THE ENCYCLOPEDIA OF SKIN AND SKIN DISORDERS

THE ENCYCLOPEDIA OF SKIN AND SKIN DISORDERS Third Edition

Carol Turkington Jeffrey S. Dover, M.D.

Medical Illustrations Birck Cox To the memory of Dottie Kennedy, for her unfailing support h

The Encyclopedia of Skin and Skin Disorders, Third Edition

Copyright © 1996, 2002, 2007 by Carol Turkington All rights reserved. No part of this book may be reproduced or utilized in any form or by any means, electronic or mechanical, including photocopying, recording, or by any information storage or retrieval systems, without permission in writing from the publisher. For information contact:

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Library of Congress Cataloging-in-Publication Data

Turkington, Carol. The encyclopedia of skin and skin disorders / Carol Turkington, Jeffrey S. Dover ; medical illustrations, Birck Cox.— 3rd ed. p. cm. Includes index. ISBN 0-8160-6403-2 1. Dermatology—Encyclopedias. 2. Skin—Diseases—Encyclopedias. 3. Skin—Encyclopedias. I. Dover, Jeffrey S. II. Title. RL41.T87 2006 616.5003—dc22 2005057402

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This book is printed on acid-free paper. CONTENTS

Foreword vii Introduction xv Acknowledgments xvii Entries A–Z 1 Appendixes 405 Glossary 425 Bibliography 429 Index 439

FOREWORD

The future of skin disease prevention and treat- longed, lasting months to years after a 20-week ment is bright. Better understanding of the course, a result unable to be achieved by any genetics of disease will help researchers to dis- other acne medication. Some side effects from cover the causes of many common ailments, isotretinoin are seen in most of its users, but usu- and continued technological developments ally resolve one to three weeks after treatment. will ensure even better treatments. The major These include dryness of the skin, mouth, and advances in dermatology over the last decade membranes, as well as chapped lips and patches include revolutionary anti-acne medication and of eczema. Fragile skin and susceptibility to sun- drugs that combat immune diseases; advances burn are frequently reported. Dry eyes, nose- in skin cancer awareness; new lasers and light bleeds, hair shedding, muscle and joint pains are sources engineered to improve skin appearance, common. Bone and blood lipid abnormalities can texture, and tone; and the development of Botu- also occur. Recently, depression and suicide have linum Exotoxin A and fi llers to decrease facial been reported among patients taking isotretinoin, lines and creases. although in the past some studies had shown an The single most notable event in the fi eld improvement in emotional well-being. Whether of acne treatment was the crucial discovery of isotretinoin plays a role in depression is unclear. isotretinoin in 1979 for the treatment of severe A recent large study failed to show an increased acne. This drug’s approval in 1982 revolution- risk of depression in isotretinoin users compared ized therapy; today the drug remains the treat- with other acne patients. ment of choice for resistant severe nodular cystic One of the most signifi cant problems with acne, although it is under increasing regulatory isotretinoin is its risk of the development of serious scrutiny because of uncommon but potentially birth defects in the infants of women who conceive signifi cant side effects of birth defects and depres- while on treatment. This requires that no woman sion. Isotretinoin belongs to a class of compounds being put on the drug become pregnant under any called retinoids, which are vitamin A derivatives. circumstances. To prevent pregnancy in women It is the only truly effective treatment against undergoing isotretinoin treatment, contraceptive severe cystic acne and has been shown to pre- counseling prior to starting treatment is essential, vent scarring, a disastrous result of acne. Isotreti- and strict monitoring of women of childbearing noin affects the sebaceous gland, suppressing age during the treatment course is performed. Two sebum production to preteen levels and causes negative pregnancy tests are required prior to the a decrease in the levels of bacteria responsible start of therapy, and monthly testing is compul- for acne. It also promotes shedding of skin cells. sory for sexually active females during treatment. Isotretinoin can reduce acne by 90 percent or Guidelines suggest that pregnancy is safe one more within three months. Its effects are pro- month after stopping the drug.

vii viii Foreword

Immunologic Drugs in an effort to reduce the risk of overuse of these highly effective treatments. IFN-a Interferon alpha is an agent that can modulate the immune system used in the treat- ment of cancers of the blood, immune diseases, Systemic Biologics and in the treatment of genital warts. A large Recent advances in technology have led to a pro- number of new clinical uses of interferon are being liferation of new strategies for treating diseases developed. The recent introduction of interferon with agents that can be designed to act specifi cally alpha into current therapies for malignant mela- on the immune system and may prove to be safer noma is notable. As immune control mechanisms than traditional therapies. Biologic agents are seem to be important in the behavior of mela- proteins that can be extracted from animal tissue noma, biological agents have been the subject of or synthesized in the laboratory. These medica- many studies involving treatment. Results sug- tions are divided into two categories: monoclonal gest that interferon alpha may be benefi cial, most antibodies and fusion receptor proteins. Mono- clearly in preventing recurrence but also perhaps clonal antibodies are usually derived from mouse in overall survival. Further studies are needed in antibodies and engineered to be better tolerated order to determine its benefi t, and it cannot yet by human beings. Fusion receptor proteins are be recommended as a standard therapy in high- human antibodies that are constructed in the risk malignant melanoma, although it remains a laboratory from components that are not normally promising mode of treatment. combined by the human body. Over the last decade, immune mediated diseases Topical Immunomodulators Imiquimod cream such as Crohn’s disease and rheumatoid arthri- induces the release of interferons and has been tis have been successfully treated with biologic approved in the United States for the treatment of agents. In 2003 the Food and Drug Administra- genital warts, as well as actinic keratoses (pre–skin tion (FDA) approved alefacept, a fusion receptor cancers). Research also shows that it is effective protein, for the treatment of moderate to severe in the treatment of superfi cial spreading basal psoriasis. This drug reduces the number and func- cell carcinoma, a slowly growing local type of tion of specifi c white blood cells important in skin cancer; studies are currently under way that infl ammatory reactions of the skin. Efulizumab, examine its effectiveness in the treatment of pre- an example of a monoclonal antibody, similarly cancerous skin growths due to the sun, nongenital decreases the ability of white blood cells to par- warts, molluscum, and alopecia areata. ticipate in infl ammation. Etanercept, a fusion Tacrolimus ointment (Protopic) and pimecro- receptor protein, binds the infl ammatory molecule limus cream (Elidel) are powerful topical anti- tumor necrosis factor-alpha (TNF-a). The reduc- infl ammatory agents approved for the treatment tion of TNF-a leads to the improvement of many of eczema. The greatest development in the treat- infl ammatory disorders of the skin. ment of eczema since the discovery of steroids in These three drugs have been approved for the the 1950s, its major advantage over topical cor- treatment of moderate to severe psoriasis. Other ticosteroids, the mainstay of treatment of atopic biologics, such as adalimumab and infl iximab, dermatitis treatment, is that it is not associated have been used to successfully treat psoriasis, with the development of the side effects such as though they are not approved by the FDA for this thinning of the skin and the formation of promi- use. Many of these biologics have demonstrated nent blood vessels and stretch marks. These new the ability to improve other infl ammatory dis- agents are particularly useful at sites where the eases of the skin such as hidradenitis suppurativa skin is more delicate, such as the face, groin, and and pyoderma gangrenosum. These agents and underarms. They should be used only on the their effectiveness in treating other diseases will affected area until it clears and then treatment remain an area of intense investigation in the should be discontinued until the next outbreak future. Foreword ix

Systemic biologics are an exciting new option Advantages of pulse therapy include effective- in the management of some skin diseases. These ness with a similar or decreased frequency of side drugs are signifi cantly more expensive than tradi- effects, economy, and convenience. tional systemic medications such as methotrexate and acitretin, though they may prove to be safer UVB narrow band for chronic use. Long-term evaluation of the cost effectiveness and safety of these new medications Among the most effective therapies for psoria- will determine their ultimate role in dermatology. sis is ultraviolet light phototherapy at 290–320 nm wavelength, and more recently narrowband UVB at 311 nanometers wavelength, which has Antifungals been shown to be more effective than broadband Today most cases of nail fungus can be cured using UVB. Using phototherapy, the optimal wavelength new oral antifungal agents terbinafi ne or itracon- for clearing psoriasis is 313 nanometers. In nar- azole. Terbinafi ne was discovered in 1974 and was rowband UVB phototherapy, conventional bulbs fi rst approved internationally for the management emitting primarily at 311–312nm are used. UVB of nail fungus in the United Kingdom in 1990. It phototherapy typically requires 30 sessions to pro- was introduced into the United States in 1991, and duce clearing. However, the development of skin is now available worldwide. The preferred mode of cancer in response to UVB phototherapy is a real treatment for nail fungus and fungal skin infection concern. is continuous therapy, although there are some reports where an intermittent treatment regimen Excimer laser with terbinafi ne has been used. Terbinafi ne inhib- The excimer laser emits laser light at 308 nano- its a fungal enzyme causing buildup of squalene, meters, within the ultraviolet B range and holds which leads to disruption and destruction of the promise for the treatment of localized psoriasis fungal cell wall, ultimately killing the fungus. It and vitiligo. It is thought that the light tissue is taken up into already formed nail through the interaction may be different for ultraviolet light in entire nail bed, and spreads through the whole nail the form of laser light as opposed to conventional as treatment continues. It is able to reach infected light. Also, because laser light is emitted from a sites rapidly, is detected in nail clippings at three hand piece only, psoriatic plaques are exposed weeks, and has been found to remain in the nail while uninvolved skin is spared exposure, unlike for 10 months, well after drug administration has conventional ultraviolet light treatments. Prelimi- ended. nary studies have indicated that excimer laser has Itraconazole was discovered in 1980 and was great potential in the treatment of psoriasis and fi rst approved for treatment of nail fungus in 1987. vitiligo. Since then, there has been a change to a pulsed form of treatment—a seven-day course given four weeks apart, which is now preferred. Itraconazole Surgical Updates has been detected in skin within hours of admin- Mohs Surgery In the 1930s Frederick Mohs pio- istration, and in the far ends of the fi ngernails neered the unique concept of using a zinc chloride and toenails within one and two weeks of starting paste for the treatment of skin cancers. In 1970 treatment. Following two pulses of itraconazole for Tromovitch and Stegman developed a technique fi ngernail fungus, the drug has been detected in of using the Mohs approach without zinc chloride, the far end of the nail nine months from the start with frozen sections. This method, called the “fresh of treatment, and at the far end of toenails after tissue technique,” allowed similar cure rates. The three pulses, 12 months from the start of treat- chief advantage of this approach was that the ment. In contrast, in the blood the drug concentra- defects created could be repaired immediately. Ini- tion decreases to almost undetectable levels within tially the tumor is debulked, tissue is excised by a 10–14 days of stopping a course of pulse therapy. beveled (saucer-shaped) excision just beyond the x Foreword debulked area, the excised specimen is subdivided, Secondary prevention consists of a national mapped, and unfolded (fl attened) to allow the campaign that promotes greater public awareness entire margins to be examined. Instant slides of the about the signifi cance of risk factors, early warn- specimen are prepared using a frozen technique ing signs of evolving tumors, and skin awareness, in the lab for examination under the microscope, as well as self-examination and free examina- enabling the dermatologist to determine whether tions to detect evolving tumors, sponsored by the entire cancer has been removed. The cancer the American Academy of Dermatology and the is removed layer by layer until a negative margin American Cancer Society. Melanoma and non- is obtained. Today dermatologists perform these melanoma skin cancer have a high chance for repairs in a day surgery setting, with tremendous cure if detected and treated in an early phase of cost savings over traditional hospital surgery. development. Most melanoma deaths are related The introduction of Mohs surgery also encour- to patient delay in seeking medical care, attrib- aged dermatologic interest in the science of wound uted mostly to lack of knowledge. More attention healing. Dermatologists have been leaders in is needed to encourage timely consultation for research on the biology of healing wounded skin changing tumors and predisposing risk factors and and have also been instrumental in developing to focus screening and surveillance efforts of those new biological dressings based on wound healing people at greatest risk. research. It is hoped that increased public and profes- sional awareness and education in all areas relat- Sentinel node biopsy Sentinel lymph node ing to the prevention, detection, and treatment of biopsy has recently gained acceptance in the sur- malignant melanoma will contribute to decreasing gical management of high-risk melanoma. The trends in the incidence and mortality from this technique is becoming routine in many medical cancer in the future. centers. Its use enables the identifi cation of move- ment of microscopic cancer cells to lymph nodes, Cosmetic Treatment of the may reduce the number of unnecessary lymph node removals, and may lead to a survival benefi t. Aging Face Fillers Over the past two decades, dermatologists Skin cancer awareness, early have been at the forefront of development and experience with various fi lling agents and tech- detection, and sunscreens niques. These have become increasingly popular Malignant melanoma continues to present a sig- for patients in whom age-related changes develop nifi cant public health problem as its incidence as contour defects or who desire volume enhance- is rising faster than that of any other cancer in ment for various areas of the face. A variety of the United States. At current rates, one in 74 agents and techniques are currently available that, Americans will develop melanoma. In the United when used appropriately, can improve or correct States, primary prevention of melanoma and non- wrinkles and facial volume loss. melanoma skin cancer has focused on encouraging The ideal fi ller agent should be safe and effec- sensible sun-exposure behaviors through public tive, easy to maintain and administer, have a education. One of the most effective measures of minimal risk for infection, extrusion, or migra- protection is minimization of ultraviolet exposure tion, produce no allergy, and last for an acceptable from sunlight, by the use of sunscreens contain- degree of time. It should also be cost effective, ing relatively new physical sun block agents such show consistency and reproducibility, and ulti- as micronized titanium dioxide and zinc oxide, or mately yield highly acceptable positive aesthetic Parsol 1789. Other effective sun protective mea- results with no clumping or puffi ness. sures include the use of hats and protective cloth- ing and avoidance of greatest sun exposure at peak Collagen With formal approval by the U.S. Food times during the day. and Drug Administration, collagen became the Foreword xi preferred fi lling agent for superfi cial wrinkles or of local allergic reaction. A positive skin test has skin depressions that do not originate with move- not occurred in any recipient to date. Autologen ment. Until recently, bovine collagen was the col- is a dispersion of intact collagen fi bers and colla- lagen type most readily available. More recently, gen tissue matrix made from a patient’s own skin, human-derived collagen has replaced bovine col- obtained during a cosmetic surgical procedure. lagen as the collagen of choice. It is used to fi ll fi ne Excised skin is placed in sterile containers and lines around the mouth, skin folds between the sent to laboratories on ice by express mail. “Cus- nose, mouth, and chin area, and for lip enhance- tom collagen” is then created and sent back to the ment, currently a much sought after procedure, physician’s offi ce to be used for the same patient. which returns the lip to its fuller, more youth- Collagen can then be made at any time in the ful state. Skin testing to determine whether the future by request. patient is allergic to collagen, something that had to be done twice with bovine collagen, is unnec- Hyaluronic acid Injectable hyaluronic acid, essary with human collagen because of the low a natural component of the skin, has recently risk of allergic reaction. As collagen resorts over a emerged. This agent is derived from rooster combs period of months, enhancement is temporary with or produced through bacterial fermentation and touch-ups required approximately every three stabilized. It is used for the correction of contour months. defects of the skin, particularly in cases of aging or to increase the lips. Twenty years of experience Fat Deep cosmetic defects, such as age-related with hyaluronan from rooster combs confi rm its changes of the face with loss of volume, are best reliability. It is used extensively in Canada and in addressed by replacing the substance that has been Europe and so far it has been used in study sites depleted—fat. Fat injections are most often admin- in the United States. Approval by the USFDA is istered at the time of fat harvesting, a procedure in pending. which excess fat below the skin is taken from the patient’s abdomen, buttocks, or outer thigh. Fat is Cymetra Cymetra is particulated tissue bank– then processed into a less viscous form, which can quality skin. It has been available since 2005 and be injected below the skin. is injected into the lower part of the skin for fi lling Fat transplantation was repopularized with the in one to two sessions. However, long-term results development of liposuction in the 1980s. Klein’s are not yet available. Studies so far on at least development of the tumescent technique has 200 patients have revealed no allergic reactions, profoundly altered the way liposuction and fat but side effects related to the injection of Cymetra transplantation are performed. The new proce- have not yet been fully evaluated. dure of microlipoinjection was introduced in May 1986. Fat could be aspirated and reinjected with- Others A number of other modern fi ller agents out major incisions or scars. Dermatologists in the have recently become popular. These include United States have played an important role in the particulate human fascia lata from tissue banks, refi nements and development of fat transplanta- expanded polytetrafl uoroethylene (a suture- tion. These procedures continue to be increasingly like material that can be implanted below the popular today. skin), micro droplet injectable liquid silicone, and collagen–wrapped polymethylmethacrylate Dermalogen Recently, injectable human col- microspheres. lagen has become available. Dermalogen is a suspension of collagen fi bers and human collagen Lifts Until recently, face-lifting and eyelid lifting tissue matrix from skin donors from approved tis- were the only treatments available for the aging sue banks accredited by the American Association face. While there have been many important of Tissue Banks. Skin tests are presently recom- recent developments that have revolutionized mended before treatment to ensure the absence the treatment of the aging face, lifting remains an xii Foreword important aspect of facial rejuvenation. Refi ned in an improvement in wrinkles and appearance of and simplifi ed face-lift techniques including endo- the skin. The erbium laser emits laser energy in the scopic procedures are improving outcomes. near-infrared invisible light spectrum and leads to superfi cial skin removal and new collagen forma- Relaxers tion with less heat injury than the carbon dioxide laser and hence a faster healing time with less risk Botox Botulinum neurotoxin is a paralyzing of side effects. Both these resurfacing lasers create agent that prevents the release of a molecule called wounds in the skin, resulting in downtime and can acetycholine from nerve junctions. Botox has been be associated with complications such as redness, used throughout the 1990s to treat muscular neck delayed healing, pigment changes, and scarring. disorders. More recently, cosmetic uses of botu- Subsurface remodeling, also termed photo- linum A toxin for reduction of wrinkles caused rejuvenation, represents the newest approach to by facial expressions in the aging face and neck improving damaged skin. High rates of undesirable have become popular. By relaxing the muscles side effects associated with traditional techniques involved, it can dramatically reduce frown lines of have led to the development of new non-ablative the forehead, between the eyebrows, and crow’s- laser technologies. The non-ablative technique is feet. Dermatologic surgeons also pioneered its use meant for those individuals who do not wish to for sweat reduction of the palms and underarms. take time away from their daily activities in order However, an important potential side effect of to laser improve the quality of their sun-damaged Botox is drooping of the upper eyelid. The effects skin. These systems improve wrinkles without of Botox are temporary necessitating touch-ups at the creation of a wound. Selective heating below four to fi ve monthly intervals. the skin surface leading to formation of collagen The development and launch of Myobloc, a without surface damage is produced using cooling commercially available Botox neurotoxin-B com- techniques such as cryogen sprays to protect the plex, will add to the two currently available Botox skin surface. Non-ablative lasers hold potential for neurotoxin-A products. It has been studied widely skin tightening, as well as the treatment of stretch in clinical trials, and as it has a different site of marks, scars, and a variety of other conditions. In action it is believed that exotoxin B will be effec- the future lasers may be created that can cause tive in individuals who have no response to exo- the same degree of improvement as that seen with toxin A. ablative systems without the potential complica- tions and downtime from such systems. Smoothers Laser Skin Renewal R. Anderson and J. Parrish Erasers Intense pulsed light sources emit light in developed the theory of selective photothermoly- the 500–1,200 nm range and is a safe new technol- sis and the pulsed dye laser at Harvard Medical ogy effective in hair removal, treatment of vascular School in the early 1980s. The concept that selec- lesions, and removal of lesions such as sunspots tive tissue injury can be produced by using appro- and freckles. Intense pulsed light selectively targets priate laser wavelengths and pulse duration has and destroys pigment of hair follicle, allowing hair revolutionized treatment of a variety of skin disor- removal. Pigment irregularities due to sun damage ders. Through the 1980s and 1990s into the new are one of the newest uses of intense pulsed light. century, many useful laser applications have been Chemical peels have been performed to enhance developed, including treatments for pigmented the tone of skin since the time of Cleopatra. Wide- lesions, tattoos and blood vessels, excessive hair, spread use of more superfi cial peeling agents such and sun-damaged skin. as alpha-hydroxy acids started in the 1980s and The carbon dioxide laser is the best treatment 1990s to the point where they have become stan- for severe sun damage and emits an infrared beam, dard treatment to maintain skin glow and tone. which heats and destroys thin layers of the skin Aluminum oxide crystal microdermabrasion, a and promotes new collagen formation, resulting technique developed in Italy in 1985, has become Foreword xiii extremely popular within the last few years in tion. There has been an overwhelming perceived the offi ces of plastic surgeons, dermatologists, and benefi t in the skin’s appearance and texture from lay spas for the management of fi ne wrinkles, patients undergoing a course of therapy. sun damage, mild surgical scars, acne, skin dis- Retinoids, derived from vitamin A, are highly coloration and irregularities. It is a nonsurgical effective in treatment of moderate sun damage. An procedure being used to rejuvenate the skin. The increase in collagen in the skin has been observed device gently pulls the skin into a hand piece by with use of topical tretinoin (Retin A®). Patients mild suction, which initiates the fl ow of crystals. who are not candidates for tretinoin therapy may Surface debris and dead skin cells are removed benefi t from other newer retinoids, such as ada- by the impact of the particle on the skin’s surface. palene and tazarotene, which were developed in The treatment is typically performed in a series of the 1990s. weekly visits. After the procedure the subject can return to normal daily activities with no interrup- —Jeffrey S. Dover, M.D., FRPCP

INTRODUCTION The Encyclopedia of Skin and Skin Disorders, Third Edi- • prohibited cosmetic ingredients tion has been designed as a reference guide to a wide • skin fi llers range of terms related to skin and skin disorders. It also includes extensive appendixes with informa- • spider bites tion and addresses for organizations that deal with • syringomas skin problems. It is not a substitute for prompt assessment and treatment by experts trained in the In addition, almost every entry has been diagnosis of dermatological problems. revised and updated to include the latest informa- In this new, revised edition, we have tried to tion on cause and treatments of certain diseases present the latest developments, based on the and conditions, such as Addison’s disease, basal newest information in the fi eld, the latest research, cell carcinoma, Behcet’s syndrome, bites and and current FDA approvals of new treatments. In infestations, Bowen’s disease, Bloom’s syndrome, this revision, readers will fi nd a number of com- burns, Candida paronychia, canker sore, chicke pletely new topics, including entries on: pox, chloasma, Cockayne-Touraine syndrome, contact urticaria, collodion baby, cradle cap, cuta- • autologous fat transplants neous diphtheria, dermatitis artefacta, dermato- • biological implants fi brosarcoma protuberans, drug-induced acne, ecthyma, EPS, erythema multiforme, fi fth disease, • dermal stimulator folliculitis, gangrene, granuloma faciale, Homer’s • dihydroxyacetone (DHA) syndrome, HPV, hyperhydrosis, Kawasaki disease, latex allergies, Lawrence-Seip syndrome, len- • elephantiasis tigines, leptospirosis, leukoplakia, Lyme disease, • infantile acropustulosis measles, neurocutaneous syndromes, panniculi- tis, pressure sores, psoriasis, scabies, scleroderma, • laser hair removal scorpions, seaweed dermatitis, strawberry birth- • Louis-Bar syndrome marks, strep infections, ulerythema, and vitiligo. The newest updates on terrorist-related poison- • Merkel cell cancer ing with effects on the skin include revisions on • microdermabrasion entries about smallpox, bubonic plague, dioxin, and anthrax. The latest genetic updates include • nevi entries the newest information on alopecia, congeni- tal Lawrence-Seip, Darier’s disease, erythropoietic • pemphigoid protoporphyria, Louis-Bar syndrome, neurofi bro- • post-infl ammatory pigmentation matosis, porphyria, psoriasis, rosacea, scleroderma,

xv xvi Introduction

Sturge-Weber disease, tuberous sclerosis, and improve aging skin. Revised entries related to Urbach-Wiethe disease. these subjects include topics such as aging and Skin-related medications and product updates the skin, alopecia, alpha hydroxy acids, anthralin, include the newest revisions in entries about Artecoll, Autologen, biological implants, bovine AHA peels, Accutane, benzoyl peroxide, Dry- collagen, collagen injections, composite cultured sol, lindane, NSAIDs, and retinoids. Techniques skin, CosmoDerm, Cymetra, human-derived col- also continue to advance at a dizzying pace, and lagen, hyaluronic acid gel, liposuction, and soft this encyclopedia updates the latest information tissue fi llers. on cosmetic acupuncture, dermabrasion, inter- As researchers uncover more and more prob- feron, lasers, laser resurfacing, prohibited cos- lems with sun exposure, the revision has included metic ingredients, pulsed dye laser, and silicone information on a variety of solar-related entries, implants. such as sun protective clothing, hats and the sun, Vaccines are always being developed, discarded, skin cancer, malignant melanoma, Melanotan, or improved upon, and this revision includes the tanning beds, tanning pills, sunscreen, SPR regula- latest information on new shingles prevention tions, and solar urticaria. vaccines related to the chicken pox shot, the Lyme In addition, the appendixes have been com- vaccine recall, and new skin cancer vaccines now pletely updated; many new organizations have being developed. At the same time, skin-related been added, and the latest addresses, phone medications and products are also continually numbers, and Web sites added and checked for changing; revised updates include entries on AHA accuracy. peels, Accutane, benzoyl peroxide, Drysol, lin- Information in this book comes from the most dane, and thalidomide. Techniques also continue up-to-date sources available and includes some of to advance at a dizzying pace, and this encyclo- the most recent research in dermatology. Readers pedia updates the latest information on cosmetic should keep in mind, however, that changes occur acupuncture, dermabrasion, interferon, lasers, very rapidly in this fi eld. References have been laser resurfacing, prohibited cosmetic ingredients, provided for readers who seek additional sources pulsed dye laser, and silicone implants. of information. All entries are cross-referenced, In addition, aging-related issues are a big part and appendixes provide additional information. of dermatology, and we have revised many entries related to the effects of age on the skin and related —Carol Turkington structures along with the newest methods to Cumru, Pennsylvania ACKNOWLEDGMENTS

Thanks to Birck Cox, for providing terrifi c draw- Types, the National Tuberous Sclerosis Association, ings; to my editors, James Chambers and Vanessa the National Institutes of Health, Maggie Bartlett Nittoli, for patient editing; and to my agents, Ed and Donna at the National Cancer Institute, the Clafl in, Gene Brissie, and Bert Holtjer, for their National Institute of Arthritis, Musculoskeletal and tireless efforts. Skin Diseases, the Society for Pediatric Dermatol- Thanks also to the staffs of the American Acad- ogy, the Psoriasis Research Institute, the National emy of Dermatology, the American Dermatological Vitiligo Foundation, the Skin Cancer Foundation, Association, the American College of Allergy and Suzanne Corr at the National Rosacea Society. Immunology, Jeff Bender at the American Acad- Thanks also to the librarians of Hershey Medi- emy of Allergy and Immunology, the American cal Center medical library, the National Library of Hair Loss Council, Susan Kastner at the American Medicine, the Reading Public Library, the Read- Leprosy Missions, the American Society for Der- ing Hospital Medical Library, the Chester County matologic Surgery, the American Society of Plastic Library, and the Pennsylvania State Library/Berks and Reconstructive Surgeons, the Dystrophic Epi- Campus. dermolysis Bullosa Research Association of Amer- Finally, thanks to Kara and Michael for unfail- ica, the Foundation for Ichthyosis and Related Skin ing support.

xvii

ENTRIES A–Z

A abdominoplasty A surgical technique used to Abscesses may be found in the soft tissues tighten up a sagging abdominal wall that has beneath the skin, such as the armpit and the become fl accid due to pregnancy or weight loss. The groin—two areas with a large number of lymph most common of these techniques involves a long glands responsible for fi ghting infections. incision in the lower abdomen or directly above the Bacteria (such as staphylococci) are the most pubic hairline. The skin and subcutaneous tissues of common cause of abscesses. Fungal infections the abdominal wall are lifted off the muscle, where sometimes cause abscesses as well. they are redraped and the excess skin removed. After the wounds are closed, a new opening is made Symptoms and Diagnostic Path for the navel, which is sutured into place. Most larger abscesses cause body-wide symptoms such as fever and chills. Abscesses close to the skin Risks/Complications usually cause infl ammation with redness, increased Risks include scars, numbness in the lower abdom- skin temperature, and tenderness. inal wall, and blood clots in the veins of the lower Abscesses usually can be diagnosed visually, legs. although an imaging technique (CAT scan, MRI or radionuclide scans) also may be used to confi rm Outlook and Lifestyle Modifi cations the extent of the wound. This operation is considered major surgery and requires general anesthesia and post-surgical recov- Treatment Options and Outlook ery of up to a week in a hospital and several weeks Antibiotics are usually prescribed to treat a bacterial more rest at home. LIPOSUCTION can be used as an infection, and antifungal agents are used to treat alternative to abdominoplasty in some patients. fungi. However, the lining of the abscess tends to cut down on the amount of drug that can get into the source of the infection from the blood. There- abrasion A graze that involves a superfi cial loss of fore, the abscess cavity itself needs to be drained epithelium, the tissue that covers the external sur- by cutting into the lining, and allowing the pus to face of the body that results in oozing and crusting. escape either through a drainage tube or by leaving No treatment is necessary. the cavity open to the outside of the skin. Many abscesses heal after drainage alone; others require both drainage and medication. abscess An infl ammatory nodule containing a collection of PUS, usually caused by a bacterial infection. The pus is made up of dead and live acantholysis Disruption of intercellular con- microorganisms and destroyed tissue from white nections between KERATIN-producing cells in the blood cells carried to the area to fi ght the infection. outer skin layer. It is caused when the cementing An abscess may become larger or smaller depend- substance between cells dissolves, and is associ- ing on whether the white blood cells or the bacteria ated with a form of blisters in diseases such as win the fi ght. PEMPHIGUS.

1 2 acanthosis acanthosis Increased thickness of the surface acne A very common infl ammatory reaction in layer of the skin (EPIDERMIS), found in a wide vari- oil-producing follicles. While most common in ado- ety of skin disorders. lescence, the problem may affect people of any age, See ACANTHOSIS NIGRICANS. including infants and the middle-aged. Acne is the most common skin disease in the United States, and accounts for 25 percent of all acanthosis nigricans A rare untreatable condi- visits to dermatologists. Because it most commonly tion characterized by thick velvety dark gray or affects the face and can lead to permanent scarring, brown patches of skin on the groin, armpits, neck, acne can have profound and long-lasting psycho- and other skin folds. logical effects. It can either be an inherited genetic disorder In boys, acne usually begins in early adoles- appearing during childhood or adolescence, as a cence; it tends to be more severe than in girls and result of an endocrine or metabolic disorder (such improves in the early to mid-twenties. In girls, acne as Cushing’s syndrome) or a symptom of malignant usually begins slightly later (mid-teens), and is tumors. In addition, at least one drug (nicotinic often less severe. In some individuals, acne can last acid) may cause acanthosis nigricans. into the 30s. Patients with severe acne often have When caused by obesity or heredity, the condi- a family history of severe acne. tion progresses very slowly; however, acanthosis Normally, oil is produced in the oil glands in the nigricans associated with cancer appears and devel- skin, travels up to the hair follicles, and fl ows out ops more rapidly. onto the surface of the skin. When oil glands within the hair follicles are stimulated and begin to enlarge Symptoms and Diagnostic Path (usually as a result of the hormonal change at “Pseudoacanthosis” nigricans is a far more com- puberty), they produce more oil. Acne bacteria inside mon condition found in overweight patients with the follicles multiply and produce fatty acids, which dark complexions. Skin in the fold areas (groin, irritate the lining of the pores. Simultaneously, there armpits, or neck) is both thicker and darker than is an increased number of thicker cells in the lining of the surrounding skin. There also may be excessive the pores, which tend to clump together, narrowing sweating in this area. and clogging the pore openings with a backup of oil, skin cells, and debris inside the pores. Treatment Options and Outlook As the pressure builds within these clogged Treatment for patients with acanthosis nigricans is pores, the constant production of oil together with aimed at recognizing and treating the underlying irritation from bacterial action ruptures the pore disorder. With treatment of the malignancy, the walls. When the oil pathway gets blocked and the condition should improve. plug pushes up to the surface, it causes a blackhead (open COMEDO). When the opening is very tightly closed, the material behind it causes a whitehead acarophobia See DELUSIONS OF PARASITOSIS. (closed comedo). While there are many factors behind the infl am- matory changes in acne, one of the most important Accutane See ISOTRETINOIN. is the different levels of bacteria found on the skin. While acne is not a bacterial infection, it is believed that infl ammation results from the byproducts acid mantle A fl uid made up of an oily substance released by the bacterium PROPIONIBACTERIUM ACNES, called SEBUM, sweat, and dissolved cells that bathes found deep in the hair follicle. the top layer of the skin and protects against infec- Emotional stress, cosmetics, and certain drugs tion. Care of this acidic fl uid mantle is very impor- (such as the birth control pills that have higher tant, especially in people with oily skin prone to amounts of progesterone and lower amounts of infection or ACNE lesions. estrogen) may worsen the condition. Estrogen, acne 3 however, will improve acne; women who use an ways to fi ght acne is to kill the bacteria. Those estrogen-dominant birth control pill usually notice products that are effective in treating acne actually their acne improves. cut down the oil production of the glands slightly, Acne is hereditary, and the tendency to develop and destroy (or decrease) bacteria in the follicles. the condition runs in families. If both parents have The most popular antibiotics in the treatment of acne, then three out of four of their children also acne are tetracycline, minocycline, and erythro- will have acne. mycin. For mild cases of acne, antibiotics are used Oil in cosmetics can contribute to acne. Cosmetic directly on the skin. For more advanced disease, products that contain lanolin, sodium lauryl sulfate, they are taken by mouth. isopropyl myristate, laureth-4, and D&C red dyes Retin-A, a drug made with TRETINOIN (an acid should be avoided, since all of these ingredients can related to vitamin A) is an effective treatment for promote acne. Makeup should be washed off each comedones, infl ammatory papules, and pustules. night with a mild soap; patients should be sure to It is also effective in reversing sun-induced skin rinse six or seven times with fresh water. aging. Retin-A is often used in combination with (To fi nd out how oily a cosmetic is, patients benzoyl peroxide or antibiotics. should rub a thick blob of makeup on a piece of Those with the most severe types of acne may typing paper; within 24 hours, the oil will make a be given a stronger vitamin-A related drug called ring on the paper; the bigger the ring, the more oil Accutane (ISOTRETINOIN). This drug has more seri- in the makeup.) ous side effects, including birth defects, and requires Acne is not caused by diet, dirt, or surface oil. strict medical supervision. No woman should become Oily foods have nothing to do with the oil on the pregnant when taking Accutane. It is not safe to become skin; oil on the skin is manufactured locally in the pregnant until two months after the course of medi- oil glands, no matter what a person eats. cation is fi nished.

Symptoms and Diagnostic Path TYPES OF ACNE Acne is characterized by lesions on the face, neck, Acne conglobata Severe hereditary acne that generally causes chest, back, shoulders, and upper arms, including scarring on face and back several types: pimples, cysts, pustules, whiteheads Acne detergens Acne caused by overuse of abrasive cleansers and blackheads. Acne excoriée A psychosomatic disease involving neurotic picking of the face Treatment Options and Outlook Acne mallorca Acne caused by sunbathing There are excellent types of therapy for all kinds Acne mechanica Acne caused by mechanical irritation (such of acne, including topical treatment, systemic as under the chin straps in football players) antibiotics and other medications, and hormonal Acne medicamentosa Acne caused by medications manipulation. A properly-structured regimen is Acne neonatorum Infant acne caused by hormones from the required for all those with acne, but most people mother to the newborn that usually disappears without benefi t from a combination of skin peeling, bacte- treatment rial destruction, and comedo-affecting products. Chloracne Acne induced by constant exposure to hydrocar- bons in motor oil or insecticides Patients should wash with soap and water Imaginary acne Imagining acne where none exists every night, eat well, and exercise regularly. For Pitch acne Lesions caused by coal tars or dandruff tar sham- milder cases of acne, medications containing poos BENZOYL PEROXIDE (beginning with a 5 percent Premenstrual acne Acne breakouts induced by hormonal solution) or those containing SULFUR, or a combi- change that fl are each month prior to starting a period nation of sulfur and RESORCINOL or SALICYLIC ACID Steroid acne An infl ammation of hair follicles caused by inter- are effective. nal steroids or from topical corticosteroids on the face Since oil accumulation attracts bacteria, and the Tropical acne Acne fi rst described in World War II by soldiers bacteria’s enzymes produce fatty acids that irritate in the Tropics who developed severe acne with terrible scars. the skin and cause infl ammation, one of the best 4 acne, adult

It is possible that some cases of acne can be MINANS; ACNE KELOIDALIS; ACNE MECHANICA; ACNE controlled by regulating the androgen/estrogen MYTHS; ACNE VULGARIS. hormone balance in those women who have an increased activity of the enzyme that converts tes- tosterone (a male androgen) into a more potent acne, cosmetic True cosmetic ACNE is probably form that affects the oil glands. Since androgen quite rare. While it is commonly believed that has been implicated in the increased secretion most acne seen in adult women is related to their of sebum that starts an acne blemish, androgen use of cosmetics containing comedogenic material, blockers that reduce the size of oil glands may this is probably inaccurate. There are three main help women whose acne is associated with other groups of ingredients that may aggravate acne. changes, such as excessive hair growth or balding. These are lanolins, isopropyl myristate, and some These drugs could be in the form of high-estrogen pigments. birth control pills. However, this benefi t should be LANOLIN (sheep skin oil) is an extremely com- balanced against the health risks associated with mon ingredient in cosmetics, but the fatty acids taking estrogen, including heart problems and in lanolin tend to aggravate acne in some people. breast cancer. Many lanolin derivatives in cosmetics, such as Steroids (cortisone) are very effective for infl am- etoxylated lanolins and acetylated lanolins, are matory or cystic acne when injected into a lesion; it harmful to acne-prone individuals. The partially can heal the cyst in about 24 hours. The injection synthetic lanolins are able to penetrate skin POREs is relatively painless, clears the skin rapidly and even better than natural lanolin. Lanolin oil itself prevents scarring. is acceptable. See also ACNE, ADULT; ACNE, COSMETIC; ACNE, CYS- Another problem ingredient in cosmetics is a TIC; ACNE, DRUG-INDUCED; ACNE, INFANT; ACNE, OIL; penetrating oil called isopropyl myristate, which is ACNE, TREATMENT FOR; ACNE DETERGENS; ACNE FUL- used to give cosmetics a slicker, sheer feel. There MINANS; ACNE KELOIDALIS; ACNE MECHANICA; ACNE are many chemicals similar to isopropyl myristate MYTHS; ACNE VULGARIS. in cosmetics, including isopropyl palmitate, iso- propyl isothermal, putty sterate, isostearyl neo- pentonate, myristyl myristate, decyl oleate, octyl acne, adult Pimples, pustules, and papules may sterate, octyl palmitate and isocetyl stearate, and be the bane of the teenage years, but they can also PPG myristyl propionate. All can worsen acne. crop up in adulthood—even in people who were Another ingredient in cosmetics that may trigger never troubled with breakouts during their ado- acne are the red tints used in blushes. Some of the lescence. In fact, some estimates suggest that acne red dyes are comedogenic. The easiest way to avoid affects 70 to 80 percent of all individuals in their these agents is to check the label for ingredients 20s and 30s. and to be sure to use only noncomedogenic prod- Why these skin blemishes suddenly occur in ucts that do not worsen or cause acne. older patients is a mystery. The hormonal upheaval See also ACNE, ADULT; ACNE, CYSTIC; ACNE, DRUG- that triggers acne in teenagers is not usually a fac- INDUCED; ACNE, INFANT; ACNE, OIL; ACNE DETERGENS; tor in adult acne, and while stress, dirt, and pollu- ACNE FULMINANS; ACNE KELOIDALIS; ACNE MECHAN- tion are prime suspects, there is no direct evidence ICA; ACNE MYTHS; ACNE VULGARIS. that either is the cause. In 30- to 40-year-old women, the cause is clearly related to hormones. acne, cystic A type of severe ACNE in which the Treatment Options and Outlook SEBUM (together with dead cells and bacterial prod- Treatment is the same as for teenage ACNE. ucts) ruptures through the follicle wall, causing an See also ACNE, COSMETIC; ACNE, CYSTIC; ACNE, infl ammatory reaction that may end in scarring. DRUG-INDUCED; ACNE, INFANT; ACNE, OIL; ACNE, See also ACNE, ADULT; ACNE, COSMETIC; ACNE, TREATMENT OF, ACNE; ACNE DETERGENS; ACNE FUL- DRUG-INDUCED; ACNE, INFANT; ACNE, OIL; ACNE acne, oil 5

DETERGENS; ACNE FULMINANS; ACNE KELOIDALIS; ACNE ever recorded in human history. What constitutes MECHANICA; ACNE MYTHS; ACNE VULGARIS. a lethal dose of dioxin has never been established because no one has ever been known to die from it. However, dioxin poisoning at such lethal levels acne, drug-induced Many drugs can cause ACNE is linked to the development of chloracne, cancer, when administered systemically. The most com- and system-wide organ failure. Scientists confi rm mon are phenytoin (Dilantin), isoniazid, lithium, he was poisoned by TCDD, the most harmful bromides, iodides, androgens, and corticosteroids. dioxin, a key ingredient of Agent Orange, an her- Of these, topical and systemic corticosteroids bicide defoliant used as a weapon during the Viet- are the most common acne inducers. In drug- nam War, and blamed for myriad health problems induced acne there may not be any blackheads; in U.S. Vietnam veterans. instead, patients experience uniform papules and See also ACNE, ADULT; ACNE, COSMETIC; ACNE, CYS- pustules. TIC; ACNE, INFANT; ACNE, OIL; ACNE DETERGENS; ACNE Lithium worsens ACNE VULGARIS, and can cause FULMINANS; ACNE KELOIDALIS; ACNE MECHANICA; a severe case of acne in patients who never before ACNE MYTHS. had a skin problem. Oral contraceptives contain- ing agents such as norgestrel or norethindrone can induce or worsen acne vulgaris; this may improve acne, infant ACNE is not unusual among new- when pill prescriptions are switched. Medications borns; it is triggered by hormones passed from the containing potassium iodide, bromide (especially mother to the child before birth. The hormones cold remedies) and chlorine (chloral hydrate) may cause the SEBACEOUS GLANDS in the skin to produce cause acne with very small pustules. oil; if these glands become blocked and infl amed, Steroids may cause acne several days to weeks WHITEHEADs and pimples may develop on the after treatment begins with either oral or topical baby’s face. Newborn acne usually clears up on its steroids. Steroid-induced acne is distinctive, with own in three or four months. If it is troublesome tiny red papules and pustules limited to the area or persistent a pediatrician may prescribe a topical where the steroid was applied, or on the chest, medication. back and shoulders in people on systemic therapy. Contrary to popular belief, infant acne is not Steroids thin the outer skin layer, making follicles associated with the development of acne in ado- more susceptible to rupture. Because infl ammation lescence or later in life. However, on rare occa- is controlled by steroids, the lesions are usually sions infantile acne becomes severe and persists small or they may appear after the drug is stopped. for months to a few years. This is associated with Acne fades after the medicine is stopped, but it may a family history of acne, usually in the father, and take some time to completely clear. often is followed by severe acne at adolescence. Other substances associated with acne are dioxin, See also ACNE, ADULT; ACNE, COSMETIC; ACNE, actinomycin D, cod liver oil, halothane, thiouracil, CYSTIC; ACNE, DRUG-INDUCED; ACNE, OIL; ACNE DETER- thiourea, trimethadione and vitamin B12. GENS; ACNE FULMINANS; ACNE KELOIDALIS; ACNE The chemical dioxin also can cause a type of MECHANICA; ACNE MYTHS; ACNE VULGARIS. severe acne called CHLORACNE. In 2004 dioxin was used by his enemies to poison Ukrainian presi- dent Viktor Yushchenko during his presidential acne, oil A form of ACNE caused by heavy petro- campaign. The strikingly handsome Yushchenko leum lubricating oils and greases that irritate the was terribly disfi gured by the dioxin, with swol- follicles, resulting in plugging of comedones or len, distorted facial features and a severe case of pustular folliculitis. chloracne that pitted and scarred his face. Experts say it is impossible for Yushchenko to have natu- Symptoms and Diagnostic Path rally acquired levels of dioxin more than 6,000 The lesions usually occur on the hands and fore- times higher than normal—the second highest arms, but they may be severe on covered areas 6 acne, pomade of the body if clothing is saturated with oil. The creams; the water-based gels are least likely to appearance of lesions in places other than outside irritate the skin. the bridge of nose, chin, forehead, back, and chest, Probably the most popular of these over-the- plus a history of exposure to oils, is a good way to counter products is benzoyl peroxide, an extremely distinguish oil acne from ACNE VULGARIS or bacterial effective topical antibacterial agent. When applied FOLLICULITIS. to the skin it markedly suppresses the bacterium Propionibacterium acnes. The benzoyl in the product Treatment Options and Outlook draws the peroxide into the pore where it releases This condition responds immediately when the oxygen, killing the bacteria that can aggravate exposure to the irritating oil is stopped. Eliminat- acne. Benzoyl peroxide also suppresses fatty acid ing skin and clothing contact with the offending oil cells that irritate pores, and it helps to open up and grease is the best way to avoid oil acne. Appli- BLACKHEADs and WHITEHEADs. Benzoyl peroxide cations of BENZOYL PEROXIDE may also help. is most effective for patients with infl ammatory See also ACNE, ADULT; ACNE, COSMETIC; ACNE CYSTIC; acne; by inhibiting bacteria growth, it decreases the ACNE, DRUG-INDUCED; ACNE, INFANT; ACNE DETER- infl ammatory components in the skin. GENS; ACNE FULMINANS; ACNE KELOIDALIS; ACNE Benzoyl peroxide is sold in strengths ranging MECHANICA; ACNE MYTHS. between 2.5 percent to 10 percent, but dermatolo- gists usually advise patients to start with a 2.5 or 5 percent product, since the lower concentration acne, pomade A type of ACNE that occurs primar- is usually just as effective and less likely to cause ily in African-American patients who use pomades irritation. Most over-the-counter products contain or thick oils daily on their hair to eliminate the benzoyl peroxide in a lotion base or in treated pads; curl. The pomade gets transferred to the skin the prescription items contain the chemical in a gel from the fi ngers and hair, and blocks the skin’s oil base. Some irritation, redness, and swelling may glands, causing acnelike lesions. In this condition, follow use of benzoyl peroxide, and allergic sensiti- which was fi rst described in 1970, many closed zation has occasionally occurred. comedones and sometimes infl amed lesions are For more severe cases, dermatologists may pre- packed close together on the head and temples scribe Retin-A, a drug made with TRETINOIN (an near the hairline. acid related to vitamin A), or topical or oral antibi- otics. Tretinoin is the principal drug for topical use Risk Factors and Preventive Measures in acne with comedones (open whiteheads), and is Patients should wash hands after applying the oil, available as a gel, cream, or lotion. (The lotion is keep hands away from the face and avoid hairstyles potentially more irritating and the creams are less where the hair constantly touches the skin of the irritating.) Less irritation develops if tretinoin is face. applied at least 30 minutes after washing. Tretinoin, like benzoyl peroxide, should be started in the lowest concentration available and be applied only acne, treatment for There are a range of therapies every other day. Patients should protect their skin for all kinds of acne, including topical treatment, from exposure to the sun, since tretinoin increases systemic antibiotics, hormonal manipulation, or the skin’s sensitivity to ultraviolet radiation. ISOTRETINOIN (Accutane), a synthetic derivative of While tretinoin is best used for acne with vitamin A. open whiteheads, it may also help patients with For milder cases, some people fi nd relief infl ammatory acne since it helps to prevent with over-the-counter medications containing infl ammation. BENZOYL PEROXIDE or SULFUR, a combination of Topical antibiotics (including TETRACYCLINE, sulfur and RESORCINOL, or SALICYLIC ACID. These ERYTHROMYCIN, CLINDAMYCIN, and meclocycline) medications are sold as liquids, gels, lotions, or have been used topically as an antibacterial acne, treatment for 7 approach to treating acne. Experts believe antibiot- This seems to affect those with an existing tendency ics are not as effective as benzoyl peroxide except toward depression. It is important for patients to in mild infl ammatory acne. A preparation combin- discuss all these potential side effects with their ing 3 percent erythromycin with 5 percent benzoyl doctor before starting Accutane. peroxide in a gel base may be more effective than Acne medications may cause reactions if the either component by itself. skin is exposed to the sun; experts recommend staying away from sunlight, infrared heat lamps, Systemic Therapy and sunscreens until patients understand how the About 10 percent of all tetracycline sold in the product works. United States is used to treat acne, although the condition is not a bacterial disease. The effective- Surgical Techniques ness of oral antibiotics is probably related to the fact Acne surgery removes open and closed comedones that the drugs interfere with infl ammatory byprod- and sometimes very small pustules; removal of ucts of some types of bacteria, which prevents the the closed comedones is important, since they can development of new infl ammatory lesions. It does lead to infl ammatory lesions. Open comedones are take some time, however, before the antibiotic removed only for cosmetic reasons, since they do approach works. Erythromycin and minocycline not usually become infl amed. are probably as effective as tetracycline, but mino- The direct injection of corticosteroids into a cycline is much more expensive. lesion can reduce infl ammation in larger cysts in Preparations that interfere with the production order to avoid a depressed scar. This technique is of sebum (an oily substance produced by sebaceous not used for papules and pustules. glands) may also be effective, including cortico- steroids and estrogens. (Estrogens should only be Topical Applications used for women whose acne has not responded to The directions on most topical acne medications other types of treatment). In addition, a medication say to “apply to the affected area” after washing. called cyproterone acetate has been used in Europe This does not mean apply to pimples only, since to successfully treat acne. these medications do not really fi ght pimples that Those with the most severe types of acne may already exist. However, there is the possibility that be given an even stronger vitamin-A related drug benzoyl peroxide applied to a pimple may cause it called Accutane (isotretinoin). Accutane is the only to go away a bit faster. treatment that can potentially cure acne. Sixty per- It’s not a good idea to mix acne medications. If a cent of those with severe scarring acne who receive patient is using a nonprescription acne product, it Accutane never again need treatment. Accutane should be stopped if a prescription product is used. is very effective against the most stubborn cases of acne, and has produced remarkable clearing in What Not to Do those with severe cystic acne. The drug has also Picking or squeezing blemishes can inhibit heal- resulted in remissions that have persisted for years ing and lead to scarring. For this reason, patients in most patients. should never squeeze pimples or whiteheads. Unfortunately, Accutane has serious side effects Because regular pimples are the result of infl am- and requires strict medical supervision. Side effects mation, squeezing can simply worsen the infl am- include those found in excess levels of vitamin A mation and cause an infection. However, pimples (dry mouth, itching, small red spots on the skin with a little yellow PUS head in the middle can and eye irritation). Its most serious side effect is be gently squeezed, which will pop the pimple that it can cause serious birth defects. Acutane must and allow it to heal more quickly. Unfortunately, not be given during pregnancy. nothing can make a pimple go away faster—the Research suggests it may also trigger serious life of a pimple lasts between one and four depression, and in rare cases, suicidal thoughts. weeks. 8 acne detergens

Whiteheads, which do not involve infl amma- acne fulminans This is an acute, severe necrotic tion, should never be squeezed. If a whitehead is variety of ACNE that is accompanied by systemic squeezed, the wall of the plugged pore can break symptoms such as fever and joint pain. and the contents can leak out into the skin, caus- Acne fulminans may be triggered by high levels ing a pimple. (A pimple forms from the rupture of of testosterone, either legally prescribed or illegally a whitehead pore.) taken to enhance muscle growth. Blackheads may be squeezed, since they will not result in a pimple. Blackheads are simply open Symptoms and Diagnostic Path comedones or open whiteheads. The black color The condition, which almost always affects males, is from melanin and from oxidation of the pore includes the following symptoms: contents. • abrupt onset Risk Factors and Preventive Measures • infl ammatory and ulcerated nodular acne on Acne sufferers should try to avoid excess stress if chest and back prone to breaking out. Patients taking birth control • severe acne scarring pills that cause acne (especially Ovral, Loestrin, Norlestrin, and Norinyl) may be able to switch to • fl uctuating fever a different pill or use an alternative birth control • painful joints method. • malaise • loss of appetite and weight loss acne detergens This form of ACNE occurs in some • high white blood cell count patients who are compulsive face washers. There is some evidence that this may be a variety of ACNE MECHANICA. Treatment Options and Outlook See also ACNE, ADULT; ACNE, COSMETIC; ACNE, CYS- Management can be diffi cult, and several medica- TIC; ACNE, DRUG-INDUCED; ACNE, INFANT; ACNE, OIL; tions are usually required, including high doses ACNE FULMINANS; ACNE KELOIDALIS; ACNE MECHAN- of oral antibiotics such as ERYTHROMYCIN or anti- ICA; ACNE MYTHS; ACNE VULGARIS. infl ammatory medications such as aspirin. Most cases require Accutane and oral corticosteroids such as prednisone, DAPSONE, or ISOTRETINOIN. Acne acne excoriée One of a group of disorders in medications applied directly to the skin are not which a patient, because of an exaggerated sense helpful. of abnormal conditions, causes a skin rash by con- See also ACNE, ADULT; ACNE, COSMETIC; ACNE, CYS- stantly picking or squeezing facial blemishes. In these TIC; ACNE, DRUG-INDUCED; ACNE, INFANT; ACNE, OIL; cases, one or a few small blemishes are so upsetting ACNE DETERGENS; ACNE KELOIDALIS; ACNE MECHAN- that the individual constantly picks or washes them, ICA; ACNE MYTHS; ACNE VULGARIS. actually making the lesions worse. People with this problem may refuse to believe their actions are making the lesions worse by constant irritation, and acne keloidalis Also called dermatitis papillaris may seek plastic surgery to correct the problem. capillitii, this disorder affects hair follicles in people However, in these cases they are quite often dissatis- of African descent. fi ed with the results of surgery. Severely distraught patients may even attempt suicide. Symptoms and Diagnostic Path See also ACNE, ADULT; ACNE, COSMETIC; ACNE, CYS- It creates fi rm papules and pustules on the nape of TIC; ACNE, DRUG-INDUCED; ACNE, INFANT; ACNE DETER- the neck. In severe cases, large lesions may result in GENS; ACNE OIL; ACNE KELOIDALIS; ACNE MECHANICA; signifi cant scarring and permanent hair loss. Com- ACNE MYTHS; ACNE VULGARIS. plications may include infection, scarring resulting acrocyanosis 9 in limited range of neck movement; squamous cell ACNE DETERGENS; ACNE FULMINANS; ACNE KELOIDALIS; cancer may rarely develop. ACNE MECHANICA; ACNE VULGARIS.

Treatment Options and Outlook While no single treatment is effective for all acne neonatorum See ACNE, INFANT. patients, therapies include corticosteroid injections and topical corticosteroid preparations, which may limit the formation of scars. A variety of surgi- acne products, over-the-counter There are a num- cal techniques also may be attempted, including ber of ingredients found in non-prescription products removal of individual papules with scissors, a that are considered safe and effective in the treatment scalpel, or lasers. In more severe cases, the entire of ACNE by the U.S. Food and Drug Administration. affected area is removed and the wound is stitched They include BENZOYL PEROXIDE 2.5 to 10 percent, closed. RESORCINOL 2 percent (in certain combinations), See also ACNE, ADULT; ACNE, COSMETIC; ACNE, CYS- resorcinol monacetate 3 percent (in certain combina- TIC; ACNE, DRUG-INDUCED; ACNE, INFANT; ACNE, OIL; tions), SALICYLIC ACID 0.5 to 2 percent, and SULFUR 3 ACNE DETERGENS; ACNE FULMINANS; ACNE MECHAN- to 10 percent (in certain combinations). ICA; ACNE MYTHS; ACNE VULGARIS. All of these products dry and peel the skin to some degree. However, used together they may increase skin dryness and cause irritation. acne mechanica Acne caused by physical trauma such as rubbing, tight clothes, or underneath chin straps of helmets worn by athletes. Heat and sweat acne rosacea See ROSACEA. also contribute to this condition.

Treatment Options and Outlook acne vulgaris Another name for common ACNE. Topical treatments such as a solution of salicylic acid, Retin-A, or benzoyl peroxide can be applied directly to the affected area. acrochordon See SKIN TAG.

Risk Factors and Preventive Measures Acne mechanica can be prevented by wearing acrocyanosis A condition induced by abnormal clean clothes made of cotton or another material cold sensitivity, which causes spasms in small blood that wicks moisture away from the skin, and wash- vessels. These spasms result in a loss of oxygen in ing the area after exercise. the blood, which makes hands and feet blue, cold See also ACNE, ADULT; ACNE, COSMETIC; ACNE, CYS- and sweaty. The problem is usually worsened by TIC; ACNE, DRUG-INDUCED; ACNE, INFANT; ACNE, OIL; cold weather, and young women are particularly ACNE DETERGENS; ACNE KELOIDALIS; ACNE FULMINANS; susceptible. Acrocyanosis is distantly related to ACNE MYTHS; ACNE VULGARIS. RAYNAUD’S DISEASE, a more serious circulatory dis- order in which the skin of the fi ngers and toes may be damaged by chronically reduced blood fl ow. acne medicamentosa See ACNE, DRUG-INDUCED. Treatment Options and Outlook Treatment is often unnecessary. Drugs to dilate the acne myths A wide range of ACNE taboos are blood vessels are not usually prescribed. groundless, such as the idea that acne is worsened by chocolate, nuts, fatty foods, and shellfi sh. Risk Factors and Preventive Measures See also ACNE, ADULT; ACNE, COSMETIC; ACNE, CYS- The condition can be prevented by avoiding cold TIC; ACNE, DRUG-INDUCED; ACNE, INFANT; ACNE, OIL; and tobacco. 10 acrodermatitus enteropathica acrodermatitis enteropathica A rare inherited actinic conditions Conditions caused by overex- disease in which the skin of the fi ngers, toes, posure to the sun. These include actinic dermatitis mouth, anus, mouth, and scalp of infants is red- (infl ammation of the skin), ACTINIC KERATOSIS (a dened, ulcerated and covered with pustules. In rare sun-induced premalignant condition characterized instances, the disorder can lead to blood poisoning by redness and swelling), BASAL CELL CARCINOMA, and death if unrecognized and untreated. and SQUAMOUS CELL CARCINOMA. All these condi- The disease is caused by low levels of zinc in the tions can be prevented by avoiding the sun and skin as a result of problems in zinc metabolism. using sunscreens from an early age. The problem occurs after weaning because human See also DERMATITIS, ACTINIC. breast milk contains a substance (believed to be picolinic acid) that permits zinc absorption even when the intestinal factor normally controlling actinic dermatitis See DERMATITIS, ACTINIC. the absorption of zinc is defi cient or absent. After weaning from breast milk, symptoms in affected babies occur in both boys and girls. actinic keratosis Also known as solar keratosis, this lesion is a dry, scaly, rough pink-to-tan thick- Symptoms and Diagnostic Path ening of the skin caused by long-standing overex- Symptoms appear about four to 10 weeks after birth posure to the sun. This common skin lesion affects in bottle-fed babies, or after weaning in breastfed one out of six people; it is a precancerous condition babies. They include failure to thrive, diarrhea, hair that can lead to malignant skin tumors (SQUAMOUS loss, nail problems, conjunctivitis and photophobia CELL CARCINOMA). (hypersensitivity to light), emotional instability, decreased appetite, and skin problems. Symptoms and Diagnostic Path The condition is usually found in older patients; Treatment Options and Outlook however, with increased exposure to the sun it is Zinc dietary supplements reverse all symptoms. being seen in younger and younger patients. The supplements should not be taken with food Lesions occur most often on the face, back of the (especially bread); nausea is a common side hands and forearms, neck, and exposed scalp. The effect. lesions develop slowly, eventually growing to the While the disease is lifelong, proper treatment size of a quarter inch, sometimes fading and reap- leads to remission and a normal life span. The pearing. There are usually several keratoses at one disease usually improves during adolescence, but time on areas of the body exposed to sunlight. The it may persist into adulthood when it begins to skin surrounding the lesion often shows evidence resemble PSORIASIS. of chronic sun damage, including scaling, pigment variation, wrinkling, and atrophy. Actinic damage of the lips is called “actinic chei- acrodermatitis, papular See GIANOTTI-CROSTI litis,” if it proceeds to squamous cell carcinoma, SYNDROME. about one-fi fth of these lesions will spread. Untreated, this type of cancer can invade the surrounding tissues or internal organs. The pres- acroparesthesia A medical term for the feeling of ence of this skin lesion indicates that the sun has tingling in the fi ngers or toes. damaged the skin, and any type of skin cancer can See also PINS AND NEEDLES SYNDROME. develop. Since more than half a person’s lifetime sun exposure usually occurs before age 20, keratoses actinic Pertaining to changes caused by the ultra- can appear in a person’s 20s if that person has not violet rays of the Sun. been suffi ciently protected from sun damage. actinomycosis 11

Treatment Options and Outlook Risk Factors and Preventive Measures While not all keratoses need to be removed, there Those at greatest risk for these lesions have fair are a number of treatments for those that do. skin, blond or red hair, and blue, green or gray The most common treatment is cryotherapy with eyes because their skin has less protective pig- LIQUID NITROGEN. With cryosurgery, the physician ment. However, even those with dark skin can freezes the lesions by applying liquid nitrogen with develop keratoses if they are exposed to the sun a special spray or a cotton-tipped applicator and without protection, although those with black removes the lesions. This method does not require skin rarely have these lesions. Individuals with anesthesia and produces no bleeding. White spots compromised immune systems as a result of may sometimes appear afterward on the skin’s chemotherapy, AIDS, or organ transplants are at surface, but if done properly this is relatively higher risk. uncommon. Actinic keratoses are more likely to appear in In another method, CURETTAGE AND ELECTRO- older people because of the cumulative effects of DESICCATION, the physician scrapes the lesion and the sun; one recent survey of individuals who had takes a biopsy to test for malignancy. During the been exposed to large amounts of sunlight found procedure, bleeding is controlled by electrocautery keratoses in more than half of the men and a third (heat produced by an electric needle). of the women aged 65 to 74. Some experts believe Alternatively, a physician could shave the kera- that most people who live to be 80 or older have tosis by a process called “shave removal” to obtain actinic keratoses. a specimen for testing; the base of the lesion is destroyed and the bleeding is stopped by cauteriza- tion (heat). actinic lentigo See LENTIGO SIMPLEX. DERMABRASION removes the upper layers of the skin by sanding or using a fi ne wire brush; redness and pain usually disappear after a few days. actinomycosis A deep bacterial infection of the Chemical peeling causes the top layers of the skin caused by Actinomyces israelii or Arachnia skin to slough off by applying glycolic acid, trichlo- propionica, normal bacteria always present in the roacetic acid or phenol while the patient is sedated; mouth and tonsils that can cause infection when the skin is usually replaced within seven days by a introduced into broken tissue. It is also possible to new growth of skin. transmit this bacteria via a human bite. LASER SURGERY may be used to treat actinic chei- litis by focusing a beam of light from a carbon diox- Symptoms and Diagnostic Path ide laser; the damaged skin can be vaporized. The most common form of the disease affects the Two medicated creams—5-FLUOROURACIL or mouth and jaw, causing a painful swelling. Small masoprocol are also effective in removing kera- openings later develop on the skin of the face toses (especially when there are many lesions). A around the mouth, discharging PUS and character- solution or cream of 1 to 5 percent fl uorouracil is istic yellow granules. Poor oral hygiene may con- applied by the patient twice a day from two days tribute to this form of the infection. a week to daily for four to nine weeks. Treatments A diagnosis is usually confi rmed by presence of cause the skin to become intensely red, causing the granules. some pain and skin breakdown. After treatment, the skin may be treated with a topical steroid Treatment Options and Outlook (such as hydrocortisone 1 percent) to alleviate the Adequate surgical drainage is important, together infl ammation. with bed rest and good diet. Treatment with large Masoprocol cream (10 percent) is applied for doses of penicillin injections is usually successful, four weeks and is now available by prescription. although medication may be needed for several Redness and fl aking are common side effects. months in severe infections. 12 acyclovir acyclovir (Trade name: Zovirax) An antiviral the disorder. It is likely that the late president John drug introduced in 1982 used in treating the virus F. Kennedy suffered from this disease. causing HERPES SIMPLEX INFECTION, SHINGLES, and Addison’s disease occurs when the adrenal CHICKEN POX. Acyclovir is available in topical or glands do not produce enough of the hormone cor- oral form. Severe cases may be treated with intra- tisol and in some cases, the hormone aldosterone. venous (IV) acyclovir. For this reason, the disease is sometimes called chronic adrenal insuffi ciency, or hypocortisolism. Oral Acyclovir Failure to produce enough cortisol can occur Acyclovir is effective in managing both the ini- for different reasons. The problem may be due to a tial infection and recurrent infections of herpes disorder of the adrenal glands themselves (primary (including ECZEMA HERPETICUM) and in the treat- adrenal insuffi ciency) or to inadequate secretion of ment of shingles. It is effective in preventing sub- acrinocorticotropic hormone (ACTH) by the pitu- sequent viral attacks if taken continuously soon itary gland (secondary adrenal insuffi ciency). Most after infection. In patients with recurrent genital cases of Addison’s disease are caused by the gradual herpes, acyclovir therapy reduces the duration of destruction of the adrenal cortex, the outer layer viral shedding, and makes the lesions heal quicker, of the adrenal glands, by the body’s own immune providing symptom relief. system. About 70 percent of reported cases of In addition, acyclovir has been helpful to patients Addison’s disease are due to autoimmune disor- receiving bone marrow transplants to prevent ders, in which the immune system makes antibod- the subsequent development of herpes simplex ies that attack the body’s own tissues or organs and infection. slowly destroys them. Adrenal insuffi ciency occurs when at least 90 percent of the adrenal cortex has Topical Acyclovir been destroyed. As a result, often both glucocor- The topical form does not prevent new lesions from ticoid and mineralocorticoid hormones are lack- forming during the course of the disease, nor does it ing. Sometimes only the adrenal gland is affected; prevent the development of latency. When applied sometimes other glands also are affected. to an existing blister, however, it may relieve symp- Less common causes of primary adrenal insuf- toms, speed healing, and shorten the duration of fi ciency are chronic infections, mainly fungal infec- the infection and the contagious period. tions; cancer cells spreading from other parts of the body to the adrenal glands; amyloidosis; and surgi- Adverse Effects cal removal of the adrenal glands. Adverse effects are rare. The ointment may cause skin irritation or rash. Taken by mouth, the drug Symptoms and Diagnostic Path may cause headache, dizziness, or nausea/vomit- The disease begins with a feeling of malaise and ing, confusion, or hallucinations. Rarely, acyclovir is characterized by weight loss, muscle weakness, injections may cause kidney damage. and fatigue. The symptoms of adrenal insuffi ciency See also VALACYCLOVIR; FAMCICLOVIR. usually begin gradually. Nausea, vomiting, and diarrhea occur in about 50 percent of cases. Blood pressure is low and falls further when standing, Addison’s disease A rare endocrine or hormonal causing dizziness or fainting. Skin changes also are disorder characterized by a defi ciency of the hor- common in Addison’s disease, with areas of dark mones hydrocortisone and aldosterone. The dis- tanning covering exposed and nonexposed parts ease, which affects about one in 100,000 people, of the body. This darkening of the skin is most occurs in all age groups and affl icts men and visible on scars; skin folds; pressure points, such women equally. It was invariably fatal before hor- as the elbows, knees, knuckles, and toes; lips; and mone treatment became available in the 1950s. mucous membranes. The disease was named for the English physician Addison’s disease also can cause irritability and Thomas Addison (1793–1860), who fi rst diagnosed depression. Because of salt loss, craving of salty age spots 13 foods is common. Low blood sugar is more severe no virus-specifi c therapy, serious adenovirus illness in children than in adults. In women, menstrual can be managed only by treating symptoms and periods may become irregular or stop. complications of the infection. Because the symptoms progress slowly, they are usually ignored until a stressful event like an illness or an accident causes them to become worse. adipose nevi A rare type of connective tissue In its early stages, adrenal insuffi ciency can BIRTHMARK characterized by grouped yellowish be diffi cult to diagnose. A review of a patient’s nodules that form plaques, usually appearing on medical history based on the symptoms, especially the lower torso and upper thighs. The condition, the dark tanning of the skin, will lead a doctor to also known as nevus lipomatosus superfi cialis Hoff- suspect Addison’s disease. A diagnosis is made by mann and Zurhelle, does not require treatment. biochemical laboratory tests to determine whether there are low levels of cortisol. X-ray exams of the adrenal and pituitary glands also are useful adipose tissue A layer of fat beneath the skin and in helping to establish the cause, as are the ACTH around internal organs. After puberty, the distribu- stimulation and insulin-induced hypoglycemia tion of this superfi cial adipose tissue changes in tests. males and females; women have a greater propor- tion of total body weight in adipose tissue accumu- Treatment Options and Outlook lated on breasts, hips, and thighs. In adult males, The pigmentation disappears slowly when the adipose tissue accumulates around the shoulders, patient receives glucocorticosteroid replacement waist, and abdomen. therapy. Still, most patients retain a slight tan color Adipose tissue is constructed from fat deposits for the rest of their lives. left by excess food intake and serves as an energy store; too much adipose tissue causes obesity. The tissue is an insulator and keeps the body warm, adenoma sebaceum See ANGIOFIBROMA. especially in babies, and it also helps absorb shock in areas subject to sudden or frequent pressure (such as the buttocks and feet). adenosine monophosphate (AMP) A metabo- lism byproduct that may help ease the pain of SHINGLES. The treatment has no side effects, and adnexa of skin The cutaneous structures that works best within the fi rst few months of pain make up the hair, nails and sebaceous, eccrine, and when the nerve endings have experienced mini- APOCRINE GLANDS. mal damage. See also SEBACEOUS GLANDS. Otherwise, the pain following a shingles out- break (POSTHERPETIC NEURALGIA) is treated with the painkillers Tylenol and codeine, if necessary. In age spots Blemishes that appear on the skin as a addition, ZOSTRIX (CAPSAICIN) has been found to be person ages. The most common of these spots are effective. SEBORRHEIC KERATOSES—brown or yellow-brown raised spots that may occur anywhere on the body. Other common age spots in the elderly are LIVER adenovirus One of a group of viruses that cause SPOTS (lentigines), ACTINIC KERATOSES, and Camp- infections of the upper respiratory tract, producing bell De Morgan’s spots (cherry ANGIOMAS)—red, measleslike eruptions and symptoms of the com- pinpoint blemishes. mon cold. Adenoviruses are often diagnosed in the Treatment is usually not necessary except for winter and spring. actinic keratoses, which may become malignant. Most infections are mild and require no therapy Freezing the keratoses with liquid nitrogen and or only symptomatic treatment. Because there is removing them is the usual treatment, although 14 aging and skin they may be removed surgically with a local hand, hair begins to appear in unwanted places anesthetic. (ears, nose, and eyebrows in men and upper lip While most age spots are harmless, any inexpli- and chin in women). cable blemish (or one that bleeds or grows rapidly) may represent skin cancer and should be examined Treatment Options and Outlook by a physician. Brown spots that have irregularities There are literally hundreds of products on the of brown color or irregular borders also should be market that claim to reverse the consequences of shown to a physician. aging. Lotions containing ALPHA HYDROXY ACID and See also KERATOSIS. Retin-A have been shown to reverse some features of skin aging; no other skin products have ever been shown to improve or slow the aging process. aging and skin Loss of elastic tissue and COLLAGEN Alternatively, it is possible not to reverse aging causes the skin to sag and wrinkle; weakened blood but to erase it with injectable soft tissue fi llers, capillaries cause skin to bruise more easily. This which are designed to produce a smoother, more damage is accelerated by exposure to the sun or by youthful appearance with minimal recovery time smoking. In fact, there are really two types of skin and maximum safety. In the past, doctors have aging—chronological aging and photoaging. used bovine (cow) collagen and the patient’s own Chronological aging is just what it sounds body fat to safely diminish creases and give the face like—the inherited tendency to age. Photoaging a more youthful appearance. (or solar-induced aging) is caused by damage from While these methods are effective, the fi llers exposure to the sun, and this type of skin problem (especially collagen) were not a long-term solution; is more common today than skin problems due to they required frequent offi ce visits to maintain the chronological aging. youthful look. As a person ages, the skin produces fewer cells However, in early 2003 the U.S. Food and Drug and repairs damaged cells more slowly, while cells Administration (FDA) approved two injectable in the horny layer of the skin become dryer and products containing human collagen that plump rougher. At the same time, the number of mela- up the skin. Later in the year and in 2004, they nin-producing cells (MELANOCYTES) drops, leading approved two hyaluronic acid fi llers that lasted to patchy skin color. Wound healing is also slowed longer than collagen injections. Injectable soft down, and there is usually a decreased ability to tissue fi llers are used to improve the appearance clear foreign material and fl uid. Increasing rigid- of fi ne lines and wrinkles, fi ll out hollow cheeks, ity, inelasticity, and a decrease of dermal collagen lighten scars, lessen deep folds, and repair other and elastin fi bers make the skin begin to wrinkle facial fl aws. Results are, or close to, immediate; and sag. however, it may take more than one treatment to Fat distribution in the skin also changes with achieve the desired effect. The length of time that age, redistributing itself to the waist in men and you can expect the results to last varies. the thighs in women. At the same time, the SUBCU- Bovine collagen The oldest and best-known TIS begins to thin in certain areas such as the face, fi ller is purifi ed bovine collagen, which derma- hands, feet, and shins. tologists use to fi ll in fi ne lines around the eyes In addition, aging glands produce less oil and and deep lines from the nose to the corners of the smaller amounts of perspiration, and so there is less lips, as well as enlarge lips and erase acne scars. oil to trap moisture on the skin’s surface and less Typically, a series of injections will help fi ll out the perspiration to moisturize skin. Heat, air condition- imperfections and give almost immediate results, ing, and wind can further dehydrate the skin. each session lasting about 10 to 30 minutes. Age also affects hair color, graying or whitening While this method is certainly effective, the it because of a decrease in the number of melanin- procedure must be done again within three to producing cells. Most people also notice thinning four months, depending on the size of the area and slower hair regrowth rate, while on the other treated, how much collagen was injected, and aging and skin 15 how healthy the fi lled skin was. The procedure Hyaluronic acid gel For years, dermatologists often causes some redness, swelling, or bruising have known that wrinkles result from the loss of around the injection site, which usually disap- three crucial skin components—collagen, elastin, peared in a few days. Patients with a history of and hyaluronic acid. Today, doctors can replace allergic reactions or cold sores risk further possible two of these components (collagen and hyaluronic outbreaks. acid). Patient’s body fat For years dermatologists also Hyaluronic acid holds together collagen and have been successfully injecting the patient’s own elastin, providing a framework for the skin. When body fat. Since the patient’s own body fat is used injected into the skin in gel form, hyaluronic acid to fi ll in the creases, potential allergic reactions are binds to water and adds volume to easily fi ll in not an issue and allergy testing is not required. larger folds of skin around the mouth and cheeks. In this procedure, the dermatologist transfers Patients notice an immediate plumping of the skin the patient’s own fat from a part of the patient’s in the treated areas. body with excess fat to an area that has lost fat as HYALURONIC ACID GEL (Restylane) and hylan- a result of aging. Typically, the fat is used to plump Bgel (Hylaform), both approved in 2005 by the up deep creases around the nose and mouth, to FDA, are injected into facial tissue to smooth fi ll scars, or to replace fat pads in the cheeks. This wrinkles and folds, especially in the folds around technique may require follow-up visits to achieve the nose and mouth. Hyaluronic acid is a protec- the desired effects. Results last longer than with tive, lubricating and binding gel substance that is bovine collagen—typically between one to three produced naturally by the body. These two fi llers years. Treatment of scars with this method tends work by temporarily adding volume to facial tissue to last longer. and restoring a smoother appearance to the face for Potential side effects with this method are simi- an effect that lasts for about six months. lar to other fi llers; swelling and bruising and some- The hyaluronic fi llers are injected by a doctor times lumps can develop around the lips or the into areas of facial tissue where moderate to severe eyes where body fat does not naturally occur. facial wrinkles and folds occur. The gel temporarily Human-based collagen Two products contain- adds volume to the skin and can give the appear- ing human-based collagen (COSMODERM and COS- ance of a smoother surface. Restylane and Hylaform MOPLAST) received FDA approval in March 2003 for will help smooth moderate to severe facial wrinkles the correction of facial wrinkles, acne scars, resto- and folds. In one study, most patients needed just ration of the lip border, and other soft-tissue con- one injection to smooth out the wrinkles; about tour problems. Allergy testing is not required with one-third of patients needed more than one injec- these fi llers, which makes same-day treatment pos- tion to get a satisfactory result. sible. Side effects are usually limited to temporary One of the main advantages of hyaluronic acid redness and swelling around the injection site. As gel is that it rarely triggers allergic reactions, nor with bovine collagen, results are noticeable almost is there a risk of transmitting animal diseases by right away, and last about three to four months. injection as there is with bovine collagen. Since a Repeated treatments may be needed to achieve the skin check for allergies is not required with hyal- desired effects. uronic acid gel, patients can be treated on their fi rst Although human collagen was an improvement visit to the dermatologist. In addition, hyaluronic over bovine collagen because it did not trigger acid treatments last about four to six months or allergies, dermatologists still needed a fi ller that longer and require less volume to fi ll wrinkles and could safely and effectively fi ll folds but last longer hard-to-treat skin folds compared to collagen. than three to four months. Finally, two new fi llers Hyaluronic acid fi llers have side effects, and have been approved by the FDA that can replace pain is a problem. Since hyaluronic acid gel does the skin’s hyaluronic acid lost during aging. These not contain the anesthetic lidocaine, injections fi llers work by pulling water into the skin, plump- are painful. In addition, there is usually tempo- ing up the skin and adding volume. rary infl ammation that produces swelling and 16 AIDS and skin disorders redness following injection with hyaluronic acid cells are grown can cause an allergic reaction. If no gel—especially in the lip area. allergic reaction occurs within two weeks, treat- Some dermatologists combine hyaluronic acid ment can begin. and collagen. Injecting collagen fi rst numbs and supports the area, stabilizing the skin to prevent Risk Factors and Preventive Measures bruising. Then hyaluronic acid gel is injected pain- Obviously, prevention offers the best chance to lessly. Using these fi llers together replaces two of avoid excess age-related damage to the skin. Those the skin components that are lost with skin aging. who have stayed away from the sun’s rays for Silicone Until it was banned by the FDA in most or all of their lives will have much healthier 1992, injectable silicone was used in the United skin than the senior citizen who has been a sun- States for many years to successfully treat wrinkles worshipper for decades. and ACNE scars as well as enhance lips, cheekbones, Health habits also play a role—getting enough and the chin. However, problems emerged when sleep, fresh air, exercise, and good food. Cutting medical-grade silicone was diluted with foreign down or eliminating smoking will also improve the substances, such as mineral oil, when non-medical condition of the skin. Research suggests that smok- grade silicone was injected and when it was ers (whether young or old, male or female, smiling injected in large volumes. or unsmiling) tend to look fi ve or more years older What makes silicone unique is that the results than their chronological age. are permanent. Studies are showing that once the desired results are achieved, there is no need for future treatments unless it becomes necessary as AIDS and skin disorders The skin symptoms of the patient ages or disease processes continue. AIDS can range from a severe form of normally Unfortunately, side effects may include delayed mild eruptions to unusual lesions such as the pink- reactions that trigger redness and lumpiness as the purple spots of KAPOSI’S SARCOMA, and oral hairy body rejects the silicone. In the past, more prob- LEUKOPLAKIA. In fact, skin symptoms may be the lems were reported with silicone breast implants. very fi rst sign of a suppressed immune system. However, side effects are rare when silicone is injected by a dermatologic surgeon skilled in the Viral Infections microdroplet technique, in which tiny amounts of A wide range of viral infections may plague silicone are injected at four- to eight-week intervals the patient with AIDS, including HERPES SIMPLEX until the desired effect is achieved. Using silicone as (1 and 2), SHINGLES, MOLLUSCUM CONTAGIOSUM, a fi ller is not approved by the FDA, but it is used by WARTS, and oral hairy leukoplakia. Herpes attacks some physicians as a fi ller in the United States in an are far more common in patients with AIDS than off-label manner. in the general population, and they are more likely Fibroblasts Harvesting the patient’s own to be deep, painful, and slow to heal (especially in collagen-producing cells (FIBROBLASTS) holds prom- the perianal area). Occasionally, herpes simplex ise for fi lling fi ne facial lines, enhancing lips and infections in patients with AIDS are resistant to correcting scars. Results reportedly last a bit longer ACYCLOVIR, the primary drug treatment for herpes than bovine collagen, and side effects are minimal. simplex. However, the procedure is time-consuming and it The appearance of shingles in an individual is is not FDA-approved. First, a dermatologist must highly suggestive of HIV infection, and the likeli- remove a small amount of the patients skin tis- hood that the patient will go on to develop full- sue and close the area with adhesive or sutures. blown AIDS is high. In addition, recurrent shingles The tissue is shipped to a company that cultures may also occur in patients with AIDS. the fi broblasts, using its patented process. In six Both common WARTS and CONDYLOMATA ACUMI- weeks, the harvested cells are delivered to the NATA are common and can be very diffi cult to treat dermatologist’s offi ce, and the patient must return in this patient population. Warts in the anal area for skin testing because the substance in which the may become large and require surgical removal. albinism 17

The lesions of oral hairy leukoplakia which are air travel and the skin Frequent airplane travel fairly specifi c to patients with AIDS, appear on the can have a negative effect on skin and hair, espe- side of the tongue as white linear lesions. cially for those with dry skin. The low humidity and lack of fresh air on board can greatly increase Bacterial Infections fl aky skin, dryness, and irritation. Even those with Treatment of SYPHILIS may be diffi cult in patients oily skin complain that they develop dry patches of with AIDS, and one dose of penicillin may not cure skin on cheeks and chin during plane travel, fol- the disease. Other bacterial infections that may lowed by a “rebound effect” of excess oiliness. be seen include CAT SCRATCH FEVER, mycobacterial If possible, women should not wear makeup dur- infections, ECTHYMA, CELLULITIS, ABSCESSES, IMPE- ing air travel, but apply a moisturizer and eye cream TIGO, and FOLLICULITIS. the morning of the fl ight, reapplying it during any trip longer than two hours. For those who must wear Fungal Infections makeup during air travel, use a water-based founda- Oral CANDIDIASIS is very common. Fungal infec- tion and undermakeup primer or moisturizer. tions are frequent, including ATHLETE’s FOOT, JOCK Travelers should refrain from drinking alcohol ITCH and nail infection. CRYPTOCOCOCCIS as either a or caffeinated beverages on a plane, since alcohol single skin lesion or as herpeslike ulcers or histo- and caffeine are natural diuretics, minimizing the plasmosis are also common. amount of moisture available to skin cells. Some travelers carry a mineral water spritzer to refresh Parasitic Infections and moisturize complexions. Travelers should AMEBIASIS or SCABIES may occur among patients always wear a lip balm or moisturized lip color on with AIDS. board, to prevent lips from drying and cracking, and reapply hand cream several times during the trip Skin Tumors (especially if hands are washed during the fl ight). In addition to Kaposi’s sarcoma, patients with AIDS For irritated eyes (especially for those who wear have a high incidence of lymphoma. contact lenses), cotton pads soaked in distilled water or milk should be applied to closed lids Miscellaneous Skin Lesions for several minutes. Contact lens wearers might Patients with AIDS are much more likely than consider abandoning the lenses altogether for the other patients to experience drug reactions. Explo- duration of the fl ight. sive PSORIASIS may occur in these patients. Often, A few minutes before landing, the face should patients with AIDS develop seborrheic DERMATITIS be cleansed and moisturizer should be applied; of the scalp, face (especially center of the face), women can then apply water-based foundation, armpits, chest, groin, and genitals. mascara, blusher, and lip gloss. In addition, these patients may experience itchy papular eruptions over the body, acquired ICHTHYOSIS and very dry skin. An atopic-like der- albinism A rare congenital inherited condition matitis has developed in about half of all children characterized by a partial or total lack of the with AIDS. pigment MELANIN that gives color to skin, eyes, and hair. Found in people of all races, albinos Hair Problems often suffer visual problems, skin infl ammations, As the disease progresses, patients report their hair severe sunburn, and a tendency toward SKIN becomes softer, lighter, thinner, and silkier. CANCER. The most common type of albinism is inher- Nail Problems ited in an autosomal recessive pattern. Usually Yellow colored nails have been reported; others parents have normal skin coloring, but they carry notice bluish bands that occur during administra- the gene defect in a hidden form. If parents with tion of zidovudine (AZT). normal pigmentation have an albino child, there 18 Albright’s syndrome is a one in four chance that future children will the development of endocrine disorders. There is be affected. an increased incidence of sudden death caused by Less than fi ve per 100,000 people in the United heart rhythm problems. States and Europe are affected, although the preva- lence is much higher in some parts of the world (about 20 per 100,000 in southern Nigeria, for alcohol An organic compound with strong instance). grease-cutting properties used in many cosmet- The most serious complication of the disease is ics as an antiseptic astringent. Alcohol cools the the lack of melanin, which protects the skin against skin as it evaporates. It is very drying, however, the harmful radiation in sunlight. Because the skin and people with dry skin should avoid products cannot tan, it ages prematurely and is prone to skin containing alcohol. Alcohol can be found in some cancers. Visual problems common in albinos can soaps, deodorants, skin fresheners, colognes, acne also cause problems. products, mousses, gels, and setting lotions.

Symptoms and Diagnostic Path The most common type of albinism is called ocu- alcohol and skin cancer Research suggests that locutaneous albinism, in which the hair, skin, and alcohol use can contribute to malignant melanoma eyes are all affected. In the more severe form, the (the most deadly form of skin cancer). Several stud- skin and hair are snowy white throughout life. ies appear to have uncovered a link between alco- Less severely affected individuals may be born hol and melanoma. Experts recommend women with white skin and hair, but both darken slightly limit themselves to one drink a day, and men to no with age and numerous FRECKLES develop on sun- more than two drinks a day. exposed parts of the body. In both forms, the eyes See also MELANOMA, MALIGNANT. cannot tolerate bright lights and are often affected with abnormal fl ickering movements, squinty eyes, and nearsightedness. More rare types of albinism alkaptonuria See OCHRONOSIS. affect either only skin, hair, or the eyes.

allergens Foreign substances that induce allergic Albright’s syndrome The popular term for fi brous reactions that include skin rashes. Some common dysplasia, a condition characterized by a few large examples are certain foods, dust, plants, and so on. dark fl at spots with very irregular borders (often compared to the coast of Maine). There are also developmental abnormalities, such as bony lesions allergies and the skin The skin is one of the fi rst and endocrine problems, such as precocious sexual sites where the symptoms of allergy may appear. development. A rash occurs when the immune system tries to The syndrome is not genetic, although it is more fi ght off a foreign substance (called an ALLERGEN) common in girls. that comes in contact with the skin. Some of the most common skin allergens include poison ivy Symptoms and Diagnostic Path (more than 50 percent of people are allergic to Symptoms include bone pain, fractures, and skin these plants), fragrances, preservatives, hair dyes, pigment changes. Other related symptoms include formaldehyde, nickel, cement, shoe leather, and mental defi ciency, epilepsy, and headaches. rubber.

Treatment Options and Outlook Chromium/Chromates There is no specifi c treatment for this disorder Contact with these substances is the most common other than observation and treatment of bone frac- cause of rash in men, usually occurring on the tures or deformities, together with screening for job. Chromium is typically found in the environ- allergies and the skin 19 ment, and therefore is not easy to avoid. A primary Skin testing may confi rm allergy to penicillin, source of chromium is in cement, widely used in but it may be ineffective for other medications. machining and construction. Shoes made from Antihistamines usually ease common symp- leather tanned with chromates can cause ECZEMA toms; prednisone or topical steroids may also be on the feet of sensitive people. prescribed. Epinephrine treats anaphylaxis.

Collagen (Injectable) Foods About 3 percent of healthy people are allergic to A range of common foods may bring on aller- injectable collagen, used to smooth out facial wrin- gic reactions on the skin, including citrus fruits, kles and creases; about half of them experience eggs, fi sh, artifi cial coloring, sugar alcohols, or the allergy after the actual treatment has begun. milk. Acute hives usually result from an allergic Once an allergy develops, further treatments are reaction to foods such as shellfi sh, nuts, berries, not advisable. tomatoes, eggs, citrus fruits, chicken, and pork. Less commonly, individuals develop hives from Cosmetics contact of food with skin (chicken, fi sh, and cer- Allergic reactions to cosmetics are usually caused tain vegetables). Allergy prick or scratch skin test- by fragrances such as cinnamic alcohol, cinnamic ing to determine food allergies is often ineffective, aldehyde, hydroxycitronnella, musk ambrette, sometimes producing a false positive (showing an isoeugenol, and geraniol. allergy when no symptoms actually appear when the food is eaten) or a false negative (showing no Drugs reaction when tested on the skin but having strong Almost any medication can cause an allergic reac- reactions when the food is eaten). tion in a sensitive individual, although allergic reactions to most drugs are uncommon. A reaction Footwear is caused by a hypersensitive immune system trig- It is possible to develop a contact allergy to footwear gering a misdirected response against a substance chemicals, especially rubber or rubber cements, that does not affect most people. The body becomes leather-tanning products, or dyes. They cause itch- sensitized by the fi rst exposure to the medica- ing, redness, swelling, and small blisters. These tion, and subsequent exposure will then trigger symptoms appear most readily on the thin sensi- an immune response. Reactions can range from a tive skin of the tops and sides of the feet. Avoiding mild rash or hives to life-threatening anaphylaxis. such an allergy may mean buying special shoes and Serum sickness is a delayed type of drug allergy keeping the feet dry, since potential allergens can that occurs a week or more after exposure to a be leached out of footwear by sweat. medication or vaccine. Penicillin and other antibiotics in that family are Fragrances the most common cause of drug allergies. Other A wide variety of products contain fragrances allergy-causing drugs include sulfa medications, that may trigger an allergic reaction in some barbiturates, anticonvulsants, insulin preparations people, including soaps, tissues, creams, and (especially from animal sources), local anesthetics, deodorants. Since manufacturers closely guard and iodine (found in many X-ray contrast dyes). the specifi c ingredients in scented products (the Common symptoms include hives, skin rash, and products usually simply list “fragrance” on their itchy skin or eyes. Other symptoms include wheez- label), sensitive consumers may fi nd the “fra- ing and facial swelling. Anaphylaxis may trigger grance free” products to be their best choice. nasal congestion, diffi culty breathing, cough, blue Those marked “hypoallergenic,” while good for skin, fainting, light-headed dizziness, anxiety, con- sensitive people, may still contain some scent that fusion, slurred speech, rapid pulse, palpitations, may cause a reaction in very sensitive individu- nausea, vomiting, diarrhea, abdominal pain, or als. “Unscented” products are not a good choice cramping. because they contain some fragrance traces that 20 allergies and the skin have been included to mask unpleasant odors to appear in other areas of the body whenever the naturally found in the product. person touches objects containing nickel. In aller- Some eaux de cologne, which contain oil of ber- gic individuals, necklaces, bracelets, belt buckles, gamot, can cause a berloque DERMATITIS (dark color and other jewelry that have never before caused a when exposed to the sun on neck and cleavage of problem may suddenly cause a rash after the ears women) in the area of skin where the cologne is are pierced. Those at high risk for developing an applied. Those sensitive to some types of perfume occupational nickel allergy include hairdressers, could try spraying the product on hair or clothing nurses, cashiers, and metal industry employees. instead of skin. People with newly pierced ears should wear only steel posts until earlobes heal (about three Genital Deodorants weeks). Surgical steel is the best choice and is avail- These products can produce a contact dermatitis, able most often in earrings specifi cally designed for including swelling and itching. sensitive skin. Individuals should avoid the heat when wearing this type of jewelry, and buy only Hair Dye high-quality jewelry that is at least 14-karat gold; Permanent dyes contain paraphenylenediamine, the higher the karat, the lower the percentage of which can cause an oozing red rash in allergic nickel. A few dermatologists warn highly sensitive patients. This is the reason why patch tests are patients to avoid foods that may contain traces of recommended before dyeing hair. For sensitive nickel, such as coffee, beer, tea, apricots, chocolate, people, temporary or vegetable hair dyes are a and nuts. good alternative. Parabens Lanolin A group of often-used preservatives, parabens This type of animal fat derived from sheep oil can be found in a variety of products (especially glands is commonly included in moisturizers. cosmetics). Many people with sensitive skin are allergic to lanolin. Plastics Plastics such as epoxy resin can affect workers; fi n- Nail Products ished plastic products rarely cause sensitivity. Allergic reactions can occur from a wide variety of nail products, including nail polishes, nail harden- Preservatives ers, and artifi cial nails. Most nail products contain A wide variety of cosmetics, shampoos, creams, toluenesulfonamide formaldehyde resin, which and lotions contain preservatives to extend their can set off an allergic response when it comes shelf life and prevent bacteria buildup. The most in contact with eyelids, the neck, or other sensi- toxic of these are quaternium 15, imidazolidinyl tive areas. If nail products contain this chemical, urea and dialozolidinyl urea. women should be sure the nails have dried for an hour before touching the skin. Rubber (Latex) The stretchy material used in many types of sur- Nickel gical gloves and condoms, bras, waistbands, and This shiny stainless metal is often used in surface sneakers cause two types of allergic reactions. Most plating of metal objects such as buttons, costume common is a red, oozing, blistering eruption. Less jewelry, and kitchen equipment. It is also an ele- common are hives. About a third of those who ment in many alloys, and is widely used in den- develop hives from contact with latex also develop tistry. Allergy to nickel occurs 10 times more often other symptoms, including hay fever, asthma and in women then men, and is often triggered by ear even anaphylactic shock. This type of reaction is piercing. Having the ears pierced and using ear- often seem among medical workers because of rings with nickel posts causes subsequent rashes the extensive use of latex gloves. Those sensitive AlloDerm 21 to rubber should avoid clothes with exposed rub- Because it is human derived, no skin test is ber, since rubber covered by cloth usually does required by the manufacturer. Studies so far have not cause a problem. Women who are allergic to found no evidence of allergic reactions, although rubber condoms should have their partner wear temporary bruising, redness, and swelling occur in a lambskin condom over a latex one (a lambskin a few patients. condom alone won’t protect against HIV). Men AlloDerm is obtained from tissue banks, which allergic to rubber should wear a lambskin condom surgically remove a thin layer of skin from deceased under a latex condom. donors, using sterile operating room techniques. The skin is placed into an antibiotic solution and Sun processed to remove the top layer of skin cells and While most people think of the sun as the source all of the cells in the deepest layer. The remaining of a so-called “healthy” tan, it can also cause aller- material—the AlloDerm—is a COLLAGEN framework gies in some people, who develop bumps, blotches, that provides strength to the skin, but without any hives, or blisters. Some people are allergic to the components left to cause rejection or infl amma- sun alone, others to a combination of cosmetics, tion. Therefore, when transplanted to a patient, the soaps, detergents, perfumes, or topical or systemic AlloDerm graft gradually becomes a natural part of medications, that react with the sun. the patient’s own tissue. Before any processing of the skin takes place, the tissue donors are rigorously Topical Agents screened by the tissue bank and extensively tested Many people are sensitive to the active or inactive for infectious diseases. The donor must be found free ingredients in topical drugs or cosmetics, including of hepatitis B and C, HIV and AIDS, and SYPHILIS. In lanolin, bacitracin, neomycin, local anesthetics, any case, human viruses including HIV need cells to formaldehyde, and preservatives. live and reproduce; the AlloDerm process removes See also FORMALDEHYDE, SENSITIVITY TO; SOLAR all cells, getting rid of the components necessary for URTICARIA; OIL OF BERGAMOT; POLYMORPHIC LIGHT the survival and transmission of these viruses. ERUPTION. AlloDerm was fi rst used in 1992 to treat burn patients and in 1994 for periodontal and plastic surgery. Currently, more than 50,000 patients have allergy tests See PATCH TESTS. received AlloDerm grafts. AlloDerm is the only available product capable of regenerating normal soft tissue. Since it is AlloDerm A soft SKIN FILLER made of human tis- human tissue, it does not trigger an infl ammatory sue donated in much the same way as other trans- or allergic reaction, and the pretreatment skin test- plantable organs and approved by the U.S. Food ing required with bovine collagen is not needed. In and Drug Administration (FDA) for cosmetic use. addition, patients report that the graft does not feel AlloDerm may be used to enhance the lips or to fi ll hard the way other synthetic materials do. When in lines and creases that develop with aging. AlloDerm is used as an implant, it completely elim- AlloDerm is processed from donated human inates any need to take donor fat or skin from one cadaver tissue prepared in such a way that it retains part of the body to transplant to another area. its underlying structure. It has been used for a vari- Although AlloDerm appears to be long last- ety of surgical reconstructive procedures to replace ing, there have been reports of a small number of lost, damaged, or diseased tissues, and is now used patients completely absorbing the AlloDerm within to fi ll in facial wrinkles, where it is considered six months. AlloDerm lip enhancement is irrevers- stable and may last from one to two years. ible after a period of seven to eight weeks. Given A micronized form of AlloDerm, called CYMETRA, the increasing number of safe and effective fi llers is also available. This material is rehydrated with available in the United States, the use of AlloDerm lidocaine in the physician’s offi ce before injection has declined dramatically by the early 2000s. so the procedure is much less painful. See also BIOLOGICAL IMPLANT. 22 allograft allograft A type of tissue or organ graft (also is most effective if begun early; patients who have known as homograft) between two members of the been balding for less than fi ve years or who have same species. smaller bald patches report the best results. It may See also AUTOGRAFT; PINCH GRAFT; SKIN GRAFT. take several months for hair growth to begin, and if the treatment is stopped, the newly regrown hair will fall out. Minoxidil is effective for both men and aloe vera A wild succulent (Aloe barbadensis women. It was developed to treat high blood pres- Miller) of the lily family used for centuries as a sure, and it increases the diameter of blood vessels. healing agent and beauty aid. Aloe vera juice Alternatively, HAIR TRANSPLANTS or scalp reduc- (obtained from slicing the tip of leaf and squeezing tion (removal of the bald area of the scalp) are out the gel) appears to be effective in relieving the effective treatments for men with male pattern pain and infl ammation of sunburn. The aloe vera baldness. gel contains vitamins B1, B2 and B6, calcium, potas- See also ALOPECIA, FRICTION; ALOPECIA, TRACTION; sium, chlorine, enzymes, and other ingredients ALOPECIA AREATA. that have not yet been identifi ed.

alopecia, friction The loss of hair caused by con- alopecia, androgenetic The most common type stantly wearing snug-fi tting wigs or hats. of hair loss that includes hereditary HAIR LOSS and See also ALOPECIA, ANDROGENETIC; ALOPECIA, male pattern baldness. Normal genes and male TRACTION; ALOPECIA AREATA; HAIR LOSS. hormones (especially testosterone) cause progres- sive shrinking of certain scalp follicles over time. The shrinking follicle produces a smaller, fi ner hair alopecia, traction Loss of hair caused by pony- with each growth cycle. In addition to a smaller tails, braids, or cornrows that are pulled too tight, follicle, androgenetic alopecia is characterized by a pulling the hair out by its roots. shortened growth phase, which results in shorter See also ALOPECIA, ANDROGENETIC; ALOPECIA, hair. FRICTION; ALOPECIA AREATA; HAIR LOSS. The balding process is a gradual conversion of active, large hair follicles to less active, smaller fol- licles, resulting in short, thin hairs that are barely alopecia areata A common form of hair loss that visible and that eventually disappear completely. usually begins with a small, round bare spot on the In men, hereditary baldness is characterized by a scalp; in extreme cases it progresses to total hair receding hairline above the forehead and loss of loss on the entire body. It can affect people of all hair at the crown. If male pattern baldness pro- ages, although it most often occurs in children and gresses to its fi nal stage, the person is left with hair young adults. only around the sides and back of the head. The condition is generally believed to be an In women, hereditary hair loss is a general or autoimmune disorder in which the body produces diffuse thinning of the hair over the top of the antibodies that cause hair follicles to stop hair pro- head; half of all women have a notable thinning by duction. It may run in families, especially those age 50, but rarely lose all their hair. The hairline in with a history of asthma, ECZEMA, or autoimmune front is almost always maintained. disorders such as rheumatoid arthritis or LUPUS ERY- THEMATOSUS. Alopecia areata affects about 4 million Treatment Options and Outlook Americans of both sexes and all ages and ethnic A topical solution of MINOXIDIL (Rogaine) 2 per- backgrounds. It often begins in childhood. Patients cent applied twice daily to the scalp lessens falling with a close family member with the disease have hair and stimulates new hair growth; one third of a slightly higher risk of developing the condition. If patients using this product report moderate hair the family member lost the fi rst patch of hair before growth after one year. Treatment with minoxidil age 30, the risk to other family members is greater. alopecia areata 23

Overall, one in fi ve people with the disease treatment for children. After a month or two, new have a family member who has it as well. In those hair growth becomes visible; the injections usu- who are genetically predisposed, some type of ally have to be repeated monthly. Large areas can- trigger—perhaps a virus or something in the per- not be treated, however, because the discomfort son’s environment—brings on the attack against and the amount of medicine involved is too large the hair follicles. and affects the entire body. Alopecia areata often occurs in people whose Oral corticosteroids Corticosteroids taken by family members have other autoimmune diseases, mouth may be used in more severe cases of alo- such as diabetes, rheumatoid arthritis, thyroid dis- pecia areata. However, because of the risk of side ease, VITILIGO, systemic lupus erythematosus, per- effects (such as high blood pressure and cataracts), nicious anemia, or ADDISON’S DISEASE. People who they are used only occasionally for alopecia areata have alopecia areata do not usually have other and for shorter periods of time. autoimmune diseases, but they do have a higher Topical ointments Ointments or creams con- occurrence of thyroid disease, atopic eczema, nasal taining steroids rubbed directly onto the affected allergies, and asthma. area are less painful than injections and are some- times preferred for children. However, corticoste- Symptoms and Diagnostic Path roid ointments and creams alone are less effective In alopecia totalis, hair suddenly falls out in a gener- than injections; they work best when combined alized pattern, ending in complete baldness of the with other topical treatments, such as MINOXIDIL or scalp but body hair is preserved. In alopecia areata ANTHRALIN, a skin irritant. universalis all body hair is lost, including head, Minoxidil (5%) (Rogaine) Topical minoxidil pubic, underarm, eyebrow, and eyelid hair. The solution promotes hair growth in several condi- most common form of alopecia areata (also known tions in which the hair follicle is small and not as localized alopecia) is characterized by a com- growing to its full potential. As well as in pattern plete loss of hair on the head in one circular patch thinning or genetic baldness, Minoxidil is approved from one to 10 cm in diameter; the nails also may for nonprescription use in treating male and be affected by pitting, ridging, or splitting. female pattern hair loss, and may also be useful in promoting hair growth in alopecia areata. The Treatment Options and Outlook solution, applied twice a day, has been shown to While there is no cure, in the localized form hair promote hair growth in both adults and children, frequently regrows without treatment. and may be used on the scalp, brow, and beard CORTICOSTEROIDS are powerful anti-infl ammatory areas. With regular and proper use of the solution, drugs that suppress the immune system, and are new hair growth appears in about 12 weeks. often used to treat various autoimmune diseases, Anthralin (Psoriatec) This synthetic tarlike including alopecia areata. Corticosteroids may be substance alters immune function in the affected administered in three ways for alopecia areata—by skin, and is an approved treatment for PSORIASIS. injection, orally, or topically. It is also commonly used to treat alopecia areata, Local injections Injections of steroids directly where it is applied for 20 to 60 minutes. When into hairless patches on the scalp can boost hair it works, new hair growth is usually visible in growth in most people within a month. Injections eight to 12 weeks. Anthralin is often used in deliver small amounts of CORTISONE to affected combination with other treatments, such as cor- areas, avoiding the more serious side effects ticosteroid injections or minoxidil, for improved encountered with long-term oral use. The main results. side effects of injections are temporary pain, mild Topical sensitizers These drugs provoke an swelling, and sometimes changes in pigmentation, allergic reaction when applied to the scalp that leads as well as small indentations in the skin that go to itching, scaling, and eventually hair growth. If away when injections are stopped. Because injec- the medication works, new hair growth is usu- tions can be painful, they may not be the preferred ally established in three to 12 months. Two topical 24 alpha hydroxy acids sensitizers are used in alopecia areata: squaric acid the dermatologist’s offi ce in concentrations of up dibutyl ester (SADBE) and diphenylcycloprope- to 70 percent. none (DPCP). Precisely how the acids interact with the skin Oral cyclosporine Originally developed to keep is not entirely understood, but the products do people’s immune systems from rejecting trans- improve the appearance of the skin by accelerat- planted organs, oral cyclosporine is sometimes ing the natural process of shedding dead skin cells. used to suppress the immune system response Used properly, the acids work gently, producing in psoriasis and other immune-mediated skin only a slight tingling or stinging sensation in some conditions. However, suppressing the immune users. AHA peels are much quicker and milder system can lead to a higher risk of serious infec- way to freshen the skin than a deeper peel or tion, kidney problems, and possibly skin cancer LASER RESURFACING. An AHA peel takes about 15 and lymphoma. Although oral cyclosporine may to 20 minutes, and is usually repeated every two regrow hair in alopecia areata, it does not turn to four weeks. The face is cleansed thoroughly the disease off, and most experts believe the dan- and then the peel solution is applied for three gers of the drug outweigh its benefits for alopecia to four minutes. The solution is then neutralized areata. and washed off. Treated skin may be a little pink Photochemotherapy In this treatment used immediately after treatment, and less often, a only for extensive disease, a person is given a little peeling may occur over the next few days. light-sensitive drug (a PSORALEN) and then exposed It can be disguised with moisturizer or normal to an ultraviolet light—a combination treatment makeup. called PUVA. Used primarily to treat psoriasis, it also With repeated use, the acids can clear up ACNE- triggers cosmetically acceptable hair growth in alo- prone skin, soften tiny lines around the eyes and pecia areata using photochemotherapy. However, mouth, smooth dry skin, and fade dark spots the relapse rate is high, and patients must go to a caused by sun or hormonal changes (such as those treatment center where the equipment is available caused by pregnancy). Fastest results occur in the at least two to three times per week. Furthermore, physician’s offi ce, since dermatologists can pre- the treatment carries the long-term risk of develop- scribe the strongest products. ing skin cancer. Legally, these acid products are considered COS- See also ALOPECIA, ANDROGENETIC; ALOPECIA, METICS, not drugs, and therefore are not regulated FRICTION; ALOPECIA, TRACTION; HAIR LOSS. by the Food and Drug Administration. However, alpha hydroxy acids can be dangerous; the avail- ability of “bootleg” formulations in high concen- alpha hydroxy acids (AHA) A generic term that trations have caused irritations and even burns refers to any one of several organic chemicals that in some people. Due to an increasing number of serve as mild chemical peels, working to loosen lawsuits by injured consumers, the U.S. Food and and slough off dead skin cells to expose newer, Drug Administration is reviewing the products to fresher skin. In six to eight weeks, skin treated with see whether strength thresholds should be estab- alpha hydroxy acids appears softer and smoother; lished by law. AGE SPOTS and FRECKLES also appear to fade. Over-the-counter products manufactured Also called “fruit acids,” these products are by reputable companies are safe and generally derived from sugar cane, apples, grapes, and citrus. quite mild, containing less than 10 percent AHA. The popular GLYCOLIC ACID derived from sugar cane Responsible fi rms do not sell products with stron- is one of the alpha hydroxy acids, all of which are ger concentrations over the counter because of applied as an ointment, cream or lotion directly to the danger to consumers and the resulting liability the skin. threat. Because these acids have caused problems Alpha hydroxy acids are available over the for people with sensitive skin (being acids, they can counter in mild strengths of 10 percent; in beauty sting), the newest products are formulated to work shops in concentrations of up to 40 percent, and in effectively without irritating. amyloidosis 25

Some of these products contain only 4 percent plex, and slathering on products containing amino glycolic acid. Many company experts state that acids will not necessarily help the skin utilize these most women can safely switch to the new 8 per- chemicals to produce new skin. However, sham- cent formula once their skin adjusts to this acid. poos and hair conditioners that contain amino Other companies have introduced a four-step acids do help fi ll in cracks in the hair shaft caused program that gradually accustoms skin to increas- by harsh soaps and processing; these new proteins ing levels of AHAs. However, some experts believe do not rebuild the hair shaft, but they do lend these nonprescription products are not really support. strong enough to do anything more than soften the skin. While the acids are less powerful than Retin-A ammoniated mercury A bleaching agent that for wrinkle removal, AHA formulations, according reduces skin color by stopping the formation of to some dermatologists, may prove useful in pre- MELANIN. It was once used to treat IMPETIGO, PSO- venting and treating fi ne wrinkles. RIASIS, and other skin conditions. Because it is not See also BETA HYDROXY ACIDS. very effective and has toxic effects in humans, ammoniated mercury in cosmetics has been banned by the U.S. Food and Drug Administration. aluminum acetate See BUROW’S SOLUTION.

amphotericin B An intravenous drug used to amebiasis Infection with the protozoa Entamoeba treat fungal infections of the skin. Fungus infec- histolytica, which is found throughout the world tions may include anything from a minor problem (primarily in tropical countries), may produce such as ATHLETE’S FOOT or vaginal yeast infec- painful skin ulcers, although skin symptoms with tions to more serious problems if these infections this infection are not common. invade the blood or internal organs when the The amoeba is transmitted by ingesting contami- immune system is not working well. Amphotericin nated food and beverages. B is only used for life-threatening systemic fungal The skin also may be infected following surgical infections. procedures, by spread of amoebic liver abscess, or The incidence of serious fungus infections has by direct inoculation by the protozoa. risen dramatically in this country, mostly because profoundly ill patients are living longer than in the Symptoms and Diagnostic Path past. Those most susceptible to serious fungal infec- Infections with E. histolytica occur primarily in tions include chemotherapy patients, AIDS and people who show no symptoms. The skin ulcer is burn patients, and transplant recipients. a painful lesion that can last from 10 days to two years. Rapid skin destruction occurs more often Side Effects among children. Vomiting, fever, headache, or seizures are among the drug’s adverse effects. Amphotericin B is Treatment Options and Outlook administered in a hospital setting because side Combinations of medication may be required; in effects may be severe. those with skin symptoms, metronidazole is prob- See also ANTIFUNGAL AGENTS; FLUCYTOSINE; FUN- ably the safest drug and is most effective when GAL INFECTIONS; KETOCONAZOLE. given in single daily doses.

amyloidosis The general term for a group of fairly amino acids The basic building blocks of protein uncommon conditions in which amyloid (a sub- that make up the skin and hair. The process by stance that contains protein and starch) builds up which amino acids build skin is extremely com- in tissues and organs. 26 anaphylaxis

Symptoms and Diagnostic Path or as a reaction to an injected or ingested drug, Primary amyloidosis is often characterized by depos- such as penicillin or tetanus serum. As the allergen its of amyloid in the skin, causing raised, waxy enters the bloodstream, it provokes the release of spots clustered around the armpits, groin, face, massive amounts of histamine and other chemicals and neck. Male Caucasians between age 50 and 60 that affect the body by widening blood vessels and are most commonly affected. Skin manifestations lowering blood pressure. occur in 40 percent of patients. The most com- mon sign is a “pinch purpura” (development of a Treatment Options and Outlook purple lesion after pinching or stroking the skin). A person who experiences such a reaction fol- Lesions may appear to be translucent, waxy, or lowing a sting or injection should lie down with amber-colored papules or nodules; less often the legs raised to improve blood fl ow to the heart and skin may look yellow, red, or with heightened pig- brain, while emergency medical care is obtained. ment. There may be a thickening of the palms and An injection of epinephrine must be given as soon enlargement of ears, lips, and eyelids, and the scalp as possible to save the person’s life. may develop deep folds; there may be hair loss and some patients develop blisters. The nails may be brittle, crumbling, or streaked, and on some Ancobon See FLUCYTOSINE. fi ngers there may be no nails. About 40 percent of deaths related to this condition occur because of heart problems; 30 percent of deaths may result androgens and acne In some women, ACNE can from kidney failure caused by deposits of amyloid. be caused by excess androgens (male hormones). Diagnosis depends on microscopic examination of a Women and teenage girls with acne may have biopsy of tissue from the affected organ. excess levels of testosterone and other male hor- Secondary amyloidosis (or reactive systemic amy- mones. Some estimates suggest that one-third of loidosis) often occurs as a result of an infectious female patients in the general community have an process such as tuberculosis or osteomyelitis, or a elevated level of androgen. chronic noninfectious infl ammatory disease such Androgens stimulate oil glands in the skin as rheumatoid arthritis. It also may occur in associ- and are known to play a role in acne develop- ation with certain nonlymphoid tumors and some ment. Genes and hormone changes throughout lymphomas (the two most common are renal cell the menstrual cycle also contribute to the skin carcinoma and Hodgkin’s disease). condition. There are no skin symptoms in secondary Individuals with acne should follow a der- amyloidosis. matologist’s recommendations for topical and systemic treatment. If the acne only gets worse Treatment Options and Outlook despite treatment, patients may need to have their Primary amyloidosis can be treated with anti-cancer hormone levels evaluated. drugs; secondary amyloidosis may be stopped or even Excess androgen can be due to a more seri- reversed when the underlying disorder is treated. ous disease such as polycystic ovarian syndrome, which can cause infertility. Elevated androgen also may signal a genetic disorder of the adrenal gland. anaphylaxis A severe, life-threatening, allergic Different treatment may be indicated if acne is reaction that may occur in individuals who have being triggered by excess male hormones than by an extreme sensitivity to a particular substance other more common causes. Topical solutions, for (ALLERGEN). example, may not work for hormone-related acne. Instead, birth control pills may be a more effective Symptoms and Diagnostic Path treatment because they suppress the production of The reaction, which often includes an itchy red androgen and help balance a woman’s hormone rash or HIVES, is most common after an insect sting levels. angiokeratoma 27 anergy Inability to react to common skin test Swelling of the upper respiratory tract may ALLERGENS (foreign substances that produce allergic cause marked swelling of the uvula and larynx. reactions), which represents a defi cit in a part of Acute laryngeal swelling is the most serious mani- the immune system. festation of this disorder and can be fatal (due to asphyxiation) in nearly 20 percent of patients. Attacks usually fade within three to four days, angioedema An allergic reaction characterized by but during this time the individual must be observed large, well-defi ned swellings that appear suddenly carefully for signs of laryngeal obstruction. in the skin and larynx. The swellings may last sev- eral hours (or days, if untreated). Angioedema is Treatment Options and Outlook primarily found in young people in their 20s and Epinephrine, antihistamines, and CORTICOSTEROIDS those who tend to have allergies. are usually prescribed, but the success of these The most common cause of angioedema is a agents is limited. If the larynx becomes obstructed, sudden allergic response to food (especially straw- tracheostomy (a surgical hole in the trachea to berries, eggs, or seafood). Less often, it occurs in relieve obstruction) may be required. response to drug injections or ingestion (especially penicillin), insect stings, snake bite, infection, emotional stress, and exposure to animals, molds, angiofibroma Several different types of benign pollens, or cold. lesions (also called adenoma sebaceum) that may appear as a solitary lesion or in groups. It may be an Symptoms and Diagnostic Path important skin symptom of TUBEROUS SCLEROSIS. Angioedema may cause sudden breathing prob- lems, diffi culty swallowing, and obvious swelling of Symptoms and Diagnostic Path the lips, face, and neck. The swelling it produces in The condition may include a fi brous papule of the the throat may lead to suffocation by blocking the nose—a single lesion on the nose that sometimes victim’s airway. looks like a red or fl esh-colored mole; this is not related to tuberous sclerosis. Treatment Options and Outlook Lesions on the face that show a great deal of Severe cases respond to injections of epinephrine, fi brous tissue around hair follicles are called peri- but use of a breathing tube or even tracheotomy follicular fi bromas. Smaller, similar lesions around may be necessary to prevent suffocation. In less the penis are called pearly penile papules. severe cases, antihistamine drugs often relieve symptoms. Treatment Options and Outlook Because these lesions are benign, treatment is not necessary. Single lesions may be removed; groups angioedema, hereditary A form of acquired of lesions related to tuberous sclerosis may be ANGIOEDEMA (an allergic reaction characterized by removed with a CARBON DIOXIDE LASER or DERM- itching and swelling) that is passed on from parents ABRASION to improve the appearance. Pearly pap- to child. Attacks, which are characterized by diffuse ules on the penis are not usually treated. nonitching swelling, are not usually accompanied by HIVES. The condition may be set off by trauma or may appear to occur spontaneously. angiokeratoma A condition resembling KERATO- SIS, characterized by benign lesions that are usually Symptoms and Diagnostic Path soft and pink to red-purple, often found over bony In addition to the swelling of the skin, symptoms prominences of the body (especially in children may include swelling of the gastrointestinal tract and young adults). Sometimes they may occur on that may cause abdominal pain severe enough to the scrotum or in groups on the legs and feet. Occa- suggest the need for surgery. sionally the lesions appear singly. 28 angiokeratoma corporis diffusum

Angiokeratomas may occur as part of the rare or physical activity that would normally provoke fatal disease known as angiokeratoma corporis dif- intense sweating. fusum of Fabry (FABRY’S DISEASE); other symptoms include heart and kidney disease and high blood pressure. Patients with this variation usually die anhidrotic ectodermal dysplasia See ECTODER- from heart or kidney failure. MAL DYSPLASIA.

