Psoriasis (scales, erythema, nail changes) See also Janeway Lesion; Splinter Haemorrhages Contact and atopic dermatitis Lichen planus (flat topped, itchy scales) Neurodermatitis (itch, thickened skin) Painful Skin (flexures) Scabies Photodermatitis [sunburn] (erythema, oedema, Polymorphic eruption of pregnancy vesiculation) Pinta (itch, lymphadenopathy) Herpes zoster [shingles] (dermatome distribution, Cutaneous anthrax (oedema, surrounding vesicles) vesicular lesions, unilateral) Tularaemia (one papule that ulcerates, adenitis) Cellulitis (erythema, oedema, fever) Gianotti-Crosti syn. (viral reaction) Trauma (itchy, red)

Pallor Pale skin Anaemia (lassitude, dyspnoea, palpitations)

7 A RATIONALE FOR RASHES Patches Bloch-Sulzberger syn. (neonate, pigmented streaks, See Macular Rash; Plaque and Patch Formation; incontentia pigmenti) Port Wine Stain Blue rubber bleb syn. (multiple blue tinged rubbery blebs, small bowel haemangiomas) Cushing syn. (central obesity, plethora, headache) Cronkhite syn. (pigmented hands and feet) Dysplastic naevus syn. (multiple large moles) Photosensitive Skin Felty syn. (polyarthritis, splenomegaly) Rashes that develop in response to sunlight Leopard syn. (multiple spots, cardiac changes) Polymorphic light eruption Leschke syn. (spots, asthenia, hyperglycaemia) Photocontact dermatitis (eg. soaps, cosmetics, Nelson syn. (postadrenalectomy) shampoo) Peutz-Jegher syn. (pigmented mouth, lips and Systemic or discoid lupus erythematosus fingers) Porphyria cutanea tarda Rothmund-Thomson syn. (erythema, telangiectasia) Pellagra Russell-Silver syn. (café-au-lait spots, dwarf) Phenylketonuria

Hartnup disease Other Xeroderma pigmentosum Varicose veins (oedema, leg ache) Congenital photosensitivity Renal failure (oedema) Bloom syn. (Jewish, reduced growth, leukaemia) Addisonism (fatigue, anorexia, nausea) Drugs (very wide range incl. tetracycline, Neurofibromatosis (eg. von Recklinghausen's phenothiazines, sulfonamides, thiazides, frusemide, disease, phaeochromocytoma) antimalarials, griseofulvin, nalidixic acid) Haemochromatosis (hepatomegaly, hepatic and

cardiac failure) Scleroderma (arthritis, Raynaud's phenomenon) Pigmentation of Mouth Sprue (bulky foul stools, weight loss, anaemia) Addison's disease (weak, anaemia, nausea) Pregnancy (face, nipples and flexure lines) Melanoma (variable colouration) Thyrotoxicosis (sweating, fatigue, weight loss) Haemochromatosis (arthropathy, hepatomegaly) Pituitary tumours (eg. acromegaly) Peutz-Jegher syn. (hereditary intestinal polyposis) Carotenaemia (yellow palms and soles) Kaposi's sarcoma (purple, raised, AIDS) Porphyria (urine colour change) Racial Familial and racial factors Acanthosis nigricans Drugs (eg. chloroquine, tetracyclines, amantadine, phenothiazines, chlorpromazine, arsenic, Pigmentation of Skin, Excess busulphan, bleomycin, amiodarone, gold, psoralens, Dermatological oral contraceptives) Freckles See also Areolar Pigmentation; Chloasma; Face Chloasma (pregnancy or oral contraceptives) Pigmented Malignant melanoma (irregular border, varying colour) Naevi (benign, demarcated, hairy) Seborrhoeic keratoses Pigment Loss Haemangiomas (red, benign) See Depigmented Skin Mongoloid spot (lower back, hereditary) Lentigo (normal in most people) Hutchison melanotic freckle (usually face) Pimples Xeroderma pigmentosa See Acne; Pustules; Vescicles Café-au-lait spots (see Signs)

Kaposi's sarcoma (purple, raised, AIDS)

Mastocytosis (red/brown spots, pruritus) Sunburn and skin trauma (eg. keloids) Plaque and Patch Formation Red Syndromes Psoriasis vulgaris Albright syn. (precocious puberty, polyostotic fibrous Tinea corporis, capitis and cruris dysplasia) Discoid lupus erythematosus

8 A RATIONALE FOR RASHES Parapsoriasis Syndromes Mycosis fungoides AIDS Red man syn. (vancomycin infusion) White Sézary syn. (erythroderma) Pityriasis alba Sjögren syn. Pityriasis versicolor Vitiligo Other Postinflammatory hypopigmentation Allergy (oedema, erythema) Insect bites (eg. fleas) Brown Hepatitis (anorexia, nausea, jaundice) Café-au-lait patches Cholecystitis (RUQ pain, nausea, jaundice) Postinflammatory hyperpigmentation Fibreglass and other irritants Congenital naevi NO RASH USUALLY PRESENT Hepatobiliary Port Wine Stain Hepatomas (fever, polycythaemia, hypoglycaemia) Idiopathic Cirrhosis (anorexia, jaundice, RUQ pain, alcoholic) Klippel-Trenaunay syn. (tissue overgrowth) Obstructive hepatobiliary disease Sturge-Weber syn. (convulsions, mental retardation) Haemochromatosis Spinal cord abnormalities (eg. spina bifida) Infections and Infestations Pediculosis (excoriation, lice on skin and clothes) Echinococcus (wheeze, allergies) Pruritus Other metazoal infestations (eg. hookworm, Itching of the skin with a skin abnormality ascariasis, hydatids) RASH USUALLY PRESENT Other intestinal parasites Dermatological Overcleaning of skin Other Ichthyosis (dry, rough, scaly skin) Diabetes mellitus (polyuria, blurred vision, fatigue) Pressure areas Thyrotoxicosis (weak, weight loss, diarrhoea) Atopic eczema (exudate, skin folds, allergic history) Hypothyroidism (dry skin, fatigue, cold intolerance) Seborrhoeic dermatitis (fine scale) Hypoparathyroidism (tetany, wheeze, abdominal Contact dermatitis pain) Stasis dermatitis (erythema, ulceration, oedema) Nephritis (reaction to disease or toxins) Lichen simplex (pigmented lichenified lesions) Uraemia (fatigue, thirst, headache) Exfoliative dermatitis (scaling, erythema, malaise) Lymphomas & Hodgkin's disease (fever, adenitis, Lichen planus (flat papules along scratches, fatigue) anxiety) Leukaemia (malaise, arthralgia, pallor) Psoriasis (red plaques, scales, nail changes) Neoplastic diseases Pityriasis rosea (herald patch, fawn scaly eruption) Multiple myeloma Urticaria (wheals, malaise, oedema) Polycythaemia vera (fatigue, headache) Intertrigo (body folds, erythema, stinging) Iron deficiency anaemia Miliaria [heat rash] (burning, vesicles, hot climate) Itchy upper arm syn. (sun damage, no rash) Dermatitis herpetiformis Fibreglass and other irritants Prurigo nodularis (nodules, red, hard, scaly) Pregnancy Mastocytosis (red/brown skin spots) Ciguatera poisoning (paraesthesiae) Pemphigoid Emotional and psychogenic causes Polymorphic eruption of pregnancy Drugs of addiction (abrupt onset, malaise, fever, Grover disease (heat stress) headache) Medications (eg. aspirin, dextran, narcotics, Infections and Infestations scopolamine) Impetigo (pustules, crusts) Tinea (ring, scaling, erythema) Scabies (vesicles, `runs', finger webs involved) Bilharzia (rash, haematuria, diarrhoea) Pruritus Ani and Proctitis Perianal itch Haemorrhoids (bleeding, pain, lump)

9 A RATIONALE FOR RASHES Fissure-in-ano (discharge, bleeding, pain) Idiopathic thrombocytopenia (epistaxis, Perianal fistula (pain, oedema, erythema) ecchymoses) Leucorrhoea (physiological, any vaginal infection) Platelet or coagulation factor disorders Candidiasis and other superficial fungal infections Vasculitis Diarrhoea of any cause Aplastic anaemia (lassitude, pallor, bleeding) Enterobiasis and other metazoal infections Acute leukaemias (malaise, arthralgia, fever) Diabetes mellitus (polyuria, fatigue, blurred vision) Disseminated intravascular coagulation (secondary Crohn's disease (abdominal pain and mass, to severe disease) diarrhoea) Intertrigo (erythema, stinging, body folds) Other Lichen simplex (pigmented lichenified lesions) Viral exanthema (eg. measles) Seborrhoeic dermatitis (erythematous vesicles) Senile purpura (ecchymoses on arms, elderly) Contact dermatitis (erythema, vesicles, oedema) Allergic conditions Psoriasis (red plaques, nail changes, scaling) Cytomegalovirus (neonate, haematuria, jaundice) Papillomata and skin tags Severe generalised bacterial infections Molluscum contagiosum (umbilicated blisters) Polyarteritis nodosa (arthritis, skin disorders, Rectal prolapse nodules) Condylomata accuminata Uraemia (fatigue, headaches, pruritus) STDs (eg. syphilis, gonorrhoea) Yellow fever (jaundice, muscle pain, oliguria) Bowen's disease Scurvy (gingivitis, arthralgia, anaemia) Poor hygiene Amyloidosis (symptoms vary with involved organ) Meningococcal septicaemia Vitamin K deficit Pruritus Vulvae Miliary tuberculosis Itchy vulva Bacterial endocarditis (murmur, fever) Candidiasis (rash, white vaginal discharge) Meningococcal meningitis (fever, headache, Bacterial vaginitis (pain, foul discharge) vomiting) Excessive sweating Trauma Tight clothing (particularly nylon) Drugs (eg. quinine, thiazides, heparin, aspirin, Over washing of area trimethoprim/sulfamethoxazole) Allergic reaction to soaps, material, toiletries, etc. Atopic dermatitis Syndromes Seborrhoeic dermatitis Bernard-Soulier syn. (excess bleeding) Psoriasis (plaques, scaling) Cushing syn. (central obesity, plethora, fatigue) Urinary tract infection (frequency, dysuria) Defibrination syn. (excess bleeding) Pediculosis (crabs seen in pubic hair) Glanzmann syn. (mucocutaneous bleeding) Scabies (burrows, inflamed skin) Henoch-Schoenlein syn. (abdominal pain, excess Human papilloma virus infection (warts) bleeding) Oestrogen deficiency (postmenopause, Waterhouse-Friderichsen syn. (petechiae, pallor) postoophorectomy) See also Bleeding, Excessive; Ecchymosis; Hess Diabetes mellitus (polyuria, polydipsia) Test Depression (poor sleep pattern, loss of interest) Lichen sclerosis (burning, fissures) Autoimmune diseases Pustules Lichen simplex chronicus (hyperkeratosis) Elevated lesions filled with purulent fluid Vulval carcinoma (induration, erythema) Acne (comedones, erythema) Trichomoniasis (yellow vaginal discharge, smell) Rosacea (face, telangiectasia, chronic) Genital herpes (vesicles or ulcers, pain) Folliculitis (hairy areas, chronic) Burning vulva syn. Chickenpox (itch, varying stages, central Contraceptive foam or cream sensitivity distribution) Herpes zoster and Herpes simplex Smallpox (historic only) Purpura and Petechiae Impetigo (crusts, erythema, itch) Cutaneous haemorrhages Melioidosis (cough, chest pain) Haematological Chancroid (sexually transmitted, ulcerates, painful) Generalised pustular psoriasis of pregnancy

10 A RATIONALE FOR RASHES Red Skin Sore See Erythema; Facial Erythema See Pustules; Ulcer

Ring Rash Spider Naevi See Annular Rash (Telangiectasia) Exp: Skin area where several capillaries can be seen radiating from a central point Rope Sign Int: (+) Cirrhosis of liver, thyrotoxicosis, Exp: Linear cords extending from the upper back rheumatoid arthritis, pregnancy, sun to the axilla damaged skin, irradiation, carcinoid syn., Int: Rheumatoid arthritis CREST syn., Louis-Bar syn., Rendu-Osler- Phys: Histological granulomas Weber syn., Rothmund-Thomson syn., systemic sclerosis, acute alcoholic and viral hepatitis, hereditary tendency

Rumpel-Leede Sign Exp: Distal shower of petechiae that occurs immediately after the release of pressure Stretch marks from a tourniquet or sphygmomanometer See Striae applied to an arm or leg. Int: Sign of disorders associated with capillary fragility. Striae (Stetch Marks) Band, streak or strip in skin Scaly Scalp Obesity Pregnancy (striae gravidarum on abdomen) Dandruff (loose, grey scales) Cushing syn. (obese, ecchymoses) Seborrhoeic dermatitis (fungal cause, inflamed Nephrotic syn. (ascites, oedema) scalp) Pituitary malfunction Eczema (widespread, marked erythema, fine white scale) Neurodermatitis (thick crusts, erythema) Psoriasis (erythema, firmly adherent scale, nail Target Lesions changes) Exp: Round, erythematous macule that becomes Pityriasis amiantacea (very thick plaque, localised) papular, enlarges and develops concentric Tinea capitis (slightly pruritic, fractured hairs) rings of colour to resemble a target. Centre SLE (plaques, scarring) of lesion may blister, erode and crust. May Kerion (pustules, crusts) become pigmented during resolution See also Dry Skin; Ichthyosis Int: (+) Erythema multiforme Phys: Precursor target lesion often not identified as erythema multiforme until widespread Scalp Dry lesions erupt See Scaly Scalp

Telangiectasia Sister Mary Joseph's Nodule See Spider Naevi Exp: Raised umbilical nodule, often erythematous and painless Int: (+) Disseminated intra–abdominal malignancy (eg. ovarian or gastric Thick Skin carcinoma) Sun exposure Phys: Retrograde lymphatic spread of carcinoma Scleroderma (arthritis, Raynaud's phenomenon) to form an umbilical deposit Neurodermatitis (itch, papules) Leprosy Icthyosis (scales, dry)

11 A RATIONALE FOR RASHES Lichen sclerosis Malignant melanoma (not always black) Porphyria cutanea tarda Other malignancies Eosinophilia-myalgia syn. (muscle pain, cough) Psychiatric disturbances (self mutilation) Neu-Lexova syn. (nose and eyelid abnormalities) Coagulation disorders Ichthyosiform erythroderma (infant, bullae) TB (symptoms vary with organs involved) Buerger's disease (smoker) Rheumatoid arthritis Thin Skin Syphilitic gummata (sexually transmitted, painless, Aging adenitis) Cushing syn. (obese, striae, moon face) Chancroid (sexually transmitted, painful) Ehlers-Danlos syn. (joint pseudotumours) Tularaemia (fever, adenitis, headache) Fröhlich syn. (late puberty, fine hair) Granuloma inguinale (large, painless, sexually Goltz syn. (scalp, thighs, iliac crests) transmitted) Topical or systemic steroids Lymphogranuloma venereum (adenitis, prostatitis) Scars Behçet syn. (uveitis, arthritis, convulsions) Postphlebitic syn. (stasis dermatitis, leg oedema) Gouty tophus Sickle cell anaemia (Negro) Third Eyelid of Morgan-Denny Hereditary spherocytosis Exp: Extra fold of skin above upper eyelid Leprosy Int: (+) Atopic eczema of eyelid, allergic Cutaneous leishmaniasis conjunctivitis, other chronic irritating Tabes dorsalis conditions of eye Yaws (adenitis, painless, poor hygiene) Phys: Caused by chronic rubbing of eye. More See also Skin Lesion Associated Syndromes common in children

Tin Tack Sign Umbilical Bruising Exp: Appearance of small horny plugs attached See Cullen's Sign to the undersurface of the scale removed from the affected site. Int: Important clinical feature in discoid lupus Vesicules erythematosus. Well defined small collections of fluid Insect and arachnid bites Burns Ugly Duckling Sign Herpes zoster and Herpes simplex Exp: A naevus that doesnʼt resemble its brother Chickenpox (fever, malaise, different stages) naevi. Contact and atopic dermatitis Int: Likely to be malignant melanoma. Hand-foot-mouth disease (fever, irritable, child) Molluscum contagiosum (central umbilication) Scabies (burrows, itch) Dermatitis herpetiformis (erythema, bullae, crops) Ulcer Vaccinia (secondary to vaccination, umbilicated Trauma and chronic pressure (eg. bed sore) vesicles) Stasis dermatitis (erythema, pruritus, oedema) Drug reaction (eg. tetracyclines, cotrimoxazole) Decubitus ulcer (elderly or debilitated) Ramsay Hunt syn. (shingles) Squamous cell carcinoma (red, hard, scales) Anthrax (oedema, sloughs) Basal cell carcinoma (telangiectasia, pearly edge) Septicaemia Varicose veins (pain and oedema of legs) Porphyria Diabetes mellitus (poor circulation) Dracunculiasis (west Africa) Cellulitis or erysipelas See also Bullous rash; Pustules Venous thrombosis (leg, tender vein)

Venous or arterial insufficiency

Polyarteritis nodosa (nodules, arthritis, fever) Peripheral neuropathy Chilblains and frostbite

12 A RATIONALE FOR RASHES V Sign Int: (+) Primary biliary cirrhosis, elderly, Exp: Photosensitivity is prominent in the ʻVʼ of the hyperlipidaemia, cholestasis neck and chest. See also Xanthomatosis Int: Dermatomyositis

Xanthomatosis Vulval Itch Exp: Cluster of pale yellow papules on a red See Pruritus Vulvae patch of skin, often on buttocks Int: (+) Hypertriglyceridaemia, other hyperlipidaemias, diabetes mellitus, biliary cirrhosis, cholestasis White Skin Phys: Deposition of excess circulating lipids in See Depigmented Skin; Pallor skin See also Arcus senilis

Xanthelasma (Xantheloma Palpebrarum) Yellow Skin Exp: Yellow-brown nodules in soft tissues around See Jaundice eye

13 A RATIONALE FOR RASHES

Section Three

DERMATOLOGICAL CONDITIONS

Many of the following images are © DermAtlas; http://www.DermAtlas.org and are used in this context as teaching aids as approved by their copyright.

1 A RATIONALE FOR RASHES DERMATOLOGICAL CONDITIONS

Common diseases that cause rashes

ACANTHOSIS NIGRICANS Acanthosis nigricans is a skin condition of the neck, groin, palms and armpits that appears in four forms - true benign, benign, malignant and pseudo. All forms cause thick, ridged skin covered in multiple dark brown or black small polyps, giving the skin a velvety appearance. The diagnosis is confirmed by a skin biopsy. True benign acanthosis nigicans is an inherited trait that often runs in families, starts in childhood, is more common in girls and worsens with puberty. There is no specific treatment, but it often settles in early adult life. Benign acanthosis nigricans is the mildest form and is often associated with hormonal abnormalities in Cushing syndrome, pituitary gland disorders or polycystic ovaries and develops in late childhood or early adult life. Treatment of the underlying hormonal imbalance is necessary. Malignant acanthosis nigricans is a reaction to cancer in other parts of the body (eg. stomach, breast, lung) and starts in late life. It is the most severe form, and requires treatment of the underlying cancer. Pseudo acanthosis nigricans occurs in obese women who have a dark complexion. Weight loss is the only treatment. See also DOWLING-DEGOS DISEASE; LENTIGO

ACNE Acne, spots, pimples, zits. It doesnʼt matter what they are called, nobody likes to have them, or look at them. Acne can vary from the annual spot, to a severe disease that may cause both skin and psychological scarring. It is generally a curse of teenage years, but it may strike later in life too, particularly in women. Acne is usually more severe in teenage males, but starts earlier in females. Acne affects Caucasians (whites) more than Negroes or Chinese races. The face, upper chest, upper back and neck are most commonly affected. Acne vulgaris is a severe form that almost invariably results in scarring of the face, back and chest, while affects mainly the buttocks and chest and causes skin abscesses and severe inflammation.

2 A RATIONALE FOR RASHES Pimples are due to a blockage in the outflow of oil (known as sebum) from the thousands of tiny oil glands in the skin. This blockage can in turn be caused by dirt (uncommon in our super-clean society), dead skin left behind during the normal regular regeneration of the skin surface, or a thickening and excess production of the oil itself. Once the opening of the oil duct becomes blocked, the gland becomes dilated with the thick oil, then inflamed, and eventually infected. The result is a white head, with the surrounding red area of infection. Eventually this bursts, sometimes leaving a scar. The most common cause of acne is the thickening of sebum caused by the hormonal changes of puberty. The severity of acne in a teenager will depend upon the degree of acne suffered by his/her parents, as this is a strongly inherited characteristic. Pregnancy, premenstrual syndrome (hormonal changes before a period), menopause and the oral contraceptive pill may all cause pimples in this way. Stress in the patient, either psychological or caused by disease, may make pimples worsen. A simple cold, or the onset of exams may see the number of spots increase dramatically. Pressure from spectacles on the bridge of the nose or tight collars, increases in skin humidity from a fringe of hair or nylon clothing, and excessive use of cosmetics that further block the oil duct openings, can all cause deterioration in a personʼs acne. Some chemicals or oils that a patient may encounter in the work place are also possible causes.

Treatment of asthma or other diseases with steroids (eg. prednisone) may worsen acne. A tumour of the pituitary gland under the brain, or the adrenal glands on each kidney, may produce higher than normal levels of steroids to mimic this problem. The severity of acne also depends on hereditary factors. There is no evidence that diet, chocolate, vitamins or herbs have any effect on acne. A number of conditions can cause a rash that looks like acne, but is not. The most common of these are rosacea and folliculitis barbae (ingrown facial hairs caused by blunt blade when shaving or other skin damage). Rosacea is a skin disease of the face, found most commonly in middle-aged women, that causes excessive intermittent flushing of the face, then sores develop that are similar to a severe case of pimples.

3 A RATIONALE FOR RASHES There is no evidence that diet, vitamins or other herbs have any effect on pimples. A small number of sufferers may find that one particular food causes a fresh crop of spots, but these people usually quickly realise this and avoid the offending substance. The first step in treatment involves keeping the skin clean with a mild soap and face cloth, and simple oil drying, antiseptic and cleansing creams or lotions. Further treatment involves combinations of antibiotics (eg. tetracyclines) that may be taken in the short term for acute flare ups or in the long term to prevent acne, skin lotions or creams containing antibiotics and/or steroids, and changing a woman's hormonal balance by putting her on the oral contraceptive pill or using other hormones. In rare cases it is necessary to take the very potent medication isotretinoin (which can cause birth deformities if used during pregnancy), give steroid injections (eg. triamcinolone) into the skin around particularly bad eruptions, and abrade away the skin around scars. The treatment of adults with maturity onset acne is more difficult than juvenile acne. Acne may cause both skin and psychological scarring. Picking acne spots can cause serious secondary bacterial infections that can spread deep into the skin (cellulitis). Although acne cannot be cured, in the majority of cases reasonable control can be achieved. It eventually settles with age. See also CHLORACNE

ACNE ATROPHICA The small pits and scars left behind after an earlier time of life when the patient suffered from severe acne is referred to as acne atrophica. See also ACNE

ACNE CONGLOBATA See ACNE

ACNE KELOIDALIS NUCHAE is a skin condition of the back of the neck that occurs mainly in curly haired Africans, particularly in the Caribbean. It is caused by the in-growth of hairs due to dermatitis and irritation in the area. Round bumps appear from hair follicles on the hairline at the nape of the neck, become pustular, scar and form a persistent hard lump. The scars may form keloids and enlarge significantly to form a hard raised ridge around the hairline. Patients should avoid any irritation of the area from clothing collars and avoid scratching. Steroid creams and injections into the affected skin may be helpful, and antibiotic tablets can be used for any secondary bacterial infection. In severe cases, isotretinoin tablets, radiotherapy, and surgical excision of the affected area of skin may be used. Unfortunately it often persists and is difficult to treat. See also KELOID

ACNE NECROTICA MILIARIS See SCALP FOLLICULITIS

ACNE NEONATORUM Acne neonatorum is a temporary and benign form of acne that occurs on the face of newborn infants due to the immaturity of the sebaceous (oil) glands in their skin. It settles within a month or two of birth with minimal or no treatment.

4 A RATIONALE FOR RASHES See also SEBACEOUS GLANDS; SEBORRHOEIC ECZEMA

ACNE ROSACEA See ROSACEA

ACNE VULGARIS See ACNE

ACRODERMATITIS ENTEROPATHICA Acrodermatitis enteropathica is a disease of zinc deficiency that starts in babies within a few days or weeks of birth. The onset is delayed in breast fed babies. The cause is a genetic disorder that prevents absorption of zinc from food. Affected babies have dry, scaly, irritated, red patches on the skin around the genitals and anus, spreading to the scalp, hands, feet and trunk. Other symptoms include hair loss, premature greying of hair, the nails are ridged and may be lost, a red tongue, mouth ulcers, light sensitive eyes, irritable mood and failure to grow. Infection of damaged skin and mouth ulcers with bacteria or fungi may be complications. Blood tests show the anaemia and low zinc levels. Zinc supplements are given by tablet or injection, and although there is no cure, it can be well controlled by appropriate treatment.

ACRODERMATITIS PARANEOPLASTICA See BAZEK SYNDROME

ACRODYNIA Acrodynia is a disease of children that is associated with mercury poisoning. It causes an itchy generalised rash, swelling of the skin, bright pink colouration of the hands, feet and cheeks, swollen painful hands and feet, excessive sweating, diarrhoea and alternating irritability and lethargy.

ACROKERATOSIS VERRUCIFORMIS The inherited condition acrokeratosis verruciformis causes flat wart-like growths on the back of the hands and the tops of the feet that sometimes spread to the forearms, shins and knees. They are harmless but unsightly.

ACTINIC KERATOSIS See HYPERKERATOSIS

5 A RATIONALE FOR RASHES ADDISON DISEASE Addison disease is also known as adrenocortical Insufficiency and chronic hypoadrenocorticism. It is a rare underactivity of the outer layer (cortex) of the adrenal glands that sit on top of each kidney, and produce hormones (chemical messengers) such as cortisone that control the levels of vital elements in the body and regulate the breakdown of food. In most cases, the reason for adrenal gland failure is unknown, but tuberculosis is a possible cause. The symptoms include weakness, lack of appetite, diarrhoea and vomiting, skin pigmentation, mental instability, low blood pressure, loss of body hair and absence of sweating. Complications include diabetes, thyroid disease, anaemia, and eventual death. A sudden onset of disease is known as an Addisonian or adrenal crisis, which may be rapidly fatal. It is diagnosed by special blood tests that measure the body's response to stimulation of the adrenal gland (synacthen stimulation test). Treatment involves a combination of medications (eg. steroids such as cortisone) to replace the missing hormones, and dosages vary greatly from one patient to another. Frequent small meals high in carbohydrate and protein are eaten, and infections must be treated rapidly. Patients must carry an emergency supply of injectable cortisone with them at all times. Treatment can give most patients a long and useful life, but they cannot react to stress (both physical and mental) adequately, and additional treatment must be given in these situations. The ultimate outcome depends greatly on the patient's ability to strictly follow all treatment regimes. The condition is named after the English physician Thomas Addison (1793-1860).

ALBINISM

Albinism is an uncommon condition in which there is a total lack of pigment in the skin and eyes. The skin is white, regardless of the race of the parents, and the iris (coloured part of the eyes) is pink. Both eyes and skin are very susceptible to damage by sunlight. Albinism is a

6 A RATIONALE FOR RASHES defect of genes that occurs from the moment of conception, but it is not inherited, and an albino person will usually have normally pigmented children. There is no treatment for the condition other than carefully protecting skin and eyes from the sun. Albinism occurs in 1:36,000 Caucasians, 1:10,000 Negroes, and the highest incidence in the world is 1:200 in the Hopi Indians of Arizona. Chediak-Higashi syndrome is an inherited condition that can pass to subsequent generations. It causes recurrent skin and lung infections, partial albinism and sometimes liver, spleen and lung damage. See also CHEDIAK-HIGASHI SYNDROME

ALBINO See ALBINISM

ALOPECIA Alopecia is a loss of hair from anywhere on the body. See also ALOPECIA AREATA; ALOPECIA TOTALIS; BALD

ALOPECIA AREATA Alopecia areata is a common cause of patchy hair loss. There is a family history in about 20% of patients, or fungal infections and drugs used to treat cancer may be responsible, but in most cases no specific cause can be found. Stress and anxiety are not usually a cause. Alopecia areata is different to baldness in that it can occur at any age, in either sex, in any race, and more common under 25 years of age. Patients have a sudden loss of hair in a well-defined patch on the scalp or other areas of body hair (eg. pubic area, beard, eyebrows), and a bare patch 2 cm or more across may be present before it is noticed. The hairless area may slowly extend for several weeks before stabilising. Several spots may occur simultaneously, and may merge together as they enlarge. If the entire body is affected, the disease is called alopecia totalis, which is not a different disease, just a severe case of alopecia areata. Patients need to be careful to avoid sunburn to exposed scalp skin. Treatment involves strong steroid creams, injections of steroids into the affected area, and irritant lotions. In 90% of patients, regrowth of hair eventually recurs, although the new hair may be totally white and it may take many months or years. The further the bare patch is from the top of the scalp, the slower and less likely the regrowth of hair. It is rare to recover from total hair loss. See also ALOPECIA TOTALIS; BALD

7 A RATIONALE FOR RASHES ALOPECIA TOTALIS Alopecia totalis (or ) is the rare total loss of all body hair, including the scalp, beard, eyebrows, armpit and pubic hair. The fine hair on the skin elsewhere on the body may also disappear. The recovery rate is far lower than in alopecia areata, but treatment is the same. See also ALOPECIA AREATA;

ALOPECIA UNIVERSALIS See ALOPECIA TOTALIS

ANDROGENIC ALOPECIA See BALD

ANETODERMA A looseness of soft skin in a localised area caused by damage to the elastin fibres in the skin is called anetoderma. Surgically removing some of the affected skin may improve the appearance of the affected area of skin. See also ELASTOSIS

ANGIOKERATOMA CORPORIS DIFFUSUM See FABRY DISEASE

ANGIOKERATOMA OF FORDYCE The angiokeratoma of Fordyce is an uncommon congenital skin condition of the genitals. Those affected have a large number of small dark red, raised, rounded lumps on the scrotum and penis of males and the vulva of females. It is diagnosed by a biopsy of a skin lump. No treatment is normally necessary, but the lumps can be treated by electric diathermy, freezing (cryotherapy), laser or excision if necessary. Although an annoying condition, it is not serious. See also ANGIOKERATOMA OF MIBELLI; FABRY DISEASE; HAEMANGIOMA

ANGIOKERATOMA OF MIBELLI Angiokeratoma of Mibelli is an inherited skin condition which has two forms. In men the elbows, knees and backs of the hands are affected. It is much rarer in females where the genitals of young women are involved. Pink to red raised lumps appear on the areas of affected skin. The condition is diagnosed by a biopsy of a skin lump. No treatment is normally necessary, but the lumps can be treated by electric diathermy, freezing (cryotherapy), laser or excision if necessary. Although an annoying condition, it is not serious. See also ANGIOKERATOMA OF FORDYCE; HAEMANGIOMA; FABRY DISEASE

ANGIOKERATOSIS An angiokeratosis is a minor unsightly skin condition that is not contagious. Dilated blood vessels form red lumps on the skin that are then covered by a fine scale. There may be one or two present or several dozen. They cause no specific problems other than bleeding excessively if damaged and are easily removed by diathermy (burning under a local

8 A RATIONALE FOR RASHES anaesthetic), cryotherapy (freezing) or laser coagulation. They usually persist long term, but sometimes resolve spontaneously. See also HAEMANGIOMA; HYPERKERATOSIS

ANGULAR CHEILITIS See CHEILITIS

ANTHRAX Anthrax is a bacterial skin, lung or intestinal infection that usually occurs in farmers, meat workers, veterinarians and others who come into close contact with animals. Infection of humans is uncommon.

The bacterium Bacillus anthracis which is found in cattle, horses, sheep, goats and pigs, is responsible. It may be caught by bacteria entering the body through scratches and grazes, or rarely by swallowing or inhalation into the lungs. Anthrax spores may remain inactive in the soil for decades, but it cannot be transmitted from one person to another. The natural incidence in western countries is about one in 100 million people every year. There are three different types of anthrax infection in humans :- - Cutaneous anthrax - A sore appears at the site of entry (which may be in the mouth), then nearby lymph nodes become inflamed, a fever develops, followed by nausea, vomiting, headaches and collapse. - Inhalation anthrax (woolsorterʼs disease) - After an incubation period of one to five days the patient develops flu like symptoms with muscle aches and fever. This is followed two to five days later by difficulty in breathing, sweating, fever, rapid pulse and blue tinged skin. The

9 A RATIONALE FOR RASHES patient collapses quickly with a severe form of pneumonia results. It may also spread into the bloodstream. - Gastrointestinal anthrax - Incubation period of one or two days, then nausea, vomiting, fever, loss of appetite, belly pain and bloody diarrhoea develop. The diagnosis is confirmed by microscopic examination of smears from the skin sores, or from sputum samples. Specific blood tests may also be positive. Treatment involves antibiotics such as ciprofloxacin or doxycycline by mouth or injection. A vaccine is available, but is only used by those who are at high risk because of their involvement with infected animals, and numerous boosters are required. Treatment clears the skin and gastrointestinal forms of the disease effectively in most cases, but anthrax pneumonia is very serious, and a significant proportion of these patients die.

ARIBOFLAVINOSIS Ariboflavinosis is caused by a lack of riboflavine (vitamin B2). Patients develop sores at the corners of their mouth, on the lips and around the eyes and nostrils. If left untreated, there may be damage to the eyes and vision and a form of seborrhoeic eczema occurs.

ASTEATOTIC ECZEMA Asteatotic dermatitis (eczema craquelé) is a common form of dermatitis, usually affecting older people who remain indoors in low humidity and with excess heating during cold weather. The drying of skin from excessive bathing and soap use is also a factor. Patients develop dry, itchy, cracked, scaling, red skin, usually on the thighs and arms, but sometimes on the hands and trunk. If scratched excessively there may be permanent scarring and damage to the skin. The diagnosis can be confirmed by biopsy if necessary. Patients should avoid soap, shower instead of bath, humidify the air in the home, and use moisturising creams and medium strength steroid creams. Resolution of the rash is slow initially, but cure is possible with good compliance with treatment. See also ECZEMA

ASYMMETRIC PERIFLEXURAL EXANTHEM OF CHILDHOOD See LATEROTHORACIC EXANTHEM

ATHLETEʼS FOOT Athleteʼs foot a fungal infection of the toes technically known as tinea pedis. The responsible fungi can be found everywhere in the environment in the form of hardy microscopic spores that may survive for decades before being picked up and starting an infection. They multiply in the moist area between the toes, particularly in athletes who sweat and wear close fitting shoes that lead to the ideal warm, damp environment favoured by the fungi. A secondary bacterial infection of the damaged skin may occur. The infection causes sore, red, cracks in the skin under and between the toes. Swabs may be taken to identify the responsible fungus in resistant cases.