Treatment Options and Outlook Angiokeratomas may be surgically removed. animal bites Each year 5 million Americans are bitten by animals; in most cases the animal involved is a dog. Less common but more danger- angiokeratoma corporis diffusum See FABRY’S ous are bites from skunks, raccoons, bats, and other DISEASE. wild animals.

Treatment Options and Outlook angioma A small collection of blood vessels over- If the skin has been broken by a bite, treatment lying and compressing the brain; when associated depends on its depth and location and on what is with a PORT-WINE STAIN, this is known as STURGE- known about the animal. WEBER SYNDROME. The area is fi rst cleaned using an antiseptic, fol- See also CHERRY ANGIOMA; HEMANGIOMA. lowed by an antibiotic (the best one is amoxicillin). Stitches may be required, but it is usually best for these wounds to heal without being sewn to pre- angiosarcoma See SARCOMA. vent any dangerous organism from getting trapped in the body. (Exception: Bites on the face probably will need to be stitched to avoid disfi gurement). anhidrosis The absence of the ability to SWEAT. This problem may be caused by processes that control the sweating response, or it may appear ANSI sunglass standard A voluntary labeling as a symptom in certain skin diseases (PSORIASIS, program by the American National Sunglass Insti- atopic DERMATITIS), as a side effect of certain drugs tute (ANSI) and the Sunglass Association of Amer- (anticholinergics, quinacrine). Many patients who ica, groups working with the U.S. Food and Drug cannot sweat in some areas have a compensatory Administration to provide consumers with uniform sweating response in other sweat glands. and useful labeling for nonprescription sunglasses. ANHIDROTIC ECTODERMAL DYSPLASIA causes a The ANSI standard is found on a label attached to decrease or absence of sweating that is most com- sunglasses, describing how much and what types monly inherited in an X-linked pattern (primarily of ULTRAVIOLET RADIATION is blocked out. According affecting males). In this case, hair may be sparse, to ANSI, the minimum requirement for a pair of light, coarse, or strawlike, with sparse eyelashes sunglasses would fi lter out 99 percent of UVB rays and eyebrows and dental abnormalities. and 60 percent of UVA rays. Since the body relies on sweating to cool itself, the inability to sweat can lead to excessively high internal body temperatures. anthralin preparations A topical prescription compound used to treat PSORIASIS (a skin disease Treatment Options and Outlook caused by excess skin cell production) and other Treatment is aimed at controlling the underlying skin conditions. Available as a cream or ointment, cause. Those with untreatable anhidrosis should anthralin works by slowing the skin cell multipli- be careful when exposed to excessive heat, work, cation rate; its effects may be improved by using anthrax, cutaneous 29 ultraviolet light treatments at the same time. in New York City and the Pentagon in Washing- Anthralin is applied to the skin and left on for a ton, D.C., a series of envelopes containing anthrax short period of time or overnight (depending on spores were mailed to a variety of news and media doctor’s orders). organizations and government offi ces. Anyone Anthralin should not be applied to raw or blis- who touched or inhaled the spores were at risk tered areas of the skin; even so, anthralin com- for infection with the skin form of the infection monly causes redness and irritation. The healthy (via touch) or the far deadlier respiratory form of skin around patches of psoriasis can be protected anthrax (by inhalation). from infl ammation by applying PETROLEUM JELLY For both livestock and humans, anthrax is a or ZINC OXIDE paste before using the anthralin. The notifi able disease in the United States. higher-strength compounds may cause irritation Cutaneous anthrax is caused by the bacterium and skin staining; lower strength compounds have Bacillus anthracis, which produces spores that can been developed that make this therapy more toler- remain dormant for years in soil and animal prod- able. Because anthralin can stain skin, hair, and ucts. Once reactivated, the spores can cause a skin clothing, users should wear gloves and old clothes infection if they enter an open wound or abrasion. when applying. The only way cutaneous anthrax can be transmit- Short contact treatment After applying anthra- ted from one person to another is by direct contact lin, the medicine is allowed to remain on the with the spores. Anthrax is not spread from person affected area for 10 to 30 minutes. It is then to person by casual contact, sharing space, or by removed by bathing with soap (if applied to the coughing or sneezing. skin) or by shampooing (if applied to the scalp). It can also be contracted by touching objects Cream form for overnight treatment If anthra- contaminated by the spores, such as in the anthrax- lin cream is applied to the skin, any medicine contaminated mail. Cross-contamination of the remaining on the affected areas the next morn- mail could occur during the processing, sorting, ing should be removed by bathing. If anthralin and delivery of mail when an envelope comes in cream is applied to the scalp, shampoo will remove contact with another envelope, piece of equipment the scales and any medicine remaining on the (such as an electronic sorting machine), or other affected areas from the previous application. The surface that is contaminated with Bacillus anthracis hair should be dried, and after parting, the cream spores. In addition, airborne spores in contami- should be rubbed into the affected areas. The phy- nated postal facilities might play a role. sician will recommend when the cream should be removed. Symptoms and Diagnostic Path Ointment form for overnight treatment: If Symptoms usually begin to appear in less than anthralin ointment is applied to the skin at night, seven days; in most cases, symptoms occur within any ointment remaining on the affected areas the 48 hours of exposure. The most common symptom next morning should be removed with warm liquid is a raised, itchy area at the site of entry that resem- petrolatum followed by bathing. If anthralin oint- bles a boil; this progresses to a large blister and then ment is applied to the scalp at night, it should be a black scab with swelling of surrounding tissue. shampooed away the next morning to clean the Nearby lymph glands may swell, in addition to fl u- scalp. like symptoms such as fatigue, fever, and nausea. If symptoms do not develop within seven days of exposure, there is only a very remote chance of anthrax, cutaneous A serious and sometimes developing the disease. fatal bacterial skin infection that in the past primar- Anthrax is diagnosed by isolating B. anthracis ily affected livestock, although it had occasionally from the blood, skin lesions, or respiratory secre- spread to humans. Following the September 11, tions, or by measuring specifi c antibodies in the 2001 terrorist attacks on the World Trade Center blood of someone with suspected infection. 30 anthrax, cutaneous

Treatment Options and Outlook • not open suspicious mail Cutaneous anthrax is curable in the early stages if • hold mail away from the face as it is opened treatment is begun promptly with antibiotics such • not blow or sniff mail or mail contents as ciprofl oxin or penicillin. However, even the skin form of this infection can be fatal if untreated. If • avoid vigorous handling of mail, such as tearing they are not treated, 20 percent of patients with or shredding cutaneous anthrax will die. • wash hands after handling the mail • discard envelopes after opening mail. Risk Factors and Preventive Measures Individuals who have been exposed to anthrax but If an individual receives a suspicious package or have no signs and symptoms of the disease can take envelope, the CDC recommends: preventive antibiotics, such as CIPROFLOXACIN, peni- cillin, or doxycycline, depending on the particular • The person should not shake or empty the con- strain of anthrax. tents of any suspicious package or envelope. There is no known case of transmission of cuta- neous anthrax from person to person. Therefore, • The person should not carry the package or household contacts of individuals with anthrax envelope, show it to others, or allow others to do not need antibiotics unless they have also been examine it. exposed to the same source of anthrax. • The person should put the package or envelope Preventive antibiotics are not recommended down on a stable surface without sniffi ng, touch- for persons who routinely open or handle mail, ing, tasting, or looking closely at it or at any either at home or at the workplace. Antimicrobial contents that may have spilled. prevention is recommended only in certain specifi c • The person should alert others in the area about situations, such as for persons exposed to an air the suspicious package or envelope. space known to be contaminated with aerosolized • The person should leave the area, close any Bacillus anthracis or for persons in a postal sorting doors, and prevent others from entering the facility in which an envelope containing B. anthra- area. If possible, the ventilation system should cis spores was processed. be shut down. If there is a risk for inhalational anthrax associ- ated with exposure to cross-contaminated mail, • The person should wash hands with soap and it is very low. For example, about 85 million water to prevent spreading potentially infectious pieces of mail were processed on the few days in material to face or skin. 2001 after envelopes containing Bacillus anthracis • The person should notify a supervisor, a security (addressed to two U.S. senators) passed through offi cer, or a law enforcement offi cial if the pack- the New Jersey and District of Columbia sort- age or envelope arrives at work. If at home, the ing facilities until they were closed. Despite the person should contact the local law enforcement fact that both of these facilities had evidence of agency. widespread environmental contamination with • The person should, if possible, create a list of B. anthracis spores and the fact that public health people who were in the room or area when the offi cials had been aggressively looking for anthrax suspicious letter or package was recognized and cases, no new cases of anthrax were identifi ed dur- a list of people who also may have handled this ing that time. package or letter. This list should be given to There are no scientifi cally proven recommenda- both the local public health authorities and law tions for preventing exposure via contaminated enforcement offi cials. mail, according to the U.S. Centers for Disease Control and Prevention. Nevertheless, there are some commonsense steps people can take. Indi- Cutaneous anthrax also can be prevented by viduals should: the anthrax vaccine (Anthrax Vaccine Adsorbed, antibiotic drugs 31 or AVA), the only anthrax vaccine licensed in the Gentamicin, another antibacterial drug, is also United States. The six-dose vaccine is only recom- effective against Staphylococcus aureus and group mended for individuals who may come in contact AB-hemolytic streptococci. While it may be used with animal products that may be contaminated topically, it is no better than other drugs mentioned with anthrax spores and for anyone who may above and it may produce an allergic reaction. come in contact with the spores. Vaccination is recommended for persons at high risk, such as vet- erinarians and those working at certain high risk antibiotic drugs A group of drugs used to treat post offi ces. infections caused by bacteria. Originally prepared Because of biological warfare threats, the vac- from molds and fungi, antibiotic drugs are now cine is mandated for all military personnel. It is made synthetically. Antibiotics help fi ght infec- currently not available or recommended for use in tion when the body has been invaded by harmful the general public. bacteria or when the bacteria present in the body The vaccine contains no dead or live bacteria. begin to multiply uncontrollably. More than one The immunization consists of three subcutaneous kind of antibiotic may be prescribed to increase the injections given two weeks apart followed by three effi ciency of treatment and to reduce the risk of more subcutaneous injections given at six, 12, and antibiotic resistance. 18 months. Annual booster injections of the vac- Many bacteria develop resistance to a once- cine are recommended thereafter. Slight tender- useful antibiotic. Resistance is most likely to develop ness and redness at the injection site occur in 30 if a person fails to take an antibiotic as directed dur- percent of recipients. ing long-term treatment. Some drugs, known as Severe local reactions are infrequent and consist broad-spectrum antibiotics, are effective against a of extensive swelling of the forearm in addition wide range of bacteria, while others are useful only to the local reaction. Systemic reactions occur in in treating specifi c types. fewer than .2 percent of recipients. Antibiotics in Acne Treatment Topical antibiotics (TETRACYCLINE, ERYTHROMYCIN, antibacterial drugs A group of drugs used to treat CLINDAMYCIN, and meclocycline) have an antibac- infections caused by bacteria. These drugs act in the terial effect when applied to the skin, in much the same way as ANTIBIOTIC DRUGS, but unlike antibiot- same way as BENZOYL PEROXIDE—except they are ics they always have been produced synthetically. probably less effective. A preparation that com- The largest group of antibacterial agents is the bines erythromycin and benzoyl peroxide in a gel sulfonamides. is probably more effective together than either Antibacterial ointments contain combinations preparation alone. of the “nonabsorbable” antibiotics (bacitracin, Systemic antibiotics can be very effective in the neomycin, polymyxin B, and gramicidin). While treatment of acne, despite the fact that acne is not these may help for mild skin wounds, more a bacterial disease. In fact, 10 percent of all tetracy- extensive bacterial skin infections require systemic cline sold in the United States is used to treat acne. antibiotics. It is believed that systemic antibiotic treatment Bacitracin is effective against organisms includ- probably prevents the development of additional ing Streptococcus, Staphylococcus, and pneumococcus. infl ammatory lesions. Erythromycin is as effective Neomycin is effective against most gram-negative as tetracycline and does not have to be taken with- organisms (gram staining is a way of identifying out food. Minocycline is also effective but is more bacterial cells). It is about 50 times more active expensive. against Staphylococcus than bacitracin, but bacitra- cin is 20 times more active against Streptococcus. Types However, neomycin causes more allergic contact Some of the most well-known antibiotics include the sensitivity than any other topical antibiotic. penicillins (amoxicillin, penicillin V, and oxacillin), 32 anticoagulation syndrome the aminogylcosides (gentamicin and streptomy- FOOT, JOCK ITCH, and scalp RINGWORM. They are also cin), the cephalosporins (cefaclor and cephalexin), used to treat THRUSH and rare fungal infections such the tetracyclines (doxycycline and oxytetracycline), as CRYPTOCOCCOSIS. erythromycin, and neomycin. Side Effects Side Effects Agents applied to the skin, scalp, mouth, or vagina Because these agents may kill “normal” bacteria may sometimes increase irritation, and antifungal naturally present in the body, fungi may grow in agents given by mouth or injection may cause their place, causing oral, intestinal or vaginal can- more serious side effects, damaging the kidney or didiasis (thrush). Some patients may experience liver. a severe allergic response, causing facial swelling, itching, or breathing problems. Types Antifungal agents are available as creams, injections, tablets, lozenges, suspensions, and vaginal sup- anticoagulation syndrome (coumarin necrosis) A positories. The most common antifungals include condition characterized by lesions beginning AMPHOTERICIN B (IV only), cyclopirox, clotrimazole, between three and 10 days after the administration naftifi ne, terbinafi ne, ECONAZOLE, GRISEOFULVIN (by of a coumarin drug (such as dicumarol or warfarin) mouth only), itraconazole (by mouth and IV only), that occurs occasionally in young women. Couma- fl uconazole (by mouth and IV only), KETOCONAZOLE, rin is administered as an anticoagulant (blood thin- miconazole, and TOLNAFTATE. While amphotericin B ner) to treat disorders in which there is excessive is the standard drug for treating fungal infections, it clotting, such as thrombophlebitis and certain heart is usually given in the hospital because of the dan- conditions. Coumarin necrosis has been associated ger of side effects. On the other hand, itraconazole with protein C and protein S defi ciency. and fl uconazole are the two most recently approved drugs to enter the antifungal arsenal. These two Symptoms and Diagnostic Path cause fewer side effects and can be taken orally on The lesions begin as minute spots or blue or purple an outpatient basis. hemorrhagic patches (usually on the lower fatty Nonprescription creams such as Monistat 7 areas of the body), quickly followed by tissue death, and Gyne-Lotrimin may be helpful in remedying which can extend into the deep subcutaneous fat; candidal vaginal yeast infections, but fatal can- the resulting ulcer may not heal for months. didal infections affecting the brain, kidney, or other organs may occur in immuno-compromised Treatment Options and Outlook patients in the hospital. Once the lesions begin to appear, their course is Anti-yeast agents, such as nystatin, do not progressive regardless of whether the drug treat- kill most fungi, but most antifungals kill yeasts ment is stopped. as well—except for griseofulvin. Drugs that are There is no effective treatment. When the breast used for both systemic fungal and yeast infections or penis is involved, amputation is recommended; include fl uconazole, ketoconazole, amphotericin-B, other areas may require surgical debridement and and itraconazole. skin grafts.

antihistamines A family of drugs used to treat antifungal/anti-yeast agents A group of drugs allergic conditions, such as ITCHING and HIVES. The prescribed to treat infections caused by either fungi drugs work by blocking the action of HISTAMINE, a or yeasts (and sometimes both in one product) that chemical that is released during an allergic reaction. can be administered directly to the skin or taken Examples of antihistamines include diphenhydr- orally or by injection. They are commonly used to amine, promethazine, terfenadine, chlorphenira- treat different types of TINEA, including ATHLETE’S mine, and so on. antioxidant beauty products 33

Without drug treatment, histamine dilates small CORTICOSTEROIDS blood vessels, causing redness and swelling; anti- The corticosteroids are a group of drugs used pri- histamines block this effect, while preventing the marily to treat infl ammation that are similar to irritation of nerve fi bers that would otherwise natural corticosteroid hormones produced by the cause itching. They are the most effective treat- adrenal glands. Skin diseases treated with these ment for hives. drugs include ECZEMA, ACNE, PEMPHIGUS, PSORIASIS, ALOPECIA, DERMATITIS, LICHEN PLANUS, ROSACEA, Side Effects and ERYTHEMA MULTIFORME. Corticosteroids include Older antihistamines caused drowsiness and diz- CORTISONE, prednisone, prednisolone, hydrocorti- ziness, but new antihistamines such as Claritin sone, dexamethasone, beclomethasone, and so on. do not enter the brain, and thus do not cause these side effects. Other possible symptoms include Side Effects appetite loss, nausea, dry mouth, blurry vision, When taken in high doses for a long time, adverse and problems in urination. Because older antihis- effects can include tissue swelling, high blood tamines have a sedative effect, they may also be pressure, diabetes mellitus, peptic ulcer, Cushing’s used to induce sleep; patients taking these types of syndrome, excess hairiness, and susceptibility to antihistamines should not drive or operate heavy infection. machinery until the effects wear off.

antimalarial drugs Also called antiprotozoals, this anti-inflammatory drugs A family of drugs used to is a group of drugs used to treat malaria. The two help decrease infl ammation and pain. This class of most common used in dermatology are hydroxy- drugs includes the nonsteroidal anti-infl ammatory chloroquine and quinacrine. These drugs have drugs (NSAIDS) and the CORTICOSTEROIDS, both of been helpful in treating skin symptoms of malaria, which fi ght infl ammation. LUPUS ERYTHEMATOSUS, PORPHYRIA, and skin lesions in DERMATOMYOSITIS. NSAIDS The NSAIDS are a group of chemically diverse Side Effects drugs widely used to treat infl ammation, which is Hydroxychloroquine and chloroquine may produce one of the body’s defense mechanisms in response retinal damage; other possible side effects include to infection and certain chronic diseases (such as aplastic anemia (a type of anemia caused by a rheumatoid arthritis). decrease in bone marrow production of all types of On their own, NSAIDs are not very toxic, but blood cells). Quinacrine may produce yellowing of they should not be used by people with gastrointes- the skin. Any antimalarial drug may cause the hair tinal disease, peptic ulcers, or poor heart function. to gray; some patients also experience a bluish- They should not be taken with other nonsteroid black discoloration of the inside of the mouth and painkillers or other anticoagulants (blood thinners), skin under the fi ngernails that improves when the because bleeding time may be prolonged while on drug is stopped. Infrequent side effects include NSAIDs. Antacids and aspirin also may reduce the HIVES, exfoliative erythroderma, and a worsening effectiveness of an anti-infl ammatory drug. of PSORIASIS. Types They include ibuprofen (Motrin, Rufen, Advil, Medi- antioxidant beauty products A wide range of pren, Nuprin), fenoprofen (Nalfon), meclofenamate beauty products contains antioxidants (molecules (Meclomen), naproxen (Anaprox, Naprosyn), sulin- that can neutralize FREE RADICALS—a destructive dac (Clinoril), indomethacin (Indocin), tolmetin form of oxygen that can cause wrinkles and sag- (Tolectin), mefanamic acid, piroxicam (Feldene), ging skin). Once activated, free radicals interfere oxyphenbutazone, and phenylbutazone. with a wide range of body processes. Research 34 antiperspirants suggests that antioxidants—especially the vitamins Drysol is applied at bedtime under a plastic fi lm, C and E, and beta-carotene—can neutralize free but it may cause irritation if used often. radicals before they damage skin. See also SWEAT AND THE SKIN; SWEAT GLANDS; Cosmetic companies reasoned that since free SWEAT GLANDS, DISORDERS OF. radicals damage skin, and vitamins C and E combat free radicals, spreading extra antioxidants on the skin should fend off the destruction. But while this antipruritic agents Drugs used to treat ITCH- may appear to make sense, skin care experts have ING; however, generalized itching is not easy to yet to prove that capturing free radicals prevents treat unless the underlying condition is identifi ed. skin damage. But because antioxidant research is Oral ANTIHISTAMINES are often prescribed, but they still in its infancy, there is no research that proves it are most effective when the underlying condi- does not work. Early results suggest that VITAMIN C tion involves the release of HISTAMINE (a chemical not only helps to reverse sun-induced skin damage released during an allergic reaction that causes but that it also works as a SUNSCREEN. infl ammation and itching, such as in HIVES). Most researchers do agree that taking a vitamin Alternatively, some patients’ itching may lessen pill probably will not protect the skin, and that it is with use of the drugs pramoxine and doxysin, or far less effective than applying the vitamins directly with a preparation containing menthol, phenol to the skin. To be effective in face creams, anti- or camphor. Menthol eases itching because of the oxidants must be present in signifi cant amounts. But cooling feeling it produces; phenol temporarily while the best concentrations are 10 percent for vita- numbs nerve endings in the skin. Camphor has a min C and 2 or 3 percent for VITAMIN E, many cos- local anesthetic effect. metic products contain less than a tenth of a percent Less often, preparations of SALICYLIC ACID or of either one. In addition, it is not easy to make sure COAL TAR may be used. Shake lotions of CALAMINE that vitamin C in creams penetrates into the skin. may also reduce itching. Over-the-counter preparations containing ben- zocaine or diphenhydramine should be avoided, antiperspirants Metallic salts designed to be since either may produce an allergic skin contact applied to the skin to control excessive unpleas- response. ant odor by reducing the production of SWEAT. They contain aluminum or aluminum-zirconium salts that block the eccrine and apocrine sweat antiseptic cleansers Chemicals designed to pre- ducts, obstructing delivery of sweat to the skin’s vent infection that are applied to the skin to surface. These products also remove unpleasant destroy bacteria and other microorganisms. The odors because they create a drier environment that use of antiseptics to prevent infection (antisepsis) reduces the number of odor-causing bacteria. They is not the same thing as the creation of a germ-free are more effective than deodorants, which simply environment (asepsis). Antiseptics are milder than remove unpleasant odors. Some deodorants also disinfectants, which are used to decontaminate contain antiperspirants. objects but are considered too strong for skin. Commercially available antiperspirants reduce Antiseptic fl uids are usually used to bathe underarm sweating by 20 to 40 percent; their effec- wounds; antiseptic creams are applied to wounds tiveness can be increased by applying in the morn- before being bandaged. ing and at bedtime. Antiperspirants should not be Commonly used antiseptics include iodine and applied to moist or irritated skin, nor should they chlorhexidine compounds and HYDROGEN PEROX- be used soon after shaving. IDE. Chlorhexidine is an antiseptic effective against For those with extreme body odor problems, many yeasts, fungi, and both gram-negative and physicians may prescribe aluminum chloride hexa- gram-positive bacteria. Well tolerated by most hydrate, 20 percent solution in absolute alcohol people, it is quick-acting and effective for a long (Drysol), for use on underarms, palms, or soles. time. Antiseptic iodine compounds (such as the APLIGRAF 35 brownish yellow providone-iodine) are effective antiviral drugs can cause side effects ranging from against bacteria, fungi, yeasts, viruses, and proto- nausea and dizziness to bone marrow suppression zoa. However, they take longer to work than other and kidney problems. antiseptics and may be ineffective in the presence of blood. While HEXACHLOROPHENE has been widely used aplasia cutis The medical name for the absence in the past (effective against many gram-positive of small areas of skin that may occur any time organisms such as Staphylococcus), it has also from before birth to early childhood. These local- been associated with neurotoxicity. Because hexa- ized birth defects are typically found on the back of chlorophene is less safe than other agents, such as the scalp, although they may occur anywhere on chlorhexidine and iodine compounds, its use is reg- the scalp (rarely, on the face, trunk, or limbs). At ulated by the U.S. Food and Drug Administration. birth, the affected area may be covered by a tough, smooth membrane or it may be raw, ulcerated, and crusted. antiviral agents A group of drugs used to treat The defect may be inherited, but is usually viral infections; some of the best known of these appears spontaneously. It is sometimes seen with drugs for use in skin infections are ACYCLOVIR, the chromosome disorder trisomy 13. FAMCICLOVIR, and VALCYCLOVIR prescribed for the treatment of various forms of HERPES, and AZT Symptoms and Diagnostic Path (ZIDOVUDINE), prescribed for the treatment of AIDS. On the scalp, affected areas tend to be hairless with Until the development of acyclovir and AZT, no sharp margins that heal slowly, eventually replaced effective antiviral agents existed. by a fl at or hypertrophic scar. Occasionally, there To this point, no drugs have been developed may be a secondary infection or hemorrhage. that eradicate viruses and cure the illnesses they There may be an underlying defect in the bone cause. This is because viruses live only within cells; that will heal on its own during the baby’s fi rst two a drug capable of killing a virus would also kill its years of life. host cell. New antiviral agents interfere with viral replication or otherwise disrupt chemical processes Treatment Options and Outlook of viral metabolism; some prevent viruses from There is no known treatment other than to cut out penetrating cells. They are effective treatments for the hairless area or transplant normal skin and hair a variety of infections. follicles. Antivirals including acyclovir, famcyclovir, and valacyclovir, are especially effective in treating herpes family infections. Antiviral drugs reduce APLIGRAF A type of ARTIFICIAL SKIN widely used the severity of the herpes symptoms and shorten by dermatologists as a skin substitute to cover skin the course of the infection, but the drugs cannot ulcers on the foot. Like human skin, APLIGRAF eliminate the virus completely. consists of living cells and structural proteins. Scientists have been testing several varieties of a Manufactured from living cells, it is considered to vaccine that appears to lessen the severity of herpes be a medical device and has been approved for the attacks. treatment of leg ulcers and foot ulcers in diabetic AZT (Retrovir) a drug still used in the treatment patients. of AIDS, works by interrupting the replication cycle Like human skin, APLIGRAF has two primary of the HIV virus, and has demonstrated effective- layers, a DERMIS and an EPIDERMIS. The epidermal ness in delaying the progression of HIV infection. layer is composed of human keratinocyte cells that form an outer protective layer. The dermal Side Effects layer lies beneath the epidermis and is made up of Antiviral drugs have a variety of side effects. human fi broblast cells. APLIGRAF does not con- Creams and ointments may irritate skin, while oral tain Langerhans’ cells, melanocytes, macrophages, 36 apocrine glands lymphocytes, white blood cells, blood vessels, hair of the blood absorbs the blue-green color of the follicles, or sweat glands. APLIGRAF should not be argon laser beam. PORT-WINE STAINS may be con- used on clinically infected wounds and in patients siderably lightened with this type of treatment, as with known allergies to bovine collagen. will telangiectases, SPIDER ANGIOMAS, venous lakes, See also COMPOSITE CULTURED SKIN. and certain pigmented lesions such as lentigines. It is also used to treat acne ROSACEA. Until the late 1980s, the argon laser was the apocrine glands See SWEAT GLANDS. treatment of choice for port-wine stains; hemo- globin selectively absorbed the laser’s light in the dilated blood vessels of these birthmarks. How- apocrine bromhidrosis See BROMHIDROSIS. ever, the therapy is limited by a substantial rate of scarring. The continuous laser energy dissipates into the surrounding dermis, causing thermal apocrine sweat See SWEAT GLANDS. damage. Less-than-optimum treatment results in pale, immature port-wine stains. Moreover, the extent of clearing and rate of scarring are primarily arginosuccinic aciduria A rare genetic disor- dependent on the technique and experience of the der caused by a defi ciency of the amino acid operator. arginosuccinase. However, more selective blood vessel damage This disorder is an autosomal recessive disorder, can be obtained by using a wavelength that is more which means that a defective gene must be inher- selectively absorbed by hemoglobin and delivered ited from both parents to cause the abnormality. in a pulse shorter than the cooling time of the Generally, both parents of an affected person are abnormal vessel, such as the PULSED DYE LASER. unaffected carriers of the defective gene. Each of There is some danger in using lasers. Because their children would have a one in four chance of the beam generates heat, there is some risk of being affected, and a two in four chance of being fi re, especially on surgical dressings. Wet dress- a carrier. ings placed around the surgical site will protect nearby normal tissue, reducing the chance of fi re. Symptoms and Diagnostic Path Protective goggles during treatment are essential, This disorder causes sparse, dull, short, and fragile and must be worn by the patient and all medical hair with frayed ends that looks like broom ends personnel. Very little discomfort is associated with pushed together. Patients develop seizures and most skin laser surgery. coma and subsequently die.

Treatment Options and Outlook Artecoll A type of synthetic BIOLOGICAL IMPLANT Some patients benefi t from a low-protein diet with developed as a SKIN FILLER in Europe, and approved arginine supplements or additions of keto ana- for use as an implant material in Canada in 1998. logues of essential amino acids. Made from lucite beads called methylmethacrylate (MMA) suspended in COLLAGEN, it is similar to ZYDERM. Experts believe this implant may soon be argon laser A tube that contains argon gas ener- approved by the U.S. Food and Drug Administra- gized by a power source (such as electricity). The tion (as Artefi ll). resulting beam of light is up to 10 million times When injected into the deeper layers of skin, more powerful than the Sun, and is absorbed by the collagen evenly disperses the microspheres different types of substances in the skin, including of MMA; the collagen is absorbed over several melanin pigment and hemoglobin in blood vessels. months, and the microspheres remain in place to The argon laser is the most effective and safest correct the defect. Because the correction is per- way to treat vascular lesions because the red color manent, a series of injections is necessary to safely athlete’s foot 37 achieve the desired result. It is very effective at fi ll- ashy dermatosis Another name for ERYTHEMA ing lines between the nose and mouth, but lumpi- DYSCHROMICUM PERSTANS. ness is common when used to fi ll the lips.

Side Effects asteatotic eczema See ECZEMA. Allergic reactions may occur in response to the collagen, and although MMA has been used for many years as a bone cement, redness, infl amma- astringents Substances that cause skin tissue to tion, and infection may occur, as with any other dry and shrink by reducing its ability to absorb synthetic implant. water. Astringents are widely used in skin ton- Although the incidence of complications has ics, but they may cause burning or stinging when been reported by the manufacturer to be less than applied. one in 10,000, infl ammation, clumping, and gran- While old-fashioned astringents were used to uloma formation have been reported in as many as dry out the skin in the treatment of ACNE they also half of patients having lip augmentation. Surgical stripped the skin of essential moisture (usually excision of the material is the only effective treat- because of a high alcohol content). Today, there’s a ment for these complications. Despite Artecoll’s new type of toner that not only cleanses less harshly impending approval in the United States, the Swiss than some of the old products but can lightly government has advised physicians in that country exfoliate, soothe, refresh, and leave skin soft and not to use it for augmentation. hydrated instead of dry and taut. These products are often marketed under a variety of names, including “toners,” “clarifi ers,” “refreshers,” “lotions,” and artificial skin Synthetic skin, often used to treat “purifi ers.” While all may be more or less inter- burn victims, is capable of preventing infection and changeable, in general toners tend to be lighter and reducing fl uid loss while not inducing an immune less drying than astringents because they usually rejection response. contain lower concentrations of alcohol. The concept of artifi cial skin dates back to at Many dermatologists advise patients to avoid least the late 17th century, when water lizard skin alcohol, which dries the skin and actually increases was applied to open wounds. Since then, the need oil production as glands are stimulated to compen- for an effective skin substitute has remained. Since sate for excess dryness. Still, while alcohol may dry those early days, many possibilities have been the skin temporarily, it does not cause any longer- explored in the fi eld of skin replacement. term damage. In addition to using animal skins, researchers Those astringents or toners without alcohol experimented with plastic sprays, sponges, and rely on natural ingredients to cleanse and refresh fresh skin from cadavers (ALLOGRAFTS). Cadaver the skin, using “botanicals” (naturally derived ele- skin proved to be the best temporary covering for ments). Botanical extracts may include lavender, large wounds, but it was hard to get and there grapefruit seed, and orchid, and serve different were problems of potential disease transmission functions, soothing, or stimulating the skin. and rejection. In the mid-1970s, scientists discovered how to culture epidermal cells to grow sheets of skin, and ataxia telangiectasia See LOUIS-BAR SYNDROME. within 10 years this technique became commer- cially available. These grafts are helpful in temporar- ily covering wounds and in helping them to heal. athlete’s foot A common fungal condition caus- See also COMPOSITE CULTURED SKIN; PINCH GRAFT. ing the skin between the toes (usually the fourth and fi fth toes) to itch, peel and crack, resulting in diffuse scaling and redness of the soles and sides of ascorbic acid deficiency See SCURVY. the foot. 38 atrophic papulosis, malignant

Athlete’s foot is usually caused by a fungal infec- Shoes should be aired regularly in the sun, tion and is called tinea pedis; secondary infection in and wiped inside with a disinfectant-treated skin cracks is caused by bacteria. cloth to remove fungi-carrying dead skin. Insides of shoes should be dusted with antifungal pow- Symptoms and Diagnostic Path der or spray. Individuals who perspire heavily It is sometimes associated with thickening and should change socks three or four times daily, crumbling of the nails. Linked to wearing shoes and wear only natural white cotton socks, rinsed and sweating, the condition is rare in young chil- thoroughly during washing. Individuals should dren and in places of the world where people do air dry feet after bathing and then apply powder, not wear shoes. and always wear sandals or fl ip-fl ops in public Itchy skin on the foot is probably not athlete’s bathing areas. foot if it occurs on the top of the toes. If the foot See also DERMATITIS, CONTACT. is red, swollen, sore, blistered, and oozing, the condition is more likely the result of some form of contact dermatitis, although infl ammatory fungal atrophic papulosis, malignant See DEGOS’ infections can sometimes look like this. DISEASE.

Treatment Options and Outlook The condition may clear up without any attention, atrophie blanche Unusual types of white scars but it usually requires treatment. An untreated with red macules and spidery red veins resembling fungal infection can lead to bacteria-inviting cracks chili peppers. This type of scar, which is usually in the skin. It is important to keep the affected found on the tops of the feet, ankles and legs, is the area dry, wearing dry cotton socks or sandals. Even fi nal result of lower leg ulcers. better—the foot should be kept uncovered. Most infections can be cured by applying the Treatment Options and Outlook nonprescription antifungal cream Lotrimin two or Combinations of aspirin and dipyridamole, which three times daily. Possible side effects include occa- affect the formation of platelets, have been helpful sional skin irritation; antifungal oral drugs cause in the treatment of some cases of atrophie blanche. few side effects and are helpful in severe cases or Other treatments have included phenformin, ethy- when the nails are involved. lestrenol, and pentoxifylline. When the acute phase of the infection passes, See also LIVEDO VASCULITIS. dead skin should be removed with a bristle brush in order to remove the living fungi. Any bits of the skin should be washed away. In addition, toenails attar of roses An extract of roses used to perfume should be scraped every two or three days with an products. This extract may cause allergic reactions orange stick or toothpick. in sensitive consumers.

Risk Factors and Preventive Measures Disinfecting the fl oors of showers and locker rooms atypical nevi (dysplastic nevi) An unusual MOLE can help control the spread of infection. Once an that is a marker for an increased risk of MALIG- infection has cleared up, antifungal cream should NANT MELANOMA. Researchers suggest that almost be used now and then—especially during warm 7 percent of Caucasians in the United States have weather. Plastic or too-tight shoes (or any type atypical nevi, and half of their close relatives may of footwear treated to keep out water) should be also be affected. avoided. Natural materials (cotton and leather) There are two types of atypical nevi: familial and and sandals are the best choices; wool and rub- sporadic. The signifi cance of familial nevi is clear: ber can make a fungal problem worse by trapping Those who have atypical moles and a family history moisture. of melanoma (two or more close blood relatives) autograft 39 have an almost 100 percent lifetime risk of devel- Risk Factors and Preventive Measures oping melanoma. If a doctor diagnoses atypical moles, the patient No one knows the true signifi cance of sporadic should discuss the family history and have close atypical moles. Although such patients with large relatives examined for any sign of moles or mela- numbers of atypical moles also appear to be at noma. Patients who have both atypical moles and higher risk for developing malignant melanoma, close family members with malignant melanoma the risk appears to be less than for those in the should have regular skin exams (as often as every familial group (an estimated lifetime melanoma risk four to six months) and supplement medical of 6 percent). Experts believe that about 50 percent checkups with self-examinations; full-body pho- of the populace has at least one of these lesions. tographs may help an individual to more easily Melanoma warning signs include moles that spot changes in moles. Patients should reduce sun are often asymmetrical (one half looks unlike exposure and use sunscreens with a high SPF and the other), have irregular or hazy borders, are consider an eye exam, since moles also may affect variegated and of irregular color, with a diameter the eyes. slightly larger than that of a pencil eraser. Although atypical moles continue to develop as the patient grows older, the lesions tend to remain augmentation mammoplasty See MAMMOPLASTY. stable. Only a small number of these spots ever undergoes malignant transformation. aurothioglucose An oil-based form of gold Symptoms and Diagnostic Path salts used in GOLD THERAPY for the treatment of Atypical moles are found most often on the back, PEMPHIGUS. chest, abdomen and extremities, but they also may occur on unexposed areas (scalp, buttocks, groin, Side Effects or breasts). They differ from ordinary acquired Side effects of gold salts can occur any time dur- moles in several ways: fi rst, atypical moles tend ing treatment or months after treatment has been to occur in larger numbers than ordinary moles— stopped. The most common adverse reaction is often more than 100. In addition, these moles infl amed skin; ITCHING can be a warning of a skin are often larger than the ordinary variety, and RASH. This drug can cause grayish blue discolor- they will often measure more than a half inch. ation of the skin, a metallic taste, and mouth sores. Although ordinary moles usually stop appear- Because gold salts can cause serious kidney and ing by early adult life, atypical moles continue to bone marrow problems, all patients require regular develop into adulthood. blood and urine test monitoring. Atypical moles also may look different from Injectable gold may cause fl ushing, dizziness, ordinary moles. They tend to have irregular con- and fainting immediately after the injection. Rarely, tours with irregular pigmentation. In addition patients can have severe allergic reactions resulting to shades of brown, atypical moles may be red in shock. or pink—colors not normally found in ordinary See also GOLD SODIUM THIOMALATE. moles. When these atypical characteristics are pro- nounced it may be diffi cult to tell the difference between an atypical mole and a superfi cial spread- Auspitz’s sign Pinpoint bleeding that occurs when ing malignant melanoma. the scale of a lesion in a patient with PSORIASIS is forcibly removed. Treatment Options and Outlook The most abnormal-looking lesions should be excised and examined microscopically. If very autograft Tissue graft taken from one part of unusual, other odd-looking moles should be the body and placed on another part of the same removed. patient; burn repair is often done by grafting strips 40 Autologen of skin taken from elsewhere on the body (usually inserted into a thick layer of fat at the donor site the upper body or thigh, called the “donor site”). (such as the thigh, buttocks, or abdomen). Depend- Unlike ALLOGRAFTS, autografts are not rejected by ing on the procedure, the syringe may or may not the body’s immune system. be attached to a high-powered suction device. See also PINCH GRAFT; SKIN GRAFT. Fat cells are drawn into the syringe and then carefully reinjected into the area to be treated. The process is repeated until the defect has been cor- Autologen A type of custom COLLAGEN used as rected. A pressure bandage is applied to the donor a COSMETIC SURGERY fi ller to correct skin-contour site and sometimes to the recipient site to prevent defects. This dispersion of intact collagen fi bers and bruising and swelling. collagen tissue matrix is made from a patient’s own skin, obtained by a cosmetic surgical procedure. Risks and Complications Excised skin is placed in sterile containers and sent No signifi cant complications have occurred. Because to laboratories on ice by express mail. “Custom col- the fat is transplanted within the patient’s own lagen” is then created and sent back to the physi- body, problems of rejection or allergic reactions do cian’s offi ce to be used on the same patient. Collagen not occur. Scarring from the injections is minimal, can then be made at some future date. Because it is because the injections are given within the creases part of the patient’s own tissues, allergic reactions of the body. are considered impossible. Theoretically, these injec- tions should last longer than other biological fi llers, Outlook and Lifestyle Modifi cations from nine months to one year. Autologen does not Fat transplants can be done under local anesthesia require approval for cosmetic corrective use. and is an outpatient procedure. Healing time is See also SKIN FILLERS. only a couple of days.

autologous fat transplant A type of natural SKIN azathioprine (Imuran) An anti-cancer drug used FILLER for wrinkles and other cosmetic procedures to treat severe autoimmune diseases when other that is produced from the patient’s own fat via drugs fail to slow the progression of the disease or LIPOSUCTION. No allergy testing is required before to improve symptoms. It is particularly effective in this procedure is done, but harvesting the fat is an conjunction with CORTICOSTEROIDS such as pred- involved, complicated process. There is no consen- nisone or CORTISONE in the treatment of blistering sus on longevity, but most experts agree results last disorders such as PEMPHIGUS. from months to years. Autologous fat transplants The drug works by reducing the effi ciency of the do not require approval by the U.S. Food and Drug body’s immune system by preventing lymphocytes Administration (FDA). (white blood cells) from multiplying. Lymphocytes The procedure is being done to “fi ll-in” areas in destroy proteins not usually found in the body, but the body where there is a lack of soft tissue, such in autoimmune disorders they attack proteins that as hollow cheeks, fi lling the lines between nose the immune system interprets as foreign. and mouth, and with depressed ACNE scars. It is also used to recontour the face, enhance the cheek Side Effects and chin, correct facial or body deformities. More Side effects include abnormal bleeding and recently it has been done as a way to augment the increased susceptibility to infection as a result of breast. reduced blood cell production. There may be nau- sea and vomiting, diarrhea, fever, HAIR LOSS, and Procedure skin eruptions. In animals, this drug causes birth Both the donor site and the area to be treated are defects. Temporary chromosomal abnormalities anesthetized and a needle attached to a syringe is when using this drug also have been reported. azulene 41

Long-term use increases the risk of skin cancer, a treatment for malignant melanoma, a deadly form frequent side effect in kidney transplant patients. of skin cancer. It is also an effective acne treat- ment when applied to the skin. Azelex is a recently developed topical cream that helps mild acne when azelaic acid A depigmenting agent originally applied to the affected area twice daily. identifi ed as the cause of a lack of pigment See also MELANOMA, MALIGNANT. (HYPOPIGMENTATION) associated with the fungus infection TINEA VERSICOLOR (a common skin condi- tion producing pigmented fl aking skin patches). azulene A chamomile extract used in face and Azelaic acid kills abnormal MELANOCYTES, melanin- body creams, SUNBURN remedies, burn ointments, producing cells. It is also being studied as a possible and bath salts. B bacterial skin infections Also known as pyoder- In addition to oral antibiotics, topical treatments mas, this type of infection can be caused by a wide may include applying warm compresses of tap variety of bacteria. Most cases are caused by either water or BUROW’S SOLUTION to the affected area, or staphylococci or steptococci. The most common of all using topical over-the-counter antibiotics. the skin infections is IMPETIGO, a highly contagious See also GROUP B STREPTOCOCCI INFECTIONS IN infection of the topmost layers of the skin causing INFANTS; NECROTIZING FASCIITIS. itchy, red, and blistering patches and honey-colored crusts. Most often appearing in childhood, impetigo is usually caused by Staphylococci. Bactroban See MUPIROCIN. Staph organisms also cause FOLLICULITIS, an infection near the openings of hair follicles that resembles ACNE and that can spread if untreated. bags under eyes Loose, baggy skin under the eyes It often occurs after repeated trauma to the area is the result of a gradual loss of skin elasticity due to of skin from shaving, or following soaking in con- aging, or because of an irreversible inherited condi- taminated hot tubs and whirlpools. tion called blepherochalasis. Puffy lower eyelids also When bacteria cause infection in deeper layers can be caused by lack of sleep, stress, or illness. of the skin, they may result in BOILS hot, infl amed The swelling can be reduced by applying damp- lesions that may look like an infected pimple ened cotton pads, CHAMOMILE teabags dipped in appearing on the face, scalp, underarms, and but- cool water, or cucumbers, and lying down for 10 tocks. Larger and deeper than boils are CARBUNCLES, minutes. abscesses fi lled with pus and bacteria that are often Once the bags have formed, they can be covered extremely painful. Boils and carbuncles should never up with makeup or surgically removed in a surgical be squeezed, since the bacteria may be forced into procedure called BLEPHAROPLASTY. the blood, causing widespread blood poisoning. A most serious skin infection is CELLULITIS, usu- ally appearing on the legs and characterized by baking soda A water-soluble powder used in high fever, weakness, shaking chills, pain, lymph baths as a soothing soak for irritated or itchy skin. gland swelling, and spreading warm redness. If Mixed with a bit of water into a paste, it can ease deep swellings appear on the face, the condition is the pain of insect stings. diagnosed as the potentially fatal ERYSIPELAS. In general, bacterial skin infections usually respond well to oral antibiotics. Strep infections baldness Absence of hair on the scalp. respond very quickly to penicillin and its deriva- See also ALOPECIA AREATA. tives, but staph infections may not; for this rea- son, physicians usually prescribe dicloxacillin or ERYTHROMYCIN to treat staph infections. All types baldness, female-pattern A typical pattern of loss of antibiotics usually require a 10-day course for a of hair in women caused by hormones, aging, or complete cure. heredity.

42 baldness, male-pattern 43

Hair grows from the hair follicle at an average loss recurs when the drug is stopped. Minoxidil is rate of a half inch a month. Each hair grows for available in a special formulation for women. two to six years, then rests, and fi nally falls out. A Hair transplants consist of removing tiny plugs new hair then begins growing in its place. At any of hair from areas where the hair is continuing to time, about 85 percent of the hair is growing and grow and placing them in areas that are balding. 15 percent is resting. This can cause minor scarring in the donor areas, Baldness occurs when the hair falls out but a which is easily covered by the remaining hair. The new hair does not replace it. While the cause of procedure usually requires multiple transplanta- the failure to grow a new hair in women is not tion sessions and is relatively expensive. well understood, it is associated with genetics, Suturing of hairpieces to the scalp is not recom- aging, and levels of male hormones (androgens). mended as it can result in scars and infections. The Changes in the levels of the androgens can affect use of hair implants made of artifi cial fi bers was hair production. banned by the FDA because of the high rate of infection. Symptoms and Diagnostic Path Hair weaving, hairpieces, or hairstyle changes The typical pattern of female-pattern baldness may disguise the hair loss and improve the cos- (more accurately known as female-pattern thin- metic appearance. This is often the least expen- ning) is different from that of male-pattern bald- sive and safest method of treating female-pattern ness. In women, the hair thins all over the head, baldness. but the hair in front of the head remains. There may be a moderate loss of hair on the crown, but this almost never progresses to total or near total baldness, male-pattern The most common cause baldness as it may in men. of hair loss in men, which is caused by a normal In addition, hair loss can occur in women for response to male hormones (androgens) in men reasons other than female-pattern baldness. These who are genetically predisposed to the condition. may include A quarter of all men start losing their hair by their third decade of life, and about two-thirds are bald • temporary shedding of hair (telogen effl uvium) or have a balding pattern by the time they are 60. • breaking of hair from styling or twisting (traction Balding can start at any time after puberty; men alopecia) who begin balding at an early age are more likely to lose more hair. Caucasian men are the most • ALOPECIA AREATA—an immune disorder causing likely to become bald (some estimates are as high temporary hair loss as 80 percent) while Chinese men are about half as • certain oral medications likely to lose their hair. • certain skin diseases Symptoms and Diagnostic Path The specifi c pattern of balding varies from person Treatment Options and Outlook to person. “Classic balding” is where the hairline The hair loss of female-pattern baldness is perma- creeps from the front toward the top of the head, nent and usually mild to moderate. No treatment but there are other patterns. For example, some is required if the person is comfortable with her men lose hair only on the top of their head while appearance. The only drug approved by the U.S. others may only keep the hair on the sides of their Food and Drug Administration (FDA) to treat head. Experts refer to seven basic types of pattern female-pattern baldness is MINOXIDIL (Rogaine), baldness, depending on which areas of the scalp are which is applied to the scalp. It may help hair grow losing hair. Type I represents the least hair loss and in 40 percent of women and may slow the loss of Type VII the most. For instance, men with type IV hair in 90 percent. Treatment is expensive, how- pattern baldness have a moderately receding hair- ever, for the recommended twice-daily use. Hair line and a small bald spot on the top of the head 44 balneotherapy while those with type VII pattern balding only have or who have early thinning. There are currently hair on the sides of the head. No matter how severe two different medications to treat this condition: the baldness in this condition, the hair on the sides FINASTERIDE and MINOXIDIL. Two drugs contain and back of the head is never lost. fi nasteride (Propecia and Proscar), which work by Male pattern baldness depends on the pres- preventing the enzyme from converting testoster- ence of male hormones, which are usually high one into DHT, the primary cause of male-pattern after puberty. Testosterone, one well-known male baldness. Proscar is prescribed specifi cally for men hormone, can be converted into a more potent with prostate enlargement. Propecia (the same hormone called dihydrotestosterone (DHT) by an medication at a lower dose) can stop hair loss and enzyme found in skin cells and hair follicles. Men actually reverse the balding process. It normally with male-pattern baldness have high levels of takes at least three months to see any results from DHT in their skin. When this hormone binds to using this drug. Between 80 percent and 90 per- a hormone receptor on the hair follicle, it slows cent stop losing hair while more than 60 percent down hair production. The follicles also produce grow a signifi cant amount of hair, and new hair weaker, shorter hair and may stop making scalp will be lost within one year after medication is hair altogether. stopped. However, male-pattern baldness does not affect The other drug used for baldness is minoxidil, all hair at the same time; some hair is more sensi- known popularly as Rogaine. This drug is con- tive to hormones than others. For instance, a man sidered a hair loss prevention drug by the U.S. is more likely to lose the hair on the temples than Food and Drug Administration. In this case, the on the top. liquid form of the drug is rubbed on the hairless patches of the scalp twice a day. According to Treatment Options and Outlook clinical trials, minoxidil slows hair loss in more There are a variety of treatments for male-pattern than 60 percent of men, but only regrows hair baldness, including HAIR TRANSPLANTS, scalp reduc- in one-third of men who use it. Hair loss will tion, tissue expansion, and medication. begin again within a few months after minoxidil In transplantation, tiny plugs of hair from the is stopped. back of the scalp are implanted to bald or thin areas. The process usually takes several sessions. Alternatively (or in combination with hair trans- balneotherapy Method of disease treatment by plants), some men prefer to undergo scalp reduc- bathing (usually in mineral hot springs), once con- tion, in which the skin on the head is stretched and sidered as fashionable “water cures.” surgically removed by a dermatologic surgeon, hair transplant surgeon, or plastic surgeon. Then hairy areas on either side of the head are stretched over bamboo hair Also known as trichorrhexis invagi- and sewn together. If the skin is too tight, tissue nata, this condition can sometimes develop in expansion is fi rst performed. normal hair as the result of overprocessing. More In tissue expansion, tiny balloons are implanted likely, it is a congenital defect that is often a symp- under the scalp in areas with dense hair, which tom of another disease, such as NETHERTON’S SYN- makes the areas up to a third larger. Over two or DROME. Netherton’s syndrome is usually present at three months, the balloons are slowly infl ated to birth, causing fl aking skin, red rashes, and sparse stretch the skin. Then the skin is removed as in a hair growth with fragile bamboo hair. This syn- scalp reduction, and the sides are pulled up to the drome is probably caused by an autosomal reces- top of the head (because hair on the sides of the sive gene that may be involved in keratinization of head is more resistant to balding than hair on the hair. Examination of hair fi bers has shown that the crown). the cuticle is normal but the internal structure is Drug treatment may be a better choice for men not completely keratinized at sporadic points along who are reluctant to undergo invasive procedures, its length. basal cell carcinoma 45

Symptoms and Diagnostic Path sunny climates; in Queensland, Australia, more This condition of the hair shaft is characterized by than half the local white population has had a basal rough hair fi bers with nodules that make the fi ber cell carcinoma by age 75. The number of new cases look like bamboo. The nodules are defects in the has risen sharply in recent years because of the fi ber where a cup-and-ball shape has developed. thinning ozone layer and popularity of sunbathing. In addition, younger and younger people are being Treatment Options and Outlook diagnosed with the disease. Bamboo hair often improves spontaneously as Chronic overexposure to sunlight is the cause the child gets older; most treatments are aimed of 95 percent of all basal cell carcinomas. In a few at preventing further trouble by avoiding cases, contact with arsenic, exposure to radiation, overprocessing. and complications of burns, scars, or vaccinations are contributing factors. People who have fair skin, light hair, and blue, green, or gray eyes are at barber’s itch The common term for sycosis vul- highest risk. Those whose occupations require long garis (infl ammation of the beard area). The con- hours outdoors or who spend lots of leisure time in dition is caused by infected hair follicles (usually the sun are in particular danger. with Staphylococcus aureus) picked up from infected On the other hand, dark-skinned individuals are razors and towels. far less likely to develop skin cancer.

Symptoms and Diagnostic Path Symptoms and Diagnostic Path PUS-fi lled blisters or boils develop around the follicles, More than 90 percent of this type of cancer is sometimes causing severe scarring unless treated. found on the face, often at the side of the eye or on the nose or other exposed area of the body, Treatment Options and Outlook although it can appear in any location. The fi ve Treatment usually involves antibiotic drugs; grow- most typical characteristics of basal cell carcinoma ing a beard may help prevent recurrence. are very different from each other, and often two See also PSEUDOFOLLICULITIS BARBAE. or more features are found in one tumor. Basal cell carcinoma may be basal cell Small round cell found in the inner- • an open sore that bleeds or oozes, remaining most part of the top skin layer (EPIDERMIS) where open for three or more weeks the rest of the epidermal cells are formed. • a reddish patch or irritated area (often on the shoulder, chest, arms, or legs) that may itch or hurt, or cause no sensation at all basal cell carcinoma The most common form of • a smooth growth with an elevated, rolled border SKIN CANCER, affecting more than 800,000 Ameri- and indented center, developing tiny blood ves- cans each year. One out of every three new cancers sels on the surface as it grows is a skin cancer, and 83.5 percent of these is a basal cell carcinoma. If untreated, the growth invades • a shiny bump that is pearly or translucent, often and grows deeper into surrounding tissues, but pink, red or white, tan, black, or brown fortunately this type of cancer almost never spreads • a scar (white, yellow or waxy) with poorly to other parts of the body. defi ned borders; the skin itself looks shiny and Until recently, those most likely to get basal cell taut. This last sign is less frequent but may indi- carcinoma were older people (especially men) who cate an aggressive tumor. spent a great deal of time outdoors. Today, skin cancer affects men and women in almost equal numbers. A diagnosis of basal cell carcinoma is made after The incidence increases signifi cantly in those physical examination and biopsy (removal and with outdoor occupations and those who live in examination of a small piece of tissue). 46 Bazex syndrome

Treatment Options and Outlook Radiation therapy In radiation therapy, X-rays If tumor cells are found, the growth can be are directed at the malignant cells; it usually takes removed by surgery or destroyed by radiation. The several treatments several times a week for a few treatment is based on type, size, and location of the weeks to totally destroy a tumor. Radiation therapy tumor and on the patient’s age and health, but it may be used with older patients or with those in can almost always be performed on an outpatient poor health. basis. Local anesthetics are used and not much pain Drug treatment Researchers are now studying is felt. the possible use of interferon, a genetically engi- Surgical removal The most common treatment neered product of the human immune system, as is simple excisional surgery. The physician removes a possible treatment of some basal cell carcino- the entire growth and an additional border of nor- mas. Interferon interferes with viral multiplica- mal skin as a safety margin. The site is then stitched tion and increases the activity of natural killer closed and the tissue is sent to the lab to determine cells (types of lymphocytes that make up part of if all malignant cells have been removed. the body’s immune system). Basal cell carcinoma Alternatively, the surgeon may perform elec- has a better than 95 percent cure rate if detected trosurgery (CURETTAGE AND ELECTRODESICCATION) in and treated. which cancerous tissue is scraped from the skin The larger the growth the more extensive the with a curette (sharp ring-shaped device) and an treatment. While this type of skin cancer almost electric needle burns a safety margin of normal never metastasizes, it can destroy surrounding tis- skin around the tumor at the base of the scraped sue. Since removal of a tumor scars the skin, large area. This technique is repeated twice to make sure tumors may require reconstructive surgery and the tumor has been completely removed. skin grafts. With CRYOSURGERY, the physician does not cut If a patient is diagnosed with one basal cell the growth but instead freezes the lesion by apply- carcinoma, there is a greater chance of developing ing LIQUID NITROGEN with a special spray or a cotton- others over the body in the future. Even though tipped applicator; this method does not require a basal cell carcinoma has been removed, another anesthesia and produces no bleeding. It is easy to can develop in the same place (or nearby), usually administer and is the treatment of choice for those within the fi rst two years after surgery. Basal cell who have bleeding disorders or are intolerant to carcinomas on the scalp, nose, and sides of the nose anesthesia. and around the ears are particularly problematic. If Laser surgery is used to focus a beam of light onto the cancer recurs, the physician may recommend a the lesion either to excise it or destroy it by vapor- different type of treatment the second time, most ization. The major advantage of this technique is likely Mohs’ surgery. Therefore, it is important to that it seals blood vessels as it cuts. In removing examine the surgical site periodically. skin cancer, incisional laser surgery offers no real advantage over scalpel surgery. Mohs’ surgery (microscopically controlled sur- Bazex syndrome A rare eruption of the nose, gery) involves the removal of very thin layers of ears, and extremities associated with cancer of the the malignant tumor, checking each layer thor- lungs, esophagus, and tongue or the gastrointesti- oughly under a microscope. This is repeated as nal tract. often as necessary until the tissue is free of tumor; this method saves the most healthy tissue and has Symptoms and Diagnostic Path the highest cure rate; it is often used for tumors Symptoms begin on the hands and feet with scal- that recur and for tumors in areas where basal ing bluish red plaques; severe nail problems may cell carcinomas are known to recur after other include fl aking and shedding of the nail itself, treatment techniques (nose, ears, and around the followed by involvement of the ear, nose bridge, eyes). elbows, and knees. The skin symptoms, which look bedsores 47 much like PSORIASIS, may appear before a tumor patients. They often affect patients with stroke or is diagnosed and can predict the malignancy with spinal cord injuries; constantly wet skin caused almost 100 percent accuracy. by incontinence also may be a factor. Common site of breakdown includes the shoulders, elbows, Treatment Options and Outlook lower back, hips and buttocks, knees, ankles, and The skin lesions fade away when the tumor is heels. removed. Symptoms may also be treated with Actor Christopher Reeve, a quadriplegic and keratolytics and topical steroids. an outspoken advocate for the disabled, died 10 years after his horseriding accident as a result of complications of a pressure sore, which indicates Beau’s lines Temporary horizontal depressions how serious these wounds can be. Although people across the nails that appear during certain acute living with paralysis are especially at risk, anyone infections such as MEASLES and MUMPS or infl amma- who is bedridden, uses a wheelchair, or is unable tory conditions such as infl ammatory bowel disease to change positions without help can develop pres- or lupus, or after a heart attack. The depression fi rst sure sores. appears at the cuticle a few weeks after the underly- ing disease begins and slowly moves out to the end Symptoms and Diagnostic Path of the nail as the nail grows over a period of months. Bedsores begin as red, painful areas that turn When this condition appears during a systemic dis- purple before the skin breaks down, eventually ease, all of the fi ngernails and toenails are likely to turning into open sores. Once the skin is broken, be affected. If only one or two nails are affected, the the sores often become infected, enlarge, deepen, condition is probably caused by trauma or cold. and are very slow to heal. Pressure sores fall into one of four stages based on their severity, according to the National Pres- bedbugs Flat, wingless brown insects that live in sure Ulcer Advisory Panel, a professional organiza- fl oors and furniture (especially beds) during the tion dedicated to the prevention and treatment of day, coming out at night to bite their human hosts. pressure sores. While they rarely transmit disease, their bites may Stage I A pressure sore begins with an area of become infected. Usually the bug sucks blood from red skin that may itch or hurt, and feel warm to several nearby sites, resulting in a group or cluster the touch. In people with darker skin, the mark of lesions. may look fl aky or ashen, with a blue or purple cast. Soon after the bite, the patient experiences Stage I wounds are superfi cial and will fade away an itchy, burning wheal with a central red mark, after the pressure is relieved. which helps differentiate this from an ordinary Stage II The pressure sore now looks like an wheal. The bedbug lesion may become fi rm or open sore, more like a blister or abrasion, affecting develop into a blister (especially in children). The either the outermost or deeper layer of skin (or both). wheal may subside soon, or it may last for several Surrounding skin may look red or purple. If treated hours. They appear most often on the back, neck, promptly, stage II sores usually heal fairly quickly. face, ankles, wrists, buttocks, or wherever the body Stage III Characterized by a deep, craterlike touches the bed. wound, pressure ulcers at this stage extend all the Bedbugs can be killed with a variety of insecti- way through the skin layers down to the muscle. cides, including malathion, lindane, or pyrethrins. Stage IV In the most serious and advanced stage, there is damage to muscle, bone, and sup- porting structures such as tendons and joints, bedsores A type of ulcer (also known as decu- along with the overlying skin. Stage IV wounds bitus ulcers or pressure sores) that develops on are extremely diffi cult to heal and can lead to fatal the skin of bedridden, unconscious, or immobile infections. 48 bee and wasp stings

Treatment Options and Outlook Treatment Options and Outlook Deep chronic ulcers may require treatment with Ice, elevation, and oral antihistamines minimize antibiotics, packing with plastic foam, and some- local pain and swelling. In the case of a delayed local times even PLASTIC SURGERY. reaction appearing after 24 hours, a fi ve-day course of systemic steroids may help. In honeybee stings, Risk Factors and Preventive Measures the stinger and attached venom sac must be scraped It is a far better idea to prevent a bedsore from from the skin; forceps should not be used, because developing than to try to treat one already in pressure on the sac can inject more venom. existence. Once a bedsore has developed, it will Highly allergic individuals should carry an emer- heal only if the pressure on the damaged skin is gency kit including a tourniquet, syringe, epi- minimized. nephrine, and antihistamine. Those who have had To prevent sores, a patient’s position should be several severe reactions should consider hyposensi- changed at least every two hours; it is important to tization; IMMUNOTHERAPY with venom is 95 percent wash and dry pressure areas carefully (especially effective in eliminating serious allergic responses. if there is incontinence). Barrier creams also may further protect the skin. A ripple bed mattress may help prevent bedsores beeswax A substance secreted by bees to build by stimulating circulation; this rippling effect is the walls of their cells in the hive; it is also used created by pumping air in and out of the mattress. by cosmetic manufacturers as an emulsifi er to Cushions and pillows may relieve pressure (place soften and protect the skin. Without emulsifi ers, them between the knees and under the shoulder). the cosmetic would separate, leaving the solids at A sheepskin under the buttocks and booties on feet the bottom and the liquid ingredients at the top. also may also relieve pressure. Beeswax has caused allergic reactions in some sen- sitive people. bee and wasp stings More than half of all deaths due to venomous animals are a result of stings by Behcet’s syndrome A rare disorder causing skin bees and wasps. The Hymenoptera order includes rashes and recurrent mouth ulcers among many three families: honeybee and bumblebees; wasps, other symptoms. Attacks often last for several weeks hornets, and yellow jackets; and several species of and recur frequently. Eye involvement many cause ants. blindness; central nervous system involvement may be fatal. The syndrome was fi rst described by Turk- Symptoms and Diagnostic Path ish dermatologist Hulusi Behcet (1889–1948). After being stung, the patient may have either an Rare in the United States, the disease is more immediate reaction within two hours or a delayed often found in some Middle Eastern countries and reaction. Immediate reactions are the most com- Japan, and is fi ve times more likely to occur among mon, and include local swelling, reddening, pain, men. The syndrome may become chronic in some and ITCHING, which usually subsides within a few patients. hours. Its cause is unknown, although some experts However, in some patients with hypersensitiv- believe the disease could be triggered by a virus, ity to venom, the local reaction is marked by more a clotting problem, an autoimmune disorder, or severe and prolonged swelling and redness, with heredity. systemic reactions ranging from mild to fatal. Ana- phylactic reactions (with breathing problems and Symptoms and Diagnostic Path internal swelling) usually occur within the fi rst 10 Behcet’s disease generally begins when individuals to 30 minutes after the sting. The faster a reaction are in their 20s or 30s, although it can happen at materializes the more severe it will be. any age, and it tends to occur more often in men benzoyl peroxide 49 than in women. A variety of skin lesions through- Benzoyl peroxide is available in a cleansing out the body have been associated with the disease bar, cream, gel, lotion, and facial mask. It is sold (PAPULES, VESICLES, PUSTULES, ABSCESSES, subcutane- in strengths ranging between 5 and 10 percent, ous thrombophlebitis, and nodular lesions). Other but dermatologists usually advise patients to start symptoms of the syndrome include genital, mouth with a 5 percent product, since the lower concen- or intestinal ulcers; eye infl ammation; arthritis; tration is just as effective and less likely to cause venous thrombosis; blood clots; or neuropsychiat- irritation. Most over-the-counter products contain ric symptoms. benzoyl peroxide in a lotion base; the prescription items contain the chemical in a gel base. A fairly Treatment Options and Outlook new prescription preparation combining 3 percent Oral and genital ulcers may be treated topically, erythromycin with a 5 percent benzoyl peroxide in although this will not prevent new ulcers from a gel base may be more effective than either com- forming. Topical CORTICOSTEROIDS may cut down on ponent by itself. infl ammation; topical anesthetics may ease pain. In Because the skin absorbs benzoyl peroxide, severe cases, systemic anticancer drugs, corticoste- it should not be used by pregnant or nursing roids, or immune suppressors (especially azathio- women unless directed by a physician. Its safety prine) may be prescribed, but treatment is diffi cult. for children under age 12 has not been established. Colchicine or levamisole are sometimes effective. Because benzoyl peroxide is a bleach, it will dis- The disorder can be fatal depending on which organ color most fabrics and hair. system is involved; affected eyes and the central ner- Over-the-counter cleansers that contain benzoyl vous system pose the greatest risk. Behcet’s disease peroxide include Fostex 10% Wash (liquid), Fostex is a lifelong disorder that comes and goes. Perma- 10% (bar), Oxy 10 Wash, Pan-Oxyl 5% and Pan- nent remission of symptoms has not been reported. Oxyl 10%. Nonprescription lotions include Acne- 10, Benozyl 5, Benozyl 10, Clearasil 10%, Dry and Clear (5%), Loroxide (5.5%), Oxy 5, Oxy 10, and benign skin cancer See SKIN TUMOR, BENIGN. Vanoxide (5%). Nonprescription creams include Acne-Aid (10%), Clearasil Maximum Strength (10%), Cuticura Acne (5%), Dry and Clear Double benzoic acid A preservative used in skin care Strength, Fostex (10%), and Oxy 10 Cover. Gels products that generally is not considered to be include Clear by Design (2.5%), Del Aqua-5, Del irritating, although it may cause an allergic reac- Aqua-10, Fostex 5%, Fostex 10%, Xerac BP5, and tion in consumers who are sensitive to similar Xerac BP10. chemicals. Side Effects While most people experience some mild burning, benzoyl peroxide An antibacterial agent con- itching or peeling, benzoyl peroxide can produce a sidered to be the most effective nonprescription stronger reaction in some people with very sensi- ACNE treatment, markedly suppressing the bacte- tive skin (especially those with very fair skin). It is rium PROPIONIBACTERIUM ACNES associated with acne. normal to experience a warm or stinging feeling, This extremely effective topical antibacterial agent with some dryness or peeling, but if the skin turns draws peroxide into the pore where it releases oxy- very red, or there is pain, a lot of scaling and swell- gen, killing the bacteria that can aggravate acne. ing, then an adverse reaction has occurred and the Benzoyl also suppresses fatty acid cells that irritate product should be discontinued. pores and helps to unplug blackheads. It is most The stronger the preparation, the greater the effective for patients with infl ammatory acne; by chance of a reaction. Benzoyl peroxide should inhibiting bacteria, it decreases the infl ammation never be applied near the eyes, where it can cause in the skin. swelling and irritation; some patients are also 50 berloque dermatitis sensitive around the nose and mouth. Hands Both AHA and BHA-containing cosmetics are should be washed thoroughly after using the prod- derived from the chemical peels that dermatolo- uct; eyes should never be rubbed with contami- gists and plastic surgeons have used for years to nated fi ngers. help remove undesirable signs of skin aging, such Some studies have reported that benzoyl perox- as discoloration, roughness, and wrinkling. The ide may be carcinogenic, although this conclusion chemicals cause the skin to peel off, revealing a is controversial and inconclusive. fresher-looking layer of skin. Known as chemical exfoliation, the procedure is done in aestheticians’ salons at low concentrations and at higher, more berloque dermatitis See DERMATITIS, BERLOQUE. effective strengths in doctors’ offi ces. Cosmetic manufacturers began to market similar but milder versions of these chemical peels con- bergamot oil See OIL OF BERGAMOT. taining AHAs and BHAs for salon and at-home use around 1989; today, every cosmetic company has AHA and BHA in their products. beta-carotene A plants substance that the body Some in the cosmetic industry have suggested can convert into VITAMIN A; it acts as an antioxidant that AHA and BHA products are more than simple and immune system booster. Some experts suspect cosmetics, coining the term COSMECEUTICAL to it may be possible to shield the body’s immune describe them instead. The U.S. Food and Drug system from harmful UVA rays and reduce the Administration (FDA) has a particular concern risk of skin cancer by supplementing the diet with about them because, unlike traditional cosmetics, beta-carotene. they seem capable of penetrating the skin barrier Most, but not all, beta-carotene in supplements and altering skin function. is synthetic, consisting of only one molecule. Natu- While both AHAs and BHAs act as exfoliants, it ral beta-carotene found in food is made of two has been claimed that BHAs are effective in reduc- molecules. Researchers originally saw no meaning- ing the appearance of fi ne lines and wrinkles and ful difference between natural and synthetic beta- improving overall skin texture, without the occa- carotene, but this view was questioned when the sional irritation associated with the use of AHAs. link between beta-carotene–containing foods and BHA ingredients may be listed as lung cancer prevention was not duplicated in stud- ies using synthetic pills. • SALICYLIC ACID (or related substances, such as Beta-carotene is found in green and orange- salicylate, sodium salicylate, and willow extract) yellow vegetables. The most common beta- • beta hydroxybutanoic acid carotene supplement intake is probably 25,000 IU • tropic acid (15 mg) per day, though some people take as much as 100,000 IU (60 mg) per day. • otrethocanic acid Excessive beta-carotene (more than 100,000 IU, or 60 mg per day) sometimes tints the skin yellow- Today, the most common BHA in cosmetics is sali- orange. Individuals taking beta-carotene for long cylic acid. Rarely, citric acid is also cited as a BHA periods of time should also supplement with VITA- is cosmetic formulations, but more often it is con- MIN E, as beta-carotene may reduce vitamin E sidered an AHA. levels. The safety of salicylic acid used as a cosmetic ingredient has been evaluated by both the cosmetic industry and the FDA. Products containing salicylic beta hydroxy acids A topical exfoliant used acid should either contain a sunscreen or bear (sometimes in combination with ALPHA HYDROXY directions advising consumers to use other sun ACIDS) as ingredients in skin-care products designed protection, according to the COSMETIC INGREDIENT to reduce the signs of aging in the skin. REVIEW (CIR) Expert Panel, the cosmetic industry’s birth control pills 51 independent body for reviewing the safety of cos- risk of disease transmission from the donor of the metic ingredients. material. The long-term safety of salicylic acid in cosmet- Examples of biological implants include bovine ics also is being evaluated in studies initiated by COLLAGEN (ZYDERM), human collagen (Cosmoderm the FDA and sponsored by the National Toxicol- and Cosmoplast) synthetic or naturally derived ogy Program. These government-sponsored stud- HYALURONIC ACID (RESTYLANE and Hylaform), or ies are examining the long-term effects of both acellular dermal grafts (ALLODERM, CYMETRA). glycolic acid (an AHA) and salicylic acid on the skin’s response to ultraviolet (UV) light. These studies have determined that applying glycolic biotin deficiency A lack of this water-soluble vita- acid to the skin can make people more suscep- min important in amino acid metabolism may cause tible to the damaging effects of the sun, including fi ssured lips; red, tender tongue; and reddening sunburn. and dryness of mucosal surfaces. In infants, a lethal Until these safety assessments are completed, form of biotin defi ciency may cause a generalized the FDA advises consumers that similar precau- SEBORRHEIC DERMATITIS or ICHTHYOSIS; a different tions be taken for the use of cosmetics containing form of infant biotin defi ciency may cause diffuse BHAs. Consumers should test any product that reddening, scaling, and crusting at skin junctions contains an AHA or BHA on a small area of skin and mucosal surfaces together with hair loss. before applying it to a large area. Cosmetics with Although rare, biotin defi ciency can occur when these substances that cause skin irritation or pro- raw egg whites are eaten or with tube or injection longed stinging should not be used. Consumers feeding without biotin supplements. should not exceed the recommended applications and avoid using AHA- or BHA-containing products Treatment Options and Outlook on infants and children. The intravenous administration of biotin is an effective treatment for this condition. biologic agents Substances made from a living organism used to prevent, diagnose, or treat dis- birth control pills (the Pill) Contraceptive medi- ease. Scientists have begun to focus on the suc- cations have been linked to a number of skin cessful treatment of skin diseases such as PSORIASIS problems, including ACNE, hair loss, and blotchy and PYODERMA GANGRENOSUM using biologic agents pigmentation. Their use also can be associated with designed to inhibit immune responses that are cen- ERYTHEMA NODOSUM, an infl ammatory skin disease tral to these conditions. characterized by red-purple swellings. Biologic agents include alefacept, etanercept, Many varieties of the birth control pill (such and infl iximab. These agents bind to and inhibit as Norlestrin, Norinyl, Ovral, and Loestrin) can a molecule central to the immune response that aggravate acne and can also increased sensitivity drives psoriasis and other infl ammatory skin dis- to the sun, resulting in swelling of skin that has eases. They hold promise for revolutionizing the been exposed to the ultraviolet rays. Because of treatment of skin diseases. hormonal changes, hair may be lost while taking the Pill or after the Pill has been stopped. Women who develop skin problems while using birth con- biological implants A type of SKIN FILLER material trol pills may be able to have their prescriptions used to correct wrinkles, soft tissue defects, and changed to a different type of pill. depressed scars that is readily available in a variety Pills with slightly higher estrogen levels, such as of shapes, sizes, and quantity, and are less likely Demulen and others with 50 mg of estrogen, may to become infected or displaced than synthetics. actually improve acne. Disadvantages to this type of skin fi ller include the Between 5 and 30 percent of women taking possibility of allergic reactions and the theoretical the Pill develop a blotchy, heightened skin color 52 birthmarks on their face, regardless of whether their prescrip- Treatment Options and Outlook tion contained primarily estrogen or progesterone. Because fl ies and mosquitoes can spread disease, This darkening, called melasma or CHLOASMA, is the bite area should be washed with soap and often seen during the last trimester of pregnancy, water followed with an antiseptic. A nonprescrip- although it also appears in women who are neither tion antihistamine, CALAMINE lotion, or ice packs pregnant nor taking birth control pills. Exposure to can control itching. Itching also can be controlled the sun will make this darkening worse. with a paste to spread over the bite made out of: When the Pill is taken for longer periods of time salt and water; baking soda (1 tsp. in a glass of and at higher dosages, skin changes are likely to be water, place on bite for 20 minutes); or epsom salts noticeable. (1 Tbs. in 1 quart of hot water).

Risk Factors and Preventive Measures birthmarks An area of discolored skin present Many mosquitoes and biting insects are especially at birth; the most common birthmarks are MOLES likely to bite around dusk and dawn. It is important (nevi), which are malformations of pigment cells. to apply repellent during these times. However, in STRAWBERRY BIRTHMARKS are bright red, spongy many parts of the country, there are mosquitoes and protuberant; PORT-WINE STAINS are purple-red, that also bite during the day. The safest decision fl at and often cover large areas. Both strawberry is to apply repellent whenever individuals are marks and port-wine stains are malformations of outdoors. blood vessels. Consumers should follow the directions on the True strawberry (superfi cial) HEMANGIOMAS all repellent to determine how frequently it needs to disappear by age seven, although they may leave be reapplied. Sweating, perspiration, or getting wet an unsightly scar. may mean that it needs to be reapplied more often. Port-wine stains never go away. In a few cases If a person is not being bitten, it is not necessary to (referred to as STURGE-WEBER SYNDROME) port- reapply repellent. wine stains are associated with abnormalities in the Repellents containing a higher concentration of blood vessels of the brain. active ingredient (such as DEET) provide longer- lasting protection. DEET (NIN-diethyl-m-toluamide) Treatment Options and Outlook is the most effective of all bug repellents. A product Unattractive moles can be removed at any time containing 23.8 percent DEET provides an average from late childhood through adulthood. Port-wine of fi ve hours of protection; 20 percent DEET pro- stains can be lightened signifi cantly using LASER vides almost four hours of protection; 6.65 percent treatment. DEET provides almost two hours of protections; and The PULSED DYE LASER is highly effective at light- 4.75 percent DEET and 2 percent soybean oil are ening port-wine stains; treatment should be started both able to provide roughly one and a half hours within the fi rst few weeks of life. of protection. Consumers should choose a repellant that provides protection for the amount of time that they will be outdoors. A higher percentage of bisulfites A substance contained in the mildest DEET should be used if the person will be outdoors permanent waving solution used for body waves for several hours. It may be used on children but and color-treated hair. should not be applied to infants. It should be kept out of eyes. New preparations combine SUNSCREEN and a bug repellent in one cream. bites and infestations Fly and mosquito bites may cause swelling and ITCHING for several days and may lead to infection if sores are scratched blackhead A dark semisolid plug of greasy SEBUM open. blocking the outlet of an oil-producing gland in bleaching creams 53

Cross Section of Blackhead substance because of its toxicity and the incidence of allergic reactions. The agent HYDROQUINONE can sometimes be suc- cessful as it both helps to prevent new melanin production and bleaches existing pigment. It may be purchased over the counter in concentrations of 2 percent or less. Higher prescriptions require a Sebum Plug prescription. Hydroquinone may be prescribed in combination with RETINOIC ACID (to enhance pene- Intact Stratum tration) and a CORTICOSTEROID (to reduce irritation). Germinativum It may require several months’ treatment before a good response is achieved. Rarely, hydroquinone Sebaceous Gland can trigger an allergic response or irritation in some people or produce a mottled appearance. Monobenzoyl ether of hydroquinone (Beno- quin) should never be used to bleach the skin Hair because it destroys melanocytes and leaves perma- Follicle nent disfi guring white spots (it should only be used for patients with extensive VITILIGO in an effort to bleach their remaining unaffected skin so that they will be uniformly colored). Prescription products containing hydroquinone the skin, most commonly found on the face, chest, include Eldopaque Cream, eldoquin, Eldopaque back, and shoulders. It is associated with increased Forte (4 percent hydroquinone), Solaquin Forte (4 sebaceous gland activity in adolescents, and often percent hydroquinone, PABA ester, benzophene), appears as part of ACNE. The black color is not dirt, Lustra (4 percent hydroquinone and glycolic acid), but a reaction that occurs when the plug mixes Glyquin (4 percent hydroquinone and glycolic with air and skin pigment. acid), Lustra AF (4 percent hydroquinone, glycolic acid, and sunscreen), Alustra (4 percent hydro- Treatment Options and Outlook quinone and retinol), and Melanex (3 percent SALICYLIC ACID and Retin-A are particularly effec- hydroquinone). tive treatments for blackheads, but BENZOYL PEROX- Nonprescription products include Esoterica IDE also may be effective. Blackheads may be gently Cream, Altra HCQ Kit (4 percent hydroquinone, squeezed; cosmetologists also may remove them. 1 percent hydrocortisone) and Ambi (2 percent See also ACNE, TREATMENT FOR. hydroquinone, PABA ester). Combined medications include hydroquinone 4 percent and salicylic acid 2 percent; hydroqui- bleaching creams Nonprescription cosmetic none 2 percent or 4 percent, hydrocortisone 2 bleaching creams do not change the color of the percent, and tretinoin cream 0.05 percent applied skin that has darkened as a result of hormonal sequentially; hydroquinone 4 percent, tretinoin 0.1 imbalances, chemicals, sun exposure, and so on. percent, and dexamethasone 0.1 percent applied Instead, they prevent the formation of MELANIN. sequentially. A variety of substances has been used in the Trichloroacetic acid may be effective in light- past to bleach the skin, including lemon juice, tea, skinned people, but it should not be used on black and salicylic acid. AMMONIATED MERCURY was used skin. This highly caustic agent must be used with until 1974, when the U.S. Food and Drug Admin- great caution to avoid instant tissue necrosis and istration barred the sale of creams containing this permanent SCARs. In mild concentrations, it can be 54 bleb painted on pigmented lesions, which produces a rake without gloves, or as a result of wearing tight mild lightening. The best concentration of this acid shoes). There are a number of skin diseases that is one which produces lightening without excessive also can cause blisters, including ECZEMA, IMPETIGO, injury to the skin. EPIDERMOLYSIS BULLOSA, PORPHYRIA, ERYTHEMA MUL- Alternatively, gentle freezing with LIQUID NITRO- TIFORME, and the bullous diseases of PEMPHIGOID, GEN to treat localized colored spots may be effective PEMPHIGUS, and DERMATITIS HERPETIFORMIS. by decreasing the amount of color. Melanocytes are In addition, small blisters develop in the early particularly sensitive to destruction using this tech- stages of many viral infections, including CHICKEN nique. This process does not work in those with POX, SHINGLES, and HERPES SIMPLEX. These blisters dark or black skin, however, because of the risk of contain infectious particles capable of spreading permanent depigmentation. the infection.

Treatment Options and Outlook bleb A tiny blister usually formed by injecting a A blister should not be disturbed, but left to heal small amount of fl uid under the outer layer of the on its own. It may be pierced at the edge using a skin, such as in a tuberculin test. sterile needle, allowing the fl uid to slowly seep out. A blister should not to be unroofed, as the roof protects against infection. Left intact even after the bleomycin An antibiotic obtained from a soil fun- blister has been drained, the skin fl ap will act as a gus used to treat certain cancers, such as KAPOSI’S type of Band-aid; it will eventually harden and fall SARCOMA and WARTS that have not responded to off by itself. However, patients with large, trouble- other treatment. some or unexplained blisters should seek medical advice; some experts believe that a large blister Side Effects on a weight-bearing area almost always has to be Painful injections, localized swelling and the devel- pierced. opment of a bleeding scab, bone marrow suppres- Otherwise, a patient should try applying a mole- sion, or anemia. skin pad (available at drug stores) cut to resemble a doughnut with the blister in the middle; the mole- skin will absorb the friction of daily activity. blepharoplasty See EYELID LIFT. Triple antibiotics (such as Neosporin) may elimi- nate bacterial contamination, whereas iodine or camphor-phenol slow down healing. blister A raised oval or round collection of fl uid within or beneath the outer layer of the skin. Blis- Risk Factors and Preventive Measures ters larger than a half inch in diameter are some- People should always wear socks with shoes, and times called bullae; small blisters are also called gloves on hands when working with tools. Feet VESICLES. Blisters that have been inadvertently should be powdered when wearing new shoes. If pierced may be susceptible to infection. If there an individual is worried about getting blistered feet, is redness, swelling, heat, increased pain, or the blister-prone areas can be coated with PETROLEUM drainage has an odor or is not clear, then the blister JELLY or DIAPER RASH ointment (such as A&D oint- has become infected. ment) to cut down friction. A blister appears after minor skin damage when While there is controversy over the kind of fl uid leaks from blood vessels in underlying skin. sock material that best prevents blisters, current The fl uid is usually sterile, and the blister provides research suggests that acrylic spun fi bers may actu- valuable protection to the damaged tissue. ally be better than cotton in the presence of water. Blisters often appear after burns, SUNBURN, and Wearing two sets of different materials on each foot friction (such as damage to hands from using a with properly fi tted shoes helps prevent blistering. Bloom’s syndrome 55 blistering disorders Blistering (or bullous) dis- laries that connect the arteries to the veins. In the eases are not common, but they are very dramatic embryo, certain cells are responsible for stimulating and can be quite serious. Many of these diseases blood vessel development. The blood vessel net- are triggered by problems in the immune system. work is the fi rst organ to begin developing in the Some are inherited; these can be diagnosed during embryo, which continues until adulthood. pregnancy. Some blood vessel disorders are the result of the Among the blistering disorders are PEMPHIGUS, overproduction of blood vessel cells. For example, DERMATITIS HERPETIFORMIS, and the PEMPHIGOID a HEMANGIOMA that often appears soon after birth group (bullous pemphigoid, HERPES GESTATIO- goes through a period of rapid growth in which the NIS, cicatricial pemphigoid, epidermolysis bullosa blood vessel cells multiply too much. As the tumor acquisita and linear IgA dermatosis). shrinks and the skin eventually returns to a near- Treatment for these disorders varies according to normal appearance, the cells gradually die off. cause and severity. Creams are sometimes effective, Other blood vessel disorders occur from mal- but sometimes systemic treatment is needed. formations between the fourth and 10th week of pregnancy. Malformations of blood vessels, such as PORT- Bloch-Sulzberger syndrome A disorder of pigmen- WINE STAINS, are usually present at birth, although tation (also known as incontinentia pigmenti) probably some appear years later. They tend to grow along transmitted as an X-linked dominant disorder that is with the patient, although periods of more rapid usually lethal to male fetuses, and that occurs in development can occur. baby girls of all races who carry the trait. It is some- During pregnancy, hormonal infl uences can times associated with multiple defects of the central cause blood vessel changes. As a result, some nervous system within the fi rst month of life. Most women develop many tiny dilated blood vessels affected individuals have numerous skin symptoms, in the skin’s surface layer (spider ANGIOMAS). They as well as malformations of the eyes, teeth, bones, typically blanch under pressure; when released, the nails, heart, central nervous system, and hair. Men- blood returns quickly. Many of these blood vessels tal defi ciency is usually associated. The syndrome is fade away after pregnancy, when hormone levels divided into two forms: incontinentia pigmenti type return to normal. If they do not, laser treatment is I and type II. Type II is lethal in males. available to eradicate them. Lasers have revolution- ized the treatment of many blood vessel growths. Symptoms and Diagnostic Path Streaks of red papules or vesicles over the arms, legs and trunk in a swirled or marbled pattern. Bloom’s syndrome This inherited syndrome is Over a period of weeks, the swirls evolve into characterized by an intense sensitivity to light papules that eventually heal, leaving a brown-gray beginning in infancy, which causes reddening, blis- hyperpigmented discoloration. tering, and eventually persistent areas of reddened skin and TELANGIECTASIA on the face and hands. At Treatment Options and Outlook birth, there is proportionate dwarfi sm; adults are There is no effective treatment; the child rapidly short, with normal intelligence and sexual devel- passes through the stages of the disease, and the opment, although males often have small testes. lesions are usually gone by the age of two. The The condition is found most often among Ash- unusual pigmentation usually fades by age 20. kenazi Jewish men originally from southeastern Poland and northwestern Ukraine. While Bloom’s syndrome is characterized by many chromosomal blood vessel disorders and the skin The blood abnormalities, the basic genetic defect is not supply in the skin is delivered by an interconnect- known. More than 100 cases have been reported in ing network of small arteries, veins, and tiny capil- the United States. 56 blush

Treatment Options and Outlook because they are accustomed to their own incom- Bloom’s syndrome has no specifi c treatment. Red- petence or because they do not care about the rules ness and photosensitivity, and resistance to infec- of behavior. tions, improve with age. Various types of leukemia develop at about age 22; patients who survive beyond age 22 typically develop solid tumors at blusher A type of colored cosmetic designed to an average age of 35 years. Fortunately, these give the face a healthy-looking glow. Blushers come tumors are sensitive to chemotherapy and radio- in four basic types: powder, cream, liquid, and gel. therapy. Infection gradually improves with age. Powder blushers have a soft fi nish and can be used There is a higher risk of premature death in the to produce as much or as little color as desired. Pow- 20s or 30 because of secondary infection due to dered products work well on any skin characteristic, malignancies. especially for those with oily or combination skin. Because of the sensitivity to sunlight, the risk Powder blushers should be applied with a fl uffy of SKIN CANCER increases signifi cantly with this brush over foundation or directly on bare skin. syndrome. Cream blushers are good choices for those with normal or dry skin; they camoufl age fi ne lines Risk Factors and Preventive Measures and wrinkles better than powder products. How- Topical SUNSCREENS will prevent the SUNBURN reac- ever, creams must be applied carefully or they tion and decrease sun damage. will streak. A bit of moisturizer is blended into the blusher, then smoothed onto cheeks using a moist- ened cosmetic sponge for more control. It should blush An involuntary reaction to unwanted atten- be applied in a soft arc along the cheekbones, tion, or embarrassment, that sends blood rushing blending edges until there is no obvious line. It to the face, neck, upper chest, and ears. When a should never be applied in a circle, because the person is embarrassed the body experiences this as color will look artifi cial. stress, and involuntarily heats up. As a result, the Liquid blushes (also called “color rubs”) are sheer hypothalamus (the body’s temperature regulator) and can be used to color cheeks or as an all-over directs heat to the face, the site of the most capil- facial tint. They work best for dry or normal skin, laries (tiny blood vessels that let heat escape). The where they should be blended onto the skin with result is a red blush. fi ngertips, working quickly for even coverage and Some women during menopause also experi- a sheer fi nish. ence blushing due to changes in hormonal activ- Gel blushers are more transparent than liq- ity; facial fl ushing also occurs with the carcinoid uid products, and work best on normal or dry syndrome (a rare condition characterized by facial skin. They must be applied gently with fi ngertips fl ush, diarrhea, and wheezing caused by an intesti- because they streak easily; they also can be used nal or lung tumor). for total facial tint. Four out of fi ve people have the tendency to For an idea of where to apply blusher, the con- blush, but how easily this occurs also depends on sumer should place index and middle fi ngers in a person’s genetic makeup. One way to stop a tell- a “v” formation over the cheekbones. Individuals tale blush is to sip cold water to head off the body’s should avoid applying too much blusher close to response to heat. the nose or too close to the eyes. Blusher too high This nonverbal sign of embarrassment is under- or too low on the cheek can look unnatural; it is stood in all human cultures. Studies have shown always easier to add more than take some away. that those who appear embarrassed often appear to The color of blusher should complement skin be more likeable. tone. Fair-skinned blondes look best with beige- Researchers conclude that those who do not pink to coral shades; fair-skinned brunettes are show signs of embarrassment after a blunder send better in rosy to pale pink shades. Olive skin looks a disturbing message—either they are unfazed best with reddish bronze, soft rose, or coral shades, borax 57 and black skin is best with a sheer tint of soft pink, until it erupts, drains and fades away, or it can be pink-mauve, or blue-red (dark mauve blush tends reabsorbed by the body. Recurrent boils may occur to emphasize ashiness). in people with known or unrecognized diabetes mellitus, or other diseases involving lowered body resistance. Bockhart’s impetigo See IMPETIGO, BOCKHART’S. Signs of a spreading infection include general- ized symptoms of fever and chills, swelling lymph nodes, or red lines radiating from the boil. boil An infl amed PUS-fi lled section of skin (usu- ally an infected HAIR FOLLICLE) found often on the Treatment Options and Outlook back of the neck or moist areas such as the armpits Bacteria from a boil may fi nd its way into the and groin. A large boil is called a CARBUNCLE. blood, causing blood poisoning; for this reason, Boils are usually caused by infection with the doctors advise against squeezing boils that appear bacterium Staphylococcus aureus, which invades the around the lips or nose, since the infection can be body through a break in the skin, where it infects a carried to the brain. Instead, patients should apply blocked oil gland or hair follicle. When the body’s a hot compress for 20 minutes every two hours to immune system triggers the production of white relieve discomfort and hasten drainage and heal- blood cells to kill the germs, the resulting infl am- ing. The compress should be changed for a new hot mation produces pus. one every fi ve minutes during the 20-minute inter- vals. After treating a boil, hands should be washed Symptoms and Diagnostic Path thoroughly before cooking to guard against staph A boil begins with a red, painful lump that swells infection getting into food. as it fi lls with pus, until it becomes rounded with a It may take up to a week for the boil to break yellowish tip. The boil may either continue to grow on its own. To further reduce the chance of infec- tion, patients should shower (not bathe). If the boil is large and painful, a physician may prescribe Cross Section of Boil an antibiotic or open the boil with a sterile needle to drain the pus. Occasionally, large boils must be lanced with a surgical knife; this is usually done using a local anesthetic.

Risk Factors and Preventive Measures For patients prone to boils, some experts recom- mend washing the skin with an antiseptic soap to Pus prevent infections.

Infl ammatior borate An abrasive sometimes used to remove Blocked superfi cial ACNE lesions, although it probably is not Hair Follicle effective since acne is deeply rooted in the follicles, according to the U.S. Food and Drug Administra- tion. The PDA ruled it had not received enough clinical evidence to support the effectiveness of BORIC ACID and sodium borate as acne treatments.

borax A white odorless mineral that is a mild Nerve cleanser and antiseptic. It is most often used as an 58 boric acid emulsifi er in COLD CREAM, but it also is included in lines between the eyebrows, it also can be used to mouthwashes, vanishing creams, bath salts, eye lessen the horizontal wrinkles in the middle of the lotions, cleansing lotions, and scalp lotions. It has forehead. When Botox is administered by a trained not been found to cause allergic reactions. medical professional directly into an overactive muscle, it interferes with the release of a neu- rotransmitter that causes muscles to contract. This boric acid An antiseptic, bactericide, and fungi- paralyzes the underlying muscles so the skin is not cide prepared from sulfuric acid and natural BORAX pulled down. As the relaxed muscles release the that should not be ingested or inhaled, and should skin, the wrinkles slowly disappear. After several not be used on babies. Boric acid had been used weeks, the muscles beneath the skin shrink and in talcum powders in the past, and was once used start to waste away. Botulinum toxin has revo- as a dressing for WOUNDs and BURNS. However, lutionized the treatment of aging skin, especially after a number of people died following exces- frown lines. Since botulinum toxin decreases the sive absorption of boric acid in extensive wounds, patient’s ability to frown or squint, it also safely borax fell out of favor as a salve for burns. Borax and effectively prevents the progressive worsening is no longer included in the manufacture of baby of these lines over time. products. Botox was fi rst used (and has been approved by the U.S. Food and Drug Administration [FDA]) to treat lazy eye (strabismus) and uncontrolled eye Botox (botulinum A toxin) A purifi ed form of the blinking and neck spasm. It was approved in 2002 toxin that causes botulism, now used to reduce by the FDA for cosmetic use. facial lines in people 18 to 65. Botox is the brand Botox is the fi rst botulinum toxin approved name for a purifi ed form of the deadly toxin botu- for marketing in the United States. Because of its linum Type A, which is produced by a bacterium safety, low cost, and simplicity of use, it is one of called Clostridium botulinum—the same one that the fastest-growing new procedures for treating causes botulism. The product called Botox contains wrinkles. Myobloc (botulinum exotoxin B) was only tiny quantities of the isolated toxin, with no recently approved for eye and neck spasm and is intact bacteria. This means there is no chance of now being used to treat facial frown lines. getting botulism from the injections. Botulinum toxin has also been successfully When carefully injected in very low doses, used before and after skin resurfacing procedures, botulinum toxin is a modern tool that can reduce including lasers, chemical peels, and DERMABRA- the signs of aging. When a person frowns, the tis- SION, to maintain good results. When injected sue between the eyebrows is gathered into a fold. prior to the procedure, botulinum toxin allows Eventually, over many years, this muscle motion smooth healing of resurfacing by preventing move- causes a chronic furrow. Tiny injections of Botox ment. Injected after resurfacing, botulinum toxin can paralyze certain facial muscles beneath the prevents the reappearance of movement-induced skin, wiping away forehead creases and wrinkles. wrinkles. Injecting botulinum toxin into the skin is a quick Botulinum toxin has also been approved to treat and easy almost painless offi ce procedure that takes individuals who suffer from HYPERHIDROSIS (exces- less than 30 minutes. sive sweating) not managed by topical products. Botulinum toxin can be used to decrease sweating Procedure on the palms or soles, underarms, or forehead by Injecting Botox is a very different way of removing injecting the toxin into the affected areas. Once wrinkles than has been used in the past. Unlike injected, botulinum toxin paralyzes the sweat COLLAGEN or fat injections that work by fi lling in glands of the skin that are responsible for excessive the furrows of a person’s face, Botox weakens the perspiration. muscles above the brow and removes wrinkles A single treatment of botulinum toxin injected naturally. While it is most effective for the frown directly into the affected skin can provide up to brown recluse spider bites 59 six months of relief to patients who have tried cised males); they occur less frequently on the antiperspirants, oral medications, and even surgi- vulva. These lesions are bright red with a velvety, cal approaches to control severe sweating. These glistening surface. While microscopically identical procedures can be performed in an offi ce environ- to Bowen’s disease, these lesions have a higher ment without anesthesia and can be repeated once rate of malignant transformation and the result- or twice a year to maintain dryness. ing squamous cell carcinomas are more aggres- sive than those arising from ordinary Bowen’s Risks and Complications disease. In small doses, there is no scarring and no side effects. However, if Botox migrates from the injec- Treatment Options and Outlook tion site it can cause a droop of the eyebrow or The condition is treated by surgically removing the upper eyelid for a week or two. For this reason, diseased patch of skin. Once removed, these skin patients should not massage the injection site for conditions do not return. The most accurate and 12 hours after treatment. Allergy to Botox is very tissue-sparing form of excision is Mohs’ surgery, rare, and no serious side effects have been reported rather than the vertical sections of standard surgi- in thousands of patients in 10 years. cal excision.

botulinum A toxin See BOTOX. breast enlargement See MAMMOPLASTY.

bouba See YAWS. breast lift See MAMMOPLASTY.

Bowen’s disease A precancerous condition also breast reduction See MAMMOPLASTY. known as SQUAMOUS CELL CANCER in situ, causing a scaling, reddish-pink slightly raised growth usu- ally on the face or hands. The disease is more often bromhidrosis A condition caused by sweat that found among men with fair skin; chronic sunlight has become foul-smelling because of bacterial exposure is the primary cause. Chronic ingestion decomposition. of inorganic arsenicals also causes Bowen’s disease, See also SWEAT GLANDS. although this is rare today. About one-third of these patients have multiple lesions. bromoderma A pustular skin eruption due to Symptoms and Diagnostic Path ingestion of bromides. Bromides, once prescribed Squamous cell cancers that occur as a result of as a sedative, are no longer administered because of Bowen’s disease are usually more aggressive than their unpleasant side effects—including ACNE. The those from ACTINIC KERATOSES. It is not uncommon acne fades once bromides are discontinued. for the cancer developing from Bowen’s disease to spread to the lymph nodes. In addition, some stud- ies suggest that patients with Bowen’s disease may brown recluse spider bites The bite of these spi- develop other premalignant and malignant tumors, ders of the Loxosceles family cause severe skin tissue such as actinic keratoses, BASAL CELL CARCINOMAS, death and extensive sloughing of the skin at the and adnexal carcinomas. site of the bite, which also may be accompanied by Bowen’s disease lesions on mucosal surfaces generalized symptoms. have a different appearance and biologic poten- The United States species of this deadly spider, tial; when they occur on the penis they are called L. reclusa (or the Missouri brown spider), lives in erythroplasia of Queyrat (usually in uncircum- about half of the states, although it is most often 60 bruise found in the central and south-central area of the Treatment Options and Outlook country. Ounce for ounce, the venom of this spi- If a brown recluse bite is suspected, a physician der is more deadly than that of many poisonous should be consulted at once. There is no specifi c snakes. The venom of the female is more deadly antivenin, although antivenin for other species of than that of the male. brown spiders of South America could give protec- It is believed that the spider was mistakenly tion. Small bites may require only cold compresses, imported to this country in fruit crates and vegeta- elevation, painkillers, and a tetanus shot. bles within the last 50 years; since then it has been DAPSONE may prevent tissue death, and although making its way steadily north and west. The secre- CORTICOSTEROIDS are sometimes used for larger tive spiders get their name from their fondness for lesions, their usefulness has not been proven. dark, secret storage spaces, under boxes and in Antibiotics may prevent infection. In addition, closets. While these spiders are not aggressive and antihistamines and muscle relaxants may provide will try to escape when cornered, if trapped they some relief. will bite. Its brown to fawn-colored body is about Exchange transfusions in which nearly all the a ½ inch long, with a dark brown violin-shaped patient’s blood is replaced by a donor’s blood may marking. be attempted. Immediate excision of the bite area may be the Symptoms and Diagnostic Path only way to prevent the massive necrosis caused Reaction to the brown recluse bite varies consider- by this spider, although not all experts agree on ably from one person to the next, depending on this treatment. Most physicians will not touch the the amount of venom injected, the patient’s age, lesion until all the destruction has occurred, which and health. The bite can cause a skin injury rang- may not happen until 40 weeks after the bite. ing from a small papule to a huge necrotic ulcer, Skin grafts may be necessary to heal the ulcer. together with a systemic reaction. Severe systemic reactions and death occur most often in children, but even this is rare. bruise A deep blue or black discoloration on the The bite of this spider causes little pain at fi rst, skin following trauma, caused by bleeding under but within eight hours the pain becomes severe, the skin. Initially the bruise looks blue or black; as and the area of the bite will get red. The local skin the hemoglobin begins to break down, the bruise reaction may be minor, with mild ITCHING and a turns yellow. While most bruises occur after a plaque or a small area of dead tissue that heals by bump, they may also follow a period of heavy exer- itself within fi ve days. cise; exercise sometimes causes tiny tears in blood However, brown recluse spider venom contains vessels below the skin, allowing blood to seep out. a substance that is very destructive to tissue; in Easy bruising also may be a sign of disease, espe- more severe cases, a blue-gray halo appears at the cially blood disorders such as anemia. In addition, bite site, followed within 18 hours by a small blis- some drugs (such as aspirin and other blood thin- ter and surrounding area of redness and swelling. ners) may lead to increased bruising; other drugs, Eventually, the blister ruptures, and within a week such as anti-infl ammatory agents, antidepressants, the skin cells in the area begin to die, creating a or asthma drugs may interfere with blood clotting thick black scar on the base that slowly separates under the skin. AIDS can cause purplish bumps over several weeks. In a small number of patients; that seem to be bruises that do not fade. Substance the ulcer does not heal for months. abusers also may fi nd they have an increased sus- The bite can also cause systemic reactions includ- ceptibility to bruising. ing fever, chills, weakness, nausea and vomiting, Some studies suggest that patients who lack joint pain, and a generalized rash. In fatal bites, the vitamin C in their diets tend to bruise more eas- patient usually dies within the fi rst 48 hours as a ily and their wounds heal more slowly. This may result of kidney failure. be due to the fact that VITAMIN C helps build sup- bubonic plague 61 portive COLLAGEN around blood vessels in the skin, bubonic plague The most common form of which helps protect the vessels from rupture. For PLAGUE, also known as “The Black Death” or black those who bruise easily, some experts suggest 500 plague, because of the black spots it produced on mg of vitamin C three times a day to help build the skin. It is also characterized by the appearance collagen (although vitamin C is not toxic, patients of a swollen lymph node (BUBO) in the groin or taking high doses of vitamin C should consult with armpit early in the illness. their physician). Bubonic plague is primarily transmitted from rodents to humans by fl ea bites. Fleas become Treatment Options and Outlook infected by feeding on rodents, such as the chip- The discoloration of a bruise can be minimized munks, prairie dogs, ground squirrels, mice, and by immediately applying cold, to keep down the other mammals that are infected with the bacteria swelling and constrict blood vessels, which helps Yersinia pestis. Fleas transmit the plague bacteria to to decrease the internal bleeding. An ice pack humans and other mammals during the feeding should be applied at 15-minute intervals immedi- process. The plague bacteria are maintained in the ately after the bump for the fi rst 24 to 48 hours. blood systems of rodents. After the bite, the bac- Patients without access to ice can use a clean teria spread through the body to the lymph nodes, cold soda can, applying it for fi ve to 10 minutes which became painful and enlarged. In the past, the every 15 minutes. After 24 hours, heat should death rate was 90 percent. In the worst case, the be used to dilate the blood vessels and improve lungs became infected and the pneumonic form was circulation. spread from person to person by coughing, sneezing, or simply talking. Typically, the time of infection Risk Factors and Preventive Measures to death was less than one week. The three major Because vitamin C helps build up supportive tissue epidemics of the black plague in the sixth, 14th, and around blood vessels, those who bruise easily may 17th centuries killed more than 137 million people. fi nd that 500 mg of vitamin C taken three times a day to build collagen may be effective. Although Symptoms and Diagnostic Path vitamin C is not considered to be toxic, experts Bubonic plague is characterized by enlarged, ten- advise patients to get their physician’s approval der lymph nodes, fever, chills, and prostration. It before using high doses of vitamin C. is fatal between 50 and 90 percent of the time if untreated; it is fatal 15 percent of the time when properly diagnosed and treated. bubble bath Detergent cleansers containing A few cases of bubonic plague still occur through- ingredients capable of making bathwater foam out the United States. can be irritating to mucous membranes and the In the United States, the last urban plague epi- skin if used in too great a concentration, especially demic occurred in Los Angeles in 1924–25. Since in people with dry skin or ECZEMA, because these then, human plague in the United States has detergents tend to dry out the skin. Consumers occurred as mostly scattered cases in rural areas should swirl the bubble bath throughout the water, (an average of 10 to 15 persons each year). In and use a moisturizer after the bath. The drying or North America, plague is found in certain animals irritating effect of bubble bath can be prevented by and their fl eas from the Pacifi c Coast to the Great adding bath oil (such as Nivea oil or Lubriderm oil) Plains, and from southwestern Canada to Mexico. to the bath water. Most human cases in the United States occur in two regions—northern New Mexico, northern Arizona, and southern Colorado; and California, bubo A swollen and infl amed lymph node (par- southern Oregon, and far western Nevada. ticularly in the axilla or groin) due to BUBONIC In the United States, people at risk are those PLAGUE, tuberculosis, or SYPHILIS. exposed to rodent fl eas, wild rodents, or other 62 bulla susceptible animals in western states. The highest Severity of Burns rates occur among Native Americans (especially The severity of a burn depends on two factors: how Navajo); other high-risk groups include hunters; deep the tissue destruction has penetrated, and the veterinarians, and pet owners handling infected amount of body surface that has been affected. cats; or campers or hikers entering areas with out- Burn recovery is also infl uenced by the age and breaks of animal plague. general health of the victim, the location of the Plague also exists in Africa, Asia, and South burn and any other associated injuries. America. Globally, the World Health Organization Traditionally, physicians have characterized reports 1,000 to 3,000 cases of plague every year. burns as fi rst-, second-, or third-degree, depend- ing on the depth of skin damage. By accurately Treatment Options and Outlook estimating the extent of damage, the physician can Today, modern antibiotics are effective against best determine the appropriate treatment. plague, but if an infected person is not treated First-degree burns This type of minor burn promptly, the disease is likely to cause severe ill- affects only the EPIDERMIS (top layer of skin), caus- ness or death. ing reddening but no blisters or swelling. Typically, pain ebbs within 48 to 72 hours, and the burn heals quickly without scars, although the damaged bulla A large fl uid-fi lled BLISTER, usually two cen- skin may peel off in a day or two. A sunburn is an timeter or more in diameter. example of a fi rst-degree burn. Second-degree burns This type of burn destroys the skin on a deeper level, creating redness and burns Burn injuries have become much more blisters; the deeper the burn, the more blisters, common in recent years, and are now considered which increase in size within a few hours after the a health care problem more serious than was the injury. However, some of the DERMIS (deep layer polio epidemic at its peak. In the past several years of the skin) remains, so that this type of burn can the medical profession has revolutionized under- usually heal without scarring as long as there has standing of problems associated with burns. been no accompanying infection. Second-degree In the 1950s there were fewer than 10 hospitals burns may be extremely painful. How well a sec- in the United States that specialized in burns. Since ond-degree burn heals depends on the amount of that time, there has been signifi cant advancement skin that has been damaged. in understanding the problem of burn injuries, and there are now about 200 special burn care centers in the United States. Every year, about 2.4 million Americans are Degree of Burn burned or scalded badly enough to require medi- cal care; about 75,000 are hospitalized. This type of injury is most common among children and Hair the elderly and are usually due to preventable Epidermis First accidents in the home. Because the skin is a living Second tissue, temperatures that even briefl y reach 120° F Dermis will destroy its cells. Third Burns can be caused by contact with hot sub- stances, fl ames, chemicals, radiation (in sunlight, X-rays, or ionizing radiation). While most accidental Sweat Gland burns are visible almost immediately after the acci- dent, burns from SUNBURN may appear several hours to a day later. It may be 10 to 30 days before the full Subcutaneous Layer effects of ionizing X-ray irradiation burns appear. burns 63

However, in very deep second-degree burns, the the least resistance. Bone offers the most resistance healed skin may resemble scars from a third-degree to electrical current, followed in descending order burn. These deeper burns take longer to heal— by fat, tendon, skin, muscle, blood, and nerve. The often up to a month or more—and the healing top path the current takes determines whether the vic- skin layer is extremely fragile. In fact, some of the tim will survive, since current passing through the worst burn scars are caused by these very serious heart or the brainstem will result in almost instan- second-degree burns. taneous death from a disturbed heart rhythm. Third-degree burns This is the most serious As current passes through muscle, it can set off type of burn, which destroys all the layers of the severe spasms that can fracture or dislocate a bone. skin. If the burn is very deep, muscles and bones Although bone does not conduct the current well, may also be exposed. The affected area will look it stores the heat from the electricity and can dam- white or charred, and even if the burned area is age surrounding muscles. only small, it will require special treatment and Electrothermal (fl ash or arc) burns are heat skin grafts to help prevent serious scarring. injuries to the skin that occur when high-tension In this type of burn, there is no pain because the electrical current touches the skin, causing intense, pain receptors have been destroyed along with the deep damage. Damage is severe because the arc rest of the dermis and blood vessels, sweat glands, carries temperature of about 2,500° C—hot enough sebaceous glands, and hair follicles. Fluid loss and to melt bone. metabolic problems in these injuries are profound. Skin at both the entry and exit of the current These burns always heal with scarring. Exten- is usually gray, yellow, and depressed; there may sive third-degree burns require aggressive treat- be some charring. All of these wounds must be ment in a hospital burn unit, and the death rate is debrided. signifi cant. Fourth-degree burns Occasionally, burns even Extent of Burn deeper than a full thickness of the skin occur, such When a health care worker estimates a burned as when a part of the body is trapped in fl ame, or patient’s injuries in a percentage (“a burn over 60 in an electrical burn. These deep burns enter the percent of the body,” for example) the percentage muscle and bone and are also called “black” or is not simply a guess. Health care workers use a “char” burns (because of the typical color of the “rule of nines” to estimate the amount of body area burn). If a fourth-degree burn involves more than affected by a burn. The percentage fi gure is com- a very small area of the body, the prognosis is very puted by dividing the body into sections: 9 percent grave, since these deep burns can release toxic to the head and neck, 9 percent to each arm, 18 materials into the bloodstream. If the burn involves percent to each foot and leg, and 18 percent each a small area, it should be cut away down to healthy to the front and back of the trunk. The remaining tissue; a charred large area on an extremity usually 1 percent makes up the perineum (the region of requires amputation. the body between the anus and the urethral open- Electrical burns Electrical accidents can cause ing). This rule is more accurate for adults, but less several different types of burns, including fl ame reliable in children, whose body proportions are burns caused by ignited clothing, electrical current different. injury, or electrothermal burns from arcing cur- rent. Sometimes all three types of burns will be Effects of Burns found in one victim. Because a burn destroys a large area of skin, it also Flame burns from ignited clothing may be the disrupts fl uid balance, metabolism, temperature, most serious part of the wound. An electric current and immune response. Fluid is lost in part by ooz- injury is characterized by focal burns at the point ing from BLISTERs (called a “weeping burn”) and where the current entered and left through the also from dilation of blood vessels that leak fl uid skin. Once an electric current enters the body, its into the area beneath the burned skin 36 to 48 path within the body is determined by tissues with hours after the injury. After this period, the fl uid is 64 burns slowly reabsorbed by the body. This fl uid and salt The grease should then be washed off the skin, loss can be signifi cant, depending on the percent- and the burn should be soaked in cold water. If age of the burn. clothing sticks to the skin, it should not be pulled While there is not much weeping from second- off. Instead, the victim should go to the emergency and third-degree burns, the underlying fl uid loss room. is extensive; there may even be fl uid loss from If a fi rst- or second-degree burn is smaller than remote capillaries in unburned tissue (such as the a quarter on a child, or smaller than a silver dol- lungs). If fl uid loss is not reversed within an hour lar on an adult, the burn can be treated at home. after the burn, the fl uid loss begins to interfere Any burn on an infant, a person over 60, or a large with organ function and shock sets in. Once the burn, should be treated by a professional. fl uid loss reaches a critical level, the circulatory Butter should never be placed on a burn, since shock becomes irreversible and nothing can be the fat can hold in heat and worsen the injury, pos- done to save the patient’s life. sibly causing infection. Burn patients also experience an increase in After rinsing with cold water, the burn should the metabolic and oxygen use rates. This meta- be wrapped in clean dry gauze and left alone for bolic increase is at fi rst fueled by glycogen stored 24 hours. Antiseptics or other irritating substances in the liver and muscles, but when these stores should not be applied. A good way to remember are depleted the body begins to break down its how to treat a fi rst-degree burn is not to put any own protein structures. This metabolic response substance on the burn that the patient would not reaches a maximum level in burns of more than put in an eye. 40 percent. Third-degree burn treatment A third-degree Most burn patients die from infections of the burn should be seen by a doctor as soon as pos- skin, bloodstream, and lungs, in part due to a sible and treated in a specialized burn unit. These weakened immune system. wounds should not be plunged into water, since cool water may worsen the shock that often Treatment Options and Outlook accompanies a severe burn. Instead, the injury It is only since World War II that treatment of should be covered with a bulky sterile dressing burns has made much progress. In fact, since or with freshly laundered bed linens. Clothing ancient times physicians knew very little about stuck to the wound should not be removed, and proper burn management technique. EMOLLIENTS no ointments, salves, or sprays should be applied. with unusual ingredients were often placed on the The burned feet and legs should be elevated; burn, and bleeding was a popular treatment for burned hands should be raised above the level burns throughout the Middle Ages. Until the mid- of the heart. Breathing should be closely moni- 1940s, the best treatment that could be offered was tored. to wash the burn with soap and water, leaving it The doctor will either lightly dress these burns exposed to the air. with an antibacterial dressing, or leave them Generally, fi rst-degree burns can be treated exposed to enhance healing. Every effort is made with proper fi rst aid. Second-degree burns cover- to keep the skin germ free by reverse isolation ing more than 15 percent of an adult’s body, or nursing. If necessary, painkillers and antibiotics 10 percent of a child’s body, or burns of the face, are prescribed, and intravenous fl uids are given to hands or feet require prompt medical attention. All offset fl uid loss. people with third-degree burns should get immedi- Extensive second-degree and all third-degree ate medical help. burns are treated with skin grafts or artifi cial skin First/second-degree burn treatment First burns to minimize scars. Extensive burns may need should be fl ushed with plenty of cold water for 15 repeated plastic surgery. to 30 minutes; if the burn was caused by hot grease Despite the widespread use of antibacterial or acid, the saturated clothing should be removed. agents, infection remains one of the most serious butyl stearate 65 complications of burn wounds. Acute gastrointesti- Risk Factors and Preventive Measures nal ulcers often complicate recovery. Children are Burn accident statistics show that at least half of also prone to developing post-burn seizures, prob- all burn accidents can be prevented. For example, ably from electrolyte imbalances, low oxygen blood one of every 13 structure fi re deaths in the United levels, infection, or drugs. Youngsters are also States is caused by a child setting a fi re. Children prone to high blood pressure after a burn injury, playing with fi re account for more than one-third probably related to the release of certain stress hor- of preschool child deaths by fi re. mones after the burn. Common complications of burn grafts are the formation of fi brous masses of scar tissue called Burow’s solution One of the most common HYPERTROPHIC SCARS and KELOIDS, especially in ASTRINGENTS used with wet dressings. This clear, dark-skinned individuals. Direct pressure on colorless substance is also known as aluminum infl amed tissue reduces its blood supply and colla- acetate. gen content, which can head off the development of these scars. This pressure can be provided by wearing a variety of special burn splints, sleeves, burrow An excavation by parasites in the STRA- stockings, and body jackets. Special cases may TUM CORNEUM (topmost layer of epidermis) of dif- require body traction. fering sizes and shapes. Scars are most common after effects of a serious See also SCABIES. burn and may require years of additional plastic surgery after skin grafting to release the contrac- tures over joints. Unfortunately, despite modern Buschke-Lowenstein tumor See WARTS. cosmetic surgical techniques, burn scars are almost always unsightly and the results are almost never as good as the patient’s preburn condition. Buschke-Ollendorff syndrome A genetic disor- Burn scars should be carefully treated, even der, also known as osteopoikilosis with connective after they have completely healed. They should tissue moles, that is passed on to 50 percent of all not be exposed to sunlight, and those areas of offspring of an affected parent. It is characterized the skin exposed to the sun should be covered by by multiple raised yellow-orange skin PAPULES, SUNSCREEN. Since deep burns destroy oil and sweat with a marked increase of connective tissue within glands, the patient may need to apply emollients these lesions. The condition usually appears in and lotions to prevent drying and cracking. the 20s or 30s, with nodules or plaques on the Recovery from serious burns may take many thighs, buttocks, or abdominal wall. No treatment years. Patients may require extensive psychological is required. counseling in order to adjust to disfi gurement and See also CONNECTIVE TISSUE NEVI. physical therapy to regain or maintain mobility in damaged joints. See also CHEMICAL BURNS. Nevertheless, despite the best and most inten- butyl stearate One of the most common stea- sive treatment, between 8,000 and 12,000 patients ric acids used in cosmetics such as nail polish with burns die, and approximately 1 million sus- removers, lipsticks, and cleansing creams. Butyl tain substantial or permanent disabilities resulting stearate may cause an allergic reaction in sensitive from their burn injury each year. consumers. C café-au-lait macule Pale, coffee-colored oval Symptoms and Diagnostic Path patches that may develop up to three inches across, Found most often on the feet, a callus may occur anywhere on the skin. While a single such spot has anywhere on the body that experiences constant no signifi cance, the presence of six or more spots friction. larger than 1.5 cm may be a sign of NEUROFIBRO- A small focal callus with a hard core is called a MATOSIS, a hereditary disease of the nerve fi ber CORN. Corns are often surrounded by callus. Initial sheaths. thickening of the skin is a protective response, and The hyperpigmentation is due to increased the resulting callus is not painful unless very thick MELANIN in the skin. These spots are not related to or fi ssured. ultraviolet radiation exposure, and may be present Some amount of callusing may be benefi cial, at birth or acquired later in life. especially for those who go barefoot a great deal or who perform a repetitive activity such as shoveling, Treatment Options and Outlook gymnastics, or weight-lifting. Calluses protect the Laser therapy may fade these patches. skin from heat, rough surfaces, and cuts.

Treatment Options and Outlook calamine A pink compound of ferric oxide and Often, it is best to leave a callus alone because of zinc oxide that is applied (as a lotion, ointment, its protective capability. A painful or troublesome or dusting powder) to the skin. Calamine cools, callus on the foot may be treated by a dermatolo- dries, and protects skin that is irritated or itchy gist or podiatrist, who can pare away the thickened because of DERMATITIS, ECZEMA, POISON IVY, INSECT skin in layers with a scalpel. But calluses caused BITES, or SUNBURN. It also may be combined with a by foot deformities almost always recur unless the topical local anesthetic such as benzocaine, or with underlying problem is corrected either surgically or CORTICOSTEROIDS or ANTIHISTAMINES, which reduce by using a molded shoe insole. infl ammation. For patients with a lot of callused tissue, some experts suggest soaking the feet in diluted chamo- mile tea, which will soothe and soften hardened calcinosis cutis A condition in which abnormal skin. Those with bad calluses should treat the area amounts of calcium are deposited as nodules in the daily after a warm bath by abrading lightly with a skin and connective tissue. Calcinosis is often asso- callus fi le or pumice stone, followed by a moistur- ciated with disorders of the connective tissue, such izing cream. This treatment should not be used on as DERMATOMYOSITIS or SCLERODERMA. hard corns. Patients with diabetes or those with reduced sen- sation in their feet should never treat themselves. callus An area of thickening of the stratum cor- neum caused by regular or prolonged pressure or friction, or if body weight is carried unevenly. It is camouflage cosmetics Special types of cosmetics the body’s protective response to repeat friction. used for those with scars or discolored patches on

66 cancer, skin 67 the skin. The key cosmetic for camoufl age is an color in reddened or yellowish skin), and contour- opaque, heavyweight foundation (usually a cream) ing (disguising swelling and creating the illusion of that is thicker than regular foundation and may be highlights and shadows). applied under regular foundation. Spread over an Camoufl age cosmetics tend to be thicker and area with skin problem, it can make many disfi gur- more adherent than everyday makeup, so it is ing marks (including BIRTHMARKS, SCARS, and even important to remove them every night. A cleansing discoloration left by SUNBURN) less noticeable. Both cream should be used to remove all makeup. Then men and women can use these products that come a gentle, alcohol-free toner should be applied with in cream, powder, and stick formulas. Today, the a cotton ball to remove any cleanser residue. This use of opaque ingredients such as titanium dioxide is followed with a moisturizer formulated for skin allow consumers to use lighter, more “breathable” type: oily, dry, or combination. coverup products. For women interested in concealing dark shad- The key to using any corrective makeup is ows under the eye, the key is to use as little cover- to blend the edges into surrounding skin; the up as possible. The best idea is to apply concealer best results come from using products that are under the dark circles, which are often caused by precisely matched to skin color. However, for shadows cast by excess skin or fat below the eyes. some people a slightly darker shade will hide Small dots of concealer is blended upward into a defect more completely. Opaque foundations the darker area with light strokes of the fi ngertips. (also called concealing creams) are available in White under-eye concealer should be avoided shades from pale ivory to dark chocolate, and because it looks too unnatural. may be found at cosmetic counters in large It is also possible to change the color of the skin department stores. with these products. A delicate pale green base A coverup product used only on one small will neutralize a reddish complexion. To improve area, such as a birthmark, should be applied a yellowing complexion, a peach or lavender base under foundation; once a translucent foundation is should be used. A fl esh-colored concealing cream applied over it, it will seem as if the skin—not the or regular makeup base can then be applied over makeup—is what is showing through. this. Foundation cream is applied by fi rst warming If applied thickly enough, the opaque cream can it in the hand and then applying with a fi nger also be an effective SUNBLOCK; a better choice is a or makeup sponge, using a pat/dab motion, cream that specifi cally includes a SUNSCREEN. beginning in the center of the area to be cov- ered and blending outward. Rubbing causes an uneven application. After fi ve minutes, a special camphor A volatile fragrant compound derived translucent setting powder should be applied; from an Asian evergreen tree that is used as an after another fi ve minutes, any excess should be antiseptic in some skin care products because it brushed away. feels soothing to the skin. It also may help stop When covering recent scars, always discuss the product ITCHING and is a rubefacient (it reddens the skin). safety with a dermatologist or surgeon fi rst. Most people Camphor is absorbed almost immediately in the can begin applying makeup to cover bruising or skin, causing a feeling of warmth and then numb- disguise swelling as early as a day or two after sur- ness. Camphor will not affect the outcome of an gery. To hide incision lines, a patient will need to ACNE breakout, but it is helpful for chapped skin wait until the stitches have been removed and the and as a counter-irritant in liniment rubs, where it incision is completely closed. After a chemical peel warms and soothes sore muscles. or DERMABRASION, any crust must be completely If inhaled for a long time, camphor can induce gone before makeup can be used. a severe headache. There are three basic approaches to camoufl age cosmetics after surgery: concealing (hiding incision lines and bruises), color correcting (neutralizing cancer, skin See SKIN CANCER. 68 Candida albicans

Candida albicans The yeast that causes the infec- clear up the infection, but it may recur. Those with tion called candidiasis, often within the vagina or a tendency toward this type of infection should on other areas of mucous membrane (such as the keep the skin dry. However, primary irritation or inside of the mouth). The infection is also known allergy rarely may occur due to topical medica- as thrush or moniliasis. tions and worsen the skin condition. Compresses See also CANDIDA INFECTION. with BUROW’S SOLUTION, plenty of air, and infrared heat lamps to dry the affected parts may help. candida infection A type of YEAST INFECTION Risk Factors and Preventive Measures caused by Candida albicans. The infection is also Yogurt (18 oz. daily serving), which contains lacto- known as “thrush,” moniliasis, or candidiasis. Can- bacillus acidophilus, reduces the colonization of the dida produces skin disease by invading the keratin- vagina and mouth and is effective in preventing ized EPIDERMIS—rarely, in some forms of chronic recurrent yeast infections. infection of the skin and mucous membranes, the See also CANDIDA PARONYCHIA. infection may invade the dermis and subcutaneous tissue. The yeast that causes candidiasis naturally grows candida paronychia A yeast infection in the nail in both the vagina and the mouth, where it is usu- fold that is relatively common, usually among ally kept under control by bacteria present in the people with jobs requiring prolonged immersion body. However, the yeast may grow if the bacteria of hands in water. Microorganisms, both Candida are destroyed, for example, as during antibiotic species and bacteria, invade the area under the nail therapy, if the body’s natural resistance to disease is fold. It usually affects the fi ngernails, and far less affected (as in AIDS), or if a person is taking drugs often affects the toenails. that suppress the immune system. The fungus also may fl ourish in the presence of some disorders Symptoms and Diagnostic Path (diabetes mellitus), during hormonal changes of This infection is characterized by redness, swelling, pregnancy, or while taking birth control pills. infl ammation, and sometimes PUS. The cuticle is Candidal infection of the penis, which occurs lost and the nail plate surface develops irregular more often among uncircumcised males, may be ridges and deformity. There may be some lifting transmitted from an infected partner. Similarly, it of the nail (ONYCHOLYSIS), which can worsen the can also spread from the genitals or mouth to other condition. moist areas of the body (such as the skin folds in Swabs or scrapings of the nail fold for micro- the groin or under the breasts). It may crop up with scopic examination and culture may be helpful if diaper rash in infants. the diagnosis is uncertain.

Symptoms and Diagnostic Path Treatment Options and Outlook Infection of the skin of the mouth causes sore, A topical imidazole (either as a cream or paint) is white-colored raised patches which are usually usually effective. It may require three to six months asymptomatic. In skin folds or with diaper rash, it of treatment, until a new cuticle has formed. Com- forms an itchy red rash with fl aky white patches. bined topical preparations of an antifungal with a There may be burning or stinging and itching in CORTICOSTEROID may be considered for infection skin folds or other affected areas. The skin looks with uncomfortable and severe infl ammation, beefy red or scalded with an irregular margin; a or if the patient also has ECZEMA. Systemic treat- chronic scaly form may occasionally occur. ment is needed only rarely, if the patient does not respond to topical treatment. Severe, chronic Treatment Options and Outlook candida paronychia may occur in people with a Antifungal drugs (such as clotrimazole, micon- suppressed immune system; systemic treatment is azole, nystatin, or econazole nitrate) will usually usually necessary in this case. Antiseptics may be capsaicin 69 necessary to treat associated bacterial infection of Treatment Options and Outlook the nail fold. While the ulcers will heal themselves, topical pain- killers ease the pain; healing can be hastened by using a CORTICOSTEROID OINTMENT or a tetracycline candidiasis See CANDIDA INFECTION. mouthwash. Over-the-counter medications containing carb- amide peroxide (Cankaid, Glyoxide, and Amosan) canker sore A small painful ulcer on the inside also may be effective in treating the sore, but none of the mouth, lip, or underneath the tongue that are effective in preventing them. Other treatments heals without treatment. Canker sores are not the include liquid or gel forms of benzocaine, men- same type of skin lesion as HERPES simplex (also thol, camphor, eucalyptol and or alcohol, or pastes known as “cold sores” or “fever blisters”). (such as Orabase, or Zilactin, a mix of tannic acid The difference between canker sores and COLD and alcohol in a gel) that form a protective “ban- SORES is their appearance and location. Cold sores dage” over the sore. For short-term pain relief, often involve the skin of the lips, and cankers do a prescription mouthwash containing 2 percent not; cold sores often strike the gums, and cankers viscous lidocaine can help. In severe cases, rins- rarely do; cold sores are often accompanied by ten- ing with topical corticosteroids after meals may be der lymph glands in the neck. necessary. Unlike cold sores, canker sores are not caused by a virus but are probably the result of bacteria Risk Factors and Preventive Measures or a temporarily malfunctioning immune system. No treatments have been demonstrated to reli- Because hemolytic streptococcus bacteria have ably prevent canker sores. Patients who are prone so often been isolated from canker sores, experts to canker sores should avoid coffee, spices, citrus believe they may be caused by a hypersensitive fruits, tomatoes, walnuts, strawberries, choco- reaction to the bacteria. lates, commercial toothpastes, and mouthwashes. Other factors often associated with a fl areup Instead, patients should brush teeth with baking include trauma (such as biting the inside of the soda for a month or two, and rinse with warm salt cheek), acute stress and allergies, or chemical irri- water. tants in toothpaste or mouthwash. More women than men experience canker sores, which are more likely to occur during the premenstrual period and capsaicin The active ingredient in hot peppers are also more likely to occur if other members of that produces an irritating effect when used on the the family suffer from them. skin; it has been found to ease the incessant itch of About 20 percent of Americans at any one time PSORIASIS and the pain of herpetic neuralgia. Cap- experience a canker sore, commonly between ages saicin is believed to interfere with the substance P, 10 and 40. They are particularly common in chil- the chemical in the body that transmits both the dren who wear braces. The most severely affected pain and the “itch” impulses to the brain. When people have almost continuous sores, while others a patient applies capsaicin to the skin, the local have just one or two per year. nerves release a large amount of substance P, thus depleting the supply. The itch or pain subsides Symptoms and Diagnostic Path because the body takes some time to build up the A canker sore is usually a small oval ulcer with a stores of the chemical again. grayish white center surrounded by a red, infl amed While capsaicin does not cure the underlying halo, which usually lasts for one or two weeks. A condition, it can decrease the pain or itch. canker sore should heal within two weeks. If the The cream may burn or tingle when fi rst applied sufferer cannot eat, speak, or sleep, or if the sore to the skin, but this sensation should lessen over does not heal not within two weeks, medical help time. should be sought. See also ZOSTRIX. 70 carbenicillin carbenicillin (Trade names: Geopen, Pyopen) A the CO2 beam. Still, everyone in the room must synthetic penicillin, available by mouth or by intra- wear special protective eye goggles. venous injection, that is effective against a wide Because the beam generates heat, there is also range of bacterial skin infections. a risk of fi re (especially on surgical dressings). Wet dressings placed over normal neighboring skin will reduce the chance of fi re and of inadvertent dam- carbolic acid A caustic acid formerly used in age to surrounding tissue. CHEMICAL FACE PEEL. Carbolic acid is too caustic for this purpose and is therefore no longer used in skin care. carbuncle A cluster of BOILs (PUS-fi lled infl amed hair roots) commonly found on the back of the neck and the buttocks usually caused by the bacte- carbolic soap A disinfectant soap with about 10 rium Staphylococcus aureus. Carbuncles usually begin percent phenol used to treat oily skin. as a single boil that spreads. They primarily affect patients with lowered resistance to infection.

Treatment Options and Outlook carbon dioxide (CO2) laser A versatile laser that can be operated in either focused or defo- Carbuncles are treated with oral and topical anti- cused mode. When defocused, the target area is biotics and hot compresses. These may relieve the larger and the beam surface vaporizes the surface pain by causing the pus-fi lled heads to burst; if this of the target and destroys cells instantly. The heat- occurs, the carbuncle should be covered with a ing and destruction occur so quickly, in fact, that dressing until it has healed completely. there is little heat conducted to adjacent cells, and Once the infl ammation has been controlled, the the zone of injury is small and can be carefully lesion may be cut and drained. The cavity may then controlled. need packing with a PETROLEUM JELLY or iodoform In the focused mode, the beam diameter nar- dressing. In some cases, draining is not necessary if rows to just 0.1 mm; this intense beam is capable a 10-day course of antibiotics and topical antibiot- of cutting tissue, the depth and precision of which ics cures the infection. depends on the speed with which the laser beam is moved along the tissue. Because it produces Risk Factors and Preventive Measures heat, the laser actually sterilizes the cut as it goes, Recurrent carbuncles are usually caused by auto- and seals blood vessels so that the surgical fi eld is inoculation (that is, patients carry the bacteria that bloodless unless a large blood vessel is cut. Because causes carbuncles and constantly reinfect them- the heat is concentrated on a small area, there is selves). Regular washing with antibacterial soap little tissue damage, so the tissue can be preserved, (especially around rashes, irritations, shaving, or and examined later. areas of heavy sweating) can help prevent reinfec- The CO2 laser can be used to treat a variety of tion. Hands and bedding should be washed often. benign or malignant skin conditions. However, while warts also can be destroyed with this tech- nique, the resulting plume of smoke may contain carcinoma, basal cell See BASAL CELL CARCINOMA. infectious wart particles.

Risks and Complications carcinoma, squamous cell See SQUAMOUS CELL There are some risks associated in the CO2 laser CARCINOMA. treatment. Because the CO2 beam is invisible, the potential for damage to eye is great; usually, a small red helium-neon laser is used with the CO2 beam, carnauba wax A type of wax derived from the so that its red light marks the area being struck by pores of the Brazilian carnauba palm tree used to cat scratch disease 71 give cosmetics a more solid consistency. This wax is it is used in some medical-grade creams and pastes, included in depilatories, creams, and stick deodor- and several types of eyedrops. ants. It has not been shown to induce an allergic reaction. catagen The brief stage of the hair growth cycle in which growth stops and resting starts. carotenemia Yellowing of the skin resembling See also HAIR, ANATOMY OF. JAUNDICE caused by excess carotene in the blood, most commonly found on the palms, soles of the feet, and central third of the face, and in the cat scratch disease A bacterial infection caused sweat. Carotenemia does not usually affect the by Bartonella henselae as a result of being bitten whites of the eyes, which helps distinguish it from or scratched by a cat. A small skin lesion typi- jaundice. cally develops at the point of injury, and lymph This condition is caused by eating too much of nodes (especially near the head, neck, and arms) certain vegetables and fruits rich in carotene, or become swollen. This may be followed by a slight is the result of therapy with BETA-CAROTENE for fever. Kittens are more likely to be infected and certain disorders (such as ERYTHROPOIETIC PROTO- to transmit the bacteria to people; about 40 per- PORPHYRIA). Too much carotene in the blood also cent of all cats carry B. henselae at some point. may be a symptom of hypothyroidism, diabetes Although B. henselae has been found in fl eas, so mellitus, hypopituitarism, or anorexia nervosa. far scientists have found no evidence that a bite from an infected fl ea can transmit cat scratch dis- Treatment Options and Outlook ease (CSD). When carotenemia is caused by beta-carotene ther- Although CSD occurs all over the world, it is apy or excess dietary ingestion, the skin returns to an uncommon disease. The Centers for Disease normal several months after the diet or therapy Control and Prevention estimates that there are has stopped. 2.5 cases of CSD per 100,000 people per year in the United States. cartilage-hair hypoplasia A genetic disorder char- Symptoms and Diagnostic Path acterized by thin hair shafts with little or no pig- Between three to 10 days after a bite or scratch, the ment, and short-limb dwarfi sm. Because of defects patient notices swollen lymph nodes, which may in the immune system, there may be other prob- become painful or tender. After three to 10 days, a lems such as recurrent respiratory infections and red round lump usually appears at the site of infec- severe SHINGLES. There is no known treatment. tion. A small infected blister sometimes develops at See also HAIR, DISORDERS OF. the original wound site. There also may be fever, headache, fatigue, and a poor appetite. A biopsy of the swollen lymph node can be casein A whole-milk protein used in cosmetics as taken, and a skin test using cat scratch disease anti- an emulsifi er (especially in massage creams) that gen may be performed. does not affect the skin’s health in any way. Treatment Options and Outlook Painkillers may be needed to relieve fever and castor oil A vegetable oil derived from the castor headache; a severely affected lymph node or bean. Used in many cosmetics as an emollient, it blister may have to be drained. In most cases, forms a hard fi lm when dry. It is often used in lip- the illness fades after one or two months, and sticks, but because of its unpleasant smell, it is not the cat does not need to be destroyed. Rare com- often found in other cosmetics. Because it is rarely plications of B. henselae infection are bacillary associated with skin irritation or allergic reactions, angiomatosis. 72 causalgia

Risk Factors and Preventive Measures cayenne pepper spots Tiny red spots often asso- Cats that carry B. henselae do not show any signs ciated with infl ammation of tiny blood vessels of illness. People with impaired immune systems, (capillaritis). These spots are seen typically in a such as those undergoing chemotherapy for cancer, group of conditions called progressive pigmentary organ transplant patients, and people with HIV/ purpura. AIDS are more likely than others to have complica- tions with CSD. Most people who contract CSD are under age 17 and are usually under age 12. cellulite The so-called dimpling of the legs in To prevent transmission of CDS, pet owners women that describes an anatomically normal should avoid any activity that may lead to cat irregularity found in almost all women’s skin. In scratches and bites. The wound from any cat bite fact, there is no such thing as “cellulite” itself; the or scratch should be washed immediately and thor- appearance of dimpling simply occurs because the oughly with running water and soap. fat deposits in a woman’s leg are different from those in a man’s leg. In women, the subcutaneous fat appears in large channels, whereas men have causalgia A persistent burning pain (usually in connective tissue strands that hold in the fat, pre- an arm or leg) with red and tender skin over the venting the dimpling effect. painful area; conversely, the skin may sometimes European clinics inject enzymes into the leg to be cold, blue, and clammy. Experts are not sure “dissolve” this nonexistent substance, and topical of the cause. The pain may become worse during aminophylline cream has recently been used in the times of emotional stress or by normal sensations United States, but there is no effective treatment (such as touch). for “cellulite” except to physically remove fat with liposuction or by decreasing the amount of fat in Symptoms and Diagnostic Path the legs with diet and exercise. Typical features include dramatic changes in the color and temperature of the skin over the affected area, along with intense burning pain, skin sensi- cellulitis A bacterial infection of loose connective tivity, sweating, and swelling. tissue (particularly subcutaneous tissue) usually caused by B-hemolytic streptococci and staphylo- Treatment Options and Outlook cocci. Untreated, the disease may lead to bactere- Because there is no cure, treatment is focused on mia, blood poisoning or GANGRENE; facial infections relieving painful symptoms. Doctors may prescribe may spread to the eye socket. Very rarely, cellulitis topical painkillers, antidepressants, corticosteroids, develops after childbirth and may spread to the pel- and opioids to relieve pain, but no single drug or vic organs. Before the development of antibiotics, combination of drugs results in consistent long- cellulitis was occasionally fatal. Today, any form of lasting improvement. cellulitis is likely to be more serious in those with Other treatments may include physical therapy, compromised immune systems. sympathetic nerve block, spinal cord stimulation, and drug pumps to deliver opioids and local pain- Symptoms and Diagnostic Path killers into the spinal cord. Affected area (usually face, neck or limbs) is usu- Full recovery may take many months. In some ally hot, tender, and red, with associated fever and cases patients may have crippling pain without chills. remission, in spite of treatment. Treatment Options and Outlook Antibiotics (penicillin, cephalosporins, or clinda- cavernous hemangioma mycin) must be taken for up to two weeks to clear See HEMANGIOMA, CAVERNOUS. the infection. Chediak-Higashi syndrome 73 cerate An ointment or cream made with wax Microscopic examination of a smear of the and oil. chancre will reveal the spirochete, which causes the disease; blood test results are usually negative early in primary syphilis. chalazion Also called a meibomian CYST, this is a round, painless swelling on the eyelid. It is caused Treatment Options and Outlook by an obstruction of one of the meibomian glands Penicillin injections almost always prevent primary responsible for lubricating the edge of the eyelid. A syphilis from developing into more serious stages large swelling may exert pressure on the cornea at of the disease. the front of the eye, blurring the vision.

Symptoms and Diagnostic Path chapped skin Red, dry and cracked painful skin The cysts can occur at any age, but they are espe- caused by low humidity (especially during fall and cially common in people with ACNE, ROSACEA, or winter). seborrheic DERMATITIS. If the cyst becomes infected, the lid swells even more, becoming even more Treatment Options and Outlook painful and red. Badly chapped skin should not be put in water; related washing removes the oil layer, allowing Treatment Options and Outlook moisture in skin to evaporate. Instead of using soap, About one-third of the cysts fade without treat- patients should rub on soap-free skin cleanser, work- ment. Compressing with hot compresses for 20 ing it into a lather and then wiping it off—or wash minutes, four times a day for several days is often skin with bath oil. Warm, not hot, water should be effective. Large chalazions usually need to be surgi- used in the bath. Patients should always add oil to cally removed with local anesthetic. the bath, pat dry, then apply body lotion, such as Lubriderm, Complex 15, Moisturel, and Eucerin. chamomile An herb that scientists have found to have real value for hair and skin. A mild mixture of Chediak-Higashi syndrome An inherited defect chamomile leaves produces an oily substance that of pigment characterized by partial ALBINISM, PHOTO- is soothing to the skin, used most often by adding it PHOBIA, silvery hair, and susceptibility to infection. to the bath. A solution of concentrated chamomile The disorder has been observed not just in left on the hair for a few hours will lighten it by humans, but also in many different mammals, several shades. including cats, Aleutian minks, beige mice, and even killer whales. chancre An ulcer (usually on the genitals) that Symptoms and Diagnostic Path develops during the fi rst stage of SYPHILIS. A few patients have white hair and skin, and some have nystagmus (involuntary eye movements). Most Symptoms and Diagnostic Path have blond or gray hair, blue eyes, and fair skin. Appearing fi rst as a dull red spot between three to Skin infections occur frequently and may be four weeks after exposure. It can also appear on fatal, ranging from a superfi cial PYODERMA (ulcer) the lips or in the throat if oral sex has taken place. to deep, slow-healing abscesses and ulcers that may The spot gradually develops in a painless ulcer with cause scars. a clearly defi ned fi rm, heaped up edge and a rub- bery base. If the chancre is the result of a sexually Treatment Options and Outlook transmitted infection (which is very common) the There is no known treatment. The use of 500 mg. ulcer may be painful. of VITAMIN C three times a day is controversial. 74 cheilitis

Patients should protect themselves against expo- chemical exposure and the skin Certain chemi- sure to the sun, wearing protective clothing, ultra- cals used in manufacturing are dangerous to the violet blocking sunglasses, and sunscreens. skin, but only to employees—not the general The disease is often fatal in childhood as a result public. Workers should use appropriate protective of infection or bleeding; few patients live to adult- clothing. hood, although survival into the 20s or 30s has Another concern about chemical exposure is the been reported. effect of FREE RADICALS on the skin. Free radicals are unstable molecules that can disrupt healthy cells during metabolic processes, and are believed cheilitis Infl ammation, dryness and cracking of to speed up aging and even cause cancer. They are the lips and corners of the mouth that can be produced naturally in the body, but they also occur caused by a downturned mouth, poorly fi tting in cigarette smoke, nitrous oxide, ozone, and toxic dentures, dental work, local infection, COSMETIC wastes. ALLERGY, SUNBURN, skiing, or windburn. Patients As a result of these concerns about pollution, should apply Vaseline (or other lip balms in stick skin care companies have devised a range of pol- form) hourly to ease the pain until the underlying lutant-fi ghting treatments, some which prevent cause is identifi ed and treated, and avoid licking oxidation and others that just shield the skin from the lips. pollution. But experts disagree as to whether these products are just a fancy marketing gimmick or whether they represent serious skin safeguards; cheiloplasty Cosmetic surgery to reshape the none has ever been studied. lips. Until more research has been completed, experts advise consumers to wash with mild soap and apply moisturizer, which creates an extra barrier chemabrasion See CHEMICAL FACE PEEL. against dirt and debris. chemical burns Although most industrial chem- chemical face peel A controlled burn using icals are relatively weak and require prolonged a caustic chemical to repair facial damage such contact before visible changes occur, some (such as ACNE scars, wrinkles, or pigmentation caused as concentrated sulfuric acid) can be quite harm- by sun damage. A chemical peel is the means of ful. Almost any substance encountered in the regenerating elastin or COLLAGEN (the skin’s sup- workplace may become an irritant if exposure is portive tissue) lost to age and sun exposure. There frequent enough. Workers are usually exposed to are two major types of peels: superfi cial and deep. many different potential irritants, and skin BURNS While it may sound like a facial, a chemical peel may be the accumulation of multiple exposures. is in fact surgery, using potent chemicals (glycolic acid, lactic acid, trichloroacetic acid, phenol and Treatment Options and Outlook or resorcinol) that actually dissolves the top layer The irritant agent must be identifi ed, and exposure of skin, erasing irregular pigmentation, mild acne to the skin eliminated. Severe cases may be treated scars, crow’s feet, fi ne cheek wrinkles, and tiny with an oral CORTICOSTEROID such as prednisone. vertical lines above the upper lip. The deeper the Topical steroids, which reduce infl ammation, may peel, the more effective it is. be applied to the skin. High-potency topical cor- After a deep peel, a thick crust lasts for a ticosteroids are more useful when infl ammation week, and the purple-red skin color may take is moderate to severe; gel and cream preparations six months to fade away. It is a painful, emo- absorb moisture and help to dry oozing, weeping, tionally diffi cult process to endure, but after the vesicular DERMATITIS. skin heals the result is pinker, tighter, smoother cherry angioma 75 and relatively wrinkle- and blemish-free skin, chemical pollutants and the skin The daily which may remain younger-looking for 15 years onslaught of smog, car exhaust, and acid rain take or more. their toll on building facades in America’s cities, On the other hand, a “surface” or freshening and some dermatologists believe chemical pollu- peel is more like a superfi cial facial, leaving the tion can also harm the skin. skin glowing for a week or two, but not going deep Some experts blame toxics for a range of prob- enough to erase scars or wrinkles. lems from minor irritation to premature aging, The procedure is not for everyone. Subjects although there have been few controlled stud- with dark or olive skin may end up with a blotchy ies of the problem. Some experts believe the appearance, and those with poor liver, heart, or increase in airborne toxicants contributes to the kidney function could be affected by the solution rise of skin cancer; others believe that ozone in that strips away the upper layers of the skin, which smog can penetrate and damage the skin’s outer is absorbed into the bloodstream. layer. Others point to the effect of FREE RADICALS, Prospective patients of any peel, no matter how unstable molecules that can disrupt healthy cells minor, should investigate the surgeon’s ability and in a process known as oxidation; they have been experience, since it takes a great deal of expertise to linked to premature aging and cancer. They are apply a good chemical peel. Consumers should ask produced naturally in the body, but they are also whether the procedure comprises a large portion found in cigarette smoke, nitrous oxide, ozone, and of the person’s practice (one of the two or three toxic waste. Critics of this belief point out that a procedures most often performed). Ask how many person’s skin was designed to keep out such harm- peels the doctor does a week, and how he or she ful substances. learned the procedure. Experts advise patients to wash with mild The cost of a peel ranges from $200 to $3,000 soap and apply a moisturizer, which creates an depending on the area of skin to be treated, the extra barrier against dirt and debris. Washing depth of the peel and the area of the country in the facial area thoroughly at the end of the day which the dermatologist practices. with soap or a soap substitute and water is also Chemical skin peels have been around for important. thousands of years, with women using everything from sour milk to wine residue to freshen their complexions. Since the 1950s, American women chemosurgery See MOHS’ MICROSCOPICALLY CON- have gone to plastic surgeons and dermatologists TROLLED EXCISIONS. for peels using phenol or trichloracetic acid. While these products are still used for those who need fairly deep chemical peels, newer milder, products cherry angioma A common benign skin growth are now on the market. that appears as a small, smooth, cherry red bump. These new products, called ALPHA HYDROXY They are most common after age 40, and they can ACIDS, are available over the counter in concentra- occur almost anywhere on the body but most com- tions of less than 10 percent, in beauty salons in monly develop on the trunk. The size of the skin concentrations of up to 40 percent, and in derma- growth may vary. Although they are painless and tologist’s offi ces in concentrations up to 70 percent. harmless, cherry angiomas may bleed profusely if These milder peels improve the skin’s appearance injured. by speeding up the shedding of dead skin cells, The cause is unknown. clearing up acne-prone skin, softening tiny lines around the eyes and mouth, smoothing dry skin Symptoms and Diagnostic Path and fading dark spots caused by sun or hormonal The bright red, smooth skin lesion is small, from changes. about the size of a pinhead to about ¼-inch See also DERMABRASION; GLYCOLIC ACID. diameter. 76 chicken pox

Treatment Options and Outlook If possible, a child with suspected chicken pox Cherry angiomas do not usually require treatment. should not be brought into a doctor’s offi ce where If cosmetically displeasing, however, they may be others may be exposed to the disease; it can be removed by surgery, freezing (CRYOTHERAPY), burn- very dangerous to newborns or those with sup- ing (ELECTROCAUTERY), or laser therapy. Cherry pressed immune systems. The virus can be spread angiomas are benign and generally harmless, and both through the air and by direct contact with an removal usually does not cause scarring. infected individual. Instead, a physician should be contacted by phone and describe symptoms. chicken pox A once-common childhood infec- Symptoms and Diagnostic Path tious disease characterized by a rash and fever The incubation period after exposure ranges from that—prior to the development of a vaccine in one to three weeks, and is followed by a rash on 1995—affected about 3.9 million people each year the body (torso, face, armpits, upper arms and legs, in the United States. About 90 percent of cases inside the mouth, and sometimes in the windpipe occur in children under age 10, primarily in win- and bronchial tubes, causing a dry cough). The ter and spring. Since the vaccine was introduced, rash is made up of small, red, itchy spots that grow there has been a steady decline in cases of chicken into fl uid-fi lled BLISTERS within a few hours. After pox. The availability of a safe and effective vari- several days, the blisters dry out and form scabs. cella vaccine has reduced the impact of the disease New spots usually continue to form over four to substantially. seven days. Patients are contagious fi ve days before High vaccination coverage levels among all age the rash appears and until all the skin lesions have groups are necessary to ensure that children do not crusted over (usually about a week after they reach adolescence or adulthood without having appear). immunity to varicella. By June 2004, 44 states had Although children usually have only a slight implemented child care or elementary school entry fever, adults often experience fever, breathing requirements for varicella. However, by March problems, and severe varicella pneumonia. In rare 2005, only 18 states included middle- or high cases, children may develop this type of pneumo- school varicella vaccination requirements. nia or Reye’s syndrome; they may also develop Chicken pox is also known as varicella, after bacterial infections. Occasionally, chicken pox can the virus (varicella-zoster, or VZV) that causes the lead to varicella encephalitis (an infl ammation of disease. VZV is a member of the family of herpes the brain). Immunocompromised patients who viruses and is similar to the herpes simplex viruses are susceptible to VZV are at high risk for hav- (HSV). The virus is spread by airborne droplets. ing severe varicella infections with widespread While an attack of chicken pox creates a lifelong lesions. immunity to the disease, the virus does not disap- pear. It remains dormant within a patient’s nerve Treatment Options and Outlook tissues after the attack. In later life, the virus can In most cases, rest is all that is needed for children, reactivate and cause an attack of herpes zoster with chicken pox, who usually recover within 10 (SHINGLES). days. Adults take longer to recover. ACETAMINO- Most people throughout the world have had PHEN may reduce fever, and CALAMINE, baking soda, the disease by age 10, and chicken pox is rare in or OATMEAL baths and oral antihistamines ease the adults. When it does occur after childhood, it can itch. Compresses can dry weeping lesions. Scratch- be deadly. About 90 people in the United States die ing should be avoided, since it can lead to bacterial every year as a result of chicken pox, and another infection of lesions and increases the chance of 9,300 must be hospitalized. The infection strikes scarring; children may need to wear gloves during hardest in infants, adults, and those with immune sleep to avoid nighttime scratching. system problems. Adults are much more likely to Aspirin should never be given to a child who has be hospitalized than children. been exposed to (or has recently recovered from) chigger bites 77 chicken pox. Aspirin in these cases has been linked of the vaccine are required, four to eight weeks to the development of Reye’s syndrome. apart. The drug ACYCLOVIR may be prescribed for Immunization with the chicken pox vaccine will chicken pox patients. It is usually recommended prevent most children from getting chicken pox. If for people with chronic skin or lung disorders, in vaccinated children do get chicken pox, they gener- severe cases of chicken pox, or for those with com- ally have a much milder form of the disease. They promised immune systems. Unlike herpes simplex have fewer skin lesions, a lower fever, and recover viruses, VZV is relatively resistant to acyclovir, and more quickly. In fact, the disease may be so mild doses required for treatment are much larger than that the skin lesions look like insect bites. Even so, for other diseases. While the drug may decrease vaccinated children with a mild case of chicken pox the length of the illness and mitigate symptoms, can still infect others at risk of getting chicken pox. its high cost and marginal effectiveness have Currently, revaccination with the chicken pox prompted the American Academy of Pediatrics not vaccine is not recommended. However, studies are to recommend it as a routine treatment. underway to determine how long protection from the vaccine lasts and whether a person will need Risk Factors and Preventive Measures revaccination in the future. The American Academy of Pediatrics recommends High-risk, susceptible patients may also obtain the chicken pox vaccine (VariVax) for all children, passive immunization with VZV immune globulin, teens and young adults who have not had the dis- which can abort or modify infection if administered ease. The vaccine, which has been used in Japan within three days of exposure. for some time, was approved by the Food and Rarely (in less than one person out of 1,000) Drug Administration in April 1995. Although its there may be seizure caused by fever. Very rarely, approval had initially met with some controversy, pneumonia may result. Other serious problems, pediatricians today recommend the vaccine for including severe brain reactions and low blood their patients. Since the chicken pox vaccine was count, have been reported after chicken pox vacci- licensed in 1995, several million doses of vaccine nation. These happen so rarely experts can not tell have been given to children in the United States. whether the vaccine causes them or not. If it does, Studies continue to show the vaccine to be safe it is extremely rare. and effective. See also VA R ICELLA VIRUS VACCI NE LIVE. The vaccine is made from a live, weakened virus that, once injected in a human patient, creates a mild infection similar to natural chicken pox—but chigger bites A bite from the chigger (or harvest without related complications. The mild infection mite) causes an intense, itchy swelling up to half spurs the body to develop an immune response to an inch across. The swelling usually fades without the disease; these defenses are then ready when treatment between three days to a week. the body encounters the natural virus. The female mites are attracted to warm moist The vaccine is considered to be safe. Proponents areas of the body, such as the skin underneath of the vaccine point out that it makes sense to vac- sweat bands, where they burrow under the skin’s cinate children because they are likely to suffer surface. from chicken pox. The larvae of these mites of the genus Trom- The American Academy of Pediatrics recom- bididae live outdoors throughout the southeastern mends a single dose of the chicken pox vaccine for United States, and they are especially active in the all children between 12 and 18 months of age who grass near trees in summer. They attach themselves have not had chicken pox. Older children should to their patient’s legs where they feed on blood. be immunized at the earliest opportunity, also with The swelling may progress to form a BLISTER, and a single dose. For healthy children older than 13 the ITCHING can last for weeks. who have not had chicken pox and have never Secondary infection may occur as a result of been immunized against the disease, two doses scratching. 78 chilblains

Risk Factors and Preventive Measures swelling and bruising, and the bandage is removed Close-fi tting clothing with shirts tucked in and after the fi fth day. Stitches are removed a week pants tucked into socks will discourage chiggers. after surgery, and swelling usually subsides in the second week. chilblains An injury of the skin tissue caused by cold, but not freezing, temperatures. Also known chloasma Also known as melasma or the mask as “pernio,” chilblains are most commonly seen of pregnancy, this condition often appears during on the earlobes, nose, fi ngers, and toes of young pregnancy in which blotches of pale brown skin women. pigmentation appear on the face. It may occur in women who have been exposed to too much sun. Symptoms and Diagnostic Path Chloasma also occurs as a side effect of taking con- Chilblains look like itchy purple lesions that occur traceptive pills and injected depot contraceptive after exposure to cold. These lesions may last preparations. It may also be noticed in apparently from days to weeks, with burning, ITCHING, and healthy, normal, nonpregnant women where it is pain. Repeated episodes of chilblains may lead to presumed to be due to some mild and harmless a chronic condition that persists throughout the estrogen stimulation of pigment receptors in the winter. skin. Occasionally, the skin darkening will appear in men or postmenopausal women. The tendency Treatment Options and Outlook to develop chloasma may run in families. Administration of vasodilating drugs may provide some relief. Symptoms and Diagnostic Path The pigmentation primarily appears on the fore- Risk Factors and Preventive Measures head, cheeks and nose, sometimes merging to form Chilblains may be prevented by wearing ade- the “mask of pregnancy.” It is made worse by even quate clothing in cold temperatures. Severe lesions brief exposures to sunlight. While it usually fades respond to bed rest and gentle rewarming in a 105 away over a period of time, in some patients it degree bath. The patient with chronic chilblains becomes permanent; it also tends to recur in suc- must avoid exposure to cold. cessive pregnancies.

Treatment Options and Outlook chin augmentation A surgical procedure often The condition may improve if the patient avoids performed together with NOSE REPAIR (rhinoplasty) sunlight or uses a strong sunblock and (if appro- in order to rearrange the facial balance, accentuat- priate) changes the brand of (or stops using) ing and fl attering the neckline. BIRTH CONTROL PILLS. In addition, some patients may respond to hypopigmenting agents containing Procedure HYDROQUINONE or to the combination of TRETINOIN The incision may be placed either inside the mouth cream and hydroquinone. Chloasma in premeno- or under the chin, which creates a pocket in the pausal women may improve after menopause, chin into which an implant can be placed. The even without therapy. wound is then closed with stitches and a tape ban- dage applied to the chin. chloracne An ACNE-like eruption caused by expo- Outlook and Lifestyle Modifi cations sure to chlorinated hydrocarbon products. These If the incision is in the mouth, antibiotics are lesions may occur in up to 95 percent of cases administered to prevent infection, and a liquid where toxic generalized symptoms (such as liver diet is required for 48 hours to avoid getting food disease) are also present. Chloracne is caused when in the wound. Elevating the head prevents excess toxic materials cause the underlying sebaceous chromosomal defects and skin disease 79 glands to atrophy, forming KERATIN-fi lled cysts. The remain local, involve the entire extremity or turn hydrocarbon product most often associated with into a generalized infection. chloracne is 2,3,7,8-tetrachlorodibenzodioxin. This tropical infection is caused by a group of Chloracne has usually been associated with closely related molds found in the soil. It affects massive hydrocarbon exposure, such as in an people involved in manual labor with soil or its industrial accident or contamination during the products. While it is not clear why the infection manufacturing process. occurs only in the tropics, it is believed that in New chloracne lesions usually stop forming colder climates, workers wear shoes, which protect within six months after exposure, but existing feet from contracting the infection. Still, even in lesions often take a long time to heal and may per- the tropics this disorder is not common. sist indefi nitely. The condition is chronic and may last for years or decades, leading to the necessity of amputation, Symptoms and Diagnostic Path the development of ELEPHANTIASIS, or SQUAMOUS Symptoms include numerous closed BLACKHEADS CELL CARINOMA. with some infl ammatory pustules and noninfl am- matory, straw-colored cysts. In addition to the Symptoms and Diagnostic Path usual acne areas, the ears also may be affected, and The infection begins with itchy, watery PAPULES covered areas outside the usual acne distribution or an ulcer on the leg or foot, followed by foul- may be involved in severe cases. smelling plaques of the foot, ankle, knee, elbow, or hand. The papule or ulcer slowly enlarges over Treatment Options and Outlook months to years; as it spreads, the central area Chloracne is often resistant to treatment, and does becomes scarred. Many patients develop secondary not respond well to systemic antibiotics and topical bacterial infections. BENZOYL PEROXIDE. Topical derivatives of VITAMIN A, such as retinoic acid creams or gels (Retin-A) Treatment Options and Outlook may help. Oral vitamin A sometimes helps and Bed rest, elevation of affected body part, and anti- sometimes does not; anecdotal reports indicate that biotic therapy to control secondary infections are ISOTRETINOIN (Accutane) may be effective. In some recommended. Surgical excision of the affected cases, acne surgery is the only effective treatment. area, destruction of the affected tissue or drug treatment (potassium iodide, fl ucytosine, thiaben- dazole, KETOCONAZOLE, and topical heat) may be chlorophyll A chemical in the cells of green successful. plants that absorbs light so that plants can syn- thesize food. It is widely used as an ingredient in deodorants, toothpastes, and mouthwashes to pro- chromosomal defects and skin disease Abnor- tect against odor. malities in the human chromosome are often associated with prominent skin defects. Deletion of the short arm of chromosome 4 (4P) causes chromate, allergy to See ALLERGIES AND THE SKIN. central scalp defects. An extra autosome (trisomy 8) causes short nails, excess skin on the back of the neck, and no knee cap. Trisomy 10 causes chromomycosis An invasive fungal infection of congenital scalp defect and trisomy 13 causes scalp the top two layers of the skin in the feet and legs defects. Down syndrome (trisomy 21) may include that almost always begins at the site of trauma, ELASTOSIS PERFORANS SERPIGINOSA, unusual creases or penetration of a foreign object. It is most com- on the palms, a shortened fi fth fi nger, premature mon in the tropics. Also called chromoblastomy- wrinkles, frequent hair loss, and fi ssured and fur- cosis, chromomycosis is characterized by a pile of rowed skin. Turner’s syndrome (defi ciency of one warty sores, usually on the legs. The infection may X chromosome or presence of an abnormal X) 80 chrysotherapy may cause congenital and persistent lymphedema, clay A mineral used in face and body powder, moles, cystic hygromas, low hairline in back, and face masks and foundations that is particularly increased skin aging. Klinefelter’s syndrome (XXY) helpful for normal and oily skin, and ACNE condi- may be associated with leg ulcers. tions. It does not cause allergic reactions.

chrysotherapy See GOLD THERAPY. cleansing products While it is true that skin problems such as ACNE have more to do with trapped oil and bacteria in the oil glands than oil cimetidine (trade name: Tagamet) An anti- on the skin’s surface, cleansing agents can give a histamine developed for the treatment of gastroin- feeling of improvement because they do remove testinal ulcers, cimetidine is occasionally effective surface oil. Skin cleansing can remove dirt, cos- in the treatment of chronic HIVES and has recently metics, cellular debris, body secretions, sweat, and been studied as a treatment for multiple warts in microorganisms. children. How often and how vigorously a person should clean the skin depends on skin type, daily activities, and the environment. Washing alone is the most cinnamate A SUNSCREEN that blocks both ultra- effective method of skin cleansing; while water violet-B (UV-B) and, less well, UV-A sun rays. Cin- alone removes many types of dirt, a soap or deter- namate is one of more than 20 chemicals that the gent helps to remove oils. In the United States, soaps U.S. Food and Drug Administration recognizes as account for about 90 percent of the toilet bars sold. safe, effective sunscreen ingredients. The success of People with normal skin should wash the face the product depends on how well, how often, and no more than twice a day with gentle cleansers. how consistently it is used. However, cinnamate Very hot water should be avoided, and a low-alco- can cause a rash. hol astringent or an alcohol-free toner should be used after each washing. Oily skin should be washed three times a day; ciprofloxacin (trade name: Cipro) An oral anti- “gentle” or “rich” cleansers should not be used. Peo- microbial drug used to treat skin infections such as ple with oily skin can use hotter water than people cutaneous ANTHRAX. with other skin types; an astringent with a high alcohol content should be used after each washing. Side Effects The skin should be exfoliated twice a week. Nausea and vomiting, diarrhea, abdominal pain, Combination skin requires the same regimen as sun sensitivity, and headache. those with normal skin; astringent on nose, chin, and forehead. Sensitive skin should be washed once a day, citric acid Chemical found in citrus fruits that is with a very gentle cleanser and lukewarm water. used as a grease-cutter in shampoos. Abrasives such as rough washcloths, grains, and toners or astringents with alcohol should not be used. citronella A strong-smelling substance obtained Abrasive cleansers/pads contain small gritty par- from the Cymbopogon nardus grass of Asia, used ticles that mildly sand the skin. These are designed as an insect repellent and perfume. Some sensi- for people who want to scrub their acne away, but tive individuals may develop skin sensitivity to in fact most experts believe they are too irritating citronella. and are not that helpful. Soaps, lotions, and cleansers work about as well as abrasives but they are not as harsh. All induce a clavus See CORN. mild exfoliation by helping to remove superfi cial clothes and sun protection 81 skin cells, but they cannot really remove the oil in Administered by mouth, the drug should be the follicles. In some cases, soaps can be excessively taken with meals or milk; about 70 percent is drying and irritating. absorbed within the small intestine. For most skin Soap-free cleansers or emollients may be used by conditions, the drug needs to be taken for at least those with sensitive skin. two months before any benefi t is seen. Astringents, fresheners, toners, or refi ning lotions are The drug should not be taken during the fi rst usually composed of alcohol-in-water combina- three months of pregnancy, in patients prone to tions used by those with oily skin to remove SEBUM diarrhea or recurrent abdominal pain, and in those or makeup. While many of these products are said with kidney or liver disease. to shrink pores, in fact it is impossible to perma- nently shrink pores. The pores may appear smaller Side Effects as acne lesions are treated and oil and blackheads The most obvious side effect is pink, red, or brown- are removed. ish black discoloration of the skin, especially in See also SOAP AND THE SKIN; COSMETICS; MAKEUP. areas exposed to sunlight. Hair, sweat, sputum, urine and feces may also be discolored. These pig- mentation side effects are related to dosage, how- climatotherapy The use of climate in the treat- ever, and begin to fade when therapy is stopped. ment of disease. This type of therapy is especially Other side effects include XERODERMA, ICHTHYOSIS, popular in the treatment of PSORIASIS, which ITCHING, sensitivity to sunlight, and acnelike skin responds well to hot, dry climates. Many patients eruptions. There also may be nausea and vomiting, often visit Hawaii, Florida, Mexico, and the Carib- abdominal pain, and diarrhea. bean to clear their skin conditions by sunbathing, since the natural sunlight in regular doses will often clear most cases of psoriasis. clothes and sun protection A variety of cloth- As yet there are no climatotherapy centers for ing products can help protect consumers from the psoriasis in the United States; the most organized sun’s rays, including laundry additives and clothing centers for psoriasis are located in the region of the made from UV-protected fabric. Regular clothing Dead Sea between Israel and Jordan. has a SUN PROTECTION FACTOR of between 2 and 6. While most people think their clothing gives them adequate protection from the sun, that is not clindamycin An antibiotic drug used to treat ACNE always the case. In fact, many white cotton T-shirts and serious infections that have not responded, or provide only an ultraviolet (UV) protection factor are resistant to, other antibiotics. Clindamycin is of 5, signifi cantly less than the recommended SPF especially effective against most anaerobic bacte- (SUN PROTECTION FACTOR) of 15. ria, including PROPIONIBACTERIUM ACNES, which are Sun-protective clothing offers another way to often responsible for acne. It is also an excellent protect skin from the harmful effects of the sun. agent against Staphylococcus aureus and streptococ- Sun-protective fabrics differ from typical summer cal species. fabrics in several ways: They typically have a tighter weave or knit and are usually darker in color. Sun- protective clothes have a label listing the garment’s clofazimine A dye used primarily to treat LEPROSY. Ultraviolet Protection Factor (UPF) value (that is, It is also effective in some patients with PYODERMA the level of protection the garment provides from GANGRENOSUM, DISCOID LUPUS ERYTHEMATOSUS, ACNE the Sun’s UV rays). The higher the UPF, the higher FULMINANS, and GRANULOMA FACIALE. the protection from the Sun’s UV rays. This drug has a remarkable lack of toxicity, and The UPF rating indicates how much of the sun’s although there is no evidence of birth defects, it UV radiation is absorbed by the fabric. For exam- does cross the placenta and cause pigmentation in ple, a fabric with a UPF rating of 20 only allows offspring. 1⁄20th of the Sun’s UV radiation to pass through it. 82 cloxacillin

This means that this fabric will reduce the skin’s six weeks, or may be done at home with a portable UV radiation exposure by 20 times where it’s pro- machine or natural sunlight. tected by the fabric. Everything above UPF 50 may be labeled UPF 50+; however, these garments may not offer substantially more protection than those Cockayne-Touraine syndrome A variant form of with a UPF of 50. EPIDERMOLYSIS BULLOSA dystrophica, that usually A garment should not be labeled “sun-protec- occurs in infancy or early childhood. It is believed tive” or “UV-protective” if its UPF is less than 15. to be an inherited condition, which was fi rst Sun-protective clothing may lose its effectiveness if reported in 1895. it is too tight or stretched out, damp or wet, and if it has been washed or worn repeatedly. Symptoms and Diagnostic Path Rit, a producer of home dyes and laundry treat- It is characterized by recurrent, noninfl ammatory ments, has created a laundry additive that washes blistering eruptions mainly on the feet, less promi- UV protection into clothes to help block more nently on the hands. Symptoms typically begin than 96 percent of the sun’s rays. Their product, after BLISTERS appear in early childhood, but they Sun Guard, lasts for 20 washes on light-colored may also appear during adulthood, especially in clothes. warm weather. The lesions heal without residual See also SOLUMBRA; SUNBURN; SUNSCREEN; scarring or other changes, such as thickening of the SUNTAN. skin. They are occasionally associated with HYPER- HIDROSIS (excessive sweating). cloxacillin A penicillin-type antibiotic used to treat staphylococcal infections. This drug should cocoa butter An oil extracted from roasted cocoa not be taken with acidic fruits or juices, or aged nut seeds used to soften and lubricate the skin, cheese. Taken with alcohol, this drug could cause often used instead of wax or harder creams. It stomach irritation. Use with birth control pills may has the same emollient properties as any other impair the effi cacy of the contraceptive. vegetable oil, and it has not been associated with allergic reactions. coal tar derivatives Thick, black substances com- monly found as an ingredient in ointments and coconut oil A white saturated fat derived from some shampoos, used to treat skin and scalp condi- coconuts that melts at body temperature and is tions such as ECZEMA, PSORIASIS, and certain types used to smooth and lubricate the skin. Because it of DERMATITIS. produces an excellent lather, it is often included as Crude coal tar or coal tar solutions are available an ingredient in soap. Coconut oil can cause skin as over-the-counter and prescription preparations, irritation in some sensitive individuals. depending on strength. In the treatment of psoria- sis, it may be applied directly to the affected area or may be added to bath water for a daily body soak. cold cream A pharmaceutical and cosmetic prod- It also can be used with topical steroids, reducing uct of animal fat or mineral oil and a sodium salt the size and redness of itchy patches. with a dispersing agent to enhance its vanishing In addition, the coal tar may be used with quality. ultraviolet light (UV-B), followed by exposure to radiation treatments in resistant cases of psoriasis. The tar is partially removed from the skin before cold sore A small skin blister on the mouth exposing it to UV-B light and then to radiation usually found in a cluster, caused by the HER- therapy. The treatments are given daily for three to PES SIMPLEX VIRUS (HSV). The viral strain usually collagen diseases 83 responsible for cold sores is herpes simplex Type I skin. Both zinc products are available at health (HSVI); up to 90 percent of all people around the food stores. world carry this virus. Sores can be protected with a dab of PETROLEUM Cold sores tend to appear when the individual JELLY (applied with a clean cotton swab); the swab is under stress, exposed to sunlight, cold wind that touched the affected area should not be dipped or another infection, or feels run down. Women back into the jar. tend to experience more cold sores during their menstrual periods, but some people are affl icted at regular intervals throughout the year. People with collagen A tough natural constituent of connec- compromised immune systems may experience tive tissue that is the body’s major structural pro- prolonged attacks. tein, forming an important part of tendons, bones, and connective tissues. The most common protein Symptoms and Diagnostic Path in the body, its tough insoluble nature is what gives The fi rst attack may not even be noticed, or it may skin its elasticity, and helps hold the cells and tis- cause a fl ulike illness with painful ulcers on the sues together. Collagen makes up 77 percent of the mouth or lips (called gingivostomatitis). An out- fat-free dry weight of the skin. Injectable collagen break is often signaled by a tingling in the lips, fol- is a natural animal protein made from the skin of lowed by a small BLISTER that soon grows, causing cattle and injected into human skin to eliminate ITCHING and soreness. Within a few days the blisters wrinkles or facial depressions. It has long been burst, encrust, and then disappear within a week. touted as a potent weapon against the appearance The virus then retreats along the nerve where it lies of aging. dormant in the nerve cell; in some patients, how- To restore lost collagen, researchers have found ever, the virus is constantly reactivated. that treating photodamaged skin with Retin-A resulted in an 80 percent increase in collagen, Treatment Options and Outlook whereas patches treated with a placebo cream For mild symptoms, the sore should be kept clean showed a 14 percent collagen reduction. However, and dry so it will heal itself. For particularly viru- researchers note that the results of improved colla- lent outbreaks, the antiviral drug ACYCLOVIR or gen after treatment with Retin-A were observable idoxuridine paint may relieve symptoms or briefl y only under the microscope; the increase in collagen shorten the length of the outbreak by no more was not readily apparent to the naked eye. than one day, but there is no evidence of acyclovir See also COLLAGEN DISEASES; COLLAGEN INJECTION; ointment is particularly helpful. Otherwise, there LUPUS ERYTHEMATOSUS; SCLERODERMA. are a range of nonprescription drugs available containing a numbing agent (such as CAMPHOR or phenol) that also contain an emollient to reduce collagen diseases There are two groups of dis- cracking. For patients with frequent outbreaks of eases called COLLAGEN diseases: the true collagen HSV, acyclovir may be prescribed to be taken from diseases, and connective tissue diseases. True col- seven to 10 days, as soon as the patient feels tin- lagen diseases are rare and are usually inherited; gling. This usually prevents the outbreak, but does they are usually caused by faulty formation of col- not prevent future outbreaks. In patients with very lagen fi bers. True collagen diseases are character- severe symptoms, daily acyclovir application is ized by slack skin and poor wound healing. occasionally prescribed. Connective tissue diseases are caused by a mal- Some studies have suggested that ZINC may help function in the immune system that affects blood prevent outbreaks because zinc interferes with her- vessels, producing secondary damage in connective pes viral replication. Studies found that both zinc tissue. For this reason, these diseases are sometimes gluconate and zinc sulfate helped speed up healing called collagen vascular diseases, and include rheu- time, but zinc gluconate was less irritating to the matoid arthritis, systematic LUPUS ERYTHEMATOSUS, 84 collagen injection

PERIARTERITIS NODOSA, SCLERODERMA, and Collagen injections are a good choice for someone DERMATOMYOSITIS. who wishes to avoid the risks of surgery and is not ready for a moderate or deep peel, DERMABRASION, laser abrasion, or a full FACE-LIFT. Collagen injec- collagen injection One of the less painful, more tions are safe, and the least likely of all the wrinkle- conservative ways to temporarily remove wrinkles, removal methods to develop complications. now superseded by Retin-A treatments. The colla- gen framework is intact in young people, and the Procedure skin is moisturized and fi rm. Eventually, however, Collagen should be injected into the skin only by as the years pass the skin’s support structure weak- a trained health care professional. By supplement- ens and the skin loses its elasticity. As the collagen ing the skin’s own collagen, collagen replacement support wears away, the skin begins to lose its tone. therapy helps smooth facial lines as well as acne Every time a person smiles, frowns, or squints, the SCARs. collagen in skin is stressed. The effect of these con- Tiny drops of thick collagen are injected with stant facial movements builds up, and eventually a fi ne needle underneath the skin to replace facial lines begin to appear. collagen lost by the body. During this injection, Creams that contain collagen that are applied some patients may feel some stinging. The entire to the skin surface cannot penetrate the skin procedure may take between two and 10 min- because the molecules are too big. No moisturizer utes, and patients recover in about two to three can reverse the cumulative damage caused by the hours. breakdown of collagen, but creams containing reti- After treatment, there may be some redness noic acid can reverse sun-induced collagen damage lasting up to 10 days; a few patients also experience and stimulate production of new collagen. Creams bruising, temporary stinging, burning sensations, can keep the skin supple by slowing the rate of faint redness, swelling, or excessive fullness. Other water loss from the skin. patients have no reaction at all. Collagen injections can also replenish the skin’s natural collagen. As the support structure of the Risks and Complications skin is restored, the skin appears smoother and Because about 3 percent of the population is more youthful. allergic to bovine collagen (developing a rash and Zyderm and Zyplast are bovine-derived collagen swelling), physicians usually perform two separate products designed to replace lost collagen due to skin tests and wait a month after each to be sure aging. Zyderm and Zyplast collagen are placed into the patient has no allergic reaction. Other possible the middle layers of the skin. However, 3 percent of risks include contour irregularities, infection, or people have allergic reactions to bovine collagen. local ABSCESS. COSMODERM and COSMOPLAST are bioengineered Not everyone is a suitable candidate for collagen human collagen products that are used in the same injections. They are not recommended for anyone way as bovine collagen, but do not carry the risk with a history of immunological disorders such as of allergy and therefore do not require a skin test LUPUS ERYTHROMATOSUS or rheumatoid arthritis. prior to the fi rst treatment. The injections can fi ll According to the U.S. Food and Drug Administra- in deep vertical wrinkles between the eyebrows, tion (FDA), more studies are required to establish deep wrinkles running from mouth to nose, and whether or not collagen is linked to certain con- forehead wrinkles. Results, however, last only nective-tissue disorders. between three and 18 months, averaging about six months. The price will vary depending on the part of the country where the procedure is carried out. collagenomas A rare connective tissue BIRTH- Each nose-to-mouth crease requires a full syringe, MARK made of COLLAGEN, characterized by yellow- and between a quarter to a half syringe of collagen ish plaques up to several inches in diameter that is needed to fi ll furrows between the eyes. usually occur on the upper trunk and sometimes composite cultured skin 85 the arms and legs. Usually present at birth or The life expectancy and diffi culties that the shortly after, no treatment is necessary. collodion baby faces depend upon the particular See also CONNECTIVE TISSUE NEVI. underlying condition. collodion baby An infant enclosed in a taut colloid milium A papular skin disease that usu- yellow-pink cellophane-like membrane at birth ally occurs on the face that has been extensively that may temporarily distort facial features (espe- overexposed to the sun. The condition consists of cially the ears, lips, and eyelids). degenerated COLLAGEN.

Symptoms and Diagnostic Path A collodian baby is usually affl icted with LAMELLAR comedo Another name for BLACKHEAD (open ICHTHYOSIS (a skin disorder characterized by rough, comedo). The plural of comedo is comedones. reddened, scaling skin). The membrane may be per- forated by LANUGO (downy fetal hair) and scalp hair. Shortly after birth, the membrane begins to composite cultured skin (CCS) A wound dress- crack and peel, revealing underlying red skin. It ing made of living human cells taken from the skin may take several weeks for the membrane to be of healthy donors, used to treat children with a completely shed so that a new membrane may rare skin disease called recessive dystrophic EPIDER- form temporarily. MOLYSIS BULLOSA (RDEB). The cells are grown on a Infants born with collodion membrane rarely sponge made from cow COLLAGEN (a protein found have normal skin after shedding. Patients with this in skin and bones). When applied to a wound, condition will have lifelong scaling and dry, rough CCS serves as a temporary protective dressing that skin. However, 10 percent of these babies do have allows the body’s cells to grow. normal underlying skin (known as a “self healing” In RDEB, BLISTERs and sores appear on the collodion baby). skin, (especially the fingers and toes), which Although often born prematurely, collodian can produce SCARs that makes the fingers grow babies are otherwise healthy. More severely together so that the hand looks like a mitten. The affected babies may lose hair or nails, and have child’s affected hand is surgically rebuilt, using some problems in eating and breathing. These pieces of the child’s own skin for grafts and flaps babies often have secondary bacterial and fungal as needed. CCS may be used along with pieces infections because their skin must be softened by of the child’s own skin to cover wounds cre- high humidity in their isolettes. ated during the rebuilding of the affected hand. CCS eliminates the need for taking skin from Treatment Options and Outlook the patient’s own body, lessening the chance of At birth, a baby with this condition is usually trans- complications. ferred to a neonatal intensive care unit where an The new type of cultured skin product was incubator provides a humidifi ed, neutral tempera- approved by the U.S. Food and Drug Administra- ture environment. Other supportive treatments tion (FDA) in spring 2001. such as intravenous fl uid and tube feeding are Epidermolysis bullosa is such a severe disease often necessary. It is important to keep the skin that the FDA approved the use of artifi cial skin soft and attempt to reduce scaling. The collodion under special humanitarian rules that allow hos- membrane should not be removed. pitals to use it to operate on carefully selected Treatment may include regular emollients such patients. as petrolatum to keep the skin moist, pain relief, The product is similar to other artifi cial skin mild topical steroids to reduce secondary infl am- already used to treat hard-to-heal wounds; a com- mation, and artifi cial tears if there is severe out- peting product (see APLIGRAF) also is being stud- ward turning of the eyelid. ied as a possible treatment for EB. 86 concealing creams concealing creams See CAMOUFLAGE COSMETICS. up bunches that form caulifl ower-like masses. They are subject to injury and can bleed, although they are generally painless. conditioner Products whose ingredients change Giant condylomata acuminata can invade local the surface structure of the hair, allowing it to be tissue (Buschke-Lowenstein tumor), which may more manageable. These structural changes in the rarely develop into squamous cell carcinoma. surface texture also provide softness and sheen. Conditioners are made up of ingredients that Treatment Options and Outlook cling to the hair cuticle; some conditioners penetrate There is no known treatment to specifi cally eradi- and bind with the cuticle in a tight chemical bond. cate human papilloma virus from the skin. The While shampoos and conditioners share many virus may survive even the most aggressive treat- ingredients, their combinations and sequences vary ment, such as lasers. Recurrence, therefore, is widely. common. Treatment is aimed at physically remov- Most conditioners contain basically the same ing warts in the patient, and in affected sexual ingredients: water, slip agents, and lubricants partners. Condoms should be worn to help reduce (dimethicone and cyclomethicone), quaternary transmission. compounds, thickeners, and more lubricants (stea- Most lesions in moist areas can be treated with ryl alcohol, cetyl alcohol, protein, or balsam), podophyllum resin in tincture of benzoin, which humectants (propylene glycol, glycerin, sodium a doctor can paint on the lesion. It is then washed PCA, mucopolysaccharides, hyaluronic acid), pre- off four hours later. Extensive areas should not servatives, fragrance, and coloring agents. Many be treated at one time, since absorption of the resin can be toxic. For the same reason, pregnant conditioners also add more exotic “natural” ingre- women should not be treated. dients to appeal to consumers. The active chemical in podophyllum resin has There are differences between conditioners, been identifi ed and is now available in the pre- depending on the hair’s condition, and there scription product Condylax. are differences in amounts of specifi c ingredients CRYOSURGERY (freezing) with liquid nitrogen (some of which are better than others). is often effective, and it is nontoxic and does not Beauty experts caution that most consumers require anesthesia. CURETTAGE AND ELECTRODESIC- apply conditioner improperly. Instead of applying CATION may also be successful. near the top of the head and working it toward While alpha interferon is available for treatment the ends, consumers should bend over and apply of resistant cases, it is not frequently recommended conditioner to ends fi rst, using little or none on the because of its high likelihood of toxicity, low effec- roots. Sparing the roots helps to avoid weighing tiveness, and expense. them down. The CARBON DIOXIDE LASER and more conven- tional surgery may also be helpful in cases of extensive growths, especially for those who have condylomata acuminata A type of GENITAL WART not responded to other treatments. caused by infection with the human papilloma In pregnant patients, cryotherapy is most effec- virus. Found throughout the world, the disorder tive. Birth control pills are believed to cause the is often diagnosed in sexually transmitted dis- warts to grow. Therefore, women taking birth ease clinics, since the warts are usually spread by control pills should stop taking the pills before the sexual contact. warts can be successfully treated.

Symptoms and Diagnostic Path Risk Factors and Preventive Measures The WARTS primarily appear in the moist genital Because these warts are easily spread, sexual con- folds and creases, and while just one wart may tact with affected individuals should be avoided. appear, they are more commonly found in heaped- See also PAPILLOMA VIRUS, HUMAN. cornstarch 87 congenital absence of skin See APLASIA CUTIS. corn A small area of thickened skin (CALLUS) with a hard core, usually found on the toe, caused by the pressure of a tight shoe. Patients with high congenital disorders of the skin A range of skin arches suffer most from corns, because the arch disorders can be present at birth. These include increases the pressure on the tips of toes while abnormalities of KERATIN such as ICHTHYOSIS; of pig- walking. “Soft corns” are caused by the rubbing of ment, such as CONGENITAL TISSUE NEVI and PIEBALDISM; two bones from adjacent toes; they remain slightly of fat, such as lipodystrophy; of blood vessels, such as softer than “hard corns” because of foot perspira- PORT-WINE STAINS and HEMANGIOMAS; of nerves, such tion. Women with wide feet who wear pointed as NEUROFIBROMATOSIS; and TUBEROUS SCLEROSIS. shoes are vulnerable to getting corns.