10 A RATIONALE FOR RASHES Treatment involves antifungal creams, lotions and powders, but in severe cases, antifungal tablets may be taken. Most patients respond well to treatment, but the infection often recurs, particularly if treatment is ceased too soon. See also PITTED KERATOLYSIS; TINEA MANUM

ATOPIC DERMATITIS See ATOPIC ECZEMA

ATOPIC ECZEMA Atopic eczema or dermatitis is an abnormal reaction of skin to an irritating substance. The rash may be triggered by changes in climate or diet, stress or fibres in clothing, and tends to occur in areas where the skin folds in upon itself (eg. groin, arm pits, inside elbows, eyelids). It is more common in winter and urban areas, has a peak incidence between 6 and 12 months of age, and there is an hereditary tendency. Up to a third of the population are atopic, but only 5% of children will develop this skin condition.

Patients develop an extremely itchy rash, but any blisters that form are rapidly destroyed by scratching which changes the normal appearance of the eczema, so that it appears as red, scaly, grazed skin that may be weeping because of a secondary bacterial infection. With repeated irritation, the skin may become hard, thickened, and pebbly. In most cases, the responsible substance cannot be identified, but skin and blood tests can be performed to tell if a person has an atopic tendency. Soothing moisturising creams and steroid creams are prescribed to reduce inflammation and itch, and soap substitutes are used to prevent drying the skin. In severe cases, steroid

11 A RATIONALE FOR RASHES and antihistamine tablets are necessary. There is no cure, but effective control can be obtained in the most cases. The majority of children grow out of the condition. See also ALLERGIC ECZEMA; DERMATITIS; ECZEMA; WINTER ITCH

AUTOSENSITISATION DERMATITIS Autosensitisation dermatitis is a reaction in the skin on one part of the body (often the trunk) in response to a form of dermatitis on another area of the body (often the limbs). The cause is a substance (cytokine) released from the initially affected area of dermatitis that travels through the blood and sensitises skin in other areas of the body so that a new rash or skin irritation, that may have a totally different appearance, develops. This effect is more likely if the initial rash is very itchy and repeatedly scratched or rubbed by the patient. The symptoms include itchy, red, scattered, raised or flat spots on the skin, often affecting the trunk. It usually spreads slowly and steadily. There are no specific tests and the diagnosis is difficult, often not becoming apparent until the autosensitisation rash settles after the initial form of dermatitis is treated. Creams or tablets containing are the main treatments and the prognosis is good. See also DERMATITIS

BAIRNSDALE ULCER A Bairnsdale ulcer (Buruli ulcer) is an uncommon skin infection that occurs in the tropics and affects mainly children and young adults in Australia and Africa. The cause is an infection of the skin with the bacteria Mycobacterium ulcerans. It may develop from a prick or cut from plants in a moist environment, but symptoms may not appear until three months after the initial injury.

Those affected develop a small painless nodule that breaks down into a large to huge, deep, pain free skin ulcer. Swabs or a biopsy from the ulcer will demonstrate the responsible bacteria. A secondary bacterial or fungal infection of the ulcer is possible. Antibiotics are often used in treatment, but the response is poor. If possible, the ulcer is widely cut out and the wound sutured. Hot packs may speed the healing. Untreated the ulcer persists for months or years before healing spontaneously and significant scarring may occur. See also FISH TANK GRANULOMA

12 A RATIONALE FOR RASHES BALD By far the most common form of baldness is that caused by hereditary tendencies in men (androgenic alopecia). If your father or grandfather was bald, you have a good chance of developing the same problem. Baldness is a gender linked genetic condition that is very rare in women, but passes through the female line to men in later generations. There are no cures available, and none are likely for some time to come. There are many other causes for patchy or diffuse hair loss including ageing, skin diseases, stress, the menopause, lack of iron or zinc, an under active thyroid gland, drugs (particularly those used to treat cancer) and a dozen or more rare diseases. Some people, particularly young women, develop patches of baldness that are scattered across their scalp. This condition is known as alopecia, and is very difficult to treat. Many cases settle by themselves after some months or years, but most require prolonged care by a dermatologist. Almost always male pattern baldness commences with gradual hair loss, starting at the front of the scalp on either side, or in a circular area on top. It is usually accompanied by excess hair on the body due to higher levels of testosterone. The connection between baldness and sexual potency is unproved. Minoxidil or finasteride tablets, or minoxidil scalp lotion, may slow or stop hair loss, but the only real treatments are hair transplants, scalp flap rotation or a wig. See also ALOPECIA AREATA; TELOGEN EFFLUVIUM

BARBERʼS ITCH Sycosis barbae is the technical term for barberʼs itch, an inflammation and infection of the hair follicles on a manʼs face caused by aggressive shaving. The treatment involves infrequent light shaves, and antibiotics tablets and cream. See also FOLLICULITIS

BASAL CELL CARCINOMA Also known as a rodent ulcer, these shiny, rounded lumps are a cancer of the deeper (basal) layers of the skin. Basal cell carcinomas (BCC) are caused by prolonged exposure to sunlight, and occur most commonly on the face and back. They are not as serious as the more superficial squamous cell carcinomas (SCC), but occur at an earlier age than SCCs, although rarely before 25 years.

BCCs often change in size and colour, or they may present as an ulcer that fails to heal. The ulcer often has a pearly, rounded edge.

13 A RATIONALE FOR RASHES Whenever a BCC is suspected, it should be removed surgically. The specimen is then sent to a pathologist for examination to ensure that the diagnosis is correct, and that all the tumour has been removed. Alternate treatments in more difficult areas include anticancer creams, irradiation and diathermy. If correctly treated, they can be completely healed, but if left until large, significant plastic surgery may be necessary as they will slowly invade deeper tissues, and after many years may cause death. See also GORLIN GOLTZ SYNDROME; SKIN CANCER

BASAL CELL CARCINOMA NAEVUS SYNDROME See GORLIN GOLTZ SYNDROME

BASAL CELL PAPILLOMAS See SEBORRHOEIC KERATOSES

BAZEK SYNDROME Bazek syndrome (acrodermatitis paraneoplastica or paraneoplastic acrokeratosis) is a rare complication of cancer in the mouth, throat or intestine. Patients develop finger and toenail destruction and eczema on the ears, hands, cheeks and knees. The worsening eczema and nail damage does not respond to treatment or recurs rapidly after treatment. The diagnosis is not usually made until the symptoms of cancer become apparent. Treatment involves control of tissue damage with steroid and antibiotic cream while treating the underlying cancer appropriately. The prognosis depends on the cancer.

BAZIN DISEASE See ERYTHEMA INDURATUM

BCC See BASAL CELL CARCINOMA

BECKER NAEVUS See NAEVUS

BED SORE A bed sore (pressure ulcer) forms in skin on which the body rests and so most commonly affects areas the heels, buttocks, back of the head and the skin over the lower part of the backbone. If the blood supply to the skin is significantly reduced, the affected skin dies. When pressure is applied to the skin for many hours without relief, the area will break down into an ulcer. Elderly, infirm, paralysed or unconscious patients who spend long periods in bed, or sitting, may not have the ability to move themselves or the sensation necessary to prompt movement, so that a particular area of skin may carry a great deal of the body's weight for a prolonged period of time.

14 A RATIONALE FOR RASHES Prevention involves moving patient regularly so that no area bears pressure for a prolonged period of time. Sheep skins, ripple mattresses, water beds and other devices are placed under affected patients to spread their weight as much as possible. Once present they are often difficult to heal, but may be cured by avoidance of any further pressure to the area, antibiotic dressings, special absorbent bandages or dressings, and, in resistant cases, surgical treatment to cover the area with a skin graft. These sores may become infected very easily and require antibiotic treatment. Once affected, the same area is very susceptible to future damage, and extra precautions must be taken to avoid their recurrence. See also TROPHIC ULCER

BEJEL Bejel is a form of syphilis caused by the spirochete bacteria Treponema pallidum that is transmitted by close personal contact, but without sexual contact, in the same way as yaws and pinta. It tends to occur in children with very poor hygiene in the Middle East and is characterised by sores around the mouth, followed by a pimply rash on the rest of the body. Rarely the condition can develop a third stage similar to syphilis. Penicillin cures the infection. See also PINTA; SYPHILIS; YAWS

BENIGN FAMILIAL CHRONIC PEMPHIGUS See HAILEY-HAILEY DISEASE

BENIGN JUVENILE MELANOMA See SPITZ NAEVUS

BENIGN LYMPHOEPITHELIAL CONDITION See MIKULICZ DISEASE

BERNARD-SOULIER SYNDROME The Bernard-Soulier syndrome is an inherited defect of platelets (blood cells essential for clotting), which fail to stick together to form a clot. Excessive bleeding occurs, particularly from mouth and nose. Bruises and red spots and patches under skin, particularly on feet. The condition is aggravated by aspirin. Blood tests on platelet function and bleeding time are diagnostic. Blood transfusions on a regular basis are the only treatment for this lifelong defect that may cause significant disability.

BIRT-HOGG-DUBE SYNDROME The Birt-Hogg-Dube syndrome is a rare skin disorder that is inherited from one parent. The symptoms include multiple lumps in the skin arising from hair follicles on the head, chest, back and arms that develop in adult life. It is often accompanied by kidney cancer (Wilms tumour) and other associated features may include lung cysts, kidney cysts and pneumothorax. A biopsy of a skin lump is diagnostic. The disfiguring skin lumps can be excised and appropriate treatment is given for the kidney cancer, but there is no cure, and the prognosis depends on the management of kidney cancer and other complications.

15 A RATIONALE FOR RASHES BLOCH-SULZBERGER SYNDROME The Bloch-Sulzberger syndrome (incontinentia pigmenti) is a rare, congenital skin disease of newborn infants that affects females only as males die as a foetus and are passed as a miscarriage. It is characterised by lines of grouped blisters on the skin that become warty then subside to leave pigmented streaks. It may also cause brain, dental and eye abnormalities. It is incurable and no treatment is available.

BLOOD BLISTER A blood blister is merely a blister formed by another process (eg. friction on the skin) that has filled with blood due to damage to the blood vessels at the base of the blister. It is no more sinister than a normal blister, but has merely damaged deeper layers of tissue. The blister should be lanced with a sterile blade or a needle that has been sterilised in a flame, so that the blood can be squeezed out as this will allow it to heal faster. Blood blisters are more likely to become infected than a normal blister, and if this occurs antibiotics will be necessary.

BLOOM SYNDROME Bloom syndrome is an extremely rare familial genetic abnormality that occurs in Jews. These children are small at birth, have light sensitive skin, underdeveloped cheeks, leukaemia and other malignant diseases. Some have spider naevi (blood vessels) on the facial skin. People who are carriers of the gene, but do not suffer from the syndrome, are more likely to develop cancers. No treatment is available and death in adolescence is common. See also RILEY-DAY SYNDROME

BLUE NAEVUS A blue naevus is a benign (non- cancerous) blue coloured mole that may be found anywhere on the body, and usually appears on older children and teenagers, but may develop at any age. They are caused by overproduction of pigment in the deeper layers of the skin by melanocytes (skin cells that are responsible for pigment production). No treatment is necessary unless the mole is cosmetically unacceptable, when it can be surgically excised. See also BLUE RUBBER BLEB NAEVUS SYNDROME

16 A RATIONALE FOR RASHES BLUE RUBBER BLEB NAEVUS SYNDROME Strange as it may sound, the blue rubber bleb naevus syndrome is a real medical condition. It is a rare disorder of small blood vessels in skin and bowel caused by the congenital overgrowth of capillaries. Patients have multiple blue tinged rubbery growths (blebs or haemangiomas) in the skin and small bowel that bleed easily. Blebs may also develop in the liver, spleen and brain. Blood can be found in the faeces, and blood tests show anaemia and low levels of iron. Surgical removal of the affected gut and skin blebs, iron supplements and blood transfusions are the only treatments as there is no cure. See also BLUE NAEVUS; HAEMANGIOMA

BOIL A boil (or furuncle) is a small superficial abscess that develops when a hair follicle becomes infected by bacteria. As a result, people who are very hairy will develop more boils. Commonly affected areas are the armpits, buttocks and groin. Patients develop an acutely painful, red and tender lump, which gradually enlarges, causing more and more pain until it ruptures, discharging pus. Treatment involves antibiotic tablets, applying antiseptic or antibiotic ointment to the boil, and when pus is obviously present, lancing the boil with a scalpel or needle. Repeated attacks may require long-term antibiotic treatment, antiseptic soaps and antiseptic lotions applied regularly. In some cases infection can spread to cause boils in other areas, or in severe cases, the infection may enter the blood stream to cause septicaemia. Boils should never be squeezed, as the pus they contain may rupture internally, and spread through the blood stream to the brain and other vital organs. A carbuncle is several boils in a limited area that join together to form an interconnecting infected mass. It usually degenerates into an abscess. See also FURUNCULOSIS; SUPPRAVITA

BOUCHARD NODES Bouchard nodes are bony lumps on the top of the finger joints between the first and second finger bones (proximal interphalangeal joints). They are a sign of severe rheumatoid arthritis.

BRACHIORADIALIS PRURITUS See ITCHY UPPER ARM SYNDROME

BULLOUS IMPETIGO See SCALDED SKIN SYNDROME

BULLOUS PEMPHIGOID See PEMPHIGOID

BUNION Hallux valgus is the technical term for a common bunion. If the big toe is constantly pushed across towards the smaller toes by tight shoes, it may become semi-permanently deformed in this direction. The end of the long bone in the foot behind the toe bones is then able to push against the skin. A protective, fluid-filled sac (a

17 A RATIONALE FOR RASHES bursa) forms between the bone end and the skin and slowly enlarges to form a tender and painful bunion. They usually start in childhood but may not cause significant discomfort until adult life. A number of surgical procedures are available to correct the deformity, but in elderly people it may be preferable for a protective pad to be worn inside soft or especially made shoes.

BURULI ULCER See BAIRNSDALE ULCER

CAFÉ-AU-LAIT SPOTS Café-au-lait (white coffee) spots are multiple light brown spots on the skin. They occur with von Recklinghausen's disease of multiple neurofibromata, pityriasis versicolor, tuberous sclerosis and ageing.

CALCIFYING EPITHELIOMA OF MALHERBE See PILOMATRIXOMA

CALLUS A callus (callosity or keratoma) is an abnormal thickening of skin keratin caused by recurrent injury to, or rubbing. The patient should remove any pressure to the area if possible (eg. correct footwear, protective pads), and can then carefully peel away the layers of keratin with a scalpel or apply salicylic acid ointment. A callus may become painful, and rarely infected, if trimmed excessively. See also CORN

CAMPBELL de MORGAN SPOTS

18 A RATIONALE FOR RASHES Campbell de Morgan spots are also known as cherry angiomas and senile haemangiomas. They are a common skin disorder affecting the trunk of older people caused by overgrowth of blood vessels in the skin. There is a genetic tendency to develop them. Patients develop red to maroon, raised, dome shaped growths on the skin a few millimetres across that steadily increase in number with age. Normally no treatment is necessary, but cautery, laser treatment or surgical excision can be used if cosmetically unacceptable. See also HAEMANGIOMA; VENOUS LAKE

CAPILLARITIS Capillaritis (lichen aureus, Schamberg disease, Majocchiʼs purpura or purpura annularis telangiectodes) is a harmless skin condition caused by leaky capillaries under the skin that become inflamed. Blood passes through small gaps between the cells that make up the capillary walls and tiny red dots appear on the skin. These join together to form a flat red patch, which becomes brown and then slowly fades away over weeks to months. The cause is usually unknown but the condition occasionally arises as a reaction to a medication, a food additive, a viral infection or it may flare after exercise. There are several different types of capillaritis: - Schamberg's disease (progressive pigmented purpura) - most common type. Crops of red-brown flat patches with tiny red spots on their borders appear on the lower legs and other parts of the body. - Gourgerot-Blum disease (pigmented purpuric lichenoid dermatosis) - less common. The patches are thickened and itchy, rather like eczema. - Majocchiʼs purpura (purpura annularis telangiectodes) - dilated capillaries as well as brown patches and red spots. The patches gradually spread outwards. - Lichen aureus - a solitary brown-yellow patch that is very persistent and often overlies a varicose vein. Those affected should discontinue any medication for several months if possible to see if the condition improves, and avoid food preservatives and artificial colouring agents. Steroid creams help itching but rarely clear the capillaritis. If the lower leg is affected, consider wearing compression elastic stockings. There is no cure, but it can disappear within a few weeks, recur from time to time, or persist for years.

CAPILLARY HAEMANGIOMA See STRAWBERRY NAEVUS

CAROTENAEMIA Vitamin A is found in leafy green vegetables, dairy products, liver and yellow coloured foods such as carrots, pumpkin, mangoes, paw paws, oranges and apricots that contain large quantities of a yellow substance known as carotene. Excess levels of carotene and vitamin A (hypervitaminosis A) therefore occur simultaneously in most cases. Carotenaemia is caused by taking excessive amounts of vitamin A tablets or eating large quantities of yellow fruit and vegetables. Huge quantities must be consumed, but patients who develop a craving for one particular type of food can consume sufficient for the symptoms to appear in a few weeks.

19 A RATIONALE FOR RASHES The symptoms may include loss of appetite and weight, yellow colouring of the skin (particularly the palms and soles, but unlike liver diseases, not the whites of the eyes), brittle nails, dry and cracked skin, sore gums, headaches and other more bizarre symptoms. It can cause deformities to the foetus of a pregnant woman, and therefore large doses of vitamin A should be avoided during pregnancy. All liver blood tests remain normal, but yellow palms and soles are diagnostic features. The amount of carotene present in the blood can be measured. The normal range is 0.93 to 3.7 µmol/L. and higher levels are characteristic of carotenaemia. High carotene levels can also occur in patients with an under active thyroid gland (hypothyroidism) or excess fat in blood (hyperlipidaemia), while low levels are possible with tropical sprue or a poor absorption of fat. The only treatment is not eating the offending foods and vitamin supplements. Almost invariably the condition resolves slowly over a few weeks without long-term damage.

CAT SCRATCH DISEASE Cat scratch disease is a curious condition caused by a scratch from a cat claw, often to the face. The bacterium Bartonella henselae, that may be present on cat paws, is responsible. When a person is scratched by a cat, the bacteria enter the damaged tissue. A few days after being scratched, about one third of patients develop a scab-covered sore at the site of the scratch. Between one and three weeks later, a fever and headache occur, and are accompanied by enlarged lymph nodes in the groin and the side of the neck or armpit nearest the scratch. Occasionally the infected nodes develop into an abscess. No specific tests are available to confirm the diagnosis, and blood tests merely show that an infection is present, but not what has caused the infection. No treatment is available or necessary, but sometimes it is necessary to surgically drain an abscess. It usually settles spontaneously within a week or two, but very rarely a form of encephalitis (brain inflammation) and skin rashes may occur.

CAVERNOUS HAEMANGIOMA A cavernous haemangioma is a benign growth that consists of greatly dilated veins that can vary in size from a pinhead to several centimetres across. They most commonly occur on the face, scalp and neck skin of babies, but may also develop internally and not be discovered until they bleed or they are incidentally found during surgery. Cavernous haemangiomas are delicate and bleed very easily if damaged. They may be treated by surgical excision, irradiation, cautery or injecting sclerosing substances to destroy the blood vessels. See also HAEMANGIOMA

CELLULITIS Cellulitis is a bacterial infection of the tissue immediately under the skin that may start from a bite or wound, but sometimes occurs for no apparent reason. The area affected is hot, red, tender, swollen and painful. The infected area slowly spreads, and once the lymphatic system becomes involved, red streaks may run towards the nearest lymph nodes (adenitis), and the patient will develop a fever and become quite ill.

20 A RATIONALE FOR RASHES A swab may be taken from any sore to determine the type of bacteria responsible, and the appropriate antibiotic to treat it is then prescribed. An abscess may develop in the tissue if treatment is delayed, and rarely, the infection may spread to the blood to cause septicaemia. Most cases respond rapidly to antibiotics. See also ERYSIPELAS

CERCARIAL DERMATITIS Cercarial dermatitis (swimmerʼs itch or clam diggerʼs itch) is caused by an infestation of the skin by the larval form (cercaria) of the parasite Schistosoma cercariae, which normally lives in birds and small mammals. It occurs world-wide in salt and fresh water. The parasiteʼs eggs are shed with animal faeces into water, where they hatch, then infect snails, from which they emerge as larvae. The larvae penetrate the skin of humans or other animals. Victims experience a sudden onset of itchy red lumps on the skin at the site(s) of penetration by the larvae. In very sensitive patients, an allergy reaction (hives) can occur on the skin around the lump, or in severe cases may be generalised. The microscopic larvae cannot survive in humans and die just under the skin. Antihistamine tablets and steroid creams may ease itch and skin reaction, but the lumps and sores settle within a week. See also HIVES

CHAGAS DISEASE Chagas disease (American trypanosomiasis) is an infestation by the protozoan (single celled) parasite Trypanosoma cruzi that is widespread in tropical America from Texas to Bolivia. It is transmitted from wild animals to humans by bug bites to the skin or bug faeces in the eye. The disease goes through three stages - acute, latent and chronic. Initially a sore develops on skin at the site of a bite or in the eye, and in many patients, no other symptoms ever occur until after a latent stage lasting 10 to 30 years when a chronic stage with heart disease occurs causing irregular heart rhythm, congestive heart failure, and pulmonary thromboses (blood clots in lung). A minority of patients go through an acute illness, which causes enlarged lymph nodes near the bite, fever, tiredness, headache, and enlarged liver and spleen. Acute heart or brain infection may be rapidly fatal. Long-term infection may cause severe heart disease. The disease is diagnosed by specific blood tests, but may be undetectable in the latent stage. Treatment is generally unsatisfactory. Medications may be tried in the acute stage, but are of no use in the chronic stage. Chagas disease is fatal in 10% of acute illnesses, and death from heart disease may occur in the chronic stage. The condition is named after the Brazilian physician Carlos Chagas (1879-1934).

CHANCRE A chancre is a sore that starts as a small lump (papule) and breaks down into a painless ulcer. The most common cause of a chancre is syphilis, in which the chancre heals after a few weeks without treatment or leaving a scar, but the underlying syphilitic infection progresses in other parts of the body.

21 A RATIONALE FOR RASHES CHANCROID Chancroid is a sexually transmitted infection caused by the bacteria Haemophilus ducreyi, that is rare in developed countries, and more common in the tropics and Asia. Three to five days after sexual contact with a carrier, a sore develops on the penis or vulva, which rapidly breaks down to form a painful ulcer. Several sores and ulcers may be present at the same time. Lymph nodes in the groin then swell up into hard, painful lumps, that may degenerate into an abscess and discharge pus. The patient is feverish and feels ill. Some patients develop a mild form with minimal symptoms, but they can transmit the disease. This is particularly common in women, where the sores may be hidden internally in the vagina. The condition is diagnosed by taking swabs from the sores and identifying the bacteria present in the pus, or skin tests that often remain positive for life. Antibiotics (eg. azithromycin, ciprofloxacin) cure the infection, but balanitis (infection of penis head) and phimosis (contracture of foreskin) are possible complications.

CHÉDIAK-HIGASHI SYNDROME The Chédiak-Higashi syndrome is a familial (runs through families) failure of white blood cells to function or develop. Patients have recurrent skin infections, partial albinism (loss of skin pigment) and a lack of white blood cells. Some patients have a large liver and spleen, and severe respiratory infections. Blood tests show abnormal and low number of white cells. Antibiotics can be used for bacterial infections, and steroids, bone marrow transplants and vitamin C supplements may also be helpful. The prognosis is poor. See also ALBINISM

CHEILITIS Angular cheilitis or perlèche) is inflammation at the corner of the lips. The cause is drying of the lips for various reasons including mouth breathing, loss of teeth in the elderly (upper lip overhangs lower one), dribbling, repeated nervous licking of lips, dry skin, lack of vitamin B or iron, and the uncommon disease Sjögren syndrome. Red, sore, cracked and sometimes bleeding occurs at the outer corners of the lips. Fungal or bacterial infection of the damaged tissue may occur. It is necessary to exclude any serious causes, but normally no investigations are necessary. Patients should use a moisturising or mild steroid cream and any secondary fungal or bacterial infection must also be treated. It is usually easily managed, but may be chronic in the elderly. See also RHAGADES

22 A RATIONALE FOR RASHES

CHERRY ANGIOMA See CAMPBELL de MORGAN SPOTS

CHICKENPOX Chickenpox (varicella) is a generalised infection caused by the virus Herpes zoster. Infection occurs when the virus passes to another person from the fluid-filled blisters that cover the body of patients, or in their breath and saliva. Patients are infectious for a day or two before the spots appear, and remain infectious for about eight days. The incubation period is 10 to 21 days.

Early symptoms are similar to those of a cold, with a vague feeling of being unwell, headache, fever and sore throat. The rash usually starts on the head or chest as red pimples, then spreads onto the legs and arms, and develops into blisters before drying up and scabbing over. New spots may develop for three to five days, and it may be two weeks or more before the last spot disappears. The diagnosis can be confirmed by varicella antibody blood tests, but none are usually necessary. Treatment involves bed and home rest until the patient feels well, and medications to relieve the itch (eg. calamine lotion, antihistamines), fever and headache. Children must be excluded from school for at least five days from the appearance of the first blisters and until all blisters have developed a dry scab. There is a vaccine has been available since 2000 to prevent the disease. One injection is necessary if given between 12 months and 12 years of age, but two injections six weeks apart in older children and adults.

23 A RATIONALE FOR RASHES Complications are more common in adults, and include chest infections and a type of meningitis. It is unusual for the pockmarks to scar unless a secondary bacterial infection occurs. Complete recovery within ten days is normal. Once a person has had chickenpox, it is unlikely (but not impossible) that they will ever catch it again. Once a patient has had chickenpox, the virus never leaves their body but migrates to the nerves along the spinal cord where it remains forever. The virus may be reactivated years later at times of stress to give the patient the painful rash of shingles. See also SHINGLES

CHICLERO ULCER See CUTANEOUS LEISCHMANIASIS

CHIGGER Chiiger is skin irritation and itching caused by the larva of the mite Trombicula which is found in long grass in Europe and North America and sticks to the skin.

CHIGOE Chigoe (jigger or tungiasis) is an infestation by the female flea Tunga penetrans which burrows into the skin of the foot, particularly around the base of a small toe where it lays its eggs. The infestation causes damage to the tissue, an ulcer, and may result in gangrene of a toe.

CHIKUNGUNYA The arboviral infection chikungunya is transmitted from one person to another by a mosquito bite and is found mainly in tropical Africa. The cause is an Togavirus. It causes a fever, rash, joint and muscle pain, but usually settles after a few weeks with no treatment. In severe cases it causes bleeding into the skin and a form of viral encephalitis, which may be fatal.

CHILBLAINS Chilblains are a mild form of frostbite caused by exposure to extreme cold. Itchy, red skin spots develop on the fingers, toes and other exposed areas such as the nose. The spot may form a blister, and the itching is aggravated by warmth. Treatment involves gradual warming in a warm room. The fingers or toes should NOT be immersed in hot water or placed near a heater or fire, nor should the area be rubbed or massaged as this may cause further damage. Sometimes damaged skin may become infected and require antibiotics. Recurrent chilblains can lead to a permanent scar forming at the site, but if not exposed to further cold, the skin will heal in a day or two. See also FROSTBITE

24 A RATIONALE FOR RASHES CHLOASMA Chloasma (melasma) is a pigmentation disorder of the skin that occurs almost invariably in women, and more commonly in those with a dark complexion. The deposits of pigment on the forehead, cheeks, upper lip, nose and nipples are often triggered by pregnancy or starting the oral contraceptive pill. Treatment is unsatisfactory. Numerous blanching agents have been tried with minimal success, but the pigmentation usually fades slowly over several years.

CHLORACNE This rare skin condition chloracne, occurs as a reaction to toxic chemicals (eg. dioxin, chlorbenzene, polychlorbiphenyls, chlorophenol, pyrazole) found in insecticides, herbicides and wood preservatives. The chemicals may be touched, inhaled or swallowed. Whiteheads and blackheads similar to acne (pimples) that are not inflamed (red), develop on the skin of the cheeks, neck, armpits and groins. Because the chemicals are stored in body fat, more pimples may develop for some time after exposure to the chemicals has ceased. The source of exposure must be identified and further exposure prevented. Antibiotics and isotretinoin are used to slowly clear pimples. After an attack the palms and soles may be excessively sweaty, the liver may be damaged, excess fat is found in the blood, impotence may occur, patients may become tired and nervous, and porphyria cutanea tarda may develop. Provided there is no more exposure to the responsible chemicals, the pimples usually clear within two years. See also ACNE; PORPHYRIA CUTANEA TARDA

CHOLINERGIC URTICARIA A skin reaction that occurs in some individuals, cholinergic urticaria is characterised by multiple small itchy lumps surrounded by a reddened area of skin. It is caused by a contraction of blood vessels from excessive nerve sensitivity at times of stress, exertion, heat or sweating. It is not an allergy reaction, but may be treated by antihistamines and cooling the affected skin.

CHONDRODERMATITIS NODULARIS CHRONICA HELICIS Chondrodermatitis nodularis chronica helicis is a painful inflammatory condition affecting the ear of middle-aged and elderly men. It is caused by pressure on the ear between the head and pillow at night. It occurs in people who usually sleep on only one side, and may also be due to a minor injury (eg. tight headgear or telephone headset), or by exposure to cold. Reduction in the blood supply to the ear with ageing prevents healing of minor damage to the ear cartilage. A benign exquisitely tender lump a few millimetres

25 A RATIONALE FOR RASHES across develops in the cartilaginous part of the ear. There is often a tiny central core, which may discharge a small amount of scaly material. An ulcer may form on the ear if left untreated. Patients should avoid sleeping on the affected ear, use a soft pillow with a hole in it if necessary, and wear a warm hat over the ears when outside in the cold and wind. It may be treated with a cortisone injection, frozen with liquid nitrogen or surgically removed. If ulcerated, antibiotic ointment may be applied. The condition is annoying but not serious and there is a 10% recurrence rate after surgery.

CHROMOMYCOSIS Chromomycosis or chromoblastomycosis is a persistent fungal infection of the skin caused by various fungi that normally live in the soil and decaying wood in tropical climates. It enters the skin through a graze or cut. An ulcer or sore develops that will not heal and forms a crust, while slowly enlarging over many years. Secondary infection by a bacteria and spread of the fungus to deeper tissues may occur with time. The diagnosis is confirmed by a biopsy that is examined under a microscope, and culture of a wound swab for fungi. A complete cure usual with prolonged treatment with antifungal medications (eg. itraconazole).

CICATRIX A cicatrix is abnormally thickened, hard, white scar tissue.

CIRCUMSCRIBED DERMATITIS See LICHEN SIMPLEX

CIRCUMSCRIBED SCLERODERMA See MORPHEA

CLAM DIGGERʼS ITCH See CERCARIAL DERMATITIS

CLEAVAGE LINES See LANGERʼS LINES

COFFIN-SIRIS SYNDROME The Coffin-Siris syndrome is a familial (runs in families) developmental abnormality in which both parents must be carriers. Patients have poorly developed toenails, are very hairy at birth but have sparse hair in later life, suffer intellectual disability and coarse facial features. There are no specific diagnostic tests, and no treatment is available, but life expectancy is reasonable.

COMEDO A is a black or white headed pimple on the skin filled with sebum (oil) as in acne. See also ACNE

26 A RATIONALE FOR RASHES COMEDONE NAEVUS A comedone naevus is an unusual type of birthmark that may occur anywhere on the body. It is caused by the localised overgrowth of oil and sweat glands in the skin and appears as a tightly clumped patch of pimples on the skin that is present from birth. It may become inflamed and infected. Surgical removal of the patch is performed if possible as it persists long term unless removed. See also ACNE; NAEVUS

CONDYLOMA ACCUMINATA See GENITAL WARTS

CONGENITAL POIKILODERMA See ROTHMUND-THOMSON SYNDROME

CONTACT DERMATITIS Contact dermatitis (housewifeʼs dermatitis or irritant eczema) is one of the most common forms of dermatitis. It is particularly troublesome in some occupations including hairdressers, painters, kitchen workers, mechanics and those working with chemicals. Soaps, medicated creams, detergents, chemicals, solvents, cosmetics, perfume, jewellery, metals, rubber, animals and plants are the most common substances causing contact dermatitis. Substances that a person has used or touched regularly for many years without any adverse effect may suddenly cause a reaction. This is particularly common with solvents, dyes, rubber, inks and cosmetics. The rash is more common on exposed parts of the body, but may occur on other areas if, for example, underclothes are washed in a detergent to which the patient reacts.

The affected area of skin is red, itchy, swollen, burns and may blister. After a few days, it may become crusted and weep. The dermatitis may become secondarily infected by bacteria, and then antibiotics are required. A person's reaction to suspect agents may be investigated, but these tests, in which a patch of skin is exposed to a substance to test its response, are often inconclusive.

27 A RATIONALE FOR RASHES If the substance causing the dermatitis can be identified and avoided, the problem is solved. Gloves can be used to avoid detergents, soap substitutes used for washing, and changes in occupation to avoid solvents. If the irritating substance can be tracked down, it may be possible to desensitise the patient. The main treatment is a steroid cream, lotion or ointment. Placing a plastic dressing over the dermatitis and cream increases the effectiveness of the treatment. In severe cases, steroids may need to be given in tablet form, or even by injection. Provided the causative agent is not touched again, the dermatitis should settle with treatment, and not recur. See also DERMATITIS

CORN A corn is a hard mass made of dead skin cells that overlies a bony prominence on the foot or hand. They are caused by persistent friction and pressure between the skin and a shoe or other hard surface. They are treated by preventing further friction and pressure by modifying footwear, altering work practices and using a protective adhesive ring (corn pad) around the corn. The corn can then be softened with acidic creams and the excess callus can be carefully cut away.

CORYNEBACTERIUM MINUTISSIUM See ERYTHRASMA

COWPOX Cowpox is a mild viral infection that can be transmitted from cattle to man by close contact. It causes blisters on the affected part of the skin, which settle without treatment after a couple of weeks. It is usually the hands that are affected as it can be caught by manual milking. Cowpox was found to give immunity against smallpox as it is caused by a related virus, and this was the basis of the first vaccine against smallpox.