Treatment Options and Outlook connective tissue diseases See COLLAGEN Different shoes may make the corn gradually dis- DISEASES. appear. Corns should not be pared with a sharp instrument. Until the corn disappears, a corn pad may be connective tissue nevi A group of rare conditions used to cushion surrounding skin from pressure. (sometimes inherited) characterized by lesions The pad should be cut into the shape of a horse- and tumors of the connective tissues of the skin. shoe, not an oval (which can make the corn bulge The lesions are usually normal or slightly yellow- through the oval opening in the middle). The pad ish colored. They include ELASTOMAS, COLLAGENO- should be placed far enough behind the corn so it MAS, SHAGREEN PATCH and BUSCHKE-OLLENDORF would not rub. SYNDROME. A nonprescription corn plaster (as a liquid, salve or disk) should be applied to the corn to shield it. Treatment Options and Outlook Because the plasters contain harsh acids that may No treatment is necessary for most connective burn normal skin as well as the corn, patients tissue lesions, since they do not cause any severe should use them with caution. If irritation devel- cosmetic defects. Surgical removal is occasionally ops, they should not be used for a day or two. performed. At the fi rst sign of pain, a bit of lanolin can be used to soften the corn; a pad on the area can relieve pressure. A few strands of lambswool or Conradi’s disease Also known medically as a toe separator/spacer can be placed between the “chondrodysplasia punctata,” this genetic disorder toes to keep them from rubbing together. is characterized by skin abnormalities in 30 percent of patients, together with facial abnormalities and congenital cataracts. At birth, the skin is dry and corn oil A vegetable oil that can be used as an cracked, especially around hair follicles; some hair emollient. Corn oil is not usually associated with loss also may occur. allergic reactions. See also HAIR, DISEASES OF.

cornstarch A starch derived from corn kernels, contact dermatitis See DERMATITIS, CONTACT. used as a nonabrasive powder for irritated skin. Although cornstarch may encourage fungal skin infections (especially in people with diabetes), some contracture A deformity caused by shrinkage of experts suggest using a powder made of cornstarch scar tissue in the skin or connective tissue. They instead of talcum powder. Reports have linked tal- are common following extensive BURNS, and can cum powder with cancer and higher rates of ovar- restrict movement. ian cancer in women using talcum powder in the 88 corrosive chemicals genital area, but experts at the National Institutes of corticosteroids A group of hormones similar to Health conclude the data on talc are inconclusive. the natural hormones produced by the cortex of the adrenal glands. Developed more than 30 years ago, the fi rst topical corticosteroid revolutionized corrosive chemicals Certain corrosive chemicals dermatologic therapy with its strong anti-infl am- (such as oven cleaners, drain cleaners, and dish- matory properties; stronger and stronger com- washer detergents) contain alkalizers, which can pounds have been developed ever since. cause serious BURNS on the skin. Alkalizers (which They are used both on the skin and internally have a pH of 11.5 or more) include potassium, to treat a wide variety of skin disorders from mild sodium, ammonium, and calcium; of these, potas- ECZEMA to widespread blistering disorders such as sium hydroxide is the strongest. When considering PEMPHIGUS. Their broad anti-infl ammatory effects the danger from these products, the higher the are the basis for both the therapeutic benefi ts and concentration of these ingredients in the alkalizer, the adverse reactions associated with use of these the more serious the burn caused. drugs. While most people think of acids as corrosive, Applied in the form of creams, ointments, an alkalizer is even more so; acid walls off its burn, lotions, and aerosols, their absorption is increased if while an alkalizer actually spreads in the skin, dis- the drug is applied when the skin is moist (such as solving tissue as it goes. right after bathing). Absorption of topical cortico- steroids also varies with body location; absorption Treatment Options and Outlook is greater through the layers of skin on the scalp, Any severe burn should be treated in a hospital emer- face, and genital area than on the forearm; as a gency room. For a mild alkalizer burn, the affected result, these areas are more susceptible to the side area should be washed in lukewarm water for at effects of the drugs than other sites. Excessive use least 15 minutes (preferably longer). Any contami- of over-the-counter topical steroids (especially on nated clothes or jewelry should be removed. If eyes large areas of infl amed skin) can lead to more side are involved, contact lenses should be removed effects and decreased therapeutic effects. immediately. If the alkaline substance is solid, the Some skin problems may be masked or wors- skin should be scrubbed to make sure all particles ened by using topical corticosteroids. Infections are removed; a weak acid (such as vinegar, lemon, and infestations (especially candidiasis, IMPETIGO, or orange juice diluted with four parts of water) and SCABIES) may be either worsened or hid- should be used to neutralize the alkaline that may den, and ROSACEA may be worsened by topical have penetrated deeper in tissues. corticosteroids. Exception: calcium oxide, or quicklime. Quicklime tends to absorb water and creates slaked lime, Side Effects which gives off heat. The quicklime should be The incidence of adverse effects depends on dos- removed before it comes in contact with water. The age, the form of the drug, and how long it was skin should be oiled before the lime is wet, and a administered. Side effects are uncommon when stream of water should be applied at high pressure given as a cream or by inhaler because only small to immediately remove oxide particles. Any lime amounts of the drug are absorbed into the blood. left on the skin can cause burns. Infants and children have a greater risk of devel- Corrosive burns also can be caused by strong oping adverse effects, and should be treated with acids, such as a toilet bowl cleaner (usually sul- topical corticosteroids of low potency. furic or hydrochloric acid). Unfortunately, these Acute side effects can include atrophy and thin- acids are not usually listed on the container. If ning of the skin, especially when used on the skin these products contact the skin, the area should be of the face. washed with large amounts of lukewarm water for Tablets taken in high doses for long periods may 15 to 30 minutes. Salves and ointments should not cause tissue swelling, high blood pressure, diabetes be applied to the burn. mellitus, ulcers, HIRSUTISM (excess hairiness), and cosmetic allergy 89

(rarely) psychosis. High doses also increase the needles into the acupuncture points on the face, susceptibility to infection by interfering with the which increases local circulation to the face and body’s immune system. Because long-term use of stimulates COLLAGEN production. This may fi ll out these drugs suppresses the production of natural the lines and gives fi rmness to the skin. corticosteroid hormones, sudden withdrawal of the Acupuncture has been used for thousands of drug may lead to collapse, coma, and death. Cor- years to treat many conditions and illnesses. The ticosteroid dosages should always be tapered off in effectiveness of acupuncture has been related to decreasing amounts. the manipulation of the energy points on the body to balance and to remove blockages in the merid- ians (channels of blood and energy) to stay healthy cortisone A synthetic CORTICOSTEROID drug used and prevent diseases. to reduce infl ammation in severe allergic, rheu- A 1996 report in the international journal of matic and connective tissue diseases, among other Clinical Acupuncture reported that among 300 cases things. treated with cosmetic acupuncture, 90 percent had noticeable effects after one course of treatment. Side Effects However, this work has not been reproduced. High doses for long periods of time can cause swell- Cosmetic acupuncture is said to take between ing, high blood pressure, diabetes, excess hairiness, fi ve and 10 years off the face, helping eliminate and inhibited growth in children. They can also fi ne lines and make the deeper lines look softer. interfere with the immune system, leaving the It also supposedly helps to minimize dark circles, patient vulnerable to illness. Sudden withdrawal of puffy eyes, double chin, sagging skin, and drop- the drugs may lead to collapse, coma, and death. ping eyelids, relax muscle tone, tighten the pores, and brighten the eyes. It also moisturizes the skin from inside. cosmeceutical Cosmetic products that have medicinal or druglike benefi ts. The U.S. Food, Drug Procedure and Cosmetic Act defi nes a “drug” as something In this process, needles are inserted into acupunc- that cures, treats, mitigates, or prevents disease or ture points on the face (and sometimes on the that affects the structure or function of the human body), followed by a moisturizing facial massage. body. Cosmetics are not considered to be “drugs” Several treatments are usually required for best because they do not alter the function of skin. results. However, many skin products (such as GLYCOLIC ACID and RETINOL) are quite effective at rejuvenat- ing skin. Because they are not considered drugs but cosmetic allergy About 6 percent of all allergic are more effective than cosmetics, the new desig- skin reactions are linked to cosmetics, although this nation “cosmeceutical” has been applied. How- number is declining because of more sophisticated ever, the Food, Drug and Cosmetic Act does not testing of cosmetic products. recognize the term “cosmeceutical.” While drugs While “HYPOALLERGENIC,” “allergy-tested” or are subject to a review and approval process by “dermatologist-approved” labels seem to indicate the FDA, cosmetics—and cosmeceuticals—are not a safe choice for those allergic to cosmetics, in approved by the FDA prior to sale. fact these labels are not regulated by the govern- ment and do not guarantee that the product has been any more extensively tested than any other cosmetic acupuncture A specialized type of acu- cosmetic. puncture designed to help tighten facial muscles The U.S. Food and Drug Administration has not and stimulate good circulation in facial skin. This established a legal defi nition of such terms as “hypo- nonsurgical treatment is purported to reduce the allergenic” and while only a few products may signs of aging by inserting very thin disposable actually be labeled “dermatologist tested,” in fact 90 Cosmetic Ingredient Review (CIR) Expert Panel most cosmetic safety testing is performed by der- the independent Expert Panel consisting of world- matologists who work for private cosmetic-testing renowned physicians and scientists who review labs. the available data. Expert Panel members must be Experts do agree that even the best products free of any confl icts of interest and must meet the labeled “hypo-allergenic” do not guarantee than same confl ict-of-interest requirements as outside no one will experience a reaction; the label simply experts to the U.S. Food and Drug Administration means that these products are less likely to cause an (FDA). allergic reaction. According to its 1999 Annual Report, CIR has Hypo-allergenic means that a manufacturer has found the following ingredients unsafe: tried to eliminate as many of the known common sensitizing ingredients as possible (such as fl avor- • chloroacetamide (a preservative), because of ings, some preservatives, and fragrances) and has allergic reactions tried to cut out manufacturing by-products that • ethoxyethanol and ethoxyethanol acetate (a sol- might contaminate the fi nal product. Manufactur- vent), because of reproductive and developmen- ers also work closely with dermatologists to fi nd tal toxicity out the source of allergies to their products by • HC Blue No. 1 (a hair coloring ingredient), providing samples of the individual ingredients for because of possible carcinogenicity testing. Those with highly sensitive skin should choose • p-Hydroxyanisole (an antioxidant), because of products that are labeled “fragrance free,” since skin depigmentation. many studies have determined that it is the fra- • 4-methoxy-m-phenylenediamine, 4-methoxy- grance in a product that most often causes an allergic m-phenylenediamine HCl, and 4-methoxy-m- reaction. However, consumers should understand phenylenediamine sulfate (hair dye ingredients), that “unscented” is not the same as “fragrance because of possible carcinogenicity. free”—an unscented product often contains mask- • pyrocatechol (used in hair dyes and skin care ing fragrances to neutralize unpleasant odors. preparations), because of carcinogenic and co- As a general rule, all consumers should apply carcinogenic potential. (CIR describes this sub- cosmetics carefully near the eye, since this area is stance as unsafe for leave-on products and the most vulnerable to an allergic reaction, due to considers available data insuffi cient to assure the thin, sensitive nature of the skin here. safety for use in hair dyes.) If consumers suspect they may be allergic to a product, they should bring it (along with pack- age and ingredients label) to a dermatologist. The The seven CIR expert panel voting members American Academy of Dermatology allows any include physicians and scientists who have been board-certifi ed dermatologist to obtain help from publicly nominated by consumer, scientifi c, and most cosmetic companies in determining the ingre- medical groups; government agencies; and indus- dients list of specifi c products. try. Three liaison members serve as nonvoting members representing the FDA, Consumer Fed- eration of America, and CTFA. By uniting industry, Cosmetic Ingredient Review (CIR) Expert consumers, and government, the expert panel cre- Panel An unbiased panel of scientifi c experts that ates a unique environment for discussions affecting was established in 1976 by the COSMETIC, TOILETRY, public safety. AND FRAGRANCE ASSOCIATION (CTFA), to check the Working on the high-priority ingredients, CIR safety of ingredients used in cosmetics. staff conduct extensive literature searches, compile Although funded by CTFA, CIR and the review data, and prepare draft reports. CIR staff organize process are distinctly separate from CTFA and the the literature into chemistry, including physical cosmetic industry. The heart of the CIR program is properties and manufacture; use, including cos- cosmetic ingredients, prohibited 91 metic and noncosmetic; general biology, including exceeding 65 parts per million (0.0065 percent) absorption, distribution, and metabolism; animal of mercury calculated as the metal (about 100 toxicology, including acute, short-term, subchronic, ppm or 0.01 percent phenylmercuric acetate or and chronic studies, as well as dermal irritation and nitrate) and provided no other effective and safe sensitization; and a clinical assessment, which may preservative is available for use. All other cos- include epidemiology studies along with classic metics containing mercury are subject to regula- repeat insult patch tests. In vitro test data are also tory action unless it occurs in a trace amount of gathered and incorporated into the review. less than one part per million (0.0001 percent) If the open, scientifi c literature does not con- and its presence is unavoidable under conditions tain enough information, the panel will order of good manufacturing practice. specifi c studies or provide previously unpublished • Chlorofl uorocarbon propellants: The use of chlo- data. After completion of a development process rofl uorocarbon propellants in cosmetic aerosol that includes multiple opportunities for public products intended for domestic consumption is comment and open, public discussion of the prohibited. report, a fi nal report is issued. These fi nal reports are available from CIR. Eventually, CIR fi nal • Bithionol: Prohibited because it may cause photo- reports are published in the International Journal contact sensitization of Toxicology. • Halogenated salicylanilides: Prohibited because it may cause photocontact sensitization. • Chloroform: Prohibited because of its animal car- By law, the cosmetic ingredients, prohibited cinogenicity and likely hazard to human health U.S. Food and Drug Administration does not have the authority to approve cosmetic products or • Vinyl chloride: Prohibited as an ingredient of ingredients, except for color additives. However, aerosol products, because of its carcinogenicity regulations prohibit or restrict the use of several • Zirconium-containing complexes: Prohibited in ingredients because of safety concerns. In addition, aerosol cosmetic products because of toxic effects cosmetic and fragrance trade associations have on lungs recommended avoiding or limiting the use of some • Methylene chloride: Prohibited because of its ani- substances. mal carcinogenicity and likely hazard to human Regulations specifi cally prohibit or restrict the health use of the following ingredients in cosmetics:

• Hexachlorophene: Because of its neurotoxic effect Color Additives and ability to penetrate human skin, hexachloro- Color additives also are strictly regulated. In order phene may be used only when an alternative to protect consumers from harmful contaminants, preservative has not been shown to be as effec- many cannot be used unless the color comes from tive. The concentration of hexachlorophene may a batch certifi ed by the FDA and that batch is not exceed 0.1 percent, and it may not be used provided with its own individual certifi cation lot in cosmetics that in normal use may be applied number. Their uncertifi ed counterparts are not to mucous membranes, such as the lips. allowed, and addition of the color to a product will • Mercury compounds: Mercury compounds are make the entire product adulterated. While colors readily absorbed through the skin on topical exempt from certifi cation are not subject to such application and tend to accumulate in the body. testing, manufacturers must assure that each color They may cause allergic reactions, skin irritation, additive complies with the identity, specifi cations, or neurotoxic manifestations. The use of mer- labeling requirements, use, and restrictions of color cury compounds as cosmetic ingredients is lim- additive regulations. With the exception of COAL- ited to eye area cosmetics at concentrations not TAR hair dyes, all color additives, whether or not 92 cosmetic labeling they are subject to certifi cation, must be approved affects the function of the skin in order to decrease by the FDA for their intended use. the amount of sweat. While both cosmetics and drugs are regulated by the U.S. Food and Drug Administration, almost cosmetic labeling Federal regulations require all of the FDA’s time is taken up with drugs and ingredients to be listed on product labels in descend- very little is spent on investigating cosmetics. While ing order by quantity. Consumers can check the cosmetics may be loosely regulated, they have been ingredient listing to identify ingredients they wish required to list their ingredients on the label since to avoid. Based on the amount used, an ingredient 1975, although they do not go into details regard- such as water is usually found at the beginning of ing concentration or purity. the product’s ingredient listing, while additives and fragrances, used in small amounts, are normally Ingredients seen at the end. Cosmetics are made up of a variety of sub- Cosmetic ingredients regulations apply only to stances, including preservatives, stabilizers, emul- retail products intended for home use. Products sifi ers, antioxidants, and so on. Preservatives are used exclusively by beauticians in beauty salons included in order to extend a product’s shelf life. that are labeled “For Professional Use Only” and Most preservatives are divided into two types— cosmetic samples such as those given out free at antimicrobial agents and ANTIOXIDANTS. Antimi- hotels and department stores are not required crobial agents, which work by inhibiting the to include the ingredient declaration. However, growth of microbacteria and fungi in the cosmetic, these products must state the distributor, list the include organic acids, alcohol, aldehydes, essential content’s quantity, and include all necessary warn- oils, ammonium compounds, mercury agents, ing statements. phenolic agents, and acid agents. Antioxidants The Food and Drug Administration regulates work by reducing oxidation and destruction of only the labels that appear on cosmetic products fats and oils in the product; they include both themselves. Unfair and deceptive advertising that organic and inorganic agents. Preservatives are appears in magazines, in newspapers, or on televi- so important to the ingredients of cosmetics that sion generally falls under the authority of the Fed- preservative-free cosmetics would have to be kept eral Trade Commission. in the refrigerator. Cosmetics also contain some unusual ingredi- ents. Squalene, used in moisturizers for its anti- cosmetics Preparations that are applied to the bacterial qualities, originates in olives and sharks’ skin to enhance appearance. Since earliest times, livers. The red color found in many cosmetics women have been applying vegetable dyes and is derived from carmine (crushed shells from a color pigments to their faces, pounding out prepa- beetlelike slug). Some frosted eye shadows contain rations from leaves and fl owers and natural ores. guanine (crushed fi sh scales). Ambergris (mate- In 1992, Americans spent $3.5 billion on skin-care rial coughed up by whales) was once coveted as a products alone—a 5.5 percent increase over 1991, fragrance fi xative, although cheaper fi xatives are according to the cosmetic consulting fi rm Kline used today. & Co. At best, most cosmetics are only helpful in improving appearance; others may be actively Contamination harmful to the skin. Cosmetics should never be shared with anyone Cosmetics are not drugs, which are products else. Bacteria, viruses, and fungi can all fl ourish in that change the function or structure of the skin. makeup. (There are no known cases of AIDS trans- For example, a deodorant is not a drug because it mitted via cosmetics, however). does not alter the body’s sweating, it simply adds a To counter the risk of infection, stores that perfume. But an antiperspirant is a drug, because it once offered communal lipsticks and eye pen- coumarin (Coumadin) necrosis 93 cils are now using safer sampling products. For and whether they will be able to put up with the example, some companies now offer one-time- pain and other aftereffects. use tubes of mascara; other companies provide Before a cosmetic operation, a responsible sur- sterile swabs and sponges for consumers eager geon will ask a patient all the above questions, to sample the latest makeup shades. Some stores consult the persons medical history and ask about forbid their clerks to apply lipstick directly, even other surgeries. All options will be presented, and on someone’s hand; instead, they use a new the surgery itself will be explained in detail. applicator for each customer. If consumers cannot See also ARGON LASER; CARBON DIOXIDE LASER; fi nd single-use makeup samples or fresh applica- CHEMICAL FACE PEEL; COLLAGEN INJECTIONS; EYELID tors, they should bring cotton swabs or applica- LIFT; FAT TRANSPLANTS; FIBREL; FREE-FLAP SURGERY; tors from home. LASER TREATMENT; NOSE REPAIR; MAMMOPLASTY; LASER RESURFACING. Choosing Cosmetics Experts recommend that consumers should analyze their skin type before buying skin-care products. CosmoDerm or CosmoPlast Human-derived Consumers should always read labels to fi nd out COLLAGEN used to repair wrinkles and other facial what ingredients are included. While HYPOALLER- imperfections, and considered to be safer than GENIC products have the simplest formulations, bovine-derived collagen. Both products have been there is no guarantee that a reaction will not occur. approved for cosmetic corrective use by the U.S. See also MAKEUP. Food and Drug Administration. CosmoDerm is used for minor skin defects, and CosmoPlast is used for defects that are more signifi - cosmetic surgery Operations performed to cant. This technique typically lasts between three improve the appearance, instead of improving and four months. function or treating disease. Individuals seek out See also SKIN FILLERS. cosmetic surgery for a wide range of reasons, for example, to appear younger, to reduce too-large breasts, or resculpt a nose. coumarin (Coumadin) necrosis Another name Cosmetic surgery can include operations of the for an anticoagulation syndrome, this severe reac- brow and upper face and eyebrows to remove signs tion to the anticoagulant drug coumarin occurs of aging; mid-face lift, to lift and restructure the infrequently, usually in young women. The reac- mid-face; neck and chin (segmental meloplasty), tion begins between three and 10 days after begin- to remove sagging excess neck skin and/or rebuild ning treatment with a coumarin drug such as the chin; full FACE-LIFT (rhytidectomy) to lift the dicumarol or warfarin. Neither stopping nor con- whole face; eyelids (blepharoplasty); nose (rhino- tinuing the drug changes the course of the lesions, plasty) to reduce or reshape; abdomen (abdominal once they appear. lipectomy) to remove excess fat tissue and skin; They begin as tiny red spots or a blue-purple breast reduction/augmentation, to change the hemorrhagic patch, quickly followed by tissue shape of the breast; ears (otoplasty) to pin back death, which can extend deep into the subcutane- ears or change their shape; LIPOSUCTION, to remove ous fat and take months to heal. About 80 percent excess fat; laser resurfacing chemical peels, and of the lesions occur on the lower body, such as the photorejuvenation to improve the appearance of thighs, abdomen, and breasts (especially in areas the complexion. fi lled with subcutaneous fat). Those who are contemplating cosmetic surgery The condition has been associated with a lack of should ask themselves the reasons why they want protein C, a vitamin K-dependent plasma protein the operation, whether expectations for results are that interferes with blood clotting. realistic, whether they can afford the procedure See also HEPARIN NECROSIS. 94 Cowden’s disease

Cowden’s disease An inherited skin disease that be washed out, because if this is left in the hair it appears in childhood or puberty, characterized by could aggravate the problem. shiny PAPULES on the face, palms, tongue, and in This treatment may need to be repeated for the mouth area. There is also a strong association several days until all the scales are washed off. between Cowden’s disease and the development of Baby’s hair should be brushed daily with a soft- breast cancer in women, and thyroid and gastroin- bristle brush to help loosen scales that can then be testinal cancer in males and females. removed with a fi ne-tooth comb. Cowden’s disease is an autosomal dominant A physician should be consulted if the skin looks disorder, which means that only one defective infl amed or the condition worsens. A mild cortico- gene (from one parent) is needed to cause the steroid solution or cream may be prescribed until syndrome. Each child of an affected person usually the condition clears. has a one in two chance of inheriting the defec- tive gene and of being affected, and a one in two Risk Factors and Preventive Measures chance of being unaffected. Once the condition has improved, cradle cap can be prevented from recurring by frequent hair Treatment Options and Outlook washing with a mild baby shampoo. Occasionally, Facial lesions can be removed with electrocautery a stronger medicated shampoo may be needed, but by surgery or with laser therapy. a pediatrician should make the decision. After the child’s fi rst birthday, the condition will not recur Risk Factors and Preventive Measures until puberty. Some experts suggest that bilateral preventive Sometimes, YEAST INFECTIONS become superim- mastectomies should be carefully considered for posed on the affected skin, most likely in the crease women with a strong personal or a strong family areas rather than on the scalp. If this occurs, the history of Cowden’s disease. area will become extremely reddened and quite itchy. In this case, the pediatrician might prescribe specifi c anti-yeast cream containing the medicine crab lice See LICE. Nystatin. cradle cap A harmless, common skin condition cream, cleansing An emulsifi er that is really a in infants in which thick yellow scales form in soap, and therefore more alkaloid than the pH of patches over the scalp. It is a form of SEBORRHEIC the skin. Cleansing creams are all basically varia- DERMATITIS, which also may occur on the face, tions on old formulas containing borax, water, neck, behind the ears, and in the diaper area. mineral oil, and bees-wax. Cleansing lotions and Without treatment, it may persist for months but, aerosol foams are basically variations of the same when properly cared for, usually fades away within product in a different format. a few weeks. Soap and water are better at removing oily dirt from the skin, but cleansing creams are better at Treatment Options and Outlook removing oily makeup. Because of their alkalinity, The baby’s hair should be washed with baby sham- cleansing creams can be irritating to sensitive skin. poo or a mild anti-dandruff shampoo once a day; See also COSMETICS; MAKEUP; SOAP AND THE SKIN. after lathering, the scaly scalp should be massaged with a soft toothbrush for a few minutes. For very crusty conditions, olive or mineral oil should CREST phenomenon Acronym for a condition be rubbed into the baby’s scalp an hour before a that includes the symptoms of “calcinosis (abnor- shampoo. The oil loosens and softens the scales, mal calcium deposits in the skin), RAYNAUD’S which can then be washed off. All the oil must PHENOMENON, esophageal dysmotility, sclerodac- cryptococcosis 95 tyly and telangiectasia.” It is found in a group of less often used. The liquid nitrogen is applied to patients with progressive systemic sclerosis. the skin with a cotton-tipped applicator or via a Cryospray unit for fi ve to 30 seconds, depending on the diagnosis. Cryotherapy precludes the need Cronkhite-Canada disease An extremely rare for anesthesia, which makes the procedure sim- disorder characterized by multiple benign growths pler than cold steel surgery. Dressings are usually in the intestines and stomach, loss of scalp hair, not required after treatment. The area is washed widespread areas of dark spots on the skin, and the twice daily with mild soap and water followed loss of fi ngernails. The skin symptoms are thought by application of an antibiotic ointment to pre- to be due to protein loss and malabsorption. vent bacterial infection. Most lesions are red and Usually reported in older men, Cronkhite- scaly for several days to a few weeks, eventually Canada syndrome is relentlessly progressive, with crumbling away and leaving a smooth surface a poor prognosis. However, cases of spontaneous behind. A BLISTER may form and may cause mild remission have been reported following aggressive discomfort. nutritional support. Because it involves minimal scarring, it is espe- cially helpful for cosmetic reasons. The most common use of cryotherapy is for the Cross-McKusick-Breen syndrome A very rare treatment of lentigines (liver spots), SEBORRHEIC disorder featuring lack of skin color. KERATOSES, ACTINIC KERATOSES, WARTS and MOL- LUSCUM CONTAGIOSUM. Skin cancers, such as BASAL Symptoms and Diagnostic Path CELL CARCINOMA and some in-situ SQUAMOUS CELL In addition to altered skin color, symptoms include CARCINOMAs, also may be treated with cryotherapy. mental retardation, short stature, writhing move- Some lesions may require more than one treat- ments, and gingival fi bromatosis. ment (usually spaced three weeks apart).

Treatment Options and Outlook Risks and Complications Patients with this syndrome should avoid the mid- Complications may include HYPOPIGMENTATION or, day sun and use UVA-UVB sunscreen. Sunglasses less often, scarring. will help combat eye sensitivity to light. While nei- ther BETA-CAROTENE nor PUVA can offer solar protec- Outlook and Lifestyle Modifi cation tion, beta-carotene may help improve skin color. Some malignant lesions (basal cell or squamous cell carcinomas) treated with aggressive cryosur- gery have reported cure rates of 95 percent. crotamiton cream (Trade name: Eurax lotion) A treatment for SCABIES that is not particularly effec- tive. Experts suggest that fi ve daily applications cryptococcosis A rare FUNGAL INFECTION caused may be better than the two currently recom- by inhaling Cryptococcus neoformans, found through- mended, but current data are not conclusive. Its out the world, especially in soil contaminated toxicity is unknown; it is applied to the whole body with pigeon droppings. Although it usually affects below the neck, left on for 48 hours, and then adults, infection can occur at any age, especially washed off. among those already ill with cancer, such as leukemia or lymphoma, or those who have sup- pressed immune systems (such as patients with cryosurgery The surgical destruction of tissue AIDS). Infection with this fungus is unusual in using below-freezing temperatures. patients who are otherwise healthy. In the United The standard agent for this type of surgery is States, 85 percent of cases occur in HIV-infected liquid nitrogen at –195.6° C. Carbon dioxide is patients. 96 cucumber

Symptoms and Diagnostic Path through the skin. Multiple bruises (called Bate- While meningitis is the more usual and seri- man’s purpura) are also common, and minute tears ous form of the disease, the infection also can in the skin on the backs of the hands and forearms cause a range of granular lesions, including ulcers, may cause scars. This condition is most likely to ABSCESSES, tumors, PAPULES, and nodules into the occur in areas of aged skin exposed to excessive skin and lungs. amounts of sunlight. Atrophy may also result from some infl ammatory skin conditions or as a type of Treatment Options and Outlook scarring. Fluconazole freely passes through the central ner- vous system and is the drug of choice; intravenous AMPHOTERICIN B and oral FLUCYTOSINE also may be cutaneous diphtheria A bacterial infection com- helpful. If untreated, this infection may be fatal. mon in the tropics, but also found in Canada and the southern United States. It is caused by the organism Corynebacterium diphtheriae, normally cucumber As a fresh vegetable or in extracts, the found in the mucous membranes of the nose and naturally acidic cucumber contains VITAMIN C and throat and probably on human skin. CHLOROPHYLL; slices of cucumber can be helpful in Diphtheria is rare in the United States and soothing tired, puffy eyes. While the fresh cucum- Europe, where health offi cials have been immu- ber can be benefi cial, heavily processed commer- nizing children against it for decades. In the United cial extracts do not usually contain any benefi cial States, fewer than fi ve cases have occurred each ingredients. year since 1980, according to the Centers for Disease Control and Prevention. Most cases of diphtheria occur in unvaccinated or inadequately curettage and electrodesiccation The removal of vaccinated people. Diphtheria poses a threat to tissue with a sharp instrument called a curet, fol- U.S. citizens who may not be fully immunized and lowed by electrosurgery in which tissue is destroyed who travel to other countries or have contact with by burning with an electric spark. Bleeding also can immigrants or international travelers coming to the be stopped by electrodesiccation. Curettage is often United States. used to remove WARTS, SEBORRHEIC KERATOSES, and Symptoms and Diagnostic Path BASAL CELL CARCINOMA. Superfi cial ulcers on the skin with a gray-yellow Procedure or brown-gray membrane in the early stages that In the procedure, the bulk of a lesion is fi rst can be peeled off; later, a black or brown-black removed with a curet under local anesthesia and scab appears, surrounded by a tender infl amma- the base is destroyed afterwards with electrodesic- tory area. cation. Because the current does not penetrate very deeply, scooping out tissue with a curet increases Treatment and Options and Outlook the effi ciency of the procedure. Antibiotics and specifi c antitoxins are useful. Oral For treating most basal and some SQUAMOUS penicillin V potassium is effective in mild cases. CELL CANCERs, the procedure is usually repeated While the antibiotics will inhibit the growth of three times. the bacteria, diphtheria antitoxin is required to inactivate the toxin. Complications and death are very rare. cutaneous atrophy The medical term for thin- ning of the skin. It is a normal part of aging result- Risk Factors and Preventive Measures ing in the loss of substance from the fi rst two layers Today, diphtheria in the United States and other of the skin. In this condition, the skin is thin, easily developed countries is extremely rare because the wrinkled and fragile, with blood vessels showing triple DPT vaccine (against diphtheria, pertussis, cutis marmorata telangiectatica congenita 97 and tetanus) is given routinely to children in the Localized forms of cutis laxa may be hereditary, fi rst year of life. and may occur only in certain areas of the body as an independent disorder or as a part of the gener- alized form of the disease. The localized form may cutaneous focal mucinosis See MUCINOSES. be the only expression of the disease, or it may be a precursor for later development of a more wide- spread form. cutaneous infections, noninvasive See TINEA. Blepharochalasis (abnormal looseness of the eyelids) may result from aging or may begin early in life. In the localized form, there may be coin- cutaneous tag See SKIN TAGS. sized areas of loss of tissue in the skin, with out- pouching of underlying tissue. These patches may appear spontaneously, or after the skin has been cuticle A layer of solid or semisolid material that injured by infl ammation or disease (such as SYPHI- covers the EPITHELIUM. LIS, ERYTHEMA MULTIFORME, ACNE, HIVES, CHICKEN POX) Lesions will continue to appear throughout life, although most appear during childhood and cutis The skin. adolescence.

Treatment Options and Outlook cutis hyperelastica The medical name for EHLERS- There is no helpful treatment for either the general- DANLOS SYNDROME. ized or the localized form of cutis laxa. Any attempt at surgical tightening is followed by prompt reap- pearance of the skin folds. cutis laxa A group of genetic or acquired diseases Patients with the localized form should avoid of the connective tissue characterized by loss of injury that could lead to infl ammation and new normal skin elasticity, resulting in skin abnormali- lesions. ties that may either be generalized or localized. Unattractive lesions can be surgically excised, but the wounds may not heal well and the scars Symptoms and Diagnostic Path may spread and gape. Generalized cutis laxa, also called generalized elastolysis, is characterized by loose folds of skin on the sides of the face, leading to sagging jowls cutis marmorata telangiectatica congenita Also and a bloodhound appearance. It appears around known as van Lohuizen’s disease, this congenital puberty or later. Changes appear in connective tis- circulatory disorder causes an exaggerated network sues in other parts of the body, leading to pulmo- marbling (fi xed LIVEDO RETICULARIS) of the skin of nary emphysema, gastrointestinal tract and bladder the trunk, legs and arms, face, and scalp. problems, and multiple hernias. In its most severe form, the saggy skin over the entire body (not just Symptoms and Diagnostic Path sun-exposed areas) produces a striking appearance The demarcation between normal and abnormal of old age. skin is sharp and often seen at the midline. In addi- Congenital forms of cutis laxa are characterized tion, ulcers may appear on the affected skin. The by loose, pendulous skin present at birth or shortly condition usually improves with time. thereafter, giving the child a prematurely aged Other symptoms include atrophy of the soft tis- appearance. The skin can be pulled up but will not sues and bones of the affected part. Other develop- spring back when released. Multiple organs may mental abnormalities also can occur. HEMANGIOMAS be affected because of the defect in supporting and areas of nevus fl ammeus may be associated structure. with this disorder. 98 cyanosis

This disease should not be confused with cutis include mouth ulcers, increased discoloration of marmorata, which is the term used to describe the skin and nails, jaundice, clotting abnormalities, the normal transient physiological reaction of mottled complete absence of sperm, or lack of ovulation. blue skin in reaction to the cold that is seen in This drug causes birth defects. about half of all normal children and adults.

Treatment Options and Outlook cyclopiroxolamine (ciclopiroxolamine) (Trade Only local treatment is needed if complications name: Loprox) A topical agent used to treat fungus such as ulcers develop. infections that inhibits the growth of dermatophytes (microscopic fungi), Candida albicans, and the agent causing TINEA VERSICOLOR (a type of RINGWORM). cyanosis Bluish discoloration of the skin due to an excess of deoxygenated hemoglobin in the blood, most easily seen in the nail beds of fi ngers and toes, cyclosporine An immunosuppressant drug and on lips and tongue. It occurs most often when derived from soil fungus that suppresses the body’s blood fl ow through the skin slows down because of natural defense against abnormal cells. Introduced cold; however, this type of cyanosis is not serious in 1984, it is used primarily to prevent and treat and does not indicate any underlying disease. organ transplant rejection. It is also helpful in the In other instances, cyanosis can be a serious treatment of skin diseases such as recalcitrant PSO- symptom of disease. It may indicate poor blood RIASIS, pemphigus vulgaris, GRAFT-VERSUS-HOST circulation in the extremities, in which fi ngers DISEASE, and BEHCET’S SYNDROME. Benefits from and toes turn blue even when the environment is cyclosporine have also been reported in patients fairly warm. Cyanosis also may be a sign of heart with severe atopic DERMATITIS, ALOPECIA, ICHTHYO- problems (such as heart failure) or fl uid in the SIS vulgaris, EPIDERMOLYSIS BULLOSA acquisita, lungs. PYODERMA GANGRENOSUM, systemic LUPUS ERY- Cyanosis present at birth could be a sign of con- THEMATOSUS, cutaneous T-cell lymphoma, and genital heart disease in which some of the blood SARCOIDOSIS. does not reach the lungs to pick up oxygen but instead goes directly to the rest of the body. Side Effects Because cyclosporine interferes with the immune system, patients treated with this drug are more cyclophosphamide (Trade names: Cytoxan and susceptible to infection. Any fl ulike illness or local- Neosar) An anticancer drug that has been used ized infection requires immediate medical atten- with some success in those with PEMPHIGUS and tion. Because cyclosporine is metabolized primarily BULLOUS PEMPHIGOID. Other skin diseases that may by the liver, patients with liver disease may experi- respond to this drug include LUPUS ERYTHEMATOSUS, ence problems with this drug. and PYODERMA GANGRENOSUM and in some types of In addition, the drug has been found to cause vasculitis, such as Wegener’s granulofosus. Patients kidney problems; therefore, regular kidney func- with advanced forms of mycosis fungoides have tion monitoring is necessary for anyone being been treated with chemotherapy combinations given this drug. If signs of kidney damage appear including cyclophosphamide. (such as protein in the urine), the dosage needs to be reduced or other drugs may be substituted. Side Effects In many people, kidney problems disappear after Common side effects are hair loss, nausea, vom- the drug is stopped, but some people experi- iting, and cystitis. Cystitis may be avoided if the ence irreversible kidney damage from use of patient drinks plenty of water shortly before and up cyclosporine. to two hours after taking the drug orally followed Other side effects may include high blood pres- by frequent urination. Less common side effects sure, gastrointestinal problems, fatigue, develop- cytotoxic drugs for skin diseases 99 ment of secondary cancer (primarily lymphomas), Dermoid cysts are found in parts of the body that and infections. Another fairly common side effect fused during fetal development. Sometimes a der- is swelling of the gums and hairiness. moid cyst may appear after an injury. Treatment is surgical removal.

Cymetra A micronized version of ALLODERM soft tissue fi ller that is rehydrated with the anesthetic cytotoxic drugs, skin side effects of Anticancer lidocaine in the physician’s offi ce before injection drugs that kill or damage cells also may cause so the procedure is much less painful. Cymetra is HYPERPIGMENTATION (darkening of the skin). While approved for cosmetic corrective use, but it is not cytotoxic drugs primarily affect abnormal cells, recommended for use between the eyes or around they can also damage or kill healthy cells, especially the eye area. It is effective for nasal-labial folds and those that multiply rapidly, such as in the skin. lip enhancement. Cytotoxic drugs that may affect the skin include See also SKIN FILLERS. BLEOMYCIN, which causes the skin to become deeply tanned because of pigment cell stimulation. In addition, cyclophosphamide and melphalan can cyst A closed cavity or sac containing a liquid or cause bands of hyperpigmentation of the skin and semisolid material beneath the skin. Cysts may be in the nails. caused by a variety of reasons; those affecting the skin may be caused by a blocked duct leading from a fl uid-forming sebaceous gland to the skin gland. cytotoxic drugs for skin diseases There are sev- While these cysts are benign, they may become eral cytotoxic drugs that can be used in the unsightly and may be surgically removed. treatment of a variety of skin diseases. These Other types of skin cysts include DERMOID cysts, include AZATHIOPRINE (Imuran), CYCLOPHOSPHA- a type of skin cyst that may contain particles of MIDE (Cytoxan), HYDROXYUREA (Hydrea), and hair follicles, sweat glands, nerves, and even teeth. METHOTREXATE. D dandruff A harmless very common condition dapsone (4,4’-diaminodiphenyl-sulfone) An anti- (also called SEBORRHEA) in which the scalp sheds bacterial drug that has been used to treat resis- dead skin, producing unattractive white fl akes in tant ACNE, LEPROSY, and DERMATITIS HERPETIFORMIS. the hair that often fall onto the collar and shoul- Results with this drug, the most often-used of the ders. When it worsens into an itchy, infl amed scalp sulfones, have been variable, but in some cases rash, it is called seborrheic dermatitis (see DERMA- there have been excellent results. Its mechanism of TITIS, SEBORRHEIC), and is also found on the face, action is unknown, although it does interfere with back, and chest. neutrophil function. Other diseases that may be treated with dapsone include bullous diseases and Treatment Options and Outlook PYODERMA GANGRENOSUM. While no cure for dandruff exists, consumers fi nd The introduction of the sulfones in the 1950s some relief with frequent shampooing; the more had a dramatic impact on the treatment of leprosy. often, the easier it is to control dandruff. Because Of these, dapsone was the fi rst safe and effective dandruff is often caused by an oily scalp, a mild drug available, killing the bacteria (Mycobacterium nonmedicated shampoo may be enough to control leprae) and eliminating the need for patient isola- the problem. tion. Although resistance to dapsone is becoming If the mild shampoo is not effective, an anti- widespread, it remains the drug of choice in the dandruff product may work. Those with selenium treatment of leprosy in conjunction with other sulfi de or zinc pyrithione offer the quickest results medication. by slowing down the rate at which scalp cells mul- tiply, but no matter which type of anti-dandruff Side Effects shampoo is used, the lather should not be rinsed The adverse effects of this drug tend to be dose- off too quickly. related, and adverse effects are uncommon with Products with SALICYLIC ACID and SULFUR low doses. Concerns over safety may have been loosen up the dandruff so it can be washed away, exaggerated by the high doses used in some early while antibacterial shampoos reduce bacteria studies, according to some experts. on the scalp. Very stubborn cases may respond Severe allergic reactions may occur, including to tar shampoos, which work by slowing down TOXIC EPIDERMAL NECROLYSIS and STEVENS-JOHNSON cell growth; the tar lather should be left on the SYNDROME. Other side effects may include nausea, hair for up to 10 minutes so the tar can work. vomiting and rarely, damage to the liver, red blood (Blond or silver hair may be stained by tar cells, and nerves. There may also be sensory and compounds.) signifi cant motor nerve problems. During long- More and more dermatologists prescribe anti- term treatment, blood tests are conducted to moni- fungal shampoos (such as Nizoral 2 percent sham- tor liver function and the red blood cell level. poo) to curb fl aking by controlling the growth of Neurological symptoms (such as psychosis) are a yeast that occurs naturally on the scalp. Other believed to be dose-related; those with a history of choices include a corticosteroid cream or lotion to psychiatric problems may be more likely to develop apply to the scalp. mental problems on this drug.

100 Degos’ disease 101

The cases of agranulocytosis (defi ciency of blood Treatment Options and Outlook cells due to bone marrow damage) seen among Patients with mild disease should avoid sun expo- troops in Vietnam taking dapsone to prevent sure and use SUNSCREEN. Secondary infections malaria could have been caused by concurrent use should be treated with antibiotics. Wet compresses of other antimalarial drugs. According to reports, and tap water soaks can help lessen odor and millions of patients have been successfully treated crusts, and DERMABRASION may be effective in mild with dapsone for years with relatively low rates of cases. Synthetic retinoids (ACITRETIN or ISOTRETI- toxic side effects. NOIN) often induce remission, but chronic use is often necessary to prevent relapse. Because many patients on long-term retinoids have developed dif- Darier’s disease Known medically as keratosis fuse skeletal abnormalities this chronic administra- follicularis, this is a disorder of KERATINIZATION tion is rarely justifi ed. (the process whereby cells become horny as they Deep dermabrasion followed by skin grafts may approach the surface of the skin); it affects the skin, help some patients with severe problems. mucous membranes and nails. An uncommon While the disease comes and goes, there is a ten- inherited disease, this disorder usually begins in dency for it to become more severe over time. childhood or adolescence and gets worse following exposure to ULTRAVIOLET RADIATION. Patients are also at risk for secondary bacte- Darier’s sign Itching and hives that occur rial infection and for serious, widespread viral after stroking or rubbing lesions of URTICARIA skin infections usually due to the herpes simplex PIGMENTOSA. virus. It is inherited in an autosomal dominant pat- tern, which means that a single gene from one Darier-White disease See DARIER’S DISEASE. parent causes the condition. The child of an affected parent has a 50 percent chance of inher- iting the abnormal gene, but not all people with decubitus ulcer Another name for BEDSORES. the abnormal gene will develop symptoms of the disease. The abnormal gene involved in the develop- Degos’ disease The common name for malignant ment of Darier’s disease has been identifi ed as atrophic papulosis, this is a rare disease, occurring ATP2A2, found on chromosome 12q23-24.1. The most often in men. exact way this abnormal gene causes the disease is still under investigation, but it seems as if the way Symptoms and Diagnostic Path skin cells join together may be disrupted if there is Symptoms include porcelain-white skin lesions insuffi cient calcium. (from fi ve to more than 100) in the skin and gastrointestinal tract. Up to 60 percent of the Symptoms and Diagnostic Path patients with this disease develop these lesions in Itchy, greasy, foul-smelling brown papules form the gastrointestinal area, which results in loss of plaques on scalp, ears, face, neck, and upper blood to the area and subsequent tissue death in trunk—these lesions are often induced by sun- weeks or years; these complications are usually light. Distinctive nail changes include fragile, short fatal. and relatively wide nails with notching, ridging, and red and white linear streaks. Darier’s disease Treatment Options and Outlook is diagnosed by its appearance and family history, There is no effective treatment, but patients with but it is often mistaken for other skin problems. skin lesions only have a good prognosis. Those with A skin biopsy may be required for a defi nitive lesions in the gastrointestinal have a more serious diagnosis. and sometimes fatal outcome. 102 delusion of bromhidrosis delusion of bromhidrosis The psychotic belief Treatment Options and Outlook that a person’s own body odor is profoundly offen- Some experts recommend confronting the patient sive. This problem usually occurs during adoles- with the delusion, but others counter that confron- cence, often in conjunction with fastidious habits tation can be disastrous since the patient is abso- and no body odor. These patients usually show an lutely sure of the infestation. The patient’s belief ambivalent sexuality and little emotion. should never be treated as factual, and antiparasitic lotions should not be administered. Depression or Treatment Options and Outlook other psychological problems should be treated. There are no published data regarding the treat- Pimozide (a drug used to treat Tourette syn- ment of this disorder with pimozide, the drug drome) may help control, but not cure, the dis- used to treat Tourette syndrome and DELUSIONS order, although side effects include irreversible OF PARASITOSIS. The patient’s delusion must never body movements (tardive dyskinesia), EKG abnor- be reinforced. Outlook is very poor for these malities, drowsiness, and sometimes death. Still, patients, who often go on to develop serious men- chronic administration of pimozide allows many tal illness. patients to live normal lives. delusions of parasitosis The erroneous belief Demodex folliculorum A mite found in the hair that the skin is infested with parasites. Most follicles and sebaceous secretions (especially in the patients also suffer from some type of men- face and nose). The mites usually cause no prob- tal disorder, such as psychosis or an obsessive- lems but may occasionally cause an infl ammation compulsive disorder. of hair follicles called demodex FOLLICULITIS. Demo- Patients may report feelings of bugs crawl- dex are harmless and do not transmit diseases, but ing within the skin, and will go to extraordinary large numbers of demodex mites may cause ITCH- lengths to remove the bugs. They may try to rid ING and skin disorders, referred to as demodicosis. themselves of “parasites” by washing often, apply- ing insecticides or parasiticides, avoiding others to contain the “contamination.” Some patients may deodorant A modestly effective substance paint their homes, destroy “infested” bedcovers, designed to be applied to the skin to control and call on pest control companies for help. unpleasant odor, usually containing antimicrobial Also called acarophobia or parasitophobia, it is agents; it also may contain fragrance to disguise classifi ed as a hypochondriacal psychosis. While odor and antiseptics to destroy bacteria. Deodorant treatment for parasitic delusions was once thought is a useful help against body odor caused by bac- to be hopeless, a few patients have recovered. teria in decomposing sweat on the skin, but is less effective than ANTIPERSPIRANTS. Symptoms and Diagnostic Path See also SWEAT GLANDS; SWEAT GLANDS, DISOR- While there is no evidence of skin problems, these DERS OF; DRYSOL. patients may insist there is; some puncture the skin with fi ngernails or needles to dig out the “para- sites.” These “insects” are then produced (usually depigmentation The removal or absence of skin bits of skin, hair, crusts, and other debris). Patients pigment (usually MELANIN). usually reject any suggestion that the parasites are See also DEPIGMENTATION, CHEMICALLY INDUCED; not real with scorn or disbelief, and refuse to seek and DEPIGMENTATION, POST-TRAUMATIC. psychological counseling. Chronic attempts to clean the skin may cause tissue breakdown; isolation to prevent “contamina- depigmentation, chemically induced A variety tion” may result in psychological problems. Suicide of chemicals (mostly derivatives of phenol or is possible. HYDROQUINONE) can produce DEPIGMENTATION of the depilatory 103 skin that looks very much like VITILIGO. Progres- area of permanent depigmentation, since pigment sive depigmentation beginning on the hands and cells in the hair bulbs are destroyed. spreading to other parts of the body may be caused by exposure to phenolic compounds, especially if the patient works in the plastics and rubber indus- depigmentation disorder Any disorder that tries, or uses germicidal agents. results in absence of PIGMENT CELLS from the skin, too few melanosomes, or improper MELANIN Treatment Options and Outlook synthesis. First, the patient should be protected from further exposure to industrial cleaning solutions, germi- cidal agents, rubber products, or depigmenting depigmenting agents The skin may lose pigmen- medications. It may be possible to repigment hair- tation by using a range of agents, including HYDRO- bearing skin with PUVA. QUINONE, monobenzyl ether of hydroquinone, or Disorders of congenital depigmentation due AZELAIC ACID. to absence of melanocytes include PIEBALDISM, See also DEPIGMENTATION, CHEMICALLY INDUCED. ALBINISM, and WAARDENBURG’S SYNDROME. Disor- ders involving acquired depigmentation caused by the absence of melanocytes include vitiligo, post- depilatory A chemical agent (such as barium sul- traumatic depigmentation, and chemically induced fi de) for removing or destroying hair that is avail- depigmentation. able in a cream or paste. Depilatories are used for See also DEPIGMENTATION, POST-TRAUMATIC. cosmetic purposes and for the treatment of excess hairiness (HIRSUTISM). They dissolve the hair at the skin’s surface but do not affect the hair’s root. Hair depigmentation, post-traumatic Any physical, grows back within a few days; therefore, they are chemical, or infectious agent that destroys the only a temporary solution to hair removal. outer skin layer (EPIDERMIS) will also destroy the Depilatories should not be used immediately PIGMENT CELLS along the basal skin layer. Normally, after a hot bath or shower, since heat increases skin is repigmented as PIGMENT CELLS proliferate blood fl ow to the skin, opening skin pores and and migrate from hair bulbs and adjacent skin. If increasing the amount of chemical absorbed into an injury destroys the hair bulbs or other nearby the body. skin, the normal reservoir of new pigment cells is Today, the most popular chemical depilatories destroyed. That skin will probably remain perma- are made of thioglycolates combined with calcium nently white. hydroxide. Earlier depilatories contained alkaline Injuries that cause this type of depigmenta- earth sulfi des that had an unpleasant odor and tion include BURNS, radiation, deep lacerations, or irritated the skin. They are still used, however, ABRASIONs. Likewise, any infections that leave deep by some African-American men to remove beard scars (such as SHINGLES or CHICKEN POX) often leave hair. depigmented areas. Many lesions of DISCOID LUPUS Although chemical depilatories offer a smoother ERYTHEMATOSUS may be permanently depigmented. skin surface than shaving, only about 1 percent of Pigment cells are particularly vulnerable to American women use them exclusively for hair injury from cold; freezing the epidermis by CRYO- removal; 8 percent of American women use depila- THERAPY may cause a temporary depigmentation, tories in combination with other methods. Many but new pigment cells will eventually migrate into consumers consider them expensive, slow, and the area. Therefore, minor lesions in dark-skinned irritating to the skin, with an unpleasant odor. patients should be treated with cryotherapy with great caution. Side Effects Deep freezing to destroy basal cell epithelioma Chemical depilatories may cause an allergic reac- or SQUAMOUS CELL CARCINOMA may also leave an tion characterized by swelling and infl ammation, 104 dermabrasion and are not usually recommended for use on the the treated skin remains a little lighter or blotchy face. Because the chemical structure of the KERATIN in appearance. of the top-most skin layer resembles hair chemi- Some patients may develop tiny WHITEHEADS cally, depilatories should not be left on the skin too after surgery that eventually disappear by them- long or they will cause irritation. selves or with the help of an abrasive pad or soap; See also HAIR REMOVAL; ELECTROLYSIS. occasionally, the surgeon may have to remove them. Some patients may develop enlarged skin pores, although these usually shrink to near-nor- dermabrasion Surgical removal of the surface mal size once the swelling has subsided. layer of the skin by high-speed sanding to refresh Infection and scarring occasionally occur with the skin and reduce pitted scars of ACNE, improve dermabrasion. Some individuals develop excessive appearance of raised scars, or remove tattoos. It is scar tissue (KELOID scars); these are usually treated also used to smooth out WRINKLES and to remove with the application or injection of steroid medica- pre-cancerous growths (KERATOSES). Dermabrasion tions. Patients can reduce these risks by choosing a is the most dramatic resurfacing technique that qualifi ed plastic surgeon and closely following the dermatologists can use, and it leaves the skin rela- doctor’s advice. tively smooth. If the skin begins to get worse instead of better, becoming redder or itchier after starting to heal, it Procedure may signal the formation of abnormal scars, and The skin is numbed with a local anesthetic. Using the surgeon should be consulted immediately. an abrasive wheel or wire brush rotating at high speeds, the dermatologist removes layer after layer Outlook and Lifestyle Modifi cations of skin to reach the smooth skin underneath scars, Right after the procedure, the skin will be quite and remove precancerous lesions, broken blood red and swollen, and eating and talking may be vessels, wrinkles, and tattoos. diffi cult. There will probably be some tingling, burning, or aching; but any pain can be controlled Risks and Complications with medications prescribed by the dermatologist. Age, skin type, coloring, and medical history all The swelling will begin to fade in a few days to a affect how well the procedure works. For example, week or two. people with dark skin may become permanently After the procedure, a scab will form over the discolored or blotchy after a skin-refi nishing treat- treated area as it begins to heal. This will fall off as ment. People who develop allergic rashes or other a new layer of tight, pink skin forms underneath. skin reactions, or who get frequent fever BLISTERs The face may itch as new skin starts to grow; or COLD SOREs, may experience a fl are-up. FRECKLES doctor-recommended ointments can ease the dis- may disappear in the treated area. comfort. If ointment is applied immediately after Most surgeons will not perform treatment if the surgery, little or no scab will form. patient has had radiation treatments, a bad skin The new skin will be a bit swollen, sensitive, and BURN, a previous deep chemical peel, or active acne bright pink for several weeks. During this time, the on the facial skin. patient can slowly start returning to normal activi- Dermabrasion is normally safe when per- ties, and may go back to work in about two weeks. formed by a qualifi ed, experienced board-certifi ed The dermatologist will typically advise patients to physician. The most common risk is a change avoid any activity that could bump the face for at (either darkening or lightening) in skin pigmen- least two weeks. More active sports (especially ball tation. Permanent darkening of the skin, usually sports) should be avoided for four to six weeks. caused by exposure to the sun in the days or Swimmers should use only indoor pools to avoid months following surgery, may occur in some sun and wind, keeping the face out of chlorinated patients. On the other hand, some patients fi nd water for at least four weeks. It will be at least three dermatitis, asteatotic 105 to four weeks before patients can drink alcohol dermatitis The general term used to refer to without experiencing a red fl ush. It is most impor- a group of infl ammatory conditions of the skin tant to protect the skin from the sun until the pig- (derm meaning “skin” and itis meaning “inflam- ment has completely returned, which may take as mation of”). While people often use the terms long as six to 12 months. ECZEMA and dermatitis interchangeably, eczema While pain is not considered to be a prob- is actually dermatitis in its advanced stages, with lem, many patients are bothered by the red, raw BLISTERs, fissures, oozing, crusting, scabbing, appearance of the skin for about 10 days after the thickening, peeling, and discoloration. While procedure. there are a wide variety of dermatitis conditions, As with other types of facial peels, dermabra- the three main categories are atopic, contact, and sion may cost several thousand dollars. A list of seborrheic. dermatologists qualifi ed to perform dermabrasion See also DERMATITIS, ASTEATOTIC; DERMATITIS, is available via the toll-free hotline maintained by ATOPIC; DERMATITIS, BERLOQUE; DERMATITIS, CONTACT; the American Society for Dermatologic Surgery. DERMATITIS, EXFOLIATIVE; DERMATITIS, HAND; DERMA- TITIS, IRRITANT CONTACT; DERMATITIS, NICKEL; DERMA- TITIS, NUMMULAR; DERMATITIS, PERIORAL; DERMATITIS, dermal fillers See SKIN FILLERS. SEAWEED; DERMATITIS ARTEFACTA; DERMATITIS HER- PETIFORMIS; DERMATITIS PAPULOSA NIGRA; ALLERGIES AND THE SKIN; CRYOSURGERY; DIAPER RASH; DRY SKIN; dermal stimulator A substance that stimulates GOURGEROT-BLUM SYNDROME; OIL OF BERGAMOT; skin cells to make COLLAGEN, providing a slow cor- SALYCYLIC ACID; SULFUR. rection of aging and WRINKLES over time. Poly-L lac- tic acid is a new dermal stimulator approved in 2005 by the U.S. Food and Drug Administration to fi ll the dermatitis, allergic See ALLERGIES AND THE SKIN. hollow cheeks from loss of fat seen in HIV-positive patients receiving treatment for AIDS. It is used to treat patients every month for four to fi ve months dermatitis, asteatotic A disorder also known as until the full correction is achieved. These results “winter itch” fi rst described in 1907 using the term should last for one to three years, experts suggest. eczema craquele. Although research studies of poly-L lactic acid There are many different factors that may lead for cosmetic use are just beginning, if proven effec- to asteatotic dermatitis, including friction, frequent tive, it could be a new option for patients looking or prolonged bathing in hot water, use of soap and for a safe, long-lasting fi x for wrinkles, skin creases, infrequent use of emollients, decreased sebaceous and loss of cheek fullness with age. and sweat gland activity, radiation, nutritional defi - ciencies, ZINC defi ciency, thyroid disease, medica- tion side effects, and some cancers. dermaplaning A process that scrapes away dead cells to smooth away SCARs. Dermaplaning is far Symptoms and Diagnostic Path less aggressive than DERMABRASION, which sands The condition is characterized by itchy, dry, away the outer layer of skin (EPIDERMIS) and the cracked, and fi ssured skin with irregular scaling superfi cial DERMIS to smooth down scars. found most often on the shins of elderly patients, In dermaplaning, the physician uses an instru- although it may be present on the hands and ment called a dermatome, which resembles an trunk. The skin looks almost like cracked por- electric razor whose blade moves back and forth celain, and can lead to superfi cial bleeding and to skim off the top layer of skin surrounding facial fi ssures as the EPIDERMIS loses water, splits, and defects such as ACNE scars. The technique feels cracks. The infl ammation can be associated with something like a fi ngernail scraping the skin. asymmetrical leg swelling. 106 dermatitis, atopic

Although most cases get better, the condition Atopic dermatitis tends to wax and wane; in can be chronic, with frequent relapses during the chronic stages, there is scaling and skin color winter and times of low humidity. Men over age changes. Most patients improve during the sum- 60 develop asteatotic dermatitis more often than mer and worsen during the winter, which is prob- women, but the condition also can be found in ably related to humidity and temperature. younger people. Treatment Options and Outlook Treatment Options and Outlook Adequate hydration of the skin and avoiding irri- Patients should take short baths without hot water tants may be all that is required in those with mild and little or no soap on the affected areas, followed cases. Irritant detergents include wool clothing, by a good moisturizer such as a petrolatum-based strong detergents, and water. Irritant detergents emollient after bathing. Topical steroid ointments can be avoided by using a mild detergent (such as with or without polyethylene occlusion should be Ivory Snow fl akes or Dreft), by avoiding wool, and applied. Many patients will heal with mild topical adding bath oil to bath water. Emollients such as steroids alone, depending on the severity of the white petrolatum should be applied immediately skin lesions, how well patients comply with treat- after bathing, and topical CORTICOSTEROIDS and tar ment, and if patients use little soap and hot water preparations are useful. in the affected areas. In acute cases, a medium-potency topical cor- Asteatotic dermatitis responds well to therapy, ticosteroid lotion or cream should be applied after but recurrences are common. bathing or after applying aluminum acetate or saline compresses. For chronic cases, potent topical corticosteroids dermatitis, atopic Also known as atopic ECZEMA, should be applied right after bathing; soaking or this condition is a chronic superfi cial infl ammation using compresses of water-soluble tar preparations common in infants, often appearing between two may decrease the need for topical corticosteroids. and 18 months of age. It typically occurs in those Adequate doses of antihistamines can control with an inherited tendency to develop allergy and itching and prevent scratching, which could lead is found in 10 percent of the population. It is usu- to secondary infection. With severe involvement, ally associated with asthma, hay fever, or allergic a short course of systemic corticosteroids may be rhinitis, and it may affect as many as seven to 24 needed; however, the risks of systemic corticoste- of every 1,000 individuals. The highest prevalence roids limit their use in long-term treatment. is in children. Oral antibiotics are helpful in infections of Typically, the condition begins in the fi rst year eczematous skin, a frequent complication in itchy of life in about 60 percent of cases, and before age children. fi ve in 85 percent. The disease fades away in about Although there is no cure, the long-term prog- 40 percent of individuals by adulthood, although nosis is good; spontaneous remission occurs in patients with severe disease are more likely to have almost half of all patients by age 15. Those who a persistent course. may go on to struggle with persistent disease often have a family history of atopic dermatitis, associ- Symptoms and Diagnostic Path ated asthma or hay fever, and late onset of severe In acute cases, this form of eczema is character- disease. ized by a mild, very itchy rash on the face, neck, wrists, inner elbow creases, and behind the knees, with red, scaling skin and pimples. If scratched, the dermatitis, berloque A type of phototoxic contact pimples leak a clear liquid, forming large weeping dermatitis causing an irregular hyperpigmentation areas; infection may occur if the condition appears usually found on the neck. Berloque (French for in the diaper area. ITCHING is often worse at night. “pendant” or “drop-like”) dermatitis is caused by dermatitis, contact 107 perfumes that contain OIL OF BERGAMOT, a naturally preservatives in cosmetics and industrial products occurring photosensitizer (PSORALEN). and are often masked by other names. Chromates Chromium (in the form of chro- Symptoms and Diagnostic Path mates) is the most common cause of contact After exposure to the sun, hyperpigmentation with dermatitis in men, usually from exposure on the sharp margins and streaks begins to appear, with job. Because chromates are common, they are very little reddening, on the neck or hands. often hard to avoid. A main source is cement, Exposure to certain concentrated plant juices affecting those in the building trades. Leather (such as limes) that contain psoralens, followed by that has been tanned with chromate may also exposure to the sun, may produce a more severe cause contact dermatitis on the feet of sensitive reaction involving painful redness and blistering. individuals. Symptoms, which often resemble NUMMULAR Treatment Options and Outlook ECZEMA, are scaling, redness, and dryness. They Patients with berloque dermatitis should use a may take years to improve, even after contact is daily SUNSCREEN with SPF 30 or higher to help avoided. In fact, most severely affected people keep the condition from worsening. Perfume never fully recover, probably because of the preva- should be be avoided on areas of the skin that are lence of chromates in everyday life. Workers with exposed to the sun. TRETINOIN (Retin-A) or Keralyt only a mild or moderate problems may remain gel applied to the affected areas will improve this on the job if they can avoid the substance, but a condition. change in the work area does not guarantee the The reaction usually appears within 24 hours dermatitis won’t recur. By adding ferrous sulfate to after sun exposure, peaking within 48 hours. cement, the chromate becomes less sensitizing and this may be a breakthrough in preventing occupa- tional chromate allergy. dermatitis, cement See ALLERGIES AND THE SKIN. Rubber A hypersensitivity to rubber may be suspected if the patient has a history of direct skin contact with a rubber product. There are dermatitis, contact An infl ammation of the skin many rubber chemicals that may produce allergy, caused by an allergic reaction to direct contact with especially those contained in disinfectants and a substance to which a person is sensitive. Usually preservatives in industrial processes (tetramethyl- an itchy or scaly rash erupts at the point of con- thiuram disulfide and 2-mercaptobenzothiazole tact, which can be anywhere on the body. While and thiourea derivatives). Because of the large the immune system normally protects against bac- number of different allergenic chemicals, it is not teria and viruses, an allergic response causes the easy to perform patch testing for this problem. It immune system to overreact to usually harmless is also common to find cross-reactions between substances like dyes or metals. related chemicals. Substances that are often implicated in contact Topical medications About a third of all der- dermatitis include metals (especially nickel); dyes matology patients with a contact allergy will test and chemicals in clothing, furs, shoes, hair prod- positive for sensitivity to some type of ingredient ucts, rubber compounds, paints, textiles, ink, and in topical drugs or cosmetics. The most com- paper; cleaning products or detergents; cosmetics, mon include lanolin, neomycin, local anesthetics, perfumes, shaving lotions; POISON IVY; and insecti- formaldehyde, and preservatives (such as parabens cides. Formaldehyde is a potent antimicrobial that or benzoisothiazides). causes many cases of contact dermatitis, and is Lanolin, a skin cream product derived from found in industry, medicine, the home (as a pre- sheep fl eece, causes a reaction in some people. An servative) in permanent press clothes, newspapers, artifi cial hypoallergenic lanolin derivative is now and so on. Formaldehyde-releasers are used as available. 108 dermatitis, diaper

Neomycin is a widely used topical antibiotic that not be too hot or cold). Two cups of colloidal oat- may cause a contact dermatitis. The risk of allergy meal (available in drugstores) or baking soda to the decreases when the antibiotic is used only for bath may help. simple cuts or surgical wounds. It may be hard to Individuals allergic to ANTIPERSPIRANTS—specifi - diagnose neomycin allergy, since the dermatitis is cally the metallic salts (such as aluminum chloride, not vesicular or bullous but appears to be an aggra- aluminum sulfate and zirconium chlorohydrate) vation of preexisting dermatitis. that are the active ingredients—should avoid Parabens are widely used preservatives found in them. Sensitive consumers should look for prod- foods, drugs and one-third of all cosmetics. Consid- ucts with anti-irritants such as zinc oxide, magne- ering how widespread they are, sensitization to the sium oxide, allantoinate, aluminum hydroxide, or parabens is low. Although hypersensitivity usually triethanolamine. occurs when a person contacts the ALLERGEN with In severe cases of weeping sores, cold milk any part of the body, parabens may be tolerated compresses may help soothe the itching of con- on normal facial skin but may cause dermatitis on tact dermatitis. CALAMINE LOTION with MENTHOL or eczematous skin. phenol may be another good choice to help a dry oozing rash. Symptoms and Diagnostic Path See also DERMATITIS, NICKEL. Contact dermatitis usually starts as an itchy red rash, evolving into blisters with cracking and peeling skin. The severity of this type of dermatitis depends on dermatitis, diaper See DIAPER RASH. the particular substance, and how sensitive a person is. Symptoms should subside within a few days or weeks if the offending substance is avoided, although dermatitis, exfoliative A severe, extensive infl am- some kinds of dermatitis can become chronic. matory condition (also known as ERYTHRODERMA) Once an allergic reaction to a substance has that causes scaling and redness of all the skin of occurred, a person can become sensitized; even the the body. An uncommon disorder, it is three times briefest subsequent contact will probably set off more common in men than women. Average age another attack. at onset is 50 years. Allergy patch tests may be helpful in determin- Drug reactions are the most common cause of ing the substances that are provoking the reaction. exfoliative dermatitis, responsible for about 40 In the test, a physician exposes small areas of skin percent of cases. Common medications associ- to a variety of known allergens, observing the skin ated with this disorder include sulfonamides and for development of a reaction. penicillin; less commonly, antimalarials, barbitu- rates, allopurinol, nonsteroidal anti-infl ammatory Treatment Options and Outlook drugs, diphenylhydantoin, and gold are suspected Mild cases of contact dermatitis do not require to trigger this disorder. Once the offending drug is treatment, but frequent or severe outbreaks should no longer administered, the skin lesions will often be referred to a physician. Topical medications clear within weeks. (CALAMINE, antihistamines, or over-the-counter In 30 percent of cases, the disorder is due to cortisone creams) usually ease symptoms. Hydro- preexisting skin conditions—most commonly, PSO- cortisone cream (in 0.5 percent strength) is avail- RIASIS or atopic dermatitis. Other associated skin able without a prescription; stronger creams, which conditions include LICHEN PLANUS, Reiter’s syn- are necessary for cases of signifi cant contact derma- drome, PITYRIASIS RUBRA PILARIS, PEMPHIGUS, allergic titis, can have serious side effects and are available contact dermatitis, or stasis dermatitis. Most people only with prescription. suffering from this condition will usually fi nd their It is a myth that patients with dermatitis should exfoliative dermatitis clearing within weeks to avoid bathing; regular bathing is as a way to reduce months after effective treatment is begun, although infection and soothe irritated skin (water should recurrences are common. dermatitis, hand 109

Up to 20 percent of erythroderma is caused by There may be many different causes behind the cancer (usually either lymphomas and leukemias). development of this condition. Contact dermatitis is Approximately 10 percent of cases have no known the most common type of hand dermatitis, which cause. can produce an irritant or allergic eczematous reac- In those without a known cause, the disease tion. Irritant dermatitis accounts for about 70 per- lasts on average about fi ve years. Intermittent cent of contact hand dermatitis; detergents, soaps, fl are-ups are frequent. and solvents are the most important causes. Contact allergic hand dermatitis is seen in between Symptoms and Diagnostic Path 25 and 30 percent of cases. A preexisting irritant While the causes of exfoliative dermatitis may dermatitis can predispose an individual to the vary, the symptoms are the same: generalized red- development of allergy. Contact allergic hand ness, warmth, swelling, itch, thickened and scal- dermatitis usually evolves into chronically thick- ing skin that begins in one small area and spreads ened skin that can not be distinguished from that across the skin within days to weeks to months. caused by irritant dermatitis. The primary offend- While the mucous membranes are not usually ers behind the allergic type of hand dermatitis are affected, the palms, soles, scalp, and nails are often nickel, chromate, rubber compounds, paraphenyl- involved. Other common systemic complaints enediamine, and parabens. Nickel allergy, affecting include chills or fever, dizziness on standing up, about 5 percent of the population (mostly women), dehydration, enlarged lymph nodes, and swelling. is caused by costume jewelry, coins, handles, pens, Because of the profound effect this disorder has surgical instruments, and kitchen utensils, any on the metabolic system, the basal metabolic rate of which can be associated with hand dermatitis. may rise by as much as 50 percent above normal, Those with a chromate sensitivity can develop resulting in huge increases in exfoliation that may hand dermatitis from exposure at work (especially cause malnutrition (caused by the protein loss in to cement, leather, paint, and photography dyes). the fl aking skin). Chemicals added to rubber (such as mercaptoben- zothiazole and thiuram) cause rubber sensitization, Treatment Options and Outlook producing hand dermatitis through contact with Hospitalization may be required to stabilize fl uid rubber gloves and tubing. Paraphenylenediamine volume and temperature and to treat added infec- is found in azo dyes, and often is a problem among tion. Nutritional supplements and medication to hairdressers. Paraben-sensitive patients may fi nd control itching may be required. Steroids, emol- they are sensitive to many topical medications, lients, and moisturizing baths may make the cosmetics and foods. patient more comfortable. Failure to implement these supportive treatments may require adminis- Symptoms and Diagnostic Path tration of methotrexate and retinoids. The condition is characterized by itchy BLISTERs up Death rates in the past have been as high as to an inch across on the palms, with dry cracked 30 percent, and are related to infection. Death skin across the hands. The acute stage is character- from erythroderma has become rare with medical ized by dry blisters and redness; in the subacute advances. stage the skin is red and scaly. Chronic hand der- matitis is characterized by thick, scaly, and dry skin with more and more skin markings. dermatitis, hand Also known as “hand ECZEMA,” this condition is usually caused by exposure Treatment Options and Outlook to detergents, cleansers, or dishwashing soap, The condition usually improves if the patient although in some a specifi c cause may never be wears cotton gloves under rubber gloves when found. It is restricted to the hands, with little der- touching any possible irritant; the hands should be matitis elsewhere, and affl icts between 4 and 8 thoroughly dried after immersion in water and an percent of the population. unscented hand cream or white petrolatum should 110 dermatitis, irritant contact be applied several times a day. If the condition is metal, is often used in surface plating of metal severe, topical CORTICOSTEROIDS may be prescribed objects, such as buttons, costume jewelry, and for infl ammation and antibiotics may be needed to kitchen equipment. It is also an element in many combat infection. alloys, and is widely used in dentistry. See also DERMATITIS, IRRITANT CONTACT; ECZEMA. It is found 10 times more often in women than men, and is often triggered by ear piercing. Hav- ing the ears pierced (using earrings with nickel dermatitis, irritant contact Irritant contact der- posts) causes subsequent rashes to appear in other matitis is a local infl ammatory reaction (not an areas of the body whenever the person touches allergic reaction) caused by a single or repeated objects containing nickel. Necklaces, bracelets, belt exposure to toxic chemicals. buckles, and other jewelry that have never before caused a problem may suddenly cause a rash after Symptoms and Diagnostic Path the ears are pierced. The appearance of lesions depends on the type of Nickel dermatitis is also associated with an irritant, which can range from a blistering reac- increased risk of developing dermatitis of the hand. tion to a scaly, red thickened skin. An acute case Those at high risk for developing an occupational may result after only one contact with a highly nickel allergy include those in regular contact with toxic irritant. Easily diagnosed, it often occurs after the metal: restaurant workers, hairdressers, nurses, industrial accidents. cashiers, and metal-industry employees. A cumulative case is more common than acute dermatitis and is caused by repeated contact with Risk Factors and Preventive Measures mild irritants over a long period of time. The fi rst People with newly pierced ears or other body parts signs are usually dry, cracking skin with redness, should wear only gold or steel posts until skin scaling, PAPULES, VESICLES, and thickening. heals (about three weeks). Surgical steel is the best This type of dermatitis may involve a combina- choice, and is available in some types of earrings tion of irritants, set off by one highly toxic irritant specifi cally designed for sensitive skin. (such as a caustic agent or a solvent). The irrita- Perspiration plays a big role in nickel dermatitis tion is sustained by subsequent use of detergents because it leaches out the nickel in nickel-plated and soaps. The skin all over the body may become jewelry. It is best to avoid the heat when wearing this sensitized so that an acute condition on the hands type of jewelry. Only high-quality gold jewelry that can lead to increased sensitivity of the skin on the is at least 14-karat gold should be worn; the lower back. Because of the similarity between irritant and the karat, the higher the percentage of nickel. allergic contact dermatitis, patch testing can help A few dermatologists go so far as to warn highly distinguish between them. sensitive patients to avoid foods containing traces of nickel (such as coffee, beer, tea, apricots, choco- Treatment Options and Outlook late, nuts, and so on). Irritant contact dermatitis can be a diffi cult prob- See also DERMATITIS, CONTACT; DERMATITIS, lem to treat, and may last for a long time. More- ATOPIC. over, it can lead to the development of allergic contact dermatitis. People who have experienced atopic dermatitis as children are more susceptible dermatitis, nummular Also known as nummu- to developing irritant contact dermatitis as adults. lar ECZEMA, this stubborn, itchy condition usually See also DERMATITIS, ATOPIC; DERMATITIS, CONTACT. occurs in adults, causing circular, scaly patches anywhere on the body, very similar to RINGWORM (tinea). The lesions may be clear in the center, dermatitis, nickel An itchy skin reaction follow- resembling ringworm or a fungus. The condition ing contact with nickel, probably the most com- tends to be chronic, with periods of waxing and mon form of dermatitis. Nickel, a shiny stainless waning. dermatitis, seaweed 111

While the cause is unknown, it is more common dermatitis, pigmented purpuric lichenoid See in the winter and is often associated with dry skin. GOUGEROT-BLUM SYNDROME. Wool, soaps, and frequent bathing (more than once a day) often worsen the condition. Clothes washed or dried with liquid or sheet fabric softeners may dermatitis, radiation See RADIODERMATITIS. also irritate the skin.

Treatment Options and Outlook dermatitis, seaweed A rash of bumpy red lesions There is no cure, but there are effective ways of caused by poisonous marine algae found in salt controlling nummular dermatitis. Vaseline, tar, and fresh water around the world. The rash is usu- and CORTISONE compounds applied to the skin ally caused by algae trapped underneath a bathing are the best treatments. Weak cortisone salves suit. can be used safely for years. When large areas Epidemics of this seaweed-induced rash occa- of the body are treated or when strong cortisone sionally occur in the Pacifi c. In Hawaii, the highest preparations are used, however, periodic medi- number of cases occur during the summer, when cal checkups are necessary. Strong cortisones persistent trade winds may dislodge the seaweed shouldn’t be applied to the face, armpits, groin, from the bottom. Fragments then drift into swim- or anal area. ming bays and beaches. The skin should be lubricated, and a bath oil or Seaweed dermatitis should not be confused Aveeno powder can be used in the tub. Patients with SEA BATHER’S ERUPTION, an eruption caused should use lukewarm, not hot water, and should by stings from larval forms of certain sea anemo- blot the skin afterwards so there is still some water nes and thimble jellyfi shes, or SWIMMER’S ITCH, an left on the skin. Next, the patient should apply eruption due to a bite from freshwater parasitic a moisturizer to all of the skin, such as Vaseline, fl atworms. Lubriderm, or Moisturel. There are more than 3,000 species of algae; Wool or rough clothing should be avoided. Cot- seaweed dermatitis is caused by direct contact with ton (100 percent) clothes are best. Clothes should Lyngbya majuscula (also known as Microcoleus lyng- be laundered without any fabric softener or dryer byaceus). The fi ne, hairlike, dark brown seaweed is sheets, and should be washed using dye-free, found in certain tropical and sub-tropical shoreline fragrance-free detergents. waters at certain times of the year. The toxicity of this seaweed varies greatly depending upon region, season, and type. Not all strains of this seaweed dermatitis, perioral A rash of tiny pimples and are toxic. Lyngbya majuscula is a blue-green alga. It pustules around the mouth usually found in usually grows in clumps, looking like dark, matted women in their 20s and 30s. These lesions leave masses of hair or felt. Most often this seaweed is no scars. blackish green or olive green, but it also grows in Excessive use of corticosteroid creams, fl uori- shades of gray, red, or yellow. nated toothpastes, moisturizing creams, cosmetics, and birth control pills have been linked to perioral Symptoms and Diagnostic Path dermatitis, but often the cause is unknown. Symptoms include an itching and burning sensa- tion that begins anywhere from right away up to Treatment Options and Outlook 24 hours after leaving the water. A red, sometimes Oral tetracycline can cure the problem within blistering rash occurs, sometimes in a swimsuit pat- two to eight weeks, although some patients need tern. It often occurs in men in the scrotum, and in repeated courses of treatment. Recurrences are females under the breasts, but this depends on the common. Alternatively, topical antibiotics such as type of swimwear used. clindamycin or erythromycin or topical SULFUR or Other symptoms include swollen eyes, irritation SALICYLIC ACID may be prescribed. of the nose and throat, skin sores, headache, and 112 dermatitis, seborrheic fatigue. Symptoms typically last four to 48 hours. dermatitis is not caused by dryness. It is believed to In more serious cases, skin sores may appear for have a genetic link, although how the condition is several weeks. A rash also can occur on the face inherited is not clear. It is most common in boys and in the eyes and mouth; some victims have after puberty, and its incidence increases with age. swelling of eyes and mouth, but no rash. Seborrheic dermatitis has also been observed in patients with Parkinson’s disease, mental retarda- Treatment Options and Outlook tion, and a range of neurologic disorders. Use of The skin should be scrubbed with soap and water some drugs (such as neuroleptics) has been associ- and fl ushed extensively with freshwater, rinsing ated with the skin problem. with isopropyl (rubbing) alcohol. Hydrocortisone cream 1 percent may be applied Treatment Options and Outlook two to three times daily for itching, but should be Treatment is similar to other eczemas, with sham- discontinued immediately if any signs of infection poos containing tar, sulfur, SALICYLIC ACID, or sele- appear. nium daily. Hydrocortisone 1 percent cream will CALAMINE lotion or, occasionally, systemic ste- control the skin condition on the face and chest. roids are effective. If the wound shows any evi- If shampoos do not work, a steroid solution such dence of infection, such as redness, PUS, pain, as fl uocinolone 0.01 percent may be applied to foul odor, heat, or fever, antibiotics are usually the scalp one or two times a day. Alternatively, recommended. ketoconazole 2 percent cream twice daily to the Antihistamines reduce itch, and topical emol- affected area may also be helpful, or systemic anti- lients may provide relief from symptoms. biotics may also be useful. If the reaction is severe, oral steroids (predni- Untreated dandruff may progress to seborrheic sone) may be required. Irrigate exposed eyes with dermatitis, with psoriasis-like plaques and second- tap water for at least 15 minutes. Any diffi culty ary infections as a result of scratching. breathing may signal an allergic reaction. If the skin shows any evidence of infection, antibiotics may be needed. dermatitis artefacta Any self-induced skin con- dition, ranging from a mild self-infl icted scratch Risk Factors and Preventive Measures to severe and extensive mutilation by a disturbed The only sure way to avoid seaweed dermatitis is patient. to avoid swimming in the ocean where seaweed The problem occurs more often in women and is blooms have been reported. Health authorities usually the result of psychological problems, often generally keep a close eye on algal blooms and acting as an emotional release in situations of dis- report them through the media. In some countries, tress, or part of attention-seeking behavior. health authorities have powers to close public The condition, also known as factitial dermatitis, beaches. usually affects women in their teens or early adult- After swimming in the ocean, individuals should hood who tend to be emotionally immature or shower with lots of soap and water as soon as have psychosocial or interpersonal issues. possible. Swimmers also should thoroughly wash Various methods of causing lesions include swimsuits, towels, and any associated swim gear to applications of caustic substances (silver nitrate or get rid of any attached algae. phenol), injection of foreign material, BURNS, beat- ing, or pricking the skin with a pin. dermatitis, seborrheic An extremely common Symptoms and Diagnostic Path form of ECZEMA that causes scaling around the Skin damage may range from ulcers, blisters or nose, ears, scalp, mid-chest, and along the eye- scratches, and often exhibits an asymmetrical or brows, it is often misdiagnosed by non-physicians bizarre pattern that does not resemble any normal as DRY SKIN. However, the fl aking from this type of skin disease. dermatitis papulosa nigra 113

The well-defi ned lesions may include redness, dermatitis herpetiformis Also known as Duhring’s blisters, ulcers, abscesses, swelling, superfi cial GAN- disease, this is a rare chronic skin disorder in which GRENE, and skin rash. The lesions are often shaped clusters of tiny red itchy blisters appear in a sym- in bizarre ways, with irregular outlines in a linear metrical pattern on various parts of the body, espe- or geometric pattern, and are usually quite differ- cially the back, elbows, knees, buttocks, and scalp. ent from surrounding normal skin. The disease usually appears in people between The appearance of lesions varies depending on the late 20s and early 40s, much more often in the methods used to injure the skin, which may be white males. It appears less often among African produced by a variety of mechanical or chemical Americans and is quite rare among the Japanese. means, including with fi ngernails, sharp or blunt About half of these patients also experience gas- objects, lit cigarettes, or caustic chemicals. Lesions tric hypoacidity and gastric atrophy. Males have a do not evolve gradually, but appear almost over- higher frequency of lymphoma (a type of cancer). night without any prior signs or symptoms. They Treatment Options and Outlook are usually found on sites that are readily accessible to the patient’s hands, such as on the face, hands, Oral DAPSONE or sulfapyridine usually improves arms, or legs. The patient will usually deny that the the skin condition but has no effect on the prob- rash is self-induced. lems occurring in the small intestine. Topical and systemic CORTICOSTEROIDS do not usually work. Treatment Options and Outlook Removing foods containing gluten from the diet The treating health care expert is often regarded results in an improvement in skin condition and as an adversary, and treatment can be diffi cult intestinal health, but this may take more than a because on a deeper level these patients do not year. Further, a wheat-free diet is expensive and really want to get better. Patients can be diffi cult, especially diffi cult to maintain. manipulative, evasive, untruthful, and ungrateful. The skin condition also has improved following Often, they are either unaware of, or they conceal, continuous treatment with PUVA (PSORLENS plus the real nature of their lesions. ultraviolet light A). Patients should not be directly confronted about See also PUVA. the cause of their lesions. Instead this information should be conveyed indirectly. The doctor should dermatitis papillaris capillitii Another name for create an accepting, empathetic, and nonjudg- ACNE KELOIDALIS. mental environment in which the patient can be closely supervised, which can lead to a doctor- patient relationship in which psychological issues dermatitis papulosa nigra Groups of small, very may gradually be introduced. If appropriate, psy- dark seborrheic KERATOSES that develop on the faces chiatric referral may be recommended, although of African Americans. This disorder occurs earlier this is often refused. Medication (such as tran- in life than seborrheic keratoses in fair-skinned quilizers) has little effect. The prognosis is good patients. in those patients who have suffered only a brief, In this disorder, the number of lesions increases traumatic experience, but is not good in those as time goes on, although the lesions do not carry who are chronic sufferers. Resolution of the cur- a risk of malignancy. Unlike warts, they do not rent underlying psychological problem will bring spontaneously disappear. about a temporary cure, but dermatitis artefacta tends to wax and wane with the circumstances of Treatment Options and Outlook the patient’s life. To minimize future occurrences, The lesions may be removed by a variety of meth- a patient should continue to see the doctor for ods, but their removal may be followed by changes supervision or support, whether or not lesions are in pigment. Hyperpigmentation often results fol- present. lowing CRYOSURGERY, since pigment-producing 114 dermatofi broma cells are easily destroyed. While cautery may be begins as a very small bump on the surface of the better tolerated, this technique must be performed skin, usually seen on the trunk, quickly undergo- carefully to prevent scarring. Hypopigmentation is ing a period of very rapid growth where the many also a risk. Light brown-skinned people often expe- small bumps form a larger, more noticeable mass. rience hypopigmentation after treatment. Some- This mass swells and bulges outward, which is times physicians elect to treat only one lesion at where it gets the name “protuberans.” The area fi rst, to assess how the patient’s skin responds to becomes tender and may bleed because the top the treatment technique. layer of the skin is stretched so tightly. Dermatofi - See also KERATOSIS, SEBORRHEIC. brosarcoma protuberans usually does not spread to other parts of the body, but grows locally. Because the initial growth phase is so slow, it dermatofibroma A type of benign tumor arising can be a few years before the patient notices the from connective tissue cells, this skin NODULE is tumor and experiences enough discomfort to seek found most often on the arms and legs. Also known medical advice. To diagnose this condition, a doctor as histiocytoma cutis, it is composed of fi broblasts, will biopsy a sample of the affected tissue to deter- COLLAGEN, capillaries, and histiocytes. mine whether the cells and growth pattern in the Many patients with this type of skin lesion sample are characteristic of dermatofi brosarcoma report some type of preceding trauma, such as an protuberans. insect bite, scratch, or a minor skin puncture. They occur at any age, although they usually appear in Treatment Options and Outlook early adulthood through middle age. This condition has commonly been treated by removing the tumor and a signifi cant amount of Symptoms and Diagnostic Path the tissue surrounding it. Mohs’ microscopically Most patients have only one or two lesions; infre- controlled surgery is considered to be the treatment quently, there are many tumors. Most of the lesions of choice. In this procedure, the tumor is removed are slightly elevated and fi rm, although some may and then the physician continues to remove the be depressed below the skin’s surface. They may edges of tissue around the tumor site. After each bit range in color from dusky pale to medium- or pink- of tissue is removed, it is examined under a micro- ish brown, with a smooth or rough surface. When scope for signs of malignant cells. Tissue around the squeezed, the skin over a tumor often dimples. tumor site is continually removed until there is no Tumors may continue to grow slowly, once formed. longer any sign of malignant cells under the micro- scope. How the area is closed after wide excision Treatment Options and Outlook or Mohs’ surgery depends upon how much tissue Because these tumors are completely benign, no must be removed. treatment is necessary, although they can be Dermatofi brosarcoma protuberans has a high excised if the patient desires. recurrence rate because the tumor has many pro- jections beyond the main mass, which may be left behind when the tumor is removed. However, dermatofibrosarcoma protuberans An invasive Mohs’ surgery has proven very effective in reduc- tumor that occurs in the second layer of skin. After ing the recurrence rate. Chemotherapy is not an excision, it tends to recur in up to 75 percent of effective treatment because the tumor grows so cases, although the malignancy rarely spreads to slowly. Radiation therapy may be recommended other parts of the body. More common in young for some patients. men than in women, these tumors usually appear If the tumor is going to recur, it will most likely on the upper trunk and shoulder. happen during the fi rst three years after surgery.

Symptoms and Diagnostic Path The condition begins as a slow-growing fi rm nod- dermatoglyphics Patterns of skin ridges on the ule, ranging from brown to dusky red. The tumor fi ngers, palms, toes, and soles. On the fi ngers, dermatology 115 ridges occur in patterns of loops, whorls, arches, tumors. While all dermatologists treat SKIN CANCER, and compounds (combinations of the fi rst three). some have extra training in the surgical manage- Fingerprint classifi cations are based on an analysis ment of skin cancer and limit their practice to the of these ridges. Fingerprints are accepted as a legal treatment of this disease. Others have expertise in identifi cation since no two individuals share the laser surgery, while still others specialize in skin same pattern of ridges—not even identical twins. resurfacing with chemical peels, DERMABRASION, or LASER RESURFACING. Many dermatologists perform some COSMETIC dermatographia Literally “writing on the skin,” SURGERY. For example, they can remove moles, in this condition, stroking or scratching the skin destroy small capillaries on the face, and remove with a dull instrument produces HIVES that can last brown spots. Some inject COLLAGEN or fat to up to 30 minutes. This form of chronic hives may smooth out facial creases and WRINKLES. FACE-LIFTS be inherited and usually persists for life. Antihista- or breast augmentations are sometimes performed mines (especially hydroxyzine) may help. by dermatologists. Many dermatologists supply patients with lotions and creams that are tailored to each patient’s skin dermatologic surgeon A DERMATOLOGIST who care needs. deals with the diagnosis and treatment of medically See also DERMATOLOGIC SURGEON. necessary and cosmetic conditions of the skin, hair, nails, veins, mucous membranes, and adjacent tis- sues by various surgical, reconstructive, cosmetic, dermatology The study of a vast fi eld of knowl- and nonsurgical methods. A dermatologic surgeon edge about the physiology and pathology of the repairs or improves the function and cosmetic skin and hair, nails, SWEAT GLANDS, and oil glands. appearance of skin tissue. Robert Willan in England (1757–1812) was the Most dermatologic surgeries are now minimally fi rst to publish and classify information about skin invasive and require only local or regional anes- disease, which was further explored by Jean-Louis thesia. Dermatologic surgery procedures include Alibert (1768–1837) in Paris, who considered each anti-aging treatments, injectable and implant- dermatosis as a specifi c branch of dermatology. But able soft-tissue fi llers, correction of ACNE scarring, it was not until the discovery of the microscope chemical peeling, tumescent LIPOSUCTION, vein that dermatologists were able to see the skin in all therapy, hair restoration, laser surgery, skin cancer its structural and cellular detail. At the same time, treatment, and reconstructive fl aps and grafts. the infant science of bacteriology revealed the secrets of infectious diseases such as IMPETIGO and BOILS. By 1906 the spirochete causing SYPHILIS had dermatologist A physician who specializes in been isolated, and in 1914 PELLAGRA was shown diagnosing and treating skin problems. Derma- to be a simple nutritional defi ciency, although the tologists spend at least one year after medical missing vitamin (nicotinic acid) was not identifi ed school in a hospital practicing general medicine, until the 1930s. then go on to complete at least three years in Today, the fi eld of dermatology includes the advanced training in dermatology. Dermatologists investigation of disease (such as examining skin are experts in all aspects of the skin, including scrapings under a microscope), diagnosis, and hair, nails, and mucous membranes, and treat skin treatment, ranging from application of creams and problems with medicine or surgery. They are care- ointments to DERMABRASION, LIPOSUCTION, surgical fully trained to understand how diseases of the excision, to laser surgery. In fact, dermatologists skin can be related to many other, more general perform a wide variety of surgeries in the treat- medical conditions. ment of skin diseases, from sophisticated plastic Dermatologists treat common skin disorders surgical excisions to Mohs’ technique for histo- such as ACNE, ECZEMA, and PSORIASIS. They also logical tracking of the furthest reaches of SKIN diagnose and treat skin growths, WARTS, cysts, and CANCER. The newest surgical techniques include 116 dermatome

LIPOSUCTION for skin contour control, and the use bination with physical therapy to prevent muscles of lasers for treating a variety of skin growths and from scarring and shrinking. Death occurs in less marks, including tattoos and PORT-WINE STAINS. than 10 percent of patients. dermatome A part of the mesoderm in the early dermatopathology The study of the microscopic embryo that forms the deeper layer of the skin appearance of diseased skin. (DERMIS). The entire surface of the body forms an interlocking web of dermatomes, the pattern of which is very similar from one person to another. dermatophagy The practice by amphibians and Loss of sensation in a dermatome means that a reptiles of eating their own skin. While scientists particular nerve root has been damaged. originally believed this was a rare practice, a new “Dermatome” also refers to a surgical instru- survey of more than 100 zoos and aquariums ment for cutting different thicknesses of skin for around the world has documented the practice in use in skin grafting. 285 species of frogs, lizards, salamanders, snakes, turtles, tuatara, and caecilians. Herpetologists believe the animals eat their skin for the extra pro- dermatomyositis A rare (sometimes fatal) disease tein, although some argue that the practice protects involving skin infl ammation and a skin rash. One the vulnerable animals from predators by eliminat- of a group of autoimmune disorders, dermatomyo- ing the evidence of their presence. sitis is sometimes associated with an underlying Because animals can eat their skin very quickly, cancer of an internal organ. It is most often found there had been few reports of dermatophagy until in middle-aged women. researchers at the Smithsonian Institution sought The average age at diagnosis is 40, and almost help from animal caretakers for the new data. twice as many women are affected. About half the They note, however, that observations still need to patients recover fully within two years; in about be made in the wild, since captivity may affect the 30 percent of cases the condition persists, and the skin-eating behavior. remaining 20 percent experience a progressive and sometimes fatal form of the disease that affects lungs and organs. dermatophyte Superfi cial fungal infection that affects the skin, hair, and nails, usually caused by Symptoms and Diagnostic Path the fungi Microsporum, Epidermophyton, or Tricho- Symptoms begin with a red rash on nose and phyton. This type of infection can be spread by per- cheeks, followed by purple discoloration on eye- sonal contact from person to person, to humans lids, and a red rash on the knees, knuckles, and from soil, or from an animal to a person. It usually elbows. As the disease progresses, muscles begin has a Latin name using the term TINEA (“RING- to weaken, becoming stiff and painful, and the WORM”) with the part of the body affected (such skin over the muscles of the shoulders and pel- as “tinea pedis” for ATHLETE’S FOOT). Although vis becomes thickened. Other symptoms include there are many different kinds of dermatophytes, weight loss, nausea, and fever. The role of sunlight seven species cause more than 90 percent of all in this disease has not been thoroughly examined, infections. The organisms are transmitted by either but in certain patients, exposure to sunlight may direct contact with an infected host (human or ani- worsen skin symptoms and probably systemic mal) or by direct or indirect contact with infected symptoms as well. exfoliated skin or hair in combs, hair brushes, clothing, furniture, theater seats, caps, bed linens, Treatment Options and Outlook towels, hotel rugs, and locker room fl oors. CORTICOSTEROID and immunosuppressant drugs can Depending on the species, the organism may control the skin infl ammation and are used in com- survive in the environment for up to 15 months. diaper rash 117

There is an increased susceptibility to infection dermoid Resembling the skin. when there is a pre-existing injury. See also TINEA BARBAE; TINEA CAPITIS; TINEA COR- PORIS; TINEA MANUUM; TINEA NIGRA PALMARIS; TINEA desquamation The continuous process of shedding VERSICOLOR. of the skin. This is an important factor that limits the bacterial population on the skin, since epithelial cells colonized with bacteria are always being shed. The dermatophytid A skin eruption caused by hyper- entire external layer of the skin is almost completely sensitivity to a type of fungus DERMATOPHYTE such replaced every three to four weeks. Dead cells con- as RINGWORM. tain large amounts of keratin (a fi brous portion that forms the outer barrier of the skin). dermatophytosis A type of fungus infection (also called TINEA) caused by Trichophyton, Epidermophy- developers Oxidizing agents (usually containing ton or Microsporum sp. HYDROGEN PEROXIDE) that supply oxygen to the molecules of HAIR DYE so that a particular shade is achieved. dermatosis cinecienta Another name for a pro- gressive pigmented disorder called ERYTHEMA DYS- CHROMICUM PERSTANS. DHA See DIHYDROXYACETONE. dermis The lower layer of the skin beneath the diaper rash Known medically as diaper DERMATI- EPIDERMIS. The dermis is composed of fi bers called TIS, this is a common condition of infancy caused COLLAGEN and ELASTIN, which are complex proteins by skin irritation from substances in feces or urine. responsible for the support and elasticity of the It is probably worsened by friction from rough dia- skin. It is collagen and elastin that enable the skin pers and prolonged wetting of the skin. to snap back into shape after being stretched or While babies vary in their susceptibility to dia- pulled. per rash, skin infl ammation in some infants can be Also found in the dermis are tiny twiglike sen- severe. In general, breast-fed babies have a lower sory nerve endings that allow a person to sense incidence of diaper rash than bottle-fed babies, and touch, temperature, vibration, and pain. the resistance continues long after the baby has Each square foot of dermis contains 15 feet of been weaned. In some infants, diaper rash is the small blood vessels that provide nutrients and oxy- fi rst indication of sensitive skin heralding a long gen; it is the constriction and dilation of these ves- series of later skin problems, such as ECZEMA. sels in response to extremes of heat and cold that help regulate temperature throughout the body. It Symptoms and Diagnostic Path is also these vessels that are responsible for keeping The skin appears reddened at fi rst and, as the rash the skin healthy and removing harmful metabolic becomes chronic, the skin becomes dry and scaly. wastes. In chronic severe cases, the skin is covered with Interestingly, nutrients can not be easily sup- PAPULES, BLISTERs, and erosions that can be mistaken plied to the skin by applying substances to the skin for bacterial infection or even BURNS. A long-term surface. This means that slathering on fruits, veg- rash that will not clear may be caused by a candida etables, cream, lotion, or vitamins on the skin in (fungus) infection, PSORIASIS, or atopic eczema. the hope of getting the substance into the skin may be unproductive. Certain substances, however, can Treatment Options and Outlook penetrate into the skin where they are biologically Some of the oldest advice is still the best in this active. case—expose the rash to air; take off the diaper and 118 diascope lay the baby facedown (with face turned to one lon of water during the fi nal rinse water to help side) on towels over a waterproof sheet, as long as match the cloth’s pH to baby’s skin. The cloth dia- someone is there to watch the infant. Protective pers must be well rinsed. Diaper rash enzymes are ointment (zinc oxide or “diaper rash ointment”) most active in an environment with high pH (often will help prevent and clear the problem. In severe found in cloth diapers after washing). cases, a mild corticosteroid drug is necessary to Cloth diapers provided by diaper services are control infl ammation, often given in combination usually very close to a baby’s pH level, and are with an antifungal drug to kill any organisms that usually tested at regular intervals to ensure the might cause THRUSH. products’ pH level. About half of all cases of diaper rash go away by themselves within a day. The other half of these rashes may last up to 10 days or more. diascope A glass or clear plastic plate (usually a microscopic slide) placed against the skin to Risk Factors and Preventive Measures observe the skin after the blood vessels have been Prevention of this skin condition is always better compressed. This diagnostic tool is used to blanch than trying to cure it once it appears. The aim in away any redness, which allows the underlying a preventive diaper rash program is to keep the color of any lesion to be seen. baby’s skin as dry as possible for as long as possible. Since a newborn breast-fed baby urinates about 20 times a day and has a bowel movement after each diet and skin Experts generally agree that a good feeding, this can be a major undertaking! Still, healthy diet is benefi cial to a good, healthy skin; diapers should be changed as often as possible fol- they also stress that ACNE is not caused by a diet rich lowed by application of a water-repellent emollient in oil, chocolate, or seafood. with each change. (If possible, the diaper should be A wide variety of studies has shown links with left off at least an hour a day). certain vitamins and healthy skin. VITAMIN A is Critics still disagree on the relative merits of important for healthy, normal growth of skin cells. cloth vs. disposable diapers and diaper rash, with Studies now being conducted with natural and each contingent asserting that only one type of synthetic derivatives of vitamin A may soon reveal diaper prevents diaper rash. Recent research has that the vitamin holds the key to bolstering the indicated that diapers containing absorbent gelling skin’s immune system, preventing acne and skin material signifi cantly reduces skin wetness, leaving cancer. These derivatives, called retinoids, may skin closer to the normal pH than either conven- someday be to skin diseases what antibiotics are to tional disposable diapers or cloth products. Propo- infections. nents of cloth diapers insist that the cloth allows for In addition, some B-complex vitamins and zinc more air circulation to the skin and, because the defi ciencies cause scaling and redness, especially cloth diapers do not hold as much water, these type around the mouth and nose. of diapers tend to get changed more often than do Dietary defi ciencies can also profoundly affect disposable diapers. your skin. For example, VITAMIN C defi ciency may While it is important to keep the diaper area result in SCURVY, causing bleeding gums, swell- clean, drying sensitive baby bottoms with a towel ing skin, and large black and blue bruises over can be irritating to some infants. Experts suggest the body. (In fact, British sailors are nicknamed drying irritated bottoms with a hair dryer set on “limeys” because during the heyday of the great low; afterward, zinc oxide ointments (diaper rash sailing vessels, they were fed limes and lemons ointments) can be applied. Since a baby’s urine to prevent scurvy). Vitamin C is also important in is sterile, the infant’s bottom need not be cleaned the production of COLLAGEN, the main supportive after urination—only patted or air dried. protein of skin. Parents who do use cloth diapers and wash their A defi ciency of vitamin A can cause acne and own should add one ounce of vinegar to one gal- other skin problems. Extremely low levels of vita- diphenhydramine 119 min B2 (ribofl avin), B3 (niacin) and B6 are linked cocamide DEA to skin infl ammations and mucous membrane cocamide MEA sores. DEA-cetyl phosphate Severe malnutrition (such as experienced in DEA oleth-3 phosphate Third World countries) can cause changes in color lauramide DEA and texture of hair and skin, and low iron levels linoleamide MEA result in yellowish, pallid skin. myristamide DEA At the other end of the spectrum, too many oleamide DEA nutrients can also cause skin problems. Excessive stearamide MEA intake of iodine (from too much iodized salt or TEA-lauryl sulfate shellfi sh) can cause breakouts of deep pustules and triethanolamine cysts on the face and back. Too much BETA-CARO- TENE (from some vegetables or carrots or supple- ments) can turn skin yellow; high levels of vitamin dihydroxyacetone (DHA) A sunless tanning A can cause dryness and cracking skin and mucous ingredient that works by reacting with the KERA- membranes. TIN protein in the top layer of the skin, providing a temporary tan. The DHA in sunless tanners is refi ned from a vegetable source such as sugar beets diethanolamine (DEA) A wetting agent used in or sugar cane. cosmetics that may be linked to cancer in lab Discovered to be a temporary skin coloring animals, according to the National Toxicology Pro- agent back in the 1920s, DHA was fi rst sold in an gram (NTP). The NTP completed a study in 1998 over-the-counter sunless tanning product in 1960 that found an association between cancer in lab as Coppertone Quick Tan, also known as QT. In the animals and the topical application of DEA and 1970 the U.S. Food and Drug Administration added some DEA-related ingredients. For the DEA-related DHA to their list of approved cosmetic ingredients. ingredients, the NTP study suggests that the cancer In the late 1980s cosmetic companies found a is linked to possible residual levels of DEA. The NTP way to produce better results that were less orange study did not establish a link between DEA and the and more brown with DHA by using an improved risk of cancer in humans. refi ning process yielding a higher quality, more Although DEA itself is used in very few cosmet- predictable DHA. Since then, DHA has been further ics, DEA-related ingredients are widely used in improved, leading to an explosion of self-tanning a variety of cosmetic products. These ingredients products. function as emulsifi ers or foaming agents and gen- erally are used at levels of 1 percent to 5 percent of a product’s formulation. DIN The European equivalent of SPF (SUN While the U.S. government believes that at the PROTECTION FACTOR), the rating system used for present time there is no reason for consumers to SUNSCREEN products. DIN stands for Deutsches be alarmed based on the use of these substances in Institut fur Normung, the institution that devel- cosmetics, consumers wishing to avoid cosmetics oped the European rating system. The DIN rating containing DEA or DEA-related ingredients should system uses lower numbers than the American review the ingredient statement on the outer con- SPF system for equivalent sun protection. For tainer label. example, SPF 12 is equal to DIN 9; SPF 19 is With the exception of color additives and a few equal to DIN 15. prohibited ingredients, a cosmetic manufacturer may use almost any raw material as a cosmetic ingredient. The following are some of the most diphenhydramine An antihistamine drug used to commonly used ingredients that may contain treat HIVES; it may be given as an injection to treat DEA: anaphylactic shock (a severe allergic reaction). 120 discoid lupus erythematosus

Side Effects unattractive, they are not life threatening. Only Possible side effects include drowsiness, dry mouth, about 10 percent of patients with DLE will go on and blurred vision. to develop SLE.

Risk Factors and Preventive Measures discoid lupus erythematosus (DLE) A chronic DLE cannot be prevented, but fl ares can be lessened type of lupus erythematosus that usually affects in patients with the disease by avoiding exposure exposed areas of the skin. The more serious and to the sun and consistently using sunscreen. potentially fatal form (SYSTEMIC LUPUS ERYTHEMA- TOSUS, or SLE) affects many systems of the body, including the skin, joints, kidneys, and nervous dishpan hands See CHAPPED HANDS. system. This is an autoimmune disorder in which the body’s immune system attacks a variety of tissues as DLE See DISCOID LUPUS ERYTHEMATOSUS. though they were foreign, causing infl ammation.

Symptoms and Diagnostic Path dressings Protective bandages over wounds that In DLE, a rash starts as one or more red, circular, may be used to control bleeding, prevent infection, thickened areas that later scar. The lesions are red- or absorb secretions. Dressings may be sterile or dened with follicular plugs, atrophy, scaling, and nonsterile. Sterile dressings are used to avoid infec- spidery veins. They may be found on the face, tion, and should be absorbent enough so the skin behind the ears and on the scalp, sometimes caus- around the wound does not become moist, which ing permanent hair loss. Lesions can also occur on could encourage infection. Unless the wound other parts of the body. Individuals with DLE tend must be cleaned often, the dressing should not be to be sensitive to light. disturbed. Although one-fi fth of SLE patients also experi- Skin dressings also are used to keep topical ence these discoid lesions, less than 5 percent of medications in place, and to relieve itching or pain. patients with DLE ever develop SLE. The occlusive dressing is a very effective means to Diagnosis of DLE usually requires a skin biopsy increase the local skin temperature, enhancing the of a discoid lesion, which will reveal certain micro- absorption of topical medication. Occlusive dress- scopic characteristics that allow it to be identifi ed. If ings also promote the retention of moisture, which antibodies exist in the blood, or if other symptoms stops the medication from evaporating. In an occlu- or physical signs are found, it is possible that the sive dressing, an airtight plastic fi lm (such as plastic discoid lesions are a sign of SLE rather than DLE. kitchen wrap) is placed over the medicated skin. Plastic surgical tape containing CORTICOSTEROID in Treatment Options and Outlook the adhesive layer can be cut to size and applied There is no cure; treatment aims at reducing to individual lesions. Occlusive dressings should be infl ammation and alleviating symptoms. It is essen- removed for 12 of every 24 hours in order to avoid tial to use SUNSCREENS, and avoid the sun whenever local skin atrophy, bandlike streaks, telangiectasia possible. The use of a potent topical CORTICOSTEROID (small red lesions caused by dilated blood vessels), or an injection into the lesion is appropriate, since infl amed hair follicles, nonhealing ulcers, and sys- these lesions often cause permanent scarring or temic absorption of corticosteroids. hair loss if left untreated. Sometimes, short-term Wet dressings are compresses soaked in water or treatment with oral steroids will be used for par- saline, used for oozing, weeping, crusted, eroded, ticularly severe DLE outbreaks. Medications used or ulcerated skin, that are usually applied for 10 to to treat malaria are often used to treat DLE. 30 minutes three or four times a day. Evaporation The prognosis for most people with DLE is from the dressing soothes and dries by cooling the excellent. While the lesions may be cosmetically skin surface. dry skin 121 drug reactions A skin rash is one of the most ethylenediamine, diphenhydramine (in Caladryl), common side effects of a wide range of drugs, and parabens (preservatives found in many topi- and may be the fi rst sign of a generalized toxic cal preparations, including some CORTICOSTEROIDS). reaction. And yet, while skin symptoms of a drug Neomycin is the most sensitizing of currently-used reaction are quite common, scientists do not really topical antibiotics; approximately 5 percent of understand the mechanism underlying most of the people have a sensitivity to it. effects. Most drug-related skin eruptions will fade away The risk of a drug-related rash is higher in cer- within two weeks after the drug is stopped, leav- tain groups: 35 to 50 percent more women than ing no permanent scars or discolorations. How- men, 50 to 80 percent of patients with infectious ever, some skin reactions may be life threatening, mononucleosis who take ampicillin. The risk of a including anaphylaxis, toxic epidermal necrolysis, drug rash is much higher in patients taking ampi- vasculitis, severe ERYTHEMA MULTIFORME, and exfo- cillin and allopurinol together than either drug liative ERYTHRODERMA. Usually the wider the area alone. Reasons behind the development of this of affected skin, the longer it will take for side rash are unknown. effects to fade. If a patient develops a rash following use of a Symptoms and Diagnostic Path certain drug, then continued use of the medica- Skin rash is the most common adverse skin reac- tion may induce a life-threatening eruption or an tion to a drug, occurring in two to three percent exfoliative erythroderma. However, patients who of all patients. The rash is characterized by a fi ne, have developed rashes due to sulfonamides, peni- papular eruption that usually appears within the cillin, or carbamazine have been desensitized by fi rst seven to 10 days after the drug is begun. withdrawing the drug until the rash resolves, and Antibiotics and allopurinol may induce rashes two then restarting the medication gradually, increas- or more weeks after they are started. Drug rashes ing doses until therapeutic doses are achieved. often begin in areas of trauma or pressure, such as on the backs of bedridden patients or on the extremities of patients who are not bedridden. dry skin Also known as “xerosis,” dry skin usu- Drugs most frequently found to cause a rash are ally begins in the 30s and worsens as a person antimicrobial agents, blood products, nonsteroidal ages. Dry skin may come and go depending on the anti-infl ammatory drugs (NSAIDs), and central weather. It is worse in the cold, and it is related to nervous system drugs. According to one survey, a decrease in the relative humidity and dry air from drugs with reaction rates above one percent central heating. If the dryness worsens, the skin include trimethoprimsulfamethoxazole, ampicil- may seem irritated to the point of developing into lin, amoxicillin, semisynthetic penicillins, penicil- DERMATITIS, with redness and skin fi ssures. One of lin, red blood cells, and cephalosporins. the worst aspects of dry skin is the itch, which may Hives are the second most common allergic skin increase during stressful periods. reaction to drugs, and are most often caused by antibiotics, blood products, radiocontrast agents, Treatment Options and Outlook NSAIDs, and opiates. The hives usually last for less Daily bathing in lukewarm water with an added than 24 hours and are replaced by new lesions in bath oil will also help to add water to the skin. The new places. most effective emollients are often those people Allergic contact dermatitis to medications used on fi nd least acceptable—semisolid oils that work to the skin is common, featuring papules, blisters, prevent evaporation, instead of moisturizers, which and vesicles. Patch testing may be used to dem- immediately soften the skin but can not seal the onstrate contact hypersensitivity to a suspected water into the EPIDERMIS. Studies have indicated topical medication. Substances found in topical that petrolatum and LANOLIN are very effective at medications that are often associated with allergic abolishing dry skin within two weeks. There are contact dermatitis include neomycin, benzocaine, many excellent MOISTURIZERs that, used daily, can 122 Drysol (aluminum chloride hexahydrate) prevent progressive dry skin. Moisturizers contain- Duhring’s disease See DERMATITIS HERPETIFORMIS. ing lactic acid, which helps to draw moisture from the dermis into the epidermis, may be effective. dyshydrotic eczema See POMPHOLYX.