COXSACKIE VIRUS INFECTION There are two main types of Coxsackie virus (A and B), but these are further broken down into more than 50 subtypes. The symptoms depend on where the infection occurs. It may cause viral meningitis, cold like symptoms, fevers, ulceration of the mouth and throat (herpangina), inflammation of the pleura around the lungs (Bornholm disease), hand foot mouth disease, myositis (inflammation of muscles), and inflammation of the heart or the pericardium that surrounds the heart. Rarely, if the heart is infected, it may be permanently damaged. There is no cure other than time and rest, but symptoms may be eased by appropriate medication when necessary. Most patients recover uneventfully unless the heart is involved. See also HAND FOOT MOUTH DISEASE

CRABS Crabs (pubic pediculosis) is an infestation of the pubic hair with the lice (parasitic insect) Phthirus pubis, that lives by sucking blood from the soft pubic skin. Caught by being in close bodily contact with someone who already has an infestation (eg. during sex), but as the lice can survive away from humans for a time, they can also be caught from borrowed clothing, towels or bedding.

28 A RATIONALE FOR RASHES Often there are no symptoms and many people are unaware of the presence of lice. In others the lice cause an itchy rash in the pubic area, which may be raw and bleeding from constant scratching. Secondary skin infections may develop in these sores, and this infection can cause further symptoms including a fever and enlarged glands in the groin. Lice may be seen by examining the pubic hair through a magnifying glass. A number of lotions are available to kill the crabs. The affected individual, and all sex partners, must be treated simultaneously to prevent reinfestations occurring. All clothing and bedding must be thoroughly washed in hot water. A repeat treatment after 24 hours and again after seven days is advisable in order to kill any lice that have hatched in the interim. Antibiotics may be required to treat secondary infections. Correct treatment should result in a complete cure.

CRADLE CAP See SEBORRHOEIC ECZEMA

CREEPING ERUPTION See CUTANEOUS LARVA MIGRANS

CREST SYNDROME The name of this syndrome is an acronym for its symptoms :- - Calcinosis (the formation of hard calcium containing nodules under the skin) - Raynaudʼs phenomenon (fingers and toes to become cold and blue) - Oesophageal (Esophageal - American spelling) inflammation causing difficulty in swallowing - Sclerodactyly (thickening and hardening of the skin on the fingers and toes) - Telangiectasia (multiple dilated blood vessels in the skin). It is known as CRST syndrome if the oesophagus is not involved. The cause is unknown, but it can be diagnosed by a biopsy of affected tissue and detecting the presence of centromere autoantibodies in the blood. There is no cure, and the condition is usually slowly progressive, but medications can be given to ease symptoms. Scleroderma may be a complication. See also SCLERODERMA

CRONKHITE-CANADA SYNDROME The rare Cronkhite-Canada syndrome is the thickening of the lining of the stomach, small bowel and colon to form non-cancerous polyp-like lumps. The cause is unknown. The symptoms include abdominal discomfort, irregular bowel habits and bleeding from the bowel to give dark or black motions. Other symptoms may include abnormal skin pigmentation (particularly of the palms and soles), poorly developed finger and toenails, hair loss and diarrhoea. It is diagnosed by gastroscopy and/or colonoscopy. No treatment is available.

29 A RATIONALE FOR RASHES “CROTCH ROT” See TINEA CRURIS

CUTANEOUS LARVA MIGRANS Cutaneous larva migrans, or creeping eruption, is a skin infestation by a larval nematode worm. The rash is caused by the burrowing of hookworm larvae through the skin. The larvae hatch from dog or cat faeces, mature in the soil and then penetrate human skin. Patients develop several centimetre long red, very itchy, twisting tracks in and under the skin. Large blisters may form later. Secondary bacterial infection of skin may occur due to damage by both the larvae and scratching. A skin biopsy is sometimes used to make the diagnosis. Treatment involves medication by mouth and ointment to kill the larvae, and other creams to ease the skin irritation. The larvae cannot mature in humans, and die after several weeks, and then the skin tracks slowly heal.

CUTANEOUS LEISCHMANIASIS Cutaneous leischmaniasis has numerous local names in different parts of the world including Chicleroʼs ulcers, oriental sore and uta. It is an ulcerating skin infection caused by the protozoan (single celled animal) Leischmania tropica, Leischmania aethiopica, Leischmania mexicana, or Leischmania peruviana depending upon the geographic location. It is transmitted from one person to another by sand flies. Occurs throughout the tropics in Asia, Africa and particularly America. The symptoms depend upon which protozoan is causing the disease, and vary from a self healing ulcer (Oriental sore), to persistent multiple mutilating sores and ulcers (Chicleroʼs ulcers), or widespread non-ulcerating plaques on the skin. Secondary bacterial infection of sores can allow rapid spread of the protozoa and gross disfigurement. Smears taken from ulcer edge show the protozoan under a microscope, and specific blood tests may be positive. Single ulcers are treated with heat packs, cryotherapy (freezing), radiotherapy or specific ointments. Widespread disease is difficult to treat but numerous medications may be tried. Antibiotics are given for secondary infections. The prognosis depends on the infecting organism and form of disease. Single ulcers often heal after a few months, but widespread disease may be steadily progressive without treatment. See also KALA-AZAR

30 A RATIONALE FOR RASHES

CUTANEOUS NEUROENDOCRINE TUMOUR See MERKEL CARCINOMA

CUTANEOUS PAPILLOMA See SKIN TAG

CUTIS HYPERELASTICA See EHLERS-DANLOS SYNDROME

CUTIS LAXA Cutis laxa is an inherited condition in which there is a lack, or reduced number, of elastic fibres in the skin resulting in abnormally slack, loose, folded, wrinkled skin, particularly around the neck. Particularly disfigured areas may be helped by plastic surgery.

DANDRUFF Dandruff is A very common form of scalp irritation. It is actually a disease in itself, but most people describe a scalp that is shedding copious quantities of skin scale as dandruff. Over a period of a few weeks, the skin totally replaces itself. New cells are produced deep in the skin, slowly move out as new cells are produced beneath them, thin out to form a hard scaly layer, and eventually slough off. Dandruff is an acceleration of this natural process in which the rate at which cells are produced on the scalp is increased, so that the excess cells produced form a scale on the skin. The underlying skin may become inflamed and itchy. It is thought that a mild fungal infection of the scalp causes this increased rate of cell loss. Emotional stress, overworking, hot climates and a poor diet all aggravate dandruff. Dandruff must be differentiated from other skin diseases such as psoriasis, dermatitis, eczema, neurodermatitis and other fungal infections. A biopsy is sometimes necessary to make the diagnosis. Seborrhoeic dermatitis is an inflammation of the scalp that is more common in babies, when it is known as cradle cap. Good scalp hygiene, and an antidandruff lotion or shampoo containing pyrithione zinc are the main treatments, but excessive use of shampoos or soap may aggravate the problem by further drying and irritating the scalp. Resistant cases may be helped by steroid scalp lotions, and antifungal lotions (eg. selenium sulfide) or gels. Most patients have recurrences, with bad and good periods, often for no apparent reason, but reasonable control is normally possible. See also PSORIASIS; SEBORRHOEIC ECZEMA; TINEA CAPITIS

DARIER DISEASE A rare skin condition that usually starts between 8 and 15 years of age, Darier disease (keratosis follicularis) affects the face, back, scalp, groin and armpits. It is an inherited disorder causing the production of abnormal keratin (hardening substance in skin) that may worsen with heat and sweating. Patients develop small, brown, firm lumps on the skin that slowly enlarge and become covered in greasy

31 A RATIONALE FOR RASHES scales. They may appear as small pits on the soles and palms. The diagnosis can be confirmed by a skin biopsy. Salicylic acid and retinoic acid ointments are used in treatment. In serious cases the lumps in the skin may merge together to form a hard crusted plaque, and the nails become brittle, ridged and discoloured in persistent cases. Secondary bacterial infections may also occur. The syndrome may be associated with subnormal mentality and reduced height in some patients. In the early stages, the disease may settle spontaneously, but if it becomes prolonged the disease is difficult to control.

DERCUM DISEASE Dercum disease (adipositas dolorosa) is a familial (runs in families) condition that causes the development of tender lumps under the skin in middle aged and elderly. It is much more common in women. Multiple, tender, soft, fatty lumps (lipomas) form under the skin. The condition is often associated with emotional instability and weakness in women. A biopsy is usually necessary to confirm the diagnosis. Excision of lipomas that are particularly painful or disfiguring is the only treatment. The condition persists, but there is a good response to the treatment of individual lumps.

DERMATITIS Any inflammation of the skin can be called dermatitis, so there are many different types of dermatitis. It is often very difficult to determine any cause, for although the skin is the most visible of our organs, its diseases are very diverse and often difficult to diagnose. In most cases simple steroid anti-inflammatory creams will control dermatitis, but it may become persistent and widespread. For further information see the specific types of dermatitis. See also ATOPIC ECZEMA; AUTOSENSITISATION DERMATITIS; CONTACT DERMATITIS; DERMATITIS ARTEFACTA; DERMATITIS ARTEFACTA; DERMATITIS HERPETIFORMIS; DERMATITIS MEDICAMENTOSA; ECZEMA; EXFOLIATIVE DERMATITIS; NEURODERMATITIS; PERIORAL DERMATITIS; PHOTODERMATITIS; POMPHOLYX; PSORIASIS; SCALDED SKIN SYNDROME; STASIS DERMATITIS

DERMATITIS ARTEFACTA Dermatitis artefacta is a rash that is deliberately self-inflicted to attract attention or obtain special treatment. Patients may be disturbed psychiatrically, prisoners, deprived of affection or attention, senile or confused. They may use heat, sharp instruments, sandpaper, chemicals or their fingernails to create the rash. Women are five times more likely to have the condition than men. The rash can be extraordinarily varied in its form, and quite bizarre in its presentation. It usually does not respond to treatment, and occurs on unusual parts of the body. Treatment involves psychiatric counselling and medication, and dressings that cannot be easily removed by the patient. Plaster casts may occasionally be necessary to stop a patient constantly picking at an ulcer that will not heal. Sometimes the rash may become infected or gangrenous, but if effective psychiatric care given, treatment is usually successful. See also DERMATITIS

32 A RATIONALE FOR RASHES

DERMATITIS, ATOPIC See ATOPIC ECZEMA

DERMATITIS EXFOLIATIVA NEONATORUM See SCALDED SKIN SYNDROME

DERMATITIS HERPETIFORMIS This is an uncommon blistering itch that occurs on the elbows, knees and backside. There are several different causes, including gluten, which is found in many cereals. Patients develop small, intensely itchy, fluid-filled blisters on red, inflamed skin. Often appears scratched and bleeding because of the almost irresistible itching. The diagnosis can be confirmed by a biopsy of a skin blister. Treatment requires avoiding gluten containing cereals, and using very potent steroid creams or tablets, or rarely dapsone. The rash can be cured by avoiding any cause that can be discovered, otherwise control may be difficult. See also DERMATITIS

DERMATITIS MEDICAMENTOSA Dermatitis medicamentosa (a drug eruption or toxic erythema) is an abnormal reaction to a medication that causes skin inflammation. There is the sudden onset of a bright red, itchy rash. Some patients have a fever, tiredness, joint pains, headache and nausea. Blood cell damage, severe allergy reactions (anaphylaxis), kidney and liver damage may also occur. The diagnosis is often difficult, as there is usually no specific test. Patients should stop the use of responsible medication, and antihistamines are taken for the itch. Steroid creams or tablets may also be used. The rash usually settles with cessation of the responsible medication, but if complications occur, the condition may be serious. See also DERMATITIS; ERYTHEMA MULTIFORME; FIXED DRUG ERUPTION

DERMATOFIBROMA Dermatofibromas (histiocytomas) are common non-cancerous fibrous skin lumps that usually occur on the legs and arms. Their cause is unknown, but they may arise at the site of a minor injury such as an insect bite or thorn prick. Patients develop firm yellow-brown nodule in the skin, that if squeezed forms a dimple because the skin is tethered to the nodule. No treatment is necessary unless the lumps are cosmetically unacceptable, when they can be removed surgically, frozen (cryotherapy) with liquid nitrogen or injected with a steroid. They usually persist for years unless surgically removed.

33 A RATIONALE FOR RASHES DERMATOGRAPHIA See DERMOGRAPHISM

DERMATOHELIOSIS Dermatoheliosis (photoaging) is a form of skin damage from prolonged exposure to sunlight. Ultraviolet B in the sunʼs rays causes damage to the skin. It affects older people, particularly males with fair skin who have worked outdoors for years. It is far more common in Caucasians than in darker skinned races. Those affected have highly wrinkled, leathery, dry skin on sun-exposed areas such as the face and forearms. Hyperkeratoses are almost invariably present and there is a significantly increased risk of developing skin cancer. The condition is better prevented than treated by using sun protection creams and shading hats. Tretinoin cream may reduce severity of wrinkles. Although disfiguring, dermatoheliosis is not otherwise serious unless skin cancers develop. See also HYPERKERATOSIS

DERMATOMYCOSIS A dermatomycosis is any superficial fungal infection of the skin. Examples include tinea and pityriasis versicolor. See also PITYRIASIS VERSICOLOR; TINEA

DERMATOMYOSITIS Dermatomyositis is a rare disease that combines a persistent rash with muscle weakness. When it occurs without the rash (which is present in only 40% of cases) it is called polymyositis. The cause is unknown, but it commonly attacks those in late middle-age. Patients experience a gradually progressive weakness and pain of the muscles in the neck, upper arms, shoulder, buttocks and thighs. Patients may also develop a dusky red rash on the cheeks and nose, shoulders and upper chest and back. The eyelids are often swollen and appear bruised. Unusual symptoms include redness and bleeding under the nails, cold hands, and a scaly rash over the knuckles. The condition is diagnosed by blood tests, muscle biopsy and by measuring the muscle's electrical activity. Drugs such as steroids, methotrexate and azathioprine are commonly used in treatment. Para-amino benzoic acid is sometimes used on the skin. One in ten patients risk developing cancer, but there is no cure. Most patients can lead a relatively normal life, although a minority are disabled by muscle weakness.

34 A RATIONALE FOR RASHES DERMATOSIS PAPULOSA NIGRA The presence of multiple benign dark pigmented raised spots on the skin of dark-skinned people is called dermatosis papulosa nigra. It is an inherited characteristic, the spots are most common on the face and neck and the number of spots increases with age.

DERMOGRAPHISM Dermographism is an exaggerated skin response that usually occurs in young adults when the skin is rubbed. It is caused by the excessive release of histamine into the skin from mast cells. In severe cases, pressure from clothing (eg. belts, bra straps), chairs, clapping hands, tools or even kissing may start the reaction. In normal skin, firmly rubbing a blunt rounded object over the skin produces a white line for a few seconds. In about one third of people, the white line is followed by a red line and slight swelling of the underlying skin which subsides quickly. In the approximately 4% of the population who suffer from dermographism this response is exaggerated and pressure results in an itchy, red, raised weal that follows the course of a firm blunt pressure on the skin. Any part of the body can be affected, and although the welts develop in a few minutes, they may take many hours or days to fade away. The response is often worse when the patient is anxious, after a hot bath or in warm weather. Dermographism may be a temporary phenomenon that lasts for a few months, or may persist life long. It is a condition that can develop at any age, but is far more common in women than men. The cause of dermographism is unknown and there is no permanent cure, but patients who have serious problems with the condition can take antihistamine tablets on a regular basis to reduce the severity of attacks. Most victims find that the condition is severe at some times, and less severe at others. There is a tendency for the severity of the reaction to slowly subside over many years.

DESMOPLASTIC TRICHOEPITHELIOMA See TRICHOEPITHELIOMA

DESQUAMATION Desquamation is the natural continuous loss of the outer surface of the skin which comprises dead epithelial cells. Excessive desquamation may occur with skin inflammation and irritation and result in a scaly appearance to the skin and trapped skin cells in surface hairs (eg. dandruff). See also DANDRUFF

DIAPER RASH See NAPPY RASH

35 A RATIONALE FOR RASHES DISCOID ECZEMA Discoid or nummular eczema is a persistent rash that is often confused with a fungal infection. the cause is unknown, but it usually occurs in young adults. The rash appears as discs of scaling, red, thickened skin on the back of the forearms and elbows, back of the hands, front of the legs and the tops of the feet. The affected areas can vary in size from a few millimetres to three centimetres or more. The diagnosis can be confirmed by biopsy. Steroid creams and tablets are effective, but antihistamine tablets are sometimes needed for the itch. The rash heals rapidly with correct treatment, but unfortunately, there is a tendency for recurrences. Attacks usually cease after 6 to 12 months. See also ECZEMA

DISCOID LUPUS ERYTHEMATOSUS Discoid lupus erythematosus is an uncommon disfiguring inflammatory skin disease. Its cause is an autoimmune condition in which the body inappropriately reject patches of skin for no known reason. Patients develop distinct red plaques on the face (particularly the cheeks), scalp and ears that worsen with sun exposure. Permanent facial hair loss and loss of pigmentation in dark skinned races may also occur. The diagnosis is confirmed by a skin biopsy and some specific blood tests may be abnormal. Treatment involves protecting the affected skin from the sun, strong steroid creams, injections of steroids into the spots and medications such as chloroquine, dapsone and retinoic acid. All these must be used with great care as they have significant side effects. The condition is often persistent, and only 60% of patients adequately controlled.

DISSEMINATED SUPERFICIAL ACTINIC POROKERATOSIS Disseminated superficial actinic porokeratosis (DSAP) is an unusual inherited condition that increases the risk of sun damage to the skin in people of European descent. Half the children of an affected parent will have the condition, but only if they have excessive sun exposure will it be a problem. New spots may also be caused by ultraviolet light in sun lamps. The average age of onset is about 40, and severity increases steadily with age. It does not occur in childhood. Spots begin as a 1-3 mm cone shaped lump, brownish red or brown in colour and usually around a hair follicle. The spot expands and a slightly raised dark brown ring develops and spreads out to a diameter of 10 mm or more. The skin within the ring is thin and

36 A RATIONALE FOR RASHES mildly reddened or slightly brown, and sometimes may ulcerate and crust. Sweating is absent in affected areas and sun exposure may cause itching. The condition becomes more prominent in the summer and may improve in winter. Affects sun exposed areas, appearing mainly on the cheeks, forearms and lower legs and occurs more frequently in women than men. The diagnosis can be confirmed by a skin biopsy. There is no satisfactory treatment, but cryotherapy (freezing) and creams containing 5 fluorouracil, tretinoin or alpha hydroxy acid may be tried. It is important to reduce sun exposure by wearing long sleeves shirts and slacks and using sunscreens. See also DERMATITIS

DONOVANOSIS See GRANULOMA INGUINALE

DOWLING-DEGOS DISEASE Abnormal pigmentation of the armpits and groin may be due to Dowling-Degos disease, which is also known as the reticular pigmentation anomaly of the flexures. This is a familial (runs in families) condition, which causes dark, mottled to solid, brown to black pigmentation in the armpits, groin, under the breasts and in other areas of skin infolding. There may be small raised lumps in the pigmented area. Sometimes pigmentation also occurs on the back of the hands and at the base of nails. Uncommonly, pitted scars may occur around the mouth and acne-like sores on the face and upper back. There is an increased incidence of skin cancer (squamous cell carcinoma) in the areas of worst pigmentation. A skin biopsy confirms the diagnosis. Laser therapy may reduce intensity of pigmentation but there is no cure for this annoying but relatively harmless condition. See also ACANTHOSIS NIGICANS; LENTIGO; MELANOMA

DYSPLASTIC NAEVUS A dysplastic naevus is a brown coloured skin mark that usually develops in middle age or later, often on sun affected areas of skin. It may have varied colouration from light brown to almost black, and an indistinct and irregular edge. A small percentage may progress to become a malignant melanoma, and as a result they probably should be excised. See also DYSPLASTIC NAEVUS SYNDROME; MELANOMA

DYSPLASTIC NAEVUS SYNDROME Malignant melanomas are becoming more common because of excessive sun exposure, particularly in childhood, but there is a small group of people who are born with an excessive number of brown and black moles on their body that have the increased propensity to become malignant melanomas. These people have the dysplastic naevus syndrome. They have scores or hundreds of small, irregularly pigmented and irregularly shaped moles with poorly defined borders scattered across their skin. Once diagnosed, regular detailed photographs of their body are taken and compared every few months. Any moles that alter in shape, size, colour or regularity are excised and examined by a pathologist. Because of their large number, excision of all moles is impractical. See also MELANOMA; NAEVUS

37 A RATIONALE FOR RASHES ECCHYMOSIS Ecchymosis is a term used in medicine for a bruise.

ECZEMA The term eczema describes a large number of skin diseases that cause itching and burning of the skin. The many different forms of eczema also have innumerable causes, both from within the body (eg. stress) and outside (eg. allergies, chemicals). The appearance of eczema depends more on its position on the body, duration, severity and degree of scratching than the actual cause. Typically it appears as red, swollen, itchy skin that is initially covered with small fluid-filled blisters that quickly break down to a scale or crust. No investigations are usually necessary, but a biopsy is can be diagnostic. Treatment depends upon cause of eczema, but steroid creams and tablets are commonly used. The main complication is a secondary bacterial infection of the skin See also ALLERGIC ECZEMA; ASTEATOTOC ECZEMA; ATOPIC ECZEMA; BAZEK SYNDROME; CONTACT DERMATITIS; DISCOID ECZEMA; ECZEMA HERPETICUM; GRAVITATIONAL ECZEMA; LICHEN SIMPLEX; PHOTOSENSITIVE ECZEMA; SEBORRHOEIC ECZEMA; VARICOSE ECZEMA

ECZEMA CRAQUELÉ See ASTEATOTIC ECZEMA

ECZEMA HERPETICUM A widespread viral skin infection with the Herpes simplex virus (which is also responsible for cold sores) may be referred to as eczema herpeticum. It usually occurs in people with reduced immunity and pre-existing eczema. The symptoms are widespread itchy crusting skin blisters mainly affecting the face, fever, tiredness and irritability. Effectively, these people have hundreds of cold sores spread all over their face and body. The sores may be infected by bacteria, and the Herpes infection may involve the eyes causing damage to the cornea (eye surface). The diagnosis is confirmed by testing swabs from a skin sore for the virus. Aciclovir or similar antiviral medications should be started immediately the diagnosis is suspected. The underlying eczema must also be treated as well as any secondary bacterial infections. Untreated the condition may persist for six weeks or so. If antiviral treatment is started soon enough, the duration of the viral infection will be dramatically reduced. See also COLD SORES; ECZEMA

EHLERS-DANLOS SYNDROME Ehlers-Danlos syndrome (cutis hyperelastica or the elastic skin syndrome) is a congenital abnormality of skin development with eight clinically and genetically different variants. Patients have over extendable joints, excessively elastic and fragile skin, scarring of skin and growths on their knees and elbows, and premature arthritis may occur. It is diagnosed by a skin biopsy. There is no treatment or cure available, but life expectancy is normal. The syndrome is named after Danish dermatologist Edvard Ehlers (1863-1937) and French dermatologist Henri Danlos (1844-1912).

38 A RATIONALE FOR RASHES

See also PSEUDOXANTHOMA ELASTICUM

ELASTIC SKIN See EHLERS-DANLOS SYNDROME; PSEUDOXANTHOMA ELASTICUM; RHAGADES

ELASTOSIS Elastosis is the degeneration of elastic tissue in the skin, particularly in elderly people, so that it wrinkles around a joins rather than springing back into shape with movement of a joint. See also ANETODERMA; CUTIS LAXA

ELEPHANT MAN DEFORMITY See PROTEUS SYNDROME

EPIDERMAL See

EPIDERMOLYSIS BULLOSA Epidermolysis bullosa is a rare familial (runs in families) skin disease of which there are several subtypes. The slightest injury to the skin causes large, firm blisters and so these children may be referred to as cotton wool babies. In infants blisters develop on knees and hands as the child starts to crawl, but later may occur anywhere. In severe forms the disease continues throughout life, the fingers may become bound together by scar tissue, the mouth and throat may be involved, and nails and teeth may be damaged. On healing,

39 A RATIONALE FOR RASHES blisters leave behind a scar that causes significant disfigurement and cancer may develop in the affected tissue. The diagnosis is confirmed by a skin biopsy. Steroids are the only treatment available, but are not particularly effective, so avoiding injury to the skin is imperative. There is no cure, and the subtypes vary in severity from an inconvenience to life-threatening. See also BLISTERS

EPIDERMOPHYTON See TINEA CAPITIS; TINEA CORPORIS; TINEA CRURIS

ERYSIPELAS Erysipelas (St. Anthonyʼs fire) is an infection of the skin, caused by any one of a large number of bacteria, but usually Streptococci, and most commonly involving the cheek, but any area of the body may be affected. It may start at the site of a scratch, crack or bite, but often there is no apparent cause.

The skin is red, swollen, painful and hot, and the patient may be feverish, shiver and feel very ill. Fluid-filled blisters sometimes develop on the infected area. Swabs may be taken to identify the responsible bacteria, then an antibiotic (eg. penicillin, erythromycin) capsule or tablet is prescribed. It was a very serious disease and often killed children before effective antibiotics were available, but now recovery is rapid once antibiotics are started, and it usually heals without scarring. See also CELLULITIS; ERYTHRASMA

ERYTHEMA INDURATUM Erythema induratum (Bazin disease) is a skin disease that usually affects the calves and back of the upper arms of young and middle aged adults. The cause is unknown, but it has been associated with tuberculosis in the past. Painful, soft, purplish lumps (nodules) develop on the skin and then gradually join together and ulcerate. It is sometimes necessary to biopsy a lump to make the diagnosis.

40 A RATIONALE FOR RASHES No treatment is necessary in most cases, but steroids may be given in persistent cases. Most ulcers heal without treatment in a few months, but leave a permanent scar.

ERYTHEMA INFECTIOSUM See FIFTH DISEASE

ERYTHEMA MULTIFORME Erythema multiforme (which can be loosely translated as “red spots of many shapes”) is an acute inflammation (redness) of the skin and moist (mucus) membranes lining body cavities. It may be triggered by drugs, bacterial or viral infections, cold sores and other Herpes infections, or may appear for no apparent reason. 75% occur after a Herpes or cold sore infection, and half of the remainder are caused by drugs - particularly sulfa antibiotics. Attacks caused by cold sores and other infections tend to be mild, but those that occur as a result of drug sensitivity can be very severe. Patients experience the sudden development of several types of rash simultaneously. The easiest rash to identify appears as multiple red, sore rings on the skin with a pale centre that vary in diameter from a few millimetres to 2 or 3 cm. Other forms include red patches, swollen lumps, fluid-filled blisters, itchy red stripes, and painful hard dome-shaped bumps. The insides of the mouth and the vagina, and the eye surface, may be involved with ulcers developing in some cases. The rash may occur anywhere, but is more common on the front of the leg, over the shoulders, above and below the elbow on the outside of the arm, and on the soles and palms. Most patients have only a mild fever, but those severely affected may be acutely ill with a very high fever and generalised weakness, and rarely it may progress to the Stevens- Johnson syndrome. No blood or other tests can confirm the diagnosis.

If a drug is suspected as the cause, it is immediately ceased; but if an infection is thought responsible, this is treated appropriately. The discomfort can be minimised with painkillers such as paracetamol and aspirin, and with creams, lotions and dressings to ease the skin irritation. Steroid tablets are taken in severe cases. There is no cure, but the vast majority of cases are mild and settle in two to four weeks, but severe cases may persist for up to six weeks, and in rare cases, with lung involvement

41 A RATIONALE FOR RASHES (Stevens-Johnson syndrome) in the elderly or chronically ill, death may occur. Recurrent attacks are quite common. See also COLD SORE

ERYTHEMA NODOSUM Erythema nodosum is an unusual skin inflammation for which the cause is often unknown, but it may be a reaction to certain bacterial infections, medications (eg. penicillin) or more serious underlying diseases (eg. leukaemia, tuberculosis, syphilis, hepatitis B or ulcerative colitis).

Very tender, painful red lumps develop on the front of the leg, usually below the knees, while less commonly affected areas include the arms, face and chest. Patients also have a fever, joint pains and general tiredness, and skin ulcers may be a complication. The diagnosis is confirmed by a skin lump biopsy, and other tests are done to find any underlying cause. If a cause can be found, this is treated (eg. infection) or removed (eg. medication), but there is no specific treatment, although steroids and painkillers may ease the symptoms. The condition lasts about six weeks before slowly disappearing with no serious after-effects, but recurrences are common.

ERYTHRASMA Erythrasma is a common superficial infection of the outermost layer of the skin caused by the bacteria Corynebacterium minutissium that usually affects the groin, armpit and under the breasts. It causes well defined, red-brown, scaling, slightly itchy patches that slowly enlarge and become wrinkled. A culture of skin scrapings can identify the responsible bacteria, and antibiotic tablets (eg. tetracycline, erythromycin) and ointments (eg. fusidic acid) are used to cure the infection. See also ERYSIPELAS

ERYTHRAEMIA See POLYCYTHAEMIA RUBRA VERA

ERYTHRODERMA See EXFOLIATIVE DERMATITIS; LEINER DISEASE

42 A RATIONALE FOR RASHES

ERYTHROPLASIA OF QUEYRAT The erythroplasia of Queyrat is a form of skin cancer (Bowenʼs disease) on the penis. The cause is unknown, but it is much rarer in circumcised males. It appears as a raised, velvety, red patch on the head of the penis, and is diagnosed by a biopsy. Anticancer cream containing 5-fluorouracil gives good results, but if left untreated, the cancer may spread onto the foreskin and break down into an ulcer. See also BOWENʼS DISEASE; SQUAMOUS CELL CARCINOMA OF THE SKIN

ERYTHROPOIETIC PROTOPORPHYRIA Erythropoietic protoporphyria is sometimes called “sunlight allergy”. It is a distressing inherited excessive skin reaction to sun exposure that normally starts in childhood, has an incidence of one in 100,000 people and affects both sexes equally. Red, swollen, crusted, irritated, painful, raised patches develop on sun exposed areas of the body, particularly the face. The rash starts minutes to hours after sun exposure, and slowly settles after hours or days. Milder attacks may involve skin pain with minimal rash, but areas of skin frequently affected by attacks may develop scars, skin thickening and wrinkling, and there is a higher than normal incidence of gall stones and liver damage (cirrhosis). Specific blood tests can detect abnormalities that aid in diagnosis, and a skin biopsy is also abnormal. Sun avoidance is essential, and beta-carotene used regularly reduces the severity of the reaction. Although it is a life long condition, its severity slowly decreases with age. See also PORPHYRIA CUTANEA TARDA

ESPUNDIA See MUCOCUTANEOUS LEISCHMANIASIS

EXANTHEMA A rash of any form is medically known as an exanthema. See VIRAL EXANTHEMA

EXANTHEMA SUBITUM See ROSEOLA INFANTUM

43 A RATIONALE FOR RASHES EXFOLIATIVE DERMATITIS Exfoliative dermatitis (generalised erythroderma) is a form of dermatitis in which there is extensive peeling of skin. It is often associated with drugs or foods, such as gold injections (used for rheumatoid arthritis), sulfa antibiotics, some diabetes tablets and some anti- inflammatory medications, and exposure to heavy metals (eg. lead in battery factories) may also be responsible. There is widespread scaling, peeling and redness of the skin, and patch testing of the skin may be undertaken to determine the cause. Removal of the substance that the causes the rash is the obvious treatment, and steroid creams can be used to ease the inflammation. Rarely the condition may become very severe and debilitating, but in most cases the outcome is good, particularly if the trigger substance can be found, but may still take many months to settle.

FABRY DISEASE Fabry disease (angiokeratoma corporis diffusum) is a rare inherited inborn error in body chemistry that affects the skin and internal organs of males. Tiny dark red raised spots appear on the lower abdomen, buttocks, penis and scrotum. The heart and brain are also affected to cause transient ischaemic attacks, strokes, angina, heart attacks (myocardial infarction) and excruciating attacks of body pain.

44 A RATIONALE FOR RASHES Women who carry the gene but who do not actually develop the disease may develop cataracts in their eyes. It is diagnosed by a biopsy of skin spots and family history. No specific treatment is available, but the symptoms may be eased. See also ANGIOKERATOMA OF FORDYCE; HAEMANGIOMA

FAVUS Favus (witkop in southern Africa) is an infection of the scalp by the fungus Trichophyton schoenleinii, which causes redness of the scalp followed by matting of the hair and gradual formation of a thick off-white crust on the skin. Permanent skin damage and hair loss occurs with severe infections. Examination of the skin under a microscope shows characteristic changes. Griseofulvin or other antifungal tablets are taken for several weeks to cure the infection.

FIBREGLASS RASH Insulating batts are usually made of fibreglass that is loosely spun. Tiny slivers of glass fibre can easily break off and penetrate the skin to cause pain, irritation and inflammation. While the glass remains, the rash will persist. With time, the body will reject the tiny pieces of glass, but until then, irritation may be intense. Secondary infections may develop in some areas, and these require antibiotic treatment. Various anti-itch and anti-inflammatory creams can be prescribed, but unfortunately time is the usual cure. Anyone dealing with uncoated fibreglass should wear protective clothing, and eye protection, to prevent this problem. Coated and sealed fibreglass as used in boats and car bodies is quite safe unless it is cut or sawed, when the dust produced may cause irritation.

FIBROEPITHELIAL POLYP See SKIN TAG

FIFTH DISEASE Fifth disease (erythema infectiosum) is a common childhood viral disease caused by the Parvovirus that last from two to five days, but occasionally may persist for weeks. It occurs in epidemics every few years, and virtually every child will eventually develop the infection before their teenage years. The infection is characterised by red flushed cheeks (slapped cheeks appearance), paleness around the mouth and a red patchy rash on the arms and legs. Many children will have very mild symptoms that may be overlooked, or confused with German measles. Rarely joints may become sore and inflamed. Complete recovery is normal and no treatment is necessary. Six diseases that caused a rash were known by numbers. They were first disease (measles), second disease (scarlet fever), third disease (German measles - rubella), fourth disease (Dukeʼs disease - Coxsackie virus infection) and

45 A RATIONALE FOR RASHES sixth disease (exanthema subitum - roseola infantum). Only the fifth disease nomenclature is commonly used today. See also GERMAN MEASLES

FISH TANK GRANULOMA Fish tank (or swimming pool) granuloma is a skin infection that occurs in contaminated water. It is common in exotic fish fanciers. The cause is the bacteria Mycobacterium marinum, which infects a tiny skin abrasion that is immersed in water. The main symptom, that may develop months after initial infection, is a red, inflamed, crusted, raised patch on the skin, often on fingers and hands, knees and elbows that may be itchy and slightly painful. Usually only a single patch occurs, from 1 to 3 cm. in diameter, but it may break down into an ulcer. A skin biopsy is usually necessary to confirm the diagnosis.