Drysol (aluminum chloride hexahydrate) A pre- scription ANTIPERSPIRANT useful in patients with dyskeratosis congenita Almost all cases of this severe HYPERHIDROSIS (excessive sweating). Drysol rare inherited disorder have been found in boys. is a 20 percent solution in absolute ALCOHOL. It can By age fi ve or six, the child experiences blistering be used under the arms, on palms, or on soles. Dry- of palms and nail beds, leading to a loss of nail sol is reported to work in 80 percent of the people plates and atrophy of the ends of the fi ngers and who use it for excessive sweating. Doctors gener- toes. There is a very high incidence of cancer and ally recommend applying it to problem areas after leukemia. In the teenage years, HYPERPIGMENTATION drying the skin completely. Wearing it only at bed- surrounding a central lack of pigment appears on time and then washing it off in the morning with the face and trunk and patients may be sensitive plain water reduces the chance of skin irritation. to light. Treatment is typically repeated each night until sweating is under control. This may happen after Treatment Options and Outlook just two or more treatments. Thereafter, it can be There is no treatment other than relieving the skin applied once or twice weekly, or as needed. symptoms. Patients should avoid known cancer- Drysol should not be applied to broken, irri- causing substances, including ultraviolet light and tated, or recently shaved skin, and it should not tobacco. be used with regular daytime antiperspirants or DEODORANTS. See also DEODORANTS. dysplastic nevus syndrome See NEVUS SYNDROME, DYSPLASTIC. duck bumps See GOOSEFLESH. E ear repair See OTOPLASTY. Children are more commonly affected with echthyma, which is usually associated with poor hygiene, malnutrition, and minor skin injuries eau de cologne A light, fresh scent that can be from trauma, insect bites, or SCABIES. The condition reapplied often, and that is not as strong as pure commonly occurs during unfavorable conditions, perfume (parfum), because it is diluted with water. such as war or captivity. Eau de cologne has a 2–6 percent concentration of pure perfume, compared to eau de toilette (4–8 Symptoms and Diagnostic Path percent) and eau de parfum (8–15 percent). Echthyma may begin with a PUS-fi lled BLISTER, very See also FRAGRANCE. much like IMEPTIGO, but in this case the infection penetrates through the outer layer of skin and into the deeper layer, developing into an ulcer ecchymosis The medical term for a BRUISE, a with raised borders covered by a hard crust. Unlike blue or purple hemorrhage in the skin or mucous impetigo, echthyma can sometimes cause scarring. membrane. Examination by a doctor is usually enough to diag- nose echthyma. Lesions may be skin biopsied or cultured in some instances. eccrine gland See SWEAT GLANDS. Treatment Options and Outlook ERYTHROMYCIN or dicloxacillin can be effective. The econazole (Ecostatin) An antifungal drug used lesions should also be soaked, and crusts removed. to treat RINGWORM of the scalp, ATHLETE’S FOOT, Full recovery is expected. JOCK ITCH, nail fungus, candidiasis, and others. Available in powder, cream, lotion, ointment, or vaginal tablet, the medication acts quickly (often ectoderm The outermost of the three primary within two days), killing fungi by damaging the germ (living substance capable of developing into an fungal cell wall. The drug may take up to eight organ) layers of the embryo. From it are developed weeks to cure the infection. Rarely, the drug may the EPIDERMIS and epidermal tissues (such as nails, cause skin irritation. hair, and skin glands), as well as the nervous system, the external sense organs (eye, ear, and so on), and the mucous membranes of mouth and anus. ecthyma A deep ulcerative skin infection caused by bacteria (usually group A streptococci or staphy- lococcus) that often results in scarring, usually ectodermal dysplasia (ED) A group of genetic dis- found on the legs and protected areas of the orders that are identifi ed by the absence or defi cient body. The condition begins with one lesion which function of at least two of these: teeth, hair, nails, or enlarges and encrusts; beneath this crust is a pus- glands. At least 150 different (EDs) have been iden- fi lled “punched ulcer.” tifi ed. Charles Darwin identifi ed the fi rst EDs in the

123 124 ectoparasite

1860s, and today the number is believed to affect as middle layer (the mesoderm), and an outer layer many as seven out of every 10,000 births. (the ectoderm). Defects in formation of the outer There is usually no reason to expect anything layer lead to ED. The reason that so many parts of but normal intelligence with ectodermal dysplasia. the body are affected is because the ectoderm of Some of the extremely rare forms have been asso- the surface of the developing baby forms the skin, ciated with mental retardation. As with the general nails, hair, sweat glands, parts of the teeth, the lens population, some individuals affected by ED may of the eye, and the parts of the inner ear. Another be very bright, some may be average, and others portion of ectoderm forms the brain, spinal cord, may fi nd challenges in learning. nerves, the retina of the eye, and the pigment cells of the body. Symptoms and Diagnostic Path Individuals affected by EDs have abnormalities of Treatment Options and Outlook sweat glands, tooth buds, hair follicles, and nail There is no cure. Because most people with ED development. Some types of EDs are mild, while have missing or malformed teeth, dental treatment others are devastating. Many individuals affected is necessary beginning with dentures as early as age by EDs cannot perspire. Air conditioning in the two, multiple replacements as the child grows, and home, school, and workplace is a necessity. Other perhaps dental implants thereafter. Orthodontic symptoms may include defi cient tears and saliva, treatment may also be necessary. frequent respiratory infections, poor hearing or Precautions must be taken to limit upper respi- vision, missing fi ngers or toes, cleft lip and/or pal- ratory infections, and care must be provided for the ate, poor immune system, sensitivity to light, lack skin to prevent cracking, bleeding, and infection. of breast development. Professional care may minimize the effects of Lifespan can be affected in some rare types of vision or hearing defi cits, and surgical or cosmetic EDs, but there are very few documented examples procedures may improve other deformities. of a death because of an inability to perspire. There is no evidence that the lifespan of a per- There are four different types of ectodermal dys- son diagnosed with one of the common ectodermal plasia: anhidrotic, anhydrotic, hypohidrotic, and dysplasias is shorter than average, but a few rare hypohydrotic. syndromes may lead to a shortened lifespan.

• Anhidrotic means “no sweating” and is derived from the Greek words an (none) and hidros ectoparasite A parasite that lives on the skin, (sweat). A person who does not sweat at all getting nourishment either from the skin or by could be said to be anhidrotic. sucking the host’s blood; various types of ticks, lice, • Anhydrotic means “no water” from the Greek an mites, and some types of fungi may occasionally be (none) and hydro (water). Those who are totally ectoparasites on humans. (Parasites living inside the devoid of water could be said to be anhydrotic. body are called “endoparasites.”) Diseases caused by these parasites include SCABIES and PEDICULOSIS • Hypohidrotic means “defi cient sweating” from the (louse infestation). Greek hypo (under/defi cient) and hidros (sweat) Someone whose sweat function is diminished (sweats little in response to heat or in response to ectothrix A fungus that grows outside the hair stress only) could be said to be hypohidrotic. shaft. • Hypohydrotic means “defi cient water.” Those who See also ENDOTHRIX. are partially or totally devoid of water could be said to be hypohydrotic. eczema A superfi cial infl ammation of the skin As a baby is developing, three layers of tissue can primarily affecting the outer skin layer (EPIDERMIS) be identifi ed: an inner layer (the endoderm), a that causes itching and a red rash often accompa- Ehlers-Danlos syndrome 125 nied by BLISTERs that weep and then crust. This eczema herpeticum A rare skin condition caused may be followed by scaling, thickening, or discol- by the HERPES SIMPLEX virus infection in a patient oration of the area. with a preexisting skin condition, such as DER- MATITIS. It is characterized by extensive blister- Symptoms and Diagnostic Path ing, oozing, and crusting. The condition usually Eczema has many forms with two main divisions— remains only on the skin. eczematous dermatitis, which is caused by external factors, and endogenous eczema, occurring with- Treatment Options and Outlook out any obvious outside cause. Administration of acyclovir is effective. Symp- Classifi cation of endogenous eczema is based toms can be treated by applying compresses and on its appearance and site. The fi ve types are atopic bathing. (commonly found in childhood and sometimes associated with a family history of allergy, also called atopic dermatitis); discoid (small well-defi ned egg Commercially produced skin care products areas, also called nummular eczema or nummular containing egg do not help the skin, since the pro- dermatitis); POMPHOLYX (found on hands and feet, teins in egg cannot be utilized by the skin in this formerly called dyshidrotic pompholyx); seborrheic way. However, a fresh egg mask can create a fi lm (scaly plaques in areas of the greatest sebum pro- on the face, locking in water and allowing the skin duction, also called seborrheic dermatitis) and vari- to build up a supply of water, which will temporar- cose (develops on the legs in association with poor ily soften dry skin. circulation). Other types of eczematous diseases include asteatotic eczema (due to overdrying of the skin) Ehlers-Danlos syndrome A hereditary group of and polymorphic light eruption. disorders in which there is a defi ciency or defect of See also DERMATITIS, ATOPIC; DERMATITIS, HAND; normal COLLAGEN (the most important protein in DERMATITIS, NUMMULAR; DERMATITIS, SEBORRHEIC. the body) that causes easily bruising, stretchy, thin skin. Known medically as “cutis hyperelastica,” the Treatment Options and Outlook disease is also characterized by paper-thin scars Treatment of eczema depends on the cause, but from wounds that have failed to heal properly. it usually includes the use of locally-applied Contortionists in circus side shows are often vic- CORTICOSTEROIDS. Creams, lotions, and antihista- tims of Ehlers-Danlos syndrome, since the disease mines may help stop itching. Coal-tar ointments allows the skin to be stretched far beyond its usual are often used when the problem has persisted length; the skin can still resume its original shape for months or years and the skin has become after distention. thickened and leathery. To reduce scratching and The syndrome includes a family of 10 or more irritation, soothing ointments should be covered separate genetic disorders with varying inheritance by a dressing and absorbent, nonirritating materi- patterns, some dominant, some recessive, and als should be worn next to the skin. Fabrics such some X-linked. Four have been linked to specifi c as wool, silk, and rough synthetics should be enzyme defi ciencies. avoided. Children with atopic eczema should be bathed Symptoms and Diagnostic Path with a mild neutral soap no more than three times Patients with this group of disorders do not become weekly. Bath oil may prevent excess skin drying, obviously distorted until late in life, when they and fi ngernails should be clipped to decrease dam- may begin to experience signifi cant cosmetic defor- age from scratching. mity caused by loose skin, joint changes, and scars resulting from the skin’s fragility. Gaping wounds may develop from the slightest injuries, and sur- eczema, atopic See DERMATITIS, ATOPIC. gical sutures do not hold well. Often, prominent 126 elastic fi bers scars appear on sites of frequent injury, such as the to form a fi lm on the skin that helps lock in forehead, chin, knees, and shins. moisture. Repeated tearing and bruises may cause skin to “outbag” and form pseudotumors. Joints may be hyperextendable; the fi ngers may often be able to elastomas A rare type of CONNECTIVE TISSUE NEVI bend 90 degrees backwards, and the thumb can be characterized by overgrowth and distortion of the bent back to the wrist. Other characteristics include elastic fi bers of the skin. Also known as “NEVUS soft handshakes, high-arched palate, long neck, ELASTICUS OF LEWANDOWSKY,” this type of nevus is and sloping shoulders, with possible spine defor- usually found as a collection of smooth skin-colored mities. Common injuries include dislocations of papules forming patches and plaques, most often the kneecap, hips, and temporal mandibular joints; on the trunk. No treatment is necessary. eventually these can lead to arthritis of the large joints and spine. elastosis Degeneration of elastic tissue. It is most Treatment Options and Outlook often seen as the result of long-standing sun expo- There is no known treatment, but unnecessary sure in photo-aged skin. injuries should be avoided. Surgery of various defects may be attempted, but there is a danger of bleeding and poor wound healing. Patients should elastosis perforans serpiginosa A rare disorder protect fragile skin and joints, and avoid unneces- in which the skin is perforated, as though the body sary injuries or extending skin, ligaments, or joints. were trying to push out defective elastin, causing a Woman should understand that pregnancy carries circular or wavy indented lesion. a serious risk of hemorrhage. The syndrome may be inherited and usually Despite the lack of treatment, most patients appears during the 20s or 30s; male patients out- have a normal life expectancy. Milder cases may number women four to one. correct themselves with aging, but other patients experience a progressive decline into severe arthri- Symptoms and Diagnostic Path tis and skin looseness over distorted joints. Death EPS is a disease of the connective tissue that occurs may result from a number of related internal organ in three different forms: problems. Idiopathic EPS: The cause of idiopathic EPS is unknown, but it may be inherited. elastic fibers Connective tissue fi bers that help Reactive EPS: This form is associated with sys- to give the skin elasticity so that it returns to its temic, inherited, fi brous tissue abnormalities, normal position after stretching. such as EHLERS-DANLOS SYNDROME, Marfan syndrome, osteogenesis imperfecta, SCLERO- DERMA, and PSEUDOXANTHOMA ELASTICUM. elastin The protein that (together with COLLAGEN) Drug-induced EPS: This form is caused by a side is the primary substance in connective tissue. While effect of D-penicillamine and occurs in about collagen gives connective tissue strength, elastin 1 percent of patients treated with the drug. gives skin its elastic properties, allowing the skin to stretch and spring back into place. Elastin becomes Lesions usually appear on the back of the neck less elastic with age; as the skin and subcutaneous or arms, although they may also appear on the face fat thins with age, the skin becomes looser. Elastin and lower extremities. can be further damaged by extensive sun exposure, which can lead to wrinkling. Treatment Options and Outlook In cosmetic products, elastin cannot make the There is no satisfactory treatment for this syndrome; skin tighter. Used as a moisturizer it is thought surgery may be attempted. In most cases, cutaneous electroporation 127

EPS is only a cosmetic problem. A rare systemic to destroy a small tumor, larger growths may also version is fatal, in which abnormal elastic tissue is require curettage. found in the walls of ruptured blood vessels. See also CURETTAGE AND ELECTRODESICCATION. electrical injury An electric shock can damage electrolysis A treatment in which an electric cur- the skin, if an electric current passes through the rent is used to permanently remove excess body body. More than 1,000 people die from electrical hair by destroying the hair’s root bulb from which accidents in the United States each year, and many it grows. Although unwanted hair can be removed more are seriously injured. Because the internal in a variety of ways (such as waxing, plucking, tissues of the body are moist and salty, they are and so on), electrolysis is the only permanent hair good electric conductors. On the other hand, dry removal method. skin provides good resistance. For this reason, a To remove a hair, a fi ne needle is inserted into shock to someone in a full bathtub will probably the follicle along the hair shaft, destroying the root be fatal, whereas someone who is dry and standing with a small electric current; the hair is then pulled outside the tub, wearing rubber-soled shoes (that out. The procedure may be slightly painful, but it is do not conduct electricity), is far less likely to be harmless when performed by trained operators. A hurt by the same shock. number of sessions may be required until treatment All shocks except for the most mild are likely is successful. At this point, there should be no more to cause unconsciousness, but the extent of tissue hair growth from that follicle, and minimal scarring. damage depends on the size and type of current. Electrolysis can be performed on almost any Skin tissues become charred where signifi cant cur- part of the body, although it should be avoided on rent enters and exits the body. the lower margins of the eyebrows because the skin in this area is delicate and easily damaged. FIRST AID FOR ELECTRICAL INJURY Some experts also disapprove of electrolysis in the armpits because of the danger of bacterial infec- Rescuers should NOT attempt any type of fi rst aid until con- tact with the energy source is broken. The victim should tion. Electrolysis is rarely used to remove leg hair not be touched with anything wet. because treatment of such large areas requires so The plug should be pulled out of the socket, or the rescuer many sessions that it is too time-consuming and should stand on a dry object and push the victim away expensive for most people. from the source with a dry stick. Before selecting an electrologist, it is important If the victim is unconscious and not breathing, CPR should be to make sure the operator is fully trained, since started. incompetent electrolysis can cause permanent If the victim is breathing, fi rst-aid advice for burns and shock should be followed until an ambulance arrives. disfi gurement. electrodesiccation A dermatologic treatment electroporation A series of short electrical pulses method that destroys tissue by heat from a high- that rearrange fatty layers in the outer skin layer frequency electric current. The technique is used to create temporary pores through which drugs to treat a variety of skin lesions from SKIN TAGS, may be administered. While the skin’s outer layer WARTS, and precancerous changes in the skin to of dead, fl attened cells is an effective barrier to skin cancers. It also may be used to destroy small microbes, chemicals and other toxic agents, tempo- tumors. rarily increasing the skin’s permeability would be In the technique (which is usually performed of benefi t when it comes to administering certain with a local anesthetic), the physician applies an medications. electric probe to the tissue for one or two sec- Researchers at Massachusetts Institute of Tech- onds; the current fl ows to and through the lesion, nology successfully achieved a 1,000-fold increase destroying the tissue. While this may be enough in skin permeability using the technique, which 128 elephantiasis delivers a series of millisecond electrical pulses do have some toxic side effects. A vaccine is not every fi ve seconds. yet available. People infected with adult worms Before the technique can be used in drug delivery, can take an annual dose of medicine that kills the researchers will need to answer questions about the microscopic worms circulating in the blood. While technique’s safety and effectiveness. The technique this does not kill the adult worms, it does prevent also may be used to transport fl uids out of the body infected people from giving the disease to someone (such as a noninvasive way to take blood samples). else. Even after the adult worms die, however, lymphedema can develop. To prevent the lymphedema from getting worse, elephantiasis A parasitic disease (also known as patients should lymphatic fi lariasis) caused by microscopic, thread- like worms (Wuchereria bancrofti, Brugia malayi, or B. • wash the swollen area with soap and water every timori) that live only in the human lymph system day (which maintains the body’s fl uid balance and fi ghts • use anti-bacterial cream on any wounds to stop infections). Elephantiasis affects more than 120 mil- infections lion people in 80 countries throughout the Tropics • elevate and exercise the swollen arm or leg to and sub-Tropics of Asia, Africa, and the Western move the fl uid and improve the lymph fl ow Pacifi c, and parts of the Caribbean and South Amer- ica. The worms do not occur in the United States. • apply elastic bandages to the affected parts, When an infected female mosquito bites a per- which may help son, she may inject the worm larvae into the blood, which reproduce and spread throughout the blood- The disease usually is not life threatening, but stream, where they can live for many years. Often it can permanently damage the lymph system and disease symptoms do not appear until years after kidneys. Elephantiasis is a leading cause of per- infection. As the parasites accumulate in the blood manent and long-term disability throughout the vessels, they restrict circulation and cause fl uid to world. People with the disease can suffer pain, dis- build up in surrounding tissues. fi gurement, and sexual disability, and communities Many mosquito bites over several months to often shun those disfi gured by the disease. Many years are needed to get lymphatic fi lariasis. People women with visible signs of the disease will never living for a long time in tropical or sub-tropical marry, or their spouses and families will reject areas where the disease is common are at the great- them, and patients often are unable to work. est risk for infection. Short-term tourists have a very low risk. emollients Substances that soften and smooth Symptoms and Diagnostic Path the skin, helping to replace oils and prevent mois- At fi rst there are no symptoms, until after the adult ture loss. Common emollients present in almost all worms die. At that point, the most common, visible skin creams include LANOLIN, petrolatum, mineral signs of infection are excessively enlarged arms, oil, and squalane. genitalia, and breasts, although the legs are most See also AGING AND THE SKIN. commonly affected. The syndrome gets its name from the appearance of the skin of the legs, which resembles elephant hide. emotion and the skin Many experts believe Unfortunately, the disease is diffi cult to detect that emotion plays a role in almost all skin dis- early, and improved laboratory tests are needed. eases, whether or not the cause of the disorder is physical. Emotional factors sometimes cause skin Treatment Options and Outlook disease, and often can either reduce or intensify Medicines to treat lymphatic fi lariasis are most itching and pain—even when the physical disease effective when used soon after infection, but they itself remains unchanged. epidermolysis bullosa 129

The psychological stress of illness or a variety become part of the horny layer. It is this horny of personal and family problems are often exhib- layer that protects against external chemical and ited outwardly as skin problems. For example, antigen damage and inhibits injury from microbes, even though SHINGLES or recurrent genital herpes fungi, parasites, or insects. are caused by a virus, and PSORIASIS is hereditary, negative emotions can trigger the onset of these diseases—or worsen a condition that already exists. epidermoid cysts A closed sac containing cheesy Stress has also been linked with increased ACNE materia that may be common or benign. There breakouts and worsening of HIVES. are two types of epidermoid cysts—epidermal and One study evaluated more than 4,500 people to pilar cysts. Epidermal cysts may be found alone or in determine the link between emotional stress and groups, most often on the face, neck, upper chest, skin disorders, as well as the time it took for the and back. As they enlarge, the skin thins and begins stressful event to trigger the disorder. Emotions to look yellow white; if the cysts become infected were found to trigger ITCHING almost 100 percent the skin becomes red and tender. Ultimately, these of the time; hives, 68 percent; and psoriasis, 62 cysts may rupture and drain PUS. percent. Pilar cysts involve hair follicles and are much See also HERPES SIMPLEX. less common than the epidermal variety. They are found most often on the scalp, although they may also crop up alone or in groups on the face, neck, endothrix A DERMATOPHYTE (superfi cial fungus) and trunk. They look identical to an epidermal cyst, whose growth and spore production are confi ned but they can be differentiated under the micro- primarily within the hair shaft, without forming scope by the appearance of the epithelium (tissue conspicuous spores on the outside of the hair. that covers the external surface of the body). Pilar See also ECTOTHRIX. cysts tend to run in families. In the past, pilar and epidermoid cysts were wrongly known as “sebaceous” cysts. In fact, true entoderm The innermost of the three primary sebaceous cysts are rare, and this term should only germ layers of the embryo, from which the epi- be used for a quite different type of cyst fi lled with thelium of the pharynx, respiratory tract, digestive a clear oily liquid made by sebaceous glands. Most tract, bladder, and urethra are formed. cysts are either epidermoid (they originate in the epidermis and are fi lled with dead outer skin cells and keratin) or pilar cysts (originating in the skin ephelis Another name for FRECKLE. lining hair follicles).

Treatment Options and Outlook epidermis The surface layer of the skin. This Both types of cysts must be completely removed or layer covers the DERMIS and contains the basal cell the epithelial sac must be destroyed; otherwise, the layer, STRATUM SPINOSUM, STRATUM GRANULOSUM, lesion may recur. Some lesions can be completely STRATUM LUCIDUM, AND STRATUM CORNEUM. cut out in a wedge excision, while in other cases There are two major zones of the epidermis—an the sac may be removed through a small overlying inner region of moist cells and an outer layer of incision after drainage of the cyst. fl attened dead cells known as the “stratum cor- neum” (or horny layer). In the epidermis, there are three layers of living epidermolysis bullosa This rare inherited blis- cells—the basal, spinous, and granular layers. The tering condition loosens the outer layers of the basal cells at the bottom of the dermis constantly skin, allowing the cells to be easily separated into divide, giving birth to daughter cells that begin its various layers. As a result, blisters form either to move toward the skin’s surface, where they spontaneously or after minor injury. The disorder 130 epidermotropism is found primarily in young children and may erysipelas Formerly called St. Anthony’s fi re, range in severity from mild foot blistering in hot this contagious infection of the facial skin and weather to widespread and severe blistering and subcutaneous tissue is usually caused by group A scarring all over the body. streptococci. It is marked by rapid-spreading red- Epidermolysis bullosa is a group of inherited ness and swelling, which is believed to enter the defects. Some are autosomal dominant (each child skin through a small lesion. While this disease is of an affected parent has a 50 percent chance of contagious, it does not produce epidemics such as inheriting the defect); others are autosomal reces- those of SCARLET FEVER. Erysipelas may affect both sive (each of the children of two unaffected carrier children and adults. The legs are affected in up to parents has a one in four chance of inheriting the 80 percent of cases; the face accounts for up to 20 defect). percent of infections.

Treatment Options and Outlook Symptoms and Diagnostic Path There is no specifi c treatment for this disorder. After a fi ve- to seven-day incubation period, the Even the slightest injury to the skin should be skin feels tight, uncomfortable, itchy, and red, with avoided. Wound care is essential once blisters or patches appearing most often on the face, spread- open sores develop. In mild cases, there may be ing across the cheeks and bridge of the nose. The gradual improvement, but more seriously affected patient also may notice sudden high fever (above children may experience serious disease. 100° F) with headache, malaise, and vomiting. The lesions also occur on the scalp, genitals, hands, and legs. Within the infl ammation, pimples appear, epidermotropism The infi ltration of the top layer blister, burst, and crust over. The diagnosis of ery- of the skin (epidermis) by lymphocytes. sipelas is based on the characteristic appearance of the skin lesion; skin biopsies are usually not needed. Blood cultures rarely reveal the infection. epiloia An acronym for TUBEROUS SCLEROSIS that designates “epilepsy, low intelligence, and ADE- Treatment Options and Outlook NOMA SEBACEUM.” Penicillin and antibiotic relatives of penicillin are the usual choice of treatment, and should cure the infection within seven days. Bed rest, hot packs, epithelioma Any tumor derived from EPITHELIUM. and aspirin for pain and fever also may help. Before the advent of antibiotics, this disease could be fatal (especially in infants and the elderly). epithelium The cells that cover the entire surface Today, it can be quickly controlled with prompt of the body. The skin consists of many layers of treatment. epithelium. The epithelium varies in cell type and See also NECROTIZING FASCIITIS. thickness, according to its function in any particu- lar area. There are three basic cell shapes: squa- mous (thin and fl at), cuboidal (resembling a cube), erythema Redness of the skin caused by infl am- and columnar (resembling a column). Because it is mation that may occur for a variety of reasons. Red- constantly subject to trauma, the outermost layer dening of the skin is caused by an increased amount of cells are dead and constantly being shed. of blood in dilated blood vessels in the skin. Unlike a hemorrhage, the red skin color of erythema fades when the skin is compressed, since the blood is epsom salts Magnesium sulfate crystals used in pushed out of the skin’s vessels. (In a hemorrhage, baths to soothe the skin. It is effective in drying an the blood remains in the tissue outside the blood oozing, infl amed area of skin and is also very effec- vessels so that compression does not remove the tive as a soak for tired, sore muscles. blood, and the red color does not disappear.) erythema dyschromicum perstans 131

A range of external factors may cause erythema, own over a few months. If the condition is severe such as heat, sun rays, cold, and chemical irritants. and the skin red and thinned, there is a possibility Internal causes may include hot fl ashes, blushing, that SQUAMOUS CELL CARCINOMA may form after a histamine release, fever, hot drinks, alcohol, or period of years. Any persistent sore or lump within spices. Erythema also may be caused by a range of the rash should indicate the necessity of perform- infl ammatory skin conditions such as ACNE, DERMA- ing a skin biopsy to rule out the possibility of SKIN TITIS, ECZEMA, ERYSIPELAS, and ROSACEA. CANCER. Treatment with topical tretinoin or laser In addition, erythema is a symptom of disorders may improve the appearance, but abnormally pig- including ERYTHEMA MULTIFORME, ERYTHEMA NODO- mented skin may persist for years. Examples of this SUM, LUPUS ERYTHEMATOSUS, and FIFTH DISEASE. Ery- sort of heat-related damage have been reported thema often occurs with other primary skin lesions throughout the world; “kangri cancer of India” is such as MACULES, PAPULES, NODULES, or surrounding caused by holding pots of coal next to the skin; blisters. kange cancer of China is caused by sleeping on hot bricks; kairo cancer of Japan is associated with benzene-burning fl asks next to the skin, and turf erythema ab igne A skin reaction caused by or peat fi re cancer in Ireland is caused by sitting chronic exposure to heat, such as by sitting too too close to a peat fi re. These aggressive types of close to open fi res or electric space heaters, or lying squamous cell cancers may appear after a latency for long periods of time on a heating blanket. period of 30 years. In the past, it caused the typical telangiectasia (distended blood capillary vessels) and red-brown discoloration on the legs of those who sat in front erythema annulare centrifigum One of a group of open fi res or coal stoves in Great Britain and of annular erythemas (ringlike rash) characterized Europe. The condition became less common with by expanding ring-shaped plaques. The lesions, the development of central heating. In the United which are usually found on the trunk, enlarge States, the rising popularity of space heaters, wood- slowly. While the disorder can occur at any age, burning stoves, and fi replaces saw a resurgence in most patients are young adults when stricken. this syndrome. Erythema ab igne is also seen on Symptoms may last for only a short time, or they the skin of glassblowers, bakers, and kitchen work- may persist for decades, depending on the cause. ers. Chronic use of heating pads may also lead to This type of erythema may be associated with a this problem. DERMATOPHYTE infection, yeast infection (Candida albicans), parasitic bowel disease, or autoimmune Symptoms and Diagnostic Path disorders. Limited exposure to heat that is not hot enough to cause a direct burn can cause instead this mild Treatment Options and Outlook and transient lacy red rash. Prolonged and repeated Eliminate the cause (that is, the fungus or para- exposure causes a marked redness and thinning. site). Erythema annulare centrifugum caused by a Rarely, sores may develop. Some patients may com- yeast infection has been cured following treatment plain of mild itchiness and a burning sensation. with oral and vaginal nystatin (an antibiotic effec- tive against fungi). Treatment Options and Outlook The dryness and itching may be eased by applying an EMOLLIENT; the redness will fade, although the erythema chronicum migrans See LYME DISEASE. telangiestasia and discoloration does not usually disappear completely. Chronic exposure to heat must be stopped and erythema dyschromicum perstans A progressive avoided. If the area is only mildly affected with pigmented disorder of unknown cause that is one slight redness, the condition will improve on its of the group of reactive ERYTHEMAS. It also has been 132 erythema gyratum repens called “ashy dermatosis” because of the characteris- erythema marginatum A type of reactive red skin tic slate-gray color of patients’ skin. color associated with rheumatic fever, a delayed complication of the upper respiratory tract caused Symptoms and Diagnostic Path by hemolytic streptococci, and characterized by Other than the ashy appearance of the skin, there rapidly changing ring-shaped red patches. The syn- are few symptoms; patients usually are dark- drome is becoming less common with the decline skinned individuals of Latin American heritage. in rheumatic fever cases. Many slate gray MACULES and patches develop over the trunk, arms, and legs; the scalp, palms, Symptoms and Diagnostic Path soles, and mucous membranes are usually not The lesions tend to appear on the trunk, changing affected. Some researchers suspect that the pig- in size and shape, fading and reappearing over a ment changes represent a post-infl ammatory matter of months. hyperpigmentation. The condition is chronic and In addition to the reddish lesions, patients usu- tends to spread. ally have signs of active rheumatic fever including arthritis, fever, and so on. Treatment Options and Outlook There is no effective treatment, but makeup can Treatment Options and Outlook cover cosmetically unattractive areas. Deliberate The skin symptoms do not itch and do not require suntanning can also mask the lesions. topical treatment, but rheumatic fever requires immediate attention. erythema gyratum repens One of a group of dis- orders called annular erythemas characterized by a erythema multiforme A type of allergic reaction red ringlike rash (annula). that occurs in response to medications, infections, or illness. Medications that can trigger erythema Symptoms and Diagnostic Path multiforme include antibiotics such as sulfon- Erythema gyratum repens causes reddened skin in amides and penicillins, and anti-epileptics such as a wood-grain pattern that is usually, although not phenytoin and barbiturates. Associated infections always, associated with cancer, most often of the include HERPES SIMPLEX and mycoplasma infections. breast, lung, uterus, or upper gastrointestinal tract. This acute infl ammation of the skin and mucous This rare reactive erythema begins with an itchy membranes characterized by a distinctive lesion rash, found mostly on the trunk, arms, and legs, called the “target lesion.” Erythema multiforme characterized by large lesions that fl ow together. literally means “skin redness of many varieties.” The eruptions often look like coils of rope running Traditionally, the condition has been divided into parallel to each other, or growth rings on a tree. In major and minor forms (the latter is known as about 60 percent of cases, the lesions occur before STEVENS-JOHNSON SYNDROME). the cancer is diagnosed; in the other 40 percent of Erythema multiforme is most common in cases, erythema gyratum repens is diagnosed at the women in their mid-20s; the characteristic rash, same time or shortly after the cancer diagnosis. which consists of a number of target lesions, is self-limiting, but may recur in up to 37 percent of Treatment Options and Outlook cases, especially when caused by the herpes sim- Treating the underlying cancer usually results in plex virus. complete disappearance of the eruption. While The exact cause is unknown, but the disorder topical therapy is of little benefi t, emollients may is believed to involve a hypersensitivity or aller- help relieve the itch. gic reaction to something that damages the blood vessels of the skin and skin tissues themselves. Approximately 90 percent of erythema multiforme erythema infectiosum See FIFTH DISEASE. cases are associated with herpes simplex or myco- erythema multiforme 133 plasma infections. The disorder occurs primarily in to 15 percent of patients. Involvement of the con- children and young adults. junctiva of the eyes may cause severe eye damage Erythema multiforme may become noticeable that can result in blindness. If the patient survives, with a classic skin lesion, with or without symp- there may be problems related to scarring in the toms involving the entire body. In Stevens-Johnson eyes and other mucous membranes. syndrome, the systemic symptoms are severe and The diagnosis is primarily based on the appear- the lesions are extensive, involving multiple body ance of the skin lesion and its typical symmetrical areas, especially the mucous membranes. Toxic distribution, especially if there is a history of risk epidermal necrolysis (TEN syndrome, or Lyell’s syn- factors or associated diseases. A lesion biopsy and drome) involves multiple large BLISTERs that blend microscopic examination may help differentiate together, followed by sloughing of all or most of the erythema multiforme from other disorders. Micro- skin and mucous membranes. scopic examination of the tissue may also show Alternatively, it may be associated with a viral antibody deposits. or bacterial infection, radiation therapy, internal disease, chemical exposure, vaccination, or preg- Treatment Options and Outlook nancy. Herpes virus-associated erythema multi- Suspected medications must be discontinued. In forme is found most often in teenagers and young mild cases, no treatment may be required and adults; the minor form usually occurs 10 days after the condition will fade away within two to three an acute eruption with either type 1 or type 2 her- weeks. If no cause can be found, symptoms are pes virus. treated and supportive care may include wet dress- Half of all cases have no apparent cause. ings or soaks and painkillers. If possible, however, the underlying cause of Symptoms and Diagnostic Path erythema multiforme should be diagnosed and Erythema multiforme minor is usually preceded by treated. Antihistamines are not effective against malaise, fever, headache, sore throat, and cough this condition. for seven to 10 days. Target lesions then appear Short courses of topical CORTICOSTEROID drugs on the skin of palms and soles for three to fi ve are given to relieve the infl ammation of erythema’s days and last up to two weeks. The target lesion minor form, although there is little support in the may appear abruptly or slowly develop over two literature for this treatment. days, beginning as a pale central area surrounded Herpes virus–associated erythema multiforme is by one or more rings of erythema; the center may treated with daily doses of oral acyclovir. occasionally blister. Lesions usually heal without The severe form of the condition is treated with scarring. Occasionally, erythema multiforme minor painkillers, fl uids, and sedatives. Lesions may be does not cause a target lesion, but instead produces treated with wet compresses; extensive erosions hivelike plaques. should be treated as a third-degree burn. Use of Erythema multiforme major is a more severe con- corticosteroid drugs to treat the severe form is con- dition, beginning with an initial illness of fever, troversial, although often given despite a lack of malaise, and prostration followed by an explosive controlled studies proving their effectiveness. eruption of target lesions over the body and mucous These patients usually respond to treatment, but membranes, with severe ulceration, infl ammation they may become seriously ill if shock or systemic and bleeding in the eyes, mouth, nasal passages, infl ammation sets in. IV fl uids and electrolyte and genitals. Appearance of these symptoms is a replacement may be necessary; mouth lesions may dermatologic emergency. Secondary infection is be treated with a topical anesthetic, and petrola- common; 20 percent of patients experience signifi - tum or other ointments may reduce cracking of cant pain, eye problems, breathing problems, and dry lips. diffi culty maintaining oral fl uid intake. Diagnosed Mild forms of erythema multiforme usually get most often among children, fl uid and electrolyte better within two to six weeks, although the condi- imbalance or breathing problems can be fatal in 3 tion may recur. More severe forms may be diffi cult 134 erythema nodosum to treat. Stevens-Johnson syndrome and toxic infl ammation. Some experts fi nd potassium iodide epidermal necrolysis are associated with signifi cant to be effective, although the reason is unknown. death rates. Even when the cause is unknown, the prognosis for recovery is good. erythema nodosum An infl ammatory skin dis- ease associated with reddish purple swellings typi- erythema toxicum neonatorum A common, tran- cally on the lower legs that also may be a result of sient skin condition found in newborn infants dur- another illness, such as SARCOIDOSIS, infl ammatory ing the fi rst few days of life that usually disappears bowel disease, COLLAGEN DISEASE, lymphoma, leu- before the end of the fi rst week and is characterized kemia, or from drug hypersensitivity or infection. It by PAPULES, PUSTULES, and pink MACULES. The skin occurs most often in women between ages 20 and condition may consist of only a few lesions or may 50, although the disease can appear in both sexes cover the entire body except for palms and soles. at any age. Less common in premature infants, the condi- Streptococcal throat infection is the most tion has been attributed to allergies, although its common underlying cause in the United States, true cause is unknown. although erythema nodosum is also frequently associated with tuberculosis and sarcoidosis else- Symptoms and Diagnostic Path where in the world. Frequent other associations The condition usually develops in the second to include drug reactions from sulfonamides, penicil- fi fth day after birth, but it may appear as late as lin, salicylates, and the birth control pill. About 30 two weeks post-partum. While a few infants may percent of the time no cause can be found. The be born with the condition, it may in fact represent exact mechanism behind the disease is not known, a different but similar disorder called transient neo- although it is believed to be some type of immune natal pustular melanosis. reaction around large blood vessels in the subcu- The typical skin lesion of erythema toxicum taneous fat. neonatorum is a white pustule on a red base; if pustules do not appear, there may be papules or Symptoms and Diagnostic Path macules or a splotchy red mark. While the condi- Shiny, tender swellings up to four inches across tion may appear anywhere, lesions are usually appear suddenly on shins, thighs, and some- found on the trunk. There may be one or two times arms. There is usually also fever and pain lesions or a generalized eruption. in muscles and joints, and there may be other Examination by a doctor during a routine well- symptoms, including chills, malaise, headache, or baby exam is usually enough to make the diagno- sore throat. sis. No testing is usually needed. Pain may be severe and disabling, but perma- nent problems from this disease are rare. Lesions Treatment Options and Outlook usually disappear within one or two months, The condition does not require any treatment although recurrences are common. and has no effect on future health. There are no complications. Treatment Options and Outlook Treat any underlying illness; alter medication if con- dition is a response to drugs. Bed rest with the legs erythrasma A chronic bacterial infection of the raised is important; for ambulatory patients, support toe web, groin, and underarms that causes mild stockings may help. Warm water compresses may be burning and itching. More common in warmer soothing and tenting the bedcovers may relieve dis- climates, it is caused by Corynebacterium minutis- comfort from rubbing against material. Otherwise, simum, which produces porphyrins that fl uoresce treatment may include painkillers or sometimes a coral red color that is observable under Wood’s nonsteroidal anti-infl ammatory drugs to reduce Light. erythropoietic protoporphyria 135

Symptoms and Diagnostic Path erythropoietic protoporphyria An uncommon Symptoms include sharply outlined dry, brown, subtype of PORPHYRIA that primarily affects the skin, slightly scaly, and slowly spreading patches. causing it to be overly sensitive to sunlight. Begin- The condition is diagnosed with a Wood’s lamp ning in childhood, areas of skin exposed to the sun test (when examined under this ultraviolet light, (especially the face and hands) begin to itch, sting, the lesions glow a coral red color) and with a cul- and burn, lasting for hours to days after exposure. ture of cells from the lesion. The skin becomes red and swollen in some cases, but usually heals without scarring. These signs and Treatment Options and Outlook symptoms are often milder than the skin damage C. minutissimum is very sensitive to a wide variety seen in other types of porphyria. No factors other of antimicrobial drugs; extensive cases may also than sun exposure are known to trigger symptoms. require oral administration of ERYTHROMYCIN, but Symptoms and Diagnostic Path topical treatment with antibiotics such as eryth- There may also be redness, swelling, and fl uid- romycin or anti-fungals such as clotrimazole are fi lled blisters in the exposed area. Chronic expo- usually effective. sure to the sun may cause thickened skin and fi ne Recurrences are common. scars, most often seen on the upper lip and the backs of the hands. While the exact incidence of this disease is not erythroderma Redness over the entire body. known, more than 300 cases have been reported See also DERMATITIS, EXFOLIATIVE. worldwide. It begins (often in infancy) when chil- dren are fi rst exposed to sunlight; they cry and begin to develop swellings in the exposed areas of erythromycin An antibiotic used to treat a variety skin. The skin may erode and scar, especially on the of infections, including some skin infections. It is hands, nose, eyes, and ears. As the child ages, the often used as a systemic treatment for ACNE and in skin over the knuckles appears thick and wrinkled. patients allergic to penicillin. In children under age Other internal fi ndings include gallstones, mild 14 it is the alternative to TETRACYCLINE (an antibi- hemolytic anemia, liver failure with jaundice, and otic that can permanently stain developing teeth cirrhosis of the liver. and bones). Mutations in the FECH gene cause erythro- Because uncoated erythromycin is destroyed by poietic protoporphyria, but exactly how this gene acid in the stomach, the drug should be taken in is inherited is not yet fully understood. Experts enteric coated forms or as a compound. Otherwise, suspect most cases are inherited in an autosomal it could cause stomach distress. dominant pattern, which means one copy of the altered gene is enough to trigger symptoms. Many Side Effects people with one altered copy, however, do not ever Possible side effects include nausea and vomiting, develop signs and symptoms of the disorder. The abdominal pain, diarrhea, and an itchy rash. To condition shows autosomal recessive inheritance reduce side effects, erythromycin may be taken in a small number of families, which means two with food to reduce the chance of irritating the copies of the gene must be altered for a person to stomach. be affected by the disorder.

Treatment Options and Outlook erythroplasia Red plaque on the mucous mem- Oral administration of beta-carotene may reduce branes of the mouth that may be benign or photosensitivity. Some patients have responded to malignant. Two types of erythroplasia are often treatment with iron or hematin, though this type malignant—smooth macular plaques and velvety of treatment has been found to worsen the condi- red patches dappled with white. tion of other patients. 136 eschar

Risk Factors and Preventive Measures ISOTRETINOIN, is an analogue of vitamin A. It is Patients with this condition should avoid sunlight more effective than isotretinoin for disorders of and wear protective clothing when outdoors. keratinization such as psoriasis and PITYRIASIS RUBRA PILARIS, while isotretinoin is more effective for ACNE. It is especially effective in treating pus- eschar A scab produced on the surface of the skin tular and erythrodermic types of psoriasis. Psoria- by BURNS, corrosive agents, some skin diseases, and sis requires long-term treatment with etretinate. infections or GANGRENE. Etretinate may be used alone, or together with more conventional psoriasis treatment (such as topical CORTICOSTEROIDS, tars, ANTHRALIN, PUVA, or essential fatty acids (EFAs) Polyunsaturated fats METHOTREXATE). necessary for healthy skin; a lack of these acids Combining etretinate with photochemotherapy lead to dry scaly skin and HAIR LOSS. However, defi - using oral PSORALENS and PUVA (called RE-PUVA) ciency is quite rare, since just one teaspoon per day is popular in Europe as a treatment for exten- of a polyunsaturated fat (such as corn oil) provides sive psoriasis. It has the benefi ts of reducing the enough EFAs. amount of UVA exposure and the dose and length While these acids are recognized as important of etretinate therapy. in the diet, there is no evidence that they can be Side Effects absorbed from the skin. Most experts believe that Dry skin and eyes, nosebleeds, hair loss, bone EFAs are important in slowing the evaporation of and joint pain. Etretinate is a very potent cause water from the skin’s surface. One EFA, gamma of birth defects and should never be taken during linolenic acid (otherwise known as EVENING PRIM- pregnancy. ROSE OIL), is thought to be helpful in the treatment of atopic ECZEMA. evening primrose oil A type of ESSENTIAL FATTY ACID (also known as gamma linolenic acid). Taken essential oils Oils extracted from fl owers and in capsule form, this oil (alone or in combination herbs. This term is often more generally used to with fi sh oil) is believed by some experts to signifi - mean any perfumed oil that imitates a real scent. cantly improve cases of atopic ECZEMA when taken in high doses. However these claims have not been proven and the long-term safety of high doses of estrogen A female sex hormone produced by the oil is not known. the ovaries used in some facial creams designed Those who support the use of evening primrose for dry and lined skin. The U.S. Food and Drug oil do admit it takes six to eight capsules per day Administration permits only low doses of estro- for at least six months before any results may be gen in these creams, which do not alter the observed in patients. Experts also report cases of growth of skin cells but do enable the skin to fake capsules, so consumers should avoid evening retain water. Medical-grade estrogen is allowed primrose oil available in no-name brands. to contain higher levels of estrogen than nonpre- scription products, and some experts believe that estrogen at this dosage level can improve skin exanthem subitum The medical name for ROSE- tone on a limited basis. OLA INFANTUM, a viral disease caused by human herpes viruses 6 and 7 (HHV 6 and HHV 7). etretinate (trade name: Tegison) A derivative of VITAMIN A used to treat severe PSORIASIS and excoriation Injury to the skin’s surface caused by some disorders of KERATINIZATION. Etretinate, like abrasion (scratching) or chemical reaction. exfoliation 137 exercise and the skin Research suggests that the skin does not need any help in sloughing off exercise has especially important benefi ts for the dead skin and rank overcleansing as the biggest skin. When comparing middle-aged athletes with a skin care mistake because it can overdry and irri- matched group of people who did not exercise, sci- tate the skin. entists found the athletes’ skin was denser, thicker, Exfoliation supporters say the technique works more elastic, and stronger. best for those with healthy, normal, or dry com- Researchers suspect that exercise fl ushes the plexions, and for those with dull, sun-damaged skin, bringing oxygen-rich blood to the surface. skin or skin with lots of BLACKHEADs. Even thin It may also be that the production of COLLAGEN is skin can be helped by milder exfoliants as long enhanced by internally-generated heat (which is as there are no broken blood vessels. Patients not the same as applying heat from the outside). who have had acne but whose complexions have Movement itself also seems to send messages to improved may fi nd that mild exfoliating keeps the the cells in the body that manufacture the skin’s pores unclogged and the complexion healthier. elastic fi bers. When working out, individuals should never Techniques wear makeup, because blocking the evaporation of There are two types of exfoliation—mechanical sweat by sealing the skin with makeup interferes and nonmechanical. Mechanical exfoliants include with the process of cooling the body by perspiring. a wide range of techniques ranging from very mild Before exercise, the face and neck should be (washcloths and sea sponges) through exfoliation cleaned with lotion and water. Hair should be tied sponges, loofahs—to the severe exfoliation meth- back, since sweat that is trapped against skin by ods utilizing pumice stones, cleansing grains, and hair is thought to be a cause of after-exercise skin scrubs. breakouts. Harsh astringent should not be used Mechanical exfoliants stimulate the skin, but before removing skin oils, because these natural they may be too rough for sensitive skin or skin skin oils can protect skin against the acid content with broken blood vessels. People with this type of perspiration. of skin usually have fair, thin skin that reddens if For exercise outside, a moisturizing SUNSCREEN touched. Dermatologists suggest that patients with should be applied. acne not use mechanical exfoliation either, since the WHITEHEADs or closed comedones may rupture beneath the skin when rubbed, leading to more exfoliation Removal of dead cells on the surface infl ammatory acne. of the skin with a cosmetic buffi ng sponge or a Nonmechanical exfoliants include cosmetic masks grainy cleanser. that work on the skin surface cells, Retin-A, and As the skin matures, the turnover of epidermal chemical exfoliants (such as ALPHA-HYDROXY ACID). (upper-layer) skin cells slows down. Because the Masks never penetrate deeper than the dead super- dead skin cells cling together on the surface, the fi cial layer of the skin, and vary in strength accord- complexion may appear dull and rough. ing to the chemical used and its concentration. By exfoliating properly, some dermatologists Depending on the concentration and the amount say, it is possible to increase the epidermal-cell of time chemical exfoliants are kept on the skin, turnover, making the skin look smoother and these can penetrate to living tissue. They should pinker again. Exfoliation also helps stimulate the be used only under medical supervision. production of young epidermal cells. Generally, it is not possible to exfoliate the same However, the subject of exfoliation generates way all year; the skin changes depending on the sea- strong and differing viewpoints among dermatolo- son and the temperature. In the summer, skin has gists. Some believe this procedure may help skin more moisture and in the winter tends to dry out. look newer, fresher, plumper, and younger-looking, The mildest exfoliations are the sea sponge, the and encourage faster cell renewal. Others (includ- face cloth, and cosmetic masks designed for sensi- ing the American Academy of Dermatology) insist tive or dry skin. A complexion brush moved in 138 exfoliative dermatitis circular motions with some moisturizer can be skin to look creased and droopy. This aging process, a good exfoliator. For normal to thick skin, sea which can be accentuated by weight loss and stress sponges or exfoliation sponges can be used effec- and is accelerated by sun exposure, makes the tively, but should be used no more than three times eyelids look baggy. Removing the excess skin and weekly in summer and no more than once a week redistributed fat can greatly improve appearance. in the winter. Body exfoliation, on the other hand, is safe for Procedure all skin types, as long as any areas with infl amma- During the operation, the surgeon removes a hori- tory acne are avoided. It is especially benefi cial for zontal fold of skin from the center of the upper lids, knees and elbows, especially when immediately so the scar will run in a natural crease line. Inci- followed by moisturizers. Self-tanning lotions also sions in the lower lids are made either just below look best when applied after exfoliation. or just above the eyelashes to minimize the scar. Excess fat is removed from the upper and lower lid but extra skin is usually removed only from the exfoliative dermatitis See DERMATITIS, EXFOLIATIVE. upper lids. After the operation, the patient can minimize swelling and bruising by applying ice packs to both exudate Fluid containing PUS, cells, and protein eyes. Swelling usually subsides within three days, that has been discharged from blood vessels into a but bruising may last from two or three weeks. tissue (or tissue surface) and is usually a result of Three to fi ve days after the operation, the sur- infl ammation. geon removes some of the stitches, and removes the remaining stitches within seven to 10 days. eyelid lift An operation (blepharoplasty) that Outlook and Lifestyle Modifi cations removes wrinkled, drooping skin from the upper The scars usually fade in time to unnoticeable and/or lower eyelids. The outpatient operation is marks within a year. Effects of the surgery can be usually performed with a local anesthetic and seda- expected to last between 10 and 20 years. Patients tion, and takes about one and a half to two hours. can go back to work within fi ve to 14 days. As a person grows older, the skin loses its elasticity Actual cost may vary depending on the part of and fat stores, becomes redistributed, causing the the country in which the surgery is performed. F

Fabry’s disease (Anderson-Fabry disease) The Patients with Fabry disease often survive into common name for angiokeratoma corporis dif- adulthood, but they are at increased risk of strokes, fusum, an hereditary disorder of fat metabolism heart attack and heart disease, and renal failure. resulting from an enzyme defi ciency that causes widespread lesions (especially in the umbilical and knee areas), extremely painful neuralgias in hands face-lift (rhydectomy) Cosmetic surgery to and feet during hot weather, hardening of the improve the appearance by smoothing out wrin- arteries and kidney disease. kles and lifting sagging skin in the lower third of the face. Symptoms and Diagnostic Path A face-lift is usually performed on an outpatient Fabry’s disease is an X-linked recessive disease basis using a local anesthetic and lasts between caused by a defect on the X chromosome, usu- two and four hours. Loose skin is separated from ally leading to problems in males only. Women underlying muscle and pulled upward and back- can be carriers of the defect; their male children ward all around the face, going back 3 to 4 inches have a 50 percent chance of being affected by the from the side of the face. When the skin is lifted disease. well away from the face, it is pulled up and draped It is primarily characterized by the angiokera- over the face. The excess skin that overlaps the toma, a 1- to 3-mm reddish purple raised skin incision line is removed, and the skin is sewn at lesion. Other skin symptoms include enlarged the incision line. blood vessels, fi ngernail deformities, and reddened Cotton and gauze pads are placed over the face skin. Sweating may be inhibited. and eyes, and the whole face (except nostrils and Kidney problems can lead to kidney failure and mouth) is wrapped in an elastic bandage. Pads are high blood pressure. Tissue death in the brain or kept in place for 24 to 48 hours, and then removed. heart due to decreased blood fl ow is common. After less than a week, the entire bandage is removed. Treatment Options and Outlook Bruising is expected and there may be some Enzyme replacement may help slow the progres- discomfort, which is usually controlled with minor sion of the disease, and the pain in the hands and painkillers; within a few weeks, however, these feet usually responds to anticonvulsants such as signs of surgery disappear and the face begins to phenytoin and carbamazepine. Gastrointestinal show improvement. The stitches are removed hyperactivity may be treated with metoclopramide. three days after the operation, and the scars are Some individuals may require dialysis or kidney usually hidden by natural crease lines and the hair, transplantation. fading within a year. Kidney transplants can replace the missing Patients may be back to work in 10 to 14 days, enzyme and help ease pain and sweating. The although bruising can last up to three weeks. After angiokeratomas may be destroyed, but this does a face-lift, the face must be cleaned twice a day not often occur because they are small. with a mild, neutral soap and creams should not

139 140 facial be used because the pushing and pulling of cream- famcyclovir (Famvir) An antiviral medication ing the face puts strain on the newly sewn tissue, that is the oral form of penciclovir, a drug similar which can cause the skin to sag again. Facial mas- to ACYCLOVIR, both used to treat herpes. However, sage should never be applied after cosmetic sur- famcyclovir lasts up to 10 times longer in the body gery, since it will spread the scars and make them than does acyclovir. seem broader and thicker, and puts strain on newly Famcyclovir reduces the severity of outbreaks sutured skin. and prevents the development of new blisters, and has also been shown to be effective for preventing Risks/Complications genital herpes outbreaks. The two most signifi cant side effects are oozing and infection. Occasionally, bleeding under the skin Side Effects causes a blood clot that interferes with successful Famcyclovir has few side effects; primary side effects healing. An infection may lead to severe scarring are headache, fatigue, diarrhea, and nausea. that may require a SKIN GRAFT.

Outlook and Lifestyle Modifi cation Farber’s lipogranulomatosis An inherited con- Face-lifts cost an average of $4,000, although the nective tissue disorder characterized by multiple exact amount will vary depending on the part of subcutaneous nodules. the country where the operation is performed. The disease is an autosomal recessive disorder, The results last for two to 10 years, and can suc- which means that a defective gene must be inher- cessfully be repeated several times in a lifetime. ited from both parents to cause the abnormality. Although many people believe that repeated Generally, both parents of an affected child are face-lifts will cause a masklike expression, in unaffected carriers of the defective gene. Each of fact a mask effect after a face-lift is an indication the children has a one in four chance of being that the skin was tightened too much during the affected, and a two in four chance of being a surgery. carrier. See also PLASTIC SURGERY; PLASTIC SURGEON. The disease is caused by a defi ciency in lysosomal acid ceramidase, which allows free ceramides to build up in tissues. This leads to the development facial A skin treatment of the face designed to of subcutaneous nodules. clean, tone, and improve the skin’s texture. Facials range from a simple mask applied at home to a Symptoms and Diagnostic Path sophisticated regimen in a beauty salon that may Infants typically have a weak, hoarse cry and involve electrical currents, aromatic oils, or spe- swollen joints. Most patients die by age two, and cialized creams. While the facial may moisturize or almost none live beyond age 10. There is no known stimulate circulation in the skin, it cannot remove treatment. or prevent wrinkles. A full facial in a salon usually begins with an examination of the skin itself, followed by cleans- fat atrophy The presence of fat in the subcu- ing and toning. Steaming may follow so that skin taneous tissue under the skin provides a full, impurities can then be removed (using extrac- supple appearance. When fat cells are destroyed tion or exfoliation, for example). The face may or removed, the surface of the skin appears to be be massaged to increase circulation and to relax depressed. The bony prominences of the body con- muscles before a mask appropriate to skin type is tribute to a gaunt appearance. applied. A group of rare disorders featuring localized or generalized fat atrophy are known as the lipo- dystrophies or lipoatrophies. They include par- factitial dermatitis See DERMATITIS ARTEFACTA. tial lipodystrophy (Barraquer-Simmons disease), fi fth disease 141 lipoatrophic diabetes (generalized lipodystrophy), New collagen then begins to be deposited at the and insulin lipoatrophy. site of the Fibrel injection; it usually takes three months for the newly formed collagen to replaced Symptoms and Diagnostic Path the injected substance. Barraquer-Simmons disease is characterized by the partial loss of subcutaneous fat over a large part Risks and Complications of the body over a course of several years, and is As with collagen injections, it is important to test often triggered by a fever. The depletion of fat cells for allergy before treating, although a positive reac- usually begins on the face and proceeds downward, tion occurs in less than 1 percent of all cases. Fibrel and occurs four times as often in women. is less allergenic than cow-derived collagen and Generalized lipodystrophy can be either present longer-lasting than other liquid collagens (such as at birth or acquired (usually after a high fever). In Zyderm). Still, redness, swelling, itching, and bruis- both cases, the fat loss appears over the entire body. ing can occur, and the injections are very painful. Symptoms also include a wide variety of other See also SOFT TISSUE AUGMENTATION; BIOLOGICAL complaints, including insulin-resistant diabetes. IMPLANTS. Insulin lipoatrophy is caused by repeated injec- tions of insulin that reduce fat cells in a localized area. The depression appears about six months fibroblasts Cells in the dermis (middle layer of after injection, though rotating injection sites mini- skin) that produce COLLAGEN and elastin fi bers. mizes this problem. Spontaneous resolution of the depression may take up to 10 years. fibrosis The deposition of fi brous tissue (SCAR) Treatment Options and Outlook or connective tissue that may occur as a response Fat transfer (the technique of fat injection) allows to infection, infl ammation, or injury. Fibrosis may fat to be removed from the patient’s unaffected also be caused by a lack of oxygen in a tissue areas, cleansed, and then reinjected into the affected because of reduced blood fl ow. sites, where it appears to stay permanently. See also FAT TRANSPLANTS. fibrous hamartoma of infancy See FIBROMATOSES. fat transplants See AUTOLOGOUS FAT TRANSPLANT. fibroxanthoma of skin A typically benign tumor of the skin found most often on the sun-exposed fever blisters Another name for a “cold sore.” areas of older people’s skin. The lesion usually appears fi rst as a small nodule that slowly gets bigger, though seldom exceeds 3 cm. This type of Fibrel A freeze-dried gelatin extracted from pig lesion rarely becomes malignant and is cured by connective tissue that, combined with a patient’s surgical excision. blood and a chemical, stimulates the natural pro- duction of COLLAGEN at the site of the injection. Fibrel was approved in 1985. fifth disease Also known as “slapped cheeks” disease because of its dramatic symptom of a Procedure bright red rash across the cheeks, this is the least The material is injected until the SCAR or WRINKLE is well known of the fi ve common infectious child- elevated; the injections are given one or two weeks hood diseases—MEASLES, mumps, CHICKEN POX, and apart. As with collagen implants, overcorrection is rubella (GERMAN MEASLES). necessary because there is some absorption by the A parvovirus (B 19) usually occurs in small body. outbreaks among young children in the spring. Pet 142 fi fth disease dogs or cats may be immunized against “parvo- There is often a mild fever in addition to the skin virus,” but these are animal parvoviruses that do rash, which may itch. not infect humans. Therefore, a child cannot catch A physician can diagnose fi fth disease by seeing parvovirus from a pet dog or cat, and an animal the typical rash during a physical examination. If cannot catch human parvovirus B19. it is important to confi rm the diagnosis, a blood Although fi fth disease is primarily an illness of test may reveal antibodies to parvovirus. If immu- childhood, an adult who is not immune can be noglobulin M (IgM) antibody to parvovirus B19 is infected with parvovirus B19 as well, and either detected, the test result suggests that the person have no symptoms or develop the typical rash of has had a recent infection. fi fth disease, joint pain or swelling, or both. Usu- ally, joints on both sides of the body are affected. Treatment Options and Outlook The joints most frequently affected are the hands, Fifth disease is usually a mild illness that resolves wrists, and knees. The joint pain and swelling usu- on its own among children and adults who are ally resolve in a week or two, but they may last otherwise healthy. Joint pain and swelling in adults several months. About half of adults, however, usually resolve without long-term disability. Treat- have been previously infected with parvovirus ment of symptoms such as fever, pain, or ITCHING B19, have developed immunity to the virus, and is usually all that is needed. Adults with joint cannot get fi fth disease. pain and swelling may need to rest, restrict their Parvovirus B19 has been found in the saliva, activities, and take aspirin or ibuprofen to relieve sputum, or nasal mucus of infected individuals symptoms. before the rash appears, when they appear to have The few people who have severe anemia caused a cold. The virus is spread from person to person by by parvovirus B19 infection may need to be hos- direct contact with those secretions, such as sharing pitalized and receive blood transfusions. Persons a glass or utensils. In a household, as many as half with immune problems may need special medical of susceptible persons exposed to a family member care, including treatment with immune globulin who has fi fth disease may become infected. During (antibodies), to help their bodies get rid of the school outbreaks, 10 percent to 60 percent of stu- infection. dents may get fi fth disease. However, parvovirus B19 infection may cause A susceptible person usually gets sick within four days to two weeks after being infected with severe anemia in persons with sickle-cell disease or the virus, but it may take as long as three weeks similar types of chronic anemia, and people who for symptoms to appear. A person infected with have problems with their immune systems may parvovirus B19 is contagious during the early part also develop a chronic anemia with parvovirus B19 of the illness, before the rash appears. By the time infection that requires medical treatment. People a child has the characteristic reddened cheeks, for who have leukemia or cancer, who are born with example, he or she is probably no longer conta- immune defi ciencies, who have received an organ gious and may return to school. This contagious transplant, or who have human immunodefi ciency period is different from that for many other rash virus (HIV) infection are at risk for serious illness illnesses, such as MEASLES, for which the child is due to parvovirus B19 infection. contagious as long as the rash is apparent. Once Occasionally, serious complications may develop infected with the virus, people develop lasting from parvovirus B19 infection during pregnancy. immunity that protects them against infection in the future. Risk Factors and Preventive Measures No vaccine or medicine will prevent parvovirus Symptoms and Diagnostic Path B19 infection. Frequent hand-washing is a practi- The rash starts as rosy red spots on the cheeks that cal and effective way to lessen the chance of infec- join into a red rash; within a few days, the rash has tion. Keeping the patient with fi fth disease home spread over the body, buttocks, and arms and legs. from work or school is not likely to prevent the fl at warts 143 spread of the virus, since people are contagious filiform warts Slender fi ngerlike WARTS that are before they develop the rash. often found on the face (especially around the eyes and eyelids). They can be treated by cryotherapy, simple excision or ELECTRODESICCATION. filariasis A group of tropical diseases caused by a See also PAPILLOMAVIRUS, HUMAN; PLANTAR WARTS; range of parasitic worms and larvae that transmit GENITAL WARTS; FLAT WARTS. disease to humans. About 200 million people are affected by fi lariasis, which occurs in tropic and subtropic areas of Southeast Asia, South America, fillers See SKIN FILLERS. Africa, Asia, and the Pacifi c. When mosquitoes bite into the skin they inject the worm larvae, which migrate to the lymph nodes where they develop fingernails See NAILS. into mature worms in about a year. Some of the species live in the lymphatic ves- sels, which become blocked, causing ELEPHANTIASIS fissure A crack or split in the skin. (swelling of limbs with thickened, coarse skin). Another type of worm can be seen and felt just underneath the skin, which produces irritating and flap A section of full-thickness skin that has been painful swellings called calabar swellings. left attached at one end while the other end is sur- gically transferred to an adjacent part of the body. Symptoms and Diagnostic Path A fl ap differs from a graft in that a portion of tissue Initial infl ammatory symptoms occur between is attached to its original site and retains its blood three months to a year after the mosquito bite, supply. Flaps are used to cover wounds or repair with swelling, redness and pain in arms, legs, or defects caused by congenital deformity, accident, scrotum. ABSCESSES may occur as a result of dying or surgery. worms and secondary bacterial infection. Repeated Because a fl ap retains its color and texture, it is episodes of infl ammation lead to obstruction of more apt to survive than a graft. However, several the lymphatic system, especially in the genital operations usually are needed to move a fl ap. The and leg areas. Chronic swelling stimulates the major complication is necrosis at the base because growth of connective tissue in the skin, causing of failure of blood supply. massive permanent enlargement and deforming Free fl aps, on the other hand, are completely (elephantiasis). severed from the body and transferred to another site, when it receives its blood supply. The proce- Treatment Options and Outlook dure is usually completed in only one surgery. Three weeks of the antihelminthic drug diethylcar- bamazine cures the infection. Large doses are not given initially because reactions to large numbers of flat warts Multiple WARTS (also called juvenile dying parasites are severe—fever, malaise, nausea, warts) commonly found on the face, neck, fore- and vomiting—so doses are usually low at fi rst. Oral arms, knees, and the backs of the hands. These antihistamines may help control HIVES and elastic fl at, fl esh-colored papules may appear in groups of stockings may help control swelling. No treatment, up to 100. however, can reverse elephantiasis. Surgery may ease massive enlargement of the scrotum. Symptoms and Diagnostic Path They are often found in lines or streaks, as a result Risk Factors and Preventive Measures of scratching and passing on the virus. On the face, In infested areas, fi lariasis can be controlled by tak- they can resemble ACNE, melanocytic nevi, or SEB- ing diethylcarbamazine preventively, and by using ORRHEIC KERATOSES. Flat warts on the arms or legs insecticides, repellents, nets, and protective clothing. may resemble LICHEN PLANUS. About the size of a 144 fl eas pinhead, these growths are smoother than other niture, under rugs, in beds, etc. Remove rubbish or kinds of warts, with fl at tops; there can be as many sandpiles, and dust pets and pet bedding every two as 100 fl at warts in a cluster. weeks with insecticides.

Treatment Options and Outlook Flat warts are stubborn and require repeated flesh-eating bacteria See NECROTIZING FASCIITIS. treatments. These warts may be treated by a variety of over- the-counter medications containing mild acids that flucytosine (Ancobon) A synthetic drug used to help remove the dead skin cells on the surface treat severe fungal infections caused by Candida or of the wart, and irritate the skin, stimulating an Cryptococcus. The drug is usually prescribed together immune response in the body that reacts against with AMPHOTERICIN B or KETOCONAZOLE for the treat- the wart. Alternatively, other physical methods ment of chromoblastomycosis or CRYPTOCOCCOSIS. are used. Warts may be removed by cryosurgery, Newer antifungals are replacing the agent. in which liquid nitrogen is used to freeze the wart; this treatment is usually repeated every two to three weeks for a few months. This also irritates the fluocinolone A medium-strength CORTICOSTE- skin, stimulating an immune response in the body ROID prescribed as a topical agent either as a cream, that reacts against the wart. Electro-cauterization solution or ointment to relieve skin inflammation, can be used to burn the wart away with electricity, ITCHING and redness caused by disorders such as although it must be done very gently to prevent ECZEMA or PSORIASIS. a small scar. Laser treatments also can be used to remove warts. See also FILIFORM WARTS; GENITAL WARTS; PAPIL- fluorescent lights and the skin Fluorescent bulbs LOMAVIRUS, HUMAN; PLANTAR WARTS. emit small amounts of ULTRAVIOLET RADIATION, the type of solar radiation that has been blamed for SKIN CANCER. fleas There are several types of fl eas that cause In 1989, the National Institutes of Health said skin problems: the human fl ea (Pulex irritans), the that the long-term effect of exposure to fl uores- cat and dog fl ea (Ctenocephalides felis and C. canis) cent bulbs is “an unresolved issue” and in 1990, and others found on mammals and birds. the International Radiation Protection Association stated that ultraviolet radiation exposure from Symptoms and Diagnostic Path indoor fl uorescent lighting should not be consid- Flea bites cause wheals and red papules, depending ered a malignant melanoma risk. on how sensitive the person is to fl ea bites. While the data remains inconclusive, those who As a person is repeatedly bitten, he becomes are concerned can attach a plastic diffuser to their gradually sensitized (for example, infants do not fl uorescent lighting fi xture (many lights come this respond to fl ea bites); however, those who are way), which can eliminate or reduce the intensity continually exposed eventually may become of the ultraviolet emissions. desensitized.

Treatment Options and Outlook fluoroquinolones A group of antimicrobial drugs Itchy bites can be treated with topical steroid that are effective against many bacteria, including creams and systemic antihistamines. most Pseudomonas bacteria. Several of the fl uo- roquinolones are also active against Mycoplasma, Risk Factors and Preventive Measures Chlamydia, Legionella and a few other mycobacteria. Elimination of fl eas and larvae can be accom- Fluoroquinolones are not particularly effective plished by spraying insecticides in crevices of fur- against anaerobic organisms. folliculitis 145

These drugs are used to treat many types of ness and sensitivity will gradually fade over a few infections, including soft tissue infections and weeks. Occasionally it persists for several months. urethritis. Fluoroquinolones include norfl oxacin, cipro- fl oxacin, ofl oxacin, enoxacin, pefl oxacin, fl eroxa- flush Transient redness and warmth (primarily of cin, lomefl oxacin, and several other compounds. the face and neck) associated with certain medica- tions and pathologic conditions. Side Effects See also ROSACEA; BLUSH. The drugs have fewer side effects than many other antibiotics. The most common side effect is loss of appetite and sensitivity to light. Less common Flynn-Aird syndrome A genetic disorder associ- effects include nausea, abdominal pains, diarrhea, ated with skin ulceration in which subcutane- dizziness, rash, and so on. These drugs are not rec- ous tissue atrophies and forms ulcers, similar ommended for children or adolescents, since they to conditions such as WERNER’S SYNDROME and may have toxic effects on developing cartilage. SCLERODERMA. Other symptoms include mental retardation, deafness, convulsions, baldness, and stiff joints, fluorouracil An anticancer drug often used on which may appear during the fi rst or second decade the skin; also known as 5-fl uorouracil or 5-FU. It of life. This disorder is transmitted as an autosomal is used to treat multiple ACTINIC KERATOSES and for dominant disorder, which means that only one fl at, genital, and intraurethral WARTS, PSORIASIS, defective gene (from one parent) is needed to cause BOWEN’S DISEASE, and superfi cial BASAL CELL CAR- the syndrome. Each child of an affected person CINOMA or KERATOACANTHOMAS. It is of particular usually has a one in two chance of inheriting the benefi t when surgical removal of several tumors defective gene and of being affected. located together is diffi cult. It is applied according to various schedules—from twice a day two consec- utive days a week for nine weeks, to daily or twice focal dermal hypoplasia See HAIR, DISORDERS OF. daily for four to six weeks. It is also injected within the lesion for patients with KERATOACANTHOMAS. follicle See HAIR FOLLICLE. Side Effects As treatment progresses, patients develop intense infl ammation and irritation that is worsened by follicular hyperkeratoses Disorders of KERATI- exposure to ultraviolet light. For this reason, NIZATION characterized by thickening of the skin patients with many lesions are often not treated around and/or on hair follicles. These disorders until winter. Irritation is signifi cant and occurs with include KERATOSIS PILARIS, disseminated and recur- all patients. It can be soothed by using moisturizers; rent INFUNDIBULOFOLLICULITIS, and KYRLE’S DISEASE. occasionally, topical steroids are necessary. Other possible side effects after systemic admin- istration include nausea and vomiting, scars, diar- follicular mucinosa See MUCINOSES. rhea, hair loss, and impaired blood cell production. The drug applied as a cream may cause skin infl ammation. follicular orifice See PORE. When treatment is stopped, the skin heals rap- idly. It takes two to four weeks for healthy new skin to replace the skin destroyed by the 5-FU. folliculitis Infl ammation of a hair follicle. Follicu- After healing, the treated areas are often redder litis starts when hair follicles are irritated by friction than normal and may feel more sensitive; this red- from clothing, a blocked follicle, or shaving. In 146 Food, Drug and Cosmetic [FDC] Act of 1938 most cases of folliculitis, the damaged follicles are In 1977, regulations on cosmetics labeling were then infected with the bacteria Staphylococcus. While added to the FDC act. According to this law, the staphylococcal folliculitis can occur anywhere on outside wrapper or container must tell the con- the skin, it is most often found on hairy areas of the sumer the manufacturer’s name, address, maker, or face, neck, armpits, thighs, or buttocks. distributor, the product’s weight, ingredients, and warn of any potential dangers. Ingredients listed Symptoms and Diagnostic Path must include any that are contained in the product Folliculitis is characterized by a shallow, superfi cial in concentrations exceeding more than 1 percent rash of pimples and PUSTULES around a hair follicle in descending order of predominance. Ingredients on the neck, under the arms, or in the groin. should be listed only by their recognized names. A diagnosis is primarily based on the appear- If the cosmetic also qualifi es as a drug, the drug ance, of the skin; a culture of the lesion may iden- ingredients must be listed as “active ingredients” tify the bacteria or fungi. at the top of the list. (For example, sunscreens are considered to be over-the-counter drugs, as are Treatment Options and Outlook dandruff shampoos, acne medications, and so on.) Antibiotics cure staphylococcal folliculitis. Depend- Fragrances can be listed only under the general ing on the cause, it may also be necessary to avoid heading “fragrance,” and not under the specifi c irritants or chemical exposure, minimize friction ingredients from which the fragrance is derived— from clothing, avoid shaving the area, and keep the sometimes 10 or more substances. area clean. Hot moist compresses may help drain Color ingredients can be listed in any order, extensive areas of infection. Folliculitis usually no matter how much or little of the color they responds well to treatment, but may recur. make up. Colors used in cosmetics are very strictly regulated, especially for products intended for use Risk Factors and Preventive Measures around the eye area. Many colors used in cosmetics Because the infection may be spread from one are certifi ed coal tar colors, which are prohibited person to the next in the same household, each for use around the eyes. Coal tar colors include any family member should use separate towels and having the initials D&C or FD&C before the color washcloths, bathe often and wash underclothes in name and number (such as D&C Yellow #10). boiling water to kill the bacteria. The FDA prohibits very few ingredients for cosmetics; those that are prohibited or restricted include bithionol, mercury compounds, vinyl Food, Drug and Cosmetic [FDC] Act of 1938 The chloride, halogenated salicylanilides, zirconium primary law governing the composition of cosmet- complexes, chloroform, chlorofl uorocarbon pro- ics (including all skin care products). The act was pellants, and hexachlorophene. passed in the wake of a serious cosmetics-related There are signifi cant differences in how the FDA injury in 1933, when at least one woman was handles the approval of a cosmetic and a drug. If a blinded and others were injured by using Lash cosmetic is promoted as a way to improve appear- Lure, a tint administered in beauty salons to color ance, a company can place it on the market without eyelashes and eyebrows. any pre-market approval from the FDA—provided In addition to the FDC Act of 1938, cosmetics the manufacturer understands that it is safe. If the packaging and labeling is governed by the Fair FDA later discovers there is a safety concern with Packaging and Labeling Act; both of these are the cosmetic, offi cials can take action to remove it enforced by the U.S. Food and Drug Administra- from the market. tion (FDA). Because the FDA is severely hampered For the purposes of the FDA, a drug is consid- by its budget (only about 1 percent of which is ered to be any product that purports to cure, treat, spent on cosmetics regulation), in an average year, or mitigate a disease. Drug manufacturers must the FDA makes only about 400 on-site inspections prove their medication is safe and effective before of cosmetics manufacturers. it is placed on the market. foundation 147

Furthermore, a product that the FDA has con- Treatment of an anaphylactic reaction to food sidered to be a cosmetic may be relisted as a drug depends on the severity of the reaction. If the if the product subsequently is found to have a person’s heart was stopped, CPR should be started. defi nite physiological effect on the body—even Epinephrine is injected, and antihistamines and if the company did not market the product as a steroids may also be given to prevent recurrences drug. of the reaction, and to control hives and swelling. See also COSMETIC INGREDIENTS, PROHIBITED. Risk Factors and Preventive Measures Since severe reactions to food allergies were more food reactions Allergies to certain foods can likely to be caused by foods prepared away from cause a wide range of reactions in up to 7 percent home, the National Restaurant Association (NRA) of the population, including specifi c skin symptoms and the Food Allergy Network began a program such as ITCHING, HIVES, and swelling. If the reaction to help restaurant workers understand food aller- occurs immediately after the food allergen is eaten, gies. The NRA provides free information to restau- the problem is not hard to trace. In cases where rants about the proper way to handle food allergy itching and redness do not occur until hours or requests. even days after the food is eaten, the problem may be harder to track. A range of common foods may bring on itchy formaldehyde, sensitivity to Many people can skin symptoms, including citrus fruits, eggs, fi sh, develop a sensitivity to formaldehyde, which is cola drinks, artifi cial coloring, or milk. Infants used in industry and in medicine as a preservative prone to allergies may be particularly sensitive to or antimicrobial and, in larger amounts, in nail care milk and milk products, wheat, eggs, and citrus products. Household products often contain form- fruits. Acute hives usually result from an allergic aldehyde as a preservative. Substances that release reaction to foods such as shellfi sh, nuts, berries, formaldehyde contained in cosmetics or industrial tomatoes, eggs, citrus fruits, and pork. products may be listed under a trade name and not Food additives also may cause problems. About under “formaldehyde” on the product label. 15 percent of people who are allergic to aspirin are Formaldehyde can be irritating to some people, sensitive to Yellow Dye #5 (tartrazine). and because of its toxicity the Food and Drug Many food allergies disappear with time, espe- Administration limits its concentration in nail cially in children. About a third of proven allergies products to 5 percent. disappear in one to two years if the patient care- See also ALLERGIES AND THE SKIN. fully avoids the offending foods. A food allergy is diagnosed following a detailed food history, physical exam, and pertinent tests; Fort Bragg fever See LEPTOSPIROSIS. skin testing may help identify cases of food allergy in cases of acute itching. However, skin testing is not usually helpful in diagnosing chronic itching foundation This cosmetic product is generally due to food allergy. For these cases, a food diary applied fi rst to the skin to even out skin tone. Choos- and trial elimination of suspect foods may help. ing the right foundation requires fi nding the product that most closely resembles the consumer’s skin color Treatment Options and Outlook and that is appropriate for the person’s skin type. Treatment involves eliminating or reducing the Because foundation is worn next to the skin, it should sensitive food. Drug therapy may be necessary for not be too oily nor contain too much alcohol. those with multiple food sensitivities that do not Dry skin benefi ts from foundations contain- respond to elimination. Drug therapy involves the ing mineral oil, cream-formula, or oil-in-water use of antihistamines, adrenergic agents, cortico- emulsions. Products with a “matte fi nish” or those steroids, and cromolyn sodium. labeled “pore minimizing” are good choices for oily 148 Fox-Fordyce disease skin. Those with combination skin should choose fragrance and the skin Modern fragrances usu- an oil-free, pancake, or matte foundation. ally contain about 50 different scent materials that Foundation should not be applied directly to may come from fl oral oils (fl ower petals), essential skin without fi rst applying a layer of lightweight, oils (such as citrus fruit peel), or animal perfumes skin-matched moisturizer that absorbs easily. Even (such as ambergris). By isolating the primary odor women with oily skin or breakouts should use this from a plant and combining it with chemicals, a buffer layer, and tone down the shine with a dust- new odor—or isolate—is formed. Fragrances may ing of loose translucent powder. Skin that is at all also contain manmade scents derived from petro- sensitive needs this protective shield of moisturizer latum, coal tar, and so on. to reduce the chance of developing a reaction from Fragrance may be found in a variety of forms, something in the foundation. including perfumes (alcohol solutions of 15–25 Because a person’s neck skin is often a different percent perfume concentrate), toilet water (3–5 color than facial skin, experts suggest matching the percent perfume), or eau de cologne (about the color of the foundation with the jawline. Founda- same perfume concentration as toilet water, but tion color should never be tested on the skin of the whose scent blends the oils of lemon, bergamot wrist or hand, because it won’t match facial skin. and rosemary). Foundation should not be used to change skin The odor of a fragrance depends on the chem- color (to approximate a tan, for example) because istry of the wearer’s skin, which is affected by the results will appear unnatural. genes, medication, diet, hormones, and skin type See also COSMETICS. (oily skin traps fragrance and dry skin tends to let fragrance evaporate). Therefore, to test a fragrance, it is better to dab a few drops on the skin and wait Fox-Fordyce disease Also known as apocrine a few seconds before sniffi ng it. However, the true miliaria, this is an uncommon chronic disorder of “heart” of the scent will not be apparent for several the sweat glands causing itchy lesions of the skin hours. under the arms, in the pubic area, around the Fragrances are created with different top, middle nipple parts of the genitalia, and sometimes on the and end “notes” that change the scent gradually as chest and abdomen. It is characterized by reten- it is worn over a period of hours. The top notes are tion of apocrine sweat leading to the formation of the way the fragrance smells right after it is applied yellow PAPULES. There may also be hair loss in the to the skin, and lasts for approximately 15 minutes affected areas. The ITCHING is often associated with after application. The middle notes take over for emotional situations. the next few hours, and are the heart of the scent. The disease appears after puberty, and is 10 To test a fragrance, it should be applied to the times more common in women than men. Tem- inside of the wrist. To prolong fragrance, it should porary improvement occurs during pregnancy. It be layered using several different preparations is believed to be associated with an endocrinologic of the fragrance (oil or lotion, powder, and toilet problem. Some women may fi nd that the disease water or perfume); cologne lasts for approximately may regress after menopause. two hours; eau de toilette lasts two to four hours, and perfume lasts four to six hours. Symptoms and Diagnostic Path Keep in mind that dry skin does not hold fra- This disease often causes no symptoms. grance as well as oily skin; soaking dry skin in bath oil before applying the same-scent fragrance Treatment Options and Outlook or wearing body lotion can help the fragrance last. This disease often requires no treatment. However, Pulse points (behind the ear, backs of the knees, topical application of CORTICOSTEROIDS or TRETINOIN wrists) are the best places to apply fragrance, since may help relieve symptoms, and birth control pills they tend to be warmer than other skin areas. or estrogen alone are often helpful. The only per- See also ALLERGIES AND THE SKIN; COSMETICS; manent cure is to remove affected skin areas. MAKEUP. free radicals 149 fragrance, sensitivity to See ALLERGIES AND THE When more than one of these tissues is needed SKIN; FRAGRANCE AND THE SKIN. in a special confi guration unavailable naturally, the right kind of fl ap, called a prefabricated fl ap, can be pieced together gradually and then transplanted to frambesia See YAWS. its new home once the new structure is viable. For example, a new nose can be created on the fore- arm, where it is less conspicuous than on the face, freckles Tiny round or oval patches of pigmented and transplanted once it is complete. skin that are found on areas of the skin exposed to Some uses for free-fl ap surgery include breast the sun. The tendency to freckle is inherited, and reconstruction, movement restoration in fi ngers, usually occurs in fair and red-haired individuals. and so on. Generally the more exposure to the sun, the more freckles appear. While freckles are harmless, those with highly freckled complexions should avoid free radicals A highly charged, destructive form excess sunlight and use SUNSCREENS. of oxygen generated by each cell in the body that Freckles (also called ephelids) are temporary— destroys cellular membranes through the oxida- they come and go with the sun. On the other hand, tion process, contributing to premature aging, loss LIVER SPOTS (lentigines) come and stay forever. of elasticity, discoloration, and saggy skin. Rusting Freckles are caused by the skin’s efforts to tan iron, crumbling stone, and fl aking paint on a can- in spots where there is an uneven distribution of vas are all the result of oxidation, an environmen- melanin, resulting in an irregular tanning pattern. tally triggered free radical reaction. Some people fi nd they can prevent freckles by Because free radicals are essential to many applying a sunscreen with a high SPF (SUN PROTEC- reactions in the body (they are generated by the TION FACTOR); once freckles appear, however, they immune system to fend off microbes and help the may take an entire season to fade away. digestive system break down food), they should not be destroyed entirely. It is only when the levels become excessive that damage can occur. free-flap surgery A procedure by which fl aps of Free radical damage to the skin can be offset skin are transplanted with blood vessels attached, by molecules called antioxidants, which neutral- thereby ensuring the health of the graft. In the ize free radicals before they can damage skin past, when surgeons had to rely on simple SKIN cells. They include beta carotene, selenium, the GRAFTs in areas that had little blood supply or synthetic antioxidant molecule BHT, and phlo- in which the blood vessels were impaired, blood roglucinol, a natural antioxidant extracted from fl ow could not be restored and the transplanted algae. VITAMINS E and C are particularly potent tissue would often die. Attempts to transplant antioxidants. While there is no guarantee regard- additional blood vessels to the site required ing the effectiveness of the dietary supplements multistage operations that caused long recovery of antioxidants in preventing cell damage, many delays. physicians believe and recommend the benefi ts With free-fl ap surgery, physicians can transplant of the antioxidants beta carotene, vitamins C skin and blood vessels, using microscopes that mag- and E to their patients. Still, the U.S. Food and nify the operating fi eld up to 40 times and sutures Drug Administration and the National Academy that are only one-third the width of a human hair. of Sciences believe it is premature to recommend Employing a team approach during the operation increases in vitamin C, E, and beta carotene allows donor and recipient sites to be operated on intake. Other research groups and public health simultaneously. organizations are recommending daily doses of Common sites for the donor skin and blood sup- some vitamins and minerals that are four to 16 ply include the groin, scalp, armpit, forearm, thigh, times higher than the current recommended daily or back. allowances. No one is suggesting that vitamin 150 frostbite supplements should take the place of a healthful minutes. Other heat sources (such as heating pads) diet and lifestyle, however. should not be used because the frostbitten tissue While vitamins C and E are particularly good anti- can still be burned by temperatures that under oxidants, taking these vitamins orally may do a bet- normal conditions would not harm the skin. If the ter job of protecting against free radicals in the body skin tingles and burns as it warms, circulation is than on the skin. For this reason, some researchers returning. If numbness remains as the area is warmed, are recommending that consumers apply these mol- professional help should be obtained immediately. ecules directly to the skin. Some cosmetics are incor- A frostbitten area should never be rubbed as it porating antioxidants into their ingredients as a way thaws. If feet are affected, the patient should not to make antioxidants more available to the skin. walk on them. In addition, frostbitten patients should not smoke cigarettes, since nicotine causes the blood vessels to constrict and may inhibit cir- frostbite Damage to the skin caused by exposure culation. Neither bandages nor dressings should be to very cold temperatures for a long period of time. used. The areas most likely to be affected are the feet and Thawing time is determined by the temperature hands, nose, and ears. While anyone can become of the water and the depth of freezing; it is com- frostbitten, those with circulatory problems are at plete when the extremity fl ushes pink or red. After greatest risk. rapid thawing, small BLISTERs appear, spontane- Although it is theoretically possible for tissue to ously rupturing in four to 10 days, followed by a freeze in temperatures at about 32° F, the body’s black SCAB. Normal tissue may have formed below. local internal temperature must fall to levels lower Constant digital exercises should be performed than that before freezing occurs at a specifi c area of to preserve joint motion. Further treatment is the body. The danger of frostbite increases if a per- designed to prevent infection and preserve func- son is without adequate food, clothing, or shelter; tion of the affected part. wind or wet skin also hastens the outward transfer In severe cases, antibiotics, bed rest, and physi- of heat and increases the risk of frostbite. cal therapy may be necessary after the affected part has been warmed; cigarettes should be avoided Symptoms and Diagnostic Path during the entire recovery period. Frostbitten skin appears as fi rm, pale, cold white The best chance of successful healing after frost- patches with a lack of sensitivity to touch, although bite occurs is when the affected part has not been there may be a sharp, aching pain on the affected frozen long, when thawing is rapid and when blis- area. As the skin thaws, it becomes raw and pain- ters develop early. The outlook is more uncertain ful. Frostbite damage may be described as “super- when thawing is spontaneous at room tempera- fi cial” (FROSTNIP), involving skin and subcutaneous ture, when the part is frozen for a long time, or tissues or “deep” (true frostbite), affecting muscle, if the frostbite occurred in an area of fracture or nerve, vessels, cartilage, and bone. dislocation. A poor outlook is indicated if thawing is delayed or occurs due to excessive heat, if blisters Treatment Options and Outlook are dark, or if thawing is followed by refreezing. Normal body temperature should be restored before Refreezing almost always ends in amputation. thawing any frostbitten fl esh. A small area of frost- In mild cases, damage can be reversed, but if nipped skin can be rewarmed by placing fi ngers or frostbite is severe the fl ow of blood to the area the heel of the hand over the affected area. Rapid stops. Unless immediate treatment is begun, the thawing of the affected part in warm water baths is area will be irreversibly damaged and amputation the current preferred treatment method for more of the extremity may be required. extensive frostnip and for frostbite. If immediate Major complications include infection, tissue emergency assistance is unavailable, severely frost- death, sensory loss, persistent deep pain, and bitten hands or feet should be thawed in warm, limited joint movement. Permanent effects may not hot, water (between 104–108° F) for 20 to 30 include fi xed scars, small muscle wasting, deformed fungal infections 151 joints, arthritic bone changes, and increased sensi- Frostnip is treated by drying and gently rewarm- tivity to cold. ing the injured skin by placing it against warm skin (such as under the armpits or on the abdomen). Risk Factors and Preventive Measures If exposure to the cold continues, frostnip quickly Frostbite is theoretically simple to prevent by deteriorates into full-blown frostbite, which causes wearing proper clothing in cold weather (dry and permanent skin damage. layered, warm and loose), especially on hands and feet. Nose and ears should be protected; tight apparel (boots, gloves or clothing) should never be fucosidosis A very rare genetic metabolic disorder worn. Conditions that increase the likelihood of caused by a lack of a lysosomal enzyme resulting in frostbite include emaciation, fatigue, dehydration, the accumulation of fucose between the cells. and previous frostbite. There are three types of fucosidosis, but it is To stay warm, individuals should wear cotton type III disease that causes skin symptoms, includ- blend socks (such as Orlon and cotton), not pure ing pigmentary retinopathy (disorder of the retina) cotton socks. Clothes should be loose, and layered and (occasionally) lack of sweating (HYPOHIDROSIS) to help trap heat. The inner clothing layer should and purple nail beds. In addition, patients may be made of a synthetic fabric, or a silk or wool have various neurologic problems, including sei- blend that wicks away perspiration from the skin. zures and recurrent pulmonary infections. The next layer should be something that insulates, The disorder is an autosomal recessive disease, like a wool shirt, for example. Waterproof, breath- meaning that a defective gene must be inherited able boots and outer jacket are a good choice. Since from both parents to cause the abnormality. Gen- the head is the source of greatest heat loss, a hat erally, both parents of an affected person are unaf- must be worn in cold weather; mittens are better fected carriers of the defective gene. Each of their than gloves because they trap heat from the whole children has a one-in-four chance of being affected, hand. and a two-in-four chance of being a carrier. There Individuals who must go outside in cold weather is no effective treatment. should eat warm food (oatmeal, hot soup) to raise core body temperature, and drink plenty of fl uids to stave off dehydration. Dehydration can worsen Fulvicin See GRISEOFULVIN. chills and frostbite by reducing blood volume. Caf- feinated beverages, which constrict blood vessels and interfere with circulation, should be avoided. fungal infections Diseases of the skin (also called While alcohol may temporarily warm up hands mycoses) caused by the spread of fungal organ- and feet, it has a cumulative negative effect by isms. Infection may range from a mild skin condi- increasing blood fl ow to the skin, reducing the core tion to severe disease with fatal symptoms. Fungal body temperature. skin infections are either considered to be super- In any situation where freezing has occurred, fi cial (affecting skin, hair, nails) or subcutaneous thawing must be prevented if refreezing is (beneath the skin). a possibility. While it is possible to survive local The superfi cial fungal infections include THRUSH freezing of an extremity, the body’s internal tem- (candidiasis) and TINEA (including RINGWORM, JOCK perature must be maintained, since loss of vital ITCH, and ATHLETE’S FOOT). Subcutaneous infections temperature can cause hypothermia and death. are rare; the most common is sporotrichosis, occur- ring after a contaminated scratch; most examples of this type of condition occur in tropical climates. frostnip The earliest stage of FROSTBITE, this condition is reversible. In this stage, the skin sud- Symptoms and Diagnostic Path denly turns white and frosty and becomes less Harmless fungi and yeasts are present all the time sensitive. on the skin, but they do not multiply there because 152 Fungizone of competition among bacteria or because the Occasional side effects of oral antifungals include body’s immune system fi ghts them off. Superfi - nausea, diarrhea, abdominal pain, skin rashes, head- cial fungal infections are extremely common, and ache, and fatigue. The doctor may order a blood test occur in perfectly healthy individuals. Widespread to check liver function, especially during long-term or deep fungal infections of the skin are most therapy, if the patient has an already weakened common in those taking long-term antibiotics, liver or is using high doses of medication. CORTICOSTEROID, or immunosuppressant drugs, or in patients with an immune system disorder such Risk Factors and Preventive Measures as AIDS. Some people have a genetic tendency A patient should receive effective follow-up care toward fungal infections. because fungal infections can recur and treat- There are two signifi cant ways to determine the ments are usually more successful if started early. type of fungus causing the infection. The faster It is possible to prevent fungal infection by not method involves placing a tissue sample in an alka- sharing hats, combs, brushes, or other objects. line solution of potassium hydroxide (KOH). The Wearing shoes in locker rooms, public showers, KOH changes the sample so that the fungus shows and around swimming pools can help reduce con- up more clearly under the microscope. Experts can tact with athlete’s foot fungus. Reducing moisture often identify the fungus by the fi laments it sends and humidity on the skin by drying it thoroughly out through the skin sample. Another method and by changing sweaty clothes and socks also involves growing a colony of fungus in the labo- can help prevent fungus. Cleaning or discarding ratory from a skin sample. This is more accurate infected objects and garments also helps prevent but may take weeks. Finally, some fungi exhibit a recurrences. fl uorescent glow when exposed to ultraviolet light, See also TINEA BARBAE; TINEA CORPORIS; TINEA which can also help to identify the fungus causing MANUUM; TINEA NIGRA PALMARIS; ATHLETE’S FOOT; an infection. JOCK ITCH.

Treatment Options and Outlook One common antifungal drug taken by mouth Fungizone See AMPHOTERICIN B. (GRISEOFULVIN) is effective for treating TINEA CAPI- TIS, for example, but not for CANDIDA and certain mold infections. The drug KETOCONAZOLE (Nizoral) fungus A phylum of plants (including yeasts, is effective against TINEA VERSICOLOR but not against rusts, molds, smuts, mushrooms, and so on) char- other fungal infections. acterized by the absence of chlorophyll and the Many broad-spectrum antifungal agents effec- presence of a rigid cell wall. There are more than tively treat a wide range of organisms, which 100,000 different species of fungi around the means the patient can begin taking an antifungal world, most of which are harmless or benefi cial to drug without waiting for culture results. Three human health (such as molds used to produce anti- of these new antifungals are itraconazole (Spo- biotics, yeasts used in baking and brewing, edible ranox), terbinafi ne (Lamisil), and fl uconazole mushrooms and truffl es, and yogurt cultures). (Difl ucan). However, some fungi can invade and form The treatment regimen is chosen based on the colonies in the skin or underneath the skin, lead- type and extent of the infection. Some work well in ing to disorders ranging from a mild skin irrita- the short term, while others have a longer lasting tion and infl ammation to severe or fatal systemic effect. Some work well in small quantities, while infections. others require larger doses to be effective. If only See also FUNGAL INFECTIONS. skin is involved, the treatment is relatively short (a few weeks). If the nails are affected, at least three months of treatment is required. furuncle Another name for a BOIL. Futcher’s line 153 furunculosis A bacterial infection characterized times a day. Bathing with antimicrobial soap by tender, subcutaneous nodules usually capped decontaminates other areas. Systemic antibiotics with a small PUSTULE, and infected with Staphylo- are frequently required. coccus aureus. Furuncles (BOILS) occur when a few neighboring hair follicles become infected with Risk Factors and Preventive Measures S. aureus. If more follicles are involved, the furuncle The recurrence of furunculosis may be prevented becomes a CARBUNCLE. Furuncles most commonly by improving hygiene, by taking systemic antibiot- affect the neck and upper back. Boils may also ics, and by ensuring that the source of infection is recur for years. cleared.

Treatment Options and Outlook Surgical drainage of pus is followed by the appli- Futcher’s line See VOIGT’S LINE. cation of warm compresses for 20 minutes four G gangrene Death of tissue generally associated Wet gangrene: Once the tissue becomes infected, with loss of blood supply, followed by bacterial antibiotics are given to prevent wet gangrene from infection. It may affect either a fairly small area of setting in. Once wet gangrene is diagnosed, ampu- skin or an entire limb. tation of the affected part, along with neighboring In dry gangrene, an area of the skin dies because healthy tissue, is required in order to save the of a blocked blood supply, without bacterial infec- patient. The prognosis depends on the part of the tion; this type does not spread to other tissue. It body affected, the extent of the gangrene, its cause, may be caused by arteriosclerosis, diabetes mel- and the patient’s condition. Treatment delay can be litus, a stroke, blood clot, or FROSTBITE. fatal; signifi cant involvement or other underlying Wet gangrene follows bacterial infection of dry medical conditions also can lead to death. gangrene or a wound. Gas gangrene is a particularly virulent form of wet gangrene caused by a deadly type of bacteria Gardner-Diamond syndrome This self-induced (Clostridium welchii) that destroys muscle while pro- syndrome affects women almost exclusively, and is ducing a foul odor. Gas gangrene has been respon- characterized by painful bruising of the skin after sible for millions of deaths during war. minor injury. These patients share a similar person- ality profi le—masochistic tendencies, dependent Symptoms and Diagnostic Path relationships, and intense anger toward those clos- Pain occurs in the dying skin tissue, which becomes est to them. numb and black once it dies. If bacterial infection Patients may fi rst complain of tenderness, burn- occurs, the gangrene will spread, giving off a nox- ing, or stabbing pain in the legs; skin lesions become ious odor with redness, swelling, and oozing PUS bluish from within a few hours to three days later, around the blackened area. In cases of gas gan- and eventually come to resemble bruises. Recur- grene, symptoms may include persistent or severe rent lesions in groups are common. The condition pain, fever, gas in tissues beneath the skin, a sick is thought to be self-infl icted. feeling, and septic shock. The prognosis for syndrome patients, even with Gangrene can be diagnosed during a physical extensive psychotherapy, is poor. examination, but a number of tests and proce- dures also may be performed, including blood tests (a CBC may show a high white blood cell Gardner’s syndrome A hereditary disorder featur- count), X-rays, scans, exploratory surgery, micro- ing benign skin growths that appear during the fi rst scopic examination of tissue, or tissue or fl uid 10 years of life. The skin growths include epidermal cultures. and sebaceous cysts, lipomas, and fi bromas. The disorder is an autosomal dominant disease, Treatment Options and Outlook which means that only one defective gene (from Dry gangrene: Improving circulation to the affected one parent) is needed to cause the syndrome. Each area can improve dry gangrene if it is begun early child of an affected person usually has a one in enough. two chance of inheriting the defective gene and of

154 genetic disorders of the skin 155 being affected. It was discovered in the 1950s by be inherited from both parents in order for the Dr. Eldon Gardner, who noticed multiple symp- abnormality to occur. Generally, both parents of an toms among family members in two different fami- affected person are unaffected carriers of the defec- lies. Recently, the gene responsible for Gardner’s tive gene. Each of their children has a one in four syndrome, which affects the growth cells in the chance of being affected and a two in four chance body, has been identifi ed. of being a carrier.

Symptoms and Diagnostic Path Symptoms and Diagnostic Path The syndrome also causes thousands of polyps in the The most common skin symptom is a yellow- colon, as well as the stomach and upper intestine, brown discoloration appearing over exposed areas, together with bony tumors in the jaw and skull. The mimicking MELASMA when it occurs on the face. If polyps associated with this syndrome usually appear bone marrow or liver are involved, symptoms may around age 15 and eventually lead to cancer. include blue/purple hemorrhagic patches, purple papules, pale skin, or jaundice. Treatment Options and Outlook A biochemical assay is now available to identify Since the inevitable outcome of this disease is carriers. colon cancer (typically about 10 to 15 years after the onset of the polyps), patients with documented Treatment Options and Outlook Gardner’s should have their colon and rectum Researchers are studying the feasibility of replacing removed. Although there is no recommended non- the defi cient enzyme. surgical therapy for Gardner’s, studies have shown The disease is fatal in infancy, but a less severe that the colon polyps regress to a signifi cant degree form may become apparent only in adulthood. with use of sulindac (Clinoril), a nonsteroidal anti- infl ammatory drug. Since other polyps may be present elsewhere, regular endoscopic examination gel A clear, jellylike, solid vehicle that becomes of these areas is also a good idea. liquid when warmed or rubbed onto the skin. Gels All blood relatives of a person diagnosed with usually contains volatile solvents that evaporate Gardner’s syndrome should be screened with colo- quickly when applied to the skin. Many gel prod- noscopy. There are also genetic tests to screen ucts have been refi ned to eliminate oils, fragrances, younger patients who may have not yet developed color, or emulsifi ers. Gel moisturizers and cleans- the polyps. ers also have a higher water content than most creams and lotions, which makes them feel cool and soothing on the skin. gastrointestinal bleeding, skin symptoms of If While most creams can leave the skin feeling enough bleeding in the gastrointestinal tract occurs, greasy, gels are absorbed almost instantly, like the skin may appear pale. Cirrhosis of the liver may water. Gels work well for women with normal include skin symptoms of redness, spidery veins, or to oily skin because they add moisture without jaundice. adding oil. But for those with dry skin who may need more moisture, a better skin-care choice is an emollient-rich cream or lotion, because gels have a Gaucher’s disease A hereditary disorder of lipid tendency to be drying. metabolism most often found among Ashkenazi Jews. A lack of the enzyme B-glucocerebrosidase, important to the metabolic process, leads to a genetic disorders of the skin There is a wide range buildup of fatty compounds (cerebrosides) in the of genetic diseases affecting the skin. Genetic hair liver, spleen, lymph nodes, and nervous system. defects that cause loss of hair include hidrotic ecto- Gaucher’s disease is an autosomal recessive dermal dysplasia, ANHIDROTIC ECTODERMAL DYSPLASIA, disorder, which means that a defective gene must CARTILAGE-HAIR HYPOPLASIA, trichorhinophalangeal 156 genital warts syndrome, biotin responsive carboxylase defi ciency, agers have genital HPV infections. Because they do marie unna hypotrichosis, congenital skin defect not have symptoms or recognize them, millions of (APLASIA CUTIS), CONRADI’S DISEASE, incontinen- others do not know they carry HPV. tia pigmenti, focal dermal hypoplasia, and Haller- Genital HPVs can spread whether or not warts mann-Streiff syndrome. Other genetic hair disorders are present, usually by vaginal or anal intercourse. include low sulfur hair syndromes and hypertricho- Because genital HPV infections are often unseen, sis lanuginosa. they can be spread by sex partners who don’t know Genetic blistering disorders include EPIDER- they’re infected. It may also be possible by contact MOLYSIS BULLOSA; ACRODERMATITIS ENTEROPATHICA; with the virus through such potential vehicles as tyrosinemia type II (RICHNER-HANHART SYNDROME) toilet facilities, steam room benches, shared swim- pachyonychia. suits, or underwear. Genetic diseases associated with sensitivity to People most at risk for genital HPV infections are light include BLOOM SYNDROME, XERODERMA PIG- people who MENTOSUM, DYSKERATOSIS CONGENITA. Genetic diseases associated with premature • have weakened immune systems aging and hardening of the skin include WERNER’S • are sexually involved with a number of different SYNDROME and PROGERIA. Those associated with partners abnormal skin elasticity include EHLERS-DANLOS • have sex partners who are sexually involved SYNDROME, CUTIS LAXA, BUSCHKE-OLLENDORFF with a number of different partners SYNDROME, FARBER’S LIPOGRANULOMATOSIS, and PACHYDERMOPERIOSTOSIS. • have infected partners Genetic skin disorders involving multiple new skin growths include epidermodysplasia verrucifor- The majority of those now seeking treatment for mis and GARDNER’S SYNDROME. genital warts are young women between the ages Other genetic diseases include: ANGIOKERATOMA, of 15 and 29. arginosuccinic aciduria, GENODERMATOSIS, LENTIGI- NOSIS PROFUSA, lentigo simplex, and MULTIPLE LEN- Symptoms and Diagnostic Path TIGINES SYNDROME. HPV infections cause a variety of problems, but See also CHROMOSOMAL DEFECTS AND SKIN there may be no symptoms of infection at all. DISEASE. Genital warts caused by HPV may be found on the vulva, in the vagina, and on the cervix, penis, anus, and urethra of infected women and men. They are genital warts A type of WART found in the genital only rarely found in the throat or mouth. Usually, area, anorectal region, and occasionally the ure- the warts grow in more than one location, and thra, bladder, and ureters, caused by infection with may cluster in large masses. Genital warts usually human papillomavirus (HPV) (see PAPILLOMAVIRUS, are painless, but they may itch. If allowed to grow, HUMAN). The disorder is readily spread by sexual they can block the openings of the vagina, urethra, contact. or anus and become very uncomfortable. Depend- The warts primarily appear in the moist genital ing on their location, genital warts can cause sores folds and creases. While just one wart may appear, and bleeding. they are commonly found in heaped-up bunches Genital warts often grow more rapidly during that form caulifl owerlike masses. They are sub- pregnancy. An increase in the size and number of ject to injury and can bleed, and they are usually genital warts occurs when a person’s immune sys- painless. tem is weakened by diabetes, an organ transplant, One out of 10 Americans have genital HPV Hodgkin’s disease, HIV/AIDS, or other conditions. infections, and between 500,000 and a million new There are other genital HPV infections that cannot cases of genital warts occur each year. Some studies be seen with the naked eye. Some are more dan- show that about a third of all sexually active teen- gerous than genital warts because they are associ- genital warts 157 ated with cancers of the cervix, vulva, vagina, or abdominal pain, infection, or rarely, cervical scar- penis. ring. Painkillers given before cryotherapy will ease Medical examination is the fi rst step in deter- pain, and icepacks applied externally after the pro- mining if there is a genital HPV infection. Many cedure will reduce any swelling or infl ammation. times a woman does not notice warty lesions, but Considerable watery vaginal discharge for 10 to 20 her physician may see something unusual while days after cryotherapy is normal, but fever, pain performing a routine gynecologic examination or unrelieved by analgesics, or unusually prolonged Pap smear. Pap smear results can be used to screen discharge should be reported to the doctor. for tissue changes in the cervix and help cor- Laser treatment involves a high-intensity beam roborate fi ndings of other tests like colposcopy or of light that vaporizes lesions, particularly those biopsy. Colposcopy (viewing the cervix through a that are external or in less accessible locations. In special microscope) may be used to identify subtle the hands of a well-trained physician, laser therapy tissue changes. Colposcopy also allows a sample of is highly effective in removing multiple lesions. The any suspicious tissue to be taken by the examiner. procedure is usually more expensive than other types of treatment, and carries risks of removing Treatment Options and Outlook too much tissue, and delayed healing, scarring, or HPV is a persistent and hard-to-cure organism, so pain. treatment must usually be repeated. Moreover, an Acids such as trichloroacetic acid (TCA) or infected woman should be monitored throughout bichloroacetic acid (BCA) may be painted on visible her life for recurrence or development of precan- warts using a small cotton swab or wooden applica- cerous changes, whether or not warts are apparent. tor. To be effective, TCA or BCA must be applied in Because the virus remains in the lesions it creates, proper concentrations, but these sometimes cause treatment for HPV consists of controlling infection a burning sensation after treatment. Local and by removing visible warts or precancerous lesions. systemic painkillers will help relieve pain. Scarring They can be removed by surgery, freezing, or by and chronic pain are potential aftereffects. locally applied chemicals. The method depends on 5-Fluorouracil (5-FU) cream applied to the the extent of infection, accessibility of lesions, and vulva on a regular regimen can help control malignant potential. To ensure that as many lesions external lesions. However, it should not be used as possible are treated, colposcopy may be used by pregnant women and may cause serious skin during therapy to better view internal lesions. irritation. Surgery is sometimes used to cut away warts if Interferon, a newer drug approved for injection treatment without anesthesia would cause discom- into a muscle or select lesions, can be used, but it fort or warts are so extensive that simultaneous is expensive, has signifi cant systemic side effects, reconstructive surgery is required. Surgery may and cannot be used during pregnancy. Podophyllin permit a more thorough removal of infected sites, was once a popular treatment, but is used less often although its cost must be weighed against potential now because it cannot be used during pregnancy benefi ts and risks. Surgery may either mean an or for most internal lesion sites and because it may excisional biopsy done as an outpatient procedure cause cancer or toxic reactions. or as a more involved procedure performed under After any HPV treatment, the treated area anesthesia. should be kept clean and dry with cornstarch dust- In superfi cial cryotherapy, liquid nitrogen is ing, cotton underwear, and loose clothing. Sexual applied by cotton swab to minor external warts. intercourse should be avoided until healing has Extensive lesions can be frozen faster and to a occurred externally and internally, usually within greater depth with a cold cautery device that two to four weeks. Follow-up colposcopy and Pap pinpoints warts. Cold cautery cryotherapy is usu- smears are usually scheduled at three-month inter- ally performed within a week after menstruation, vals after treatment of HPV, and yearly thereafter. and it cannot be used in pregnant women. After These tests monitor that the cervix remains free of cryotherapy women may experience cramping, precancerous or cancerous tissue. A woman with 158 genodermatosis

HPV should notify any sexual partners of her infec- developed countries because of successful vac- tion, use latex condoms with every partner (unless cination programs. The United States has tried to in a mutually monogamous relationship), and urge eradicate the disease by vaccinating all school- that the partner be treated for HPV if his physician age children. By 2002, there were only 18 cases has identifi ed HPV lesions. of rubella reported, and people age 15 to 39 accounted for 72 percent of all reported cases. Most Risk Factors and Preventive Measures reported rubella in the United States since the mid- Condoms are recommended for all sexual contacts 1990s has occurred among Hispanic young adults other than between monogamous partners. Con- who where born in areas where rubella vaccine is doms prevent transmission of infection to a partner routinely not given. and lower the risk of becoming infected with a dif- ferent form of HPV or other sexually transmitted Symptoms and Diagnostic Path diseases. Applying spermicides with nonoxynol- The infection usually affects youngsters between 9 to affected or treated areas may be helpful in the ages of six and 12 with a rash that lasts for a reducing transmission of the virus. Everyone with few days, a slight fever and enlarged lymph nodes. genital lesions, and all partners of persons with Sometimes the symptoms are so mild, the entire genital lesions, should alert new sexual partners infection comes and goes without notice. Ado- about HPV infection risk and take precautions to lescents and adults may have slightly more pro- limit spread of HPV. nounced symptoms. The virus is contagious from a few days before the symptoms appear until a day after symptoms fade. genodermatosis Any genetically determined dis- Rubella may be confused with other conditions order of the skin, such as EPIDERMOLYSIS BULLOSA, characterized by rashes, such as SCARLET FEVER or PROGERIA, GARDNER’S SYNDROME, and so on. drug allergy. See also GENETIC DISORDERS OF THE SKIN. Treatment Options and Outlook There is no specifi c treatment for rubella, although gentamicin An injectable antibiotic sometimes acetaminophen may reduce the fever. given in combination with other antibiotics to treat serious gram-negative bacterial infections. It can- Risk Factors and Preventive Measures not be given by mouth because it is inactivated Vaccination, which can provide long-lasting immu- during digestion. nity, is administered in the United States to all Blood tests are taken during treatment to reduce infants at about 15 months of age as part of measles the risk of toxic kidney damage. and mumps immunization. There is not usually any reaction to the vaccine. Infection by rubella virus also provides immunity to future infection. German measles The common name for rubella, this viral infection, as MEASLES, causes a rash on the face, trunk, and limbs. Rubella causes a mild Gianotti-Crosti syndrome A condition known illness in children and a slightly more problematic medically as papular acrodermatitis that is charac- one in adults, but is serious primarily when con- terized by skin-colored or slightly pink papules on tracted by pregnant women in the early months the face, arms, legs, and buttocks of children. The of pregnancy. During this time, there is a chance lesions do not usually itch. There is a frequent asso- the virus will infect the fetus, which can lead to ciation with hepatitis B virus. Other viruses cause a range of serious birth defects known as rubella the eruption include hepatitis A virus, Epstein- syndrome. Barr virus, coxsackievirus A16, parainfl uenza Although rubella was once found throughout virus, respiratory syncytial virus, and polio-vaccine the world, it is now much less common in most enterovirus. glomus tumor 159

Symptoms and Diagnostic Path glomus tumor A small, extremely painful swell- The patient usually feels fairly well, but has diar- ing usually found on the extremities, especially the rhea or an upper respiratory infection when hands. This relatively uncommon benign growth the skin suddenly breaks out in crops of PAP- appears as a soft or fi rm blue-red papule. ULES lasting up to two months, which then fade There are two variants, solitary and multiple spontaneously. (also known as glomangiomas), each with distinct clinical characteristics. Single glomus tumors, espe- Treatment Options and Outlook cially those occurring under the nail bed, are more There is no specifi c treatment, but itching may be common in women; multiple lesions are more relieved with an antipruritic lotion, weak topi- common in men. Solitary glomus tumors are more cal CORTICOSTEROID lotion, or sedating antihista- common in adults; multiple growths develop 10 to mines. 15 years earlier than single lesions, with about a third appearing before age 20. Very rare congenital glomus tumors are considered a variant of multiple ginseng The dried root of the Panax schinseng glomus tumors. plant that is reported to contain hormones and vitamins. However, research has not found any Symptoms and Diagnostic Path evidence that ginseng can improve the appearance Glomus tumors are characterized by a sensitiv- of the skin. Ginseng has been associated with aller- ity to cold, localized tenderness, and excruciating gic skin reactions. intermittent pain, which is described as a burning or bursting feeling. The exact incidence of glomus tumors is unknown, but the multiple variant is glanders An infection found in Asia, Africa, and rare, comprising less than 10 percent of all cases. South America that affl icts horses and donkeys and Most likely, many of these tumors are misdiag- that may be occasionally transmitted to humans. nosed as HEMANGIOMAS. The infection, which is caused by the bacterium Malignant glomus tumors (glomangiosarcomas) Burckholderia mallei, causes an ulcer or abscess are extremely rare. There has been only one report where it enters a wound in the skin. of a malignant glomus tumor that spread elsewhere in the body. Symptoms and Diagnostic Path The infection causes lesions at the site of infection Treatment Options and Outlook that may become fi lled with PUS. If the mucous Surgical removal is required. If the tumor is located membranes in the nose or mouth are involved, under the nail, repair of the nail bed must be per- extensive tissue death and damage to the septum formed after the removal of the lesions. Removal and palate may occur. The disease is diagnosed in of multiple tumors may be more diffi cult since the laboratory by isolating Burkholderia mallei from there are so many of them, and should be limited blood, sputum, urine, or skin lesions. to those causing symptoms. Other possible treatments include argon and Treatment Options and Outlook carbon dioxide lasers, or treatment with hypertonic There is no satisfactory treatment, although tetra- saline or sodium tetradecyl sulfate (especially for cyclines, streptomycin, and chloramphenicol may multiple lesions). be effective. Immediate surgical removal of lesions Treatment of glomangiosarcoma is based on followed by treatment with sulfonamide is recom- a few case reports. Wide local excision has been mended. Glanders may appear as an acute disease, found to be adequate treatment and is probably the in which it may be rapidly fatal, or as a chronic treatment of choice. condition that may persist for months or years. Excision of painful lesions usually cures the Death may occur as a result of liver disease or con- problem, although occasionally a solitary lesion tinuing infections. will recur. Malignant glomus tumors are extremely 160 glutamic acid rare and usually locally aggressive, with an overall The skin underneath has a fresher, healthier look good prognosis when treated with wide excision. with a more even color and texture. In high con- centrations and after long-term use, AHAs eventu- ally may affect the deeper layers of the skin. glutamic acid An amino acid included in some By federal law, all alpha hydroxy acid products expensive cosmetics that purport to improve the are considered to be cosmetics, not drugs, and are appearance of the skin. All amino acids combine to not regulated by the U.S. Food and Drug Adminis- form proteins under certain chemical conditions, tration (FDA). but because more than two different amino acids Over-the-counter products manufactured by are needed to form useful proteins, simply includ- reputable companies are usually mild, containing ing glutamic acid in a SKIN CREAM will not provide less than 10 percent alpha hydroxy acid. Beauty much benefi t. Further, is not possible to rebuild the salon operators use products up to 40 percent, and proteins of the skin with amino acids, and they are physicians use solutions of up to 70 percent for not absorbed when applied to the skin. their in-offi ce peels. Reputable fi rms do not sell stronger products over the counter because of the danger to con- glycerin A clear liquid made by combining water sumers and the accompanying liability threat. But and fat that is used in many cosmetics and toiletries the FDA is reviewing glycolic acid to see whether because it improves the consistency of creams and strength percentages should be established by law. lotions, and helps them retain moisture. Glycerin, Irritations and even burns have been reported by however, tends to draw water out of the skin, and those who have used “bootleg” products. can make skin drier. It has not been found to cause allergic reactions. gnathostomiasis A rare infection usually caused by ingestion of the third-stage larvae of the nema- glycolic acid One of a number of natural fruit tode Gnathostoma spinigerum found in Southeast acids (ALPHA HYDROXY ACIDS) available both as over- Asia, although several other species also cause the-counter and prescription mild skin peels. This human disease. The larvae may be found in con- topical product improves the skin’s appearance by taminated water or in undercooked freshwater accelerating the natural process of shedding dead fi sh, chicken, snails, frogs, and pigs. Rarely, larvae skin cells. Used properly, the acids work gently, penetrate the skin of those exposed to such meat producing only a slight tingling or stinging sensa- or water. In humans, the parasite may live in body tion in some consumers. Glycolic acid is the alpha tissues for as long as 10 years. hydroxy acid most frequently used for facial treat- Within one to two days after ingestion, lar- ments but citric acid and lactic acid (from milk) also vae invade the gastric/intestinal wall and migrate are useful. through the liver. Their migration through the Derived from sugar cane, glycolic acid can clear body begins from three to four weeks to several up ACNE-prone skin, soften tiny lines around the years after ingestion. Typically, episodes last for one eyes and mouth, smooth dry skin and fade dark or two weeks. With time, episodes occur less often, spots caused by sun or hormonal changes (such as are less intense, and do not last as long. in pregnancy). Fastest results are usually obtained There have been no reports of human cases of in a doctor’s offi ce, since higher strength products gnathostomiasis acquired in the United States, and are available to dermatologists. Over time, the rate it remains rare in those who are exposed abroad. at which old cells are sloughed off the surface of Gnathostomiasis is an uncommon disease even in the skin slows down, resulting in a surface layer endemic areas of Southeast Asia (including Japan, of dead skin cells that make skin look aged. AHAs Korea, Laos, Malaysia, Taiwan, and Thailand) loosen the substances holding the surface skin cells and Latin America (mainly Mexico and Ecuador), to one another, allowing the dead skin to peel off. although its incidence appears to be increasing gold therapy 161 possibly due to changing dietary habits. It is most days because of the danger of a rebound attack of common in Thailand and Japan. In Thailand, it is psoriasis. the most common parasitic infection of the central nervous system. gold sodium thiomalate A water-soluble gold Symptoms and Diagnostic Path salt used in chrysotherapy (GOLD THERAPY) to treat The most common symptoms are painful or itchy rheumatoid arthritis. More recently, it has been migratory swelling in the skin. The parasites are a used intramuscularly to treat PEMPHIGUS. common cause of parasitic eosinophilic meningitis A few patients experience a specifi c reaction caused by their migration into the central nervous within minutes after treatment with gold sodium system. Gnathostomiasis can persist for 10 to 12 thiomalate, including fl ushing, redness, weakness, years and may cause signifi cant long-term health vertigo, and low blood pressure. Other symptoms problems. Random invasion of the central nervous that appear within a day after treatment include system may lead to death in 8 percent to 25 percent arthralgia, joint stiffness, myalgia, and malaise. of cases. See also AUROTHIOGLUCOSE.

Treatment Options and Outlook The best treatment is surgical removal of the worm, gold therapy The common term for chryso- which is possible only when it is accessible. Medi- therapy, this treatment is most often used to cation may also be used, including the synthetic treat arthritis sometimes associated with PSORIA- nitroimidazole albendazole. Mebendazole, a former SIS. PEMPHIGUS also has been treated with gold drug treatment, should not be used because it is too salts. Gold, which is administered orally, has an toxic. CORTICOSTEROID therapy in central nervous anti-infl ammatory effect that can relieve pain and system disease may also be useful. stiffness, and prevent further joint damage. Two different gold preparations are used: the water- soluble GOLD SODIUM THIMALATE and the oil-based Goeckerman regimen An intensive treatment AUROTHIOGLUCOSE. regimen for patients suffering with PSORIASIS com- bining ultraviolet B light and tar ointments. This Side Effects regimen has been a standard in-patient treatment Possible side effects of gold therapy to the skin for 50 years. It involves applying 2 to 5 percent include exfoliative dermatitis (see DERMATITIS, crude coal tar ointment to the entire body at bed- EXFOLIATIVE), macules or papules, or lesions resem- time, which is then left on the skin overnight. bling LICHEN PLANUS or PITYRIASIS ROSEA. The drug Application for two hours before exposure to is usually stopped if ITCHING occurs. After gold ultraviolet light is an effective alternative. In the therapy stops, the lesions typically fade away up to morning, the excess tar is removed with mineral oil three or four months later. After that, most patients and the patient is exposed to UV light; afterwards, will tolerate further gold treatments without skin the patient bathes away remaining tar. The amount symptoms. of UV light is gradually increased over successive Other side effects of gold therapy may include treatments. Treatment is given in outpatient clin- the diffuse depositing of metallic gold within the ics or, more rarely, in a hospital. Treatment usually skin (a condition known as chrysiasis). Patients lasts for three or four weeks, and may result in who are going to be treated intramuscularly are remission for six to eight months. usually given a test dose to gauge sensitivity, fol- A modifi ed form of treatment involves applying lowed by gradually increasing doses. Patients with topical CORTICOSTEROIDS at night instead of coal tar. pemphigus may require a cumulative dose of 500 In the morning the steroids are removed and the mg before noticing improvement. patient applies tar before UV treatment. Cortico- Possible side effects unrelated to the skin include steroids cannot be used for more than four or fi ve problems with the liver and kidney, liver and bone 162 goose bumps marrow changes, appetite loss, diarrhea, nausea, and weighs their usefulness. Topical CORTICOSTEROIDS abdominal pain, and sometimes anaphylactic shock. may be helpful. Because of the risk of side effects, patients are usually monitored with serial complete blood counts, platelet counts, urinalysis, and liver func- graft-versus-host disease (GVHD) The first tion tests. symptom of this common complication to bone marrow transplantation is a skin RASH. The condi- tion is caused by cells present in the transplanted goose bumps See GOOSEFLESH. bone marrow (graft) that attack the transplant recipient’s tissues (host). The disease may occur soon after any organ transplant (acute GVHD), gooseflesh Formation of temporary raised bumps or it may not appear until months later (chronic of skin caused by the reaction of blood vessels to GVHD). cold or to fear. In the presence of the stimulus, blood vessels Symptoms and Diagnostic Path contract, which also contracts the small muscle In addition to the skin rash, there may be diarrhea, attached to the base of each hair follicle, causing abdominal pain, jaundice, infl ammation of eyes the hairs to stand up. This makes the skin look and mouth, and breathlessness. like the skin of a plucked goose—hence, the name “goose fl esh” or “goosebumps.” The medical name Treatment Options and Outlook for goosebumps is cutis anserina. Treatment consists of suppressing the immune response without damaging the new bone marrow. Immune suppressants often used to treat cancer are Gougerot-Blum syndrome A condition charac- also carefully used in decreased dosages to suppress terized by pigmented papular lesions that coalesce or prevent graft-versus-host disease. Treatment of into itchy plaques. Also known medically as pig- acute GVHD includes giving high-dose CORTICOSTE- mented purpuric lichenoid dermatosis, it is one of a RIODS and antibodies to T cells. group of skin disorders known as PIGMENTED PURPU- Sometimes treatment of the condition can lead RIC DERMATOSIS that all feature reddish brown spots to severe complications. or patches. The syndrome occurs when infl am- mation of tiny capillaries causes blood to leak into Risk Factors and Preventive Measures tissues, triggering the rust-colored pigment changes Giving immunosuppressant drugs (such as cyclo- and lesions. The exact reason why the capillaries sporine) may head off the reaction. Once the dis- should become leaky is not known for certain, but ease develops, it is treated with corticosteroid drugs experts suspect the syndrome may be a hypersen- and other immunosuppressants. sitivity reaction to viral infection, food additives, or medications. granular cell tumor A type of skin tumor that, Symptoms and Diagnostic Path like neurilemmoma, is derived from Schwann cells. The lesions are most often found on the lower legs They are most common in people between the ages but may also appear on the lower trunk, abdomen, of 40 and 60. The tumors can be found on almost and arms. The disorder is primarily a cosmetic any part of the body, but are most commonly problem, since the lesions do not usually itch and located on the tongue. Though usually appearing do not affect internal organs. alone, multiple outbreaks may occur. Only about 3 percent of all granular cell tumors are malignant. Treatment Options and Outlook There is no specifi c treatment. Systemic corticoste- Treatment roids may be effective, but their risk generally out- Surgical excision is the typical treatment. granuloma faciale 163 granulation tissue Red, moist granular tissue on bumps found most often on children’s knuckles or the surface of an open wound or ulcer during heal- fi ngers, the upper part of the feet, the elbows, or ing. It gets its name from the appearance of the ears. The raised area spreads to form a ring up to 3 skin surface, which has numerous granules. It is to 5 cm wide, with raised edges and a fl at center, made up of healing tissue consisting of numerous before slowly disappearing. blood vessels, white cells, and FIBROBLASTS. Although GRANULOMA annulare is usually local- ized, it may become widespread (generalized granu- loma annulare). This type is occasionally associated granuloma A grouping of cells associated with with diabetes. chronic infl ammation that can occur in any part Cause of this disorder is unknown. It may be of the body. They are usually a reaction to certain caused by underlying diabetes. infectious agents, although they may occur with no known cause. Treatment Options and Outlook They are typical of certain infections such as In most cases, the skin eventually heals completely tuberculosis and LEPROSY, of disorders such as SAR- over a period of months or years. In cases where COIDOSIS or Crohn’s disease, and in reactions to for- the appearance or ITCHING is bothersome, topical eign substances such as silicone, berylium, starch, corticosteroids are occasionally helpful. Most cases talc, and some tattoo pigments. (75 percent) are healed within two years. See also GRANULOMA ANNULARE; GRANULOMA, See also GRANULOMA, LETHAL MIDLINE; GRANU- LETHAL MIDLINE. LOMA FACIALE; GRANULOMATOUS DISEASES. granuloma, lethal midline A rare disorder char- granuloma faciale A fairly rare benign skin disor- acterized by an infl ammation of the skin of the der characterized by a single persistent red-brown nose and facial structures, which are progres- MACULE, plaque, or NODULE (usually on the face) sively destroyed. The condition primarily affects with a smooth, intact surface. It usually appears in middle-aged women. It may be subclassifi ed into middle-aged white men. midline malignant reticulosis, idiopathic midline granuloma, and Wegener’s granulomatosis. Recent Symptoms and Diagnostic Path research suggests that this disease is a manifesta- These lesions are usually a variety of colors and tion of lymphoma. sizes, with a raised, soft appearance and a defi - nite border. They are typically found on the face, Symptoms and Diagnostic Path although similar lesions have been found on other Ulcers and swelling within the nose spreads to tis- parts of the body such as the scalp, trunk, and arms sue destruction in the facial sinuses, gums, and eye and legs. orbits, leading to extensive destruction of the face, Diagnosis is confi rmed by a skin biopsy, which sinuses, hard palate, and larynx. Death may result is typically necessary to rule out other skin diseases from infection or hemorrhage. that have similar fi ndings.

Treatment Options and Outlook Treatment Options and Outlook Radiation therapy usually stops the progression of Granuloma faciale is a chronic condition that comes the disease and may improve symptoms. Wegener’s and goes, but spontaneous healing rarely occurs. granulomatosis responds to CORTICOSTEROIDS and The disease appears not to have any relationship cyclophosphamide. to internal disease, and treatment is mainly to improve the appearance. Various medical and sur- gical therapies have been used, but none have been granuloma annulare A harmless skin condition consistently successful. Granuloma faciale also has characterized by a raised circular area of pink the tendency to recur after treatment. 164 granulomatous disease

Treatment includes topical steroids, CORTICOS- swimming pool water. This reversible pigment TERIOD injections, antimalarial tablets, topical pso- change occurs only in swimmers with natural or ralen UV-A (PUVA), or radiation therapy. Surgery tinted blond, gray, or white hair. may be advised, but SCARs are possible. Other treat- Green hair is actually not caused by chlorine ments include DERMABRASION, ELECTROSURGERY, but, rather, by copper ions, although the chlorine CRYOTHERAPY, or 5 PULSED-DYE LASER. may act as a bleach. While this condition poses See also GRANULOMA; GRANULOMA, LETHAL MIDLINE; no serious medical concern, it can be emotionally GRANULOMA ANNULARE; GRANULOMATOUS DISEASE. upsetting for swimmers because the green tinge is so noticeable. Without proper treatment, the green color will granulomatous disease A chronic disorder asso- last as long as the hair is exposed to the pool ciated with an impaired immune system that is water. usually an X-linked hereditary condition. This The hair tinge can be removed by applying a means the disease is caused by a defect on the X 2 percent to 3 percent HYDROGEN PEROXIDE solu- chromosome that usually leads to problems in boys tion and leaving it in the hair for 30 minutes. Also only. Mothers and sisters of most male patients effective is the use of commercial chelating agents may be carriers, and half of their sons may be applied after swimming, which will solve the prob- affected. Carriers of this disorder are not more sus- lem without bleaching the hair. ceptible to serious bacterial infections, but do have characteristic skin lesions that slowly become red and painful. Grenz zone A border of connective tissue sepa- While infection gradually becomes less of a rating the EPIDERMIS from the mid-DERMIS. problem in adulthood, the possibility of severe, life-threatening bacterial infections always exists for these patients. Grenz ray therapy An outdated treatment for infl ammatory skin disease once used for ECZEMA, Symptoms and Diagnostic Path PSORIASIS, LICHEN PLANUS, TINEA CAPITIS, and ACNE. Patients with this disease have recurrent bacterial While superfi cial MYCOSIS FUNGOIDES, SEZARY SYN- infections of the skin, with lesions of the scalp, DROME, KAPOSI’S SARCOMA, and superfi cial BASAL mouth, nose, and ears. Minor cuts and bruises CELL CARCINOMA also respond to Grenz rays, often lead to furunculosis and ABSCESSES. soft X-rays are preferred because of their better penetration. Treatment Options and Outlook All infections in these patients should be treated by broad-spectrum antibiotics after culturing lesions Grisactin See GRISEOFULVIN. at the fi rst sign of infection. Long-term treatment may be needed, since these infections often do not respond well to antibiotics, and recurrences are griseofulvin (Trade names: Griseofulvin, Fulvicin, frequent. Human recombinant gamma interferon Grisactin) One of the oldest antifungal drugs has helped some patients and is being studied as a available in America, this antibiotic penicillin possible prevention of infection. derivative is given orally to treat ringworm (TINEA) See also GRANULOMA; GRANULOMA, LETHAL MID- infections that have not responded to creams or LINE; GRANULOMA ANNULARE; GRANULOMA FACIALE. lotions. It is particularly effective against superfi - cial DERMATOPHYTE infections of the scalp, beard, palms, soles, and nails, as well as ringworm of green hair A common problem unique to swim- the scalp (TINEA CAPITIS), ringworm of the body mers is the greenish tinge that their hair may (TINEA CORPORIS) and ATHLETE’S FOOT. Even with develop from long-term exposure to chlorinated prolonged treatment, many nail infections do not Grover’s disease 165 respond completely, or they recur. Griseofulvin has Treatment Options and Outlook been replaced by newer antifungals that are safer Antibiotic treatment should begin immediately, and more effective: terbinafi ne, itraconazole, and since blood poisoning is likely. Prognosis is poor if fl uconazole. Resistance may develop to this drug. It the case is advanced and there are many lesions on is not effective against bacteria, deep fungi, Candida the body. albicans, and TINEA VERSICOLOR. It is less effective against fungal infections of the nail. When griseofulvin is taken with a high-fat meal, Grover’s disease The common name for tran- it is better absorbed and tolerated by the patient. sient acantholytic dermatosis, a KERATINIZATION Griseofulvin should not be taken by patients disorder that is fairly common (especially in men suffering with acute intermittent PORPHYRIA, since over age 40). Despite its medical name, the lesions it may cause an acute abdominal attack. The drug of this disease frequently persist. It is believed may also interact with birth control pills, producing that sunlight and blocked sweat ducts may play breakthrough bleeding or allowing pregnancy. a role in the development of this problem. Most cases last six to 12 months, although it may last Side Effects longer. The most common side effects are headache and gastrointestinal problems; others include loss of Symptoms and Diagnostic Path taste, dry mouth, and increased sun sensitivity. Reddened crusted papules or vesicles appear on the Long-term treatment may cause liver or bone mar- back and extremities. ITCHING may or may not be row damage. a problem.

Treatment Options and Outlook group B streptococci infections The most com- There is no defi nitive treatment. Topical CORTICO- mon bacterial infection in newborns that may STEROIDS and retinoids (such as Retin A) clear up cause skin abscesses. A small number of infants the condition temporarily, but the rash returns as with Listeria poisoning have skin lesions (including soon as the drug is stopped. PAPULES, PUSTULES, and VESICLES). H

Hailey-Hailey disease The common name for Risk Factors and Preventive Measures familial benign chronic PEMPHIGUS, a rare genetic Patients with a family history are urged to avoid blistering disease. It is characterized by the appear- heat, moisture, and friction, and to be careful to ance of crusts with redness and blisters—on the avoid bacterial or yeast infection when possible. neck, under the arms, in the groin, and sometimes on the scalp—that may itch or cause pain. Lesions tend to get bigger, although they may spontane- hair, anatomy of Hair is composed of KERATIN, ously fade away without scarring; recurrences are the protein that makes up NAILS and the outer common. The disease usually appears between skin layer (EPIDERMIS). Each hair shaft sits in a hair ages 15 and 35. FOLLICLE, and each has a spongy semi-hollow core The disease is autosomal dominant, which means (the medulla) surrounded by long, thin fi bers (the that only one defective gene (from one parent) is cortex) with several overlapping cell layers on the needed to cause the syndrome. Each child of an outside (the cuticle). affected person usually has a one in two chance of There are about 100,000 hairs on a typical per- inheriting the defective gene and of being affected. son’s head, growing about 1⁄72 of an inch each day. However, a positive family history can only be At this rate, it takes about 75 days for scalp hair to traced in 70 percent of patients. The development grow an inch. of lesions can be triggered by bacterial or yeast infections and may be exacerbated by exposure to Growth Stages sunlight. A hot, moist environment and sweating Hair goes through distinct stages, growing for two to can contribute to the problem. six years and then resting for three months. At any one time, about 85 percent of a person’s hair is active, Symptoms and Diagnostic Path 1 percent is entering the resting phase, and about 14 While the disease is benign, it can be annoying and percent is resting. In its growing phase, there is live tends to last for a long time, with alternating peri- tissue called the hair bulb at the tip of each hair that ods of remission and active lesions. Some patients supplies keratin and melanin; this is the pale-colored show improvement with age. swelling that may be seen if a hair is pulled out of the follicle. The hair is formed by the upward growth of Treatment Options and Outlook KERATINOCYTES, which become keratin-fi lled. Treatment is aimed at controlling infection, reliev- Hair that is in the resting phase separates from ing symptoms, and avoiding heat, moisture, and the bulb, and is shed. The rate of shedding of a nor- friction. Cold water compresses and antibacterial mal adult scalp is about 100 hairs daily (usually after creams or ointments may be applied to the skin. brushing or shampooing). The hair loss is continu- Steroid creams may ease infl ammation and discom- ous, but is always in the process of being replaced. fort; systemic steroids are not effective. Systemic antibiotic treatment (TETRACYCLINE or ERYTHROMY- Types of Hair CIN) may help. Surgical removal of chronic lesions The fi rst kind of hair, developed in the uterus at followed by SKIN GRAFTS may be required. the fourth month of gestation, is called LANUGO, a

166 hair, care of 167

Hair Anatomy Other Types of Hair Eyebrows and eyelashes have a different growth Cuticle period from scalp hair. Both eyebrows and eye- Medula lashes grow for about 10 weeks and then rest for Hair Shaft nine months. This is why it takes so long to grow the eyebrows back after shaving them. Plucking the eyebrows, however, stimulates the follicles and makes them grow back faster. (This is the exception to the rule that cutting hair does not make it grow in faster). See also HAIR, CARE OF; HAIR DYE; HAIR, DISOR- DERS OF. Hair Erector Muscle hair, care of There are a host of old wives’ tales when it comes to hair. For example, it is not true that shampooing too often will harm the HAIR Follicle FOLLICLEs, that massaging the scalp will prevent hair loss, or that shaving will make hair grow back faster or thicker. Bulb There are two types of hair—terminal hair, Root which grows on the scalp, eyelashes, eyebrows and areas of sexual development; and vellus hair, the fi ne hair that covers the body until puberty. The same follicles can produce different types of hair at downy fuzz that is shed during the last month of different times in a person’s life. pregnancy. After birth and until adolescence, fi ne, In general, it takes two and a half months for short, and colorless hair (vellus hair) covers most scalp hair to grow an inch; it tends to grow for up of the child’s body. “Terminal hair” is thicker, lon- to six years, and then rest for three months. When ger and often pigmented, and grows on the scalp, a new hair begins to grow below the old hair, it eyebrows and eyelashes. At puberty, it also begins loosens and sheds. At any time, about 85 percent to grow in the secondary sexual areas such as the of scalp hair is growing, 1 percent is beginning to pubic area and the armpits, in addition to the face, rest, and 14 percent is resting. It is this hair in the chest, legs, and so on. resting phase that ends up in a brush or in the bathtub drain. Appearance As hair grows out, it is subject to weathering and The color of a person’s hair is determined by the injury to the overlapping cuticle scales that protect amount and type of pigment (MELANIN) in the hair the inner cortical fi ber of the hair. Once the hair shaft. Melanin is produced by special cells (melano- is injured, it cannot be repaired because the shaft cytes) in the base of the hair follicle. Red melanin consists of dead cells. Cuticle scales near the scalp causes red and auburn hair, and black melanin are smooth because they have not been injured; causes all other colors. White hair occurs when the those near the ends of the hair have been repeat- cells receive no pigment. edly damaged and may be worn away, exposing the Whether the hair is curly or straight depends on inner cortical fi bers, and resulting in split ends. the shape of the hair’s follicle. Straight hair grows Exposure to the sun or to chlorine from swim- from a straight follicle, whereas curly hair grows ming pools can cause changes to the KERATIN, from a very curved follicle; wavy hair grows from making the hair’s texture change. While hair can a curved follicle. tolerate changes such as permanents or dyeing if 168 hair, care of they are done carefully and not too often, these Conditioners processes can cause alkaline oxidation damage. Cream rinses are made up of quaternary cationic polymers, which form a layer on the hair shaft and Trauma lubricate it. This reduces the damage caused by In addition, combing and brushing may cause a great combing or brushing. Because anionic detergent deal of injury to the cuticle scales. Hair and scalp shampoos remove oil, the hair develops a static should be washed as often as necessary with sham- electric charge; conditioners help to dispel the poos to remove oily buildup, dead cells, microorgan- charge. Rinses also allow the strands to be aligned isms, cosmetics, and dirt. Because shampoos remove and refl ect light. African Americans in particular oil very well, those with oily scalps do not really may benefi t from using cream rinses because very need to choose a specially formulated shampoo. curly hair does not align well and does not refl ect Most North Americans shampoo more often than is light uniformly, which causes the hair to appear really necessary, but even daily shampooing is not dull. Some cream rinses also have oils to increase really harmful nor is there evidence that frequent lubrication. While damaged or treated hair can be washing increases the production of SEBUM. improved by using conditioners, fi ne hair can be overconditioned and appear dull and greasy. Dandruff Shampoos While there is no cure for DANDRUFF, frequent Silicone shampooing is the most effective treatment and One of the newest ingredients in hair care products helps to alleviate symptoms in mild cases. SHAM- is silicone (liquid plastic), which smooths the hair POOs that are effective against dandruff contain shaft and increases shine and manageability. Sili- selenium sulfi de, ZINC pyrithione, tar sulfur, or sali- cone works especially well for coarse or curly hair. cylic acid. It may help to rotate different antidan- However, regular use of silicone gels, shampoos, druff shampoos to get the best results. When using and serums can leave hair feeling sticky, dull, and such a product, the shampoo should be applied hard to style. immediately and then left on the scalp for fi ve min- Silicone works like clear NAIL POLISH, coating the utes to allow the ingredients time to work. Using a hair so it refl ects light and appears shiny. Since sili- CONDITIONER afterward would not help avoid dan- cone does not dissolve in water, it helps prevent the druff, but many improve manageability. hair from getting frizzy on damp days. However, because it does not easily rinse off, silicone tends to Acid-Balanced Shampoo build up on the hair and when used too much, it Researchers say that using a shampoo with an acid causes the hair to look dirty and feel rubbery. pH on normal hair or scalp does not provide any Fortunately, silicone will not permanently dam- additional benefi ts. However, hair damaged by age the hair, and it is not absorbed into the scalp. sunlight or dyes, bleaches, or straighteners may Experts recommend that consumers use a buildup feel slimy when regular shampoo for damaged hair remover shampoo weekly if silicone products are is used. An acid pH shampoo may make the hair used. Some salons also offer special treatments to feel more normal. remove silicone buildup from the hair.

Baby Shampoo Setting/Permanent Wave Solutions These types of shampoos contain amphoteric deter- These chemicals work by breaking the chemical gents that irritate the eyes less, which make them bonds that result in the hair’s normal consistency, useful for young children. giving it more curl or straightness (depending on their purpose), and then forming new bonds to Conditioning Shampoos keep the hair in place. Neither setting nor per- While some products contain conditioners and manent wave solutions badly weaken normal shampoos, it is usually more effective to use a sepa- hair, but if they are too strong or left on too long rate conditioner after shampooing. they can cause minor problems such as split ends hair, gray 169 or dullness, or can lead to profound structural with advancing age, this lack of melanin granules damage and hair loss. If too strong or if used too means the body is losing its ability to synthesize long, they cause breakage. Only rarely, however, the pigments from enzymes and proteins. True do the chemicals actually damage the hair follicle gray hairs are quite rare, and are caused by a itself. Therefore, chemically damaged hair will be decrease—not a total lack—of the pigment content replaced by normal hair eventually. in the hair shaft. In most people, what appears to be “gray” hair is actually a combination of pig- Bleaching mented and nonpigmented hair. Some hereditary Bleaching products can damage the hair’s protein if diseases also predispose a person to premature they are used for too long or too often, leaving the grayness. hair dull and almost colorless, and more susceptible Most people begin to develop a few gray hairs at to injury. about age 30, becoming progressively grayer over See also HAIR, ANATOMY OF; HAIR, DISORDERS OF; the next 20 years as more and more of their hair HAIR DYE. lacks pigment. By age 60 or 70, the hair often turns completely white, which means that all of the hairs on the head have lost their pigment granules. hair, disorders of While many disorders of the hair may seem to be simply a cosmetic problem, Premature Gray Hair in fact some may be evidence of an underlying Hair that turns gray prematurely (in the early 20s) disease. While brittle, unhealthy-looking hair may may often be the result of genetic factors, since be caused by excessive blow drying, combing, or the tendency seems to run in families. Severe shampooing, it may also be a sign of a vitamin or stress, mental illness, serious physical ailments, and mineral defi ciency, or hypothyroidism. Very dry traumatic experiences have been associated with hair is probably caused by too much perming, tint- premature gray hair and the acceleration of gray- ing, bleaching, or use of hot rollers—but it could ing, although scientists do not know why. A few also be a sign of malnutrition. cases of premature graying are due to a defi ciency Ingrown hairs are another hair condition that of vitamin B12 (a disease known as pernicious can cause problems, especially in people with very anemia); this can be reversed by replacing the vita- curly hair. In this condition, the free-growing end min. Vitamin B is probably most effective for those of the hair penetrates the skin near the follicle and whose grayness began after a severe strain, such as can cause severe infl ammation. a long debilitating illness or severe stress. Hair that begins to turn gray because of genetics and age is not reversible. hair, gray In most people, what appears to be Throughout history, a number of famous indi- “gray” hair is actually a combination of pigmented viduals who experienced great stress were said to and nonpigmented hair. Most people with some have turned gray overnight. Sir Thomas More and gray hair are not usually entirely gray, but have a Queen Marie-Antoinette both were said to have mixture of white hairs among those of the normal suddenly gone gray when they got the news that shades of brown, blond, red, or black. they were to be executed. As a person ages, the body’s production of MELA- Although hair strands do not actually change NIN decreases. New hair contains less pigment and color within hours, a person’s hair can seem to the shaft eventually grows in without any pigment turn gray in a matter of days. The phenomenon at all. The only color left in the hair is the color of is caused by ALOPECIA AREATA, thought to be the KERATIN itself: yellowish gray. Eventually, more an autoimmune disorder in which the body’s and more hair continues to grow in the same way immune system attacks the hair follicles. While until the entire head is fi lled with gray hair. scientists do not know why the antibodies begin White hair is due to a lack of melanin granules the attack, severe psychological stress may play a in the cortex of the hair shaft; usually occurring role. Alopecia areata can cause varying degrees 170 hair dye of hair loss, from small bald patches to the loss of molecule so big it gets trapped. The drawback to every bit of hair. permanent dyes is that as the hair continues to When the hair goes gray quickly, it is believed grow, the natural color will begin to show up again that the antibodies are selective and concentrate in about 10 days. on just the pigment-producing cells in the follicles, causing only pigmented strands to fall out. If this Semipermanent Dyes occurs in someone whose hair is in the process of Semipermanent dyes penetrate into the hair shaft, going white, the sudden loss of darker hair will but not as deeply as permanent dyes. Although make the person look as if he or she suddenly semipermanent dyes do not rinse off with water, “went gray.” Because alopecia can disappear, rapid they do fade and wash out of hair after about fi ve graying is not always permanent. to 10 shampoos.

Treatment Options and Outlook Vegetable Dyes Once hair has started to gray, there is nothing that Vegetable dyes deposit a coating of dye on the can be done to reverse the process. However, there cuticle of the hair shaft; HENNA is an example of are some hair dyes that are specifi cally used to a vegetable dye. These dyes only keep their color color gray hair. with repeated applications. Some gray hair appears to have a yellowing tinge, apparently as a result of age-related changes Synthetic (Aniline) Dyes in melanin production. This discoloration can be Synthetic dyes (including paraphenylenediamine) worsened by tobacco smoke, carbolic acid found are popular because they are easy to apply and in dry powder shampoos, setting lotions, and espe- their color is stable. Because they react chemically cially dandruff shampoos containing RESORCINOL. with hair, however, they can also react with skin The easiest way to get rid of this tinge (from either protein and trigger an allergic reaction. About 10 external or internal factors) is to treat the hair with percent of people who use these dyes will develop a bluing rinse; setting lotions or hair sprays, which an allergy to them, and break out in red splotches. have a tendency to turn gray hair yellow, should This is why a sensitivity test must be performed not be used. on every person each time an aniline product is See also HAIR, CARE OF. used. While the hair can protect the scalp skin from damage, unprotected skin that touches the dye may react. In allergic individuals, these dyes hair dye Products used to alter the color of the used in areas around the eyes, on the eyebrows hair is divided in two basic categories—permanent or the eyelashes can cause blindness as a result of and semipermanent. Permanent dye can lift out the severe allergic reaction. This is why hair dye the natural pigment and replace it with a different should never be used on eyelashes or eyebrows, color. Each strand of hair is protected by an outer and why the U.S. Food and Drug Administration cuticle constructed of transparent overlapping prohibits aniline dyes or derivatives in eyelash and scales much like shingles on a roof, and an inner eyebrow dyes. cortex where the hair’s natural pigment resides. Metallic Dyes Permanent Dyes Metallic dyes (now only rarely used) can cause poi- Permanent dyes contain ammonia, which opens soning when the metal (silver, copper, iron, or lead) the scales of the cuticle to allow the dye to pen- reacts with the sulfur in the hair. Also called color etrate the hair shaft, and peroxide, which removes restorers, they are a progressive type of dye that is natural pigment from the cortex so the new color combed through the hair and after several days, can be layered on like paint on a canvas. The gradually covers gray hair. Hair dyes with metallic color does not just wash away because once it is products will not react well to waving, straighten- deposited in the cortex, the dye produces a color ing, or to any other type of hair coloring. hair loss 171

Cross Section of Skin Showing Hair Folicle common belief, hereditary hair loss is not caused by a sudden stop in hair growth. Instead, it is the result of the gradual miniaturization of certain HAIR Hair Shaft FOLLICLEs; as this progresses, hairs become shorter and thinner, eventually ceasing to grow. Sebaceous Epidermis Every human follows a genetically programmed Gland schedule for growing, resting, and shedding hair. At any one time, as much as 85 percent of the Dermis scalp hair is growing up to an inch a month, and it Sweat may continue to grow for two to six years without Gland stopping. When the growth phase ends, each hair begins a two-to-six month resting phase, and then Subcutaneous begins a shedding phase. Only 10 to 15 percent Layer of hair is in the resting phase at any one time; Hair Bulb shedding occurs randomly. Eventually, a new hair Hair Root begins to sprout from the root deep within the hair follicle, replacing the older hair above it as a new growth period begins. Hair Dye and Cancer It is normal to shed between 50 to 100 hairs There is no strong evidence of a clear cancer risk daily—a loss that is not noticed, since most people for people who dye their hair. Most of the previous have about 100,000 hairs on their head. Excessive studies that raised concerns about hair dye were shedding (more than 200 hairs) usually becomes relatively small, and looked at the former habits of noticeable within months, and can be caused in people who had already gotten cancer. In general, men and women by medical disorders (includ- result show that women who dye their hair—even ing malnutrition), medications, or (most often) those who have used hair color for more than 20 heredity. years—are at no greater risk than those who never In most cases, hair loss is related to “andro- colored their hair. genetic alopecia,” or hereditary hair loss. Nor- See also HAIR, ANATOMY OF; HAIR, CARE OF; HAIR, mal genes and androgens (especially testosterone) DISORDERS OF. cause progressive shrinking of certain scalp follicles over time. The shrinking follicle produces a smaller, fi ner hair with each growth cycle. In addition to a hair follicle A sheath of epidermal cells and con- smaller follicle, androgenetic alopecia is character- nective tissue that surrounds the root of a hair. ized by a shortened growth phase, which results in shorter hair. The balding process is a gradual conversion of hairiness See HIRSUTISM. active, large follicles to less active, smaller follicles, resulting in short, thin hairs that are barely vis- ible and eventually disappear completely. In men, hair loss The gradual loss of hair, either as a hereditary baldness (also called “MALE PATTERN result of a disease such as ALOPECIA AREATA or by BALDNESS”) is characterized by a receding hairline hereditary and aging pattern baldness, occurs in above the forehead and loss of hair at the crown. If about 30 million men and 20 million women every male pattern baldness progresses to its fi nal stage, year. About 40 percent of all men will show some the person is left with hair only around the sides degree of hair loss by age 35; 25 percent of all and back of the head. This is also known as pattern women experience some hair loss by age 40, but thinning in women. Hereditary hair loss is a gen- about 60 percent of all women experience hair loss eral or diffuse thinning of the hair over the top of by the time they reach menopause. Contrary to the head—women rarely lose all their hair. 172 hair loss

The second most common cause of hair loss is Concealing hair loss Concealing hair loss is eas- alopecia areata, which causes hair to fall out in ier for women. Women can work with their hair- clumps. This disorder often starts at a young age dressers to make their hair appear fuller through and may progress to the point where the person properly applied mousses, shampoos, perms, and loses all scalp hair (alopecia totalis) or all body dyes. Shorter hair styles hold a curl more easily hair, including eyelashes and eyebrows (alopecia and can help hide thin hair. Both men and women universalis). In some cases, alopecia areata follows fi nd that powdered eye shadow applied to the scalp a stressful event, such as divorce or death of a sig- provides a darkened background that can disguise nifi cant other. In most people, the hair will grow thinning hair; wigs and hairpieces may completely back, but the exact cause of the hair loss is not cover the problem. known. Most experts believe it may be caused by Hairpieces HAIR WEAVING and bonding are the an immunological disorder in which antibodies are most common methods of affi xing a hairpiece to produced that attack the hair follicles. the head. Hair weaving ties the hairpiece with a Hair loss may be caused by medical disorders, tough nonshrinkable thread to clumps of exist- such as a hyperactive or underactive thyroid gland, ing natural hair that has been woven together to certain tumors, diabetes, severe infections, second- form anchoring places for the piece. Bonding uses ary syphilis, anemia, and systemic LUPUS ERYTHEMA- a medical glue to anchor the piece to the natural TOSUS. It may be caused by medications for gout, hair. Both techniques must be performed by a arthritis, high blood pressure, or depression, as trained hairdresser and require regular visits to well as high doses of VITAMIN A and chemotherapy have the piece washed and dyed. Periodic tighten- drugs. Oral contraceptives may cause hair to fall ing is required. out because of the increase of hormones. Hair loss Implants are another way to attach hairpieces, due to medication is reversible once the medication but they must be performed by a physician. By this is stopped. method, the physician implants sutures or surgical Hair that is constantly damaged by excess bleach- threads into the scalp to which the hairpiece can ing, dyeing, or permanent waving may begin to be attached. break and fall out; over-teasing hair or excessive Surgical treatments Hair transplants, scalp straightening with hot irons can also cause hair reduction, and transposition fl aps are also avail- loss. Metal combs can damage hair and scalp as able. In a transplant, surgeons move skin from well. areas of the scalp that grow hair, such as the back Traction alopecia is caused by ponytails, braids, and sides, to areas of the scalp that are no longer or cornrows that are pulled too tight, pulling the growing hair. After a period of about three months, hair out by its roots. Friction alopecia is caused by the transplanted hair begins to grow. Hair trans- constantly wearing snug-fi tting wigs or hats. plant techniques have been refi ned in the past Finally, poor diet low in protein or iron may decade. Smaller grafts are now used for a more cause abnormal hair loss. natural look. Scalp reductions treat hair loss as too much scalp Treatment Options and Outlook rather than too little hair. In this procedure, sur- Ever since ancient Egyptians anointed their bald geons cut out areas of the scalp that no longer grow spots with fats from ibex, lion, crocodile, serpent, hair. The scalp is then pulled back together and goose, and hippopotamus to encourage hair growth, help in place with sutures or surgical staples until humans have been trying to treat hair loss. In 420 it heals. Scalp reduction may also be successfully B.C., Hippocrates tried to fend off his hair loss by combined with hair replacement. whipping up typical potions of opium, horseradish, Transposition fl aps are a variation of hair replace- pigeon droppings, beetroot, and spices. ment, which involves transplanting an entire strip Today there are several options for coping with of hair-bearing skin instead of individual grafts. hair loss, ranging from sophisticated styling and Used to cover a large area of hair loss, the fl aps hair transplantation to medical treatment. are a good choice for men. However, because they hair transplants 173 involve complicated multiple surgery and are and facial beard area in men. However, hair expensive, the procedure is not often performed. quickly grows back from shaved areas and shaving Medical treatment MINOXIDIL (trade name: can cause irritation. Rogaine topical solution) is a medically proven Depilatory creams dissolve the hair just below the product that will regrow hair in men and women. skin’s surface, creating a smooth effect, but the Clinical tests conducted by dermatologists at cream may irritate sensitive skin areas and should 27 U.S. medical centers involving more than be used only on the legs. 2,300 men with male pattern baldness resulted Waxing is a technique used often in beauty salons in regrowth in about half (48 percent) of male as a way to remove hair from the legs or face. In patients. An additional 36 percent had minimal this technique, warm wax is applied to the skin and regrowth; the rest (16 percent) had no regrowth. then peeled off, pulling out the hair as it goes. In other studies, almost two out of every three Plucking with tweezers is a good technique for women were evaluated by physicians to have stray eyebrow hairs and other small areas. After regrown some hair; 13 percent had moderate all of these techniques, hair will regrow in about regrowth and 50 percent had minimal regrowth. three weeks. The rest (37 percent) had no regrowth. Among Sugaring is a type of hair removal system that subjects who did not use minoxidil, 39 percent uses honey and special strips to eliminate hair. also saw some regrowth. A thin coating of the honey hair-removal gel is applied in the direction of the hair growth; a cloth Future Research strip is then placed on the gel and stroked fi rmly Scientists are studying the anti-androgens (drugs two or three times in the direction of hair growth. that would counteract the effect of the male hor- Holding the skin taut with one hand, the consumer mone testosterone) that are responsible for signal- picks up the lower end of the cloth with the other ing hair to fall out. Growth factors are also being hand and pulls quickly in opposite direction of the studied to see if they can encourage growth in the hair growth. Proponents of this method say that tissue of the hair follicle. hair does not return for four to six weeks. ELECTROLYSIS permanently removes hair through the use of an electric current to destroy the hair’s hairpieces Also called toupees, these products root. provide fodder for jokes, but a high-quality, well- fi tted piece can be successfully worn by some men. The key to a natural-looking toupee is to buy a hair transplants A surgical operation in which good quality, custom-made hairpiece that is care- a person’s skin is moved from areas of the scalp fully matched to individual hair color and texture. genetically programmed to grow hair (such as the Lifestyle and hobbies should also be considered back and sides) to areas of the scalp that are no when making this purchase. longer growing hair. After a period of about three A hairpiece consultant can recommend ways months, the transplanted hair begins to grow. the hair can be attached to the head. Hairpieces Transplants are less often performed in women should be handled carefully and washed or cleaned because women tend to experience diffuse hair periodically. thinning all over the scalp, which complicates the identifi cation of hair that is not genetically coded to fall out. In the past few years, techniques have hair removal Hair is usually removed from a part been improved so that even women with thinning of the body for cosmetic reasons, although it may hair can benefi t from this technology. also be removed from a planned surgical site prior Transplantation is best done before an area is to an operation. completely bald. This way, the appearance of “new” Shaving removes hair at the skin level and is hair is more subtle and the procedure less obvious. suitable for hair on the legs, armpits, pubic area, Further transplants may be needed periodically as 174 hair weaving natural hair continues to fall out, but the hair that is Halotex See HALOPROGIN. transplanted will remain. Results of this procedure may be enhanced by reducing the size of the scalp area or stretching scalp skin with temporary infl at- hand, foot, and mouth disease A common infec- able bags, and then reducing the scalp area. Physi- tious disease of toddlers that produces blistering of cians charge either by the plug or for the entire palms, soles and the inside of the mouth, caused by procedure. the coxsackievirus. Toddlers sometimes exhibit no Transposition fl aps, a variation of hair replace- symptoms, but infants may develop fl ulike symp- ment, involves transplanting an entire strip of toms that last several days. The condition often hair-bearing skin instead of individual grafts. Used sweeps through day care centers in the summer. to cover a large area of hair loss, the fl aps are a The mild illness usually lasts only a few days; there good choice for men who have large bald areas. is no treatment other than painkillers to relieve blis- But because this technique involves complicated ter discomfort. There is no connection to hoof-and- multiple surgery, the fl aps are expensive and the mouth disease, which affects cattle and sheep. procedure is not often performed.

hand cream A cream designed to soften and hair weaving A procedure in which a hairpiece is moisturize the skin of the hands that may contain tied with a tough nonshrinkable thread to clumps alcohol, stearic acid, LANOLIN, and gum substances. of existing natural hair woven and braided together Hand creams are usually not as greaseless as those to form an anchoring for the piece. This technique designed to be used under makeup. must be performed by a trained hairdresser, and requires regular visits to have the piece washed and dyed. hand dermatitis See DERMATITIS, HAND. Results vary depending on hair style and texture; since the natural hair will continue to grow, regular sessions to tighten the braids will be needed. While hangnails Small torn pieces of skin on the sides the technique may be performed on both men and or base of a nail that expose a raw, painful area. women, it is more commonly done for men. A Hangnails may result after immersion in water, or weave generally lasts two to three years. from nailbiting. The raw area may go on to become Implants are another way to attach hairpieces, infected and develop into a PARONYCHIA. but these must be performed by a physician. Implants are benefi cial for those with little natural Treatment Options and Outlook hair to anchor the wave. With this method, the Trim a hangnail with scissors and keep it covered physician implants sutures or surgical threads into with a bandage until it heals. Hangnails can be pre- the scalp to which the hairpiece can be attached. vented by using a moisturizing cream.

haloderma Any skin eruption caused by the Hansen’s disease See LEPROSY. ingestion of halide.

harlequin color change A phenomenon caused haloprogin (Trade name: Halotex) A topical by vascular autonomic imbalance most often seen treatment for fungal infections available as a 1 per- in premature newborns during the fi rst week of cent cream or solution that is usually applied two life. When the infant is lying on its side, the bottom or three times a day. It is effective against DERMATO- half of the body becomes red, in sharp contrast to PHYTES and, to a lesser degree, against Candida and the top half of the body, which is quite pale. The Malassezia furfur (the cause of TINEA VERSICOLOR.) condition may last briefl y or up to 20 minutes. heat disorders 175 harlequin fetus A rare genetic form of ICHTHYOSIS the most protection, individuals should wear a hat in which infants are born with very thick, hard with a 7 cm brim (about three inches) that shades skin with deep moist fi ssures that produce a gro- the face, ears, and the back of the neck. Baseball tesque appearance. The fi ssures appear most often caps protect the forehead and nose, but leave the over areas of movement, such as the joints, neck, cheeks, chin, and neck exposed. Individuals should underarms, and groin. Ears may be underdevel- wear clothing that covers those areas, use SUN- oped and fl at, and hair and nails may be absent. SCREEN with at least SPF 15, or stay in the shade to Most are born dead, or die shortly after birth from protect the skin. respiratory failure and the inability to eat. How- For the best protection, hats should be made of a ever, recent treatment of children born with the tightly woven fabric, such as canvas, which works syndrome with etretinate, a derivative of VITAMIN best to protect the skin from UV rays. Individuals A, has showed them to have shed the armorlike should avoid straw hats with holes that let sunlight thick skin and live, albeit with severe remaining through. icthyosis. The condition, which can be diagnosed before birth, may be linked with a defect in lipid metabo- head lice See LICE. lism or abnormal protein metabolism. More than one genetic defect may produce this syndrome. heat disorders The body maintains its optimum internal temperature through the hypothalamus. Hartnup disease A rare hereditary metabolic dis- When the temperature of the blood rises, the hypo- order in which there is an eruption of lesions simi- thalamus sends nerve impulses that stimulate the lar to PELLAGRA. Usually seen in children between SWEAT GLANDS and dilate the blood vessels in the age three and nine, the disease is an autosomal skin. The act of sweating does not cool off the body. recessive trait, which means that a defective gene The cooling effect is caused by the evaporation of must be inherited from both parents to cause the the sweat from the skin. Dilation of the blood ves- abnormality. Generally, both parents of an affected sels increases blood fl ow near the surface of the person are unaffected carriers of the defective gene. skin, increasing the amount of heat that is lost by Each of the children has a one in four chance of convection and radiation. being affected, and a two in four chance of being When the hypothalamus does not function a carrier. properly, the body may progressively overheat, The condition may be triggered by poor diet, leading to a fatal heat stroke if untreated. Any mal- sun exposure, sulfa drugs, or stress. Frequency of function or overload of the body’s mechanisms for attacks lessens with age. keeping temperature on an even keel may result in a heat disorder. Poor adaptation to heat may cause Symptoms and Diagnostic Path heat cramps, heat exhaustion, or heat stroke. High Other physical symptoms include progressive summer temperatures may cause PRICKLY HEAT, and dementia, spasticity, short stature, abnormal hair, an out-of-control infection can set off high fever, and diarrhea. further damaging the body. Excessive sweating can cause an imbalance of salts and fl uids in the body, Treatment Options and Outlook which can lead to heat cramps or heat exhaus- Patients are treated with supplements of tion throughout the day. To prevent heat disorders nicotinamide. caused by excessive sweating, drink liquids (prefer- ably water) throughout the day. hats and the sun A hat can help shield the skin Risks Factors and Preventive Measures from the sun’s UV rays, as long as it is large enough Most environmental heat disorders can be pre- to provide shade for all of the head and neck. For vented by acclimation to hot conditions over a 176 heat rash three-week period, eating a light diet, avoiding a vital function (such as those blocking the eyes, alcohol, and wearing loose, lightweight clothes. ears, mouth, nose, or anus). If the marks appear on the face, there may be psychological reasons to remove these superfi cial lesions. A hemangioma heat rash A rash that occurs at high temperatures that bleeds frequently also may require removal, when sweat ducts are blocked by tight clothes especially if located on the lip or tongue, or on the made of fi bers that do not breathe. Heat rash is vulva or anus, where it could be disturbed by con- most common on the chest and back, where per- stant pressure. Superfi cial hemangiomas may be spiration is greatest, and is typifi ed by widespread removed by PULSED DYE LASERs, which is most suc- slightly raised red VESICLEs or even PUSTULES. It cessful in young patients, or by surgical excision. settles down over a period of hours to days once Deep hemangiomas are best treated surgically. the heat and sweating are eliminated. To protect against this rash, individuals should wear cotton clothing and use oil-free SUNSCREENS instead of hemangiosarcoma See SARCOMA. heavier versions, which may trap perspiration.

hemochromatosis A disease also known as helminthic infections An infestation by any spe- “bronze diabetes” in which too much dietary iron cies of parasitic worms, most of which are not is absorbed, resulting in a bronzed skin color due to found in the United States. Several types of worms pigment deposited under the skin. (or their larvae), ranging from microscopic in size This is an inherited disease primarily affecting to many feet long, can parasitize humans, although men; women rarely are affected because they regu- they do not usually multiply within the gastroin- larly lose iron during their menstrual periods each testinal tract. month. While the disease is known to be genetic, There are two main classes, the roundworms its exact mode of transmission is not known. and the platyhelminths, which include cestodes (tapeworms) and trematodes (fl ukes). Symptoms and Diagnostic Path Worm diseases with skin symptoms include During middle age, the fi rst signs of the disease FILARIASIS and schistosomiasis. are a loss of sexual desire and shrinking testes; left untreated, the iron overload causes chronic liver damage, impaired insulin production lead- hemangioma A benign tumor or BIRTHMARK ing to diabetes mellitus, heart problems, and liver caused by an abnormal number of blood vessels in cancer. the skin. Hemangiomas may be either superfi cial, superfi cial and deep, or deep. Treatment Options and Outlook The disorder is treated by removing some of the Symptoms and Diagnostic Path patient’s blood once or twice weekly; once the iron Superfi cial hemangiomas, known as strawberry level is normal, the procedure is done only three marks or capillary hemangiomas, are bright red or four times yearly. Early treatment can prevent and raised. These marks develop shortly after birth; complications; for those who have already devel- at about the age of six months, the tumor begins to oped the disease, regular blood removal (called subside and the redness slowly fades; by age seven venesection) can head off problems. In some cases, the hemangioma completely disappears. chelation therapy (administration of chemicals that Deep (or cavernous) hemangiomas are blue- bind to iron and remove it from the body) may be purple growths that do not spontaneously clear. used.

Treatment Options and Outlook Superfi cial hemangiomas do not require treatment henna The most popular of the vegetable dyes, for any medical reason, unless they interfere with this powdered substance is made from the crushed Hermansky-Pudlak syndrome 177 leaves of the Lawsonia shrub and is used primarily results in individual cases but has not been con- to give red-orange highlights to the hair. The color fi rmed in a larger series. can be built up to give the hair body and added shine that complements brown hair particularly but does not cover gray very well. Henna can be heparin necrosis Also known as anticoagulation very messy to apply, staining anything it touches syndrome, this condition is characterized by lesions and drying and stiffening the hair (making it a at an injection site, and appears between four and good choice for oily hair). Because henna builds 11 days after treatment with heparin (an anti- up on the hair, it should not be used more than blood-clotting drug). The lesions quickly enlarge three times a year, and once it has been used, into large necrotic areas. There is no successful very little else can be done with the hair until it treatment, but the disease is self-limiting. Amputa- grows out. The color does not allow for permanent tion is recommended for severe cases involving the waving, straightening, or coloring with semi-per- penis or breast; other areas require excision and manent dyes. While henna has not been found to grafting. cause allergic reactions to the scalp, it can damage See also COUMARIN NECROSIS. the hair.

herald patch The initial red, scaly eruption of Henoch-Schonlein purpura (HSP) A relatively PITYRIASIS ROSEA that occurs days before the disease rare condition in which infl amed blood vessels spreads. It resembles a RINGWORM infection that is leak blood into the skin, joints, kidneys, and intes- soon followed by multiple lesions, usually appear- tine. The disease is most common in childhood ing fi rst on the trunk. (especially among boys). In about two-thirds of the cases, HSP occurs after a respiratory infection. Incidence of the disease peaks between November hereditary disorders of the skin See GENETIC DIS- and January. ORDERS OF THE SKIN. It is suspected to be linked to an abnormal aller- gic reaction in response to infection. Hermansky-Pudlak syndrome A form of ALBI- Symptoms and Diagnostic Path NISM featuring white or pale yellow hair, many The disease usually starts with an acute and sym- freckles, deeply pigmented nevi, eye problems, and metrical rash on the skin around the ankle, the legs, heavy bleeding. Sufferers also have problems with the buttocks, and arms. After 12 to 24 hours, the lipid storage, which may cause complications such lesions become dusky red and they may coalesce as pulmonary fi brosis and pulmonary insuffi ciency. into larger patches. In children younger than three The condition is found around the world, although years the symptoms may be dominated by swelling it is most common in Puerto Rico and Brazil. The of the scalp, the hands, and the feet. The joints are severity of the condition ranges from very mild involved in up to 75 percent of the cases. About with few symptoms to severe and disabling. Since half the time there may be colicky abdominal pain HPS is an autosomal recessive disorder, both par- or bloody diarrhea. Kidney problems may occur in ents are expected to be carriers of the abnormal as many as 80 percent of the cases. gene.

Treatment Options and Outlook Symptoms and Diagnostic Path With bed rest and mild painkillers, most children People with the type of albinism found in this syn- recover within a month. In severe cases, CORTICO- drome may have varied amounts of pigmentation. STEROIDS ease the joint pain and may sometimes Some may have white or creamy skin; others may affect the stomach problems, but they would have sun freckling and yellow or light brown hair. A not infl uence the long-term outcome of kidney few with HPS may have dark brown hair and lightly disease. Plasma exchange has given encouraging pigmented skin. The visual problems inherent 178 herpes gestationis in HPS is caused by the lack of pigment during on the sex organs. More than 25 million people in eye development. This results in poor vision and America are affected by the herpes virus. frequently leads to legal blindness, light sensitivity, There are two forms of the herpes simplex virus crossed eyes, and involuntary movement of the that are most common—type 1 and type 2. Herpes eyes (nystagmus). simplex, type 1 (HSV1) is usually associated with Standard blood tests cannot identify the platelet infections of the lips, mouth, and face, while her- defect in HPS. For proper diagnosis, the platelets pes simplex, type 2 (HSV2) is usually associated must be examined under an electron microscope with infections of the genitals, and in babies, who to observe the absence of dense bodies. Special acquire the disease at birth. laboratories are needed for this test. However, there is a certain amount of overlap between the two, and conditions usually caused by Treatment Options and Outlook HSV2 may be caused by HSV1 and vice versa. Both Every person with albinism should understand types are highly infectious, spread by direct contact HPS and inform a doctor of its possibility, especially with the lesions or by the fl uid inside the blisters. before any medical or dental procedures. There is Most people have been infected with HSV1 by the currently no treatment for HPS, although symp- time they reach adulthood. toms may be treated. A person suffering an immunodefi ciency disor- der (such as AIDS) or someone taking immuno- suppressant drugs who is exposed to the virus may herpes gestationis A rare skin disorder occur- experience a severe generalized infection that can ring during pregnancy characterized by herpes-like be fatal. BLISTERs on the legs and abdomen. Unrelated to the herpes simplex virus, it is named for the appear- Symptoms and Diagnostic Path ance of the eruption. Before a blister develops, it is often preceded Unrelated to any disorders caused by the herpes by a “prodrome”—burning, tingling sensation in simplex virus, herpes gestationis is an autoimmune the area where the blister subsequently appears. blistering condition somewhat similar to bullous There also may be swollen and tender lymph PEMPHIGOID. glands. While the fi rst infection by this virus may cause no symptoms at all, there may be a fl ulike Treatment Options and Outlook illness in addition to ulcers on the skin around Systemic CORTICOSTEROIDS are used to treat the and inside the mouth for type 1 (oral) herpes. disease. Experts debate whether herpes gestatio- The fi rst outbreak for type 2 also involves a sore, nis is associated with an increased incidence in appearing three to seven days after exposure, but maternal or fetal death. The condition usually fades with type 2, the infection may be so severe as to after delivery but tends to recur in subsequent cover the penis or vagina with blistering. It may be pregnancies. accompanied by high fever, tender swollen glands in the groin, and may last as long as two to six weeks before healing spontaneously. In women, herpes progenitalis See HERPES SIMPLEX INFECTION. the swelling from infl ammation may be so severe as to impede urination. Exceptional pain, tender- ness, high fever, and extensive blister may require herpes simplex infection A group of infl amma- hospitalization. tory skin diseases characterized by spreading or Afterward, the virus remains in the nerve cells. creeping small clustered BLISTERs caused by the Many people experience recurrent reactivations herpes simplex virus. Different forms of the virus of the virus (both type 1 and 2), suffering with result in either COLD SOREs or the sexually transmit- repeated attacks of sores, especially during a fever ted disease genital herpes characterized by blisters or after prolonged sun exposure. hidrocystoma 179

The virus may infect any other part of the body, those with highly sensitive skin, the use of hexa- but often affects the fi nger, causing painful blisters chlorophene may at times produce a reaction called a herpetic whitlow. In patients with a pre- characterized by redness or mild scaling or dryness, existing skin condition (such as DERMATITIS), the especially when it is combined with excessive rub- virus may cause an extensive rash of blisters called bing or exposure to heat or cold. ECZEMA HERPETICUM. See also ANTISEPTIC CLEANSERS.

Treatment Options and Outlook The antiviral drug ACYCLOVIR taken internally is hidradenitis suppurativa Infl ammation of an effective in shortening the symptoms during the apocrine SWEAT GLAND, characterized by painful fi rst attack. If taken as soon as tingling begins at unpleasant-smelling lesions in the armpits and the start of an outbreak, it can prevent it entirely. groin area. The lesions, which are most common However, it does not prevent future attacks. in those with dark skin, appear in late adolescence and are related to bacterial infection. Risk Factors and Preventive Measures Treatment Options and Outlook Recently, scientists also have developed a therapeu- tic vaccine that reduces the frequency with which This condition is very diffi cult to treat, and scarring genital sores appear in patients infected with her- is a frequent complication. Good hygiene is critical; pes. While it fails to outperform acyclovir, it sets the skin should be washed with a mild antibacterial stage for a more effective treatment in the future. soap and cleansed fastidiously. If obesity is a prob- lem, losing weight is essential. Treatment with systemic antibiotics can help. In more severe cases, the dermatologist may consider herpes zoster See SHINGLES. administration of ISOTRETINOIN (Accutane) steroids, or surgery to remove affected tissue. heterograft Also known as a xenograft, this is a living tissue graft transferred from one animal spe- hidrocystoma A benign cystic tumor in the SWEAT cies to another, such as a heart valve transplanted GLANDS, usually appearing on the eyelid. The CYST, from a pig to a human. which is relatively common among people in the United States, grows slowly and usually persists indefi nitely. An antibacterial compound hexachlorophene The exact cause is unknown, but experts suspect once widely used that is effective against many it may be closely related to blockage of sweat duct gram-positive organisms such as staphylococcus. apparatus, which leads to retention of sweat and a However, it also has been associated with some dilated cystic structure. unpleasant effects, including neurotoxicity in chil- dren and burn patients. Because it is not as safe as Symptoms and Diagnostic Path other antiseptics, such as chlorhexidine and iodine The cyst is a dome-shaped bluish growth that may compounds, it is no longer commonly used. appear on the face, scalp, ears, or chest. Although it usually appears on the eyelid, it also may arise on Side Effects other areas of the head, neck, and trunk; It also has Adverse reactions to compounds containing hexa- been reported to occur on the penis, in the armpits, chlorophene may include DERMATITIS and sensitiv- and in the anal region. ity to sunlight. Sensitivity to hexachlorophene is rare; however, persons who have developed an Treatment Options and Outlook allergy to the sun from similar compounds also Surgical excision or carbon dioxide laser vaporiza- may become sensitive to hexachlorophene. In tion is the treatment of choice. Cysts are entirely 180 hirsutism benign and seldom recur. Vision usually is not In some patients, there may be a hereditary affected. component in the tendency to develop hives. Termed HEREDITARY ANGIOEDEMA, this condition is characterized by nonitching swellings lasting three hirsutism Excessive hairiness in women that or four days that may be triggered by trauma or grows thickly in a male pattern on face, trunk, and may appear to occur spontaneously. limbs. The condition is frequently seen in certain ethnic groups such as dark-haired Hispanics and Treatment Options and Outlook women from the Mediterranean, and is usually of The standard treatment for hives is antihistamines, no medical signifi cance. However, hirsutism some- but other drugs may also be used (including times can be the sign of a hormonal imbalance or adrenaline or epinephrine, terbutaline, oral COR- of an endocrine disease. In some cases, hirsutism TICOSTEROIDS, or cimetidine). In addition, sufferers is characterized by abnormally high levels of male should provide physicians with a detailed medical hormones (such as polycystic ovary syndrome or history, including a detailed diary of exposure to congenital adrenal hyperplasia). foods, chemicals, new products, and possible irri- tants over a period of two weeks to a month before Treatment Options and Outlook onset of the hives. In cases where no medical cause is found, the Because hives may be triggered by such a wide unwanted hair can be bleached or removed. variety of agents, it may never be possible to docu- See HAIR REMOVAL; ELECTROLYSIS. ment the exact cause. Physically uncomfortable but generally harm- less, they eventually disappear, leaving no lasting histamine A chemical found in cells throughout marks. the body that is released during an allergic reaction, resulting in infl ammation. The effects of histamine can be offset by ANTIHISTAMINES. Histamine plays an hives, sun-induced See SOLAR URTICARIA. important role in regulating the immune response. Its effects include redness, swelling, and HIVES. homograft See ALLOGRAFT. histiocytoma cutis See DERMATOFIBROMA. hookworm A small, round blood-sucking worm that penetrates the skin, causing a red, itchy rash hives A skin reaction also known as urticaria (from on the feet called “ground itch” (cutaneous larva the Latin word urtica for “nettle”), these raised, red, migrans). The worms are of the species Necator blotchy welts or wheals of various sizes can appear Americanus or Ancylostoma duodenale (New and and disappear randomly on the surface of the skin. Old World hookworms respectively), and infest About one in fi ve people experiences hives. about 700 million people in tropical Third World While the cause of the reaction is often unknown, countries. hives may result from the release of histamine and In the United States, children can become other chemicals into the skin and/or blood. A wide infested when the common hookworm is passed variety of triggers have been known to cause hives, through a dog’s feces and is deposited into the soil. including food, pollen, animal dander, drugs, insect The parasites then stay in the soil where they will bites, infections, illness, cold, heat, light, or stress. eventually hatch into larvae that can penetrate Foods that have been linked with the development through the skin or be eaten. These worms are of hives include shellfi sh, fi sh, berries, nuts, eggs, not usually affected by extreme environmental and milk. Penicillin and aspirin also may cause conditions, so they can be a problem in any area. hives in some susceptible patients. A child can become infested by playing with an Howel-Evans syndrome 181 infected dog and coming into contact with the horn, cutaneous A hard, benign, pink or yellow feces, or by walking barefoot in grass or sand growth most often seen in older persons. A slow- where a dog has defecated. Younger children growing horn may develop on the former site of are at risk when they put dirt or sand into their a WART, a sebaceous keratosis, ACTINIC KERATOSIS, mouths while playing. In children or adults who or SQUAMOUS CELL CARCINOMA; left untreated, it walk barefoot, the hookworm can penetrate the may grow quite large and may protrude as much sole of the foot and cause a lesion. The larva will as three-quarters of an inch. Surgery can remove then begin to mature while it moves toward the the growth. intestines. As in dogs, the hookworm will attach See also KERATOSIS, SEBORRHEIC; KERATOSIS, to the intestinal wall. SOLAR.

Symptoms and Diagnostic Path Humans who have become infected will show Horner’s syndrome A group of symptoms includ- symptoms of intestinal bleeding, abdominal pains, ing absence of sweating (ANHIDROSIS), narrowing anemia, severe diarrhea, and malnutrition. In of the pupil of the eye, and drooping eyelids. The minor infestations there may be no symptoms. In syndrome is caused by damage to the sympathetic more severe cases, a red linear rash can be seen at nerve fi bers (usually in the lower neck). the top of the sole of the foot or on the buttocks. Hookworms are diagnosed by examining a stool Symptoms and Diagnostic Path sample under a microscope. Counting the eggs in a Sympathetic nerve fi ber injuries can result from specifi c amount of feces allows the health care pro- a stroke in the brainstem, injury to the carotid vider to estimate the severity of the infection. artery, a tumor in the upper lobe of the lung, and cluster headaches. Rarely, Horner’s syndrome may Treatment Options and Outlook be present at birth and associated with a lack of Antihelmintic drugs (such as mebendazole applied pigmentation of the iris. Eye drops and certain as a topical cream) kill the worms. Improved diet medications may lead to this condition. and blood transfusions also may be necessary. A neurological exam can diagnose the condi- tion and fi nd the cause by determining which, if Risk Factors and Preventive Measures any, other parts of the nervous system are affected. Human hookworm infection can be prevented in Tests may include an MRI of the head, carotid the United States by giving dogs and cats proper ultrasound, chest X-ray, CT scan of the chest, blood veterinary care and teaching children sensible per- tests, an angiogram, and eye drop tests. sonal hygiene. See also LARVA MIGRANS, CUTANEOUS. Treatment Options and Outlook The treatment for Horner’s syndrome depends upon the cause. In many cases there is no treat- hordeolum See STYE. ment that improves or reverses the condition. Treatment in acquired cases is aimed at eradicating the disease that produces the syndrome. Prognosis hormones and acne Hormonal activity is impor- depends on whether treatment of the underlying tant in the development of ACNE, since the con- cause is successful. dition depends on the stimulation of the hair follicles by male sexual hormones found in men and women. Some women with acne may have Howel-Evans syndrome A genetic disorder of excessive levels of these hormones. This should be KERATINIZATION characterized by lesions of the suspected if a woman has irregular periods or facial palms and soles and cancer of the esophagus. hair. The most frequent cause of androgen excess It was fi rst described in 1958, when two Brit- in females is polycystic ovarian disease. ish families were reported to have a 70 percent 182 HPV incidence of esophageal cancer with related kera- Hunter’s syndrome is an X-linked recessive dis- tosis. No cancer was found in family members order, which means that it is caused by a defect on without keratosis. the X chromosome and usually leads to problems The disorder is inherited in an autosomal domi- in men only. Women can be carriers of the defect; nant pattern, which means that only one defective if so, half their sons may be affected. gene (from one parent) is needed to cause the The condition is one of seven major types of syndrome. Each child of an affected person usually mucopolysaccharidoses (diseases characterized by has a one in two chance of inheriting the defective a lack of certain enzymes). gene and of being affected. No one knows why the cancer and the keratosis Symptoms and Diagnostic Path appear together. Symptoms that do not involve the skin may include deafness, dwarfi sm, mental retardation, clawlike hands, and early mortality. There are also HPV See PAPILLOMA VIRUS, HUMAN. milder forms that allow the patient to live into adulthood. human bites Human bites (particularly on the Treatment Options and Outlook hand) are common, and because of the bacteria There is no effective treatment for this disorder, found in the mouth, may often cause soft tissue although researchers hope one day the condition infection. Septic arthritis or osteomyelitis may can be cured by replacing the missing enzymes. follow a human bite. Staphylococcus aureus and Streptococcus bacteria often contaminate human bites. Hutchinson’s freckle The common name for LEN- TIGO MALIGNA. Treatment Options and Outlook A human bite wound should be thoroughly cleaned, soaked, and elevated for 48 hours. It should be hyaluronic acid gel (Restylane and Hylaform) A left open; oral antibiotics are often administered. protective, lubricating, binding gel substance that is Infected injuries may require local debridement, produced naturally by the body. It is used in some hospitalization, and intravenous antibiotics. skin creams as a MOISTURIZER and is also used as a fi ller substance to fi ll out facial WRINKLES. Approved in March 2004, Restylane is injected into facial tis- humectant Substance that preserves the moisture sue to smooth wrinkles and folds, especially in the or water content of the skin. Most dry skin lacks folds around the nose and mouth and to enhance moisture rather than oil, and therefore humectants the lips. Restylane works by temporarily adding and MOISTURIZERs are needed instead of creams or volume to facial tissue and restoring a smoother oils. The most effective humectant is lactic acid, appearance to the face for an effect that lasts for which when applied to the skin, draws water from about six months. the DERMIS into the EPIDERMIS. It is injected by a doctor into areas of facial tissue where moderate to severe facial wrinkles and folds occur. The gel temporarily adds volume to the skin Hunter’s syndrome A genetic metabolic disease and can give the appearance of a smoother surface. that causes skin symptoms in 20 percent of cases. Restylane and Hylaform will help smooth moder- It is characterized by white or fl esh-colored PAPULES ate to severe facial wrinkles and folds. In one study, or NODULES on the nape of the neck, the chest, and most patients needed just one injection to smooth the upper arms and legs. Lesions may appear in out the wrinkles. children before age 10, spontaneously disappearing Side effects of hyaluronic acid fi llers include later in life. bruising, redness, swelling, pain, tenderness, and hyperhidrosis 183

ITCHING. These gels should not be used in patients The medication was discovered when African- with severe allergies marked by a history of ana- American workers who were handling rubber phylaxis, multiple severe allergies, or severe aller- products containing hydroquinone noticed that gies to gram-positive bacterial proteins. In addition, the skin on their hands and other areas exposed they should not be used for breast augmenta- to the chemical were getting lighter. Hydroqui- tion; implantation into bone, tendon, ligament, or none is prescribed in a 1 to 4 percent lotion, gel, muscle; or implantation into blood vessels, because or salve. they may obstruct blood fl ow. See also SKIN FILLERS. Side Effects Occasionally, at higher concentrations a patient will have an adverse reaction to the agent and hydrogen peroxide A mild antiseptic sometimes experience increased pigmentation or development used to treat skin infections. The solution combines of MILIA. Other adverse effects could include mild with catalase (an enzyme present in the skin) to skin irritation or allergic reaction. release oxygen, which kills bacteria and cleanses the infected areas. Currently, use of hydrogen per- oxide is not recommended because it is a feeble hydroxyurea (Trade name: Hydrea) An antican- germ killer. cer drug that inhibits DNA synthesis and that may be helpful for patients with extensive PSORIASIS. Side Effects Hydrogen peroxide sometimes causes soreness and Side Effects irritation. Patients who have received prior radiation therapy before getting the drug may experience worsening of redness. Other side effects include skin erup- hydropic degeneration Damage to the cells of tions, gastrointestinal disturbances, bone marrow the basal layer, which produces tiny spaces in the abnormalities, and (rarely) neurologic symptoms. cells. It may also cause temporary kidney problems. Because it causes birth defects in animals, it is not recommended for use during pregnancy. hydroquinone (paradihydroxybenzene) This skin bleaching agent can reduce the intensity of pigmen- tation of FRECKLES, MELASMA, and solar LENTIGO. It hyperbilirubinemia A yellowish discoloration of suppresses PIGMENTATION by blocking the activity of the skin, sclerae, mucous membranes, and ear- an enzyme involved in the synthesis of MELANIN. drums caused by high levels of bilirubin in the When applied to the skin over a period of several blood. months, the skin temporarily becomes somewhat lighter. For continued and increased effectiveness it must be used for a longer term. Sun exposure hypergranulosis An increase in the number of (even through window glass) during treatment keratin-producing cells in the granular layer of the should be avoided because it reverses the effect of skin. hydroquinone. Hydroquinone is sometimes combined with TRETINOIN for better skin penetration and because hyperhidrosis This disorder of excessive sweating tretinoin helps to lighten pigmentation, or with begins at puberty, worsening in the summer and corticosteroids to reduce the irritation occasion- affecting the palms, soles, and armpits. It also may ally caused by tretinoin. Other ingredients often be caused by certain diseases, such as fevers, or the added to hydroquinone include GLYCOLIC ACID and effect of using certain drugs. Excessively sweaty RETINOL. armpits and feet may cause unpleasant body odor. 184 hyperkeratosis

The condition often improves when the patient is also effective for the palms and soles. Botulinum enters the middle 20s to 30s. toxin may temporarily weaken the small muscles The amount of sweat produced is regulated of the hands. Regional or local anesthesia is typi- in the hypothalamus; overactivity of the hypo- cally given in these sites because the injections are thalamus or the sympathetic nerves can result in painful. hyperhidrosis. Typically, hyperhidrosis fi rst appears Iontophoresis This type of treatment involves in childhood or adolescence; other family members using electrical stimulation (usually for patients may or may not also have the problem. An increase with excessive sweating in the hands). Patients in air temperature, exercise, fever, anxiety, or spicy place their hands in a bath through which an elec- food may set off attacks of sweating, which usually trical current is passed, which seems to stun the lessen at night and disappear during sleep. sweat glands and decrease the secretion of sweat A few patients have hyperhidrosis as a conse- for between six hours and a week. quence of a medical condition. Generalized hyper- Other medications Many medicines have been hidrosis may be due to drugs, cardiovascular used with varying success, including sedatives (in disorders, respiratory failure, overactive thyroid, those patients with stress-induced hyperhidrosis) endocrine tumors, or Parkinson’s disease. Localized and medications that affect the nervous system. hyperhidrosis may be due to a stroke, nerve dam- Surgery Surgery is typically considered only age, a brain tumor, or a chronic anxiety disorder. when less invasive medical treatments have failed. The surgical treatment of hyperhidrosis involves Symptoms and Diagnostic Path destroying or removing a specifi c portion of the Hyperhidrosis is an embarrassing complaint and main sympathetic nerve, which is part of a separate signifi cantly interferes with many daily activities. and parallel nervous system. The surgical therapy Clothing gets damp and must be changed several for hyperhidrosis entails removing or destroying times a day. Wet skin folds are prone to irritation. the specifi c part that causes sweating in the under- Patients fi nd it embarrassing to shake hands and arm. Typically, the patient remains in the hospital diffi cult to write neatly. Sweaty feet develop an for a period of 12 to 24 hours after surgery. Most unpleasant smell, ruin footwear, are prone to skin patients need pain medication for between seven irritation or secondary infection, and require sev- and 10 days after surgery. eral sock changes a day. This surgery will cure between 95 and 98 per- Aluminum chloride with ethyl alcohol cent of excessive hand (palmar) hyperhidrosis and (DRYSOL) This prescription product is effective about 75 to 80 percent of armpit (axillary) hyper- in some cases of excessive sweating of the hands, hidrosis. Approximately 25 percent of patients with armpits, and feet, and is probably the least invasive hyperhidrosis of the feet (plantar) will notice some of all treatment methods. It is typically the fi rst improvement, but surgery is not designed to treat type of treatment tried. The medication applied at plantar hyperhidrosis and should not be used if this night and left on the skin for six to eight hours. is the only sweating complaint. It is then washed off completely the following See also SWEAT GLANDS; ANTIPERSPIRANTS; morning before the onset of daytime sweating. DEODORANTS. (Skin must be dry when Drysol is applied, or it will cause severe irritation.) About half of patients will develop some degree of skin irritation from hyperkeratosis Thickening of the outer layer of this product, so it is important that the application the skin caused by too much KERATIN (a protein directions be carefully followed. component of the outer skin layer). The most Botox Botulinum toxin injections (BOTOX) into common types of hyperkeratosis are CORNS and the armpits have revolutionized the treatment for CALLUSES (caused by pressure or friction). Hyper- this condition, since the injections can reduce or keratosis often occurs in scaly conditions such as even stop sweating for three to six months. Botox WARTS, ECZEMA, and LICHEN PLANUS. hypopigmentation 185 hyperpigmentation Excess pigmentation that include exfoliative dermatitis and some anticholin- causes darker-than-usual skin. Darker skin (except ergic drugs. for very black skin) often responds to trauma with See also DERMATITIS, EXFOLIATIVE. hyperpigmentation, but the phenomenon occurs in all racial and ethnic groups. Many chemicals can cause hyperpigmentation, hypohidrotic ectodermal dysplasia A rare, incur- but heavy metals can cause discoloration by being able genetic condition characterized by a decreased deposited within the skin. Arsenic, which some ability to sweat, dry wrinkly skin, sparse dry hair, patients may ingest by drinking water from con- small brittle nails, and cone-shaped teeth. taminated wells or by being exposed to insecticide sprays used in fruit orchards, can stimulate melanin formation within the EPIDERMIS, causing a brown hypomelanosis of Ito A congenital disorder of hyperpigmentation. The hyperpigmentation is not pigmentation also known as incontinentia pig- caused by arsenic deposits within the dermis. Bis- menti achromicans. muth can also cause a brown hyperpigmentation; The disorder has an autosomal dominant condi- both bismuth and arsenic were once contained in tion, which means that only one defective gene medications. from one parent is needed to cause the syndrome. Each child of an affected person usually has a one in two chance of inheriting the defective gene and hyperplasia An increase in the production and of being affected. Males are almost twice as likely growth of normal cells in skin tissue. It can result to have the disorder as females. in a thickened EPIDERMIS (outer layer of the skin). During pregnancy, the breasts grow in this fashion. Symptoms and Diagnostic Path The condition is characterized by bizarre unpig- mented areas that appear in whorls, streaks, and hypertrichosis Excessive hair growth in places not splashes on the skin of the trunk and extremities. normally covered with hair. This excess hair growth The pigment changes are present at birth, and are is often caused by certain drugs (such as cyclospo- often the fi rst indication that the infant is not nor- rine, minoxidil, and diazoxide). The condition is not mal. In addition to skin symptoms, most patients the same as HIRSUTISM (excess hairiness in women). also have other problems, including disorders of the central nervous system, eyes, hair, nails, teeth, musculoskeletal system, or internal organs. Up hypertrophic scars An enlarged or thickened to 40 percent of these patients are also mentally SCAR, remaining within the confi nes of the original retarded. wound in which excessive scar tissue rises above the skin during the healing process. Treatment Options As with other similar hypopigmentation disorders present at birth, there is no specifi c treatment for hypochondria, cutaneous See ACNE EXCORIÉE. the skin problems with this disease. Topical appli- cation of methoxsalen and exposure to ultraviolet radiation may minimize the skin disfi gurement. hypohidrosis Lessened or inability to sweat. This condition is a symptom of HYPOHIDROTIC ECTODER- MAL DYSPLASIA, a rare inherited condition char- hypopigmentation Decreased PIGMENTATION result- acterized by the decreased ability to sweat, dry ing in lightening of the skin that may be caused by wrinkly skin, sparse dry hair, small brittle nails, and a lack of pigment cells in an area of skin, or because cone-shaped teeth. Other causes of hypohidrosis the skin has too few MELANIN-producing cells. 186 hypopituitarism and skin color

Disorders of congenital hypopigmentation due all racial and ethnic groups—the more common to abnormal formation of melanin-producing disorders that produce post-infl ammatory hypopig- cells include TUBEROUS SCLEROSIS, HYPOMELANO- mentation include PSORIASIS, eczematous dermati- SIS OF ITO, NEVUS DEPIGMENTOSUS and CHEDIAK- tis, atopic dermatitis, seborrheic dermatitis, tinea HIGASHI SYNDROME. Oculocutaneous albinism is versicolor, CHICKEN POX, SYPHILIS, LICHEN PLANUS, a congenital hypopigmentation due to problems PITYRIASIS ROSEA, pityriasis lichenoides chronica, with the synthesis of melanin. TINEA VERSICOLOR and lichen striatus. is an example of an acquired case of hypopigmen- Drugs also can cause hypopigmentation. Chloro- tation caused by decreased synthesis of melanin. quine may cause hypopigmentation of the skin or PITYRIASIS ALBA is an acquired type of hypopig- bleaching of the hair; cosmetics and skin bleaches mentation caused by the decreased transfer of often available without prescription may cause melanin-producing cells. hypopigmentation. Hypopigmentation also may follow an infection or infl ammation. Many infectious and infl am- matory skin disorders fade away while leaving hypopituitarism and skin color The lack of hypopigmented macules and patches in the distri- melanocyte-stimulating hormones (MSH) can bution and pattern of the original skin lesion. Dark cause a generalized decrease in skin color. skin that has been injured often exhibits hypopig- See also DEPIGMENTING DISORDERS; PIGMENTATION mentation, but the phenomenon occurs among DISORDERS. I iatrogenic atrophy Thinning of the skin, often ichthyosis Any of several generalized skin disor- produced by CORTICOSTEROIDS taken either by ders characterized by dry, rough, scaling, darkened mouth or administered on the skin. This appar- skin that occur because of an excess amount of ently occurs because the steroids interfere with KERATIN (the main protein component of the skin). the formation of COLLAGEN. The more potent the The disorder’s name is derived from the Greek topical steroid, the faster and more severe the atro- word ichthus meaning “fi sh,” because the appear- phy. Thinning of the skin associated with systemic ance and condition of the skin resembles scales. corticosteroids affects the skin everywhere on the body. (“Iatrogenic” describes conditions that result Symptoms and Diagnostic Path from treatment.) This group of genetic diseases ranges from mild generalized dry skin (ichthyosis vulgaris) to severe widespread thickened scaly dry skin (LAMELLAR ibuprofen (Trade names: Motrin, Advil, Nuprin) A ICHTHYOSIS). nonsteroidal anti-infl ammatory drug (NSAID) used Ichthyosis vulgaris, which affects the thighs, to ease pain and reduce infl ammation in a wide arms and backs of the hands, usually appears at or variety of skin disorders. shortly after birth and improves as the child grows older. However, in severe conditions, the infant is Side Effects usually born dead, encased in skin as hard as armor Ibuprofen may cause skin rash, abdominal pain, plate. diarrhea, nausea, heartburn and, occasionally, diz- ziness. However, it is less likely than other NSAIDs Treatment Options and Outlook to cause peptic ulcers. There is no cure for any of the ichthyoses, but lubricants and ointments may help the dryness, and bath oils can moisten the skin. Washing with ice packs A treatment to reduce infl ammation, soap aggravates the condition. Ichthyosis improves bruising, and swelling of the skin. Cold causes in a warm, humid environment and worsens in the blood vessels in the skin to contract, reducing cold weather. blood fl ow; it also numbs nerves and can reduce pain. An ice pack can be made by wrapping ice in a icterus See JAUNDICE. wet cloth, applying to the skin’s surface. Chemi- cal ice packs may also be used; these are struck or shaken, which mixes the chemicals and produces a imiquimod cream (Trade name: Aldara) A topi- liquid with a very low temperature. cal drug that releases interferons that has recently If no ice is available in an emergency situation, a been approved in the United States for the treat- chilled soda can, frozen meat, or other frozen food ment of GENITAL WARTS, ACTINIC KERATOSIS, and may be used as an ice pack. (It should be wrapped BASAL CELL CARCINOMA, a slow-growing local type in material to avoid burning the skin). of skin cancer.

187 188 immersion foot immersion foot Also known as “trench foot” administered every two weeks. Eventually, the during World War I, this condition causes the skin injections can be given once a month. The therapy of the feet to turn pale, eventually becoming red, must be given for three to four years before the swollen, and painful. It occurs among shipwreck patient can be considered immune. The treatment survivors and soldiers whose feet have been wet increases a person’s ability to tolerate the irritating and cold for a long time, caused by death of skin substance. tissue after prolonged immersion in water. Side Effects Treatment Options and Outlook Because there is a risk of a severe allergic reaction At the initial stage (where the skin is pale and shortly after an injection, the technique requires there is no detectable pulse), the skin should be close medical supervision. rewarmed gradually and carefully, since overheat- See also BEE AND WASPS. ing may lead to GANGRENE (tissue death). If the condition has progressed to the latter stages, with red and swollen skin and a strong pulse, the foot impetigo A superfi cial skin infection most com- should be gradually cooled. Even so, the feet may monly found in children, caused by streptococcal subsequently be overly sensitive to cold for several or staphyloccal bacteria (sometimes both). years. Impetigo is spread through body contact and Untreated, the condition can lead to severe usually is found on exposed body areas such as the muscle weakness, skin ulcers, or gangrene. legs, face, and arms. Because impetigo is spread quickly through play groups and day care centers, children with the infection should be kept away immunity and sunlight The sun has a detrimental from playmates and out of school until the sores effect on the body’s immune system, decreasing its disappear. ability to recognize and destroy potentially lethal pathogens ranging from bacteria to cancer cells. Symptoms and Diagnostic Path Ultraviolet-B light suppresses the function of The condition starts as tiny, almost imperceptible T-lymphocytes, which are important in immune blisters on a child’s skin, usually at the site of skin surveillance. There is evidence from animal abrasion, scratch, or INSECT BITE. Most lesions occur research that this UV-B-induced suppression may on exposed areas, such as the face, scalp, and decrease the immune system’s ability to recognize extremities. The red and itchy sores begin to ooze and destroy malignant cells which initiate SKIN for the next few days, leaving a sticky golden crust. CANCER. Untreated, the infection usually will last from two to three weeks but may continue indefi nitely if not treated. It is most prevalent during hot, humid immunotherapy A preventive technique to com- weather. bat allergy to substances such as pollen, dust mites, Impetigo is diagnosed by a simple examination. wasp, or bee venom. The treatment involves giving increasing doses of the irritating substance to make Treatment Options and Outlook the patient’s immune system less sensitive to the Impetigo should be treated as soon as possible to irritant. avoid the spread of the infection to other children Before immunotherapy begins, the patient and and to prevent a rare complication: a form of kid- physician try to determine the trigger factors for ney disease called acute glomerulonephritis. the allergy with skin and blood tests. MUPIROCIN treatment is highly effective in sim- A purifi ed extract of a small amount of the aller- ple uncomplicated impetigo and is the treatment of gen is injected into the skin of the arm once a week choice. In widespread disease, systemic antibiotics for about 30 weeks, after which injections can be also can be used, such as dicloxacillin, cephalospo- infantile acropustulosis 189 rin, or erythromycin. With proper care this infec- impetigo, streptococcal See IMPETIGO. tion is quite manageable.