Antibiotics over a prolonged period are used in treatment. Sometimes quite potent antibiotics, normally used to treat tuberculosis, may be required. The sore may persist for months or years before disappearing spontaneously without treatment, but it settles far sooner with antibiotics. See also BAIRNSDALE ULCER; GRANULOMA

FIXED DRUG ERUPTION A fixed drug eruption is a persistent skin rash caused by a reaction to a drug (eg: blood pressure medications, antibiotic, arthritis drugs, oral contraceptives, food colouring, thiazide diuretics - fluid tablets) that may have been taken for years without previous reaction. Patients develop a widespread, itchy, red, patchy, raised rash, and a biopsy is sometimes necessary to confirm the diagnosis. It is necessary to stop taking the suspected drug, then use steroid creams and antihistamine tablets. In severe cases steroid tablets may be necessary. The rash may persist for months or years after causative drug ceased, but most eventually subside. See also DERMATITIS MEDICAMENTOSA

46 A RATIONALE FOR RASHES

FLINDERS ISLAND SPOTTED FEVER See TYPHUS

FOCAL DERMAL HYPOPLASIA See GOLTZ SYNDROME

FOLLICULITIS Folliculitis is a bacterial (most common) or fungal (yeast) infection of hair follicles, which occurs mainly on the neck, armpits, upper lip and groins, and is more common in men than women. Numerous different bacteria and fungi may be responsible. Staphylococcus aureus is the most common bacteria, while Pityrosporum is the most common fungus. Infection is more likely in diabetics, obesity, at times of stress, those with poor hygiene, and with oily skin. A sore, tender, and sometimes itchy pus-filled blister appears on the skin surrounded by red skin. A boil or abscess may form, and the latter will need to be cut open and drained. Antibiotic or antifungal ointments are applied to the sores, and in severe cases antibiotic tablets are taken. A swab may be taken from a blister in resistant cases to identify the bacteria or fungus responsible for the infection and the correct antibiotic or antifungal to treat it. Personal hygiene must be scrupulous, and the long-term use of antibiotics and antiseptic soaps may be required. The infection is often difficult to cure, and attacks may recur for several months or years, and any underlying cause (eg. diabetes) must be cured or controlled. See also BARBERʼS ITCH; SCALP FOLLICULITIS

FOX-FORDYCE DISEASE Fox-Fordyce disease (hidrosadenome or lichen axillaris) is a rare skin disease that occurs in women between 15 and 50 years of age. The cause is unknown, but it is possibly due to a hormonal imbalance that causes blockage of the sweat glands in the affected areas. Patients develop extremely itchy groups of small, firm skin coloured lumps in the armpits, groin and on the nipples. The itch worsens during a menstrual period. Scratching may damage the skin and allow a secondary bacterial infection. Treatments include steroid creams, and taking the oral contraceptive pill to reduce hormone fluctuations. The problem often persists long term, but may be cured by pregnancy.

FRÖHLICH SYNDROME Fröhlich syndrome (dystrophia adiposgenitalis or adiposogenital dystrophy) is a rare condition that has its onset after puberty when there is a loss of sexual function and libido due to a lack of sex hormones, which in turn may be due to a tumour of the pituitary gland in the centre of the brain.

47 A RATIONALE FOR RASHES The symptoms are a lack of sexual development and activity, the skin becomes thin and wrinkles prematurely, body hair is scanty, scalp hair becomes very fine, and fat may deposit around the buttocks and genitals. All hormones must be checked by blood tests, and a CT or MRI scan of the pituitary gland is performed. There is no cure, but long-term control possible by sex hormone supplements and surgery for any pituitary tumour.

FROSTBITE Frostbite is the freezing of living tissue due to exposure of flesh to very cold conditions that occurs most commonly in the toes, but the fingers, ears and nose may also be affected. The severity of the frostbite depends on the depth to which the freezing has penetrated. Early symptoms are numbness, itching and a pricking sensation. As the freezing penetrates deeper, stiffness and shooting pains will occur, the skin is white or yellow, and the toe or finger becomes immobile. Freezing of the skin itself is not particularly serious, but if the freezing penetrates to the bone, the tissue will die, and the finger or toe requires amputation. Late stages of frostbite are characterised by blistering, swelling, black colouration and gangrene. Treatment involves slow and gradual thawing of frozen tissue in warm water. Rapid rewarming or overheating further damages the tissue. Never warm an area affected by frostbite by rubbing or massage. If two people are present, thawing each otherʼs toes by placing them in the other person's armpit is an ideal method. After thawing, the tissue should be kept protected and warm. No dressings should be applied, but the affected areas should be left exposed in a warm room. Antiseptics may be applied to blisters and antibiotics given for infection. Only after several days or weeks, is amputation of affected fingers or toes considered, as recovery may occur from an apparently hopeless situation. Moist gangrene is an indication for immediate amputation. Any area that has been frostbitten will be more susceptible to frostbite in future. See also CHILBLAINS

GANGLION CYST A ganglion of a tendon is a benign thin-walled cyst filled with a thick, clear fluid that develops on a tendon of the wrist, hand or foot. It has nothing to do with a nerve ganglion, Tendons slide within fibrous sheaths lined with a smooth synovial membrane, which prevent the tendon from slipping out of position around a joint. Within the sheath, the tendon is surrounded by a thin film of lubricating synovial fluid. A tiny puncture in the sheath allows some of the synovial fluid around the tendon to escape and form a disfiguring hard lump on the back of the hand, wrist or less commonly on the top of the foot. Painful bleeding may occur into the ganglion, or pressure on a nerve may cause also cause pain. Rarely the ganglion may become infected.

48 A RATIONALE FOR RASHES Treatments available are either a minor operation, in which the ganglion is cut away from the tendon, or a needle is inserted into the ganglion to withdraw the thick fluid within, and a small amount of a steroid solution is then injected. Many settle spontaneously, but they may recur after injection, while most are permanently cured by surgery.

GENERALISED ACUTE PUSTULAR PSORIASIS Generalised acute pustular psoriasis (also known as von Zumbusch psoriasis) is a severe, rare form of psoriasis affecting adults. The cause is unknown, and the patient may or may not have previously had another form of psoriasis. The symptoms are a sudden onset of burning red skin that rapidly spreads within hours across a large area of the body. Pustules then form on the red skin and enlarge to form large pus filled blisters. The patient is weak, feverish, has a headache and is obviously very ill. Blood tests show a very high white cell count, but skin and blood cultures for infection are negative. Treatment is in hospital, and in the same way as a patient with severe burns. Fluids are given through a drip, antibiotics are given to prevent infection, and potent medications are given to reverse the skin inflammation. There may be one or a series of attacks. Dehydration from fluid loss through the damaged skin is a major concern. The disease is life threatening, but most people recover completely with correct treatment. See also GUTTATE PSORIASIS; PSORIASIS

GENERALISED ERYTHRODERMA See EXFOLIATIVE DERMATITIS

GENITAL HERPES Genital herpes is a contagious viral infection of the genitals caused by the Herpes simplex type 2 virus, which is caught by sexual contact with someone who already has the disease. It is possible, but unlikely, for the virus to be caught in hot spa baths and from a shared wet towel. If sores are present, there is a good chance of passing the disease on, but a patient is also infectious for several days before a new crop of sores develop. Condoms can give limited protection against spreading the disease. If a condom is worn, a woman can more easily pass the infection to a man than vice versa, and the overall risk is reduced by 75%. Normally it is easier for men to pass the infection to women. Once a person is infected with the virus, it settles in the nerve endings around the vulva or penis, and remains there for the rest of that person's life. With stress, illness or reduced resistance, the virus starts reproducing and causes painful blisters and ulcers on the penis or scrotum (sac) in the male; and on the vulva (vaginal lips), and in the vagina and cervix (opening into the womb) of the female. The first attack may occur only a week, or up to some years, after the initial infection. An attack will last for two to four weeks and then subside, but after weeks, months or years, a further attack may occur. Women are affected more

49 A RATIONALE FOR RASHES severely and frequently than men. The incidence of gynaecological cancer is increased in women with the infection and in rare cases it can cause encephalitis (brain infection). If a baby catches the infection from the mother during delivery, it can cause severe brain damage in the child. For this reason, if a woman has a history of repeated herpes infections, she may be delivered by caesarean section. The infection is diagnosed by taking a swab from the ulcer or a blood test. Antiviral tablets (eg. valaciclovir, aciclovir, famciclovir) will control an attack, but must be started within 72 hours of its onset, or they can be taken for months or years to prevent further attacks. Good control is possible with modern medications. A person taking antiviral medication long term to prevent attacks of genital herpes can still pass the infection on to a sexual partner, but the overall risk is reduced by 50%. Without any treatment, the average time for attacks to stop coming is four years, but recurrences may still occur decades later at a time when the patient is stressed or has another illness that reduces overall resistance to infections.

GENITAL WARTS Genital or venereal warts (condyloma accuminata) are a sexually transmitted viral infection caused by the human papilloma virus (HPV), which is transmitted from one person to another only by sexual intercourse or other intimate contact, but condoms can give some protection against the infection. It is not possible to catch it from toilet seats or spa baths. The incubation period varies from one to six months. Warts, sometimes of a large size, grow on the penis in men and in the genital area of women. They initially appear as flat, pale areas on the skin, or as dark-coloured, irregularly shaped lumps. Both men and women can be carriers without being aware they are infected, and in women genital warts may develop internally where they are difficult to detect. A significant proportion of women with this infection will develop cancer of the cervix, which can only be detected at an early stage by regular Pap smears. Anyone with genital warts should also have tests performed to check for the presence of other venereal disease. Small warts can be more easily seen if a special stain is applied to the skin, then treatment can be given with antiviral imiquimod cream applied three times a week for up to four months, acid paints (eg. trichloroacetic acid) or acid ointments, freezing with liquid nitrogen, or burning with electric diathermy or laser. The treatment is often prolonged, and warts tend to recur, but with careful watching and rapid treatment of any recurrence the infection will eventually settle. See also WART

50 A RATIONALE FOR RASHES GERMAN MEASLES German measles (rubella) is a contagious viral infection caused by a Togavirus, which is widespread in the community, and causes epidemics every few years. It spreads from one person to another with coughs and sneezes, but can be caught only once in a lifetime, although an infection in a child may be so mild that it is completely overlooked. The incubation period is two to three weeks. Infection occurs most commonly in children, and produces a fine rash over the body that lasts only two or three days, is not itchy, and is not accompanied by the sore eyes and cold symptoms associated with common measles. There are often some enlarged lymph nodes at the back of the neck, and in severe cases there may be a fever, runny nose and joint pains. If a pregnant woman catches the disease between the sixth and twelfth weeks of pregnancy, infection may cause blindness, deafness, heart damage and other serious defects to her child. As a result, an antibody blood test is sometimes done to confirm the disease or determine the immune status of a pregnant woman. Paracetamol for fever and discomfort is all the treatment that is necessary. Children must be excluded from school for four days after the rash first appears. An effective vaccine is available, and all children are now given mumps, measles and rubella as a combined vaccine at one and four years of age. Once infected with, or vaccinated against rubella, antibody levels rise permanently and reinfection is not possible. See also FIFTH DISEASE; MEASLES; ROSEOLA INFANTUM

GIANOTTI CROSTI SYNDROME The Gianotti Crosti syndrome is a skin rash that usually affects children between the ages of 6 months and 12 years. It often occurs in clusters, with multiple children who are in contact being affected, and usually follows an upper respiratory tract infection. the cause is an abnormal skin response to a viral infection (eg. Hepatitis B, Epstein Barr virus, Coxsackie viruses, Echo viruses, respiratory syncitial virus). Over 3 or 4 days multiple slightly raised dull red spots develop on the thighs and buttocks, then spread to the arms and face. Later spots often look purple, especially on the legs, due to leakage of blood into them from capillaries. The patient may feel quite well or have a mild fever, there may be a mild itch, slightly enlarged lymph nodes in the armpits and groins, and an enlarged liver. There is no specific treatment, but a mild steroid cream may be used for the itch. The rash fades in 2-8 weeks with mild scaling. Recurrence is unlikely but has been reported.

51 A RATIONALE FOR RASHES GLOMUS TUMOUR A glomus tumour (or glomangioma) is a painful, but benign, skin discolouration caused by a developmental defect of nerve tissue in the skin. Patients develop one or more painful, pink to purplish lumps (nodules) on the skin of the hands or feet. They may occur under the nails. The pain is worse with heat or pressure. Examination of the removed nodule under a microscope is diagnostic. Surgical removal is the only, and a very successful, form of treatment.

GOLTZ SYNDROME Goltz syndrome (also known as focal dermal hypoplasia) is a rare condition of abnormal skin development due to a partial or complete absence of normal skin in affected areas. Scar- like areas of very thin skin are found on the scalp, thighs and sides of pelvis. There may also be a lack of body and scalp hair, and nail abnormalities. A biopsy of an affected area of skin examined under a microscope can make definite diagnosis. There is no cure, but some areas may be improved by plastic surgery.

GORLIN GOLTZ SYNDROME The Gorlin-Goltz syndrome (or basal cell carcinoma naevus syndrome) is a rare inherited condition of children characterised by the development of multiple basal cell carcinoma (BCC), skin cancers and other abnormalities including calcification of areas of the brain, abnormal vertebrae and ribs, multiple cysts in the jaw and pitting of the palm. Other characteristics that may be present include a large head, skin cysts, depressed breast bone, lumps of fibrous tissue in the heart, cleft lip, and extra fingers and toes. X-rays of jaw, vertebrae and ribs can help make the diagnosis. Excision of jaw cysts and basal cell carcinomas is the only treatment, but recurrence of skin cancers and jaw cysts after excision is common. See also BASAL CELL CARCINOMA

GOURGEROT-BLUM SYNDROME See CAPILLARITIS

GRAFT VERSUS HOST DISEASE Graft versus host disease (GvHD) is an uncommon but severe immune reaction affecting the whole body due to a reaction between tissue donated by one person and the body of the recipient of the tissue. It is most common after bone marrow transplantation for diseases such as leukaemia and aplastic anaemia, where it occurs mildly in 8% of transplants, and seriously in about 1%. There are two forms of the disease, acute and chronic. Symptoms start two to twelve weeks after the transplant in acute cases, and more than three months later in chronic cases. The symptoms of acute GvHD are very variable depending on organs affected. Mild symptoms include itchy skin, skin pain and soreness, and tender soles and palms. With more severe cases, symptoms may include nausea, vomiting, red patches or lumps in and on the skin, fever, jaundice (yellow skin) from liver damage, mouth and nostril sores, belly pain, diarrhoea, eye ulceration, blistering and shedding of inflamed skin, ulcers in the oesophagus, bleeding into the lung and coughing of blood, and massive loss of skin similar to severe burn. The acute form may be a life threatening condition, as patient has little or no immunity to any

52 A RATIONALE FOR RASHES form of infection, and severe bacterial, viral or fungal infections may start in skin or lungs, and spread to blood to cause septicaemia. Chronic GvHD causes weight loss, flat-topped red raised small skin lumps, and in more severe cases hair loss, skin pigment loss (white patches) or gain (dark patches or areas), liver damage and jaundice. Numerous blood tests may be abnormal, but there is no specific diagnostic test. Prednisone by mouth is the main treatment, while creams containing steroids are used in milder cases. Ultraviolet light with associated medication may also be useful, but severe cases require a drip with steroids and other potent medications. Most acute forms respond well to treatment, but if secondary infections occur, the outlook is poor. Chronic GvHD settles slowly with time and treatment.

GRANULOMA A granuloma is a nodule of abnormal tissue that may develop on the surface of an organ or the skin. It usually occurs as a result of persistent inflammation or irritation of a tissue. A granuloma may develop around a splinter in the skin or an area that is constantly scratched. See also FISH TANK GRANULOMA; GRANULOMA ANNULARE; GRANULOMA INGUINALE

GRANULOMA ANNULARE Granuloma annulare causes one or more ring shaped lumps of 1-3 cm. diameter to develop on the back of the hands, elbows or top of the feet. The lumps are covered with normal skin but vary in colour from red to white. They are harmless, but slightly disfiguring. The cause is unknown although the may be associated with diabetes, and they are more common in teenagers and young adults. The diagnosis is confirmed by a skin biopsy. No ideal treatment exists. Application of potent steroid creams, or injections of steroids into the skin lesion are sometimes successful, while cryotherapy (freezing), ultraviolet light and medications used to treat cancer are other options. Spontaneous regression is possible over years. See also SKIN LUMPS

GRANULOMA INGUINALE Granuloma inguinale (donovanosis or granuloma venereum) is caused by the bacteria Donovania or Calymmatobacterium granulomatis, which pass from one person to another during sexual intercourse. The incubation period is one to twelve weeks and it causes painless nodules on or around the genitals that break down to shallow ulcers, and may join together into progressively larger ulcers that spread up onto the lower abdomen. Infection of the ulcers with other bacteria will cause them to fill with pus and become foul smelling.

53 A RATIONALE FOR RASHES Microscopic examination of a biopsy or swab smear from the edge of an ulcer reveals the responsible bacteria and confirms the diagnosis. Treatment is difficult, and it may be necessary to take antibiotics such as tetracycline for several months. Relapses are common unless full antibiotic course completed. See also GENITAL ULCER

GRANULOMA VENEREUM See GRANULOMA INGUINALE

GRAVITATIONAL ECZEMA Gravitational eczema occurs mainly in older women due to poor drainage of veins in the legs from varicose veins, thromboses or other circulatory problems. Excessive blood pressure in the veins increases the fluid pressure in the tissue to create the rash. The symptoms are an itchy red blotchy rash affecting the lower legs, a firm swollen leg that is worse after standing and eased by raising the leg (eg. after resting overnight in bed), and hot weather aggravates the problem. The rash may ooze and become infected by bacteria, and scratching may break down the skin resulting in thickening and permanent pigmentation due to scar formation. In severe cases, ulcers may form. An ultrasound scans may be used to check circulation. Patients should avoid prolonged standing, and when seated, should place their leg on a footstool and elevate the foot of the bed slightly at night. Steroid creams will ease the itch and irritation, and moisturising creams should be used regularly to keep the skin soft and supple. Condyʼs solution compresses may be used to dry up oozing, and antibiotics are prescribed for any infection that may develop. Patients must never scratch the affected skin. In severe cases, elastic pressure stockings may be used to reduce the collection of blood in the leg, or surgery to remove varicose veins may be considered. The condition is usually chronic, with frequent relapses. See also ECZEMA

GRÖNDBLAD-STRANDBERG SYNDROME See PSEUDOXANTHOMA ELASTICUM

GROVER DISEASE Grover disease (transient acantholytic dermatosis) is an itchy skin condition of the chest and back that usually affects men over 50, and much less commonly women or younger people. It frequently follows sweating or some unexpected heat stress to cause the sudden onset of very itchy spots on the central back, mid chest and occasionally elsewhere. A skin biopsy can be used to confirm diagnosis. Treatment is unsatisfactory as it is necessary for patients to remain cool and avoid sweating. A mild steroid lotion can be applied frequently to give temporary relief. Most cases settle in six to twelve months, but occasionally it may last longer.

54 A RATIONALE FOR RASHES GUINEA WORM Dracunculiasis (Guinea worm disease) is a worm infestation that occurs only in west and central Africa, although it used to occur in south Asia and Arabia. It is being actively eradicated from its remaining areas of infestation in Africa and may be totally eradicated by 2010. The worm Dracunculus medinensis is caught by swallowing water contaminated by microscopic crustaceans (copepods - water fleas) that contain the worm larva. In the stomach these are released, burrow through the stomach wall into the bloodstream, and migrate to the fat under the skin where they mature. After mating the male worm dies, but the mature female worm, which may be 60 to 80 cm. long, moves to the skin surface where it forms a sore, and through this discharges eggs every time the skin comes into contact with water. The eggs are then swallowed by the copepods where the cycle starts again. The worms eventually die and emerge through the skin sore, or occasionally remain under the skin. The full cycle takes 9 to 14 months. Patients experience generalised itching, fever, shortness of breath and nausea when larvae are in the blood. Redness, burning and itching occurs at the site of skin sores, usually on the foot or leg. After the worm dies a red, tender ulcer forms. Smears from skin sores show eggs when examined under a microscope to confirm the diagnosis. The patient should rest with affected leg elevated. Worms can be individually removed by exposing one end and then slowly drawing them out a centimetre at a time over several days. Medications (eg. thiabendazole) cannot kill worms, but may encourage them to be expelled through a sore. Secondary bacterial infection of an ulcer can spread to the surrounding skin (cellulitis). Abscesses can form under the skin (particularly if a worm is broken during removal), in joints or rarely in other organs that are reached by worms. The ulcers heal after a month or two and most patients recover eventually after a prolonged period of disability.

GUMMA A gumma is a rubbery sore that contains dead (necrotic) tissue and is usually caused by syphilis. They are most commonly seen in the skin of patients with third stage syphilis. See also SYPHILIS

GUTTATE PSORIASIS Guttate psoriasis is a very active form of the skin disease psoriasis that is more common in teenagers and young adults and may follow a Streptococcal bacterial infection. Patients experience the sudden appearance of multiple small, red, scale covered patches on the arms, leg and trunk that may gradually enlarge and merge, and it may progress to normal psoriasis. Usually no investigations are necessary, but if the diagnosis is in doubt it may be confirmed by a skin biopsy.

55 A RATIONALE FOR RASHES One or more of numerous skin preparations including coal tar, dithranol, calcipotriol and steroid creams are used in treatment. It may disappear spontaneously after a few weeks, or persist for many years, and is controlled, but not cured, by medication. See also PITYRIASIS LICHENOIDES; PSORIASIS

GvHD See GRAFT VERSUS HOST DISEASE

HAEMANGIOMA An haemangioma (angioma) is a localised over growth of arteries and veins in the skin, intestine, spinal cord, brain or inside other organs. They appear as a red lump that blanches (turns white) with pressure. Haemangiomas may bleed dramatically if injured, and in the gut be responsible for steady blood loss and anaemia. They may also put pressure on nerves (eg. in spine) to cause pain or loss of nerve function.

No investigations are necessary for haemangiomas in the skin. Internal haemangiomas may be detected by angiography (injecting dye into a blood vessel and taking an x-ray), CT or MRI scans, gastroscopy or colonoscopy. Surgical removal is performed if the spot is cosmetically unacceptable or causing symptoms. See also ANGIOKERATOSIS; BLUE RUBBER BLEB NAEVUS SYNDROME; CAMPBELL de MORGAN SPOTS; CAVERNOUS HAEMANGIOMA; FABRY DISEASE; SPIDER NAEVI; STRAWBERRY NAEVUS; VENOUS LAKE

HAILEY-HAILEY DISEASE Hailey-Hailey disease (also known as benign familial chronic pemphigus) is a rare, inherited skin condition that starts in middle age and involves the armpits, groin and under the breasts. It is characterised by small blisters that break down into a red, moist or crusted sore with tiny cracks across it. The diagnosis is confirmed by a skin biopsy. Secondary fungal and bacterial infections are common. Drying agents may be applied to affected areas, while small areas may be surgically excised, but there is no cure, although it usually settles in old age. See also PEMPHIGUS

56 A RATIONALE FOR RASHES

HALO NAEVUS A halo naevus is an area of depigmentation around a benign pigmented spot (naevus) that is common in Caucasian children and young adults. It is an autoimmune response to the presence of the naevus that appears as a dark brown spot surrounded by an area of abnormally white skin. The naevus often disappear over a few years. See also NAEVUS

HAND FOOT MOUTH DISEASE Hand foot mouth disease is an infection that virtually every child will eventually catch caused by a Coxsackie virus. The infection is usually so mild that it causes no symptoms, but in severe cases a child will develop blisters on the soles and palms, and mouth ulcers. It may be accompanied by a mild intermittent fever, headache and irritability. Paracetamol is the only treatment necessary. The rash persists for three to five days before settling without any problems. See also COXSACKIE VIRUS INFECTION

HANSENʼS DISEASE See LEPROSY

HARLEQUIN SYNDROME The harlequin syndrome is a rare, congenital, disfiguring disease due to abnormal skin formation. The child is born with very thick hard plates of skin separated by deep cracks, and there may also be absence of the ears, and out turning of the lips and eyelids to give a grotesque appearance. There is an inability to move joints freely due to skin hardening. The diagnosis is confirmed by skin biopsy and treated with moisturising cream in large quantities, but death within days or weeks of birth is usual, and many die before birth.

HEBERDEN NODES Heberden nodes are bony lumps on the back of the outermost finger joints (distal interphalangeal joints). They are a sign of osteoarthritis, are more common in women and

57 A RATIONALE FOR RASHES may be due to an inherited tendency. They are named after the English physician William Heberden (1710-1801). See also BOUCHARD NODES

HENOCH-SCHÖNLEIN SYNDROME The Henoch-Schönlein syndrome (anaphylactoid purpura) is a generalised inflammation of small blood vessels resulting in the formation of small red spots in the skin (Henoch-Schönlein purpura). It may be a complication of a number of different diseases (eg. after a Streptococcal bacteria infection), but its cause is often unknown, although it is more common in children. Small, slightly raised dilated blood vessels (purpura) appear on the skin as red or purple patches about five to ten millimetres across. There may also be bleeding into the intestine, lungs, kidneys and joints to cause belly pain, coughing of blood, blood in the urine and arthritis. It is diagnosed by biopsy of one of the purpura in the skin, but no treatment is normally necessary as the condition is self-limiting and usually settles without serious long-term problems in one to six weeks. If the kidneys become involved medical treatment is necessary, as long-term kidney damage may occur. Eduard Henoch (182-1910) and Johannes Schönlein (1793-1864) were German physicians.

HEREDITARY HAEMORRHAGIC TELANGIECTASIA See OSLER-RENDU-WEBER DISEASE

HERPES GESTATIONIS Herpes gestationis (pemphigoid gestationis) is a rare, generalised blistering rash that occurs in pregnancy between the fourth and seventh months, and sometimes after delivery. It occurs in less than one in ten thousand pregnancies, and is an autoimmune reaction that may be aggravated by oestrogen. It is not an infection, and not related to genital herpes. Patients develop extremely itchy, fluid filled, scattered small lumps on the body, particularly the belly, sides of the trunk, palms and soles. These may enlarge to form large fluid filled blisters, before bursting and forming crusts. A biopsy of one spot is normally necessary before the diagnosis can be confirmed. Prednisone tablets, starting at a high dose and gradually reducing are the usual treatment. The prognosis is good and the condition usually does not affect the baby, but it tends to recur in subsequent pregnancies.

HERPES SIMPLEX TYPE ONE See COLD SORE; ERYTHEMA MULTIFORME; WHITLOW

58 A RATIONALE FOR RASHES

HERPES SIMPLEX TYPE TWO See GENITAL HERPES

HERPES ZOSTER VIRUS See CHICKENPOX; RAMSAY-HUNT SYNDROME; SHINGLES

HIDRADENITIS SUPPRAVITA is an uncommon skin disorder caused by hair follicles blocked by keratin, in which painful boil-like lumps develop in the groin, armpits and under the breasts and around the anus and vulva. It is more common in women. Abscesses may develop due to secondary bacterial infection and fistulas (channels) may form into the anus and vagina. Treatment is unsatisfactory. Patients should wash with antiseptics to reduce skin bacteria, use antibiotics (eg. tetracycline, clindamycin, metronidazole) long term, and doctors may surgically remove persistent lumps. Some women benefit by taking the oral contraceptive pill. Roaccutane tablets and radical surgery to excise the entire affected area are used in very severe cases. Unfortunately, the condition often persists long term.

HIDRADENOMA A hidradenoma is a benign tumour of sweat glands that appears as a small firm lump on the skin.

HISTIOCYTOMA See DERMATOFIBROMA

HIVES See URTICARIA

HOUSEWIFEʼS DERMATITIS See CONTACT DERMATITIS

HPV See HUMAN PAPILLOMAVIRUS

HUMAN PAPILLOMAVIRUS The human papillomavirus (HPV) is the virus responsible for the development of all types of warts. More than 50 different types of papillomavirus are known to affect humans. If the

59 A RATIONALE FOR RASHES female cervix is affected, these viruses predispose to the development of cancer of the cervix. They may also aggravate the formation of squamous cell carcinomas (skin cancer). See also CONDYLOMA ACCUMINATA; GENITAL WARTS; PLANE WARTS; PLANTAR WARTS; WART

HUTCHISON MELANOTIC FRECKLE A Hutchison melanotic freckle (melanoma in situ or lentigo maligna) is an irregular flat black-blue pigmented spot, usually on the face of the middle aged or elderly, that slowly enlarges. It is diagnosed by biopsy, and small spots may be frozen (cryotherapy), but larger spots are surgically excised. Rarely they develop into a malignant melanoma. Without treatment, they slowly enlarge and thicken. See also MELANOMA

HUTCHISON PRURIGO See PHOTODERMATITIS

HYPERCAROTENAEMIA See CAROTENAEMIA

HYPERKERATOSIS A hyperkeratosis (actinic or solar keratosis) is a common form of sun damage to exposed areas of skin. Skin damage is more common during childhood and on fair skinned people. It appears as a patch of rough, raised and scaling skin, but it is not red or itchy. One quarter of all hyperkeratoses disappear spontaneously every year, while one in a thousand may progress to become a squamous cell carcinoma (SCC) every year. It may be treated when suspected by acid ointments, anticancer cream (5-Fluorouracil), freezing (cryosurgery), burning (diathermy) or surgical excision. In some elderly patients with very large affected areas it may not be practical to remove all the spots, but they should be checked regularly so that any spots that change can be treated. The prognosis is very good, but new spots tend to arise in nearby areas. See also DERMATOHELIOSIS; SEBORRHOEIC KERATOSES; SQUAMOUS CELL CARCINOMA OF THE SKIN

ICHTHYOSIS Ichthyosis is an uncommon congenital (present since birth) skin condition due to a

60 A RATIONALE FOR RASHES lack of oil glands in the skin. Numerous subtypes are known (eg. ichthyosis vulgaris - most common type; X-linked ichthyosis - affects males only; ichthyosis linearis circumflexa - affects babies). Widespread scaling, dryness and thickening of the skin occurs, and the diagnosis is confirmed by a skin biopsy. Massive quantities of moisturising creams and oils must be applied to the skin, but the skin is more susceptible to other skin diseases, sun damage and poor healing. No cure is possible.

IDIOPATHIC THROMBOCYTOPENIC PURPURA See THROMBOCYTOPENIA

IMMATURE HAEMANGIOMA See STRAWBERRY NAEVUS

IMPETIGO Impetigo or school sores, is a very common skin infection that virtually every child will catch, but it may also occur in adults. Several different bacteria may be responsible, but the most common is Staphylococcus aureus (“golden staph”). This is a serious infection inside the body, but relatively mild on the skin. Impetigo spreads from one person to another by close contact, and sometimes an infected animal may act as a source. Once one sore develops on the skin, scratching with fingers can rapidly spread the infection to other parts of the body. It is more common in warm climates and in summer. An itchy, red, raised, weeping or crusting sore appears. If there are a many sores, the patient may feel generally unwell, but normally there are no other symptoms. In new-born babies, impetigo may spread rapidly and become serious, so for this reason, infected children should be kept away from infants. If necessary, swabs can be taken from the sores to confirm the diagnosis, determine the infecting bacteria, and select the correct antibiotic.

Treatment involves antibiotic mixtures or tablets, and an antibiotic or antiseptic cream (eg. mupirocin). Antiseptic soaps, not sharing towels and bedding, and careful personal hygiene can be used to prevent the spread of infection, and a child must be excluded from school until

61 A RATIONALE FOR RASHES the sores start to heal. With correct treatment, the sores will heal without scarring in a few days. See also BOIL; SCALDED SKIN SYNDROME

INCONTINENTIA PIGMENTI See BLOCH-SULZBERGER SYNDROME

INFECTIOUS EXANTHEMA See VIRAL EXANTHEMA

INTERTRIGO Intertrigo is an inflammatory skin condition caused by heat, sweat and friction in those who are overweight, have poor personal hygiene, live in the tropics, or suffer from diabetes. Red, damaged, moist, itchy and burning skin occurs in places where the skin folds back upon itself, such as under the breasts, in the groin and armpit, and in skin folds of the abdomen and neck in obese people. In advanced cases, the skin may crack, bleed, become painful and fungal and/or bacterial infections may develop on the damaged skin. Treatment involves scrupulous hygiene, controlling diabetes, using antibiotics and antifungals to remove infection, losing weight, and applying drying powders to the affected areas. A piece of soft cloth placed under bulky breasts, and a well fitted bra may help. Plastic surgery to reduce large breasts or excessive skin on the belly may be appropriate. Unfortunately most patients remain overweight, are not consistent in their hygiene, and the problem persists or recurs.

INTRAEPITHELIAL CARCINOMA An intraepithelial carcinoma (IEC) is a common cancer in the outer layers of skin, similar to, but deeper in the skin than, a squamous cell carcinoma. They usually occur in patients who are over 50 years of age and are caused by prolonged exposure to sunlight. The rims of the ears, the face, scalp, arms and hands are commonly affected. The cancer appears as an unsightly red spot covered in fine white scales that may be itchy or sore. Small IECs are easily removed by burning with a diathermy machine or freezing with liquid nitrogen. If larger, or if the diagnosis is not certain, it is necessary to excise the spot and surrounding tissue. Any IEC that recurs after freezing or burning must be surgically excised. Rarely they may spread by blood or lymphatics to other parts of the body. Treatment is very effective in early stages of the disease. See also BOWENʼS DISEASE; HYPERKERATOSIS; KERATOACANTHOMA; SQUAMOUS CELL CARCINOMA OF SKIN

62 A RATIONALE FOR RASHES IRRITANT ECZEMA See CONTACT DERMATITIS

ISRAELI SPOTTED FEVER See TYPHUS

ITCHY UPPER ARM SYNDROME The itchy upper arm syndrome (brachioradialis pruritus) is a real disease despite its descriptive name, and is an abnormal response of the skin to long term sun damage and the constant release of the irritating substance histamine from allergy (mast) cells in the affected skin. Patients with chronic sun damage to their skin may develop intense itching and burning on outer surface of arm that is worse in summer, but have no apparent rash. A skin biopsy shows the presence of excessive numbers of mast cells. Very strong steroid creams or ointments can be tried, but the condition is generally resistant to treatment.

JANEWAY LESION A Janeway lesion is a small purplish to red nodule on the palm or sole. It is characteristic of infective endocarditis and is caused by the spread (embolism) of an infected lesion from the heart to the capillaries in the palm or sole.