Risk Factors and Preventive Measures impetigo, superficial See IMPETIGO. Cleanliness and prompt attention to skin injury can help prevent impetigo. Impetigo patients and their families should bathe regularly with antibacterial impetigo contagiosa See IMPETIGO; IMPETIGO, soaps, and apply topical antibiotics to insect bites, BULLOUS. cuts, abrasions, and infected lesions immediately. Impetigo in infants is especially contagious and serious. To prevent spreading, pillow cases, towels Imuran See AZANTHIOPRINE. and washcloths should not be shared, and should be boiled after each use. incontinentia pigmenti See BLOCH-SULZBERGER SYNDROME. impetigo, Bockhart’s A superfi cial form of FOLLICULITIS. incontinentia pigmenti achromicans See HYPOMELANOSIS OF ITO. impetigo, bullous Also called “staphylococcal impetigo,” this superfi cial skin infection is caused See ACNE, INFANT. by Staphylococcus aureus bacteria and requires infant acne immediate attention. This disease has been more frequently diagnosed since the 1970s. infantile acropustulosis A recurring disease in Symptoms and Diagnostic Path infants that causes severe ITCHING, restlessness, and fretfulness, and that is typically diagnosed between Symptoms include thin-walled, fl accid fl uid-fi lled 2 months and 10 months of age. First described in BLISTERs that rupture easily; their fl uid may be clear 1979, it is probably much more common than had or full of PUS. After rupture, the base quickly dries previously been thought. Its cause is unknown, but to a shiny veneer, which looks different than the many cases are preceded by SCABIES infestation. thicker crust found in common IMPETIGO. Lesions More often, however, cases occur despite scabies are usually found in groups, most often on the face having been thoroughly ruled out. There appears or trunk instead of arms or legs. to be no bacterial or viral cause, nor does it seem This condition is diagnosed by a simple as if the immune system is involved. While initial examination. reports suggested the problem was more common among African Americans, experts now believe it Treatment Options and Outlook affects all races equally. As with common impetigo, bullous impetigo is treated with dicloxacillin, cephalosporin, or ERYTH- Symptoms and Diagnostic Path ROMYCIN. It is important to wash the affected areas Lesions begin as small itchy lesions that then thoroughly twice a day with soap and water to form distinct VESICLES and PUSTULES that tend keep the area as clean as possible. Blood poisoning to heal with hyperpigmentation. Lesions always complications are rare. appear on the hands and the feet, usually on the palms of the hands and the soles of the feet, but they may also occur on the trunk, the scalp, and impetigo, staphylococcal See IMPETIGO, BULLOUS. the face. 190 infant skin care

Children are fretful, irritable, and obviously inflammation An essential part of the body’s uncomfortable, but otherwise healthy. Individual response to injury that results in redness, swelling, bouts last one to two weeks, recurring every two pain, and heat in the skin tissue because of either a to four weeks. chemical or physical injury, or an infection. Infl ammation occurs when skin tissue is dam- Treatment Options and Outlook aged. A chemical called HISTAMINE is released, Treatment is often unnecessary because of the self- which increases blood fl ow to the damaged tis- limited nature of his condition. Topical steroids and sue, causing redness and heat; white blood cells oral DAPSONE have been used successfully in more enter the tissue and attack the bacteria and other persistent cases. Topical pramoxine preparations foreign particles. Similar cells from the tissues are available without prescription for the itch, and remove and consume the dead cells, sometimes oral ANTIHISTAMINES may be useful. producing PUS. Histamine also makes blood capil- The intensity and the duration of attacks dimin- laries leak, causing fl uid to ooze out and create ish with each recurrence, and all cases spontane- swelling. ously resolve in a few months to three years. Occasionally, infl ammation is an inappropriate response (such as in autoimmune disorders) and results in conditions such as rheumatoid arthritis. infant skin care See SKIN CARE FOR INFANTS. Treatment Options and Outlook Infl ammation may be suppressed with CORTICO- infant skin diseases Infants are affected by a wide STEROID drugs or nonsteroidal anti-infl ammatory range of problems unique to their age group, and drugs. These drugs work by reducing the produc- they also may show unusual symptoms of more tion of prostaglandins (fatty acids that produce common skin problems found in other patients. infl ammation in injured tissue). The drugs also Because many skin problems of infants are related reduce the release and activity of white blood cells to systemic disorders, a complete physical exam is and normalize the size of blood vessels. important to diagnosis. Infant skin problems can include MILIA, SALMON PATCH, ERYTHEMA TOXICUM, PRICKLY HEAT, harle- infrared light Light in the part of the electromag- quin color changes, neonatal ACNE, HEMANGIOMAS, netic spectrum immediately after the red end of the PORT-WINE STAINS, lymphatic disorders, transient visible light. Chronic exposure, such as in cases of neonatal pustular melanosis acropustulosis, APLA- bakers or furnace workers, can produce photoag- SIA CUTIS, EPIDERMOLYSIS BULLOSA, INCONTINENTIA ing similar to that produced by longstanding sun PIGMENTI, ICHTHYOSIS, bacterial infections (such as exposure. IMPETIGO, SYPHILIS, SCALDED SKIN SYNDROME), and viral infections (such as HERPES SIMPLEX, cytomega- lovirus, RUBELLA, AIDS, toxoplasmosis). infundibulofolliculitis Infl ammation of a hair Other problems include histiocytosis X, juvenile follicle above the opening of the sebaceous gland. xanthogranuloma, MASTOCYTOSIS, and subcutane- Little is known about the cause. ous fat necrosis of the newborn. Pigmentary abnor- malities may include CAFE AU LAIT SPOTS, BLUE NEVUS, Symptoms and Diagnostic Path and CONGENITAL MELANOCYTIC NEVI. Infants may also This uncommon itchy papular eruption affects the be affected by seborrheic dermatitis of infancy, DIA- trunk, arms, and legs, and occurs almost exclu- PER RASH, and neonatal lupus erythematosus. sively in African Americans. Treatment for infant skin problems is diffi cult, complicated by the risks and toxicity of various Treatment Options and Outlook medications that would be appropriate for an older There is no cure but patients may try mild topical patient. CORTICOSTEROIDS and emollients. intertrigo 191 ingrown toenail A painful nail condition in which Topical antihistamines or anesthetics such as Bena- one or both edges of the nail has grown inward into dryl and benzocaine should be avoided. the skin around the nail bed, causing infl ammation and infection. The condition is usually caused by wearing ill-fi tting shoes, poor personal hygiene, or integument A medical name for the skin. improperly cut toenails.

Symptoms and Diagnostic Path interface dermatitis See DERMATITIS. Ingrown toenails cause pain, redness, swelling and, sometimes, an infection. The condition usually affects the big toe. interferon alpha (IFN-a) A drug used to treat Treatment Options and Outlook malignant melanoma and a number of other condi- tions. Interferon alpha is one type of interferon— Antibiotics can relieve the infection; removal of the natural proteins produced by the cells of the nail edge under local anesthetic may be necessary. immune system in response to challenges by viruses, Pain may be relieved by soaking the foot in strong, bacteria, parasites, and tumor cells. Interferon alpha warm saline solution twice daily and covering the is produced by many cell types, including T-cells area with a dry gauze bandage. and B-cells, and is an important component of the Risk Factors and Preventive Measures antiviral response. Interferon alpha is also active against tumors. Toenails should be cut straight across, not angled Interferon was scarce and expensive until 1980, down along the sides. when the interferon gene was inserted into bacte- ria using recombinant DNA technology, allowing mass cultivation and purifi cation from bacterial insect bites Minute puncture wounds in the skin cultures. Several different types of interferon are caused by any of a variety of insects, mites, mos- now approved for use in humans, and interferon quitoes, midges, gnats, sand fl ies, ticks, fl eas, and therapy is used (in combination with chemothera- bedbugs. Most insect bites are not terribly painful, phy and radiation) as a treatment for many types and cause only a temporary itch for several days. of systemic cancer. They are extremely common, especially in children. Interferon alfa 2b is used to treat malignant Papular urticaria (hives) occurs most often in two- melanoma and for chronic myelogenous leukemia. through seven-year-olds, usually in late spring or Interferon alpha was approved by the U.S. Food summer. Episodes last only two to three weeks, but and Drug Administration in 1991 as a treatment can recur over a three- or four-year period. for hepatitis C. Several different forms of interferon Direct tissue injury may result from biting, sting- alpha, including interferon alpha-2a, interferon ing, or burrowing. Local hives may occur by venoms alpha-2b, and interferon alfacon-1 are approved introduced with a bite or sting, or by contact with for the treatment of viral hepatitis. various secretions. Necrosis (tissue death) has been See also MELANOMA, MALIGNANT. produced by the bite of certain spiders, such as the BROWN RECLUSE. Secondary abrasions or infections may occur. Insects may bite either on exposed areas of the skin or parts of the body where clothing fi ts internal malignancy, skin signs of See MALIG- tightly (in these areas, the movement of the insect NANCY, SKIN SIGNS OF INTERNAL. is halted and it bites to feed or as a defense).

Treatment Options and Outlook intertrigo Skin infl ammation occurring primarily Itch and redness can be reduced with topical COR- in obese people on adjacent surfaces of the skin, TICOSTEROIDS; CALAMINE lotion also helps the itch. such as the neck creases, groin, armpits, folds of the 192 iododerma abdomen, between fi ngers and toes, and the area returns to its original levels before treatment. More beneath the breasts. than 60 percent of patients with severe acne never again require treatment. However, about one-third Symptoms and Diagnostic Path of patients need a second course of the drug, which Red, moist skin, with scales or blisters and an should be administered only after a six-month hia- unpleasant odor. The condition, which worsens tus. This second course may require higher doses. with sweating, is sometimes accompanied by seb- orrheic DERMATITIS or yeast infection. Side Effects There are several serious side effects that have Treatment Options and Outlook been associated with this medication, but the Weight reduction, good personal cleanliness, dry most serious of which are birth defects when the skin, and CORTICOSTEROID or antifungal cream. drug is taken by a pregnant woman. Isotretinoin causes the most severe birth defects if an expectant mother takes it during her fi rst trimester, when she iododerma Any skin eruption caused by iodine is least likely to know she is pregnant. It can lead or iodide ingestion. to what is known as Accutane embryopathy, in which exposed fetuses typically have a pattern of brain abnormalities as well as major malformations isotretinoin (Trade name: Accutane) A synthetic of the head, ears, eyes, face, and heart. oral form of VITAMIN A that has been used since the In the beginning of 2006, the companies that late 1970s to treat severe cystic ACNE that has failed make isotretinoin, together with the U.S. Food and to respond to other treatments. It is also effective Drug Administration, have imposed mandatory in the healing of oral LEUKOPLAKIA and is also used prescribing rules. Any woman of childbearing age to treat severe ICHTHYOSIS (disorders character- who is given the drug must ized by thickened, scaling skin). Roche, the maker of Accutane, estimates that nearly seven million • have negative pregnancy tests two months in a Americans have taken its drug. Hundreds of thou- row before starting the drug during treatment sands more have taken other brands of isotretinoin • either promise in writing to abstain from sex since they came on the market after Roche’s patent with a man or else use two forms of contracep- expired in 2002. tion, one of which must be a highly effective Isotretinoin works by decreasing formation of kind such as birth control pills or the injectable oily plugs of SEBUM, reducing the formation of KER- Depo-Provera ATIN (the tough outer layer of skin) and by shrink- • take a pregnancy test each month during her ing SEBACEOUS GLANDS—so well that it can cause treatment (usually fi ve months) unpleasant side effects such as skin dryness and nosebleeds. Isotretinoin cures or greatly reduces • document every step she takes by logging onto severe disfi guring acne in up to 80 percent of iPledge, a national online database patients. However, it can cause severe birth defects (including fetal brain, heart, and skeletal deformi- By March 1, 2006, physicians and pharmacists ties); for this reason, pregnancy must be avoided also were required to register each isotretinoin during treatment and for at least two months after prescription with iPledge to verify that they have treatment has ended. done their part to ensure against pregnancy. The Currently, isotretinoin is given for four to six new rules are meant to prevent isotretinoin-related months for the fi rst treatment; after treatment has birth defects, but the rules are so strict that some ceased, the condition may continue to improve for at doctors worry they might discourage many patients least two more months and sometimes for as long as from using the drug, the only treatment that can one year, although the sebum production gradually erase severe acne. itching 193

Other less common side effects include dry skin In addition, a wide range of disorders produce and chapped lips, as well as fatigue, severe joint itching, including HIVES, ECZEMA, and FUNGUS INFEC- pain, headache, upset stomach, and blurred vision. TIONS. PSORIASIS, LICHEN PLANUS, and DERMATITIS Some suspect that isotretinoin may also cause HERPETIFORMIS may also trigger bouts of itching. depression or even suicide, although scientifi c Itching around the anus may be caused by hem- studies have not demonstrated a connection. orrhoids, anal fi ssure, or persistent diarrhea, or by Although the link between isotretinoin and too-rough cleaning after defecating. Worms are the depression has not been scientifi cally proven (the most common cause of anal itching in children. drug’s manufacturer insists there is no such link), Itching around the vulva (pruritus vulvae) several people who have taken it claim they expe- may be caused by candidiasis (a yeast infec- rienced depression, mood swings, and even suicidal tion), hormonal changes at puberty, pregnancy, or feelings. Both the U.S. Food and Drug Administra- menopause, or the use of spermicides or vaginal tion and the drug company said depression is com- suppositories, ointments, and deodorants. mon among acne patients, whether or not they Itchiness all over the body may be caused by take isotretinoin. It appears that patients who are diabetes mellitus, kidney failure, JAUNDICE, thyroid prone to depression may be at higher risk for devel- disorders, Hodgkin’s disease, or blood disorders. oping depression while taking isotretinoin. Infestations of lice and scabies cause severe itch- ing, as can INSECT BITES. Other Symptoms In addition to itching, thinning hair, and dry and Treatment Options and Outlook fl aky skin, isotretinoin occasionally may cause ach- Specifi c treatment depends on the underlying ing muscles and bones, increased lipid levels in the cause of the itching, but in general, cooling lotions blood and, rarely, liver damage. (such as CALAMINE) can relieve the itching and irri- See also RETINA; RETINOIDS. tation. EMOLLIENTS can reduce skin drying and help ease itching. Because soap can irritate itchy skin (especially itching An intense tickling sensation on the skin if the skin is dry or has a rash), it should only be that makes a person want to scratch. The precise used when really necessary. Mild cleansing solu- reason for this response is not fully understood. tions or water alone may be enough to keep itchy Itching is the most prominent symptom in many skin clean. skin diseases. While scratching can temporarily ease the itch, Skin that is too dry and scaly commonly causes it can actually make itching worse over time by itching. Many drug reactions result in itching (espe- overstimulation. The urge to scratch can be sup- cially reactions to codeine, cocaine, and some anti- pressed by using lotions, salves, or applying cool, biotics) and some types of rough clothing, soaps, wet compresses to the affected area, or systemic and detergents can trigger an itching response in agents such as ANTIHISTAMINES. some people. J

Jarisch-Herxheimer reaction Also known as type of jaundice much like hemolytic jaundice can therapeutic shock, this reaction usually occurs develop as a symptom of mild liver disease. within 12 hours of treatment with drugs used to In hepatocellular jaundice, the transfer of biliru- kill Treponema bacteria, such as those that cause bin from liver cells to bile is prevented, causing a SYPHILIS. buildup of bilirubin. This is usually the result of The reaction is caused by the widespread death acute hepatitis or liver failure. of spirochetes. Obstructive jaundice is caused by a blockage of the bile ducts, which prevents the bile from fl owing Symptoms and Diagnostic Path out of the liver. Obstructive jaundice can also occur The reaction is characterized by a fl ulike illness, if the bile ducts are missing or have been destroyed. including a rise in temperature (100°–102° F) with As a result, bile cannot pass out of the liver, and chills, malaise, and worsening of symptoms. bilirubin is forced back into the blood.

Treatment Options and Outlook Treatment Options and Outlook Although the reaction is benign in secondary SYPHI- In all cases treatment is for the underlying disorder LIS (it heralds a favorable response to treatment), causing the jaudnice. in neurosyphilis this rare reaction may be severe. In these cases, oral CORTICOSTEROIDS may minimize the reaction. jellyfish stings The true jellyfi sh family includes about 200 species that drift along the shore- line, dragging tentacles capable of stinging when jaundice Yellow discoloration of the skin caused touched. While most stings from jellyfi sh may by the accumulation in the blood of the yellow- cause little harm, some jellyfi sh (and Portuguese brown bile pigment called bilirubin. Jaundice is a men-of-war) can infl ict severe stings, causing a primary symptom of many different disorders of victim to panic and drown. In the water, the shock the liver and biliary systems. of the sting often causes the victim to jerk away, Bilirubin is formed from hemoglobin as old red which only stimulates the tentacles to release more blood cells break down. The pigment is absorbed poison. If stung by a jellyfi sh on dry land, more from the blood by the liver, where it is dissolved poison is released if the person tries to rip off the in water and excreted in bile. The process can be sticky threads of the tentacles. disrupted in one of three ways, causing one of the three types of jaundice—hemolytic, hepatocellular, Symptoms and Diagnostic Path and obstructive. Stings can cause a severe, burning pain and a In hemolytic jaundice, the body breaks down red welt or row of lesions at the site of the sting. too many red blood cells, producing too much There also may be generalized symptoms, includ- bilirubin. A similar type of jaundice can develop ing headache, nausea, vomiting, muscle cramps, in a newborn, whose liver has not yet developed diarrhea, convulsions, and breathing problems. the capacity to break down bilirubin. In adults, a The wound site becomes red and blistered and can

194 jock itch 195 leave permanent scars. One or two weeks after a jock itch The common term for TINEA cruris, a sting, the victim may experience a recurrence of fungal infection of the male genitals characterized the lesions at the site. by reddened, itchy areas spreading from the geni- The sting of the Portuguese man-of-war (a type tals outward to the inner thighs. It is uncommon of jellyfi sh) is rarely fatal, but causes hives, numb- in women. ness, and severe chest, abdominal, and extrem- Jock itch is caused by a tiny fungus that grows ity pain. Death is usually the result of panic and best in dark, damp conditions. This common drowning. fungus often infects men who are obese or who perspire heavily. It can be transmitted to the groin Treatment Options and Outlook from the feet. The condition may occur at the same Because tentacles continue to discharge their sting- time as ATHLETE’S FOOT. It usually happens when a ing cells as long as they remain on the skin, the person has been perspiring heavily, during sports most important fi rst aid intervention is to remove or hot, humid weather. all of the tentacles. First Aid Alcohol, ammonia, or vinegar and Treatment Options and Outlook salt water (do not use freshwater) can be poured Over-the-counter antifungal drugs containing over the sting site to deactivate the tentacles, clotrimazole in topical forms such as lotion or which should then be scraped off with a towel cream can ease the itchy rash. Treatment should be or with sand held by a towel. TENTACLES MUST continued for some time after the symptoms have NOT BE REMOVED BY HAND. Alternatively, the passed to make sure the fungi has been eliminated, tentacles should be pulled, not rubbed, away using to prevent recurrence. Mild infections on the skin an implement. surface may require treatment for up to six weeks. Baking soda in a paste can be applied to the sting Bathing too often or using too much medicated to relieve pain; after an hour, it should be scraped cream can worsen the condition. off with an object to remove any remaining sting- ing cells. CALAMINE lotion will ease the burning Risk Factors and Preventive Measures sensation, and painkillers may help with the sting- Avoiding rough, textured, or synthetic fabrics will ing pain. (Other popular remedies for pain include help prevent jock itch. Loose cotton will let per- meat tenderizer, sugar, ammonia, and lemon juice. spiration evaporate and skin breathe. The fungus Some persons swear by the application of urine.) that causes jock itch can be spread easily, so people Medications If given early, the calcium blocker should never share towels or clothes. An alkaline verapamil may be effective. Antivenin is effective environment encourages the fungus to grow; since against more dangerous species, but it must be most soap is alkaline, too much scrubbing with given immediately. soap will make jock itch worse. Allergic reactions Jellyfi sh stings also may When washing, patients should make sure to cause an allergic reaction, which can be treated rinse all soap off the skin, drying well and keeping with Benadryl or CORTICOSTEROIDS. A severe reac- the area as dry as possible. Talcum powder reduces tion to the sting may require hospitalization. wetness and chafi ng. K

Kaposi’s sarcoma A condition characterized by skin Kaposi’s. Localized lesions respond well to radiother- tumors that is the most common malignant mani- apy, cryotherapy, surgical excision, or injection with festation of acquired immunodefi ciency syndrome vinblastine, bleomycin, or INTERFERON ALFA. Oral (AIDS). Before the advent of the AIDS epidemic, administration of interferon alpha is effective in Kaposi’s sarcoma was a fairly rare skin condition that about half of patients with mild Kaposi’s sarcoma. In developed slowly and was seen almost exclusively in more severe cases, chemotherapy is often required. elderly Italian and Jewish men. Today, it is at least The outcome in adult patients with AIDS and 20,000 times more common among immunosup- Kaposi’s sarcoma depends on the activity of the pressed groups in the United States. About 95 per- HIV disease, and the degree to which the person’s cent of the epidemic Kaposi’s sarcoma in the United immune system is suppressed. States is found in homosexual and bisexual men, whereas other risk groups have an incidence of 3 percent. In patients with AIDS, Kaposi’s sarcoma is Kawasaki disease An acute childhood disease of highly aggressive and causes widespread tumors. unknown cause featuring a measleslike rash over The cause of this disorder is unknown, although the body that usually occurs during the fi rst years there is some evidence that it may be the result of of life. Also called mucocutaneous lymph node a sexually transmitted infectious agent other than syndrome, it was fi rst observed in Japan during HIV, the virus that causes AIDS. the 1960s. It is the leading cause of heart disease in children. The disease occurs more often among Symptoms and Diagnostic Path boys (more than 60 percent) and among those of Epidemic Kaposi’s sarcoma may appear at anytime Asian ancestry, but it can affect every racial and during HIV infection. Purple macules fi rst appear ethnic group. More than 4,000 cases of Kawasaki anywhere on the body; in time, they may thicken disease are diagnosed each year in the United into plaques or NODULES and are often seen in the States. Less than 1 percent of those are fatal. mouth, on the hard palate, and the gums. In those Doctors do not know what causes Kawasaki with AIDS, tumors often affect the gastrointestinal disease, but it does not seem to be hereditary or and respiratory tracts, where they may cause severe contagious. Evidence strongly suggests it is caused internal bleeding. KS is diagnosed by an examina- by an infectious agent such as a virus. It is very tion of the skin and lymph nodes. The doctor also rare for more than one child in a family to develop may order other tests to see if the patient has other Kawasaki disease. Less than 2 percent of children diseases. have another attack of Kawasaki disease.

Treatment Options and Outlook Symptoms and Diagnostic Path Treatment should include an anti-retroviral agent The fi rst symptom is a persistent fever, coupled such as zidovudine, which will not affect the tumors with conjunctivitis, dry and cracked lips, swollen but will diminish the degree to which the immune lymph nodes, red swollen palms and feet, and a system is suppressed. Antiretroviral agents may also measleslike rash. By the end of the second week, boost the effectiveness of other drugs that do affect the skin at the tips of the fi ngers and toes peels and

196 keratinocytes 197 the other symptoms subside. The disease can last ermost layer of the skin, nails, horny tissue, and for more than three months and can recur. hair. Keratin is a tough substance that resists dam- While most children recover completely, sudden age from a wide range of chemical and physical death occurs in 1 or 2 percent of cases, usually due agents. to coronary thrombosis during the acute phase of See also KERATINIZATION, DISORDERS OF; KERATI- the illness. NOCYTES.

Treatment Options and Outlook Aspirin can reduce fever, rash, joint infl ammation, keratinization The process by which cells become and pain, and help prevent blood clots from form- tough and horny due to deposits of KERATIN placed ing. Intravenous gamma globulin can decrease the within them. Keratinization (also called cornifi ca- risk of developing coronary artery abnormalities tion) takes place in the EPIDERMIS (the outer layer when given early in the illness. of the skin), the hair, and the nails, where the cells fl atten out, lose their nuclei, and become fi lled with keratin as they approach the surface of the keloids Large permanent and sometimes dis- skin. fi guring scars that may develop after surgery or other injury to the skin. Occasionally they appear spontaneously (although they generally run in keratinization, disorders of Disorders usually families). Similar in appearance to hypertrophic characterized by obvious skin problems such as scars, keloids tend to grow indefi nitely. They fi ssures, scales, or thickening of the top layer are particularly apt to occur in those of Afri- of the EPIDERMIS (stratum corneum). Disorders can or Asian descent, and are less common in of KERATINIZATION include DARIER’S DISEASE, ICH- Caucasians. THYOSIS, epidermolytic hyperkeratosis, KID SYN- DROME, NETHERTON’S SYNDROME, REFSUM’S DISEASE, Symptoms and Diagnostic Path CONRADI’S DISEASE, HARLEQUIN FETUS, lipid storage Keloids are often found on the upper shoulders, the disease, FOLLICULAR HYPERKERATOSES, GROVER’S DIS- earlobes (after ear piercing), and the face, chest, and EASE, ACANTHOSIS NIGRICANS, POROKERATOSIS, PAL- neck. Rare in infancy and old age, they appear more MAR-PLANTAR KERATOSIS. often in childhood, reaching a maximum outbreak between puberty and age 30. They slowly improve as patients get older. This relationship to age (and keratinocytes Cells responsible for maintaining the fact that they sometimes appear during preg- the skin’s barrier that make up about 80 percent nancy) suggests a possible hormonal infl uence. of the body’s epidermal cells. The keratinocytes are made of the protein KERATIN; soft keratin is found Treatment Options and Outlook in the epidermal cells and hard keratin is found in Treatment is usually not satisfactory, since keloids hair and nails. tend to recur after excision, at which point they The lowest layer of the EPIDERMIS is called the can become even larger and more unsightly. basal layer, where the cells of the epidermis are Small keloids may be treated by CORTICOSTE- born; these cells reproduce rapidly and rise gradually ROIDS injected into the lesions. Large keloids can toward the surface. These cells lie right next to the be debrided surgically but must be injected with DERMIS, with its rich supply of blood vessels and glan- corticosteroids immediately after surgery and four dular secretions. Their health and growth is depen- weeks later. dent on the food and oxygen that the tiny capillaries of the dermis carry. As the cells in the basal layer are pushed up into the other layers, they undergo keratin A protein containing high amounts of many changes, including the increase in the amount sulfur that is the primary component of the out- of keratin they produce. By the time the cells of the 198 keratitis-ichthyosis-deafness syndrome basal layer reach the top layer of the epidermis, they keratolysis Dissolution of the STRATUM CORNEUM. are no longer alive and they are entirely formed of keratin. This process of growth, maturation, and death is called keratinization. Problems in the speed keratolytic drugs Drugs that soften and loosen and mount of keratin formation, as well as its dis- KERATIN (the tough outer layer of the skin) and posal, lead to many different skin problems, such as remove scales. They include preparations of SUL- thickened, cracked, and infected skin. FUR, SALICYLIC ACID, and lactic acid, which are used If the cells contain too little keratin, the appear- in the treatment of skin and scalp disorders such as ance begins to look cracked and fl aky as cells WARTS, calluses, ACNE, DANDRUFF, and PSORIASIS. slough off. This can leave the lower layers exposed to infection and irritation. Keratin needs water to keep it pliable and healthy; when there is not keratosis, seborrheic A skin lesion of unknown enough water, the keratin crumbles and the cells cause range from fl at, dark brown rough patches cannot stay together. This is what happens when to small, warty protrusions that are covered with the skin becomes dry. a greasy, removable crust. Completely harmless but unsightly, it usually appears on light-skinned people after age 40. keratitis-ichthyosis-deafness syndrome See KID While the lesions may appear alone, they are usually found in groups on the face, chest, back, SYNDROME. abdomen, and extremities. As time goes on, the lesions become more deeply pigmented, become increasingly raised from the skin and develop a keratoacanthoma A skin NODULE that usually appears on the face or arm of elderly people that rougher contour. They are not caused by exposure is often very diffi cult to distinguish from invasive to sunlight or by a virus. SQUAMOUS CELL CARCINOMA. A biopsy may be nec- Treatment Options and Outlook essary to tell the difference. When large, irritated or infl amed, they can be Initially small, it grows rapidly for two to three treated with a variety of techniques including months, reaching a maximum size of about 2 cm CRYOTHERAPY, ELECTRODISSICATION, or CURETTAGE. across. The mature nodule has the slope of a vol- See also KERATOSIS PILARIS; DARIER’S DISEASE. cano with bulging sides and a craterlike center. Its cause is unknown, but it tends to be more common in those who have had years of exposure keratosis, solar See ACTINIC KERATOSIS. to strong sunlight and in those taking long-term immunosuppressant drugs. keratosis follicularis See DARIER’S DISEASE. Treatment Options and Outlook Left alone, keratoacanthoma regresses completely, often leaving unpleasant scarring. It is best to keratosis pilaris A type of follicular HYPERKERATO- remove it. SIS characterized by sandpaper-like skin with skin plugs that typically occurs on the upper outer arms. It may fi rst begin in childhood or during adoles- keratoderma A group of skin disorders character- cence, and is more severe in winter. An associated ized by thickening of the STRATUM CORNEUM on the form of the condition causes a red halo around palms and soles. each plugged follicle. Less frequently, it may affect the thighs or the cheeks. This disorder is chronic, but it improves during keratohyaline granules Deep, irregular grains in the summer months. While it is a nuisance, it is of the outermost layer of the skin. no medical signifi cance. kissing bug bites 199

Treatment Options and Outlook kidney disease, glomerulonephritis with kidney Emollients (such as Eucerin cream), agents con- insuffi ciency can complicate the course of LUPUS taining lactic acid (Eucerin Plus), Lac-Hydrin or ERYTHEMATOSUS and SYSTEMIC VASCULITIS and have tretinoin (Retin-A) may be effective, but they must prominent skin features. In addition, patients with be used continuously for continuous effect. Most progressive systemic sclerosis can also develop kid- patients improve after being exposed to ultraviolet ney failure. radiation. Other skin symptoms associated with kidney dis- See also KERATOSIS; DARIER’S DISEASE. ease include NAIL-PATELLA SYNDROME, which causes nail plate abnormalities and progressive renal dis- ease; FABRY’S DISEASE, featuring small blue-black kerion An infl ammatory fungal infection of the papules around the navel and kidney; generalized scalp characterized by a red pustular swelling, itching during hemodialysis; bullous dermatosis of which lasts for up to two months. It may leave a renal failure, characterized by tense BLISTERs while scar and permanent loss of hair from the affected on hemodialysis and sometimes in patients with area. chronic kidney failure; and skin lesions (WARTS, chronic HERPES, SQUAMOUS CELL CARCINOMA, ALO- Treatment Options and Outlook PECIA, bacterial and fungal infections) in kidney Aggressive treatment with a systemic antifungal transplant patients. such as GRISEOFULVIN with systemic steroids is usu- ally recommended. See also TINEA. KID syndrome The common name for keratitis- ichthyosis-deafness, this rare KERATINIZATION disor- der leads to blindness and is associated with deaf- ketoconazole (Trade name: Nizoral) An antifun- ness and an unusual skin scaling. Patients with this gal drug used to treat TINEA VERSICOLOR or yeast condition have leathery skin texture, thickened infection (THRUSH), superfi cial dermatophytoses, palms and soles, and sparse hair. some systemic fungal infections, and seborrheic Other associated health problems may include dermatitis. mental retardation, tight heel cords, tooth prob- lems, and recurrent skin infections. The biochemi- Side Effects cal basis for this disease is unknown. Ketoconazole may cause nausea, but this may be avoided by taking the drug with food. It should not be taken at the same time as antacids, however, kissing bug bites Kissing bugs (members of the because ketoconazole requires an acidic stomach family Reduviidae), are also known as assassin for absorption. bugs, cone-nose bugs, Walapai tigers, or Mexican Other side effects include itching, headache, bedbugs, and cause HIVE-like nodules or plaques dizziness, abdominal pain, constipation, diarrhea, with severe itching lasting up to a week. Sensitive nervousness, rash, and liver damage. Occasionally, individuals may experience hemorrhagic, giant patients may experience hives and allergic reac- hives or anaphylactic shock. tions with the fi rst dose. The bugs bite at night in small clusters on uncov- Drug interactions with ketoconazole can be ered body parts such as the face or arms. They are serious; this drug should not be taken with generally brownish to black, medium-sized to large rifampin, isoniazid, warfarin, cyclosporine, or insects, usually found on foliage, although some phenytoin. occasionally enter houses. The adults often bite humans around the mouth; hence, its other com- mon name, the kissing bug. The kissing bug can kidney disease and skin symptoms While symp- carry relapsing fever and Chagas’ disease (Ameri- toms in the skin are not often associated with can trypanosomiasis). 200 Klippel-Trenaunay syndrome

While most are found in South America, that was once standard treatment is less common about 15 species are found in the southwestern today. Any surgical intervention should be very United states. They usually live near rodents, carefully considered. armadillos, and opossums, but they can also be found in houses, living off humans. In the Southwest assassin bugs of the genus Triatoma Koebner’s (Köbner’s) phenomenon Lesions are common, where they invade houses and may induced by scratching found in skin diseases such bite humans. as PSORIASIS or LICHEN PLANUS.

Klippel-Trenaunay syndrome A rare congenital koilonychia Also called “spoon nails,” this is a disorder of blood vessel abnormalities character- condition in which nails are thin, dry, brittle, and ized by port-wine BIRTHMARKS, VARICOSE VEINS, and concave (spoon shaped), with raised edges. In nail- other symptoms. patella syndrome, the nail may be split into two The cause is presently unknown, but is believed spoon-shaped parts. to be either genetic or the result of an intrauter- Injury to the nail, iron-defi ciency anemia, and ine trauma between the third and sixth week of LICHEN PLANUS are the main causes; the condition gestation. may be inherited.

Symptoms and Diagnostic Path The most apparent symptom of Klippel-Trenaunay kwashiorkor A severe type of malnutrition in Syndrome (KTS) is the PORT-WINE STAIN, present young children occurring mainly in poor rural at birth and typically covering a large area of the areas in developing countries, in which the child’s affected limb. The trunk can be affected, with the skin fl akes off, leaving a raw, weeping area most typical pattern being from hip to toe, involv- beneath. Hair may lose its curliness, become ing the buttocks on one side. The port-wine stain sparse and brittle, and turn from dark to fair. The may be dark pink to purple and can be raised with nails tend to be soft and thin. The illness begins nodules that bleed easily. Bleeding and skin infec- when the child is suddenly weaned on a poor tions are common with KT, and pain is a major diet low in calories, protein, and essential micro- concern with most patients. nutrients (such as ZINC, selenium and VITAMINS A In the past, KTS was sometimes called Klippel- and E). Trenaunay-Weber syndrome but “Weber” has been Derived from the Ghanaian word meaning “dis- dropped to avoid confusion with the Parkes Weber ease suffered by a child displaced from the breast,” syndrome, a condition characterized by malforma- kwashiorkor usually affects only those children tions of the arteries leading to overgrowth of arms between ages one and three. and legs similar to KTS. Kwashiorkor may also be found among elderly people and in some patients with systemic diseases Treatment Options and Outlook characterized by problems in absorbing or digesting Laser treatment with a PULSED DYE LASER is avail- protein. able to lighten the port-wine stain in children and adults. Compression garments worn on the Symptoms and Diagnostic Path affected limb can ease pain and swelling. Sequen- In addition to the skin and hair symptoms, tial extremity pumps can help compress the limb. growth is stunted, and there may be swelling. Antibiotics for CELLULITIS (skin infections) and iron Behavioral symptoms in children include apathy, supplements to combat anemia are helpful. Sclero- weakness, irritability, and inactivity. The liver therapy (injecting alcohol into the veins) is used to becomes enlarged, and the child loses resistance clot veins in some patients. However, vein stripping to disease. Kyrle’s disease 201

Treatment Options and Outlook Symptoms and Diagnostic Path Warmth and fl uids are important; infections should Symptoms include horny plugs surrounded by a be treated. The child should fi rst be fed milk and red rim that may enlarge to form plaques. The vitamin/mineral tablets, with the administration lesions are found most often on the extremities, of zinc to prevent further skin fl aking. When the although they may occur anywhere on the body. A child’s appetite returns, a high-calorie, protein-rich similar condition may appear in patients undergo- diet should be given. ing kidney dialysis. Most children treated for the condition recover, but those younger than age two are likely to suffer Treatment Options and Outlook permanent stunted growth. Severe untreated cases Administration of a keratolytic agent or liquid can be fatal; blood poisoning kills about 30 percent nitrogen may be effective, but the disease is dif- of patients with kwashiorkor. fi cult to treat.

Kyrle’s disease A disorder of KERATINIZATION known medically as hyperkeratosis follicularis et parafollicularis or en cutem penetrans. L laceration A torn ragged wound. entire body. Redness is noticeable in infancy and usually remains throughout life; hair loss occurs in some patients. LAMB syndrome See MULTIPLE LENTIGINES SYNDROME. Treatment Options and Outlook Infants should be kept in a continuous humid environment and the membrane encasing the child lamellar dystrophy of nails The splitting of nails should not be removed. Moisturizing the skin is into layers, also called onychoschyzia, often found essential, moisturizers containing lactic acid are in those who must immerse their hands in water. especially helpful. Systemic therapy with etretinate The condition may be caused by the constant or ISOTRETINOIN is extremely helpful, but results absorption and evaporation of water from the nail only last as long as treatment continues. The side plate. It is usually found in those whose hands are effects of high dose therapy are signifi cant. continually in and out of water, such as dish wash- Right after birth, after the collodion membrane ers or laundresses. is shed, newborns are at risk for secondary infec- tion and dehydration. As the child gets older, the condition can interfere with normal sweat gland lamellar ichthyosis A disorder of KERATINIZATION function, which can lead to heat intolerance. characterized by redness at birth with large, dark Although the disorder is not life threatening, it is scales on the face, palms, and soles of the feet. quite disfi guring and causes considerable psycho- This is usually a severe form of ICHTHYOSIS that logical stress to affected patients. This disorder has can produce considerable disability and deformity no cure; therefore, treatment is directed at decreas- throughout life. ing symptoms. This condition is a rare autosomal recessive trait, which means that a defective gene must be inherited in a double dose to cause the abnormal- Langerhans cell A type of cell that makes up ity. Generally, both parents of an affected person about 4 percent of all epidermal cells. It is an are unaffected carriers of the defective gene. Each extremely important part of the body’s immune of their children has a one in four chance of being system. affected, and a two in four chance of being a carrier. It occurs in fewer than one child out of 300,000. Langer’s lines Lines of cleavage of the skin deter- Symptoms and Diagnostic Path mined by the position and orientation of COLLAGEN The condition is always noticeable at birth, and is bundles and elastic fi bers. often a result of prematurity. Babies may be born encased in a membrane that is eventually shed. There is generalized severe dryness and scaling; in lanolin A mixture of purifi ed water and a yellow, some patients, large dark scales appear over the oily substance obtained from sheep’s wool that is

202 laser hair removal 203 used as an EMOLLIENT to treat dry skin. Lanolin is a tions include bacterial infections, which can result common ingredient of bath oils and hand creams. from excessive scratching. It is also used to treat mild DERMATITIS. Occasionally lanolin can irritate the skin and in some individuals Treatment Options and Outlook an allergic reaction develops. Thiabendazole is the drug of choice; its topical form is best for mild infections, applied to the tracks and normal skin around the traces. Systemic thiaben- lanugo The fi ne, downy hair on the body of a dazole is also effective, but causes many side effects fetus that fi rst appears in the fourth or fi fth month (dizziness, nausea, and vomiting). and usually disappears by the end of the pregnancy. About half of the larvae die within three months, It can still be seen in some premature babies. even without treatment. Lanugo hair (hypertrichosis lanugiosa) some- times reappears on the skin of adults with can- cer (especially of the breast, bladder, lung, or laser hair removal A nonsurgical cosmetic pro- large intestine), in patients with anorexia ner- cedure using a low-energy laser that can per- vosa, or as a side effect of some drugs (especially manently reduce unwanted facial or body hair. CYCLOSPORINE). The laser passes through the patient’s skin and is absorbed by the pigment in the hair follicle, which immediately and permanently disables a percent- larva migrans, cutaneous Also known as creep- age of the follicles. In most cases, no anesthesia ing eruption, this disease is caused by HOOKWORM is necessary. The process can take from several larvae that normally parasitize dogs, cats, or other minutes to several hours, depending on how much animals. It is contracted by walking barefoot on soil hair will be removed and the part of the body or beaches contaminated with animal feces. The involved. larvae penetrate the skin of the feet and move ran- This noninvasive technique can remove domly, leaving intensely itchy red lines (sometimes unwanted hair anywhere on the body, leaving skin accompanied by BLISTERS). looking smoother. Because it can remove more Because several different parasites produce simi- than one hair at a time, it can be used to treat lar symptoms, there may be diffi culty in diagnos- larger areas with minimal discomfort. National ing specifi c disease such as many fall under the average cost of the procedure is about $355 per umbrella of “cutaneous larva migrans.” Usually treatment, although fees vary considerably by geo- the term refers to disorders caused by cat or dog graphic region, according to the American Society hookworm larvae. for Aesthetic Plastic Surgery. Shaded, moist, and sandy areas—such as beaches, children’s sandboxes, and areas under- Risks and Complications neath houses—are the most likely spots to harbor Sometimes there is a temporary slight reddening of larvae. The eggs passed in the feces hatch into the skin or localized swelling. infective larvae that can penetrate human skin (even through beach towels). Outlook and Lifestyle Modifi cation This type of hair removal should be considered to Symptoms and Diagnostic Path be an ongoing process that requires several ses- Skin lesions usually appear in areas that are in sions. After the treatments, clients may have to contact with soil, such as feet, hands, and buttocks. use specially formulated skin care products, or a A red PAPULE appears within a few hours after the prescribed skin care regimen. SUNSCREEN is recom- larvae penetrates the skin. After a latency period mended for any treated areas that may be exposed of a few days to a few months, the larvae migrate, to the sun. causing a red, raised intensely itchy red line that Patients with darker skin may not respond may loop and meander all over the skin. Complica- well, and blond, white or, gray hairs are less 204 laser resurfacing responsive to laser treatments and sometimes can- kept moist with ointment or surgical bandages for not be treated. the fi rst few days. The skin is usually crusted pink or red, and depending on the type of laser and the patient’s condition, the pink color may last for sev- laser resurfacing A technique for removing eral days to several months. Makeup can be worn medium to fi ne wrinkles and ACNE scars. Lasers over the treated skin for one to two weeks. produce an intense beam of bright light in one CO2 laser The newest pulsed CO2 laser pro- direction, which can vaporize wrinkles, scars, and vides short bursts of extremely high-energy laser blemishes and seal blood vessels. With its unique light that vaporizes skin tissue, revealing fresh ability to produce one specifi c wavelength of light skin underneath. Its highly focused beam allows of varied intensity and length of pulse, the laser can the DERMATOLOGIST to gently remove the skin’s be used for many different purposes. surface with less risk of complications (such as There are several signifi cant advantages that scarring). It typically takes up to two months to laser resurfacing, which can be performed in heal completely. the DERMATOLOGIST’s offi ce, offers over traditional erbium:YAG (Er:YAG) Once this high-powered techniques. A relatively bloodless procedure, laser laser gently penetrates the skin, it is absorbed by resurfacing offers more control in how deep the water in the tissue’s cells, which scatters the heat beam will penetrate the skin’s surface, which so that the physician can more precisely remove allows the physician to direct the light with preci- thin layers of tissue while lessening the risk of sion and safety in treating delicate areas around damage to surrounding skin. This laser is ideal for the lips and eyes, where it is an ideal technique patients with minor scars, superficial to moderate to erase fi ne lines and wrinkles (especially on the facial wrinkles, or skin discolorations. This laser upper lip, cheeks, and forehead). The treatment also can rejuvenate sun-damaged delicate skin also can smooth and tighten eyelid skin, improve around the eyes and mouth without scarring, and crow’s-feet, soften frown lines, even out skin tone also may be used for the neck or hands. The ben- by removing brown spots and splotchy skin color, efits of this laser include less redness, fewer side fl atten scars, and repair smoker’s lines. Depend- effects, and rapid healing. ing on the type of laser and reason why it is being Long pulse lasers More recently developed used, the treatment may call for a topical anes- lasers provide results better than the CO2 but thetic cream, sedation, local anesthesia, or moni- not as dramatic as the Er: YAG. These lasers offer tored intravenous sedation. There is not much more wrinkle relief with less scarring risk, but discomfort during the procedure or throughout their lower heat levels means results may not be recovery. as dramatic. There are two basic categories of lasers that can be used to resurface the skin: ablative and Non-ablative (Non-wounding) Lasers non-ablative. These lasers have become quite popular, since this technique actually works beneath the skin’s sur- Ablative Lasers face, meaning little recovery time is required. By Ablative lasers remove the top layer of the skin, directly treating the layers beneath the top layer of heating the next layers of the skin enough so skin, the tissue can respond by regenerating skin as that they regenerate COLLAGEN, the substance that if it were repairing a wound. The process seems to makes up skin. This creates a wound that sub- stimulate collagen growth and tighten underlying sequently heals with smoother, more even skin. skin, improving skin tone and removing fi ne lines There are three types of ablative lasers used for and mild to moderate skin damage. However, non- resurfacing: carbon dioxide (CO2), erbium:YAG ablative treatments require many sessions and may (Er:YAG), and the long pulsed erbium:YAG. After take several weeks for the fi nal results to become ablative resurfacing, the treated areas usually are apparent. laser treatment 205

Non-ablative resurfacing treatments may take laser treatment The acronym for “Light Ampli- only a few minutes. Mild redness may last for a few fi cation by Stimulated Emission of Radiation,” hours with non-ablative techniques, and makeup lasers produce light of specifi c wavelengths in a may be applied afterward. Four to six treatments nondivergent beam of monochromatic radiation are usually necessary because the results from that can mobilize immense heat and power when non-ablative techniques are generally less dramatic focused at close range. They can be used as a tool than those with Er:YAG and CO2 lasers. in both diagnosis and surgical procedures. A laser is a device that contains an active medium of either a Risks and Complications gas, such as carbon dioxide or argon; a solid, such The most common complication of laser resurfac- as ruby or neodymium: yttrium-aluminum-garnet ing is a darker-than-normal skin tone that may (Nd:YAG); or a liquid, such as a dye that is powered begin three to four weeks after surgery and can by a source (such as electricity) to produce a beam last several months. Patients with darker skin are of single-colored light up to 10 million times more at higher risk for developing this HYPERPIGMENTA- powerful than the Sun. TION. Some patients may need to use BLEACHING Laser light is absorbed by different types of sub- CREAMS to help even out skin color after laser stances in tissue, depending on its wavelength, and resurfacing. it is the absorbed light which produces the effect on Although there is some risk with all surgical pro- tissue. In a matter of seconds, this intense beam of cedures, scarring is not likely with the new Er: YAG light can hit a target and remove a skin problem, and CO2 lasers. Side effects are even more greatly leaving little or no scarring. Most laser surgery can reduced with the milder non-ablative lasers. be done in the DERMATOLOGIST’s offi ce, and it is Medication given before surgery can help pre- relatively painless, simple, quick, causes no blood vent COLD SOREs, which sometimes fl are up because loss, and is very effective. of an existing herpes virus infection already pres- Lasers have revolutionized the treatment of ent in the body. skin disease. Physicians wielding lasers can treat all Common side effects may include crusting, sorts of skin problems, from precancerous growths swelling, or discoloration at the treatment site. to PORT-WINE STAINS. The color of the light a laser Other complications include ACNE fl ares and emits determines what kind of skin problem it can infl ammatory of the skin. Newer surgical tech- be used to treat. niques and meticulous postoperative care have Ruby lasers, which produce red light (694 nm), lessened the risks of pain, bleeding, swelling, and remove some tattoos and pigmented lesions such infection, but a reddened face for a few weeks as CAFÉ-AU-LAIT MACULES and lentigines or liver is not uncommon, and occasionally may last for spots. The Nd:YAG laser at 1064 nm (in the infra- months. red spectrum) is also effective for tattoos and pig- mented disorders. The CARBON DIOXIDE LASER also Outlook and Lifestyle Modifi cation produces invisible infrared radiation (10,600 nm) Laser resurfacing is not a substitute for a FACE- and is used to remove benign skin growths, warts, LIFT, and the procedure will not be able to tighten and to resurface the skin. The PULSED DYE LASER up loose facial skin or jowls. However, benefi - is the best treatment for birthmarks such as the cial tightening of loose skin can occur from laser port-wine stain and hemangiomas, telangiectases, resurfacing, easing some facial folds and creases. SPIDER ANGIOMAS, and venous lakes. Lasers are also In many cases, laser resurfacing is an alternative effective in treating scars and stretch marks, for to traditional methods of skin rejuvenation, such removing unwanted hair, and for reversing signs as DERMABRASION and deep chemical peels. It can of skin aging. also work well together with chemical peels, eyelid Not all skin problems respond to laser treatment, surgery, LIPOSUCTION of the face and neck, collagen however. While laser treatment of spider veins implants, and botulinum toxin. in the legs has improved over the past few years, 206 latex allergy they are still best treated by sclerotherapy, which sensitive to latex. Workers in the latex manu- involves injections of a saline solution or an agent facturing industry (such as glove manufacturing called aethoxysclerol. plants and latex doll manufacturers) are also at Dermatologists do not usually use lasers to higher risk. remove malignant skin growths, unless the patient Between 1988 and 1992, the U.S. Federal is taking blood thinners that could heighten the Drug Administration (FDA) received more than risk of hemorrhage during conventional surgery. 1,000 reports of adverse health effects from Lasers can be extremely dangerous when used exposure to latex, including 15 deaths due to around the eyes. A stray beam can hit the cornea such exposure. or be absorbed by the retina and blind the patient. Any product containing latex may trigger Protective goggles and eye shields are used to pre- a reaction. Medical products made with latex vent eye damage. include adhesive tape, bandages, bulb syringes, Before consenting to laser surgery, patients dental devices, electrode pads, injection ports, should make sure the physician has had formal face masks, latex gloves, mattresses on stretch- training and hands-on experience. ers, PCA syringes, rubber syringe stoppers and The American Society for Dermatologic Surgery medication vial stoppers, stethoscope and blood or the American Society for Lasers in Medicine and pressure cuff tubing, tourniquets, urinary cath- Surgery can provide a list of dermatologists quali- eters, and wound drains. Latex is also found in a fi ed to perform laser surgery. wide variety of products around the house, such as balloons, buttons on electronic equipment, carpet backing, clothing (including underwear latex allergy Natural rubber latex, the stretchy elastic), computer mouse pads, condoms, diapers, material used in everything from balloons and diaphragms, erasers, food handled with pow- baby bottle nipples to surgical gloves and con- dered latex, gloves, nipples and pacifi ers, handles doms, can cause an allergic skin reaction ranging on racquets and tools, rubber bands, sanitary and from mild irritation to life-threatening anaphylac- incontinence pads, shoe soles, sports equipment, tic shock. Those most at risk are health-care work- and toys. ers, rubber plant workers, and children with birth In addition, certain fruits (such as bananas, defects requiring multiple surgeries early in life. chestnuts, kiwi, avocado, and tomato) may also In addition, the U.S. Food and Drug Adminis- trigger symptoms in latex-allergic individu- tration has traced 16 deaths to a violent allergic als, perhaps because these foods are similar to reaction to an infl atable latex cuff used when a latex protein component. These foods have administering barium enemas; the enema appa- been responsible for anaphylactic reactions in ratus was later recalled by the manufacturer. latex-sensitive persons, while many other foods, Reactions to latex were rarely reported before including fi gs, apples, celery, melons, potatoes, 1970, but since the late 1970s many reactions papayas, and pitted fruits, such as cherries were reported each year. Since then, latex allergy and peaches, have caused progressive symptoms has become a major health concern as more and beginning with ITCHING in the mouth. People more people in the workplace have been affected. with a history of reactions to these foods have a It appears that the increase in total exposure to higher risk of developing a latex allergy. Those latex and variations in manufacturing have led who are sensitive to latex should avoid foods to to a true increase in the number of persons with which they have had previous reactions. latex sensitivity. While experts still do not know a great deal Health care workers exposed to latex gloves about food cross-reactions, it is clear that elimi- or medical products containing latex are at espe- nating all of these foods would cause signifi cant cially high risk. It is estimated that between 8 dietary restriction and is therefore not recom- and 12 percent of health care workers are now mended to every latex-allergic persons. Lawrence-Seip syndrome 207

Symptoms and Diagnostic Path identifi cation. Medical workers should carry extra Airborne latex particles that stick to the cornstarch pairs of nonlatex gloves for emergency medical or used to powder the inside of latex gloves are a dental care. source of sensitization and a signifi cant cause of See also ALLERGIES AND THE SKIN. breathing problems in sensitive individuals. Once a person has become sensitized, allergic symp- toms may appear during exposure to any product Lawrence-Seip syndrome A skin manifestation of containing latex. About a third of patients who insulin-resistant diabetes with both congenital and develop hives from contact with latex also develop acquired types. Many of the cases have involved other symptoms, including hay fever, asthma, and individuals of Portuguese or Norwegian ancestry, even anaphylactic shock. (In anaphylactic shock, although Lawrence-Seip syndrome can affect any a victim can develop shortness of breath, swollen race. Males and females are affected equally in lips, and throat, heart, and breathing diffi culties the congenital form, but more females are effected within minutes). Death can result from anaphy- with the acquired form. lactic shock without prompt treatment. Glove wearers may experience delayed hypersensitivity, Symptoms and Diagnostic Path skin irritation ranging from nonspecifi c itching to The two forms of this syndrome have different red, weepy skin. These symptoms are caused by symptoms. The congenital form of Lawrence-Seip the accelerators and chemicals used in the glove syndrome is obvious from birth, while the acquired manufacture and not by the latex itself. form usually can be diagnosed before age fi ve years Direct skin contact with latex may cause an but certainly by age 15. immediate hypersensitivity reaction of local or gen- Congenital Lawrence-Seip The congenital type eralized HIVES within 30 to 60 minutes. Some per- is typically diagnosed in the fi rst two years of life, sons have experienced anaphylactic reactions after and is inherited in an autosomal recessive pat- having no previous symptoms. In fact, it is possible tern. This means that the defective gene must be to have used latex gloves for years and to suddenly inherited in a double dose to cause the syndrome. have a progression to systemic symptoms. These infants can be easily diagnosed because of an almost complete lack of subcutaneous fat. Although Risk Factors and Preventive Measures the baby will have a few smaller-than-normal fat Health care workers now use a new set of gloves cells, they contain little fat. Organs are enlarged, for each patient they treat. More importantly, and toddlers may have a potentially dangerous avoiding latex gloves or glove liners often can overgrowth of tonsils and adenoids. These patients eliminate these symptoms entirely. have well-defi ned muscles with prominent superfi - Powder-free gloves are now available because of cial veins. Wasting away of the clitoris or penis may new ways of treating latex that make gloves easier be obvious. The earliest skin manifestations include to put on than powdered gloves. Some newer glove excess hairiness of the face, neck, arms, and legs, products have very low protein levels, although and thick, tightly curled scalp hair that extends there is a wide variation among different brands. nearly to the eyebrows. There is no special growth Health care workers and patients allergic to latex of the pubic or underarm hair. must use nonlatex gloves. The National Institute of All patients with Lawrence-Seip syndrome have Occupational Safety and Health (NIOSH) recom- ACANTHOSIS NIGRICANS, a skin disease character- mends that nonlatex gloves be used for activities ized by grayish warty pigmented lesions in body that do not involve contact with infections mate- folds and under the arms, on the elbows, knees, rials, such as food preparation, or routine house- and waist. Acanthosis nigricans can disappear with keeping and maintenance. puberty. Gigantism with advanced bone age and Anyone sensitive to latex should carry an epi- advanced appearance of teeth is an early and con- nephrine auto-injection kit and wear Medic-Alert stant feature. The growth rate is most marked in the 208 leg ulcers

fi rst four years of life; these children may reach more also are common causes of death in the congenital than 90 percent of their adult height within the fi rst form. 10 years of life. Growth eventually slows down and Patients with the acquired form tend to die in they reach short or normal height as adults. The middle age, often from gastrointestinal hemor- abnormal distribution of fat in these patients does rhage and liver failure. not affect female breast development at puberty, although females with this congenital syndrome have marked muscularity. Liver disease with cir- leg ulcers An open sore on the leg that does not rhosis is another constant feature, and an enlarged heal, usually caused by an inadequate blood sup- spleen tends to produce a protruding abdomen. ply from the area. Leg ulcers are most often found Diabetes mellitus usually begins in adolescence. among the elderly. Kidneys may be enlarged without apparent cause, BEDSORES (also called decubitus ulcers) develop and kidney failure may result. An enlarged heart on pressure spots on the legs as a result of poor is often observed with atrophied muscle and ven- circulation, pressure and immobility over a period tricular dysfunction. There may be heart murmurs of time. Leg ulcers may also be due to peripheral and possibly high blood pressure. There also may vascular disease (restricted blood supply to the be other problems with the heart, bones, and extremities caused by thickening of the artery kidneys. walls). Diabetes mellitus, which increases suscep- Acquired Lawrence Seip In this form of the tibility to blood vessel disease and skin infection, syndrome, there may be a generalized problem may also lead to leg ulcers. with fat loss over the entire body, often following an illness or infection. The fat loss becomes obvi- Treatment Options and Outlook ous in adolescence or early adult life. Most of the Treatment should be sought as early as possible. If features of the congenital form may occur, but in an ulcer is fi lled with PUS, a wet dressing should be the acquired form there are not usually any heart, applied under a bandage. This should be changed brain, or kidney problems. Bone age and genitals only every three to seven days to avoid removing are normal. There may be some degree of acantho- new skin from the area. sis nigricans. In this form of the disease, autoimmune disor- Risk Factors and Preventive Measures ders may be common, including hemolytic anemia Prevention is preferable to undergoing treatment. and chronic infl ammation of the kidneys. Patients Anyone susceptible to leg ulcers should avoid obe- with the acquired form of Lawrence-Seip syn- sity, leg injury, and immobility. drome also are prone to infection.

Treatment Options and Outlook leishmaniasis A variety of diseases that affect the Patients with Lawrence-Seip syndrome must main- skin and mucous membranes caused by infection tain a rigid special diet with four regular-sized meals with single-celled parasites (called leishmania). The a day, because of the limited ability to store energy parasites are found in dogs and rodents in many as fat. In addition, some experts have treated this parts of the world except Australia, Antarctica, the condition with leptin, a hormone secreted by fat United States (with the exception of Texas), and cells, which may improve insulin resistance, high large areas of Africa. Parasites are transmitted from blood sugar, low fat stores, and liver problems. the animals to humans via the bites of sand fl ies, Patients with the congenital form of Lawrence- which live on the fur of the animals. There are at Seip syndrome can live to young adulthood or least three types of the disease that affect the skin, early middle age, although childhood death as a one of which is common in the Middle East, North result of massive gastrointestinal (GI) bleeding has Africa, and the Mediterranean; the others are been reported frequently. Kidney complications found in Central and South America. lentigo 209

Symptoms and Diagnostic Path many other developmental problems, such as deaf- A persistent ulcer that may eventually heal but ness and short stature. can leave an ugly scar forms at the sand-fl y bite. In See also LENTIGO; LENTIGO, ACTINIC; LENTIGO, the South American form, there is more extensive MALIGNA. tissue damage (often on the face), often causing severe disfi gurement. lentigo A harmless fl at, pigmented area of skin Treatment Options and Outlook similar to a FRECKLE. They are more common in All forms of this disease are treated effectively middle-aged and elderly people, and in those who with drugs (such as sodium stibogluconate or glu- have been exposed to the sun. cantime) given by injection into a muscle or vein. Lentigines (the plural of lentigo) may evolve All types of this disorder with secondary bacterial slowly over years, or they may suddenly appear all infection also should be treated with antibiotics. at once. They are most often associated with either Current treatments for leishmaniasis are expen- a single day of excessive sun exposure or from sive; some have serious side effects and may lead to years of repeated sun exposure in fair-skinned the development of drug-resistant parasites. individuals. In the United States, lentigines are seen in as many as 90 percent of Caucasians older Risk Factors and Preventive Measures than 60 years and in 20 percent of Caucasians Studies are being conducted to develop a new younger than 35. Solar lentigines are more abun- human vaccine for leishmaniasis. The studies are dant in fair-skinned Caucasians; dark-skinned indi- being funded primarily through a $15 million viduals do not usually develop lentigines because grant from the Bill and Melinda Gates Foundation they have more natural pigment that provides through the Infectious Disease Research Institute. some degree of protection from the sun. How- Because a new canine vaccine against visceral ever, inherited patterned lentigines can appear in leishmaniasis has proven effective in early trials, African Americans, particularly those with mixed experts hope that the high incidence of the disease American Indian heritage and those with relatives in both dogs and humans can be reduced. Infected with red hair. dogs are an important reservoir for continuing These lesions are signifi cant because although disease. benign, they may eventually become malignant. If the cells in the lesion look normal, the condition is called lentigo simplex. If the cells are abnormal, the lemon A fruit that contains both citric acid and condition is known as LENTIGO MALIGNA; these cells VITAMIN C, lemon is good at cutting grease and is can turn into a malignant melanoma. one of the few natural ingredients that can retain its properties after chemical extraction. For best Symptoms and Diagnostic Path results, however, cosmetics should contain con- This common condition is more common in middle- centrated lemon juice and not just the essence for aged and elderly people, and in those who have a lemony fragrance. been exposed to the sun. They occur equally among Fresh-squeezed and diluted lemon juice is an different races and genders, and can be found in all excellent rinse for oily hair. age groups. Unlike FRECKLES, lentigo lesions do not darken in response to sunlight exposure. lentiginosis profusa Also known as generalized Treatment Options and Outlook lentiginosis, this disorder is characterized by the No treatment is necessary, but if cosmetically unac- appearance of many small dark brown spots (len- ceptable it is best treated with cryotherapy or laser tigines). It is different from MULTIPLE LENTIGINES therapy. SYNDROME, which involves multiple lentigines and See also MELANOMA, MALIGNANT. 210 lentigo, actinic lentigo, actinic Also known as a solar lentigo, Treatment Options and Outlook age spot, or liver spot, this harmless small brown Surgical removal, or cryotherapy, or radiation is macule differs from a LENTIGO simplex by its larger effective. size and by its appearance later in life on sun- See also MELANOMA, MALIGNANT. exposed areas of skin, especially the face and the backs of the hands. LEOPARD syndrome See MULTIPLE LENTIGINES Symptoms and Diagnostic Path SYNDROME. Similar in appearance to a FRECKLE, lentigines do not clear once sun exposure is stopped. They may be found alone or in groups and are more common leprosy A chronic bacterial infection known in middle-aged and elderly people and in those medically as Hansen’s disease that damages nerves who have been exposed to the sun. in the skin, limbs, face, and mucous membranes. Untreated leprosy can lead to severe complications, Treatment Options and Outlook which can include blindness and disfi gurement. No treatment is necessary, but if raised, darker Contrary to popular belief, it is not highly con- brown areas appear inside the lentigines, a physi- tagious. While the disease still carries signifi cant cian should be consulted since these areas could stigma, patient care has become integrated with develop into malignant melanoma. Lentigines can routine health care, and anti-leprosy organiza- be relatively easily treated with liquid nitrogen tions have fought to repeal unfair laws and prac- or by laser treatment with either the Q-switched tices. Patients should no longer be referred to as Nd:YAG laser, the Q-switched Alexandrite laser, or “lepers.” the Q-switched ruby laser. Although leprosy is one of the oldest diseases See also LENTIGINOSIS PROFUSA; LENTIGO, MALIGNA; in human history, it was not until 1873, when MELANOMA, MALIGNANT. Armauer Hansen fi rst saw the bacillus causing leprosy under a microscope, that the disease was discovered to be infectious instead of hereditary. lentigo maligna Also known as a melanotic freckle There were 678,758 new cases of leprosy of Hutchinson, this is considered to be a precancer- reported in 2004 in 91 countries, primarily in ous lesion that may transform itself into a malignant Asia, Central and South America, and Africa; but melanoma. It is different from an ordinary LENTIGO, probably fewer than 20 percent have access to which is benign. It is more common in women. treatment. India, Myanmar (Burma), and Nepal account for 70 percent of all cases. Africa is the Symptoms and Diagnostic Path second most common area. Brazil has 80 percent A lentigo maligna may start out as small fawn- of all cases in South America. Most cases in the colored macule—usually on the face—very similar United States occur in California, Florida, Hawaii, to a benign SEBORRHEIC KERATOSIS. As the patient Louisiana, New York, and Texas. There are about ages, it becomes larger and irregularly shaped and 100 new cases of leprosy each year in the United colored. It gradually gets bigger until it forms an States, and 12,000 new cases each week around irregular patch with jagged or notched borders, the world. Children represent about 16 percent of irregularly colored from tan to dark brown or the new cases of leprosy. black. It may also be red or white. Scientists now Leprosy is caused by a rod-shaped bacterium, believe that about 5 percent of these lesions turn Mycobacterium leprae, that is spread in droplets of into lentigo maligna melanoma. nasal mucus. A person is infectious only during The lesions are always seen on sun-exposed the fi rst phase of the disease, and only those living skin, and they are seen in patients older than those in prolonged close contact with an infected person who are seen with melanoma. are at risk. Leprosy is probably spread by droplet leprosy 211 infection through sneezing and coughing. In those forced to give up his seat after he was diagnosed with untreated leprosy, large amounts of bacteria with leprosy. are found in nasal discharge; the bacteria travel Religious customs also affected many treatments through the air in these droplets. They can survive for leprosy. In 250 B.C., Chinese patients pricked three weeks or longer outside the human body, in their swollen limbs to let out the “foul air.” Ramses dust, or on clothing. II of Egypt believed that people with leprosy who Although relatively infectious, leprosy is still used his water wells would be cured. And in medi- one of the least contagious of all diseases. This— eval Europe, it was believed that leprosy could be together with the fact that only 3 percent of the cured by the touch of a king. population is susceptible to leprosy—means that Historically, topical treatments ranged from tur- there is no justifi cation for the practice (still preva- tle soup, whiskey, and various poultices (onion, lent in some countries) of isolating patients. Only sea salt and urine in Egypt; arsenic and powdered a few people are susceptible because most people snake bones in China; water mixed with blood of acquire a natural immunity when exposed to the dogs and infants under age two in Scotland; ele- disease. phants’ teeth; the fl esh of crocodiles, snakes, lions, Most of the body’s destruction is caused not by and bears). Other ingredients ranged from carbolic bacterial growth but by a reaction of the body’s acid, creosote, phosphorus, mercury, and iodine, immune system to the organisms as they die. In and plant extracts, including madar, cashew-nut lepromatous leprosy, damage is widespread, progres- oil, gurjum oil, or chaul-moogra. sive and severe. Tuberculoid leprosy is a milder form The idea of caring for patients with leprosy of the disease. became popular among missionaries following biblical directives and the teachings of Jesus; this History service became fashionable about A.D. 1100 in Ancient religious traditions associated with leprosy Europe, after crusaders (including a king) returned continued to infl uence social policy well into the with the disease. Special hospitals were built, oper- 20th century. Leprosy was fi rst mentioned as a ated and supported by cathedrals, but with the curse in Shinto prayers of 1250 B.C.; it was also outbreak in the 1300s of bubonic plague, patients mentioned in some Egyptian legends to explain with leprosy began to be segregated again. Some the exodus of the Hebrews. For hundreds of years, countries seized the property of those with leprosy those with leprosy were taken to a priest, not a before burning them alive. doctor, and were found “guilty,” not sick. Leprosy is erroneously associated with the Old These customs led to the forcible confi nement Testament, where references to “tsara’-ath,” a term of patients in “leprosaria,” or leper colonies; their which most closely translates to “leprosy,” actually children, whether infected or not, were denied refers to a broad spectrum of problems that affected education in community schools. In eighth- cloth, leather, linen, and house walls as well century France, leprosy was considered grounds as humans. Most medical historians doubt, and for divorce, and under the Roman Empire, was archaeologists have not found evidence to support, cause for banishment. Some countries passed leg- the idea that leprosy existed among the Hebrews in islation providing for the compulsory sterilization Moses’ time. Biblical scholars also have problems of leprosy patients, and others would not permit with the translation of the Greek term lepra partly patients to handle the nation’s currency. Others because the Greeks had a specifi c term for leprosy. “steam treated” letters before allowing them in the The Greek word lepra was most likely used to refer mail, and some countries did not allow patients to a variety of severe skin diseases. Greek medical to vote. In medieval Europe, leprosy patients had writings later than the third century B.C. provide to carry a “clapper” to warn others that a person the earliest clinical references to modern leprosy. with leprosy was approaching. Even as late as No mention of leprosy occurs in the New Testa- 1913, state Senator G. E. Willett of Montana was ment after the Gospels. 212 leptospirosis

Symptoms and Diagnostic Path MDT is often distributed in blister packs con- Damage is fi rst confi ned to the nerves supplying taining a month’s supply of pills; dapsone is taken the skin and muscles, destroying nerve endings, daily; clofazimine is taken every other day; and sweat glands, hair follicles, and pigment-producing rifampin is taken monthly. There are now more cells. It fi rst causes a lightening (or darkening) of than 1 million people receiving these drugs world- the skin, with a loss of feeling and sweating. Some wide, and more than 1 million others have already types of the disease produce a rash of bumps or completed treatment. nodules on the skin. As the disease progresses, While the medication usually can cure leprosy bacilli also attack peripheral nerves; at fi rst patients within six months to two years, patients are no may feel an occasional “PINS AND NEEDLES” SENSA- longer contagious within a few days after treat- TION, or have a numb patch on the skin. Next, ment begins. To prevent a relapse, treatment needs patients become unable to feel sensations such as a to be administered for at least two years after the light touch or temperature. Gradually, even hands, last signs of the disease have disappeared. In the feet, and facial skin eventually become numb as United States, patients are eligible for treatment muscles become paralyzed. Delicate connections by the Public Health Service at special clinics and between nerve cells and nerve endings are severed, hospitals, or at the Gillis W. Long Hansen’s Dis- and whole sections of the body become totally ease Center in Louisiana, the only institution in numb. For example, if the nerve above the elbow the United States devoted primarily to treatment, is affected, part of the hand becomes numb and research, training, and education related to lep- small muscles become paralyzed, leading to curled rosy. Eleven regional centers, located primarily in fi ngers. major urban areas, treat those with leprosy on an When a patient can no longer sense pain, the outpatient basis. body loses the automatic withdrawal refl ex that No vaccine for leprosy is available because sci- protects against trauma from sharp or hot objects, entists have not been able to grow cultures in lab leading to extensive scarring or even loss of fi n- environments. However, about 95 percent of the gers and toes. Muscle paralysis can lead to further population is immune to leprosy, which occurs deformity, and damage to the facial nerve means naturally in armadillos. eyelids cannot close, leading to ulceration and Ofl oxacin causes a range of unpleasant side blindness. Direct invasion of bacteria may also effects. lead to infl ammation of the eyeball, also leading After leprosy is cured, patients must learn to to blindness. watch for wounds and injuries they do not feel, and must learn to wear special shoes to protect Treatment Options and Outlook insensitive feet. Several antibiotic agents are effective against leprosy and are best used in combinations of two or three. This multidrug therapy (MDT) is leptospirosis A rare disease characterized by a the current preferred treatment: it combines skin rash and fl ulike symptoms caused by a spiro- DAPSONE, clofazimine, and rifampin. The MDT chete bacterium excreted by rodents. Also known was developed as leprosy bacilli became resistant as Weil’s disease, there are between 100 and 200 to dapsone alone after decades of constant use. cases and a few deaths reported in the United (Dapsone, a sulfone drug, was introduced dur- States each year. ing the 1940s). The most powerful of these is Outbreaks of leptospirosis are usually caused rifampin, a drug fi rst used against tuberculosis by exposure to water, food, or soil contaminated and found to be effective against leprosy in 1968. with the urine of infected cattle, pigs, horses, Particular combinations of these drugs were rec- dogs, rodents, and wild animals. The disease is not ommended in 1984 by the World Health Organi- known to be spread from person to person. zation as standard treatment for mass campaigns Leptospirosis is an occupational hazard for many against leprosy. people who work outdoors or with animals, such lice 213 as sewer workers, veterinarians, dairy farmers, or Leukoplakia in the mouth may be caused by military personnel. It is also a risk for campers or tobacco smoke (especially pipe smoking), trauma those who participate in outdoor sports in con- from rubbing of dentures or a rough tooth. In some taminated areas; the disease had been associated cases, it is genetic. with swimming, wading, and whitewater rafting in contaminated lakes and rivers. Symptoms and Diagnostic Path The primary symptom of leukoplakia is a skin Symptoms and Diagnostic Path lesion that may occur on any mucosal surface (that After an incubation period of up to three weeks, is, skin in a cavity such as the mouth or vagina). an acute illness characterized by headache, fever It is typically found on the tongue, although it also and chills, severe muscle aches, and minute red may occur on the inside of the cheeks and occa- spots and purple PAPULES appear. The kidneys are sionally, in women, on the genitals. Usually white often affected, and liver damage and JAUNDICE are or gray, the lesion may be red, with a thick, raised, also common. The disease is diagnosed by blood or and hardened appearance. The typical white lesion urine tests. develops slowly, over weeks or months, until it eventually becomes rough and may be sensitive to Treatment Options and Outlook touch, heat, spicy foods, or other irritation. Antibiotics are effective, and in about one-third of A biopsy of the lesion will confi rm the diagno- cases the patients improve rapidly. Some patients sis. There are two types of leukoplakia: benign and go on to suffer a more persistent illness with slow malignant. recovery of kidney and liver function. The nervous system may also be affected, often producing signs Treatment Options and Outlook of meningitis. Leukoplakia is usually harmless and lesions usually clear in a few weeks or months after the source of Risk Factors and Preventive Measures irritation is removed. However, about three percent The risk of this disease can be lessened by not swim- of these lesions eventually become malignant. The ming or wading in water that might be contaminated lesion should be diagnosed and treated; eliminating with animal urine. Those exposed to contaminated the source of irritation may make the lesion disap- water or soil because of their job or recreational pear. Dental causes such as rough teeth, irregular activities should wear protective clothing. denture surface, or fi llings should be treated as soon as possible. Surgical removal of the lesion may be necessary. Treatment of leukoplakia on the leukonychia A white discoloration of the nails vulva is the same as treatment of oral lesions. that may involve the entire nail, a portion of it, or Although some studies have suggested that VITA- just a discolored band. Some patients inherit the MIN A or VITAMIN E may shrink lesions, this should condition; it may also be caused by certain treat- only be administered with close supervision by a ments for leukemia (arsenic and antimetabolites). health care provider. Patients with liver disease also may have complete discoloration. No treatment is available. lice Small wingless insects about the size of a sesame seed, with six legs and claws for grasping leukoplakia A smooth, opaque white patch found the hair. Lice are crawling insects that cannot jump mostly on the mucus membranes of the lips and or fl y, and feed on human blood. inside the mouth, primarily among the elderly. They are divided into three species: Pediculus Some patches are benign, some are premalignant humanus capitis (head louse); pediculus humanus cor- conditions, and others are malignant. Therefore, poris (body louse), and Phthirus pubis (the crab, or patients must see a DERMATOLOGIST or oral surgeon pubic, louse). All three have fl at bodies that mea- to confi rm a diagnosis. sure up to 3 mm across. 214 lice

Head lice live on and suck blood from the scalp, the use of topical formulations of LINDANE lotion leaving red spots that itch intensely and can lead and lindane shampoo for the treatment of scabies to DERMATITIS and IMPETIGO. The females lay a daily and head lice. The warning emphasizes that lin- batch of pale eggs called “NITS” that attach themselves dane products should be considered as a second- to hairs close to the scalp. The nits hatch in about a line therapy for the treatment of scabies and lice. week, and the adults can live for several weeks. While the FDA believes that the benefi ts of lindane Head lice can be found among people of all outweigh the risks when used as directed, given the walks of life. Children most often contract lice potential for neurotoxicity, patients should only be through direct contact, usually at school by shar- treated with these medications if other treatments ing hats, brushes, combs, or headrests. Pets cannot are not tolerable or other approved therapies have contact head lice. failed. The new boxed warning also states that lindane lotion and shampoo should be used with Symptoms and Diagnostic Path caution in patients who weigh less than about 110 Because lice move so quickly, it is the nits that pounds. These products are not recommended for will be seen on the hair shaft. Head lice and their infants or premature infants. nits can also be found on eyebrows and eyelashes. These warnings are based on reports to the If one person in a family has head lice, all family FDA’s voluntary reporting system, which described members should be checked, but only those who that about half of reported adverse events occurred are infested should be treated with lice pesticide. in children. Because most of the serious adverse Body lice live and lay eggs on clothing next to the events reported with lindane products are due to skin, visiting the body only to feed. Body lice affect misuse and overuse, especially with the lotion, people who rarely change their clothes. product package sizes are limited to one and two Pubic lice live in pubic hair or (rarely) armpits ounces. and beards. Pubic lice are commonly known The National Pediculosis Association also dis- as “crabs” because under the microscope they courages the use of lindane products (such as resemble a crab. Pubic lice cause incessant itch- Kwell), because it considers them to be potentially ing. They are visible to the naked eye and are toxic and no more effective than other treatments. easily transmitted during sex. It is also possible Still, no product kills 100 percent of nits, and a to pick them up from sheets or towels. They can fi ne-toothed comb should be used to remove the live away from the host’s body for up to one day, remaining nits. Lice medications are not intended and the eggs can survive on their own for several to be used on a routine or preventive basis. days. Affected patients who do not wash under- All lice-killing medications are pesticides, and wear, sheets, and towels in hot enough water therefore should be used with caution. A phar- may be reinfected. macist or physician should be consulted before using or applying pesticides when the person is Treatment Options and Outlook pregnant, nursing, has lice or nits in the eyebrows For head lice, lotions containing malathion or car- or eyelashes, or has other health problems (such as baryl kill lice and nits quickly. The lotion should allergies). Because the head lice pesticides can be be washed off 12 hours after application, followed absorbed into the bloodstream, they should not be by combing the hair with a fi ne-toothed comb to used on open wounds on the scalp, or on the hands remove dead lice and nits. Shampoos containing of the person applying the medication. These pes- malathion, lindane, or carbaryl are also effective ticides should not be used on infants, and should if used repeatedly over several days. Combs and be used with caution on children under age two. In brushes should be plunged into very hot water to these cases, lice and nits should be removed manu- kill any attached eggs. ally or mechanically. In 2004 the U.S. Food and Drug Administration Pesticides should be used over a sink (not a (FDA) issued a Public Health Advisory concerning tub or shower) to minimize pesticide absorption lichen sclerosis et atrophicus 215 and exposure to the rest of the body. Eyes of the Treatment Options and Outlook affected individual must be kept covered while Cyclophosphamide, radiotherapy, DERMABRASION, administering any pesticide. or systemic CORTICOSTEROIDS may eradicate the All nits must be removed from the hair shaft. cells producing the immunoglobulins so that the Bedding and recently worn clothing should be disease can go into full remission. washed in hot water and dried in a hot dryer. See also LICHEN SIMPLEX. Combs and brushes should be cleaned and then soaked in hot (not boiling) water for 10 minutes. Lice sprays should not be used, according to the lichenoid drug eruptions A type of allergic drug National Pediculosis Association. Vacuuming is the reaction causing an itchy eruption of PAPULES most best way to remove lice and attached nits from often appearing on the forearms, less often on the furniture, mattresses, rugs, stuffed toys, and car lower legs, genitalia, and mucous membranes. seats. While the rash resembles LICHEN PLANUS, the histol- Neighborhood parents and the school, camp, or ogy and cause is different. Medications most often child care providers should be notifi ed of any infes- associated with this condition include antimalari- tation. Children should be checked once a week for als, thiazides, and tetracyclines. head lice. Body lice can be killed by placing infested clothing in a hot dryer for fi ve minutes, by washing clothes lichen planus A common skin disease of unknown in very hot water or by burning clothes. Pubic lice origin. can be treated with an over-the-counter treatment, including A-200 Pyrinate, RID, or Nix. Symptoms and Diagnostic Path Symptoms include small, fl at-topped, itchy pink or purple raised spots on the skin of the wrists, lichenification Thickening of the skin caused by forearms, or lower legs, particularly in middle-aged repeated scratching, often by trying to relieve the patients. The inside lining of the cheek may be cov- intense itching of ECZEMA. ered by a lacy white network of spots.

Treatment Options and Outlook lichen myxedematosus A rare condition of meta- Potent topical steroids and antihistamines are the bolic dysfunction characterized by a variety of skin mainstay of therapy. For extensive cases, PUVA symptoms. and GRISEOFULVIN or systemic steroids have been used. Most cases resolve spontaneously within two Symptoms and Diagnostic Path years. Symptoms include lichenoid PAPULES of the ears, neck, scrotum, and perianal area. Facial features are exaggerated with deep furrows, which are lichen sclerosis et atrophicus (LSEA) A rela- sometimes very thickened. Other patients have tively common benign abnormality of the skin of groups of pink wheals and red or fl esh-colored the vulva characterized by marked thinning of the small papules. Still others have lichenoid plaques skin. It occurs in all age groups, but is found most resembling LICHEN PLANUS. Occasionally patients often before puberty and in menopause. with this condition develop a type of cancer called multiple myeloma. Symptoms and Diagnostic Path The condition is a proliferative process related With lichen sclerosis, the vulvar skin often appears to an abnormal immunoglobulin that stimulates white and thin; it is often itchy. Scratching may production of mucinous material that deposits in lead to secondary infections if the skin is broken. As the skin. many vulvar conditions have the same symptoms 216 lichen simplex and look similar to the naked eye, doctors often The skin’s appearance and a history of chronic take a biopsy (sample of the skin) to make an accu- ITCHING and scratching is typically used to identify rate diagnosis. There may be an association with the condition, but a skin lesion biopsy may be autoimmune diseases. needed to confi rm the diagnosis.

Treatment Options and Outlook Treatment Options and Outlook The treatment for lichen sclerosis is either topi- Dressings to cover and protect the area may be cal testosterone or CORTICOSTEROIDS. High-potency used with or without topical medications, and may prescription steroid creams are used twice a day be applied for a week or more at a time. The itch- for two to three weeks, then once a day, usually at ing and infl ammation may be treated with a lotion night, for an additional two weeks or until symp- or steroid cream applied to the affected area. Peel- toms disappear. Often, the steroid creams will be ing ointments (such as those containing salicylic continued indefi nitely once or twice a week. The acid), may be used on thickened lesions and coal regimen for testosterone is very similar. Some- tar soaps or lotions may be recommended. ANTI- times, simply applying lanolin or vegetable oil pro- HISTAMINES (especially those that are a bit sedating) vides relief. may be needed to reduce itching; steroids may be injected into lesions to reduce itching and infl am- Risk Factors and Preventive Measures mation. Psychological counseling to understand It is also important to practice good hygiene, keep the importance of not scratching, plus stress man- the vulva dry, and avoid the use of soaps, lotions agement, may help. and detergents. Over-the-counter antibiotic creams and anti-itch creams should not be used, as they cause more irritation. light treatment See PHOTOTHERAPY.

lichen simplex A skin disorder characterized limes and the skin See OIL OF BERGAMOT. by patches of thickened itchy and sometimes dis- colored skin. It is caused by repeated scratching, usually on neck, wrists, arms, and ankles. It is lindane (Trade name: Kwell) A drug (gamma most prevalent among women and is believed to benzene hexachloride), once widely used to treat be caused by extended scratching due to a psy- infestation by SCABIES or LICE. It is no longer recom- chological condition. Patients often rub patches mended by the U.S. Food and Drug Administration unconsciously when agitated or during stressful (FDA) or NATIONAL PEDICULOSIS ASSOCIATION (NPA) situations. This contributes to a cycle of skin thick- because of its potential toxicity. Other products, ening and scratching. The skin thickens in reaction such as permethrin (Elimite), work equally well to the itching, which in turn causes the skin to with less risk. thicken even more. In 2004 the FDA issued a Public Health Advisory concerning the use of topical formulations of lin- Symptoms and Diagnostic Path dane lotion and lindane shampoo for the treatment Symptoms include intense, chronic itchy skin of SCABIES and head LICE. The warning emphasized that gets worse with scratching or stress. The skin that lindane products should be considered as a lesions have distinct borders, a fl at top, and are second-line therapy for the treatment of scabies typically violet or slightly purple. When scratched and lice. While FDA explained that it believed the repeatedly, the lesions may become leathery, red- benefi ts of lindane outweigh the risks when used dened, or darkened. There may be raw areas and as directed, given the potential for neurotoxicity scratch marks. The lesions are typically found on patients should be treated with these medications the ankle, wrist, neck, anal area, forearms, thighs, only if other treatments are not tolerable or other lower leg, back of the knee, and inner elbow. approved therapies have failed. The boxed warning liposuction 217 also stated that lindane lotion and shampoo should It remains the most popular cosmetic surgical be used with caution in patients who weight less procedure in the United States—even more popu- than about 110 pounds, and that these products lar than FACE-LIFTS. There are more than 470,000 are not recommended for infants or premature procedures done annually. The procedure is effec- infants. tive because fat cells do not regenerate after they These warnings were based on reports to the are destroyed or removed; for example, people FDA’s voluntary reporting system, which described who gain weight after liposuction do not regain that about half of reported adverse events occurred signifi cant amounts of weight in areas where fat in children. Because most of the serious adverse has been removed. events reported with lindane products are due to Best candidates for the surgery are those who misuse and overuse, especially with the lotion, are healthy, at near-normal weight, who are in product package sizes are limited to one and two their 30s and 40s and whose skin still retains some ounces. elasticity and who have isolated pockets of fat in Lindane may irritate the scalp and skin, or cause certain areas. These localized fat deposits may be an itching. It is thought by some to be toxic to the inherited pattern, and typically cannot be removed nervous system. In at least one case, a child alleg- via dieting or exercise. Surgical excision but not edly suffered permanent brain damage after being liposuction is often the only way to eliminate these treated with a lindane-based pediculicide. areas. A recent study has found that injecting a medication that melts fat directly into the lipoma may help shrink it without surgery. lipoid proteinosis See URBACH-WIETHE DISEASE. While some surgeons perform liposuction under general anesthesia, it is most frequently done under local anesthesia at a hospital free-standing lipoma A common benign tumor composed of outpatient facility, or offi ce surgical suite. Some- mature fat cells that almost never becomes malig- times, the removed fat can be transferred into nant. Women are affected much more often, other areas where the fat has wasted away as a way usually in early-to-middle adult life. The tumors to augment soft tissue. appear on the neck, trunk, abdomen, forearms, In traditional liposuction, the surgeon inserts a buttocks, and thighs. tube (called a canula) through a small inconspicu- ous skin incision. The tube is attached to a vacuum Symptoms and Diagnostic Path pressure unit and is moved through fat, removing The tumor may be moveable underneath the skin’s the cells. As the canula moves through the fat, it surface. Usually painless, it will slowly grow until it creates tunnels that scar, resulting in a permanent becomes several inches across. It can appear at any fl attening of the area. Unfortunately, in the past age and will not spontaneously fade away. They this technique sucked out not only fat but blood may be confused with other types of tumors. vessels, tiny nerves, and anything else in the path of the cannula. This tended to cause signifi cant Treatment Options and Outlook bleeding, bruising, and blood loss, which limited Most lipoma require no treatment, although LIPO- the amount of fat that could be safely removed. SUCTION or surgical excision are both effective Several years ago, the “tumescent technique” means of removal. (sometimes also called the super-wet technique) was developed by a DERMATOLOGIST, which allowed removal of signifi cantly more fat during the opera- liposuction The removal of unwanted fat deposits tion with much less blood loss. With this tech- in certain areas of the body, most commonly the nique, the fat layer is injected with large amounts thighs, buttocks, abdomen, “handlebar” areas, chin, of a dilute anesthetic solution of saline and adrena- and knees. It is an excellent method of spot reduc- lin before suctioning. The same hollow metal tion but is not an effective method of weight loss. cannulas and high-powered vacuum pumps are 218 liquid nitrogen then used again to suck out the fat. Most patients fat has been removed. Fortunately, complications are back at work within one or two days. While are uncommon and most patients are satisfi ed with there is less bleeding than with the traditional their results. technique, patients still frequently require several weeks to recover fully from the bruising, pain, and swelling. liquid nitrogen Freezing with liquid nitrogen, Ultrasonic liposuction Also known as ultra- otherwise known as cryotherapy, destroys tissue sound assisted lipoplasty (UAL), this is a technical by means of extremely low temperatures of –125° advancement over other liposuction techniques. degrees to –130° C (–195° to –200° F). The liquid Introduced in the United States in 1994 and nitrogen is delivered with either a Q-tip, a spray approved by the U.S. Food and Drug Administra- thermos device, or a contact probe. tion in 1996, it is becoming a popular technique It is used for the treatment of lentigines, sebor- for fat removal and body sculpting among plastic rheic keratoses, actinic keratoses, WARTS, benign surgeons. tumors, some basal cell and squamous cell carci- In ultrasonic liposuction, a special titanium can- nomas, and occasionally LENTIGO MALIGNA. Liquid nula transmits the ultrasound energy to the fat nitrogen on plantar or palmar warts may cause layer, where it disrupts the fat cells with which it painful blood-fi lled blisters, however. comes in contact. This liquefi es the fat, which is See also ACTINIC KERATOSIS; BASAL CELL CAR- then drained or suctioned out through a hollow CINOMA; KERATOSIS, SEBORRHEIC; SQUAMOUS CELL portion of the cannula under low, gentle vacuum. CARCINOMA.

Outlook and Lifestyle Modifi cation Because the technique is more refi ned and gentle livedo reticularis A condition characterized by a to the tissues, there is less blood loss, less bruising, reddish blue netlike mottling of the skin, usually less pain, and a signifi cantly faster recovery. Stud- on the lower legs. The condition may be intermit- ies need to be performed to determine whether tent, appearing simply as a normal response to the UAL offers any advantage over traditional liposuc- cold. The permanent form of livedo reticularis may tion performed with tumescent anesthesia. An be caused by an underlying systemic disease, such elasticized bandage, sponge, or specially designed as arteriosclerosis, diseases of COLLAGEN, cerebro- garment may be placed over the treated areas. The vascular disease, and so on. It is caused by enlarge- patient will be able to go home after a few hours, ment of blood vessels underneath the skin. although some patients may stay overnight in the hospital or surgical facility. After several days, the Treatment Options and Outlook dressings will be temporarily removed so the plastic Treatment of the underlying condition in second- surgeon can examine the treated areas. There may ary livedo will cure this problem. Rewarming the be swelling, which typically begins to fade within area in cases with no known underlying cause a week or so after surgery; bruising and numbness may reverse the problem. However, eventually the can last at least three weeks. If stitches need to be blood vessels become permanently dilated and the removed, this is typically done within 10 days after livedo reticularis will become permanent no matter surgery. what the surrounding temperature.

Risks and Complications Although liposuction is very safe and effective, it is liver spots See LENTIGO, ACTINIC. still a surgical procedure and can cause complica- tions such as infection, bleeding, and nerve dam- age. In addition, aesthetic complications such as van Lohuizen’s disease See CUTIS MARMORATA skin irregularity or waviness can occur if too much TELANGIECTATICA CONGENITA. Louis-Bar syndrome 219 loiasis A form of the tropical parasitic disease loofahs A type of natural fi brous sponge har- FILARIASIS caused by an infestation of the Loa loa vested from the luffa plant, which grows like a worm, which travels beneath the skin and causes gourd and is then dried and made into sponges, an infl ammation known as a calabar swelling. mitts, or woven cloths. Loofahs are a good alterna- Swellings tend to be several centimeters in size, tive to a body brush or washcloth, since they help and may be preceded by localized pain and itching. remove dead skin cells. They should not be used on The disease may occasionally involve acute allergic the face, neck, or on broken skin. symptoms with giant hives, fever, and recurring Because loofahs are a nutrient source for bacte- episodes of angioedema, especially in Caucasian ria and cellular debris from the skin and are usually visitors to endemic areas. Evidence of heart or kid- kept in a damp environment, these products are ney problems may be found in up to 20 percent of liable to become contaminated. such cases. To keep a loofah clean, thoroughly wash with Loiasis is widely distributed and highly endemic mild soap, rinse and then dry after each use. Since in tropical West Africa. In the Congo River basin this process will not kill some organisms, soak the up to 90 percent of villagers in some areas are loofah twice a week in a solution of one part bleach infected. Humans who have microfi lariae in the and nine parts water to sterilize. blood are likely the only important reservoir Loofahs may not look contaminated (such as a of loiasis, although nonhuman primates can be color change or odor), so consumers should buy infected. Chrysops fl ies bite the human and ingest new ones regularly—about every two months. A blood containing the microfi lariae. These develop loofah needs to be replaced if it gets soft, or if pieces into larvae and are returned to man via the bite of start to fall off. the infective fl y. Synthetic products are less likely to become contaminated, but they should still be washed Symptoms and Diagnostic Path and rinsed after each use and replaced after two Symptoms of loiasis generally do not appear until months of use. several years after the bite of the fl y, although Loofahs, sponges, and brushes should not be they have been known to appear within four shared and if used on an infected part of the skin, months. Repeated infections can occur. The worms they should be thrown away. move through the skin, causing infl ammation. The worms can often be seen migrating across the conjunctiva and cornea of the eye, which is where Loprox See CYCLOPIROXOLAMINE. its nickname “eye worm” comes from. The worm sometimes enters the brain, causing encephalitis. The problem is diagnosed by detecting the microfi - lotion A liquid drug preparation that can be lariae in the blood. applied to the skin. Lotions have a soothing effect and can be used to cover large areas. Treatment Options and Outlook Diethylcarbamazine or ivermectin has been the primary drug for the past 40 years and has proven Louis-Bar syndrome A genetic disorder that causes, very effective in treating loiasis. among many other symptoms, reddish lesions of the skin and mucous membranes in early childhood Risk Factors and Preventive Measures due to permanent widening of groups of blood ves- Visitors to Africa should take preventive action sels (TELANGIECTASIA). The syndrome is inherited as against insects, including the use of an effective an autosomal recessive trait, which means that the repellent containing Deet or dimethyl phthalate, defective gene must be inherited from both parents. wearing long pants, and sleeping in well-screened The defective gene has been identifi ed as ATM (for areas. “AT mutated”) that has been mapped to the long 220 lubricants arm of chromosome 11. The ATM gene controls the the wolf—a red mark on the face. Others who had production of an enzyme that plays a role in regulat- never been attacked but who bore similar marks ing cell division after DNA damage. were believed to have the “disease of the lupus”— lupus erythematosus. Symptoms and Diagnostic Path Lupus involves the body’s immune system, This syndrome involves a wide range of symptoms. which launches an attack against itself. In one form In addition to the telangiectasia, skin symptoms (discoid lupus erythematosus, or DLE), the disease include GRAY HAIR, loss of skin elasticity, and excess affects only the skin; in the second form (systemic subcutaneous fat. Non-skin symptoms include pro- lupus erythematosus, or SLE), the disease affects gressively impaired coordination of voluntary move- the skin and organs throughout the body. Drug- ments (ataxia) and impaired functioning of the induced lupus (similar to SLE) occurs after using immune system leading to increased susceptibility to certain medications, such as the blood pressure upper and lower respiratory infections. Individuals drug hydralazine, and procainamide (used to treat with ATM also have an increased risk of developing irregular heart rhythms). Only a very few people certain cancers, including lymphomas, leukemia, who use these drugs develop drug-induced lupus, and brain tumors. It affects both sexes equally, typi- and symptoms usually fade when the medications cally being diagnosed at about the age of four years. are discontinued. In about 10 percent of all lupus cases, patients Treatment Options and Outlook will have symptoms of more than one connec- There is no treatment, other than to ease symp- tive tissue disease, including lupus. This is called toms. Death usually occurs in adolescence or early “overlap syndrome” or “mixed connective tissue adulthood from a lung infection or cancer. disease.” About 1.5 million Americans have the disease. Lupus strikes nine times as many women as men, lubricants Topical preparations containing fats or usually those of childbearing age. The condition oils used to help hydrate and protect the skin, mak- occurs throughout the world, but the incidence ing it more pliable by trapping water within the top is higher among certain ethnic groups (such as layer of the EPIDERMIS (stratum corneum). African Americans, Hispanics, Asians, and Native Lubricants work better if the skin is fi rst soaked Americans). In high-risk groups, the incidence may for fi ve to ten minutes in water. They may contain be as common as one in every 250 women. animal fats (such as LANOLIN), vegetable oils (such An autoimmune disorder, lupus causes the as olive oil), mineral oil, paraffi n, petrolatum, or body’s immune system to attack its own connec- waxes. tive tissue, causing infl ammation. Attacks can be Different brands or types of lubricants may have triggered by sunlight and by certain drugs such quite different consistency, and choice of prepara- as hydralazine, procainamide, or isoniazid. It is tion should depend on its intended use. believed that the disease is inherited, and that hor- monal factors play a part. Sometimes, a viral infec- tion may trigger symptoms. lunula The white crescent area at the base of the About 20 percent of people with lupus have nail. a close relative (a parent or sibling) who already has lupus or may develop lupus. About 5 percent of children born to individuals with lupus will lupus erythematosus A chronic autoimmune dis- develop the illness. ease that causes infl ammation of connective tissue, which affects the skin and internal organs. Symptoms and Diagnostic Path When wolves roamed Europe, it was said that In both forms of the disease, symptoms wax and the victim of a wolf (lupus) attack bore the sign of wane with varying severity. Lyme disease 221

In DLE, the rash presents itself as one or more spread, ulcerate, and produce extensive scarring red, circular, thickened areas of skin on the face, and tissue loss. behind the ears, and on the scalp. The rash may cause permanent hair loss in affected areas and Treatment Options and Outlook result in facial scars. Administration of antituberculosis drugs. SLE causes a red, blotchy butterfl y-shaped rash See also TUBERCULOSIS, SKIN. over the face that does not scar. Most patients feel sick and are tired, experiencing fever, appetite loss, nausea, painful joints, and weight loss. Complica- lycopenia A condition characterized by an tions include kidney failure, pleurisy, arthritis sei- orange-yellow skin tint caused by eating foods zures, and psychiatric problems. high in lycopene, such as tomatoes or berries. In Less than 5 percent of patients with DLE prog- lycopenia, the skin discoloration may resemble that ress to SLE; patients with SLE may also have skin of hypercarotenemia. High blood levels of lycopene lesions of DLE. may be raised and mild liver dysfunction may also occur. Treatment Options and Outlook Although there is no cure, treatment aims at reduc- ing infl ammation and alleviating symptoms with Lyme disease A tick-borne illness whose hall- nonsteroidal anti-infl ammatory drugs, antimalarials, mark symptom is a red rash that forms an irregular and corticosteroid drugs. Those whose condition is ring shape surrounding the tick bite. Untreated, worsened by sunlight should avoid exposure, wear Lyme disease in humans can cause a host of prob- protective clothing, and use sunscreens. Immuno- lems, including arthritis and disorders of the heart suppressant (or immunomodulating) drugs (che- and central nervous system. It is most commonly motherapy) are typically recommended only for found in the northeast coastal states from Maine to patients with the most severe fl ares of lupus, or to Maryland, in the upper Midwest, and on the Pacifi c reduce the steroid dose. (A “severe” fl are is one that coast. It is most often contracted in the late spring impairs one of the body’s organs.) During a severe or early summer when ticks are abundant. fl air, the function of the organ must be protected. The number of annually reported cases of Lyme Immunosuppressive or chemotherapy medications disease in the United States has increased about suppress the overactivity of the immune system 25-fold since national surveillance began in 1982, triggered by lupus, which helps limit the damage with about 22,000 cases annually reported to the and preserve the function of the involved organ. Centers for Disease Control and Prevention (CDC) Although this disease may be life threatening if through 2003. the kidney is involved, the outlook for patients has The disease is caused by Borrelia burgdorferi, a improved a great deal over the past 20 years. spirochete form of bacterium transmitted by the bite of deer ticks (Ixodes scapularis) and western black-legged ticks (Ixodes pacifi cus). The deer tick, lupus pernio See SARCOIDOSIS. which normally feeds on the white-footed mouse, the white-tailed deer, other mammals, and birds, is responsible for transmitting Lyme disease bacteria lupus vulgaris A type of skin lesion that appears in to humans in the northeastern and north-central skin tuberculosis in immune (or partially immune) United States. On the Pacifi c coast, the bacteria are patients. transmitted to humans by the western black-legged tick. Ixodes ticks are much smaller than common Symptoms and Diagnostic Path dog and cattle ticks. In their larval and nymphal Beginning early in life, the condition is charac- stages, they are no bigger than a pinhead (adult terized by scaly red plaques, which over time will ticks are slightly larger). 222 Lyme disease

Most B. burgdorferi infections are believed to be There may be joint and muscle pains with or with- caused by exposure to infected ticks during prop- out joint swelling. erty maintenance, recreation, and leisure activities. If untreated, the infection may progress to dis- People who live or work in residential areas sur- seminated disease weeks to months after infection, rounded by woods or overgrown brush are at risk with intermittent swelling and pain of one or a few of getting Lyme disease. In addition, those who joints—usually large, weight-bearing joints such as participate in recreational activities such as hiking, the knee. Some patients develop chronic thinking camping, fi shing, and hunting, away from home, disorders, sleep disturbance, fatigue, and personal- in tick habitat, and persons who work outdoors, ity changes. Infrequently, Lyme disease may be such as landscapers, foresters, and wildlife manag- severe, chronic, and disabling. ers in endemic areas, may also be at risk of getting An ill-defi ned post-Lyme disease syndrome Lyme disease. occurs in some people after treatment for Lyme Ticks search for host animals from the tips of disease. However, it is rarely if ever fatal. grasses and shrubs (not from trees) and transfer to The diagnosis of Lyme disease is based primarily animals or persons that brush against vegetation. on symptoms; patients with early disease may be Ticks only crawl; they do not fl y or jump. Ticks treated solely on the basis of objective signs and a found on the scalp usually have crawled there from known exposure. Blood testing may provide valu- lower parts of the body. able supportive diagnostic information in patients There is no evidence that a person can get Lyme with endemic exposure and objective clinical fi nd- disease from the air, food or water, from sexual ings that suggest later stage disease. contact, or directly from wild or domestic animals. There is no convincing evidence that Lyme disease Treatment Options and Outlook can be transmitted by insects such as mosquitoes, Antibiotic treatment for three to four weeks with fl ies, or fl eas. The risk of exposure to ticks is great- doxycycline, cefuroxime, or amoxicillin is gener- est in the woods and garden fringe areas of proper- ally effective in early disease. Cefuroxime axetil or ties, but ticks may also be carried by animals into ERYTHROMYCIN can be used for persons allergic to lawns and gardens. penicillin or who cannot take TETRACYCLINES. More advanced disease, particularly with brain symp- Symptoms and Diagnostic Path toms, may require treatment with intravenous Lyme disease most often begins with a character- ceftriaxone or penicillin for four weeks or more, istic “bull’s-eye” rash, accompanied by symptoms depending on disease severity. In advanced disease, such as fever, malaise, fatigue, headache, muscle treatment failures may occur and retreatment may aches, and joint aches. The incubation period from be necessary. infection to onset of the rash is typically seven to 14 days, but may be as short as three days or as Risk Factors and Preventive Measures long as 30 days. Some infected individuals have no A Lyme disease vaccine (LYMErix) was discontinued recognized illness or experience only vague symp- in 2002 because of insuffi cient consumer demand. toms such as fever, headache, fatigue, and muscle Protection provided by this vaccine diminishes over aches. time, so consumers who received the Lyme disease The signs of early disseminated infection usu- vaccine before 2002 are probably no longer pro- ally occur days to weeks after the appearance of a tected against Lyme disease. solitary bull’s-eye rash. In addition to multiple red Whenever possible, people should avoid areas lesions, early disseminated infection may produce that are likely to be infested with ticks, particu- disease of the nervous system, the musculoskeletal larly in spring and summer when young ticks feed. system, or the heart. Early brain symptoms include Ticks favor a moist, shaded environment such as lymphocytic meningitis, cranial neuropathy (espe- leaf litter and low-lying vegetation in wooded, cially facial nerve palsy), and radiculoneuritis. brushy, or overgrown grassy habitat. lymphocytoma cutis 223

Visitors in tick infested areas should wear light- Environmental Protection Agency and each colored clothing so that ticks can be spotted more state determines the availability of pesticides. easily and removed before becoming attached. Consumers interested in applying acaricides Wearing long-sleeved shirts and tucking pants should check with local health officials about into socks or boot tops may help keep ticks from the best time to apply it, as well as any rules reaching the skin. Ticks are usually located close and regulations related to pesticide application to the ground, so wearing high rubber boots may on residential properties. Consumers also can provide additional protection. contact a professional pesticide company to Applying insect repellents containing DEET (N, apply pesticides. N diethyl-m-toluamide) to clothes and exposed Bait boxes that treat wild rodents with acaricide skin and permethrin (which kills ticks on contact) are now available for home use. Properly used, to clothes should also help reduce the risk of tick these boxes have been shown to reduce the num- attachment. DEET can be used safely on children ber of ticks by more than half. The treatment is and adults but should be applied according to Envi- similar to products used to control fl eas and ticks ronmental Protection Agency guidelines to reduce on pets, and does not harm the rodents. Bait boxes the possibility of toxicity. are available from licensed pest control companies Since transmission of B. burgdorferi from an in many states. infected tick is unlikely to occur until after the tick Other methods for controlling ticks currently has been attached for at least 36 hours, daily checks under evaluation include vegetation and habitat for ticks and their prompt removal will help pre- modifi cation, devices for applying topical acaricides vent infection. Embedded ticks should be removed to deer, fungal agents for biological control, and using fi ne-tipped tweezers. PETROLEUM JELLY, a hot natural extracts that safely repel ticks. match, nail polish, or other products should not be used. To remove a tick, it should be grasped fi rmly lymphangiosarcoma See STEWART-TREVES TUMOR. and pulled away from the skin. It is not a problem if the tick’s mouth parts remain in the skin, since the bacteria that cause Lyme disease are contained lymphangitis Infl ammation of the lymphatic ves- in the tick’s midgut. The tick bite area should be sels that cause tender red streaks to appear on the washed with an antiseptic. skin caused by a spread of bacteria (usually strep- In most cases, treating everyone who gets a tick tococci) from an infected wound. bite with antibiotics is not recommended. Individu- als who are bitten by a deer tick should remove Symptoms and Diagnostic Path the tick and seek medical attention only if there The streaks extend from the site of infection toward are symptoms of early Lyme disease, ehrlichiosis, the nearest lymph nodes, and is usually accompa- or babesiosis. nied by a fever and a general feeling of illness. The number of ticks in residential areas may be reduced by removing leaf litter, brush- and Treatment Options and Outlook wood-piles around houses and at the edges This condition is a clear indication of serious infec- of yards, and by clearing trees and brush to tion, and requires immediate treatment with anti- admit more sunlight and reduce the amount of biotics. Antibiotic treatment usually clears up the suitable habitat for deer, rodents, and ticks. A infection without complication. pesticide designed to kill ticks (acaricide) can be very effective in reducing tick populations. If properly timed, a single application at the lymphocytoma cutis One of a group of benign end of May or beginning of June can reduce infl ammatory skin conditions that resemble malig- tick populations by 68 to 100 percent. The U.S. nant lymphomas. In most cases, the cause of this 224 lymphocytoma cutis disorder is unknown, although it may be induced characterized by a single fi rm, red-brown or purple by bites or stings, injected drugs, vaccinations, or NODULE or plaque on sun-exposed areas such as the acupuncture. If the lesion persists or spreads, a face and extremities. biopsy must be performed to rule out the possibility that the condition is malignant lymphoma and not Treatment Options and Outlook a benign condition. Although the lesions may be excised, they do respond to injections of CORTICOSTEROIDS directly Symptoms and Diagnostic Path into the affected area. Superfi cial, low-dose X-rays This variant, (also known as cutaneous lymphoid may also be administered. hyperplasia), seen primarily in women, is usually M macular amyloidosis See AMYLOIDOSIS. malities are usually asymmetric and cause second- ary fractures. About 30 percent to 37 percent of enchondromas can develop into cancer. macule A fl at spot on the skin, visible only by dif- fering color that is less than 1 or 2 cm in diameter. Treatment Options and Outlook Specifi c treatment of Maffucci’s disease depends on a wide variety of possible symptoms. Surgery maduromycosis See MYCETOMA. may remove or reduce the size of the hemangio- mas. No medical care is needed in patients without other symptoms, but careful follow-up is needed to Maffucci’s syndrome A rare syndrome that affects evaluate any changes in the skin and bone lesions, the skin and skeleton, with many large growths since these lesions can become malignant. with blood-fi lled spaces due to dilation and thick- Patients with Maffucci’s syndrome usually ening of the walls of capillaries (cavernous HEMAN- lead reasonably normal lives with a normal life GIOMAS), raised masses of capillaries, dilated veins, expectancy if no malignant transformation occurs. and bone fractures. Between 25 percent and 30 Although the skeletal malformations can some- percent of those affl icted with Maffucci’s disease times be crippling, patients have managed to per- develop cancer. form activities of daily living. While no particular pattern of inheritance has been identifi ed, the disease appears early in life, usually around the age of four or fi ve; 25 percent magnesium aluminum silicate An oil-absorbing of cases are present at birth. Patients apparently are chemical that is included in some skin care prod- of average intelligence, with no associated mental ucts, such as oil-free foundations. It is not consid- problems. More than 100 cases have been reported ered to be part of an effective treatment for ACNE. in the United States.