JUNCTION NAEVUS A junction naevus is a common, benign, hairless, brown, flat or slightly raised spot that may occur anywhere on the skin. They rarely become malignant, but when they do so they change in colour, shape, size and thickness and may bleed. Junction naevi that are constantly irritated (eg. on a collar line, or under a large breast) are more likely to become malignant. See also MELANOMA; NAEVUS

JUVENILE PLANTAR DERMATOSIS Juvenile plantar dermatosis is a skin disease affecting the feet of children, usually boys between four and eight years of age. The cause is excessive friction between the foot and shoe, particularly synthetic shoes in which sweating is greater. It is more common in children who have asthma, eczema, hay fever or other allergy problems. The sole at the front of the foot becomes shiny, glazed in appearance, covered in a fine scale and sensitive. Tender cracks occur under the toes and sometimes on the ball of the foot. The tops of the feet may sometimes be affected, and the condition is more severe in

63 A RATIONALE FOR RASHES hot weather. In some children, the hands are also affected. Skin scrapings may be taken to exclude a fungal infection. Treatment involves wearing well-fitted leather shoes with two pairs of socks (ideally cotton inside wool), using lubricants on dry skin (eg. paraffin) and barrier creams (eg. dimethicone) over the lubricant. Steroid ointments are used in severe cases. The problem improves spontaneously with age.

KA See KERATOACANTHOMA

KELOID Some people have an inherited tendency in which there is excessive healing of a scar that results in a keloid. In some cases it may occur at the site of an acne scar. It is more common in Negroes, and on the chest, back and neck. A red or brown, raised, thick scar that may become painful or itchy, forms at the site of skin injury. It may be improved by injection, or application under a plastic dressing, of powerful steroids. Most keloids stop enlarging after a few months, and then persist for many years, before very slowly subsiding in some cases. See also CICATRIX

KERATOACANTHOMA A keratoacanthoma (KA) is a rapidly enlarging skin growth that is often confused with a skin cancer. They are more common in the elderly and on the face, hands and other sun- exposed areas of the body, but rare in dark-skinned races. They initially appear as a small, scale-covered lump, but over a couple of months they enlarge rapidly to become a red, shiny, firm blister topped with a plug of hard scaly material that may be 2 cm. or more in diameter. Over the next few months or years it will slowly disappear, and eventually little or no trace of their presence remains, but they take about twice as long to resolve as they take to develop. No treatment is required but as most KAs are very disfiguring and unsightly they are usually removed surgically. If there is any doubt at all about the diagnosis a biopsy must be taken. Except for the disfigurement they cause, they are quite harmless. See also SQUAMOUS CELL CARCINOMA OF THE SKIN

KERATODERMA Keratoderma is an abnormal thickening of skin that may be inherited, or due to psoriasis, eczema, lichen planus or other skin diseases. Patients have very thick, rough, cracked skin on the palms and/or soles. Salicylic acid ointment or urea cream are used in treatment, but the condition often persists long term. See also ECZEMA; LICHEN PLANUS; PSORIASIS

64 A RATIONALE FOR RASHES

KERATOLYSIS See PITTED KERATOLYSIS

KERATOMA See CALLUS

KERATOSIS See HYPERKERATOSIS; KERATOSIS PILARIS; SEBORRHOEIC KERATOSES

KERATOSIS FOLLICULARIS See DARIER DISEASE

KERATOSIS PILARIS Keratosis pilaris is a very common skin condition that affects women twice as often as men, tends to run in families, and starts in the teenage years. It occurs most commonly on the back of the upper arms, front of the thighs and buttocks. The cause is excess keratin (scale) formation at the opening of hair follicles. Small rough polyps appear on the skin and salicylic acid or urea cream and other scale removing (keratolytic) agents can be used to remove the excess keratin. The condition tends to settle in mid-life. See also KERATOLYTICS

KERION A kerion is an abscess of the scalp caused by the fungi Trichophyton, Microsporum and other fungi that normally cause tinea (ringworm). A sore, boggy, raised abscess develops on the scalp and there may be spread of the fungal infection to other areas of the skin. A swab can be taken to identify the responsible fungus, then potent antifungal tablets and creams are used to cure the infection. See also TINEA CAPITIS

KLIPPEL-TRENAUNAY SYNDROME The Klippel-Trenaunay syndrome is a condition in which there is massive overgrowth of blood vessels within the skin and other tissues. The cause is unknown.

65 A RATIONALE FOR RASHES

The symptoms include artery and vein malformations on the limbs, portwine naevi (large red skin marks), local overgrowth of soft tissue, and sometimes local overgrowth of bone and abnormal connections between arteries and veins elsewhere in the body. Severe bleeding may occur from an abnormal blood vessel. Surgery and compression bandages are the only treatments. See also PORTWINE NAEVUS

LANGERʼS LINES Langerʼs lines (cleavage lines) are the faint lines in the skin, rather like fingerprint lines, that are found on all skin surfaces. They tend to rotate length wise down the arms and legs, and run diagonally across the trunk, but in other areas (eg. the face) there may be complex interconnecting patterns of lines. The lines indicate tensions in the underlying layers of skin and fibrous tissue and are generally along the line that there is least elasticity in the skin. Often skin moles and growths have a long axis in the direction of the Langerʼs lines. A surgical incision made along these lines will leave less scarring after healing than an incision made across the lines.

LARVA MIGRANS See CUTANEOUS LARVA MIGRANS

LEINER DISEASE Leiner disease (erythroderma desquamativum) is a rare disease of infants characterised by generalised dermatitis with red scaling skin all over the body, and seborrhoeic eczema of the scalp. See also SEBORRHOEIC ECZEMA

LEIOMYOMA CUTIS A leiomyoma is a benign, painful skin tumour that usually occurs on the arms and legs. The cause is unknown, but is due to overgrowth of tiny muscles in the skin. Groups of multiple, small, red-brown, painful lumps (nodules) appear under the skin. The condition is diagnosed by biopsy of a lump, and cured by surgical removal of each spot, otherwise it persists life long otherwise.

LENTIGO Lentigo is a skin pigmentation condition that starts in childhood and affects mainly Caucasians. There is an inherited tendency that is aggravated by sun exposure. Small, permanent, pigmented spots appear on the skin. Rarely it is necessary to biopsy a spot to confirm the diagnosis. No treatment is normally necessary but plastic surgery can be performed to remove disfiguring spots. See also ACANTHOSIS NIGICANS; DOWLING-DEGOS DISEASE; HUTCHINSON MELANOTIC FRECKLE

LENTIGO MALIGNA See HUTCHINSON MELANOTIC FRECKLE

66 A RATIONALE FOR RASHES

LEOPARD SYNDROME Leopard syndrome is a congenital heart and skin pigmentation disorder that passes through families from one generation to the next. The characteristics are multiple brown spots on the skin, excessive skin pigmentation, narrowing of the valve in the artery leading from the heart to the lungs (pulmonary valve), enlarged heart and other organs, and sometimes deafness. Heart failure and attacks may occur. It is diagnosed by an abnormal ECG (cardiograph) and echocardiogram (ultrasound scan of heart). There is no cure, but it is controlled reasonably by heart valve surgery.

LEPROSY Leprosy (Hansenʼs disease) is a very slowly progressive infection caused by the bacterium Mycobacterium leprae that damages the skin and nerves (neuropathy). It is spread from one person to another by prolonged close contact, most commonly in childhood. Pale, thick patches of skin on the hands and feet are the first sign, followed by slowly enlarging nodules, then nerves supplying the affected areas of skin become involved and sensation is lost. The cooler parts of the body, furthest from the heart, are affected first. As the disease progresses, a pins and needles sensation may be felt, ulcers form, and bones in the fingers and toes begin to disintegrate. There is rarely any pain. Damage and deformity is due to unintentional burns and injuries to totally numb tissue. In severe cases, fingers and toes do fall off, but this is very rare. The diagnosis can be confirmed by microscopic examination of a skin biopsy. A number of antileprotic drugs (eg. dapsone, clofazimine, rifampicin, ethionamide) are available that will slowly cure leprosy over several years. Any existing deformities must be treated with plastic surgery. With good management, cure is possible and patients can live normally in the community. Untreated, the disease progresses to death over 10 to 20 years. Curiously, the armadillo is the only animal other than humans that can catch leprosy.

LICHEN AUREUS See CAPILLARITIS

LICHEN AXILLARIS See FOX-FORDYCE DISEASE

LICHENIFICATION Lichenification is a medical term for thickening and hardening of the skin or a membrane. Repeated scratching of the skin will lead to lichenification. See also DERMATOSCLEROSIS

67 A RATIONALE FOR RASHES LICHEN PLANUS Lichen planus is an uncommon skin condition which normally affects people in their twenties to forties. It may start where the skin has been injured, may be a chronic viral infection of the skin, or may be triggered by drugs, but the actual cause is unknown. Small, red to pink, shiny, flat topped, itchy skin growths develop and may enlarge and join together to form a plaque. Multiple paques may develop. They are more common in skin creases such as the inside of the wrists and elbows, but can occur anywhere on the body, including the insides of the mouth, nose, ears, vagina and anus. It is diagnosed by a skin biopsy. Mild cases are often not treated, but more serious cases are treated with steroid creams and occlusive plastic dressings. Further treatments include steroid tablets or injections under a plaque, ultraviolet light, excision of the plaque and the use of potent medications such as retinoic acid and dapsone. The long-term course is very variable. Some patients recover in a few months, while others may suffer for years, but eventually complete recovery does occur. Some pigmentation of the skin may remain after the rash has cleared. See also LICHEN SCLEROSIS; LICHEN SIMPLEX

LICHEN SCLEROSIS Lichen sclerosis et atrophicus (to give its full name) causes scarring of the tissue on the genitals and affects women more than men. The cause is unknown, but infection or injury to the genitals may be a factor. In men a thickened area of skin develops on one side of the penis, which causes a sideways curve to the penis that may be painful during an erection, and sexual intercourse may be difficult. In women, a shiny white itchy area with a red margin appears on the vulva. It may also occur in skin on other parts of the body. Biopsy of affected skin is sometimes necessary to make a diagnosis. Minor surgery can be performed to stretch the scarred penis tissue, and steroid creams are prescribed for the itch. See also LICHEN PLANUS; LICHEN SIMPLEX

LICHEN SIMPLEX Lichen simplex chronicus (circumscribed dermatitis) is a type of persistent dermatitis that is thought to be a form of nerve rash, and patients who are anxious, tense, nervous or aggressive are more likely to develop it. In some cases, mild stimulants such as tea or coffee may aggravate the condition. Intensely itchy, dry, scaling, thick plaques develop on the skin. They may appear anywhere, but usually occur in areas, which are easy to scratch, such as the wrist, neck, thigh and groin. Permanent skin scarring may occur from scratching. A skin biopsy may help with the diagnosis.

68 A RATIONALE FOR RASHES Stopping tea and coffee may dramatically improve the itch, and it is important for patients to avoid any further damage to the skin from scratching by bandages or applying a plaster. Steroid creams and injections into the affected areas of skin may be beneficial. Avoiding stressful situations is helpful, but often not practical.

If the patient can stop scratching the skin, the disease will cure itself. See also ECZEMA; LICHEN PLANUS; LICHEN SCLEROSIS

LICHEN URTICARIUS See PRURIGO

LINEAR IgA DERMATOSIS Linear IgA dermatosis is a rare skin disease that affects teenagers. It is a congenital abnormality of the immune system due to excess immunoglobulin A (IgA) under the skin. Patients develop very itchy, severe skin blistering that occurs in groups or lines over the outer surfaces of joints (eg. knees, elbows) and on the buttocks and neck. Ulcers may form in the mouth. Secondary infection of blisters is possible, with resultant scarring. Specific blood tests are abnormal, and a skin biopsy can confirm the diagnosis. Medications such as dapsone, prednisone and specific sulfas are used in treatment. These medications are usually successful in controlling, but not curing, the disease. See also DERMATITIS HERPETIFORMIS

LINEA NIGRA Literally, linea nigra translates from the Latin as black line. It is a line of pigment that forms on the skin of some pregnant women, running from the top front of the pelvis (pubic symphysis) to the umbilicus, and sometimes up as far as the sternum. It is harmless, and tends to fade after the pregnancy.

LIVEDO RETICULARIS Livedo reticularis is a skin reaction indicating an underlying disease or generalised reaction. A maroon to red, net like or starburst pattern rash appears on the skin, particularly on the buttocks and thighs. The rash becomes more pronounced if skin exposed to cold. The cause is damage to veins in the skin from any one of many different diseases such as

69 A RATIONALE FOR RASHES arteriosclerosis (hardening of arteries), embolism (blood clots), polyarteritis nodosa, systemic lupus erythematosus, Sneddon syndrome and leukaemia, or may be a reaction to a drug such as quinidine or amantadine.

The cause of problem and any underlying disease or drug reaction needs to be identified by appropriate tests before treatment can be commenced. Low dose aspirin, pentoxifylline tablets and skin warming may help the rash.

LÖFGREN SYNDROME Löfgren syndrome is a complication of acute stage sarcoidosis that tends to occur in women of Scandinavian or Irish heritage. Erythema nodosum (skin condition) occurs, and enlarged lymph nodes in the chest seen on chest X-ray, in a patient with sarcoidosis. Anti- inflammatory medications control leg and skin symptoms, while the sarcoidosis is also treated. There is an 80% chance of spontaneous recovery See also ERYTHEMA NODOSUM

LOUIS-BAR SYNDROME The Louis-Bar syndrome is a rare form of rapidly progressive brain deterioration due to degeneration of the cerebellum (lower back portion of brain) and spinal cord. The symptoms include dilated capillaries on the whites of the eyes, the face and areas of skin flexion (eg. arm pit, behind knee); intellectual disability; recurrent infections of lungs and ears, and poor coordination that steadily worsens. Late symptoms include twitching movements of the eyes and abnormal writhing movements of the arms and legs. There is an above average incidence of cancer. Numerous blood tests are abnormal, including very low immunoglobulin levels. No treatment is available and death in teenage years is usual.

LYME DISEASE Lyme disease is a relatively common blood infection caused by the bacterium Borrelia burgdorferi that occurs in the northeast United States. It is spread by the bite of the tick Ixodes

70 A RATIONALE FOR RASHES from infected mice or deer to humans. The tic may lie dormant for up to a year before passing on the infection with a bite. The disease has three stages:- - in stage one the patient has a flat or slightly raised red patchy rash, fever, muscle aches and headache. - stage two comes two to four weeks later with a stiff neck, severe headache, meningitis (inflammation of the membrane around the brain) and possibly Bellʼs palsy. - in stage three, which may come three to twelve months later, the patient has muscle pains, and most seriously a long lasting severe form of arthritis that may move from joint to joint. Persistent crippling arthritis sometimes occurs. The diagnosis is confirmed by specific immunoglobulin blood tests, then a prolonged course of antibiotics is prescribed. Long term, one third of patients may suffer from continuing muscle and joint pains, while a smaller percentage have after effects of the meningitis.

LYMPHANGIOMA A lymphangioma (lymphangiomata) is a benign, soft, yellow to tan coloured lump that forms on the skin. It consists of a mass of dilated lymph vessels. Cysts may form in the lymphangioma and swell to an enormous size, but they can be drained to allow treatment. They can be removed by excision or diathermy.

LYMPHOEPITHELIAL CONDITION, BENIGN See MIKULICZ DISEASE

LYMPHOGRANULOMA VENEREUM Lymphogranuloma venereum (LGV) is a sexually transmitted disease that is rare in developed countries but common in Africa and Asia. It is caused by the Chlamydia organism which is a bacteria-like germ that lives inside cells and destroys them. The incubation period after sexual contact is one to three weeks. A sore develops on the penis or vulva, then the lymph nodes in the groin become infected, swollen, soften and suppurate (drain pus) onto the skin. The infection may spread to cause joint, skin, brain and eye infections. If anal intercourse has occurred, sores and pus discharging lymph nodes may form in and around the anus. The initial sore and pus discharging lymph nodes are not painful, and only if the disease spreads does a fever develop. It is diagnosed by special skin and blood tests. Antibiotics such as tetracyclines are prescribed and surgical procedures to drain pus from lymph nodes may be necessary. If left untreated disfiguring scarring will occur in the groin at the site of the infected lymph nodes, and the genitals may become permanently swollen, and

71 A RATIONALE FOR RASHES if the infection spreads to other organs, they may be seriously damaged. The majority of cases are cured by appropriate treatment.

MAJOCCHI GRANULOMA A Majocchi granuloma is a fungal infection of hairy areas of the body. A fungus infects the deepest part of a hair follicle, usually after an injury (eg. deep graze or burn) to the affected area of skin. It causes irritation, inflammation and hair loss on the scalp or other hairy area. Severe infections may result in skin thickening, pustules on the skin and tender nearby lymph nodes. A secondary bacterial infection is possible, as is spread of the fungus to other areas of the skin. Plucked hairs from affected areas may grow the responsible fungus when cultured, but a biopsy of the area may be required to make a final diagnosis. The infection usually responds well to antifungal creams or lotions, and antifungal tablets.

MEASLES Measles (technically called morbilli or rubeola) is a highly contagious Morbilli virus infection that is contagious from five days before the rash appears until it disappears. The incubation period is 10 to 14 days. It was originally a disease of cattle that was only passed to humans after these animals were domesticated many thousands of years ago. It starts with the cold-like symptoms of a snuffly nose, cough and red eyes. A rash develops about four days later, starting in the mouth where tiny white spots appear on the lining of the cheeks. Dark red blotches then develop on the face and gradually spread across the body, remaining for a week or more before gradually fading. Other symptoms include a high fever and eye discomfort with bright lights. The patient often starts to feel better once the rash has reached its maximum spread. The diagnosis can be confirmed by blood tests if necessary, and previous exposure to the measles virus or vaccine can also be confirmed by specific antibody blood tests. There is no specific treatment. Rest, paracetamol and medication are used to relieve the cold symptoms, and vitamin A supplements appear to reduce the severity of an attack. Children must be excluded from school for at least four days after the appearance of the rash. Measles may be prevented by a vaccination, which is usually given at one and four years of age in combination with the mumps and rubella (German measles) vaccine, and with widespread vaccination, it is becoming a rare infection in developed countries, and may be totally eradicated by 2020. Complications include encephalitis (a serious brain infection), pneumonia, ear infections and damage, and possibly the increased risk of developing multiple sclerosis later in life. Immediately after an attack patients are susceptible to other infections, and a significant number will develop tonsillitis, ear and lymph node infections.

72 A RATIONALE FOR RASHES The prognosis is usually very good, but significant complications occur in one in every 200 cases, and death occurs in one in every 5000 cases in developed countries, while in third- world countries one in ten children or adults who catch measles will die. See also GERMAN MEASLES; ROSEOLA INFANTUM

MEASLES, BABY See ROSEOLA INFANTUM

MEASLES, GERMAN See GERMAN MEASLES

MEDITERRANEAN SPOTTED FEVER See TYPHUS

MEDULLARY CARCINOMA A medullary carcinoma is an uncommon, soft, cancer of the skin that contains virtually no fibrous tissue, and arises from the epithelial cells of the skin.

MELANOCYTIC NAEVUS See MOLE

MELANOMA A melanoma is the most serious form of skin cancer, and it starts in the skin cells that create pigment. In Europeans (Caucasians), these cells are relatively inactive, giving a pale colour to the skin, but in Asians (Mongols) they are moderately active, and in Africans (Negroes) they are very active, giving a darker skin colour. The actual cause is unknown, but exposure to sunlight, particularly in childhood and teen years, dramatically increases the risk. Ultraviolet radiation, most of which is filtered out of sunlight by the ozone layer in the upper atmosphere, is the part of the spectrum that causes the damage. Fair-skinned people have a higher incidence than those with dark complexions, and it is rare in children, slightly more common in women than men, and most common between 30 and 50 years of age and on the legs and back. One in every 150 people in Australia will develop a melanoma at some time. It appears as a skin spot that may be black, brown, pink or blue, and the colours may be found individually or mixed. They usually have an irregularly edge, enlarge steadily, have an uneven and bumpy surface, and the pigment can be seen advancing into the surrounding skin, and in advanced cases the

73 A RATIONALE FOR RASHES spot will bleed, scab and ulcerate. They have a tendency to grow deep into the body and migrate to other organs, particularly the liver, lungs and lymph nodes in the armpit and groin. Melanomas can occur under the nail (where they may be mistaken for a bruise), in the mouth, under the eyelids, on the retina inside the eye, and in the anus, but the sun-exposed parts of the skin are the most commonly affected. It is diagnosed by biopsy or excision of the suspected mole, then the melanoma and a large area of skin around and under it, must be cut out. The lymph nodes around the melanoma may also need to be removed. If there is evidence that it has spread to other areas, the patient will also be treated with irradiation and injected medications to control its further growth. In the very early stages there is a 97% cure rate, but as the cancer enlarges, the cure rate drops dramatically. The thicker the melanoma the worse the prognosis, and ulceration of the melanoma at the time it is excised also worsens the long-term outcome. Unfortunately, sometimes the cancer may appear to be cured but can flare up decades later. See also DYSPLASTIC NAEVUS SYNDROME; HUTCHISON MELANOTIC FRECKLE

MELANOMA IN SITU See HUTCHINSON MELANOTIC FRECKLE

MERKEL CARCINOMA A Merkel carcinoma (also known as a Merkel tumour, primary neuroendocrine carcinoma of the skin or a trabecular carcinoma) is a rare form of skin cancer that usually affects the elderly. It develops from nerve cells in the deeper layers of the skin that respond to the movement of hairs, is caused by excess sun exposure over many years, and is often associated with other forms of skin cancer. The cancer appears as firm, raised, painless lumps that may be red, pink or rarely blue in colour on sun exposed skin of the face, hands and neck. In advanced cases, the overlying skin ulcerates. They may spread to nearby lymph nodes and other organs such as liver and bone. It is diagnosed by biopsy or excision of the lump. Treatment involves excision of the tumour with a wide margin of skin, usually followed by irradiation of the area and any nearby lymph nodes. Chemotherapy (potent anticancer drugs) may also be prescribed. Lymph nodes may be removed surgically if necessary. Radiotherapy is often used as an added treatment. About one-third spread to other organs, and one half recur in the skin or nearby lymph nodes. It may not be possible to effectively treat the disease once it has spread. See also MELANOMA

74 A RATIONALE FOR RASHES MILIA Milia (keratin cysts) is a problem of excess keratin (scale) production by oil glands in the skin, commonly in areas of skin damage. Tiny, firm, creamy lumps (papules) appear on the skin, usually of the face. They can be removed for cosmetic reasons by piercing with a needle or cryosurgery (freezing). They persist long term unless removed. See also TRICHOEPITHELIOMA

MILIARIA In conditions of high humidity and heat, an active person will sweat profusely. If the sweat ducts may become blocked, particularly if the person has been involved in dirty work, the blocked sweat glands will appear as small lumps (papules). Itching and redness may occur as the sweat escapes from the blocked glands into the surrounding tissue. This condition is called miliaria (heat rash or prickly heat). Treatment involves a cool, dry environment (eg. air conditioning) or a cool bath.

MOLLUSCUM CONTAGIOSUM Molluscum contagiosum is a mild contagious viral skin infection spread from one person to another by close contact. If the blisters occur on the genitals, it has probably been caught by sexual contact. Multiple small (2-4 mm.), dome-shaped, white blisters with a central dimple appear on scattered parts of their body. The abdomen, chest and face are the most commonly affected areas.

No treatment is normally required. Unsightly or persistent blisters can be removed by a doctor scraping out their contents, or heating them with an electrical cautery needle. Secondary bacterial infection of a scratched blister can occur. The rash disappears spontaneously after three to twelve months. It is not necessary to exclude a child from school.

MONGOLIAN SPOT The Mongolian spot is a diffuse dark bluish patch at the lower end of the spine over the sacrum. It is characteristic of those with Mongolian heritage, tends to run in families, and has been seen in children from eastern Europe to SE Asia, as well as in China and its surrounding areas. It tends to fade with age.

75 A RATIONALE FOR RASHES

MORPHEA Morphea (circumscribed scleroderma) is a skin condition that occurs more commonly in women and starts in early adulthood. It may occur on the forehead when it is called en Coup de Sabre (sabre cut), and on the scalp, limbs and chest. The cause is unknown. It may appear as patches or thick lines on the skin that are initially purplish in colour, then become crusted, thick and shiny. Hairs are lost from affected skin and permanent scarring may occur. It is diagnosed by a skin biopsy. Treatment is unsatisfactory. Plastic surgery is sometimes performed, and while some cases settle spontaneously over many years, most persist long term. See also SCLERODERMA

MUCOCUTANEOUS LEISCHMANIASIS Mucocutaneous leischmaniasis (espundia or naso-oral leischmaniasis) is a protozoan (single celled animal) infection of the nose, mouth and surrounding skin, caused by Leishmania braziliensis, which is transmitted from person to person by direct contact (eg. kissing) or sand flies. Dogs and rats also carry the protozoan. It occurs only in tropical central and South America. Nodules, warty growths or ulcers develop on the nose and lips, and ulcers occur inside the nostrils and mouth. Death may occur from massive ulceration and facial tissue destruction, and it may spread to affect the throat. Disfiguring scars and facial deformities may be left after healing. Secondary bacterial infection of sores is common. Scrapings from ulcers show characteristic changes under a microscope, and other specific diagnostic tests are available. Regular injections of medications to destroy the protozoan are necessary for several weeks, although in most patients sores heal spontaneously in six to 24 months. See also CUTANEOUS LEISCHMANIASIS

MUIR-TORRE SYNDROME The Muir-Torre (or Torre-Muir) syndrome is an inherited trait in which patients have multiple cancers of glands in the skin and internal organs. Unusual skin cancers involving glands develop, and further cancers involving internal organs (eg. colon, kidneys) are found. The skin cancers are unusual and may initially be mistaken for less severe forms of skin cancer. Excision and analysis treats skin cancers, but extensive investigations (eg. colonoscopy, CT scan) are necessary to detect, and then remove, internal cancers. The prognosis depends on the number of cancers found, their location and severity.

MURINE TYPHUS The most common form of typhus is murine typhus, which is spread from mice to man by a flea bite. It is caused by the bacteria Rickettsia typhi, and is common almost worldwide in urban areas with poor hygiene. The symptoms include headache, fever, muscle pains, chills

76 A RATIONALE FOR RASHES and a rash. The incubation period is 8 to 16 days, and the illness lasts about 12 days. Recovery is normal, but death may occur in the elderly and debilitated. The antibiotic tetracycline can be used in treatment. See also TYPHUS

MYCOSIS FUNGOIDES Mycosis fungoides is a rare form of cancer involving the lymphatic tissue in the skin. It may be caused by spread from other lymphatic cancers (eg. Hodgkinʼs disease) elsewhere in the body, or may arise in the skin. Red circular patches appear on the skin, that initially may be confused with a fungal skin infection (thus the disease name), and gradually spread across the body, and may spread from the skin to other organs. It is diagnosed by taking a biopsy (surgical sample) of the rash, then applications of anticancer medications are applied directly to the skin, and ultraviolet light therapy, irradiation of the affected areas of skin, and in more severe cases, anticancer tablets and injections are used. From when first diagnosed, average life expectancy is seven years. See also PARAPSORIASIS EN PLAQUE

MYXOID CYST A myxoid or mucous cyst is a common annoying but harmless cyst that forms on fingers due to degeneration of tissue under the skin on the back of the last segment of a finger. A small, smooth, shiny cyst forms under the skin on the back of a finger between the base of the nail and the last joint. The cyst contains a thick jelly-like substance and the nail may develop a lengthways groove. Uncommonly, they may become infected. They can be removed by freezing or injection if small, but larger cysts must be removed surgically under local anaesthetic. The surgical result is good, but recurrence is common.

NAEVUS A naevus (nevus in the USA) is a small area of abnormal, but benign, rough raised pigmented skin that may be single or multiple. Many different forms including blue naevus (benign blue coloured and smooth), Becker naevus (hairy, male, shoulders), junction naevus (flat, hairless, brown), sebaceous naevus (yellow, bumpy, on scalp), epidermal naevus (very common, may be extensive), halo naevus, portwine naevus, strawberry naevus, telangiectatic naevus (dark pink patches on head of infants) and spider naevus. The plural of naevus is naevi. If there is any suspicion that the spot may be malignant, it should be biopsied or cut out, otherwise they usually remain life long. See also BLUE NAEVUS; BLUE RUBBER BLEB NAEVUS SYNDROME; COMEDONE NAEVUS; DYSPLASTIC NAEVUS SYNDROME; HALO NAEVUS; JUNCTION NAEVUS; NAEVUS ANAEMICUS; NAEVUS OF OTA; PORTWINE NAEVUS; SPIDER NAEVI; SPITZ NAEVUS; STRAWBERRY NAEVUS; TELANGIECTATIC NAEVUS

77 A RATIONALE FOR RASHES

NAEVUS ANAEMICUS Naevus anaemicus is a congenital abnormality of blood vessels in the skin that causes one or more irregularly shaped white patches in the skin. The condition is harmless and caused by a persistent poor blood supply to the affected area. Staining of the skin is the only available treatment. See also NAEVUS

NAEVUS OF OTA A naevus of Ota is a congenital (but not inherited) skin pigment disorder affecting Asians (particularly Japanese) and less commonly Negroes. They are rare in Caucasians. The condition usually starts in childhood or teenage years to cause a mottled, dusky blue/brown, disfiguring pigmentation of the face that may involve the inside the mouth and the whites of the eyes. Patients have an increased risk of malignant melanoma. The diagnosis can be confirmed by biopsy. Laser treatment of the affected skin sometimes beneficial, but treatment is not particularly effective and there is no specific cure. See also MELANOMA

NAPPY ECZEMA See NAPPY RASH; SEBORRHOEIC ECZEMA

NAPPY RASH A nappy (diaper) rash is not a reflection on the mother or a sign of neglect, but a very common problem. The baby develops an angry red area of skin under the nappy due to excess moisture on the skin from wet nappies, pilchers and plastic over-pants that can cause skin damage, eczema and fungal infections (tinea cruris). Over-bathing, soap and detergents left in nappies may also irritate the skin. Red, pealing, irritated skin appears on the buttocks. If the skin folds are spared, it is probably a pure dermatitis, but if the rash extends to the skin folds and there are red satellite lesions beyond the edge of the rash, it probably has a fungal component. Uncommonly bacterial infections may occur. Zinc cream, lanolin or petroleum jelly applied to the bottom will protect it against moisture, and fungal infections will settle with antifungal creams, but eczema may require a mild steroid cream. The results of treatment are good, and even the most resistant cases settle once the child is toilet trained. See also SEBORRHOEIC ECZEMA; TINEA CRURIS

NECROBIOSIS LIPOIDICA Necrobiosis lipoidica is a rare skin condition affecting the shin of the leg. It is often a complication of insulin dependent (type one) diabetes mellitus, but may also occur in non- diabetics. The absolute cause is unknown.

78 A RATIONALE FOR RASHES One or more tender, yellow to brown patches develop slowly over many months on the shin of the lower leg. The patches may be round or oval, and as they mature, the centre becomes thin and shiny with prominent small blood vessels. The central area may degenerate into an ulcer, which is painless. The diagnosis can be confirmed by biopsy of the patch. Steroid creams or injections may be useful in treatment, and sometimes pentoxyfylline tablets are prescribed, but many cases require no treatment. The patches usually persist for many years before slowly disappearing.

NETTLE RASH Nettle rash is a very itchy rash that appears as multiple tiny red dots on areas that have come into contact with a stinging nettle, a weed common in the Americas. The rash last for several hours before settling, but may be eased by antihistamines. See also URTICARIA

NEURODERMATITIS Neurodermatitis, a nerve rash, is a rapidly developing form of dermatitis associated with stress such as an exam, job interview, marriage or any other event. It does not mean that the patient is neurotic or in need of psychiatric care, the rash is merely an outward manifestation of a sometimes minor stress in an otherwise normal person.

Multiple very itchy, small red raised lumps develop on the skin and they may fluctuate quite rapidly in their intensity. The front of the wrist, inside of the elbow and backs of the knees are the most commonly affected areas, but it may occur anywhere. A mild steroid cream is used to reduce inflammation in the skin, and if the cream is applied as soon as the rash appears, it should settle almost immediately. See also DERMATITIS; LICHEN SIMPLEX

NEVUS See NAEVUS

79 A RATIONALE FOR RASHES

NODULE A nodule is any small, hard lump in or (more commonly) on the body. The term is derived from the Latin word for knot, nodus. Nodules may form in many organs (eg. thyroid), tissues (eg. muscle, fat) or in the skin. A nodular melanoma is normally more sinister than one without nodules. See also SURFERʼS NODULE; TRICHOEPITHELIOMA

NORWEGIAN SCABIES Norwegian scabies is a very severe form of scabies that causes thickening and scaling of the skin (particularly the palms and soles) from huge numbers of scabies mites. See also SCABIES

NOTALGIA PARAESTHETICA Notalgia paraesthetica is a condition caused by nerve and skin damage on the upper back. The nerves that supply sensation to the upper back emerge from the spinal cord and run a long course through thick muscles in the back before making a right-angled turn and reaching the skin. They are easily damaged by an injury to the area, shingles or even sunburn. The skin is then further damaged by rubbing and scratching the affected area. Patients develop an itch and/or changed sensation in the area of skin just below the shoulder blade on either side of the back. There may be no visible change in the skin or there may be a brown pigmentation, patchy loss of skin colour or thickening due to rubbing. The changed sensation can be tested for by pinprick, cotton wool or heat and cold. Treatment is not always successful. Measures that may be tried include cooling lotions (eg. camphor and menthol), capsaicin cream, local anaesthetic creams and amitriptyline tablets at night. The condition is not serious but often persistent.

NUMMULAR ECZEMA See DISCOID ECZEMA

OCHRONOSIS Ochronosis is an inherited biochemical abnormality in which homogentisic acid accumulates to a high level in the body to cause arthritis, and bluish patches in the mouth, on the whites of the eyes, nose, ears, fingers, genitals and in the armpits. These blue to black patches may also be found within the body, and the urine is a darker than normal colour. There is no cure, but the arthritis can be controlled by appropriate medication.

ORF Orf is an unusual viral infection of sheep and goats that can infect the skin on the fingers and hands of people (eg. shearers, abattoir workers, veterinarians) who come into close contact with infected animals, when the Parapoxvirus can enter a minor injury to the skin. A sore develops at the site of infection after about ten days later, and this enlarges to become a large, fluid-filled, ulcerating and scabbing lump that may be one to three centimetres across. The lymph nodes in the armpit or other areas may become tender and a secondary bacterial infection of the sore may occur. The lump becomes soft, breaks down, and heals completely after four to eight weeks, leaving no scar.

80 A RATIONALE FOR RASHES

ORIENTAL SORE See CUTANEOUS LEISCHMANIASIS

ORIENTAL SPOTTED FEVER See TYPHUS

OSLERʼS NODES Oslerʼs nodes are small, tender, raised, red, transient patch on the tips of the fingers or toes that are caused by infected skin emboli (blood clots). It is a sign of bacterial endocarditis.

OSLER-RENDU-WEBER DISEASE Also known as hereditary haemorrhagic telangiectasia (HHT), this inherited blood vessel disorder starts in childhood, but only becomes serious in adult life. It is more common in Mormons but generally rare, occurring in one in every 10,000 people. The symptoms include widespread red dots and lumps caused by dilated small blood vessels (telangiectasia) just under and in the skin of the face, forearms, lips, tongue, palms and toes. The moist membranes lining body cavities (eg. nose, mouth, gut, lungs, vagina) may also be affected, resulting in serious internal bleeding and blood noses. Uncommonly the brain may also be affected. The disease is diagnosed by a skin biopsy, but the only treatment is surgical removal of bleeding internal or large skin telangiectasia. Liver involvement may occur, causing damage to the organʼs blood supply and replacement of normal liver tissue with scar tissue. Blood loss may lead to anaemia. There is no cure, but provided bleeding is not serious, life expectancy is normal.

81 A RATIONALE FOR RASHES

See also ROTHMUND-THOMSON SYNDROME

PACHYDERMA Pachyderma is the medical term used to describe excessive thickening of the skin and the underlying tissues. See also DERMATOSCLEROSIS

PAINFUL BRUISING SYNDROME The painful bruising syndrome is abnormal bruising that occurs in young women for no known cause, but it may follow emotional or physical stress. A pins and needles sensation is felt in the limbs and trunk followed by crops of bruises without injury. All blood and other tests are normal. No treatment is necessary as it is a self-limiting condition.

PALMOPLANTAR PUSTULOSIS Palmoplantar pustulosis is a persistent rash affecting the palms and soles of the hands and feet. The cause is unknown, but it is more common in smokers, there is a family tendency and it is often associated with psoriasis. It is not caused by a bacterial infection but it may become secondarily infected with a fungus or bacteria. Crops of grouped blisters full of fluid occur on thick, red, irritated, scaly skin of the palms and soles. Painful cracks may develop in the affected skin, and it is aggravated by walking on affected feet. A biopsy may be taken to confirm the diagnosis. Patients should avoid loose footwear and friction. Treatment involves copious amounts of moisturising cream, soaking in warm water with emulsifying ointments and applying strong steroid creams to the worst affected areas. Wrapping the affected areas in cling wrap or wearing plastic gloves increases the effectiveness of steroid creams. Other treatments

82 A RATIONALE FOR RASHES sometimes used include coal tar, calcipotriol ointment, ultraviolet light with psoralens (PUVA), tetracycline antibiotics, dapsone, methotrexate and acetretin tablets. There is no cure and the condition recurs intermittently for many years before subsiding. See also PSORIASIS

PANNICULITIS Panniculitis (Weber-Christian panniculitis) is an inflammation of the fat layer under the skin that usually affects young women. Numerous subtypes are known. The cause has not been identified, but it is due to inflammation of the small arteries (vasculitis) supplying the fat, and a reduced blood supply to the fat layer. Weber-Christian pannicultis is the most severe form and may rarely lead to death from reduced blood supply to internal organs. Tender lumps (nodules) develop under the reddened skin. It is diagnosed by biopsy of fatty lump. No treatment is normally necessary except for severe forms, when steroids are given to settle inflammation. It usually settles without treatment over many months to leave a dent in the skin due to lack of underlying fat.

PAPULAR URTICARIA Papular urticaria is a skin condition of children that is more common in Spring and Autumn. The cause is an allergy reaction to insects (eg. fleas, mites) in the childʼs environment, but the insect does not have to bite the child. The insects may live on household pets and not the child. Multiple, small, very itchy, red lumps that may blister are the main symptom. Crops occur every few days, usually on the legs, forearms and face, before slowly subsiding and leaving a scar that may persist for months. Scratched spots become crusted and may become infected. Steroid creams ease the irritation, as do antihistamine mixtures or tablets. Parents should fumigate the house, treat pets vigourously for fleas and keep pets outside. The problem is often recurrent but eventually disappears, often after moving to a new house. See also URTICARIA

PAPULE A papule is a small solid lump on the skin that is less than one centimetre across. There are many reasons for the presence of papules ranging from insignificant to sinister. Acne is the most common cause of a papular rash. A xanthoma is a yellowish swelling in the skin resulting from a deposit of fat. It may indicate a raised blood cholesterol level. A basal cell carcinoma, or rodent ulcer, is a slow growing malignant tumour, often at the edge of the eyelids, lips or nostrils, or on the ears. These take a long time to spread but ultimately can be very destructive of nearby tissues and should be removed. The appearance of a dark coloured papule may be a malignant melanoma and should be investigated promptly.

83 A RATIONALE FOR RASHES Molluscum contagiosum is a common viral infection of the skin that causes multiple small papules to appear.

PARAPSORIASIS EN PLAQUE Parapsoriasis en plaque is an uncommon skin disease of no known cause that is divided into two types, small and large plaque. The condition is characterised by the slow development over many months of multiple, oval to cigar shaped, red, slightly raised, scaly, non-itchy patches. They tend to avoid the forearms and lower legs and head, and to follow nerve pathways in skin. Large plaques (patches over 10 cm. in diameter) may progress to mycosis fungoides. A skin biopsy can confirm the diagnosis. Steroid creams and ultraviolet therapy control the condition, but there is no cure. See also MYCOSIS FUNGOIDES; PITYRIASIS LICHENOIDES; PSORIASIS

PEAU DʼORANGE In some forms of advanced breast cancer, the skin over the cancer takes on a dimpled appearance similar to that of an orange known as peau dʼorange (orange peel in French).

PEMPHIGOID Bullous pemphigoid is an uncommon but serious autoimmune skin disease that usually affects elderly women. There is an inappropriate immune reaction within the body that causes the skin to be rejected in the same way as a transplanted kidney is rejected by the body. The actual cause of the autoimmune reaction is unknown. Patients develop red, scaling, itchy patches, which after a few days break down into large, fluid-filled blisters on widespread areas of the body. These huge, soft bubbles develop on the arms and legs initially, but soon spread to the trunk. The face and head are rarely affected. Severe fluid loss from the body through the blisters may cause dehydration and heart rhythm irregularities.

84 A RATIONALE FOR RASHES The diagnosis is confirmed by a skin biopsy (taking a sample of the affected skin, and examining it under a microscope) and a specific blood test (basement membrane autoantibodies). Treatment involves high doses of prednisone, a steroid that reduces the immune response and allows the skin to repair itself. Once the disease is under control, the dosage is slowly reduced over a period of many months, but some patients need to remain on a low dose for years. Cytotoxic drugs may also be used. Without treatment, pemphigoid is fatal in one third of patients. With treatment, deaths are very rare, and one third of patients will require no treatment after two years. See also PEMPHIGUS

PEMPHIGOID GESTATIONIS See HERPES GESTATIONIS

PEMPHIGUS Pemphigus is a rare but severe autoimmune skin disease that occurs in all age groups and both sexes, but is very uncommon in children. There is an inappropriate immune reaction within the body that causes the skin to be rejected in the same way as a transplanted kidney is rejected by the body. The actual cause of the autoimmune reaction is unknown. The rash varies dramatically in its form from shallow ulcers, to multiple blisters, red scaling patches or massive peeling of skin. Any part of the body, including the face and the inside of the mouth, may be affected. A biopsy (sample) of the affected skin is examined to confirm the diagnosis, then large doses of prednisone or other steroids, immunosuppressive and cytotoxic drugs, all of which may have significant side effects, must be used long-term. Para-amino benzoic acid is sometimes used on the skin. Without treatment, pemphigus is invariably fatal. With adequate treatment, the mortality rate is below 25%. See also HAILEY-HAILEY DISEASE; PEMPHIGOID; SCALDED SKIN SYNDROME

PEMPHIGUS AUTOANTIBODIES See INTERCELLULAR CEMENT CELL SUBSTANCE AUTOANTIBODIES

PEMPHIGUS NEONATORUM See SCALDED SKIN SYNDROME

PENIS WART See GENITAL WARTS

85 A RATIONALE FOR RASHES PERIORAL DERMATITIS Perioral dermatitis is a common facial skin problem that tends to occur more in women who have oily skin, do not wash their face thoroughly, and use face creams, foundation and cosmetics that clog skin pores. The overuse of strong steroid creams on delicate facial skin may also be responsible. Clumps of small, red, itchy, tender spots develop on the skin around the mouth, but not on the lips. The rash may also occur around the nose and eyes. Tetracycline antibiotics clear the rash, but patients should avoid all face creams, sunscreens, cosmetics and steroid creams, and wash their face regularly with warm water without soap. The rash settles well with treatment, but sometimes recurs.

PETECHIAE Petechiae are tiny flat red spots that are scattered across the skin. They are caused by bleeding from capillaries in the skin, which occurs in diseases such as generalised viral infections, bleeding disorders (eg. thrombocytopenia), meningococcal infections, capillaritis and advanced typhoid fever.

PHOTODERMATITIS Photodermatitis is a congenital (present since birth) abnormal allergy type reaction of skin to sunlight. There are several different forms including Hutchison prurigo, polymorphic light eruption and solar urticaria. The victim develops a red, raised itchy rash on sun-exposed skin that may result in permanent skin damage and scarring. There is no cure, and the only treatment is to use clothing that covers all sun exposed skin and broad brimmed hats. See also DERMATITIS; PHOTOSENSITIVE ECZEMA

PHOTOSENSITIVE ECZEMA Photosensitive eczema is an uncommon type of eczema that usually occurs in middle-aged and elderly men and affects areas of skin that are exposed to light. It is due to a reaction in the skin to the ultraviolet wavelengths in sunlight. Fluorescent lights also give off ultraviolet radiation and can cause this reaction. A red rash covered with scales that is intensely itchy develops on the face, forearms and hands, but other areas exposed to sunlight may also be affected. In rare cases, the reaction may be so severe that the patient cannot go outside during the day, and they must reverse their lifestyle - sleeping during the day and being active at night - in order to avoid the sun. A skin biopsy may assist in the diagnosis. Wearing long-sleeved shirts and hats, and applying UV sun screen creams and very strong steroid creams are the main treatment. Occasionally steroid tablets are also required. Once established, the condition persists for life. See also ECZEMA; LIGHT SENSITIVE SKIN; PHOTODERMATITIS

PIGMENTED PURPURA See CAPILLARITIS

PIGMENTED PURPURIC LICHENOID DERMATOSIS See CAPILLARITIS

86 A RATIONALE FOR RASHES PILOMATRIXOMA A pilomatrixoma (calcifying epithelioma of Malherbe or Malherbe tumour) is a benign tumour of a hair follicle that is usually found in the arm pit or other hairy areas of skin that are subject to friction damage. It may be from a couple of millimetres to two centimetres across and grows slowly over many years. Patients notice a slowly enlarging firm solitary lump under the skin that is often attached to the skin. It usually causes little or no trouble but may be annoying and unsightly, and sometimes may become inflamed, tender and infected. It is diagnosed after surgical excision by examination under a microscope.

PINTA Pinta is a bacterial skin infection by Treponema carateum that occurs in children and young adults who are malnourished and living in conditions of poor hygiene. It is more common on the forearms and lower legs and the incubation period is one to three months. It starts with a small, pink scaly lump (papule), which gradually enlarges to form a scale-covered plaque with raised edges. Further spots appear around the original one, and then elsewhere on the body. In a second stage of the disease, the plaques become extensive, thicken, enlarge and merge together, and pigment is lost or gained to change the skin colour. It is diagnosed by a biopsy of affected skin and blood tests for syphilis, which is caused by similar bacteria, are positive. Treatment involves the use of antibiotics such as penicillin or tetracycline. There is a very good response to treatment, but pigment changes in second stage disease are permanent. See also SYPHILIS; YAWS

PITTED KERATOLYSIS Pitted keratolysis is a bacterial infection of the thick skin on the sole that is more common in young males, and those who wear tight shoes. It is caused by the bacteria Micrococcus sedentarius or Corynebacterium due to excessive sweating from the soles, and is aggravated by hot weather and synthetic shoes. A secondary fungal infection may develop, and rarely, the palm sides of the fingers may also be affected. The skin on the forefeet and/or heels becomes covered with

87 A RATIONALE FOR RASHES hundreds or thousands of tiny pits, which may be smelly and slightly itchy. The affected area of the sole looks dark red to brown. Skin scrapings can be cultured in a laboratory to identify the responsible bacteria. Treatment involves the use of antibiotic creams (eg. fusidic acid) and tablets (eg. erythromycin). The feet must be kept dry by wearing double socks (ideally cotton inside wool), and antiseptic soaps should be used twice a day. The condition usually settles well if treatment program followed carefully, but recurs frequently. See also ATHLETEʼS FOOT

PITYRIASIS Pityriasis is a term used in skin diseases to indicate the presence of a fine scale resembling natural bran flakes. See also PITYRIASIS ALBA; PITYRIASIS LICHENOIDES; PITYRIASIS ROSEA; PITYRIASIS VERSICOLOR

PITYRIASIS ALBA Pityriasis alba is a common skin condition of children and teenagers. Several round or oval, scaly, pale pink patches occur on the skin, and there is usually no irritation or itchiness. The patches are more apparent on tanned skin, as the condition prevents tanning. It settles spontaneously without treatment after a few months, although moisturising creams may remove scale, and mild steroid creams reduce redness. See also PITYRIASIS VERSICOLOR

PITYRIASIS LICHENOIDES Pityriasis lichenoides, or guttate parapsoriasis, is an uncommon skin rash that is more common in males and usually affects teenagers and young adults. A mild form is known as pityriasis lichenoides chronica, while the more severe rapidly developing form is pityriasis lichenoides et varioliformis acuta (PLEVA). The cause is unknown, but it may be a reaction to a bacteria or virus in the skin, although it is not contagious. Small, firm, raised, non-irritating, red to brown spots develop on sun-protected areas such as the trunk, thighs and inside the upper arms. A fine scale covers the spots that are 2 to 15 mm. across, and slowly flatten out over several weeks to leave a brown mark, which disappears after several months. PLEVA may be accompanied by a headache and fever. A biopsy of a spot confirms the diagnosis. Treatment is usually not necessary, but in severe cases steroid creams, sun exposure and antibiotics (erythromycin or tetracycline) may help. Severe cases of PLEVA are treated with methotrexate or oral steroids. The condition always settles without treatment eventually, but this may take many months or years.

88 A RATIONALE FOR RASHES See also PARAPSORIASIS EN PLAQUE; PITYRIASIS; PSORIASIS

PITYRIASIS ROSEA Pityriasis rosea is a skin disease of no known cause that occurs in older children and adults up to middle age. Dark red, scaling, slightly raised, oval-shaped patches appear on the chest, upper arms, thighs, neck, abdomen and back. Usually a large patch (“herald patch”) precedes other smaller patches by a week or two. There is only very slight itching or irritation, and minimal discomfort, and the forearms, lower legs and face are not usually affected. Antihistamine tablets may be taken at night for itching, and steroid creams can be applied, but the condition settles without treatment in six to eight weeks. See also PITYRIASIS

PITYRIASIS VERSICOLOR Pityriasis versicolor (tinea versicolor) is a relatively common skin disease caused by the fungus Mallassezia furfur (previously called Pityrosporum oviculare) that occurs in the tropics. It is more common in young adults than the elderly and children, and the chest, upper arms, neck, upper back and armpits are the most commonly affected areas. Pink/brown patches develop on the skin, which may have a very faint scale upon them. After a few weeks, the skin underlying the rash has less pigment, so the rash appears as white patches, which are due to sunlight being unable to tan the skin underlying the fungus. Areas not exposed to sunlight (eg. armpits, breasts) may retain the pink/brown patch appearance. This effect does not occur on Aborigines, Chinese, Negroes and other dark- skinned races. There are no other symptoms other than an occasional very mild itch.

89 A RATIONALE FOR RASHES The diagnosis can be proved by examining skin scrapings under a microscope, and then it is treated by regular use of antifungal lotions, rinses or creams. An antifungal tablet (ketoconazole) is used in persistent and widespread cases. The white patches will remain for some time after the fungus has been destroyed, until the sun tans the area again. Episodes of infection are quite easy to clear, but they often recur in the next summer. See also DERMATOMYCOSIS

PLANE WARTS Plane or flat warts are mildly disfiguring growths on the face caused by a human papilloma virus (HPV) infection of the skin. Small (1 to 5 mm.), round or oval, smooth, flat topped, slightly elevated, skin coloured or grey/cream raised areas of skin occur. They tend to follow the line of a scratch or graze and may become red, swollen and itchy. Tretinoin cream or other irritants can be applied to warts, but they disappear spontaneously in one to six months, although they do resolve faster with treatment. See also PLANTAR WART; WART

PLANTAR WART A plantar wart is known as a verruca in England. It is a type of wart that grows on the soles of the feet, and they tend to grow inwards rather than out. The cause is a very slow developing virus (human papillomavirus) that attacks softened skin. A hard, slightly raised, scar like growth forms on the sole of the foot, and becomes painful with walking. Verrucae are like icebergs, with only a small part showing on the surface and a much larger area affected deeper in the sole. They may become so large, widespread and painful that walking is very difficult. There are numerous treatments available including diathermy (burning), acid ointments, freezing, cutting out, or injecting under the wart. After surgery, a far larger hole than expected is usually left in the sole that may take some weeks to heal. Unfortunately. Recurrence is common despite the best treatment. See also WART

PLICA POLONICA Pica Polonica (Polish plait) is an extreme disease of the hair and scalp in which long hair becomes so dirty and matted that is sticks together in a solid concrete-like mass and becomes infested with lice and other insects. The scalp becomes inflamed and sore. Rare in the 21st. century, it was not uncommon in Medieval times when long hair and not washing hair were common. King Christian IV of Denmark (who died in 1648) suffered from the condition. Total removal of all head hair is the only treatment, but normal hair will regrow on the shaved scalp.

90 A RATIONALE FOR RASHES

POIKILODERMA ATROPHICANS VASCULARE Poikiloderma atrophicus vasculare is a rare skin condition with varied patches of excess or reduced pigmentation, skin thinning and bleeding into the skin (telangiectasia). It may be localised or widespread, and once present it is usually permanent.

POIKILODERMA OF CIVATTE The poikiloderma of Civatte is a common weathering effect on the skin at the sides and front of the neck, that spares the shaded area under the chin. The exact cause unknown, but contributing factors include fair skin, long term sun exposure, cosmetics, perfumes and hormonal changes. The affected skin is thin, red-brown with prominent hair follicles and dilated small blood vessels (telangiectasia). Treatment is difficult and involves sun protection with hats and sunscreen, avoiding perfumes and soaps on affected area, preparations to help fade the pigmentation, lotions containing tretinoin and laser treatment to reduce the telangiectasia

POLYARTERITIS NODOSA Polyarteritis nodosa (PAN or periarteritis nodosa) is an inflammation of small to medium- sized arteries.

The damaged artery may become weakened and balloon out to several times its normal diameter, it may scar and shrink down, or the blood passing through the inflamed section of artery may clot and completely block the artery (a thrombosis). The arteries affected may be

91 A RATIONALE FOR RASHES anywhere in the body, but the gut, liver, heart, testes, kidney, and muscles are most commonly involved. The cause is unknown, but it is more common in drug abusers and in patients with hepatitis B. Rarely it may be a side effect of medication. Men are three times more likely to develop the disease than women, and it is most common in young adults. The symptoms are very varied, depending on which arteries and organs are involved. The patient is usually feverish, and has pain in the area involved. Specific complaints may include muscle pain, palpitations, arthritis, skin ulcers, spots in the vision, abdominal pain, nausea, vomiting, diarrhoea and high blood pressure. There are no diagnostic blood tests, and the diagnosis must be confirmed by a biopsy (sample) taken from an involved artery. Taking steroids (eg. prednisone) in high doses for a long period of time is the main treatment, and immunosuppressive drugs may also be used. The prognosis varies markedly from one patient to another, depending upon the areas and arteries involved. Some patients do recover, but the majority slowly deteriorate to die within a few months or years.

POLYMORPHIC LIGHT ERUPTION See PHOTODERMATITIS

POLYMORPHOUS ERUPTION OF PREGNANCY See PUPPP

POLYMORPHOUS LIGHT ERUPTION Some people develop a varied form of rash called a polymorphous light eruption a day or two after exposure to sunlight. The rash may take the form of blisters or papules (small lumps) and is usually itchy. The rash usually settles after a week or two.

POROKERATOSIS See DISSEMINATED SUPERFICIAL ACTINIC POROKERATOSIS

PORPHYRIA CUTANEA TARDA Porphyria cutanea tarda (latent hepatic porphyria) is the most common form of porphyria, which are a group of liver diseases. It is usually inherited, but may be triggered by some poisons (eg. dioxin), and occurs in all races but is more common amongst the Bantu tribes of Africa. Patients have skin that is very sensitive to sunlight, with skin thickening and pigmentation occurring in sun exposed areas such as the face and forearms. The urine has a strange characteristic in that it turns a dark purple colour, then brown, if left standing. Liver damage may occur, and may progress to liver failure or liver cancer (hepatoma). It occurs in varying degrees of severity from so mild that it is undetected to a rapidly fatal form. It is diagnosed by special blood tests, and treatment involves careful genetic counselling of families and the use of a complex drug regime. It may be controlled, but not cured, and is rarely fatal.

92 A RATIONALE FOR RASHES PORTWINE NAEVUS A portwine or mature capillary naevus is a congenital, disfiguring skin condition due to overdilated blood vessels. Patients have a flat or slightly raised, pale pink to red or dark purple stain on the skin, usually on the face or upper chest, and on only one side of the body. Plastic surgery is sometimes possible to remove the naevus, depending on its site, otherwise these harmless marks persist life long. See also NAEVUS

PRESSURE ULCER See BED SORE; TROPHIC ULCER

PRICKLY HEAT See MILIARIA

PRIMARY NEUROENDROCRINE CARCINOMA OF THE SKIN See MERKEL CARCINOMA

PROUD FLESH Proud flesh is an overgrowth of granulation tissue on the skin to form a red lump at the site of a healing wound. It tends to occur when there is excessive irritation, inflammation or infection of the wound, and may consolidate into a keloid scar. See also KELOID

PRURIGO Prurigo (lichen urticarius) is a very itchy skin reaction that is more common in middle-aged women and poorly cared for children. It usually occurs on the back of the arms, front of the legs, buttocks, face and neck. The cause is an allergy reaction, possibly to food, insect bites or medications. Patients develop multiple, pink, dome shaped, intensely itchy lumps (papules) topped with a tiny blister (vescicle). The vescicle is soon scratched off and replaced by a brown crust. Antihistamine tablets and creams containing a steroid are used in treatment. The attacks eventually settle spontaneously, sometimes taking only a few days, or may they persist for months.

PRURIGO NODULARIS Prurigo nodularis is an intensely irritating and persistent rash that may be due to excessive scratching of another itchy rash (eg. scabies). It is more common in middle age females and those with coeliac disease (a sensitivity to gluten - wheat starch). Hard, scale covered, extremely itchy nodules (small lumps) develop in the skin. They may vary in diameter from 5

93 A RATIONALE FOR RASHES to 20 mm. and may occur almost anywhere, but the outside of the arms, front of the thighs, upper back, chest and belly are the most common areas affected. The surrounding skin may be damaged by scratching. A biopsy can confirm the diagnosis. Treatment involves powerful steroid creams or cryotherapy (freezing with liquid nitrogen). A gluten free diet is given if this is shown to be the cause. Most cases settle with appropriate treatment, but a small number persist long term.

PRURITIC URTICATED PAPULES AND PLAQUES OF PREGNANCY See PUPPP

PSEUDOFOLLICULITIS BARBAE See RAZOR RASH

PSEUDOXANTHOMA ELASTICUM Pseudoxanthoma elasticum (Grönblad- Strandberg syndrome) is a rare inherited condition (one in 100,000) disorder of elastic tissue involving the skin, eyes and blood vessels, that starts in young adults. The symptoms are yellowish small lumps or slightly raised patches on skin (particularly the neck, armpits, groin and belly) that are arranged along skin lines. Affected skin hangs loosely in folds, yellowish small lumps form inside the mouth and vagina, and decreasing vision leading to blindness from macular degeneration. Additionally there are often poor pulses, high blood pressure and heart valve damage (particularly the mitral valve). Complications include severe internal bleeding, strokes and heart attacks from damaged arteries and high blood pressure. It is diagnosed by a skin biopsy and x-rays show calcium deposits in arteries. Treatment is unsatisfactory. Cosmetic surgery may help skin problems, and lasers may slow degeneration of the retina in the eye, but there is no cure. Premature death due to complications is usual.

PSORIASIS Psoriasis vulgaris (to use the full name) is an annoying, distressing, persistent and difficult to treat skin disease that affects 2% of the population. It is an autoimmune disease in which the bodyʼs immune system is inappropriately triggered to reject tissue as though it was a foreign material. In psoriasis, varying parts of the skin are rejected. It is unusual in children but becomes more common as age increases. The rash appears as a small patch of red skin covered with fine scales that gradually enlarges, roughens and thickens the skin, and other spots may start over a period of months. The elbows, knees and scalp are the most common sites, while on the scalp it may appear to be a bad case of dandruff. The nails may also be affected, and become rough and pitted.

94 A RATIONALE FOR RASHES

The severity of psoriasis is assessed using three criteria - the area affected, the degree of inflammation and scale present and the impact the disease has on a personʼs lifestyle. The Koebner phenomenon occurs when psoriasis develops on areas of skin that have been injured, and may appear as a line of inflamed skin along a healed cut or surgical incision, or a patch at the site of a previous graze. In severe cases the joints may be attacked to cause a type of arthritis. Psoriasis has many subtypes, and it is often necessary to perform a biopsy to confirm the exact diagnosis. Treatment involves one or more of a number of keratolytic creams or ointments that are used regularly on the skin. Coal tar is the mainstay of treatment, but calcipotriol and steroid creams are also very effective. Other skin preparations include dithranol, salicylic acid, psoralen and tacalcitol. Ultraviolet light may be used in conjunction with psoralen to promote healing. In very severe cases, steroid tablets or injections, or acitretin tablets, may be given. In the first few years of this millennium new biological treatments using monoclonal antibodies (eg. efalizumab) and other natural proteins (eg. alefacept, etanercept) became available. On the other hand the rash may come and go without any treatment. There is no cure for psoriasis, but it can usually be successfully controlled. See also DERMATITIS; GENERALISED ACUTE PUSTULAR PSORIASIS; GUTTATE PSORIASIS; PARAPSORIASIS EN PLAQUE; PITYRIASIS LICHENOIDES;

PUPPP For fairly obvious reasons, the skin condition known as pruritic urticated papules and plaques of pregnancy or the polymorphous eruption of pregnancy is normally known by its acronym, PUPPP. It is a skin condition that develops in the last three months of pregnancy and is more commonly in a first pregnancy. It is a reaction within the stretch marks on the abdomen as a result of the damage within the skin. it is also more common in women who put on an excessive amount of weight during pregnancy. Small, very itchy, pink bumps develop in the stretch marks on the abdomen, buttocks and thighs. There may be a pale halo around the bump and several bumps may merge into a

95 A RATIONALE FOR RASHES raised patch. Steroid creams, moisturisers and antihistamine tablets control the itch but do not cure the rash. PUPPP does not cause any problems in the baby and always clears shortly after delivery of the baby.

PURPURA Purpura are small red or dark blue marks made in the skin by abnormal bleeding from capillaries. The most common cause is a low level of platelets in the blood (thrombocytopenia).

PUSTULAR ACUTE GENERALISED PSORIASIS See GENERALISED ACUTE PUSTULAR PSORIASIS

PYODERMA FACIALE Pyoderma faciale is a rare skin condition involving the face of young women. Men are not affected. The cause is unknown, but it is not an infection and is not contagious. There is a sudden onset of large, painful, ugly, red lumps and sores on facial skin that also becomes red. The skin immediately around the eyes is not involved. There are no diagnostic tests, and all skin swabs are negative. Treatment involves the long-term use of isotretinoin and steroid tablets, but after healing the lumps may leave long lasting scars. Although there is a poor response to treatment the condition rarely persists for more than a year.

PYODERMA GANGRENOSUM

96 A RATIONALE FOR RASHES Pyoderma gangrenosum is an uncommon cause of skin ulceration that usually affects the lower legs. It may be an autoimmune disorder, in which the body inappropriately rejects its own tissue. It occurs more frequently in patients with rheumatoid arthritis, colitis, Crohnʼs disease and other autoimmune conditions. The condition starts as a small pustule or blood blister at the site of a minor injury, then rapidly breaks down into a painful ulcer with an undermined edge that deepens and widens quite quickly. Several ulcers may develop simultaneously. Bacterial or fungal infection of the ulcer can be a complication. It may be diagnosed by biopsy, and swabs may be taken to identify any bacteria or fungi that have infected the ulcer. Treatment involves the use of steroid creams around the ulcer edges, and steroid injections under and around the ulcer. Antibiotic or antifungal tablets or creams are used for any secondary infection. Special healing gels may be applied under a dressing. Rarely, oral steroids or methotrexate tablets are prescribed. The ulcers heal very slowly over many months with intensive treatment and almost invariably leave a significant scar.

RAZOR RASH Doctors seem to insist that even the simplest medical conditions have technical names, and in the case of razor rash it is pseudofolliculitis barbae. This is a skin irritation of face and neck caused by minor damage to facial hair follicles from the scraping of a razor, and the ingrowing of hairs. It occurs more commonly in people who have curly hair. An ugly, raised, red, itchy rash develops on the neck and face. Initially, affected men should let the beard grow for a month to eliminate ingrown hairs, then use a polyester skin- cleansing pad twice a day or a moisturising shaving foam, a single blade razor, or shave frequently and as lightly as possible with an electric razor. They should not stretch the skin when shaving. Astringents and alcohol rubs may harden the skin to prevent the problem, and a mild steroid cream will settle the rash when it flares. As a last resort, they can grow a beard!

RENDU-OSLER-WEBER SYNDROME The Rendu-Osler-Weber syndrome is abnormal overgrowth of small blood vessels throughout the body. It is an inherited condition and passes from one generation to the next in families. Patients develop polyp-like outgrowths of dilated small blood vessels on the skin, tongue and throughout the gastrointestinal tract, that bleed easily to cause severe anaemia. Large connections that develop between arteries and veins may short circuit the blood supply to an organ or tissue and place strain on the heart. A biopsy of a skin or intestinal polyp is diagnostic, and blood is often found in the faeces. Treatment involves surgical removal of as many bleeding points as possible, iron supplements and blood transfusion, but there is no cure.

RHINOPHYMA is a severe form of rosacea affecting the nose that usually occurs in men. There is an increase in size of the nose due to a dramatic enlargement of the oil glands in the skin

97 A RATIONALE FOR RASHES and excessive deposition of fat and other tissue under the skin. In advanced cases it becomes very disfiguring and gives the appearance of a large growth on the nose. A skin biopsy is sometimes necessary to confirm diagnosis, then plastic surgery can be performed to remove the excess tissue. Patients obtain reasonable results from surgery. See also ROSACEA

RICKETSIALPOX Rickettsialpox is an uncommon mild infection caused by the primitive bacteria Rickettsia akar that has widespread effects. It passes from mice to humans through a mite bite in over crowded unhygienic conditions. The incubation period is seven to twelve days. The symptoms are a sudden onset of fever, chills, a single red lump on the skin at the site of the mite bite, headache and widespread muscular and joint pains. Two to four days later swelling of skin occurs with chickenpox-like blisters on the affected skin. It can be diagnosed by specific blood tests, and treated by tetracycline antibiotic tablets. Complete recovery is normal.

ROCKY MOUNTAIN SPOTTED FEVER Rocky Mountain spotted fever is a serious widespread infection that occurs throughout the Americas, but most commonly in the western United States. It is caused by the primitive bacteria Rickettsia rickettsii, which is transmitted from numerous small wild mammals and dogs to man by a tick bite. The infection has an incubation period of three to twelve days. The symptoms include a sudden onset of severe headache, shaking, very high fever, muscle pains, nausea, restlessness, delirium and collapse. The belly muscles may become very sore and pain occurs in numerous joints. A faint pink large spotted rash appears on the arms and legs about four days after other symptoms. The rash steadily darkens to a deep red, tends to be more severe over bony prominences (eg. sides of ankles), and bleeding may occur into the spots which may then degenerate into ulcers. A rapid pulse and low blood pressure develop when the heart becomes affected. Complications may include pneumonia, ear and salivary gland infections, dehydration, an enlarged spleen, and blood clots (thrombosis) in limbs, which may lead to gangrene. Permanent effects rarely occur after recovery, but may include permanent paralysis and epilepsy. The infection may be diagnosed by specific blood tests and treated with potent antibiotics (eg. chloramphenicol, tetracycline) by a drip into a vein. Up to 20% of patients die, even with good medical care, but the mortality rate is higher in the elderly.

RODENT ULCER See BASAL CELL CARCINOMA

ROSACEA Acne rosacea is a skin disease of the face, of no known cause, found most commonly in middle-aged women. Patients develop intermittent flushing of the face that becomes a permanent redness of the facial skin. After a few days or weeks, sores similar to a severe case of acne develop. In advanced cases, the surface of the eyes may be involved in a form of conjunctivitis. Treatment involves antibiotic tablets (eg. tetracycline, erythromycin) and/or metronidazole gel applied to the affected skin. Both must be continued for two or three months. Relapses are

98 A RATIONALE FOR RASHES common for years afterwards, but if medication is used immediately, it suppresses each attack effectively, and eventual a cure can be expected with good treatment.

See also RHINOPHYMA

ROSEA See PITYRIASIS ROSEA

ROSEOLA INFANTUM Roseola infantum (baby measles, sixth disease or exanthema subitum) is a contagious viral infection that is caught by virtually every child in the first two or three years of life. It has an incubation period from 7 to 17 days, and most children will have such a mild attack that it will be passed off as a slight cold. Those with a severe attack will develop a fever and a measles-like rash on the trunk and neck, which usually appears after the fever has gone. No treatment is necessary other than paracetamol for the fever, and the child recovers completely within two or three days. See also GERMAN MEASLES; MEASLES

99 A RATIONALE FOR RASHES ROSE SPOTS Rose spots are small red patches on the skin of the lower chest and upper abdomen that may occur in the early stages of typhoid fever. They fade after a few days while the infection may worsen. See also TYPHOID FEVER

ROTHMUND-THOMSON SYNDROME The Rothmund-Thomson syndrome (congenital poikiloderma) is a congenital abnormality of skin development. The skin is thin, red and pigmented, with red dots caused by dilated small blood vessels (telangiectasia) just under the skin. Patients are short, have under developed genitals, and the skin is very sensitive to sunburn. There may be scarring of the skin from sunburn and serious bleeding may occur from the telangiectasia. It is diagnosed by a skin biopsy, but there is no treatment or cure available. See also OSLU-RENDU-WEBER DISEASE; TELANGIECTASIA

SARCOPTES SCABIEI See SCABIES

SCABIES Scabies is an infestation (not an infection) by a tiny insect that burrows for 1 cm. or more through the outer layers of the skin. Most common areas affected are the fingers, palms, heels, groin and wrists, but it can spread across the entire body, although it is unusual for the head and neck to be involved. The scabies mite, Sarcoptes scabiei, is just visible to the naked eye, appearing like a spot of dust on a piece of black paper, but it cannot be seen on the skin. It spreads by close contact (eg. shaking hands) with someone who already has the disease, and can occur despite scrupulous personal cleanliness. In many third-world countries, the disease is in epidemic proportions, but it is relatively uncommon in developed countries.

The main symptom is incessant itching caused by the burrowing mite, as the tissue around them becomes red, itchy and inflamed. Scratching often damages the skin, making diagnose difficult, and allowing a secondary bacterial infection to enter the skin. Norwegian scabies is a

100 A RATIONALE FOR RASHES very severe form of infestation that causes thickening and scaling of the skin (particularly the palms and soles) from huge numbers of mites. The diagnosis can be confirmed when a skin scraping is examined under a microscope and the mites and their eggs can be seen. Treatment involves covering the entire body with a lotion or cream (eg. benzyl benzoate, malathion, permethrin, crotamiton) that kills the mites. All other members of the family, and anyone else closely connected with the patient, should be treated at the same time. It is advisable to change all the bed linen, and to repeat the treatment after a week, so that any mites that hatch from the remaining eggs after the initial treatment will be killed. The itch may continue for 10-20 days after treatment due to an allergy to the scabies bodies or their products (eggs, droppings, etc.). There is a good response to treatment, but recurrences are common. Children may return to school a day after appropriate treatment has been given.

SCALDED SKIN SYNDROME The scalded skin syndrome is a severe superficial bacterial skin infection known as Ritter disease or dermatitis exfoliativa neonatorum in newborn infants, and toxic epidermal necrolysis in older children. Milder forms are known as pemphigus neonatorum or bullous impetigo. Scalded skin syndrome and Lyell syndrome are terms that cover all forms. It is caused by the bacterium Staphylococcus aureus (golden Staph) that spreads from nose, eyes, mouth or umbilicus to areas of skin damaged by eczema or injury. It may be a complication of the Stevens-Johnson syndrome. The infant or child has severe peeling of skin that commences on the face and genitals and spreads across body. The skin appears similar to very severe sunburn. Death from fluid loss through damaged skin or internal spread of infection is possible. A culture of swabs from the nose, eyes, throat and umbilicus will confirm responsible bacteria and the appropriate antibiotic (eg. penicillin or erythromycin). The infection responds slowly to antibiotics, but most children recover. See also IMPETIGO; STEVENS-JOHNSON SYNDROME

SCALP FOLLICULITIS Folliculitis of the scalp is technically called acne necrotica miliaris. It is an inflammation of the hair follicles in the scalp caused by a bacterial infection. Multiple, small, very itchy, pus filled lumps form on the scalp, particularly on the hairline above the forehead. They often become sore and crust covered due to scratching. Swabs may be taken to identify the responsible bacteria, and blood tests may be performed to exclude any underlying disease that makes the patient more susceptible to infection (eg. diabetes). Treatment involves washing the hair regularly with antidandruff shampoo, and applying antibiotic and steroid lotions or gels to the scalp. Antibiotic tablets (eg. tetracyclines) may be

101 A RATIONALE FOR RASHES prescribed to settle flare ups, or may be taken long term to keep the condition under control. Antihistamine tablets may ease the itching. The problem often flares when treatment is ceased, but eventually settles permanently. See also FOLLICULITIS

SCC See SQUAMOUS CELL CARCINOMA OF THE SKIN

SCHAMBERG DISEASE See CAPILLARITIS

SCHISTOSOMIASIS Schistosomiasis (bilharzia) is a fluke infestation transmitted by a species of snail that is found in fresh water streams, rivers and lakes in Egypt, tropical Africa as far south as Zimbabwe, the Caribbean and eastern South America. It is often caught by bathing or washing in fresh water. The cause is a microscopic animal (trematode fluke) that enters the body by burrowing through the skin, often of the foot. Three different flukes - Schistosoma mansoni, Schistosoma japonicum, and Schistosoma mekongi - may be responsible. Once in the blood it travels to the veins around the large intestine, where eggs are laid. These pass out with the faeces or urine to infect water supplies. Once in fresh water, the eggs hatch, and the larvae seek out and burrow into the flesh of specific species of fresh water snail. They mature in the snail, and emerge from it ready to enter and infect another human. Patients do not pass out all the eggs that are laid by the fluke, and they may spread to the liver, lungs or spinal cord to cause further symptoms. Damage caused to organs by the fluke may be permanent. The first symptom is an itchy patch at the site of skin penetration. Varying symptoms then follow, depending on the areas affected by the fluke as it moves through the body, and the individual's reaction to those changes. Long-term symptoms include diarrhoea, abdominal pain and bloody urine. A particularly severe and rapidly progressive form of the disease is known as Katayama Fever. The diagnosis involves blood, urine and skin tests, and liver and gut biopsies.

102 A RATIONALE FOR RASHES Treatment is difficult, particularly late in the disease, although a number of drugs (eg. praziquantel) can be used to kill the fluke inside the body. Untreated it may cause a low-grade chronic illness, or may progress to death in a matter of months. The results of treatment are good if commenced early in the course of the disease, but advanced disease may be incurable. See also CERCARIAL DERMATITIS

SCHÖNLEIN-HENOCH SYNDROME See HENOCH-SCHÖNLEIN SYNDROME

SCHOOL SORES See IMPETIGO

SCLERODERMA Scleroderma (progressive systemic sclerosis) is an inflammatory condition most commonly affecting the skin and gut, then the oesophagus (gullet), lungs, heart and other internal organs. It is an autoimmune disease, in which the body inappropriately rejects its own tissue, and usually starts between 30 and 50 years of age, with women being more commonly affected. Symptoms vary widely but include thickening of the skin, arthritis that moves between joints, patchy changes in skin colouration, poor circulation to the hands, difficulty in swallowing, lung infections, fevers and diarrhoea. Damage to vital organs such as the heart may occur. Blood tests show abnormalities but are not diagnostic, and a biopsy (sample) of skin or other affected tissue must be taken to confirm the diagnosis. Medications can relieve the symptoms, but there is no cure, and the disease is slowly progressive over many years. Men and the elderly deteriorate more rapidly. See also MORPHEA

SCRUB TYPHUS Scrub typhus (tsutsugamushi disease) is an infection caused by the bacteria Rickettsia tsutsugamushi (also known as Orientia tsutsugamushi). It is transmitted from rats and other rodents to man by the bite of a mite and causes a black spot and lump at the site of the mite bite, a fever, severe headache, tender lymph nodes, eye pain, widespread rash and muscle pain. In severe cases the heart and brain may be infected and cause death. A specific antibody can be identified in the blood to confirm the diagnosis. Treatment with antibiotics such as doxycycline and azithromycin is usually effective. The condition is found in the western Pacific, northern Australia and southern Asia. See also TYPHUS

SEABATHERʼS ERUPTION

103 A RATIONALE FOR RASHES Seabatherʼs eruption is a skin reaction that occurs under the clothing of swimmers in the Caribbean Sea and along the Atlantic coast of the United States. It is caused by exposure of skin to the larvae of jellyfish or sea anemone. Victims develop an itchy, red rash consisting of very small lumps on the buttocks, breast and groin. Slight stinging is felt initially while swimming but the skin reaction starts three to 24 hours later. Patients may develop a crust on top of the small lumps, while sensitive individuals may develop a significant allergy reaction and urticaria (hives). Steroid creams and antihistamine tablets ease itch, but it settles with or without treatment after one or two weeks. See also URTICARIA

SEBACEOUS CYST A sebaceous cyst (epidermal cyst or pilar cyst) is full of sebum (the oil that keeps the skin moist and supple), which is produced in sebaceous glands beneath the skin all over the body, and is discharged through small ducts. In areas that become sweaty, dirty or injured it is possible to block the duct draining the . The sebum continues to be produced, and a cyst slowly forms under the skin. Cysts usually appear on the back, chest and neck, are slightly soft and often have a tiny dimple at the point where the original duct opened onto the skin. Sometimes pressure in the cyst is sufficient for its contents to be discharged through the previously blocked duct, but the cyst usually reforms. Cysts may become infected, and if antibiotics are not given soon enough, an abscess may form. Any cyst that is unsightly may be cut out, while infected cysts are treated with antibiotic tablets.

SEBACEOUS HYPERPLASIA is a harmless skin condition of the face that occurs in the elderly due to enlarged sebaceous (oil) glands in the skin. Small yellow lumps develop on the forehead and cheeks, often with a central hair. They may become infected if scratched. No treatment is n necessary unless the bumps are unsightly when they can be removed by excision, diathermy or laser. Severe widespread spots may be helped by isotretinoin tablets, but the condition persists long term.

SEBORRHOEA Seborrhoea is the medical term for oily skin due to overactivity of the oil producing sebaceous glands in the skin. It is a congenital (present from birth) condition. There is often a family tendency, and rarely it may be due to some underlying disease (eg. acromegaly). Any possible underlying cause may be excluded by blood tests. Patients have excessively oily skin that appears shiny, becomes dirty quickly and feels slippery. The face is more affected than other areas. These people also have an increased incidence of dermatitis, acne and skin infections.

104 A RATIONALE FOR RASHES Treatment involves washing regularly with soap and water, applying retinoid lotions and in women taking antiandrogen (hormone) tablets. In severe cases, isotretinoin tablets may be prescribed. The problem slowly eases with increasing age.

SEBORRHOEIC ECZEMA Seborrhoeic eczema or dermatitis is a widespread, common form of eczema that can occur at any age. It is caused by inflammation of the oil producing sebaceous glands in the skin, but the cause of the inflammation is unknown. In infants, seborrhoeic eczema frequently affects the scalp to cause cradle cap or the buttocks to cause nappy eczema. Other frequently affected areas are the cheeks, neck, armpits, groin and folds behind the knees and elbows and under the breasts. In adults, it is responsible for some forms of dandruff. On the scalp, it appears as a red, scaly, greasy rash. In skin folds, the skin is red, moist and breaks down into tiny ulcers. On exposed areas such as the face, the rash is red, scaling and may contain tiny blisters. The scalp is treated with a lotion or cream to remove the oil and scale, and regular shampooing. Tar solutions are applied in resistant cases. In other areas, mild steroid lotions or creams are used. Soap should be avoided and substitutes used. A complication may be the development of a secondary fungal infection. Seborrhoeic eczema tends to be chronic and recurrent. Children often grow out of it in the early teens, but in adults it may persist intermittently for years. See also ACNE NEONATORUM; DANDRUFF; ECZEMA

SEBORRHOEIC KERATOSES Seborrhoeic keratoses (basal cell papillomas or senile warts) are very common harmless skin growths that increase in number with age and may occur anywhere on the body, but particularly on the trunk. There is an inherited tendency to develop them, and they are more common in patients who have had any form of dermatitis.

These keratoses appear as raised, light brown, greasy surfaced spots that slowly enlarge and thicken to the point where they appear to be stuck onto the skin. The surface eventually

105 A RATIONALE FOR RASHES becomes rough and cracked, and the colour darkens. If damaged, they bleed easily, and they persist long term. They may be removed by diathermy, laser or shaving off the skin under a local anaesthetic. Smaller ones may be removed by freezing with liquid nitrogen, but they are harmless and only removed if unsightly or irritating as a significant scar may be left after removal. See also HYPERKERATOSIS

SENILE HAEMANGIOMAS See CAMPBELL de MORGAN SPOTS

SENILE WARTS See SEBORRHOEIC KERATOSES

SERUM SICKNESS Serum sickness is an uncommon reaction to a blood or serum (liquid part of blood without the cells) transfusion, or use of a blood product (eg. globulin or proteins). Uncommonly it may be caused by the use of a drug. The reaction may be immediate, or delayed for up to two weeks after a transfusion. The patient feels unwell, tired, nauseated and feverish; lymph nodes in the neck, armpit and groin become enlarged, an itchy rash develops, cramps occur in the belly, and joints may become painful. No tests are diagnostic, but blood tests show generalised abnormalities characteristic of an allergy. Antihistamines are given to counteract the allergy reaction, and steroids or adrenaline are prescribed to treat the results of the reaction. The reaction can vary widely in severity from being so mild that it passes almost unnoticed, to a very severe condition that can lead to death in a few hours.

SÉZARY SYNDROME Sézary syndrome is a form of cancer that is a variant of mycosis fungoides and starts in middle age. Patients develop persistently itchy patches of thick red skin, overlying hair loss on affected skin, and enlarged lymph nodes in neck, groin, armpits and elsewhere. It may spread to other areas of the body, and the nails may be damaged. Eventually the syndrome progresses to leukaemia or a type of sarcoma. Skin and lymph node biopsy are diagnostic, and a blood test reveals abnormal white blood cells. Low-grade irradiation of skin, and cytotoxic drugs (chemotherapy) are the main treatments, but despite these the condition is usually very slowly progressive. See also MYCOSIS FUNGOIDES

SHAVING RASH See RAZOR RASH

SHINGLES Shingles (varicella) is an infection of nerves and skin by the Herpes zoster virus, which is the same virus that causes chickenpox, and is usually caught as a child. The virus never

106 A RATIONALE FOR RASHES leaves the body, but migrates to the roots of nerves along the spinal cord, where it remains inactive lifelong. At times of stress, the virus may reactivate and move along the nerve to cause the skin and other tissues to become very painful. Shingles is far more common in older people, and uncommon in children. You cannot catch shingles from another person, but a child who has not had chickenpox may catch this from a person who has active shingles.

An acutely tender blistering rash develops, often in a belt-like line on one side of the body, and even the slightest touch causes severe shooting pain. Any nerve may be affected, and it can occur on the abdomen or chest (most common sites), or on the face or legs. Occasionally the rash leaves permanent scars, particularly on the face. A small number of elderly people can develop chronic inflammation in the nerve, and pain that persists for years (post-herpetic neuralgia). The worst complication occurs if nerves around the eye and ear are involved, when dizziness, ear noises and rarely blindness may occur (Ramsay-Hunt syndrome). No investigations are normally necessary, but if required the diagnosis can be confirmed by taking special swabs from a sore. Shingles can be cured by specific antiviral tablets, but only if treatment is started within 72 hours of the rash first appearing. If treatment is neglected until after three days from the onset of the rash, the only treatment is painkillers, drying antiseptic lotions and mild sedatives. Steroids may be used in severe cases. The rash dries out slowly and disappears over several weeks, usually healing completely. The pain is slower to disappear, and may last a month longer than the rash, but the vast majority of patients make an excellent recovery. See also CHICKENPOX

SIBERIAN TICK TYPHUS See TYPHUS

107 A RATIONALE FOR RASHES SISTER MARY JOSEPH NODULE

A Sister Mary Joseph nodule is a raised nodule in the umbilicus. It is often red and painless and may be a sign of widespread cancer in the abdomen (eg. ovarian or stomach cancer). The nodule is caused by spread of the cancer through the lymph channels to form an umbilical growth.

SIXTH DISEASE See ROSEOLA INFANTUM

SJÖGREN-LARSSON SYNDROME The Sjögren-Larsson syndrome is a rare inherited disease of the skin and brain, but both parents must be carriers for the condition to occur. These patients have widespread thick dry scaly skin and muscle spasms. There is no cure.

SKIN CANCER The various forms of skin cancer vary from the relatively innocuous, to those that can spread rapidly enough to eventually kill. Most are caused by sun exposure, primarily in childhood, but some chemicals may also be responsible and there is sometimes a familial tendency. Tropical countries with a predominantly white-skinned population have a far higher incidence. Skin cancers fall into several different categories - squamous cell carcinomas (SCC), intraepithelial carcinoma (IEC), basal cell carcinomas (BCC), Bowenʼs disease and melanomas are the most common and are dealt with separately. Signs to watch for in a spot or sore that may indicate that it is a skin cancer are any irregularity in colour, shape or outline; soreness or itchiness; bleeding or weeping. A biopsy can give a definitive diagnosis, but it may be more practical to excise whole growth. Prevention involves protecting the skin from the sun. They may be treated by freezing with liquid nitrogen, diathermy (burning), cutting out the growth, injecting anticancer drugs in and under it, or applying acid or anticancer ointments. See also BASAL CELL CARCINOMA; BOWENʼS DISEASE; DERMATOHELIOSIS; GORLIN GOLTZ SYNDROME; INTRAEPITHELIAL CARCINOMA; KAPOSI DISEASE; MELANOMA; MERKEL CARCINOMA; MUIR-TORRE SYNDROME; SQUAMOUS CELL CARCINOMA OF THE SKIN

SKIN TAG A skin tag (cutaneous papilloma or fibroepithelial polyp are the technical names) is a protuberant lump on the skin that has a narrow attachment to the body. They are more common in women and obese people, and appear more frequently after middle age. The

108 A RATIONALE FOR RASHES cause is friction to the skin from skin folds (eg. in armpits, under breasts, between buttocks) or rubbing of clothing (eg. around waist or neck). They are a small soft, rounded lump of fat surrounded by skin and connected to the body by a narrow stalk. They may be skin or brown in colour. Occasionally they are irritated, injured and bleed, or become inflamed and infected. These harmless growths persist long term but may be surgically removed, diathermied (burnt away) or tied off at their base by a thin thread.

SLAPPED CHEEK DISEASE See FIFTH DISEASE

SNEDDON SYNDROME The Sneddon syndrome is a severe, rare disorder of blood vessels affecting the skin, heart and brain. The cause is unknown. Patients develop livedo reticularis (maroon to red, net like or starburst pattern on the skin) and severe high blood pressure (hypertension) resulting in transient ischaemic attacks and strokes. Ulcers sometimes develop around ankles. Blood tests are performed to exclude any other underlying disease or cause, but a biopsy of the affected skin is diagnostic. Medication is prescribed to lower blood pressure and prevent strokes (eg. low dose heparin or aspirin). It cannot be cured, but the response to treatment is reasonable. See also LIVEDO RETICULARIS

SOLAR KERATOSIS See HYPERKERATOSIS

SOLAR URTICARIA See PHOTODERMATITIS

SORE See BOIL; IMPETIGO

SPARGANOSIS Sparganosis is an infestation caused by the larvae of the fish tapeworm that enters the body by being swallowed in contaminated water or frog flesh. It causes painful swellings under the skin, but sometimes enters the eye, which it destroys. The only treatment is cutting out the lump and the larva within it.

SPIDER ANGIOMA See SPIDER NAEVI

SPIDER NAEVI Spider naevi (spider angioma or telangiectasia) are an over dilation of a capillary that becomes visible on the skin. They are commonly caused by sun damage to the skin, but pregnancy and a number of diseases may also be

109 A RATIONALE FOR RASHES responsible including liver failure, an overactive thyroid gland, alcoholism and rheumatoid arthritis. The dilated blood vessels usually appear on the nose and cheeks and look like tiny red spiders. The small blood vessels can be seen diverging from a central point. Each individual naevus can be treated by cryotherapy (freezing), laser or diathermy (electrical heat) to the central blood vessel, which destroys it. A small white spot will remain at the site. These naevi may bleed excessively if damaged.

SPITZ NAEVUS A Spitz naevus (benign juvenile melanoma) is an uncommon skin growth that occurs on the head, neck and sometimes other skin areas of children and young adults. The cause is unknown. A small (under one centimetre), dome shaped, rapidly growing, benign, hairless lump forms on the skin. It may be pink, brown or black. The treatment is surgical excision, after which the diagnosis can be confirmed by examination of the specimen under a microscope. An inadequate excision will result in a rapid recurrence, but otherwise the prognosis is good and the growth is harmless. See also NAEVUS

SPOROTRICHOSIS Sporotrichosis is an unusual tropical and temperate climate skin infection that is more common in gardeners, farmers and florists. The cause is contamination of a puncture wound from a plant with the fungus Sporothrix schenckii, which is found in soil and on plants. The fungus is also found on the spines of the armadillo. Patients develop a pain free lump under skin that occurs several weeks after a skin injury. The lump slowly breaks down to form an ulcer and nearby lymph nodes become enlarged. The infection may spread through the lymphatic system to the lungs, joints, eyes and brain. Specific tests on swabs and smears taken from ulcer can be used to confirm diagnosis. Antifungal tablets and injections are used to treat the infection, which responds well to treatment, but sometimes recurs when treatment ceased. There is a poor outcome if the disease spreads to internal organs.

SQUAMOUS CELL CARCINOMA OF THE SKIN A squamous cell carcinoma (SCC) is a cancer of the outermost layer of skin that occurs on sun-exposed parts of the body, usually in patients who are over 50 years of age. They are caused by prolonged exposure to sunlight or irritant chemicals. The rims of the ears, the face, scalp, arms and hands are commonly affected, but the cancer may also occur on the penis. SCC can also occur in the moist mucous membrane lining the nose, mouth and throat. SCCs look like a red spot covered in fine white scales. They may be itchy or sore but often attract attention because they are unsightly. In severe cases they can spread by blood or lymphatics to distant parts of the body.

110 A RATIONALE FOR RASHES

If suspected, excision or biopsy is necessary to make the diagnosis. Small SCCs are easily removed by burning with a diathermy machine or freezing with liquid nitrogen. If it is larger, or if the diagnosis is not certain, it is necessary to excise the spot and surrounding tissue. Any SCC that recurs after freezing or burning must be surgically excised. Treatment IS very effective in early stages of the disease. See also BOWENʼS DISEASE; HYPERKERATOSIS; INTRAEPITHELIAL CARCINOMA; KERATOACANTHOMA

STAPHYLOCOCCAL SCALDED SKIN SYNDROME See SCALDED SKIN SYNDROME

STASIS DERMATITIS

If there is poor return of blood from the feet and lower legs due to damage to the valves within the veins of the leg, the long term pooling of blood results in swelling of the ankles and feet and pigmentation of the overlying skin from the haemoglobin and iron in the blood. The skin also becomes thin, damaged and petechiae (blood spots) may form. Eventually the damaged skin may break down into ulcers with minimal injury.

111 A RATIONALE FOR RASHES Treatment involves elevation of the legs, elastic stockings and surgical correction of any varicose veins. Creams and ointments are ineffectual. See also VARICOSE ECZEMA

STASIS ULCER See VENOUS ULCER

STEATOCYSTOMA MULIPLEX is a rare skin disorder that starts at puberty and affects both sexes. It is an inherited abnormality of the sebaceous (oil) glands in the skin. Numerous soft cysts up to 2cm across develop on the chest and upper arms. They are full of yellow oily liquid and may have hairs growing from them, but only rarely is the face affected. The cysts may become inflamed and leave raised scars when they heal. The diagnosis is confirmed by excising one of the cysts and examining it under a microscope. The cysts may be excised if disfiguring or irritating, and isotretinoin tablets may reduce severity of cyst inflammation. Individual cysts eventually rupture and heal, but new cysts develop throughout life, although the incidence reduces with age. See also ACNE

STEVENS-JOHNSON SYNDROME The Stevens-Johnson syndrome is a severe complication of erythema multiforme that may be triggered by drugs or infection. The characteristics of the syndrome include erythema multiforme; severe purulent ulcerating conjunctivitis; high fever; inflamed mouth (stomatitis); blisters or ulcers in nose, vagina, urethra, and anal canal; and ulceration, pain and swelling extending down the throat and into the lungs to give a form of bronchitis. The heart and lungs may become involved, and the scalded skin syndrome may develop. There is no specific diagnostic test. Treatment involves intensive steroid therapy, and if possible, removing the cause of the erythema multiforme. Most patients recover slowly, but death is possible in the elderly and debilitated. See also ERYTHEMA MULTIFORME; SCALDED SKIN SYNDROME

STRACHAN SYNDROME Strachan syndrome (also known as Jamaican neuritis) causes widespread nerve and skin damage due to poor nutrition, particularly a lack of vitamin B. It often occurs in alcoholics and with starvation, and is worse in smokers. The symptoms include amblyopia (dim vision), dermatitis around the mouth and genitals, and painful and excessively sensitive areas of skin. Some patients have muscle weakness or spasms and permanent vision damage occurs if the syndrome is left untreated

112 A RATIONALE FOR RASHES for a prolonged period. Abnormalities of the retina (light sensitive area at back of eye) can be seen when examined through an ophthalmoscope (magnifying light), and there are blood test abnormalities, and over active reflexes. Vitamin supplements and a good diet cure the condition.

STRAWBERRY NAEVUS A strawberry naevus (immature or capillary haemangioma) is a temporarily disfiguring skin blemish of children caused by the overgrowth of small blood vessels. A bright red, raised, irregular, rapidly enlarging spot appears shortly after birth, but growth ceases by nine months of age. Virtually all disappear spontaneously, completely and without a scar by the age of five years. Surgery to remove naevus leaves a permanent scar, and is never considered until at least the age of six years. See also HAEMANGIOMA; TELANGIECTATIC NAEVUS

STRETCH MARKS Stretch marks (striae or stria gravidarum) are the curse of pregnant women, when they develop on their belly and breasts, and overweight people whose stretch marks persist after they have lost weight. The tendency to develop striae is one that may be inherited. They are caused by a break down and stretching of the elastic fibres in the skin by changes in the bodyʼs hormone levels as well as direct stretching of the skin. Once they form they usually remain permanently unless removed by plastic surgery or reduced by creams containing retinoic acids. Cushing syndrome is caused by an over production of steroids such as cortisone in the body, or taking large doses of cortisone. Headache, obesity, thirst, easy bruising, impotence, menstrual period irregularities, stretch marks, acne, high blood pressure, bone pain and muscle weakness are common symptoms of this syndrome.

STRIAE See STRETCH MARKS

STURGE-WEBER SYNDROME The Sturge-Weber syndrome is a congenital developmental disorder of the brain and skin that causes intellectual disability, a red stain across part of the face, convulsions, paralysis down one side of the body and eye abnormalities.

113 A RATIONALE FOR RASHES Medication can control the convulsions, surgery can correct the cosmetic deformities, and a combination of drugs and surgery are used for the eye abnormalities. Although there is no cure, reasonable control of symptoms is possible.

SUNBURN The sun is extremely hot and will burn in the same way as fire, except that the sun is so far away we are not aware of the burning sensation that makes us draw back from fire. Obviously people with fair complexions are most susceptible to sunburn and should take extra precautions, especially in the middle of the day when the sun is at its height. When the skin is burnt by the sun, it becomes red, painful and hot to the touch. If the burning is severe, the skin will blister. After a few days the skin dries and a layer peels off. Long-term effects of overexposure to the sun are permanent freckling, blotching and premature ageing of the skin. Most cases of sunburn can be dealt with by taking a cool bath or shower, and apply cool compresses (although not iced since these may chill the victim) to the most affected parts. Calamine lotion or one of the commercial anti- sunburn moisturising creams will usually help. Paracetamol may reduce the pain, but if the sunburn is severe, the victim may develop cold shivers and a temperature, and if a child is the sufferer, medical advice may be necessary. Do not allow the victim of sunburn back in the sun without light-protective clothing until the burns have healed.

SURFERʼS NODULES Surferʼs nodules are hard calluses on the skin of the knees, feet and toes of surfboard riders caused by constant friction on these areas by the surfboard. Knee pads and fitted rubber boots can be worn to reduce their incidence and severity. They slowly subside with time if surfboard riding is ceased. If they become painful, steroid injections under the nodule ease the discomfort.

SWEET SYNDROME Sweet syndrome (acute febrile neutrophilic dermatosis) is a generalised skin disease of no known cause that is more common in women. Multiple tender red or purple skin plaques develop on the neck and limbs, and are associated with muscle pains, fever, and joint pains and swelling. Acute myeloid leukaemia develops in 20% of patients, and rarely ulcerative colitis occurs. Blood tests show excess white cells (neutrophils), and skin plaque biopsy is diagnostic. Prednisone is used in treatment. The plaques heal spontaneously over 2 or more months, but recurrences common.

SWIMMERʼS ITCH See CERCARIAL DERMATITIS

SWIMMING POOL GRANULOMA See FISH TANK GRANULOMA

SYCOSIS BARBAE See BARBERʼS ITCH

114 A RATIONALE FOR RASHES SYPHILIS In the 18th. and 19th. Centuries, syphilis was called the French pox by the English, and the English pox by the French. Syphilis is an infection that is usually sexually transmitted, and which passes through three main stages over many months or years. It is relatively uncommon in developed countries, but still widespread in poorer societies. The cause is the spirochete bacterium Treponema pallidum, which is transmitted by heterosexual or homosexual contact, sharing injecting needles, blood transfusions, or from a mother to her child during pregnancy (congenital syphilis). The same bacteria also cause yaws and bejel, which are transmitted by close body contact, but not necessarily sexual contact. The symptoms are totally different in each of the three stages:- - First stage syphilis causes a painless sore (chancre) on the penis, the female genitals, or around the anus of homosexuals, which heals after three to six weeks. There may be painless enlarged lymph nodes in the armpit and groin that also disappear. - Second stage syphilis starts a few weeks or months later with a widespread rash, mouth and vaginal ulcers, and a slight fever. The patient is highly infectious but will usually recover and enter a latent period that may last many years. - Third (tertiary) stage syphilis develops years later with tumours (gumma) in the liver, major arteries, bones, brain, spinal cord (tabes dorsalis), skin and other organs. Symptoms vary depending on organs involved but may include arthritis, bone weakness, severe bone pain, paralysis, strokes, heart attacks, internal bleeding from aneurysms, blindness, headaches, jaundice (liver failure), muscle spasms, skin ulcers, scars, nodules in the larynx and lungs, vomiting, confusion, insanity and death. - Congenital syphilis occurs in newborn infant who have teeth abnormalities, deafness, misshapen bones, deformed saddle nose, pneumonia, and intellectual disability. It can be diagnosed at all stages by specific blood tests (eg. fluorescent treponemal antibodies, syphilis IgG enzyme immunoassay), or by finding the responsible bacteria on a swab taken from a genital sore in the first stage of the disease. All pregnant women should be routinely tested. The first stage and second stages are treated by antibiotics such as penicillin (often as an injection), tetracycline or erythromycin. In the third (tertiary) stage antibiotics are also used, but can merely prevent further deterioration, as organ damage is irreversible. A child suffering from congenital syphilis is infectious when born and is treated with antibiotics. There are many complications associated with a syphilis infection. In the first stage there are usually none, but in second stage syphilis there may be spread of the infection to involve

115 A RATIONALE FOR RASHES the joints, brain, liver and kidney which may be severely damaged. In the third (tertiary) stage almost any organ can be seriously damaged. Infants with congenital syphilis may develop more serious problems if the condition is not treated aggressively. A course of antibiotics for a few weeks almost invariably cures the disease in its first two stages, but there is no cure for tertiary or congenital syphilis. Plastic surgery may correct the more obvious congenital deformities. See also PINTA; YAWS

SYSTEMIC LUPUS ERYTHEMATOSUS Systemic (or disseminated) lupus erythematosus (SLE) is a relatively common inflammatory condition affecting joints, skin, liver, and kidney most commonly, but almost any tissue in the body may be involved. 85% of cases occur in women (usually young), and it is more common in Negroes than Caucasians. Lupus is an autoimmune disorder in which the body inappropriately rejects normal tissue for no known reason. Attacks may be precipitated by stress, some medications or chemicals. There is also a familial tendency. Common symptoms are arthritis of several joints, a red scaly rash across both cheeks and the bridge of the nose (“butterfly rash”), rashes on other areas that are exposed to sunlight, mouth ulcers, poorly functioning kidneys and anaemia. Additional symptoms may include a fever, loss of appetite, tiredness, weight loss, damaged nails, loss of hair and painfully cold fingers. Less common complaints include conjunctivitis, blurred vision, chest pain, pneumonia, heart failure, belly pain, constipation, depression and convulsions. The symptoms vary significantly from one patient to another, and none will have them all. Many patients are free of symptoms for months before a recurrence. After each attack, there is slightly more permanent liver, kidney or heart damage, and eventually these problems accumulate to the point where the disease becomes life threatening. In rare cases it proceeds relentlessly to death within a relatively short time. Specific blood tests can diagnose the condition (eg. lupus anticoagulant antibody, ANCA, anti- Smith antibodies, anti-DNA, anti-dsDNA). Treatment depends upon the severity of the disease, and with mild symptoms, no treatment is required. Sun exposure should be avoided, and all non-essential medications ceased. In severe cases, a wide range of drugs, including steroids, cytotoxics, immunosuppressives and antimalarials may all be used. Regular blood tests follow the course of the condition, which is very variable, from a mild arthritic complaint to a rapidly progressive disease. There is no cure, but with careful management, compliance with treatment, and regular check-ups, 90% of patients are alive more than ten years after the diagnosis is made. See also DISCOID LUPUS ERYTHEMATOSUS

116 A RATIONALE FOR RASHES

SYSTEMIC MASTOCYTOSIS See URTICARIA PIGMENTOSA

SYSTEMIC SCLEROSIS See SCLERODERMA

TAG See SKIN TAG

TAN Suntans may look attractive, but remember that it can take ten or twenty years for skin cancer to develop. Have a look at the skin on some of the older beachside residents. Most people do not want leathery skin covered in red, scaling, lumpy cancers when middle aged. It is therefore better to limit tanning as much as possible, particularly in fair skinned and red haired people. Beach bumming now may cause a person to spend many hours under a doctorʼs scalpel later. Ultraviolet (UV) rays cause tanning of the skin, and it does not matter whether these rays come from the sun or an artificial source (eg. a solarium), the results are the same. If excessive amounts of UV rays hit the skin it will burn, and the more the skin is exposed, the higher the risk of skin cancer. A tan will not protect the skin from further burning or skin cancer. Chemical tans can give the brown colour desired by many people without any risk (except allergy to the preparation) but will not protect the skin in any way. It is sensible to avoid both the solarium and the sunʼs rays. Go on a beach holiday but follow the rules and “slip, slop, slap” (slip on a shirt, slop on sunscreen, slap on a hat) to avoid burning, excessive tanning and skin cancer. See also SKIN CANCER

TANAPOX Tanapox is a rare viral infection found in Kenya, Zaire and neighbouring countries of central Africa. The cause is a pox virus infection of a minor break in the skin that may spread from chimpanzees. Patients have a few days of fever followed by one or two, red, raised, blistering lumps on the arms or legs. A biopsy can be used to confirm the diagnosis. No treatment is necessary or available as full recovery occurs without treatment in a few weeks.

TELANGIECTASIA ERUPTIVA MACULARIS PERSTANS Telangiectasia eruptiva macularis perstans is a mouthful of a disease that has no simpler name. It is a rare form of the skin disease urticaria pigmentosa. Patients develop diffuse red skin patches that have overlying dilated capillaries (telangiectasia). The skin patches are made of abnormal collections of mast cells. These contain histamine and when the cell is disturbed, the histamine is released into the skin. Histamine makes blood vessels leak, resulting in

117 A RATIONALE FOR RASHES localised itching, swelling and redness. A skin biopsy confirms the diagnosis. Potent steroid creams, antihistamines and PUVA (ultraviolet radiation) two or three times a week for several months are used in treatment, but the condition is usually persistent. See also URTICARIA PIGMENTOSA

TELANGIECTATIC NAEVUS Telangiectatic naevi (stork bites) are a common skin condition of infants. They form dark pink patches on the head and neck that are made from dilated skin capillaries. They fade and disappear by two years of age. See also NAEVUS; STRAWBERRY NAEVUS

TELOGEN EFFLUVIUM Telogen effluvium is a form of diffuse hair loss. Both men and women have fewer hairs as they grow older, but excessive generalised hair loss from the scalp, and sometimes other hairy areas of the body (eg. eyebrows, pubic area, chest) may be a symptom of disease such as sex hormone disturbances (eg. pregnancy, menopause), an over or underactive thyroid gland, pituitary gland diseases, many other serious illness, drugs used to treat cancer, radiation therapy, too much vitamin A, and sudden and excessive loss of weight (eg. anorexia nervosa). Extreme mental or physical stress may also be responsible. Blood and other tests may be done to exclude specific causes but are often normal. If a cause can be found this should be treated. When the cause is medication, the hair usually grows back when it is ceased. See also ALOPECIA AREATA; BALD;

THROMBOCYTOPENIA Thrombocytopenia (idiopathic thrombocytopenic purpura) is a complex uncommon condition due to a lack of platelets (also known as thrombocytes), the blood cells that are responsible for controlling the rate at which blood clots. In children the condition often follows a viral illness and settles quickly, but in adults it is usually an autoimmune condition (body rejects its own cells) in which platelets are inappropriately destroyed by the spleen for no apparent reason. It can also occur as a result of adverse drug reactions, infections and other rare disorders. Patients are unable to clot their blood as quickly as normal, and they bleed excessively. They develop purpura (red dots under the skin caused by microscopic bleeding) across a wide area, bleed internally to cause black motions, have nosebleeds that are difficult to stop, may vomit and cough blood, bruise very easily, bleed around their teeth after eating and may bleed very heavily during a menstrual period. Bleeding into the brain may cause a stroke, or very rarely, death. The diagnosis is confirmed by a simple blood test. In some children, rest and time are the only necessary treatments. In all adults and most children, high doses of prednisone (a steroid) are given to settle the condition and allow more platelets to be made in the bone marrow. Immunoglobulin injections may also be used. As the spleen is the organ destroying the platelets, surgical removal of this can cure the disease in resistant cases. Other exotic medications may be used in severe cases.

118 A RATIONALE FOR RASHES The disease may last for a long time in adults, but the vast majority of patients respond well to treatment, although there are significant dangers before the patient presents to a doctor and in the first few days of treatment. It may occasionally recur in adults, but rarely in children.

TICKS Ticks are from the same family as spiders (arachnids) but are modified so much that they look nothing like their distant cousins. They have a large black body from which mouth parts protrude and grasp the skin. The tick does not have a head as such. A tube-like mouth part pierces the victim's skin to suck up blood. When the tick is full of blood, it drops off and waits for its next victim, which may be almost any warm-blooded animal, although some species preferentially attack certain animals. A full feed of blood may last the tick for a year or more. Ticks are most active in the spring and summer. Bush ticks, which are the only dangerous form of tick, live on the eastern coastal strip of Australia. The most common victims of ticks are children playing in the bush, and golfers, as ticks shelter in foliage and drop on a victim and burrow in as they engorge themselves on blood. Ticks are usually found on the head, burrowing in amongst the hair, or in body crevices. Ticks generally cause painful irritation and a raised lump on the skin. Uncommonly they may lead to paralysis if left untreated, especially in children. Symptoms of tick bite are irritation and pins and needles at the site of the bite, nausea, double vision, unsteadiness, and eventually weakness and difficulty in moving first the lower limbs, then the upper limbs, and finally the face and breathing apparatus. Do NOT attempt to pull the tick off or cut it out or squeeze it - this forces more venom into the system. To remove a tick, wash it and the surrounding skin with an alcohol solution, such as methylated spirits. Place a pair of tweezers flat on the skin so that the jaws are on either side of the tick. Grasp the tick firmly, as close to the skin as possible, twist through 90 degrees, and then lift off. The tick will come away easily with minimal pain. Some tiny black marks, the mouth parts, may be left behind, but these rarely cause any trouble. Place some antiseptic cream or lotion on the bite and leave it alone to heal over the next couple of days. If the area becomes red and angry, it may have become infected, and a doctor should be consulted. Ticks are responsible for the transmission of a wide range of infections including Lyme disease, typhus and Dutton relapsing fever.

TICK TYPHUS See TYPHUS

119 A RATIONALE FOR RASHES TINEA Tinea is a term used to describe any fungal infection of the skin, hair or nails. The technical term is dermatomycosis. Ringworm is a lay term that may be used for a fungal infection involving skin only. See also ATHLETEʼS FOOT; PITYRIASIS VERSICOLOR; TINEA CAPITIS; TINEA CORPORIS; TINEA CRURIS; TINEA MANUM; TINEA NIGRA

TINEA CAPITIS Tinea capitis is a fungal infection of the skin on the scalp that usually occurs in children. The fungi usually come from the Trichophyton, Microsporum and Epidermophyton families. It is caught by close contact with another infected human or animal (eg. cat, dog). The child develops an irregular, relatively bald patch on the scalp covered in a fine scale and broken hair stubble (the fungi invades the hairs and causes them to become fragile and break). A severely affected patch may develop a thick build-up of scale and form a fungal abscess (kerion). The diagnosis can be proved by taking a skin scraping or hair sample, and examining it under a microscope for fungal spores. Ultraviolet light (Woodʼs light) in an otherwise dark room will cause a bright green fluorescence of hair and skin affected by a fungus. Antifungal ointments, lotions, tinctures and shampoos are all very effective treatments. See also DANDRUFF; KERION; TINEA

TINEA CORPORIS Tinea corporis (ringworm) is a fungal infection of the skin that is not caused by a worm. The fungi usually come from the Trichophyton, Microsporum and Epidermophyton families, and are caught by close contact with another infected human or animal (eg. cat, dog). The fungi prefer areas of the body where there is heat (under clothing, in shoes), friction (from tight clothes or skin folds rubbing together) and moisture (from sweat), and more common in the tropics. It affects both sexes and all ages equally. The fungus settles in one spot on the skin, where a red dot may be seen. This slowly enlarges as the fungus spreads, and after a few days the centre of the red patch becomes pale again and similar to normal skin, because the infection is no longer active at this point. The infection continues to spread and forms an enlarging red ring on the skin. Multiple ring- shaped spots with a pale centre are seen on the chest, abdomen and back. It usually does

120 A RATIONALE FOR RASHES not cause an itch or discomfort. The diagnosis is proved by taking a skin scraping and examining it under a microscope for fungal spores. Antifungal creams, ointments, lotions and tinctures are usually effective. Antifungal tablets are available for more serious infections, but sometimes they are very slow to work, and may need to be taken for up to six months. Without treatment, the ringworm may persist for many months. The prognosis is very good with proper treatment, but the infection tends to recur if treatment ceased prematurely. Children may return to school a day after appropriate treatment has been commenced. See also TINEA; TINEA MANUM

TINEA CRURIS Tinea cruris (“crotch rot”) is a fungal infection of the skin in the groin. The fungi usually come from the Trichophyton, Microsporum and Epidermophyton families and are caught by close contact (eg. sexual) with an infected person, or in babies may be due to wet nappies or sweaty skin. Infection is more common in men than women, has a peak incidence in the 20s and 30s, and tends to occur more in summer and with exercise. A red, scaly rash spreads out from the skin folds in the groin to cover the inside of the thighs, the lower abdomen and the buttocks. It is often itchy and feels constantly uncomfortable. A secondary bacterial infection of damaged skin is possible. The diagnosis proved by taking a skin scraping and examining it under a microscope for fungal spores. Antifungal creams, ointments, lotions and tinctures are usually effective. Antifungal tablets are available for more serious infections, but sometimes they are very slow to work, and may need to be taken for up to six months. The prognosis is good with proper treatment, but recurrences are common. See also TINEA; TINEA CORPORIS

TINEA MANUM Tinea manum is a fungal infection of the palm of the hand. The fungi usually come from the Trichophyton, Microsporum and Epidermophyton families, and are caught by close contact with another infected human or animal (eg. cat, dog). This form of tinea is uncommon in children. Patients develop a fine scale with a faint red edge that affects the palms and palm side of the fingers. The diagnosis proved by taking a skin scraping and examining it under a microscope for fungal spores. Treatment involves antifungal tablets taken for a month or more, rather than

121 A RATIONALE FOR RASHES cream, because the thick skin of the palm makes it difficult for creams to penetrate. Results are good with proper treatment. See also ATHLETEʼS FOOT; TINEA; TINEA CRURIS

TINEA NIGRA Tinea nigra is a fungal infection of the palms and soles of the hands and feet caused by the brown fungus (mould) Exophiala phaeoannellomyces, which is found in soil. It is more common in tropical areas and in people who sweat excessively. Slowly growing, dark brown or black, lightly scaled patches develop on the soles and palms. There is no itching or pain. Skin scrapings can identify the mould and it is treated with antifungal creams. It usually clears within a few weeks with appropriate treatment. See also FUNGI; TINEA

TINEA PEDIS See ATHLETEʼS FOOT

TINEA VERSICOLOR See PITYRIASIS VERSICOLOR

TOPHI Patients with severe, recurrent gout can develop hard lumps (tophi) filled with sodium urate under the skin near their finger joints and over the ear cartilage. These tophi may ulcerate and discharge. They can be surgically removed if necessary, and once the gout is controlled, no more will form. Tophi are now rare as virtually all patients have their gout adequately managed.

TOXIC EPIDERMAL NECROLYSIS See SCALDED SKIN SYNDROME

TOXIC ERYTHEMA See DERMATITIS MEDICAMENTOSA

TRANSIENT ACANTHOLYTIC DERMATOSIS See GROVER DISEASE

TRENCH FEVER Trench fever (quintana fever) is a generalised bacterial infection caused by the rickettsial organism Bartonella. It causes a fever, rash, overwhelming weakness and aching legs. It settles with no treatment after about five days. It was a common cause of temporary disability in World War One front line troops, but is now almost unknown.

122 A RATIONALE FOR RASHES

TRICHOEPITHELIOMA Trichoepithelioma is an uncommon inherited skin condition arising from poorly developed hair follicles that is more common in women. One or more small, shiny, firm, round nodules form on the face after puberty. Their colour varies from yellow to pink or blue. Desmoplastic trichoepitheliomas are a variant that form a ring shaped nodule. A trichofolliculoma is a similarly formed solitary nodule that occurs on the face of elderly people. The condition is diagnosed by biopsy or excision. They can be excised if unsightly or annoying, but the number of nodules slowly increases with age and they persist long term if not removed. See also MILIA

TRICHOFOLLICULOMA See TRICHOEPITHELIOMA

TRICHOTILLOMANIA Trichotillomania is a self induced cause of hair loss that often starts in childhood or the teen years. Females are far more commonly affected than males, and any body hair, including pubic and eyebrows, may be involved. Patients pull and twist the hair until it breaks, usually as a subconscious habit, but sometimes in association with a psychiatric disturbance, resulting in patchy hair loss, with hair of varying lengths in the affected area. Strangely, shaving the head or pubic area (but not the eyebrows) may break the habit, but sometimes psychiatric medications are required, although most patients grow out of the habit.

TSUTSUGAMUSHI DISEASE See SCRUB TYPHUS

TUBEROUS SCLEROSIS Tuberous sclerosis (epiloia) is an uncommon nodule formation in organs of young children. It is a congenital condition (present since birth) that may occur in successive generations in the one family or develop randomly. Repeated convulsions occur in infancy due to the presence of brain nodules. Later in childhood, intellectual disability is noted and a rash consisting of red nodules (small lumps) appears on the face and neck. Other unusual rashes may develop elsewhere on the body, and lumps may form under the nails. Eye damage, cysts in the heart, bone and lungs, and nodules in the bowel, may also develop. No curative treatment is available, but medication is given to control convulsions, and surgery is performed to remove some of the more serious nodules. Mental retardation usually steadily worsens with age.

123 A RATIONALE FOR RASHES

TYPHOID FEVER Typhoid fever (enteric fever or intestinal Salmonellosis) is a widespread bacterial infection of the gut and surrounding lymph nodes, including the spleen, that occurs throughout Asia, Africa and South America.

AREAS OF THE WORLD AFFECTED BY TYPHOID FEVER

The infection is caught by eating food contaminated with the bacterium Salmonella typhi, which pass out in the faeces and urine of those who have the infection, or are symptom-free carriers of the bacteria. The incubation period is 5-14 days. Symptoms include fever, headache, tiredness, cough, sore throat, abdominal pain, red spots on the trunk (rose spots) and constipation. After a day or two, the constipation suddenly gives way to copious diarrhoea. Complications may include massive bleeding into the gut and perforation of the gut, which usually cause the death of the patient. In severe cases, it is possible for the infection to spread to the lungs, brain, kidneys and gall bladder. The diagnosis confirmed by specific blood tests (Widal test), urine and faeces tests. Antibiotics are prescribed to destroy invading bacteria, steroids are given to reduce inflammation, and a low-residue diet and intravenous fluids prevent gut irritation and dehydration. The bacteria may be almost impossible to eradicate from people who become symptom-free carriers of the disease. Preventive vaccines are available as three tablets taken over five days that give at least six months protection, or injections that give three years protection. Death occurs in up to 30% of untreated cases, but only in 2% of those who are treated in good facilities. With no treatment, survivors slowly improve after about ten days, but relapses may occur for the next two or three weeks.

TYPHUS Typhus is a worldwide infection caused by various types of the primitive bacteria Rickettsia, that causes a significant generalised illness. The bacteria pass to humans from rats and mice through a lice, tick or flea bite, and the incubation period is

124 A RATIONALE FOR RASHES 3 days to two weeks. It is more common around the Mediterranean Sea, in the Middle East and in East Africa, and different names are given to the infection in different parts of the world, and to infections caused by different species of Rickettsia. These include:- - Rickettsia typhi - Almost world wide, but often in urban areas - Murine typhus. - Rickettsia conorrii - Mediterranean Sea and East Africa - Mediterranean Spotted Fever, Fievre Boutonneuse, Astrakhan Spotted Fever, Indian Tick Typhus, Kenya Tick Typhus, Israeli Spotted Fever. - Rickettsia sibirica - North Asia - Siberian Tick Typhus. - Rickettsia africae - East and Southern Africa - African Tick Bite Fever. - Rickettsia australis - Tropical Australia - Queensland Tick Typhus. - Rickettsia japonica - Japan - Oriental Spotted Fever. - Rickettsia honei - Flinders Island, Tasmania - Flinders Island Spotted Fever. All forms have similar symptoms and treatment, but some are milder (eg. Siberian tick typhus) than others. Symptoms include a black spot on the skin at the site of the tick bite, swelling of skin, a widespread red large spot rash, fever, generalised aches and pains, tiredness, headache, joint pains, loss of appetite and enlarged lymph nodes. Liver damage and skin ulceration may be complications. It is diagnosed by specific blood tests (eg. Weil-Felix test) and/or a skin biopsy. Treatment involves antibiotics such as tetracycline and ciprofloxacin, which settle the infection in a few days. Without treatment, and with no complications, symptoms settle in three or four weeks. The prognosis is usually good in western countries with appropriate treatment, but up to 10% of patients die from liver damage without medical attention. The disease name comes from the Greek word for fever, typhos. See also SCRUB TYPHUS

ULCER An ulcer is any persistent break in a body surface that exposes underlying tissue, be it the skin or lining of a hollow organ (eg. mouth, intestine). See also BED SORE; ORF; TROPHIC ULCER; VENOUS ULCER

URAEMIC FROST In patients with chronic kidney failure and very high levels of blood urea over a prolonged time, a pale frost-like deposit of white urea crystals may become visible on the skin as the high levels of urea in sweat deposit out on the skin as the sweat evaporates.

URTICARIA Hives or urticaria (angioedema) is an allergic reaction in the skin. Angioedema is a term used more commonly when the lips or eyelid is involved and becomes severely swollen, with only slight itchiness and redness. Common causes include brushing against plants that may have stinging nettles on their surface, insect bites and chemicals (in creams, cosmetics, soaps) that are applied to the skin. Urticaria may also occur in a non-allergic form, which may be a response to stress or a viral infection. Some patients with long-term and recurrent forms of urticaria may be reacting to medications or salicylates and tartrazine, chemicals that occur naturally in a wide range of foods.

125 A RATIONALE FOR RASHES

Patients develop red, raised, itchy wheals that may be limited to a small area, or spread widely over the skin. The rash develops rapidly over a few minutes or a couple of hours, and may persist for up to two weeks, although two or three days is average. Some rarer forms may become chronic and last for months or years. Skin and blood tests can be undertaken in an attempt to identify the substance responsible for the reaction, but these are often unsuccessful. Antihistamines or steroids by mouth or injection are the main treatments. Tricyclic antidepressants also seem to benefit some patients with persistent hives. Soothing creams, lotions and baths can give relief to patients during the worst stages of an attack, and a diet which is free of salicylates and tartrazine may be of benefit. See also NETTLE RASH; PAPULAR URTICARIA; URTICARIA MEDICAMENTOSA; URTICARIA PIGMENTOSA

URTICARIA MEDICAMENTOSA The overuse of medications orally (eg. quinine) or on the skin (eg. steroids) may result in an itchy rash as a complication of the medication or its excessive use. This is urticaria medicamentosa. See also URTICARIA

URTICARIA PIGMENTOSA Urticaria pigmentosa (mastocytosis) is an allergy-like patch reaction in skin that most often affects infants. The patches are made of abnormal collections of mast cells that contain histamine, and when the cell is disturbed, the histamine is released into the skin. Histamine makes blood vessels leak, resulting in localised itching, swelling and redness.

126 A RATIONALE FOR RASHES

Brown patches develop on the skin of young children that steadily increase in number over several months or years and blister when rubbed. If many patches are activated at the same time the skin becomes itchy and the infant may become irritable, but it is uncommon for severe symptoms to arise. A severe attack can result in flushing and faintness. Rarely it occurs in adults, when the condition is usually worse, spots are itchier, and may spread to involve internal organs (systemic mastocytosis). Rubbing a patch causes redness, swelling and itching within a few minutes (Darier sign). Occasionally a skin biopsy is needed to confirm the diagnosis. No treatment is normally necessary. Exercise, heat, alcohol and some medications (eg. aspirin, narcotics - codeine and morphine) can aggravate the condition. If symptoms are significant antihistamine mixture or tablets, and steroid creams can be used. Over the a few years the skin becomes less irritable and eventually the patches fade away. By the teenage years, most patches will have gone. See also TELANGIECTASIA ERUPTIVA MACULARIS PERSTANS

VACCINIA Vaccinia was a complication of smallpox vaccination. This vaccination is now unavailable and unnecessary as smallpox has been eliminated worldwide. Smallpox vaccination was given by scratching the vaccine into the skin. If the patient had eczema, dermatitis, significant burns or other skin damage the vaccination reaction could spread across the skin to cause varying rashes, ulceration and rarely spread internally to vital organs such as the brain to cause encephalitis. Patients with vaccinia can spread the reaction to close contacts. No treatment was available.

127 A RATIONALE FOR RASHES VARICOSE ECZEMA Varicose or hypostatic eczema is a chronic skin deterioration that affects women more than men, and is far more common in the elderly. The cause is a poor return of blood through the veins from the feet to the heart, and as a result blood pools in the feet, causing pressure on the skin. It is more common if varicose veins are present. The affected skin is itchy, red, shiny, swollen, dry and covered with scales. It is easily injured and very slow to heal. The inside of the shin, just above the ankle, is the area usually affected. Ulcers are a common complication, as are bacterial skin infections, and allergy reactions. Treatment involves elevating the leg as much as possible, using support stockings or pressure bandages, and raising the foot of the bed slightly. If varicose veins are present, it may be appropriate to remove them surgically. Mild steroid creams and coal tar solutions are used on the eczema. Unfortunately the eczema is usually persistent, and the results of treatment are often poor unless the patient is very compliant. See also ECZEMA; STASIS DERMATITIS; VENOUS ULCER

VENEREAL WARTS See GENITAL WARTS

VENOUS LAKE A venous lake is a common disfiguring problem affecting older people, and usually develops on the face and ears. They are caused by sun exposure that damages veins under the skin, or a direct injury to the skin. The damaged vein dilates to form a dark blue to black, painless, raised, smooth, soft, blood filled blister under the skin. They bleed profusely if injured. Electric cautery, laser or excision can be used to remove the spot if it is cosmetically unacceptable. See also CAMPBELL de MORGAN SPOTS; HAEMANGIOMA

VENOUS ULCER A venous, stasis or varicose ulcer may occur on the shin and ankle in middle-aged and elderly people due to a poor return of blood from the ankles and feet to the heart. The ankles may be swollen, and the skin may be thin and discoloured by eczema. A slight injury to a leg affected by varicose veins may cause an ulcer, and because of the high pressure from the swollen veins in the area, the poor quality of the skin, and the poor blood supply, healing may

128 A RATIONALE FOR RASHES be very slow. Women are affected far more often than men, and they are more common in diabetics. Secondary bacterial infection of the ulcer is the only significant complication.

Treatment involves prolonged elevation of the leg to reduce the pressure in the veins, wearing compression bandages or stockings when walking, avoiding standing still for prolonged periods, and careful dressing of the ulcer with antiseptics and specialised pastes, pads or powders. In persistent cases, surgery to the swollen veins to relieve the pressure may be necessary before healing can occur. Recovery is often very slow, but most heal with persistence. See also VARICOSE ECZEMA

VIRAL EXANTHEMA A viral exanthema is any rash caused by a viral infection. These are much more common in children than adults and common examples include measles, roseola infantum (baby measles), chickenpox and German measles (rubella), but a wide range of other viral infections may be responsible. The rashes that may occur are extremely variable in their appearance. Usually there is a red or maroon, flat, widely scattered, slightly itchy rash in a child with a mild fever who is vaguely unwell, but the rash may also be a raised, crusting and highly itchy as in chickenpox. No tests are normally necessary, but blood tests and swabs of sores may be necessary to make definite diagnosis. The rash settles spontaneously within hours or days without treatment. Paracetamol and medication for the itch may be necessary.

VITILIGO Vitiligo is a skin pigmentation disorder that can occur in all races, in both sexes, and at all ages, but onset is uncommon over 50 years of age. The cause is unknown, but it is probably an autoimmune disease, in which the body's defence mechanisms inappropriately attack

129 A RATIONALE FOR RASHES normal cells and tissue, in this case destroying pigment producing melanin cells (melanocytes) in the skin. The loss of skin pigmentation in multiple patches that are sharply defined, may appear anywhere on the body, in any size and number, and overlying hair is usually white or grey. The affected skin is very sensitive to sunlight, and burns easily. In pale-skinned northern Europeans the patches may be barely noticed, but in southern Europeans, Arabs, Negroes and Chinese the resultant large white patches are quite disfiguring. There are no other side effects or complications of the disease Cosmetic stains or dyes (eg. dihydroxyacetone) are used to disguise the affected areas of skin, and may be quite effective. A number of other treatments are available, but require long-term use of tablets and/or ultraviolet light exposure, and have only moderate success. The affected area of skin usually slowly extends to involve larger areas but eventually stabilises after several years. Spontaneous recovery is uncommon.

von RECKLINGHAUSENʼS DISEASE OF MULTIPLE NEUROFIBROMATOSIS Besides having the longest disease name in any medical textbook, von Recklinghausen's disease of multiple neurofibromatosis has the characteristics of multiple light brown marks on the skin, soft fatty lumps under the skin, and, in some patients, nerves may be damaged. It is named after Friedrich von Recklinghausen (1833-1910), who was a pathologist in Strasbourg, Germany, and first described the condition in 1881. One in every 3000 people in Australia are affected by the condition. The lumps and spots are most commonly found on the trunk, pelvis and in the armpits. They also increase in size and number with age. The lumps grow from cells that form the soft sheath around every nerve in the body. The nerve damage is due to these soft lumps developing in the

130 A RATIONALE FOR RASHES spinal canal, and in other areas (e.g. the auditory nerve that is responsible for hearing) where they can cause pressure on nerves to the point where the nerve is no longer able to function. Deafness, blindness and paralysis may be the long-term result in a small number of cases. The disease passes from one generation to the next, but has a very variable result. About one third of patients merely have a couple of brown spots that never concern them, while about 10% are severely disfigured and disabled by large soft lumps under the skin, nerve weakness and multiple brown patches. Complications include scoliosis (curvature of the spine), bone cysts, uneven growth of the limbs (one arm or leg larger than the other) and arthritis. Sometimes mild mental retardation occurs, and rarely the lumps may become cancerous. The diagnosis is confirmed by examining a sample (biopsy) of the patches or lumps under a microscope, where characteristic abnormal cells can be seen. There is no treatment other than plastic surgery for any particularly bad lumps and patches. There is also no way in which you can determine whether a future child will have the condition, or how badly affected that child will be. As the disease is transmitted genetically, anyone from an affected family should not marry someone who also has this condition in their background. Any family with members affected by this disease should seek further advice from a paediatrician, neurologist or geneticist. See also NEUROFIBROMA

WART A wart is an unsightly, hard, rough, raised growth on the skin caused by a very slow- growing virus (papillomavirus), which take months or years to cause a wart. Only about a quarter of the population is susceptible to the wart virus, the rest have natural immunity. They are most common in children from 8 to 16 years of age, but people with warts should not be isolated for fear of spreading the disease, as the virus is widespread in the community. The most common sites affected are the knees, elbows, hands and feet.

131 A RATIONALE FOR RASHES Treatments that may be tried include acid paints (eg. keratolytics, podophyllum) applied regularly to eat away the wart tissue, freezing (cryotherapy) with liquid nitrogen which causes the wart to fall off after a few days, burning the wart tissue away with a high voltage electric current (diathermy) or laser, injecting a cell destroying substance (bleomycin) under the wart, immunotherapy (inducing a skin reaction under and around the wart), or rarely cutting the wart out surgically. Warts may recur after all forms of treatment, and only warts that are causing disfigurement or discomfort should be treated, as a scar may remain after any form of surgery, diathermy or cryotherapy. Warts usually go away by themselves without any treatment, but this may take many months or years. The average life span of a wart is about 18 months, but some may last several years. See also GENITAL WARTS; PLANTAR WART; SEBORRHOEIC KERATOSES

WELLS SYNDROME Wells syndrome (eosinophilic cellulitis) is a form of skin inflammation associated with skin redness, blistering and swelling. The patient has a mild fever and flame-like redness of the skin may extend away from the affected area. A blood test shows the presence of an excessive number of eosinophils (a type of white blood cell). Attacks last two to six weeks but may recur. See also CELLULITIS

WINTER ITCH Winter itch is a skin irritation caused by dry cold air in people with dry skin and atopic eczema. Using copious amounts of skin moisturiser (emollient eg. Sorbolene) is the main treatment unless a trip to a warmer more humid climate is possible. See also ATOPIC ECZEMA

WISKOTT-ALDRICH SYNDROME Wiskott-Aldrich syndrome is an inherited X-linked (passes from mothers to sons) abnormal destruction of the cells (platelets), which are responsible for blood clotting, and a lack of the cells necessary to protect the body from infection. Patients have widespread eczema, recurrent severe infections, and excessive bleeding and bruising because of a lack of platelets in the blood. Severe life threatening infections may occur. It can be diagnosed by blood tests and bone marrow biopsy. Vigourous treatment of infections is necessary, as are blood transfusions, bone marrow transplants and sometimes removal of the spleen (which is responsible for destroying the platelets), but despite the best treatment, few of these children survive into their teen years.

WITKOP See FAVUS

XANTHELASMA Xanthelasma are yellow-brown nodules in the soft skin around the eye. They are common in the elderly but may be a sign of high cholesterol or triglyceride levels, liver cirrhosis and other liver disease.

132 A RATIONALE FOR RASHES

XANTHOGRANULOMA A xanthogranuloma is a small lump (papule) on the skin. They vary in size from 1 to 10 mm across and are more common in children. Their cause is unknown. they appear as one or more red papules with a yellowish hue on the skin. The papules are not itchy or sore but they may catch on clothing or become scratched, irritated and infected. Treatment is not normally necessary, but if the diagnosis is in doubt or the papule is annoying they may be excised or biopsied. They slowly disappear without treatment over many years.

XANTHOMATOSIS Xanthomatosis is a complication of excess cholesterol in the blood that settles in the skin. Small, fatty, yellow lumps appear that are almost on top of the skin. They most commonly develop around the eyes, on the knees, elbows and buttocks. Diet and medication can lower blood cholesterol levels, but skin lumps must be destroyed by cautery (burning) or removed surgically as they persist after cholesterol levels are controlled. See also XANTHELASMA

XERODERMA PIGMENTOSUM Xeroderma pigmentosa is a rare familial (inherited) disorder of skin and nerves resulting in an inability to repair damage to the skin, brain and other tissues. Sun exposure causes skin damage. Affected children have skin sores, inflammation and abnormal pigmentation associated with small heads, mental deterioration, poor coordination (ataxia), muscle spasms (spasticity), abnormal movements of the limbs (athetosis) and under developed testes or ovaries. Other abnormalities may include deafness,

133 A RATIONALE FOR RASHES seizures, abnormal sensations and abnormal heart nerves. They also have a high incidence of cancer. There is no specific diagnostic test. Affected children should avoid the sun but otherwise no treatment is available and the prognosis is poor.

YAWS Yaws is a bacterial infection that occurs in some third-world countries with very poor hygiene. Treponema pallidum is the responsible bacterium, and this is the same bacterium that causes syphilis. It is transmitted from one person to another by close contact and poor personal cleanliness. Sores develop on the skin (particularly the legs) and in the nose and mouth, and inflamed lymph nodes appear in the armpits and groin. The sores may become large, ulcerate, penetrate to the bone and cause permanent disfigurement. The diagnosis can be confirmed by taking swabs from the sores. Treatment involves antibiotics (eg. penicillin) and improved personal hygiene, which cure the infection. See also BEJEL; PINTA; SYPHILIS

134 A RATIONALE FOR RASHES APPENDICES

Syndromes That May Cause Skin Lesions AIDS (fever, high risk group, splenomegaly) Bloch-Sulzberger syn. (vesicles fade to pigmented streaks) Bloom syn. (photosensitive skin, Jewish) Carney's complex (spotty pigmentation, atrial myxoma) Chediak-Higashi syn. (skin infections, albinism) Cogan syn. (interstitial keratitis, tinnitus) Conradi-Hunermann syn. (large skin pores, cardiac lesions) Dubowitz syn. (ptosis, micrognathia) Ehlers-Danlos syn. (fragile skin, joint pseudotumours) Felty syn. (leg ulcers, polyarthritis) Fröhlich syn. (thin skin, scanty hair, obese) Gardner syn. (sebaceous cysts, melaena) Goltz syn. (scar-like skin atrophy) Gorlin-Goltz syn. (multiple BCC, jaw keratocysts) Hand-Schuller-Christian syn. (diabetes insipidus) Harlequin syn. (severe ichthyosis) Johanson-Blizzard syn. (aplasia cutis, anal atresia) Kawasaki syn. (polymorphous rash, fever, red hands and feet) Koebner phenomenon (linear psoriasis) Leschke syn. (brown spots, hyperglycaemia, asthenia) Letterer-Siwe syn. (pruritic, papular rash) Nephrotic syn. (striae, ascites, oedema) Neu-Lexova syn. (collodion skin, face abnormal) Nezelof syn. (infant, diarrhoea, rashes, infections) Postphlebitic syn. (stasis dermatitis, leg ulcers) Proteus syn. (gross disfigurement) Ramsay Hunt syn. (herpetic vesicles, earache) Red man syn. (vancomycin infusion) Reiter syn. (arthritis, conjunctivitis, urethritis) Richner-Hanhart syn. (keratoderma, uveitis) Rothmund-Thomson syn. (skin pigmentation and atrophy) Scalded skin syn. (infant, Staphylococcal infection) Sjögren-Larsson syn. (ichthyosis, spastic) Stevens-Johnson syn. (mucous membrane vesicles) Sweet syn. (tender plaques, myalgia) Toxic shock syn. (fever, vomiting, diarrhoea) Vogt-Koyanagi-Harada syn. (vitiligo, blind) Wiskott-Aldrich syn. (eczema, thrombocytopenia)

135 A RATIONALE FOR RASHES

Sun Exposure Skin Abnormalities SKIN CONDITIONS THAT MAY BE AGGRAVATED BY SUN EXPOSURE

Albinism Alopecia Bloom syn. (photosensitive skin, Jewish) Cockayne syn. (deaf, blind, retarded) Dermatoheliosis Discoid lupus erythematosus Disseminated superficial actinic porokeratosis Erythropoietic protoporphyria Hyperkeratoses Itchy upper arm syn. (no rash, intense pruritus) Icthyosis Inta-epithelial carcinoma Lentigo Melanoma Merkel carcinoma Photodermatitis Photosensitive eczema Poikiloderma of Civatte Polymorphous light eruption Rothmund-Thomson syndrome Spider naevi Squamous cell carcinoma Systemic lupus erythematosus Venous lake Vitiligo Xeroderma pigmentosa Tetracycline antibiotics (burn easily)

© Warwick Carter www.medwords.com.au

136