Symptoms and Diagnostic Path Majocchi’s disease A disorder involving infl am- The syndrome can trigger many superfi cial and deep mation of blood vessels with particular skin hemangiomas that often protrude as soft nodules or symptoms. tumors, usually on arms or legs (although they can appear anywhere). The hemangiomas in Maffucci’s Symptoms and Diagnostic Path syndrome appear as blue NODULES under the skin. Known medically as purpura annularis telangiec- Patients are usually short and may have unequal todes, this condition is one of a group of diseases arm or leg lengths because of bone abnormalities. called PIGMENTED PURPURIC DERMATOSIS that are all The syndrome also can cause benign cartilagi- characterized by rust-colored MACULES and PAPULES nous tumors (enchondromas) that can appear any- on the lower legs. In this condition, early lesions where but are usually found on the bones of the may be redder, forming rings, but there is no itch- fi ngers and on the long bones. These bone abnor- ing involved.

225 226 Majocchi’s granuloma

Treatment Options and Outlook cases, topical CORTICOSTEROIDS may be added to the All forms of these capillary diseases are chronic and topical antifungals. Antibiotics may be needed to tend to resist treatment although topical steroids treat secondary bacterial infections. and UVB PHOTOTHERAPY may help.

makeup A group of COSMETICS including face Majocchi’s granuloma A variant of TINEA COR- powder, lipstick, mascara, eyebrow pencil, eye PORIS (RINGWORM of the body), in which there is shadow, and eye liner that are used to enhance a an infection in the hair follicles. This uncommon person’s appearance. condition is often found among young women Face powder covers up the outer layer of the skin, who frequently shave their legs. Occasionally, this creating a velvety fi nish on the face. This product problem may be caused by potent topical steroids. usually contains titanium dioxide or zinc oxide, Many species of dermatophytes can cause MG, with talc, kaolin, ZINC or magnesium stearate, color, but it is usually due to Trichophyton rubrum; other and perfume. Powdered silk, sometimes included causes include T. mentagrophytes and Epidermophyton in face powder, is a powerful marketing tool but fl occosum. Experts do not know whether these gran- contributes very little to the product’s function. ulomas appear in response to the organism itself, or Compact powder is compressed face powder with after the release of follicular contents. a binding component (such as gum arabic). Translu- The condition was fi rst described as a “granu- cent powder offers an extra opaque quality through loma tricofi tico” in 1883 by dermatology professor the addition of titanium dioxide. Domenico Majocchi. (He also described a type of Lipstick is made up of a number of components, chronic pigmented purpura known as MAJOCCHI’S including carnauba wax, beeswax, castor oil, LANO- DISEASE). LIN, preservatives, perfumes, and indelible dyes (such as D&C Red #21, D&C Orange #5, and so Symptoms and Diagnostic Path on). Symptoms include patches on any hairy area, such Mascara is a soap that emulsifi es when moist- as the scalp, face, forearms, hands, and legs. Majoc- ened; liquid mascara is emulsifi ed with alcohol. chi’s granuloma may be worsened by shaving legs Eyebrow pencil is made with the same pigments as in in an upward direction, which causes the hair fol- mascara and is basically a crayon. Cream eye shadow licles to be inoculated with ATHLETE’S FOOT fungus. is a mixture of a petrolatum and pigment, whereas The lesions may fi rst appear as single or multiple stick eye shadow contains most of the same ingredi- oval patches that evolve into PUSTULES and NODULES ents as lipstick. with or without background redness and scaling. Eyeliner contains pigments in a resin solution If the condition is associated with the use of that may often be irritating to the eyes. It also con- topical steroids, they may be affected by the com- tains a small amount of mercury, which has been plications of topical steroid therapy, including atro- prohibited in all other cosmetics. However, the phied skin and spidery veins, ROSACEA, or patches amount in eyeliner is not believed to be harmful. of loss of color on the skin that looks like LEPROSY. Sensitivity can appear in response to any cos- MG may rarely resemble KAPOSI’S SARCOMA. metic, but the eyes are especially vulnerable. Too frequent or too harsh cleansing of the eyelid can Treatment Options and Outlook also cause irritation. Majocchi’s granuloma usually responds to topical antifungal or drying powders, such as those that contain miconazole, clotrimazole, or similar ingre- malar flush Often a sign of narrowing of a heart dients. Severe or chronic infection may require valve (mitral stenosis) malar fl ush is characterized further treatment by a doctor. Stronger, prescrip- by heightened color and a slight blue tinge over the tion topical antifungal medications, such as KETO- cheekbones due to a lack of oxygen in the blood. It CONAZOLE or sulconazole, may be needed. In some usually appears after a bout of rheumatic fever. mammoplasty 227

It is possible, however, to have a malar fl ush ening in body folds, underarms, neck and groin, without any heart irregularities: Many people with with velvety brown eruptions), COWDEN’S DIS- this high coloring do not have cardiac disease. EASE (small oral nodules), dermatomyositis (red, swollen thickened skin especially of the eyelids), GARDNER’S SYNDROME (disfi guring cysts on skin), mal del pinto See PINTA. Paget’s disease (weeping, crusting or scaly skin infl ammation in anal or groin region, vulva, arm- pits, or breasts), PEUTZ-JEGHERS SYNDROME (dark mal de Meleda An extremely rare hereditary skin pigmented oral spots), PYODERMA GANGRENOSUM disease of the EPIDERMIS inherited by autosomal (ulcer with bluish borders, covering large areas of recessive transmission. This means that a defective skin), BOWEN’S DISEASE, BULLOUS PEMPHIGOID, ERY- gene must be inherited from both parents in order THEMA ANNULARE CENTRIFUGUM, ERYTHEMA GYRATUM to cause the abnormality. Generally, the parents REPENS, acquired ICHTHYOSIS (Hodgkin’s disease or of an affected person are unaffected carriers of the lymphoma), BAZEX SYNDROME, DERMATITIS HERPETI- defective gene. Each of the children of such parents FORMIS, PEMPHIGUS, PORPHYRIA cutanea tarda, and has a one in four chance of being affected, and a leukocytoclastic vasculitis. two in four chance of being a carrier. This disease is progressive and persistent. The condition was fi rst described in 1826 on the malignant melanoma See MELANOMA, island of Meleda off the coast of Bosnia Herzegov- MALIGNANT. ina. Most cases of this disease have been reported in Bosnia, Germany, and France. mammoplasty Plastic surgery of the breasts either Symptoms and Diagnostic Path to increase (breast augmentation) or decrease During the fi rst few weeks of life, the disease is (breast reduction) their size. characterized by yellow-brown, waxy, rough palms Breast augmentation is the most popular of all and soles of the feet. Other associated abnormali- operations to reshape soft tissue. In the past, fl uids ties include poor physical development, short nails were directly injected into the breast, with some and fi ngers, high palate, and abnormalities of the dreadful results. Today, a prosthesis is implanted EEG. into a pocket either directly under the breast tissue or underneath the major chest muscle. Treatment Options and Outlook In the past, the most common implants were sil- Administration of keratolytics and lactic acid-based icone gel. The U.S. Food and Drug Administration creams is the recommended treatment. (FDA) had asked for a voluntary moratorium on the sale of silicone gel breast implants in 1992 after a number of anecdotal reports linking ruptured malignancy, skin signs of internal There are a implants with immune system disorders. The FDA range of signs that can appear on the skin in con- ruled that silicone implants would be available only nection with cancer. Some of these signs include if saline-fi lled implants were not an option (silicone multiple SEBACEOUS CYSTs, increased hairiness, dry- implants were not totally banned). However, the ness, and scaling. Five percent of cancer patients FDA did not conclude that silicone implants posed may get metastatic lumps, usually in connection a health risk, but that implant manufacturers had with cancers of the breast, lung, or colon—but usu- not provided enough data to confi rm their abso- ally only after the cancer is well advanced. Up to 25 lute safety. Since then, health risk reports have not percent of lymphomas appear fi rst as a skin rash, been substantiated by controlled clinical trials. with small plaques, nodules, or ulcers. However, critics continue to insist that silicone Other examples of cancerous diseases with skin often leaks from the gel-fi lled devices, causing symptoms include ACANTHOSIS NIGRICANS (dark- cancer and neurological diseases. As a result, more 228 manicures than 90 percent of the U.S. market now uses Outlook and Lifestyle Modifi cation saline-fi lled implants, although silicone implants Activities must be restricted for several weeks post- have remained available for women who have surgery. Some scarring occurs, usually around the undergone mastectomies. nipple, under the breasts and between the nipple In July 2005, silicone gel-fi lled breast implants and the second scar. It is also possible that the moved a step closer to being reintroduced to the nipple will be less sensitive, and that breast-feeding U.S. market after the FDA issued an “approvable may become impossible. There is no evidence of an with conditions” letter to one manufacturer (Men- increase in breast cancer. Because breast reduction tor Corp.) for its implants. However, this letter does is not always simply cosmetic, some insurance com- not mean that the device is approved for marketing panies will pay for at least part of the operation. in the United States at this time. Federal law pro- See also MASTOPEXY; SILICONE IMPLANTS. hibits the government from discussing the letter’s specifi c contents, but an approvable letter is one of several intermediate steps in the FDA’s review manicures See NAILS, CARE OF. process for new products. Saline infl atables are the implant of choice in the United States. A third type, the double-lumen prosthesis, features a gel-fi lled Mantoux test See TUBERCULIN TEST. inner portion surrounded by a saline infl atable outer jacket. In breast augmentation, the incision through mask A type of skin product that can either be which the implant is inserted can be made either rinsed or peeled off that helps the skin to exfoliate above the crease under the breast, near the nipple, (shed its dead outer cells) in order for it to look or high in the armpit. The fi rst method is the most fresh and vital. Masks also stimulate the skin’s popular: The armpit incision leaves no scar on the circulation, and some help the skin hold moisture breast itself, but it is more risky since the incision better (at least temporarily). is so far from the area on which the surgeon is Newer products have been developed for a wide working. range of tasks such as improving puffy eyes in addi- After the procedure, the breast should look and tion to imparting a healthy glow to the skin and feel natural: Scars are usually not noticeable. removing dead skin cells. Masks are designed to work quickly—most of them dry in 10 minutes or Risks and Complications less and are then removed. Problems with breast hardness, caused by scar tis- Today’s masks are more effective because they sue that forms around the implant, may occur in include better ingredients designed to clean, tighten, up to 30 percent of patients. This hardness may refresh, and moisturize the face. Mixed into these appear soon after surgery or years after the proce- products are substances previously found only in dure. Other risks are rare and include loss of nipple moisturizers such as talc and nylon, to cut down sensitivity (5 to 10 percent), infection, or poor shine; buttermilk (a moisturizing ingredient); caf- healing of scars. feine extract; and grapefruit seed to soothe and Because breasts that are too large may cause lessen redness. back pain, discomfort during sports, chronic back Before choosing a mask, consumers should read strain, rashes in the creases, or a psychological bur- the label carefully; it’s important to know what den, some women choose breast reduction to solve active ingredients to look for to best treat a specifi c their health problems. In this surgical technique, SKIN TYPE. excess breast tissue is removed, the nipple position Oily skin The best masks for this skin type is raised and the skin is trimmed to fi t the new are made of kaolin (oil-absorbing clay), bentonite shape. The operation usually requires a hospital (white clay), aluminum magnesium silicate (talc), stay and general anesthesia. witch hazel, alcohol, or zinc oxide. These masks mastocytomas 229 work by cleaning the skin, absorbing excess oil MACULES or PAPULES (URTICARIA PIGMENTOSA), small (which cuts down on shine) and preventing bacte- nodules common in young children (mastocy- rial growth. Kaolin and bentonite also cause the toma), and malignant mast cell leukemia. Urticaria skin to perspire, which opens up the pores, allow- pigmentosa is the most common of these diseases. ing the ingredients in the mask to deep-clean the MASTOCYTOMAS represent 10 percent of all cases of skin. Most oily-skin masks start as a thick paste and mast cell diseases. dry to a hard crust that is removed by water. After- ward, the skin feels temporarily tightened. Symptoms and Diagnostic Path Dry skin The best masks for dry skin include Symptoms may include fl ushing, nausea, vomiting, those with collagen, buttermilk, and protein as upper stomach pain, hives, itching, and shock, or moisturizers; panthenol (a B vitamin), to help “mastocytosis syndrome.” retain moisture; amino acids, to help water pen- etrate the skin, plumping up skin cells and tempo- Treatment Options and Outlook rarily fi lling in fi ne lines; and oils or lanolin, to help Most patients with mast cell diseases can expect an keep moisture close to the skin. Masks for dry skin excellent prognosis with an uncomplicated recov- are usually gel- or cream-based and do not dry and ery. In children, the skin lesions often clear up on harden on the skin. their own, but in adulthood the lesions don’t usu- Blotchy skin The types of masks to help this ally disappear. Occasionally, patients may experi- skin problem include those made with kaolin, ence systemic involvement with collections of mast caffeine, grapefruit seed, and plant extracts such cells in internal organs and a progressively more as azulene, chamomile, and aloe. All skin types serious decline into a lymphomalike illness, but can benefi t from products with these ingredients, this is uncommon. A few cases become malignant. which can soothe and even out the complexion. Caffeine and grapefruit seeds diminish redness; chamomile extract cuts down infl ammation and mastocytomas One of the more common MAST has a cooling effect on the skin. CELL DISEASES that is found almost exclusively in Dull skin Masks made of menthol, pepper- children, characterized by a solitary brown-tan mint, or eucalyptus can help stimulate the skin, plaque rather like an orange peel (PEAU D’ORANGE) leaving it with a tingling feeling. These masks are that itches when stroked. Adults do not develop sometimes made to dry into a stretchy fi lm that is exterior symptoms from mastocytomas. peeled off; others are cream-based and are rinsed off. Both types remove dead skin cells, which cre- Symptoms and Diagnostic Path ate a dull appearance. Mastocytomas usually are diagnosed at birth or within the fi rst few weeks of life. Usually solitary, they may occur in groups of up to four, and they mask of pregnancy See CHLOASMA. are most often found on the body, neck, and arm (especially near the wrist). The brown/tan plaques may swell or itch, usually the result of gentle rub- mast cell diseases Diseases that involve the mast bing or scratching. BLISTERs also may develop from cell, a large cell in connective tissue with many the plaques. Attacks of fl ushing (either on the face coarse granules containing the chemicals hepa- or all over the body) may occur, sometimes related rin, histamine, and serotonin, which are released to bumping the lesion. during infl ammation and allergic responses. Mast cell diseases (known collectively as MASTOCYTOSIS) Treatment Options and Outlook include a wide variety of different conditions char- While isolated mastocytomas may be removed, it acterized by tissue invaded by mast cells. These may be best to leave them alone since they almost conditions include crops of benign hyperpigmented always spontaneously disappear. Most children 230 mastocytosis who develop this condition before age fi ve will out breasts—just more youthful-looking ones—the grow it by adolescence or early adulthood. When surgeon can perform a mastopexy. This does leave mastocytosis begins after age fi ve, the abnormal the same scars as a breast reduction. With this tech- collections of mast cells may sometimes involve the nique, however, nipple sensations are usually left internal organs, and the plaque may not go away. undisturbed and there may be no loss of the ability to breastfeed. mastocytosis The most common variety of MAST CELL DISEASE (also known as urticaria pigmentosa), measles A childhood viral illness causing a wide- this unusual condition is characterized by many spread blotchy, slightly elevated pink rash, which itchy, yellow or orange-brown MACULES on the develops fi rst behind the ears and then elsewhere. skin. The rash lasts from three to fi ve days. Although a commonplace disease, complications (including Symptoms and Diagnostic Path pneumonia) can lead to death. One attack usually Macules are most often found on the trunk and sel- confers lifelong immunity. The patient is infectious dom the face, although they can appear anywhere while the rash lasts; complete recovery may take on the body. The macules range in size from a few two to four weeks. millimeters to several centimeters. The skin condi- Once common throughout the world, only tion generally worsens after bathing or scratch- about 44 cases of measles were reported in the ing the skin. Mastocytosis usually appears during United States, because of strict vaccination require- the fi rst 12 months of infancy and fades away by ments for school-age children. No measles deaths adolescence. have been reported in the United States in the past few years, but measles still kills more than Treatment Options and Outlook 1 million victims a year in developing countries— There is no satisfactory treatment, although ANTI- especially among malnourished children with HISTAMINES such as Benadryl can help control ITCH- impaired immunity. ING, HIVES, and fl ushing. The measles virus is very contagious, and is spread by airborne droplets from nasal secretions. Risk Factors and Preventive Measures Symptoms appear after an incubation period of Patients should avoid aspirin, codeine, opiates, between nine to 11 days. The patient is infectious alcohol, polymyxin B, hot baths, and vigorous rub- from shortly after the beginning of this period until bing after bathing and showering, since these can up to a week after symptoms have developed. release histamine, which can trigger hives, itching, Infants under eight months of age rarely contract and fl ushing. measles, because they still harbor some immunity from their mothers. mastopexy The medical term for reshaping the Symptoms and Diagnostic Path breasts by trimming excess skin and raising the The disease begins with a fever, runny nose, sore nipple. Drooping breasts usually follow signifi cant eyes and cough; the rash appears after three or four weight loss or frequent childbirth. days, beginning on the head and neck and spread- In mild cases, the breast appearance can be ing down to cover the entire body. The spots may be improved simply by placing an implant under- so numerous that they blend together as a large red neath the breast tissue in a procedure similar to area. The rash begins to fade within three days. breast augmentation (see MAMMOPLASTY). In this procedure, the implant fi lls out the extra skin and Treatment Options and Outlook raises the nipple, giving the entire breast a more Fluids and acetaminophen are given for fever. youthful appearance. This process also makes the Antibiotics will not help the virus, but may be breast larger; in patients who do not want larger needed to treat a secondary infection. melanin 231

The most common complications include ear required for more stubborn cases. Some experts and chest infections, usually occurring as the fever recommend daily treatments for six months even returns a few days after the rash appears. There after active lesions have disappeared in order to may also be diarrhea, vomiting, and abdomi- prevent recurrence, but the value of maintenance nal pain. About one in every 1,000 patients therapy has not been established. goes on to develop encephalitis (brain infl amma- Mechlorethamine is not effective in those with tion), with headache, drowsiness, and vomiting, advanced tumor-stage mycosis fungoides. beginning seven to 10 days after the rash begins. This may be followed by seizures and coma, Side Effects sometimes leading to mental retardation or This medication is relatively less toxic than other death. (Note: seizures are common with measles antitumor agents, although more than half of all and do not necessarily indicate the presence of patients develop an irritant or contact dermatitis. encephalitis). Very rarely (one in a million cases) Nitrogen mustard causes fewer problems when a progressive brain disorder called subacute scle- applied as an ointment in lower concentrations, rosing panencephalitis develops many years after gradually increasing the concentration over time. the illness. The drug should be stopped if diffuse hyperpig- A woman who contracts measles during preg- mentation occurs. nancy will lose the baby in about one-fi fth of cases, See also BASAL CELL CARCINOMA; SQUAMOUS CELL but there is no evidence that measles causes birth CARCINOMA. defects. GERMAN MEASLES during pregnancy can cause birth defects if the mother contracts the dis- ease during early pregnancy. For this reason, girls Mees’ lines Single or multiple white horizon- should be immunized before puberty. tal bands on the nails that are a sign of arsenic poisoning. Risk Factors and Preventive Measures In the United States, children are routinely vac- cinated early in the second year by an injection Meissner’s touch corpuscles One of three spe- usually combined with mumps and rubella that cialized nerve endings found in the skin. Meissner’s produces immunity in 97 percent of patients. touch corpuscles are oval structures composed of Side effects of the vaccine are reported to be mild, coiled terminal axons within a basal lamina and including low fever, slight cold, and a rash about a collagen fi bers. They are primarily found in the week after the shot. palms and soles, and appear to assist in the sensory The vaccine should not be given to infants function of touch. under age one, to those with a history of epilepsy in the family, or to those who have had seizures before. In these cases, simultaneous injection of melanin The pigment that gives skin, hair, and measles-specifi c immunoglobulin, which contains the iris of the eyes their color; the more melanin antibodies against the virus, should be given. present, the darker the color. Its level depends on race, heredity, and sun exposure. Melanin is produced by cells called melanocytes mechlorethamine A nitrogen mustard used for (PIGMENT CELLS), special cells of the EPIDERMIS that the past 30 years as a topical treatment for early are controlled in part by the pituitary gland and by stages of mycosis fungoides (a disease featuring a hormone secreted from the hypothalamus called chronic irritating eruptions). It is administered MELANOCYTE-STIMULATING HORMONE (MSH). Mela- either as a liquid or ointment, usually over the nocytes produce two types of melanin, eumelanin entire body on a daily basis. Lesions clear up in and phaeomelanin; eumelanin is black or brown, between 50 and 75 percent of cases within two to and phaeomelanin is red. The ratio of these two pig- six months, although prolonged treatment may be ments determines hair and skin color. 232 melanocytes

Exposure to sunlight stimulates a protection melanoma, acral lentiginous The second least reaction by the melanocytes that darkens the skin common of four types of malignant melanoma by increasing melanin. Ultraviolet light B (UVB) accounting for only 10 percent of all melanomas. increases the production of melanin; UVA oxidizes It is, however, the most common malignant mela- already-existing melanin to produce immediate noma in African Americans and Asians. The diag- darkening. UVB tanning is the slow darkening nosis of this form of melanoma is often delayed, that develops after several days after sun expo- which can be fatal. sure. Localized excess melanin production causes FRECKLES and lentigines. Many chemical agents Symptoms and Diagnostic Path stimulate the production of melanin. Other agents Lesions are found on the palms, soles, fi ngers, and that boost melanin production include prostaglan- toes, or on the mucosal surfaces. The fi rst signs din E2, estrogens and other hormones, and some of acral lentiginous melanoma may appear as a chemotherapy drugs (such as bleomycin). Ingested darker streak in the nail, sometimes appearing with metals such as arsenic can darken skin by deposit- a brown discolored cuticle (Hutchinson’s sign). ing melanin in the DERMIS. Not all darker streaks in the nail are the result of PSORALENS are organic compounds found in malignant lesions. As the lesion develops it may be many plants, such as limes and celery, that in brown, black, pink, or blue occasionally becoming combination with UVA stimulate the formation of a nodule, which may ulcerate. melanin. See also DEPIGMENTATION DISORDER; PIGMENTA- Treatment Options and Outlook TION; PIGMENTATION, DISORDERS OF. Treatment of acral lentiginous melanoma is described under malignant melanoma. See also MELANOMA, JUVENILE; MELANOMA, LEN- melanocytes See PIGMENT CELLS. TIGO MALIGNA; MELANOMA, MALIGNANT. melanocyte-stimulating hormone (MSH) A hor- Historic name for NEVUS, mone that regulates human skin color by stimulat- melanoma, juvenile SPITZ. ing the production of MELANIN. Four different MSH peptides have been identifi ed, all of which are formed in the pituitary gland. Lack of MSH (such A type of malignant as in HYPOPITUITARISM) may cause a decrease of skin melanoma, lentigo maligna color all over the body. lesion that develops from a preexisting lesion of LENTIGO MALIGNA See also PIGMENTATION; PIGMENTATION, DISORDERS (melanotic Hutchinson’s freckle); OF; PIGMENT CELLS. it makes up about 5 percent of all primary skin melanomas. These lesions, which tend to occur in older women patients, always are found in sun- melanocyte system, tumors of Tumors that exposed areas (especially the face). include MOLES, congenital nevus, Spitz nevus (see This type of malignancy tends to grow over a NEVUS, SPITZ), dysplastic nevus syndrome, halo long period of time; the original pigmented lesion nevus (see NEVUS, HALO); blue nevus (see NEVUS, appears 10 to 15 years before it becomes malig- BLUE), lentigines (see LENTIGO; LENTIGO MALIGNA), nant. This transformation takes place in up to 5 malignant melanoma (see MELANOMA, MALIGNANT). percent of all patients with lentigo maligna. See also PIGMENT CELLS; PIGMENTATION. Melanoma fi rst appears within the lesion as a slow-growing, deeply colored nodule. Once the malignant cells have invaded the dermis, they may melanoma See MELANOMA, MALIGNANT. spread as any other type of melanoma. melanoma, malignant 233

Treatment Options and Outlook Defective versions of the gene also may be Treatment for lentigo maligna melanoma is the involved in many or even most cases of nonin- same as for malignant melanoma. herited melanoma, according to research. In those See also MELANOMA, ACRAL LENTIGINOUS; MELA- cases, the gene would be inherited in normal form NOMA, MALIGNANT; MELANOSIS. but would mutate following exposure to sunlight or other causes. Researchers hope that studying this gene may someday lead to a screening test for melanoma, malignant The most deadly form of those at risk, and for better treatments for the non- the three major types of SKIN CANCER, melanomas inherited disease. are brown, black, or multicolored patches, plaques, Other risk factors for developing melanoma are or NODULES with an irregular outline. Malignant severe SUNBURNS in childhood; even one severe melanoma is much more dangerous than other burn during childhood or adolescence is a potent forms of skin cancer because of its tendency to precursor of melanoma later in life. Anyone with spread rapidly to vital internal organs such as the multiple moles may also suffer from dysplastic lungs, liver, and brain. One in fi ve patients affl icted nevus syndrome and may be at increased risk for with malignant melanoma dies of this cancer. It the development of melanoma. is the most frequently diagnosed cancer among All patients with a history of malignant mela- women between 25 and 29, and it ranks second noma have about 5 percent risk of developing in frequency of occurrence only to breast cancer another separate, unrelated melanoma of the skin. among those aged 30 to 34. This process is called multiple primary melanoma In 1935 when few people habitually baked at formation. If a second melanoma of the skin devel- the beach, melanoma was a rare disease, affecting ops in a patient with a history of melanoma, it is only one in 1,500 Americans. Today, the world- very important to determine whether it is a new wide incidence of melanoma is increasing at a skin melanoma (second primary) or a spreading to faster rate than any other type of cancer, with the the skin from the original melanoma. If the lesion exception of lung cancer in women. In the United has spread, the disease must be classifi ed as Stage States alone, the incidence has tripled in the last 40 III and the likelihood of death in fi ve years rises years, nearly doubling in the last decade. An esti- signifi cantly. mated 59,580 Americans will develop melanoma Although melanoma many times begins without in 2005. Since 1981, the incidence has increased the presence of a mole, it most frequently does about 3 percent a year. begin inside a mole. Interestingly, melanoma can Those at highest risk have a family history of arise within all three major categories of moles: skin cancer, an abundance of moles (more than 100), fair skin, light hair, and blue-green or gray • atypical (dysplastic, unusual) nevus eyes. A defective gene on chromosome 9 causes • congenital (existing at birth) nevus an inherited tendency to this type of deadly skin • plain ordinary moles, which are totally different cancer, and that may also play a role in non-inher- from seborrheic keratoses ited melanoma. About 10 percent of melanoma occurs in people with an inherited tendency, and it is unclear what percentage of inherited cases are Symptoms and Diagnostic Path due to this gene. Melanoma usually begins as a pigmented growth on Normally, the gene acts as a brake on cancer, the skin, displaying many shades of color (includ- but those who inherit a defective version lose part ing brown, black, pink, white, blue, or gray). It of their protection, making them unusually suscep- often has irregular outlines and may be larger than tible to melanoma. The normal gene tells the body ordinary moles. The spots may crust, bleed, or itch, how to make a protein called p16, which helps and at times they may develop within preexisting regulate cell division. MOLES. It is therefore important that any moles that 234 melanoma, malignant change in any way be examined by a DERMATOLO- Surgical removal of the tumor and a margin GIST. Congenital moles (present at birth) seem to of normal skin is usually required, together with have an increased risk of becoming malignant, and possible surgical removal of nearby lymph nodes. therefore should be examined early in life by a der- A skin graft may be necessary after the tumor is matologist. There are four types of melanoma, each removed. Tumor removal may be accompanied or with a characteristic growth pattern: followed by radiation, chemotherapy, or medica- tions that stimulate the immune system, such as • Superfi cial spreading melanoma This is the most interferon. common type, accounting for 70 percent of all The thickness of the tumor is the single most cases. This type typically arises from a preexisting important factor in determining prognosis. Approx- nevus and expands in a radial fashion before it imately 77 percent (men) to 88 percent (women) enters a vertical growth phase. of all malignant melanomas may be cured if treated • Nodular melanoma A more aggressive tumor early. The cure rate approaches 100 percent if the found more often in men, this accounts for melanoma is found early enough. If deep local approximately 15 to 30 percent of cases. It begins spread occurs, the number of people who live for from normal skin and has no radial growth at least fi ve years is about 30 percent. With spread phase. of cancer to distant sites, fi ve-year survival is less than 10 percent. • Lentigo maligna melanoma This type accounts for Scientists have been working on creating a less than 10 percent of cases and is found more “cancer vaccine” that can prime the immune sys- commonly on the face in females and the elderly. tem to recognize malignant cells and target them The lesions, typically large and fl at, are slow for destruction. (The cancer vaccine is a treatment growing and rarely spread. for existing disease; it is called a “vaccine” because • Acral lentiginous melanoma This type, which occurs it enlists the immune system to kill malignant on the soles of the feet, accounts for less than 10 cells.) percent of lesions but occurs in a higher pro- Researchers now report that destroying healthy portion (35 percent to 60 percent) of nonwhite skin cells can incite the immune system to kill the patients. cancerous versions of these cells, with only mild side effects. The potential treatment targets pig- Because the skin is so easily seen, malignant ment cells (melanocytes) that, when malignant, melanoma can be easier to spot than internal become melanoma. In mouse studies, scientists malignancies. To make sure that people notice skin administered a vaccine containing DNA plus an cancer, dermatologists recommend that everyone antiviral drug to mice in a series of injections. In examine their skin twice a year, using a full- response to the treatment, the mice lost not only length and a hand-held mirror. Any suspicious melanoma cells but also many healthy melano- growths should be reported immediately to a cytes, leaving the black mice with white splotches dermatologist. of hair that lasted for months. The mice remained tumor-free for at least 100 days after receiving the Treatment Options and Outlook vaccine. Most skin cancers—even malignant melanomas— However, when the team implanted new tumors can be cured if discovered early enough, which in the mice 100 days after the fi rst tumors had been is why attention to symptoms and regular self- destroyed, the protection had faded and the mice examination is highly recommended. When can- died of melanoma. cers of the skin are discovered early, there are a variety of treatment possibilities, depending on Risk Factors and Preventive Measures the type of tumor, size, location, and other factors In addition to avoiding excess sun exposure, new affecting the patient’s general health. A biopsy is research isolating a gene defect that may lead to often needed before a treatment option is selected. some cases of malignant melanoma may be used meningococcal infections 235 as a screen for people at risk for the disease. These Mendes da Costa syndrome A disorder of KERA- patients could then be counseled to take steps like TINIZATION also known as erythrokeratodermia avoiding too much sun, keeping track of possible variabilis, this is a rare disorder characterized by precancerous moles, and using SUNSCREEN. two types of lesions—fi xed plaques and shifting In addition, scientists have found that some red rings or arcs frequently caused by tempera- foods and nutrients may counteract the develop- ture change. This genetic disorder is carried by ment of melanoma: best choices are fi sh with only one defective gene (from one parent). Each omega-3 fat and antioxidants (including VITAMINS E child of an affected person usually has a one in and C and beta-carotene). In one Australian study, two chance of inheriting the defective gene and of those who ate a half-ounce of fi sh daily were less being affected. likely to have melanoma than those who ate only one-fi fth of an ounce of fi sh daily. Symptoms and Diagnostic Path The plaques are most often found on the face, extremities, and buttocks; the red rings may last up Melanotan A synthetic hormone that mimics to hours or days. It is a form of ICHTHYOSIS, a group the action of melanocyte-stimulating hormone of hereditary skin disorders characterized by scaly (MSH), the hormone that induces a tan after sun skin patches. exposure. It was created and developed at the Uni- versity of Arizona and the Arizona Cancer Center Treatment Options and Outlook in 1991. Not yet approved for use by the U.S. Food Treatment with topical and oral retinoids has eased and Drug Administration, Melanotan may be an the condition in many patients. Etretinate is often effective preventative treatment for people at risk effective, although symptoms rapidly return when for SKIN CANCER. So far, it is effective only when treatment stops. Even with treatment, however, administered by injection, not orally. Its developers this condition is chronic and lasts a lifetime. hope it can reduce the risk of skin cancer in high- risk individuals by offering them the protective benefi t of a tan without the harm of sun exposure. meningococcal infections Infections caused by Its developers believe that Melanotan is effective in the bacteria Neisseria meningitidis that may cause promoting skin pigmentation with little or no risk. a rash ranging from masses of tiny pinhead- Its role in actually preventing skin cancer has not sized red dots to large blue-purple hemorrhagic yet been determined. areas or extensive gangrene. In the few who lack However, it cannot help individuals with ALBI- immunity, the meningiococcus bacteria infects NISM or VITILIGO, because these patients do not have the lining of the brain as a form of MENINGITIS, skin cells (melanocytes) with receptors for MSH. or the bloodstream as either acute or chronic The company developing the product claims it meningococcemia. will not leave streaks, blotches or, bare spots that The disease is transmitted most often through are common with other sunless tanning creams and the air in winter or by nasal droplets in spring. If lotions. It is currently undergoing clinical trials. the infection is introduced to people is closed quar- ters, it can become epidemic. Spread by a cough, a sneeze, a kiss, or a shared drink, it can kill a melanotic freckle of Hutchison See LENTIGO, healthy teenager within hours. MALIGNA. Symptoms and Diagnostic Path In addition to the rash, other symptoms include melasma See CHLOASMA. fever, headache, vomiting, delirium, convulsions, stiff neck, and back. Acute meningococcemia is rapidly progressive and often fatal, and needs early melioidosis See WHITMORE’S DISEASE. and aggressive diagnosis and treatment. 236 Menkes’ kinky-hair syndrome

Treatment Options and Outlook The cause of Merkel cell cancer (a type of neu- Aqueous penicillin G must be administered every roendocrine cancer of the skin) is not known. 24 hours for seven to 10 days by IV (or until the However, researchers have learned that it can patient’s fever subsides for fi ve days) to cure the develop quickly in people who have had an organ infection. There is a vaccine for group A and group transplant and are taking drugs to suppress their C meningococci. Treatment should also include immune system. Exposure to arsenic may also symptom control, such as reducing fever, main- increase the risk for Merkel cell cancer. Because taining fl uid and electrolyte balance, and adminis- this disease occurs so often on the face, head, neck, tering heparin when necessary. and extremities, researchers believe that exposure to sunlight may play a role.

Menkes’ kinky-hair syndrome A hereditary syn- Symptoms and Diagnostic Path drome characterized by twisted, beaded (monil- This cancer is characterized by fi rm, painless, red, ethrix) or fragile (trichorrhexis nodosa) hair shafts, pink, or blue smooth shiny lumps that vary in size usually associated with mental retardation, seizures from less than a quarter of an inch to more than and problems in walking or balance. two inches. About half of all Merkel cell cancers occur on the sun-exposed areas of the head and Symptoms and Diagnostic Path neck; another third appear on the arms and legs. The syndrome, which is caused by a problem with Occasionally, tumors also may begin on other parts copper metabolism, causes poor absorption, with of the body. This type of cancer occurs mostly often low blood and tissue copper levels. Most untreated in white men between 60 and 80. patients die by the age of four; many survive less Early detection is important because the disease than two years. can spread rapidly, and Merkel cell cancer is dif- The condition is an X-linked recessive disorder, fi cult to cure once it spreads. However, it is not which means that it is caused by a defect on the X easy to diagnose this type of cancer because Merkel chromosome, usually leading to problems in boys cells often look like cells found in other types of only. Women can be carriers of the defect, and half cancers (especially lung cancer). To diagnose it, of their sons may be affected. a tissue sample is removed from the abnormal area and biopsied. The doctor will also conduct a Treatment Options and Outlook detailed skin exam, examine lymph nodes for signs There is no treatment; supplements of intravenous of swelling, and may order blood cell counts, a liver copper are not effective. functions test, or a CT scan. Treatment Options and Outlook menthol A soothing white substance derived Surgery to remove the tumor is the usual treat- from oil of peppermint that is included in many ment for Merkel cell cancer. If the tumor cannot skin-care products because it feels cool to the touch be removed, the patient may require radiation or and may help relieve ITCHING. chemotherapy to try to shrink the tumor. Lymph nodes are often removed because they may contain cancer cells; radiation may be directed at the site of Merkel cell cancer A rare type of malignancy the surgery and at nearby lymph nodes to destroy that develops on or just beneath the skin and any remaining cancer cells. in hair follicles on the face, head, and neck. Even fairly small Merkel cell tumors can grow Researchers believe that exposure to sunlight may rapidly and often spread to other parts of the body, increase a person’s risk of this disease. People tak- most often to the regional lymph nodes, or the ing drugs to suppress their immune system after liver, bones, lungs, and brain. Merkel cell cancer an organ transplant can develop Merkel cell can- that has spread may respond to chemotherapy, but cer quickly. it is not usually curable by this method. metronidazole 237 metabolic disorders, skin signs of Disorders of diclofenac, nonsteroidal anti-infl ammatory drugs, metabolism often include symptoms of skin abnor- oxyphenbutazone, phenylbutazone, phenytoin, malities. In some disorders, skin changes are the probenecid, pyrimethamine, salicylates (including fi rst signal of an underlying metabolic problem. aspirin), sulfadoxine and pyrimethamine, sulfa Metabolic diseases with skin symptoms include drugs, and TETRACYCLINES. disorders of amino acid metabolism (phenylke- tonuria, homocystinuria, ochronosis, HARTNUP DISEASE, arginosuccinic aciduria, and tyrosinemia methoxsalen A PSORALEN drug used to treat PSO- type II). Diseases of lipid metabolism include RIASIS, MYCOSIS FUNGOIDES, and VITILIGO that belongs xanthomatoses, REFSUM’S DISEASE, XANTHELASMA, to the class of repigmenting agents. It is taken as a GAUCHER’S DISEASE, and FABRY’S DISEASE. Dis- tablet or capsule two to four hours before exposure eases of metal metabolism include problems with to sunlight or a sunlamp. In the treatment of viti- the metabolism of ZINC (acrodermatitis entero- ligo, it may take between six to nine months before pathica), iron (HEMOCHROMATOSIS), or copper results are apparent; results may be seen in 10 (WILSON’S DISEASE) and may result in numerous weeks or more for psoriasis. skin signs. See also PUVA. Other metabolic disorders include AMYLOIDOSIS, MUCINOSES, LICHEN MYXEDEMATOSUS, URBACH-WIETHE Side Effects DISEASE, MUCOPOLYSACCHARIDOSES, FUCOSIDOSIS, In addition to the above, common side effects gout, and Lesch-Nyhan syndrome. include increased skin and eye sensitivity to the sun, and nausea. Other possible side effects include red and sore skin, dizziness, headache, depression, methotrexate Sometimes used to treat PSORI- leg cramps, or insomnia. ASIS, this powerful anticancer drug can cause many unpleasant side effects. (It can also make Precautions the skin increasingly sensitive to sunlight.) It Methoxsalen should not be taken with any other should never be given to anyone besides the medication that causes skin sensitivity to the sun. patient for whom it is prescribed for any purpose, since patients require close medical Patients should avoid alcohol in any form from 12 supervision. hours before taking the drug to at least 24 hours afterward. Combining alcohol with methoxsalen Side Effects may result in a reaction causing fl ushed face, Possible effects include severe nausea and vomit- severe headache, chest pains, shortness of breath, ing, diarrhea and mouth ulcers, black stools, sore nausea and vomiting, sweating, and weakness; throat, fever, chills, unusual bleeding and bruising, severe reactions may be fatal. abdominal pain, anemia, increased susceptibility to infections, abnormal bleeding, and liver dam- age with long-term use. Extra fl uid intake eases methyl paraben A preservative used in eyeliners, methotrexate toxicity. Infrequently, side effects can hair care products, and cold creams that is the fre- include hair loss, dizziness, seizures, shortness of quent cause of allergic reaction to cosmetics. breath, and rash. Physicians perform routine follow-up medical evaluations in all patients taking methotrexate, metronidazole (Trade names: Flagyl, Metryl, Pro- including tests to check liver and kidney functions tostat, Satric) An antibiotic particularly useful in and complete blood counts. fi ghting infections of the urinary, genital, and diges- Methotrexate may negatively interact with a tive systems such as trichomoniasis, amebiasis, and range of other drugs. Possible toxicity could occur giardiasis, and for the treatment of ROSACEA. It is when taken with anticonvulsants, antigout drugs, administered by mouth or by suppository. 238 miconazole

Side Effects over the treatment area in a single, smooth stroke. Rarely, side effects may include nausea and vomit- Thicker skin on the forehead, chin, and nose can be ing, appetite loss, abdominal pain, metallic taste, treated more aggressively. and dark-colored urine. Drinking alcohol during Each treatment takes between 15 minutes to treatment with this drug can trigger particularly an hour, and is usually repeated fi ve to six times unpleasant reactions, such as nausea, vomiting, hot typically spaced two to four weeks. After the initial fl ashes, headache, and so on. series of treatments, monthly to four-times-a-year maintenance treatments are usually recommended, depending on the patient. Microdermabrasion may miconazole Antifungal agent used for topical be combined or alternated with a light chemical treatment of DERMATOPHYTES. peel to increase the effect. Microdermabrasion is only effective for fi ne lines and more superfi cial scars; it is ineffective for microdermabrasion An effective skin-freshening deeper wrinkles or scars, or anything but the most technique used to repair the skin, reducing fi ne superfi cial pigmentary abnormalities. These are lines, sun-induced, age spots, and superfi cial ACNE best treated with other methods, such as chemical scars by removing the very outer layer of skin, peels, DERMABRASION, NON-ABLATIVE SKIN REJUVENA- and by stimulating the production of skin cells and TION, and LASER RESURFACING. COLLAGEN. Microdermabrasion is one of the top fi ve nonsurgical cosmetic procedures; more than Risks and Complications 1 million microdermabrasions were completed Unlike other skin resurfacing techniques such as in 2004 (an increase of 28 percent), according to dermabrasion, chemical peels, and laser resurfac- the American Society of Dermatologic Surgery ing, microdermabrasion has fewer signifi cant risks (ASDS). Simple and quick to perform, this pain- of pigmentary changes or scarring, even though it less procedure does not require anesthesia, can requires multiple treatments. be repeated at short intervals, and does not sig- nifi cantly interrupt the patient’s life. Microderm- Outlook and Lifestyle Modifi cation abrasion is well suited for patient with mild skin After the procedure, the treated area is cleaned damage as a result of sun exposure and who have with a wet cloth to remove any leftover crystals. busy lifestyles, because the only real down time After drying, a moisturizer or ointment is applied. is during the treatment itself. The procedure does Redness usually improves within hours after treat- not require an anesthetic and is effective on all ment, allowing a quick return to normal activities. skin colors and types. However, the patient may experience a mild sun- For thousands of years individuals in search of burnlike sensation for a few days. younger-looking skin have tried to resurface their The procedure gives the skin an overall fresh, faces by using a variety of abrasive techniques, using healthy-looking glow without side effects. Normal acids, poultices of minerals and plants, and irritants activities can be resumed immediately. Patients such as fi re or rough materials. Microdermabrasion who have good skin tone will show the best as experts perform it today was developed in Italy results. in 1985 and quickly spread throughout Europe; After microdermabrasion the skin’s appearance eventually, physicians in the United States began can be enhanced even more with topical skin treat- to use the procedure as well. ments such as TRETINOIN, ALPHA-HYDROXY ACIDS, During the procedure, the physician, nurse, or RETINOIC ACID, and topical VITAMIN C. Patients being aesthetician uses a sort of sandblasting device to treated for HYPERPIGMENTATION (excess skin color) spray the surface of the skin with high-pressure should apply hydroquinone between treatments. crystals that gently abrades and suctions away the An individualized skin care program, including dead outer layer of skin, gently polishing the area use of sun blocks and protection from photoaging, as it lessens wrinkles. The handpiece is moved is usually recommended for best results. Liberal use miliaria 239 of SUNSCREEN and moisturizers can help improve develop on the face, particularly around the eyes. the appearance of the skin by helping to remove Secondary milia can be found anywhere on the skin cells and decrease sensitivity to the sun. The body at the sites affected by whatever is causing price of a microdermabrasion treatment ranges the milia. Eruptive milia occur on the head, neck, from $100 to $200. and upper body. Scarring has not been documented from micro- Painless and harmless, these bumps may also dermabrasion because the procedure barely affects appear after an injury, chronic ultraviolet light the skin any deeper than the outer layer. This is exposure, or BLISTERs, or as a result of blocked the reason for both its strong and weak points: PORES. Superfi cial injury results in quick healing and recovery with little risk, but because it is superfi - Treatment Options and Outlook cial, only fi ne lines, skin quality, shallow scars, mild Epidermal cysts and milia may be removed for sun damage, AGE SPOTS, acne scars, and enlarged cosmetic reasons or to prevent rupture using a pores can be treated. It is not effective for deep fi ne-gauge needle and a cotton-tipped swab, or wrinkles and scars or ice-pick acne scars because a comedone extractor. Infl amed lesions respond these lesions extend into the deeper layers of the well to incision and drainage. Antibiotics are not skin. This is also why it does not work for pigment normally required, unless pathogenic bacteria are problems such as melasma or post-infl ammatory present. In infants, no treatment is necessary. hyperpigmentation, because this treatment does not effectively address the DERMIS, where these problems begin. Instead, patients with these prob- miliaria A common disorder of the eccrine lems should be treated with more traditional SWEAT GLANDS that often occurs during hot, humid resurfacing techniques, such as chemical peels, weather. It is believed to result from blocked sweat dermabrasion, NON-ABLATIVE SKIN REJUVENATION, or ducts, so that eccrine sweat leaks into the epider- laser resurfacing. mis or dermis layers of the skin. The three types of miliaria are classifi ed according to the level at which obstruction of the sweat duct occurs: microlipoinjection See SKIN FILLERS. • miliaria crystallina In this condition, ductal obstruction is least severe, producing tiny, frag- milia Also known as epidermal cysts, these small, ile, clear blisters fi rm white PAPULES are usually found in clusters on • miliaria rubra (PRICKLY HEAT) In this condition, upper cheeks and around the eyes. They are com- obstruction occurs deeper within the EPIDERMIS, monly (but wrongly) called SEBACEOUS CYSTs. These causing extremely itchy red PAPULES cysts are extremely common, appearing equally • miliaria profunda This condition obstructs ducts at in all races, all ages, and both genders. Milia in the junction of the DERMIS and EPIDERMIS, leak- newborns are so common that they are considered ing sweat into the dermis and producing subtle normal. fl esh-colored papules Milia are also found in about 40 percent of full- term infants on the forehead, cheeks, and nose. Miliaria occurs in individuals of all races, Symptoms and Diagnostic Path although some studies have shown that Asians, Milia are superfi cial, pearly white to yellowish who produce less sweat than Caucasians, are less domed lesions that usually appear on the face. likely to develop miliaria rubra. Miliaria crystallina About 40 percent of infants have the bumps, and miliaria rubra can occur at any age, but are which are especially common around the nose, most common in infancy. Two cases of congenital forehead, and cheeks, and also in the mouth. miliaria crystallina have been reported. Miliaria Primary milia in older children and adults also profunda is more common in adulthood. 240 miliaria

High heat and humidity that triggers excess Miliaria profunda is itself a complication of sweating is the primary cause for the development repeated episodes of miliaria rubra. The lesions of miliaria. Binding the skin with clothing or ban- of miliaria profunda do not cause symptoms, but dages can further contribute to pooling of sweat on patients may develop compensatory excess facial the skin surface and overhydration of the top layer sweating and a widespread inability to sweat else- of the epidermis (stratum corneum). If hot, humid where, resulting from eccrine duct rupture: This is conditions persist, the individual will continue known as tropical anhidrotic asthenia and predis- to produce excessive sweat but will be unable to poses patients to heat exhaustion during exertion secrete the sweat onto the skin surface due to the in warm climates. blocked ducts. This leads to leakage of sweat en route to the skin surface, either in the dermis or Treatment Options and Outlook in the epidermis. When the point of leakage is in There is no reason to treat miliaria crystallina, as the stratum corneum or just below (as in miliaria this condition will go away on its own and does crystallina), there is little infl ammation. In miliaria not cause unpleasant symptoms. However, miliaria rubra, however, leakage of sweat into the subcor- rubra can be very uncomfortable, and miliaria pro- neal layers produces blisters. In miliaria profunda, funda may lead to heat exhaustion, so treatment of escape of sweat into the papillary dermis leads to these two conditions is necessary. white or red papules that usually do not itch. Topical treatments may include lotions contain- Normal skin bacteria, such as Staphylococcus epi- ing CALAMINE, boric acid, or menthol; cool wet- dermidis, are thought to play a role in the develop- to-dry compresses; frequent showering with soap ment of miliaria. Patients with miliaria have three (although some doctors discourage excess soap); times as many bacteria as healthy people. topical CORTICOSTEROIDS, and topical antibiotics. Top- ical application of anhydrous LANOLIN has resulted Symptoms and Diagnostic Path in dramatic improvement in patients with miliaria Miliaria crystallina is a common condition in profunda. Anhydrous lanolin is believed to prevent infants, most often at one week of age, and in ductal blockage, allowing sweat to fl ow to the skin feverish individuals or those who have recently surface. Calamine lotion provides cooling relief. moved to a hot, humid climate. Miliaria rubra is It may be possible to prevent miliaria by using also common in infants and in adults who have oral antibiotics. Patients have also been treated moved to a tropical environment, occurring in up with oral retinoids, VITAMIN A, and VITAMIN C with to 30 percent of people exposed to such condi- variable success. However, there have been no con- tions. Miliaria profunda is more rare, seen only in trolled studies to demonstrate the effectiveness of a minority of those who have had repeated bouts any of these treatments. of miliaria rubra. Since increased exertion leads to sweating, Miliaria crystallina is usually quite mild and which greatly worsens miliaria, patients should gets better without complications over a period of limit activity (especially in hot weather) until the days, although it may recur if hot, humid condi- miliaria is cured. Patients with miliaria profunda tions persist. Miliaria rubra also tends to improve are at particularly high risk for heat exhaustion spontaneously when patients are removed to a during exertion in hot weather, since they have cooler environment. Unlike patients with miliaria trouble dissipating heat via evaporation of sweat. crystallina, however, those with miliaria rubra tend to have a lot of itching and stinging. They develop Risk Factors and Preventive Measures a lack of sweat in affected sites that may last weeks Prevention of miliaria consist primarily of control- and, if generalized, may lead to heat exhaustion. ling heat and humidity so that the patient is not Secondary infection is another possible compli- stimulated to sweat. This may mean treating a cation of miliaria rubra, either as IMPETIGO or as fever, reducing tight clothing, limiting activity, pro- multiple discrete ABSCESSes known as periporitis viding air-conditioning, or (as a last resort) moving staphylogenes. the patient to a cooler climate. mites 241 miliaria apocrine See FOX-FORDYCE DISORDER. pattern baldness) in men and diffuse hair loss or thinning of the front and top of the scalp in women. It was approved by the Food and Drug miliaria tuberculosis See TUBERCULOSIS, SKIN. Administration in 1988 as a lotion treatment for male pattern baldness, and in 1991 for women with hair loss. milker’s nodule A viral infection by a pox virus Research has found that after four months, that causes tricolored, sometimes-painful, black, about 25 percent of 2,300 men with male pat- red, and white nodules on the fi ngers of people tern baldness reported moderate to dense hair who milk cows. The poxvirus (paravaccinia) is regrowth, compared with 11 percent using pla- found widely among cattle and can cause lesions cebo. No regrowth was reported by 41 percent called pseudocowpox in the animals. Cross-species (60 percent using placebo). After one year, 48 per- infection can occur when human skin touches cent of those who continued to use minoxidil rated these lesions. their new hair growth as moderate or better. Studies have shown that the response to the Symptoms and Diagnostic Path drug varies a great deal from one person to Generally, a single red macule appears on the fi n- the next, but patients should not expect to see ger (although multiple lesions may occur) between regrowth before four months of use. Minoxidil four and seven days after infection. It progresses is a hair loss treatment, not a cure, and patients into a three-colored papule with a crusted center must continue to use the drug in order to maintain surrounded by a whitish area, in turn surrounded regrowth. New hair growth is shed after minoxidil by a red base. use is discontinued. In general, clinical studies have found that Treatment Options and Outlook minoxidil works best for those patients who are There is no specifi c treatment, and the lesion usu- younger, who have been losing their hair for a ally heals on its own, although it may leave a scar. short period of time and who have less initial hair Topical antibiotics may help to minimize the risk of loss. The medication’s effectiveness appears to be secondary bacterial infection. related to the activity level of hair follicles. Side effects include itching and other skin irrita- Risk Factors and Preventive Measures tions on the scalp. Infected cows should be isolated, and protective gloves should be worn when coming in contact with infected animals. mites Tiny eight-legged parasites belonging to the group (Acarina) that includes ticks. Much like tiny spiders, many of these mites have piercing mouth mineral oil A clear, odorless oil derived from parts that suck blood from animals and humans. A petroleum that is widely used in cosmetics because mite has no antenna or wings. Medically important it is inexpensive and rarely causes allergic reactions. mites include the many species causing DERMATI- It can, however, sometimes induce ACNE lesions. TIS (Dermatophogoides). The SCABIES mite lives in human skin, and CHIGGER BITEs can cause a rash. Mites in grain or fruit can cause a variety of skin minocycline (Trade name: Minocin) A tetracy- irritations (commonly called “grocer’s itch” or cline antibiotic used to treat ACNE. “bakers’ itch”).

Risk Factors and Preventive Measures minoxidil (Rogaine) A drug that widens blood Mites can be avoided by using insect repellents vessels, used in a topical solution on the scalp such as dimethyl phthalate when walking through to treat androgenetic alopecia (also known as infested areas. 242 Mohs’ microscopically controlled excisions

Mohs’ microscopically controlled excisions A be applied to an area that will not be washed type of dermatologic treatment in which thin lay- immediately. ers of tissue are removed and immediately exam- While moisturizers do not have “use by” dates, ined for malignant cells in a specially equipped they can lose effectiveness if stored for too long. lab in the doctor’s offi ce. Layers are removed until Shopping at a store with good turnover will ensure all tissue is cancer-free. The technique is used to freshness. At most department and chain stores, remove basal cell and squamous cell carcinomas the cosmetics company automatically changes the and a variety of other more rare skin cancers. stock, but this may not be the case at off-price or Developed by dermatologist Frederic E. Mohs, discount stores that do not buy directly from a this method is now used to treat one out of every manufacturer. four or fi ve skin-cancer patients. Mohs’ surgery Some of the newest (and most expensive) prod- offers the highest cure rate and sacrifi ces the least ucts contain humectants (ingredients that help the amount of healthy tissue because it almost always water stay with the skin longer to keep it supple); removes the entire cancer without removing too some of these substances are expensive. Some much surrounding normal skin. In this technique, experts believe that two humectants—hyaluronic using local anesthesia the tumor may fi rst be acid and ceramides—are excellent moisturizing reduced by curettage and then excised; blood fl ow ingredients, but they can add signifi cantly to the is usually controlled by electrodesiccation. The price of a product. Whether hyaluronic acid is a excised tissue is then mapped, fl attened, frozen, good moisturizer remains to be proven. and then cut in horizontal sections and the entire The best humectants include lactic acid and undersurface checked for the presence of tumor. urea, which is not expensive and is very effective. Repeated slices are performed until the margins Over-the-counter products containing these com- are clear. pounds are available singly or together. This technique is indicated for patients with When shopping for moisturizers, experts sug- recurrent tumors, primary tumors known to have gest that consumers compare ingredients and try high recurrence rates, and primary lesions where the lower-priced product fi rst. While people with tissue must be preserved (such as on the eyelids, dry skin and no ACNE can use oil-based moistur- nose, fi nger, genitalia, and areas around facial izers, consumers who tend to break out need to be nerves). more careful. Those with acne-prone skin should choose water-based products while avoiding prod- ucts that could aggravate the condition. How- moisturizer While moisturizing can help dry ever, recent information suggests that oil-based skin (much like a raisin plumps up in water), no products are acceptable as long as they are not moisturizer can prevent wrinkling. (The only pos- comodogenic. Acne-aggravating products include sible exception is a moisturizer containing ALPHA ingredients such as cocoa butter, heavy mineral HYDROXY ACID, which may help keep skin young- oil, acetylated lanolin alcohols, isopropyl esters, looking by thinning out dried up cells on the isopropyl myristate, lanolin, lanolin fatty acid, surface.) linseed oil, oleic acid, olive oil, petrolatum, and The right moisturizer should prevent dryness stearic acid. Moisturizer ingredients that are good without causing the skin to break out. Consumers for oily skin include beeswax, corn oil, isostearyl who experience problems with one moisturizer neopentate, light mineral oil, octyl palmitate, pro- should switch moisturizers rather than discontinue pylene glycol, saffl ower oil, sodium lauryl sulfate, their use. The problems may have resulted from and spermacetti. reaction to a specifi c chemical in that brand. It is important to test a moisturizer in the store, especially if the consumer has had problems with moles A type of pigmented NEVUS composed of other moisturizing products. Moisturizer should nevus cells. The average young adult has at least morphea 243

25 moles. However, a change in a mole may be the tocks. The spot, which may appear alone or in a fi rst sign of an early malignant melanoma. group, may be mistaken for a bruise. It is most Malignant melanoma is a serious skin cancer common in Asian or African-American children, that originates in benign moles about a third of and is caused by a concentration of pigment-pro- the time. In early stages it can be treated, but in ducing cells (MELANOCYTES) deep within the skin. later stages it spreads to other parts of the body The spots usually disappear by age three or four. and becomes very diffi cult to treat. See MELANOMA, MALIGNANT. Regular self-examination is the best way to moniliasis See CANDIDA INFECTION. notice when a mole begins to change shape or size. It is important to realize that common moles and malignant melanoma do not look alike. A handy monilethrix A rare condition of the hair shaft way to remember what features to look for is to featuring multiple constrictions, causing the hairs remember “A-B-C-D” (asymmetry, border, color, to look like a string of beads. The disease is caused diameter). by a defect in the production of KERATIN. It is an A mole that is asymmetrical, that has uneven autosomal dominant disorder that is characterized borders, that changes color or is made up of more by hair that is normal at birth but which changes than one color, or that has a diameter larger than in the fi rst months of life. The hair breaks off at the 6 mm could be a malignant lesion and should be thinned area between the beads. checked immediately by a physician.

monobenzone A permanent depigmenting drug molluscum contagiosum A harmless viral infec- that causes permanent skin bleaching. It is used tion that causes clusters of pearly white tiny lumps only in severe cases of VITILIGO to remove residual on the skin’s surface. Each PAPULE is a small circle areas of normal pigmentation. with a central depression that produces a cheesy fl uid when squeezed. Infection is easily transmit- ted by direct skin contact or during sexual contact. monochloroacetic acid Together with di- and Symptoms and Diagnostic Path trichloroacetic acid, these are caustic treatments The papules appear primarily in children on the used for wart removal, to treat XANTHELASMAM, and genitals, thighs, and the face and in adults in the to perform moderate-depth facial peels. genital region and on the lower abdomen. They are also frequently seen in patients with advancing AIDS. Molluscum in patients with AIDS are most morbilli See MEASLES. frequently seen on the face, in fl exural areas, and on the genitals. Morgan’s lines A crease often seen on the lower Treatment Options and Outlook eyelids of patients with infl ammation (atopic der- The infection may clear up within a few months matitis) of the skin. without treatment, although it usually requires See also DERMATITIS, ATOPIC. treatment with keratolytics, liquid nitrogen, or by curettage. morphea A localized form of SCLERODERMA (hard- ening of the body’s connective tissue) in which one Mongolian spot A congenital blue-black pig- or more well-defi ned, hard, fl at, round, or oval mented NEVUS found on the lower back or but- patches appear on the skin. 244 mosquito bites

Symptoms and Diagnostic Path get no reaction to mosquito bites unless they go The white or purplish patches may be up to several for a long time without being bitten—then the inches in diameter, usually appearing on the trunk, process can start again. Other people become neck, hands, or feet. There also may be hair loss or increasingly allergic with repeated stings that can ulceration at the affected site. The condition is most trigger blisters, bruises, and infl ammatory reac- often found in middle-aged women, although it tions. For these people, avoiding being bitten is can occur at any age. important.

Treatment Options and Outlook Symptoms and Diagnostic Path Treatment includes systemic antibiotics, and potent Mosquito bites may cause swelling and itching for topical steroids, colchicine, and immunosuppres- several days; the main problem of these bites is the sive drugs may have limited benefi t. New treat- infections that may be transmitted. ments being studied include gamma interferon Treatment Options and Outlook (which may inhibit synthesis of COLLAGEN) and extracorporeal photophoresis (which may alter Because mosquitoes can spread disease, the bite immune response). area should be washed with soap and water, fol- The condition may spontaneously regress over lowed by an antiseptic. To control ITCHING, nonpre- several years. scription ANTIHISTAMINE, CALAMINE lotion, gels with mild anesthetic, or ice packs can be used. mosquito bites Female mosquitoes bite in order Risk Factors and Preventive Measures to obtain blood to produce their eggs. Because Mosquitoes are attracted to things that remind their eggs are laid and hatched in stagnant water, them of nectar or mammal fl esh. When outdoors, throughout the world they are most commonly people should wear light clothing that covers most found near marshes, ponds, reservoirs, and water of the body, keeping as much of the skin and hair tanks. covered as practical, and avoiding bright, fl oral Mosquitoes are a major health hazard and are colors. Khaki, beige, and olive have no particular responsible for the transmission of West Nile virus, attraction for mosquitoes. Mosquitoes are also yellow fever, malaria, dengue fever, encephalitis, attracted by some body odors, and for this reason and many other serious diseases. In parts of the they choose some individuals over others in a world where mosquito-transmitted diseases are not crowd. In order to avoid mosquito bites, people common, it is the bite itself that presents the great- should not use fragrances in soaps, shampoos, and est diffi culty. More infants and children are bitten lotions. by mosquitoes than by any other insect. In general, mosquitoes will choose children When the mosquito bites, it injects its saliva that as their victims rather than adults; many species is full of digestive enzymes and anticoagulants. The prefer biting from dusk until dawn. The problem fi rst time a person is bitten, there is no reaction, but is worse when the weather is hot or humid. For with subsequent bites, the person becomes sensi- this reason, children should avoid playing outdoors tized to the foreign proteins, and small, itchy, red during the peak biting times. Consumers should bumps appear about 24 hours later. This is the most use insect repellents, such as common reaction in young children. After many more bites, a pale, swollen hive begins to appear DEET (NN-diethyl-m-toluamide): By far the best within minutes, followed by a red bump 24 hours repellent, it should be applied to all exposed later. This is the most common reaction in older skin. It comes in various strengths, but the children and teens. more concentrated is more effective; children With repeated mosquito bites, some people should use milder versions because there begin to become insensitive again, much as if they have been a few cases of toxicity involving had allergy shots. Some older children and adults small children. DEET should not be applied multiple lentigines syndrome 245

under clothes, or too much of the toxic sub- mucocutaneous lymph node syndrome See stance may be absorbed. It should not be KAWASAKI DISEASE. applied to portions of the hands that are likely to come in contact with the eyes and mouth. Pediatric insect repellents with only 6 mucopolysaccharidoses A group of metabolic to 10 percent DEET are available. For greater disorders including at least seven major types and protection, clothing and mosquito nets can be 14 subtypes, each with an enzyme defi ciency in soaked in or sprayed with permethrin, which the metabolism of mucopolysaccharides (a group of is an insect repellent licensed for use on cloth- complex carbohydrates that help make up the con- ing. If applied according to the directions, nective tissue). None of these disorders can yet be permethrin will repel insects from clothing treated, but someday it may be possible to replace for several weeks. These specialty items can the missing enzyme. be purchased in hardware, back-packing, and HUNTER’S SYNDROME is the only disease in this military surplus stores. group with skin symptoms, which include white or fl esh-colored PAPULES or NODULES that may merge to Unless traveling to a high-risk area, gentler form ridges. They may appear before age 10 and may insect repellents should be used for children, such fade away later. In severe forms of this syndrome, as Skedaddle. However, neither these nor the stron- patients are mentally retarded and die young. Milder ger repellents inhibit mosquitoes from landing— forms may not be fatal, or affect intelligence. only from biting. chlorine bleach: Bathe in a tubful of warm water mucormycosis An uncommon invasive fungal with two capfuls of bleach, but do not get the infection of the lung and central nervous system solution near eyes. usually associated with kidney transplant patients bath oil: Although many consumers swear by or patients with diabetes or cancers of the lymph Avon’s Skin-so-Soft, research by the military or bone marrow. While primary skin infection is (and Avon) demonstrate that it is not nearly rare with this type of fungus, it may be commonly as effective as DEET. associated with burn wound infections. zinc: Some experts recommend daily doses (at least 60 milligrams) of ZINC, although they Symptoms and Diagnostic Path warn it can take up to four weeks to become Symptoms include a single, painful, hardened area effective; extra supplements should be taken of skin that may exhibit a blackened area in the only with approval of a physician. center. A tissue specimen must be analyzed to diag- thiamine chloride: A B vitamin that may repel nose mucormycosis. insects when taken orally; however, it may also cause ITCHING, HIVES, and a rash in sensi- Treatment Options and Outlook tive individuals. Administration of intravenous amphotericin B plus treatment of underlying disease is effective.

Moynahan’s syndrome See MULTIPLE LENTIGINES multiple lentigines syndrome A genetic syn- SYNDROME. drome characterized by multiple brown spots sim- ilar to FRECKLES (lentigines), heart irregularities, abnormal distance between the eyes, pulmonary mucinoses A group of metabolic disorders involv- stenosis, abnormal genitals, short stature, and ing mucin (the primary component of mucus). These deafness. The syndrome is also known as LEOP- disorders include LICHEN MYXEDEMATOSUS, URBACH- ARD or Moynahan’s syndrome; variants include WIETHE DISEASE, and MUCOPOLYSACCHARIDOSES. NAME syndrome, centrofacial lentiginosis, or 246 mupirocin

LAMB syndrome. Multiple lentigines syndrome fi bromas, and ephelides (freckles). The LAMB syn- was originally described as “progressive cardio- drome includes: lentigines (brown fl at spots), atrial myopathic lentiginosis syndrome“ by Moynahan. myxoma, mucocutaneous myxomas (tumor of con- The acronym LEOPARD was applied later to nective tissue), and blue nevi. Both are believed to describe the unusual appearance of the numerous be a variant of multiple lentigines syndromes. lentigines together with the major developmen- Generalized lentiginosis (LENTIGINOSIS PROFUSA) tal defects. The acronym stands for the range of is a different genetic disorder characterized by developmental symptoms that characterize the numerous lentigines without other developmental disorder: problems. lentigines Treatment Options and Outlook electrocardiographic abnormalities Most of the symptoms and developmental problems ocular hypertelorism associated with this syndrome are not treatable. pulmonary stenosis Shortly after birth, the infant should be examined abnormalities of the genitals by pediatric cardiologists, endocrinologists, and retarded growth otolaryngologists, aimed at early detecting of atrial deafness myxomas or deafness. It is possible to improve the appearance of the facial skin by superfi cial DERMABRASION. Symptoms and Diagnostic Path The patient’s family should understand that At birth, patients have only a few lentigines, but all forms of the multiple lentigines syndrome are the number increases rapidly with age until there transmitted as autosomal dominant disorders. This are hundreds of lesions by adulthood, found on the means that the defective gene must be present in face palms, soles, lips, and genitalia. Patients with only a single parent to cause the syndrome. Each centrofacial lentiginosis have lentigines in a “but- child of an affected person usually has a one in terfl y” pattern over the nose and cheeks. two chance of inheriting the defective gene and of While freckles are fl at tan or brown spots found being affected. only on areas of the skin exposed to the sun that darken with sun exposure, lentigines are medium- to dark-brown spots that appear on all areas of the mupirocin (Bactroban) A topical antibacterial skin and that do not clear in the absence of sun medication that is very effective in treating super- exposure. fi cial streptococcal and staphylococcal infections of Many patients with multiple lentigines syn- the skin. Many doctors use mupirocin instead of drome are also mentally retarded, with abnormal systemic antibiotics to treat primary and secondary EEGs. The NAME syndrome includes: nevi (moles), types of IMPETIGO. atrial myxoma (tumor in the heart), myxoid neuro- N

Naftin See NAFTIFINE. Other causes of externally induced nail discol- oration include the use of nail hardeners and syn- thetic nails, as well as contact with some chemicals naftifine (Trade name: Naftin) An antifungal (such as photo developer, anti-malarial drugs, or agent that, when applied to the skin, is effective gardening fertilizers), applying HENNA with the against the DERMATOPHYTES and Candida species. bare hands, and smoking. It is used to treat ATHLETE’S FOOT, JOCK ITCH, and If the nail continues to be discolored, the patient RINGWORM of the body, among other diseases. should see a dermatologist because the problem could be a symptom of an underlying disease. Dis- Side Effects coloration can be caused by health problems such Burning or stinging feeling on treated areas is a as yeast and bacterial infections, infl ammatory common side effect. Less common are dry skin, syndromes (such as PSORIASIS), benign tumors, itching, and redness. and even certain cancers (such as melanoma). However, in these cases, stains are located under the nail and cannot be removed. Dark-skinned nail biting A common habit that is not related individuals may notice linear longitudinal brown to any underlying medical problem. While many streaks in their nails. children bite their nails in their early school Consumers should skip commercial stain- years, most grow out of the habit, although removing products, since many of them do not it can continue as a nervous mannerism into work well on nails. Instead, for best results in adulthood. lightening or removing a stain, the nail should Nail biting is one of the causes of recurrent be lightly buffed with a white emery block. Buff- acute infl ammation of nail tissues (PARONYCHIA). ing will sand off the pigments in the top layers of Warts around the perimeter of bitten nails are the nail. (However, this should not be done on a not uncommon. Because persistent nail biting can regular basis, since too much buffi ng thins and cause pain and bleeding, painting on bitter-tasting weakens the nail.) preparations may help end the habit.

nail fungus A hard-to-cure infection (also known nail discoloration The most common cause of as ONYCHOMYCOSIS) that can develop in warm, nail discoloration is nail polish. The deeper the moist areas of the body and is more common as a shade of polish, the more likely the pigment will person ages. stain the nail. Using a clear base coat before apply- ing color seems to help a bit. Usually, externally Symptoms and Diagnostic Path induced discoloration involves the whole nail, The fungus can affect the end of the nail on fi ngers while discoloration of just a portion usually means or toes, causing the nail to crumble and turn yel- there is a problem underneath the nail. low, thickening and lifting up. Sometimes, white

247 248 nail hardeners crumbly patches or white or yellow spots appear fl exibility), resins (for body and adhesiveness), on the surface. color, and cellulose nitrate (to create a fi lm for the nail). Treatment Options and Outlook Resins are responsible for most of the cases For mild infections, cutting the nail back and of irritation caused by nail polish, but the more applying an antifungal medication may help, but severe allergic reactions are often caused by the recurrence is common. More severe cases may monomers contained in nail polish extenders. require oral medication. Using conventional anti- fungals (such as griseofulvin), cure rates are about 30 percent. It takes up to a year for medication to nails The horny plate at the top of the end of cure a nail infection on smaller toes and up to two fi ngers and toes. It is made up of KERATIN (a tough years for infections involving the big toe. Newer protein that forms the basis of skin and hair), and systemic antifungals are much more effective takes up to six months to grow from base to tip of (cure rate are about 80 percent) in a much shorter the fi nger; toenails take twice as long to grow. Nail period of time. growth is also affected by seasonal variations. While very tough, the nails may still be dam- aged by crush or pressure injuries. Among the nail hardeners Fingernail enamels (actually nail elderly, the nails on the big toes may grow polishes) that form a particularly thick coat or that abnormally thick and curved (a condition called contain nylon fi bers to protect or shield the nail. ONYCHOGRYPHOSIS). In the past, nail hardeners caused actual physical In addition, the nails can be affected by a variety changes in the keratin through the action of form- of bacterial and fungal disorders, especially TINEA aldehyde; because these formaldehyde-containing (RINGWORM) and candidiasis (THRUSH). The nail products caused adverse reactions they are limited folds can also become infl amed or infected (a con- to concentrations of 5 percent by the U.S. Food dition called PARONYCHIA). and Drug Administration. Illness in other parts of the body can also See also FINGERNAILS, CARE OF; FORMALDEHYDE, include symptoms in the nails, such as the pitting SENSITIVITY TO. (small indentations in the nail) seen in ALOPECIA AREATA, pitting and separation from the nail bed in PSORIASIS, or scarring and nail bed separation in nail-patella syndrome An hereditary disorder LICHEN PLANUS. characterized by nail abnormalities (especially of More generally, some nail symptoms may be the index fi nger and thumb), kidney problems, indications of a generalized disease. Concave, mental retardation, and lack of kneecaps. The ridged, and brittle nails can indicate the presence of prognosis is poor for infants whose kidneys are iron-defi ciency anemia, and fi bromus nails can be involved. a sign of TUBEROUS SCLEROSIS. Bleeding into the nail The condition is an autosomal dominant dis- beds that causes vertical black lines on the nail bed order, which means that only one defective gene can be an indication of infection of heart valves. (from one parent) is needed to cause the syndrome. Unusual nail color can also be an indication of Each child of an affected person usually has a one disease: bluish nails may indicate heart or breath- in two chance of inheriting the defective gene and ing problems; greenish black nails might be caused of being affected. by a bacterial yeast infection; and hard, curved yel- low nails may indicate breathing problems. nail polish A lacquer used to apply color to the fi ngernails to enhance their appearance. Nail pol- nails, care of Despite a wide variety of old wives’ ish is composed of solvents, plasticizers (to provide tales, there is actually little that can be done—even nails, disorders of 249

Nail Hangnails These partly detached dried parts of the cuticle should be cut close to the base, and not be picked or torn (which can lead to infection). To head off hangnails, emollients and gloves should be worn Cuticle in dry, cold weather or while using detergents. Lunula Nail Plate Manicures Nail Bed Manicures may improve the appearance of fi nger- nails. Carefully done, manicures can be benefi cial, but overenthusiastic buffi ng of nails with abrasive powders may injure the nail matrix. Repeatedly applying and removing nail polish can dry out the nail. Allergic reactions to nail polish usually do not appear on the fi ngers but instead may appear on by consuming calcium or gelatin—to strengthen a the eyelids or neck. healthy fi ngernail. Sculptured Nails Risk Factors and Preventive Measures Molded fake nails are created by applying an Preventive care can include avoiding injuries: acrylic monomer on the nail plate. While this pro- Objects should never be pried open with fi nger- cedure is popular because it enhances the length nails. Cotton gloves should be worn when doing of the nail, it can often induce infl ammation and chores, with heavier gloves for gardening and cause a painful separation of the nail plate from outside jobs. the bed. Because repeated drenching of nails in deter- gents and water can make nails brittle, this prob- lem can be prevented by wearing cotton-lined nails, disorders of Although the fi ngernails are rubber gloves. However, the rubber gloves should quite hard, they are susceptible to traumatic dam- be removed before hands begin to sweat. Dry nails age, usually caused by crushing or pressure. This that split easily can be treated by applying Vase- can cause splitting, ridging, breaking, or bleeding line to the nail, cuticle, and fi ngertips nightly. under the nail.

Care of the Cuticle Symptoms and Diagnostic Path When hands are damp, the cuticle should be The nails may become abnormally thick and gently pushed back with a soft towel or orange curved (ONYCHOGRYPHOSIS), a condition that usu- stick. Cuticle removers contain substances that ally occurs among the elderly. Fungal or bacterial dissolve and soften the keratin, and because of infection may also damage the nails, especially the potential hazards of caustic products contain- TINEA and CANDIDA INFECTIONS, or the nails may be ing potassium hydroxide, many DERMATOLOGISTS affected by skin diseases or more general illnesses. recommend that they be avoided. People with For example, in ALOPECIA AREATA (hair loss) the infl amed cuticles should never use cuticle remov- nails may be pitted. In PSORIASIS, the nails may be ers to achieve a smooth appearance. Although pitted and separate from the nail bed (ONYCHOLY- many manicurists do trim or clip the cuticle, this SIS). In LICHEN PLANUS, the nails may be scarred and process can cause infl ammation and should be separate from the nail bed. Brittle, ridged, concave avoided. Constantly immersing hands in water nails suggest iron-defi ciency anemia. Separation can also lead to infl ammation of the cuticle of the nail from its bed is seen in thyrotoxicosis, (PARONYCHIA). and fi brous growths on the sides of the nails are 250 nails, pitted a sign of TUBEROUS SCLEROSIS. In endocarditis and a paper cut), a bruise, or a scrape. It also can occur bleeding disorders, the nails develop splinterlike after major surgery; in some cases, its origin is a black marks. mystery. The color of the nails may indicate possible The bacteria are usually transferred by respira- diseases of the body. Blue nails may be a sign of tory droplets or direct contact with secretions of respiratory or cardiac distress. Hard, curved yellow someone carrying strep A. The bacteria destroy soft nails are seen in people with bronchiectasis and tissue beneath the skin, and are often linked with lymphedema. toxic shock syndrome. If muscle also is destroyed, Nail disorders are usually diagnosed by visual the condition is called necrotizing myositis. inspection. Symptoms and Diagnostic Path Treatment Options and Outlook Within 24 hours of infection, the person may feel Treatment of nail disorders is not easy, since some pain, which is often far more serious than creams and lotions do not usually penetrate into the original injury. This is quickly followed by the nail deeply enough, and oral medications may fl ulike symptoms, such as confusion, diarrhea, take months to be effective. dizziness, fever, nausea, weakness, and general malaise. As the body becomes dehydrated, the patient begins to feel extremely thirsty. Within nails, pitted Small depressions in the nail plates, three or four days, the wound area begins to typically found in patients with PSORIASIS. swell and the skin may have large, dark marks or a purple rash. These turn into fl uid-fi lled black BLISTERs, although the would itself may appear NAME See MULTIPLE LENTIGINES SYNDROME. blue-white, or dark and mottled. The patient’s condition typically becomes critical within four to fi ve days, as blood pressure plummets and the necrobiosis Gradual process by which cells lose body begins to go into shock as a result of toxins their function and die. Necrobiosis lipoidica causes from the bacteria. As the body weakens, uncon- patchy degeneration of the skin, resulting in white sciousness occurs. scars. It is most often seen in about one in 300 dia- A patient with any of these early symptoms betics, although others can contract this disease. should immediately see a physician to rule out this The lesions usually appear as red papules condition, since the vast majority of these cases are or plaques, followed by a yellowish depressed misdiagnosed. plaque. Treatment with steroids injected into the lesions may be effective during early stages. Treatment Options and Outlook The disease requires aggressive treatment with removal of affected skin and broad-spectrum anti- necrotizing fasciitis A potentially fatal illness biotics. Other treatments depend on the serious- commonly caused by streptococcus bacteria, char- ness of symptoms. Medications to raise blood acterized by an infection with warm, red, tender pressure, blood transfusions, and a new medicine plaques that become necrotic and spread. called intravenous immunoglobulin (IVIG) are also In this condition, commonly called “fl esh-eating used. A hyperbaric oxygen chamber is sometimes bacteria,” more virulent strains of the strep bacte- used in certain cases that involved different types ria destroy the body’s protein, affecting the lungs, of bacterial infection. skin, and bloodstream. The bacteria releases a A patient with this condition may experience toxin that can dissolve fat and muscle tissue, anything from some mild scars to death. Among causing the skin to die and leading to deadly those who survive, most patients experience some gangrene. Most often the bacteria enter the body removal of skin, which often requires skin graft- through a very minor cut in the skin (as small as ing. Amputation of legs, hands, fi ngers, toes, or neurofi bromatoses 251 arms also may be required to save the life of the neurocutaneous syndromes, but the most com- patient. Between 2,000 and 3,000 people die from mon ones include NEUROFIBROMATOSIS type 1 and strep infections each year out of 10,000 to 15,000 2, STURGE-WEBER SYNDROME, TUBEROUS SCLERO- cases of serious strep infections in the United SIS, ataxia-telangiectasia, and von Hippel-Lindau States, according to the Centers for Disease Con- disease. trol. Of these 15,000 cases, between 500 to 1,500 involve necrotizing fasciitis; of these, about 100 to Symptoms and Diagnostic Path 350 people die. The fi rst symptoms most commonly noted in See also BACTERIAL SKIN INFECTIONS. children are skin lesions, including BIRTHMARKS, tumors, and other growths. Symptoms vary con- siderably from condition to condition and from neomycin (Trade names: Mycifradin; Myciguent) patient to patient, because neurocutaneous syn- An antibiotic sometimes used to treat skin infec- dromes affect individuals in different ways. tions (often together with other drugs). Possible adverse effects include nausea and vomiting, rash, Treatment Options and Outlook itching, diarrhea, hearing loss, dizziness, and tin- Although there is no cure for these conditions, nitus (ringing in the ears). treatments are available that help to manage symptoms and complications. The conditions are always lifelong, which means that educational, neonatal acne See ACNE, INFANT. social, and physical problems must be managed throughout a child’s life.

Netherton’s syndrome A hereditary condition characterized by three primary defects: abnor- neurodermatitis See LICHEN SIMPLEX. mality in the hair shaft (especially trichorrhexis invaginata, or “bamboo hair”), ICHTHYOSIS linearis circumfl exa (a scaling skin disorder), and atopic neurofibroma A skin tumor that may occur dermatitis. alone or in groups, ranging in color from pale This disorder of unknown cause is inherited cream to lightly pigmented. in an autosomal recessive pattern, which means that a defective gene must be inherited from both Treatment Options and Outlook parents to cause the abnormality. Generally, both Single neurofi bromas may be surgically removed. parents of an affected person are unaffected carri- See also NEUROFIBROMATOSES. ers of the defective gene. Each of the affected chil- dren has a one in four chance of being affected, and a two in four chance of being a carrier. neurofibromatoses A group of genetic disor- See also DERMATITIS, ATOPIC. ders characterized by many soft, fi brous swell- ings (called NEUROFIBROMAS) growing from nerves in the skin and elsewhere in the body. There neurilemmoma See NEUROFIBROMA. also may be CAFÉ-AU-LAIT MACULEs (coffee-colored spots) on the skin. Both forms of NF are autosomal dominant neurocutaneous disorders A group of genetic genetic disorders, which may be inherited from a disorders featuring abnormalities of the skin, parent who has NF or may be the result of a new nerves, or the nervous system. The diseases are or spontaneous mutation in the sperm or egg cell. believed to begin in the abnormal development Each child of a parent with NF has a 50 percent of primitive cells found during the earliest stages chance of inheriting the gene and developing NF. of an embryo’s development. There are several The type of NF inherited by the child is always 252 neurofi bromatoses the same as that of the affected parent, although mas varies widely among affected individuals the severity and the type of symptoms may differ from only a few to thousands. There is no way to from person to person within a family. However, predict how many neurofi bromas a person will up to 50 percent of new cases are spontaneous develop. mutations. Dermal neurofi bromas rarely, if ever, become cancerous, but plexiform tumors may very rarely Symptoms and Diagnostic Path become malignant. Therefore, it is important that In the past, medical experts classifi ed the disor- patients be in the care of an NF specialist. der into two different types, neurofi bromatosis Café-au-lait spots, the most common sign of NF, type 1 and type 2 (NF1 and NF2). Today experts are fl at, pigmented spots on the skin that are called know that these are two totally separate disorders by the French term café-au-lait (coffee with milk) caused by two different genes. NF1 occurs far more because of the light tan color. In darker-skinned frequently, accounting for about 90 percent of all people, café-au-lait spots appear darker than sur- cases. rounding skin. People with NF almost always have Neurofi bromatosis 1 (NF1), also known as six or more café-au-lait spots. (Fewer café-au-lait von Recklinghausen NF or peripheral NF, occurs spots may occur in people who don’t have NF; in in one out of 4,000 births and is characterized by fact, about 10 percent of the general population multiple café-au-lait spots and neurofi bromas on has one or two café-au-lait spots.) The size of the or under the skin. Enlargement and deformation spots that identify NF varies from one-quarter of bones and curvature of the spine (scoliosis) also inch in children to more than several inches in may occur. Occasionally, tumors may develop in diameter. the brain, on cranial nerves, or on the spinal cord. Café-au-lait spots are usually present at birth in About 50 percent of people with NF also have children who have NF or, generally, appear by two learning disabilities. years of age. The number of spots may increase in Neurofi bromatosis 2 (NF2) also known as childhood and occasionally later in life. The spots bilateral acoustic NF (BAN), is much more rare, may be very light in color in infants and usually occurring in one out of 40,000 births. NF2 is char- darken as the child gets older. Smaller pigmented acterized by multiple tumors on the cranial and spots, which may be diffi cult to distinguish from spinal nerves and by other lesions of the brain and ordinary FRECKLES, may also be present in people spinal cord. with NF. In those who do not have NF, freckling usually occurs in areas of skin exposed to sun. Symptoms and Diagnostic Path With NF, café-au-lait spots and freckling are pres- Tumors affecting both of the auditory nerves are ent in other areas as well, including the armpit the hallmark. Hearing loss beginning in the teens and the groin. Armpit freckling is not seen in or early twenties is generally the fi rst symptom. every person with NF, but when present it is con- Neurofi bromas (the most common tumors in sidered strong evidence of NF. Lisch nodules are NF), are benign growths that typically develop on common in young children with NF; these brown or just underneath the surface of the skin but may pigmented areas of the iris resemble little freckles. also occur in deeper areas of the body. They usu- The nodules increase in number during adoles- ally develop at puberty, although they may appear cence, but do not impair vision. at any age. Nodulelike surface tumors are known Iris nevi are clumps of pigment in the iris that as dermal neurofi bromas; plexiform neurofi bro- usually appear around puberty. They can be distin- mas grow diffusely under the skin surface or in guished from iris freckles by a simple and painless deeper areas of the body. procedure called a slit-lamp examination, which The presence of multiple neurofi bromas is is typically performed by an ophthalmologist. Iris an important symptom of NF, although single nevi do not cause medical problems and do not neurofi bromas may occasionally occur in people affect vision, but their presence can occasionally who don’t have NF. The number of neurofi bro- help confi rm the diagnosis of NF. nevus 253

Children with NF1 are usually checked for which are present in all stages of development, are height, weight, head circumference, blood pres- distributed solely in accessible areas, often in par- sure, vision and hearing, evidence of normal allel lines. There are no primary lesions. sexual development, signs of learning disability Generally, patients pick at their skin because and hyperactivity, and evidence of scoliosis, in they feel restless; the root of the tension is some- addition to examination of the skin for café-au- times related to a specifi c cause, such as family lait spots and neurofi bromas. Further diagnostic problems. Picking their skin is another outlet for evaluations, including blood tests and X-rays, these patients’ emotional tension. are usually needed only to investigate suspected problems. Symptoms and Diagnostic Path Lesions are gouged in the skin, leaving white, Treatment Options and Outlook round papery scars when they heal against a A person with NF should see a physician for evalu- hyperpigmented background. Lesions are notice- ation and follow-up care. Specialists from many able in all stages of healing, and the small ulcers disciplines may be knowledgeable about specifi c are usually angular, the tip-off that they are self- aspects of NF; those most likely to be familiar with induced and not primary. They are most often the disorder as a whole include geneticists, neu- found on the tops of the forearms and over the rologists, and pediatric neurologists. NF referral shoulders. centers that cooperate with the National Neuro- fi bromatosis Foundation have been established in Treatment Options and Outlook a number of major medical centers in the United Usually patients with these neurotic urges to pick States. at their skin do it compulsively and fi nd it very Some neurofi bromas, depending on their loca- diffi cult to stop. Therefore, treatment should cen- tion and size, can be removed surgically if they ter on efforts to identify the source of stress in the become painful or infected, or cosmetically embar- patient’s life, although psychiatric help is not usu- rassing. However, a new tumor sometimes appears ally very effective. Attempts to physically prevent where one has been excised, especially if that the patient from picking may result either in panic tumor was not removed completely, but there is or depression. no evidence that removing growths will speed up See also ACNE EXCORIÉE. the appearance of new growths or cause incom- pletely removed tumors to become cancerous. Healthy children with NF1 are usually examined nevus (plural: nevi) A BIRTHMARK or skin malfor- at six- or 12-month intervals. mation characterized by too much (or not enough) Routine checkups for adults with NF1 gen- normal epidermal, connective, adnexal, nervous, erally include, in addition to standard physical or vascular tissue. evaluation, an examination of the skin, blood pressure, vision and hearing, and examination Symptoms and Diagnostic Path of the spine for scoliosis. Attention is given to There are many different types of nevi, with dif- any mass that is rapidly enlarging or causing new ferent appearances: colored or uncolored, with or pain. Other tests can be performed if a medical without hair, lying fl at, slightly raised, or on a stalk problem develops. Adults with NF1 who are oth- above the skin. Some nevi may be congenital, but erwise healthy usually have periodic checkups at they may develop at any time. 12-month intervals. A MOLE is another common type of colored nevus, not usually present at birth. Some nevi have a bluish color, and are known as “blue neurotic excoriations A psychogenic skin dis- nevi”; these are often found on the backs of ease characterized by repeated picking of the skin. hands in young girls. Most African-American and This condition should be suspected if the lesions, Asian infants are born with one or more blue- 254 nevus, amelanotic black spots on their lower backs, called MONGO- dermal-epidermal junction and in the underlying LIAN SPOTS. DERMIS. Compound nevi are often raised and may The above examples are all forms of melano- have a fl at area surrounding the elevated area. cytic (or pigmented) nevi, caused by an overactivity See also NEVUS, BLUE; NEVUS, CONGENITAL; NEVUS, or abnormality of skin cells that produce MELANIN. HALO; NEVUS, SPITZ; NEVUS ARANEUS; NEVUS PIGMEN- The other primary type of nevi are the vascular TOSUS; NEVUS SPILUS; NEVUS SYNDROME, DYSPLASTIC. nevi (or HEMANGIOMA), caused by an abnormal col- lection of blood vessels. They include PORT-WINE STAIN, which does not fade but can be treated with nevus, congenital Unlike the common acquired lasers, and STRAWBERRY BIRTHMARK, which usually nevi (skin malformation) that appears after birth, does disappear in early life. this type of nevus appears at birth or shortly Nevi are visually diagnosed by a physician. thereafter, and remains throughout life. Most are small and look very much like acquired nevi. Treatment Options and Outlook Rarely, congenital nevi may be large (giant con- Most nevi are completely harmless and do not genital nevi), involving major areas of the body. require treatment. Some types of vascular nevi do They are usually found on the trunk, upper back, require treatment for psychological reasons. Any and shoulders. Most have a rough surface and nevus that suddenly appears, grows, bleeds, or hair. changes color should be brought to the attention There is debate over whether small congeni- of a DERMATOLOGIST to rule out the possibility of tal nevi can become cancerous. If there is a risk, cancer. it is quite low. The lifetime risk of melanoma developing from giant congenital nevi is higher— approximately 6 percent. nevus, amelanotic A nevus that contains no See also BIRTHMARK; MOLE; NEVUS, BLUE; NEVUS, pigment. HALO; NEVUS, SPITZ; NEVUS SYNDROME, DYSPLASTIC.

nevus, balloon cell A benign nevus that changes nevus, connective tissue A BIRTHMARK (also overtime. Under the microscope it consists of bal- called nevus elasticus of Lewandowsky) involving loon cells formed of altered melanosomes. It may different parts of the connective tissue that are be confused with malignant melanoma. typically visible at birth but that occasionally do See also MELANOMA, MALIGNANT. not appear until adolescence. They may be inher- ited or acquired, and may be associated with other diseases. The nevi may appear alone or in groups nevus, blue A type of pigmented BIRTHMARK of NODULEs, PAPULES, or plaques, or in various com- (NEVUS) caused by an abnormality or overactivity binations of these lesions, but individual lesions of skin cells producing the pigment MELANIN, which usually appear as a plaque composed of fi rm, fl at, is deep blue in color. The brown melanin pigment ivory white or yellow-brown papules, often hav- is placed in a specifi c pattern, deep enough in the ing a pebbly appearance. skin for it to take on a blue color. See also NEVUS, COMPOUND; NEVUS, CONGENITAL; Treatment Options and Outlook NEVUS, HALO; NEVUS, SPITZ; NEVUS PIGMENTOSUS; No treatment is necessary for most of these con- NEVUS SPILUS; NEVUS SYNDROME, DYSPLASTIC. nective tissue nevi, since they are not unsightly. On rare occasions, surgical excision may be performed. nevus, compound One of three main types of See also BIRTHMARK; MOLE; NEVUS, BLUE; NEVUS, benign skin malformation (NEVI), located within the COMPOUND; NEVUS, EPIDERMAL; NEVUS, HALO; NEVUS, nevus araneus 255

SEBACEOUS; NEVUS, SPITZ; NEVUS ARANEUS; NEVUS nevus, Spitz A solitary pink, purple, or red PAP- DEPIGMENTOSUS; NEVUS PIGMENTOSUS; NEVUS SYN- ULE or NODULE that usually appears in childhood. DROME, DYSPLASTIC; PORT-WINE STAIN. While it resembles malignant melanoma under the microscope, this lesion is benign. nevus, epidermal An uncommon brown lesion Symptoms and Diagnostic Path present at birth that may either appear small and This lesion usually appears on the face in young singly, or in large groups that are usually either patients, but among adults is more common on linear or swirled. While this nevus usually is pres- the legs and trunk. ent at birth, it may appear during the fi rst few years of life through puberty, and rarely later in Treatment Options and Outlook life. Simple excision will cure this nevus. See also BIRTHMARK; MOLE; NEVUS; NEVUS, BLUE; Treatment Options and Outlook NEVUS, COMPOUND; NEVUS, EPIDERMAL; NEVUS, HALO; No treatment is normally required, unless the NEVUS, SEBACEOUS; NEVUS, SPITZ; NEVUS DEPIGMEN- nevus is cosmetically distressing. In that case, TOSUS; NEVUS PIGMENTOSUS; NEVUS SYNDROME, DYS- small lesions may be excised, but removal of larger PLASTIC; PORT-WINE STAIN. epidermal nevi may be diffi cult or cosmetically unappealing, as the scar may look worse than the nevi. Superfi cial removal by laser or by chemical nevus araneus The medical name for a spider destruction are possible treatment options. angioma, which looks like a bright red blood ves- See also BIRTHMARK; MOLE; NEVUS, SEBACEOUS; sel with branches radiating out from the center, NEVUS DEPIGMENTOSUS; NEVUS PIGMENTOSUS. much like a spider. This condition is common in pregnancy; it is suspected that estrogen plays a role in the development of these lesions which nevus, epithelioid See NEVUS, SPITZ. are caused by the expansion of superfi cial small veins in the skin. They are also often seen in chil- dren and in both women and men. nevus, halo A skin abnormality in which the skin surrounding the lesion whitens in color, giv- Symptoms and Diagnostic Path ing a characteristic “halo” appearance. Lesions are found most often over the face, the front of the neck and chest, and the upper arms. nevus, sebaceous A skin abnormality present at They are also often seen in patients with chronic birth or shortly thereafter that usually appears as liver disease. a hairless, yellowish orange plaque on the scalp Treatment Options and Outlook that sometimes may be mistaken for a melano- cytic nevus. These lesions should be removed Those lesions associated with pregnancy nor- during childhood because they have a tendency to mally fade after delivery, so generally they do become cancerous, usually at puberty (basal cell not require treatment. If not, the lesions may be carcinoma or other benign or malignant tumor). removed by laser surgery with the pulsed dye See also MOLE; NEVUS, EPIDERMAL; NEVUS DEPIG- laser, or they may be electrocoagulated with a MENTOSUS; NEVUS PIGMENTOSUS. fi ne needle. See also NEVUS, BLUE; NEVUS, COMPOUND; NEVUS, CONGENITAL; NEVUS, HALO; NEVUS, SPITZ; NEVUS nevus, spindle and epithelioid cell Another PIGMENTOSUS; NEVUS SPILUS; NEVUS SYNDROME, name for a Spitz nevus (See NEVUS, SPITZ). DYSPLASTIC. 256 nevus depigmentosus nevus depigmentosus A fairly uncommon dis- Treatment Options and Outlook order of pigmentation that may be either con- Highly effective treatment includes the use of short genital or acquired. pulsed lasers, such as the Q-switched ruby laser. This provides excellent results without textural Symptoms and Diagnostic Path change in most lesions. It is characterized by white macules and irregu- See also BIRTHMARK; MOLE; NEVUS, BLUE; NEVUS, lar patches on the trunk or extremities. As the COMPOUND; NEVUS, CONNECTIVE TISSUE; NEVUS, EPI- child grows, the macules enlarge. DERMAL; NEVUS, HALO; NEVUS, SEBACEOUS; NEVUS, SPITZ; NEVUS ARANEUS; NEVUS DEPIGMENTOSUS; NEVUS Treatment Options and Outlook PIGMENTOSUS; NEVUS SPILUS; NEVUS SYNDROME, DYS- There is no way to repigment the skin, though PLASTIC; PORT-WINE STAIN. cosmetic concealment may be helpful in mask- ing the problem. See also BIRTHMARK; MOLE; NEVUS, BLUE; nevus pigmentosus A benign tumor composed of NEVUS, COMPOUND; NEVUS, EPIDERMAL; NEVUS, MELANOCYTES. HALO; NEVUS, SEBACEOUS; NEVUS, SPITZ; NEVUS See also BIRTHMARK; MOLE; NEVUS, BLUE; NEVUS, PIGMENTOSUS; NEVUS SYNDROME, DYSPLASTIC; PORT- COMPOUND; NEVUS, EPIDERMAL; NEVUS, HALO; WINE STAIN. NEVUS, SEBACEOUS; NEVUS, SPITZ; NEVUS ARANEUS; NEVUS DEPIGMENTOSUS; NEVUS PIGMENTOSUS; NEVUS SYNDROME, DYSPLASTIC; PORT-WINE STAIN. nevus elasticus of Lewandowsky See NEVUS, CONNECTIVE TISSUE. nevus spilus A light-brown patch (CAFÉ-AU-LAIT MACULEs) sprinkled with dark brown macules that nevus flammeus See PORT-WINE STAIN. is present at birth or early infancy.

Symptoms and Diagnostic Path nevus of Ito and nevus of Ota Disorders of While the overall size of the spot may vary, it is pigmentation characterized by benign blue-gray- usually several centimeters in diameter and may brown pigmented patches of skin located on the be found on the trunk or extremities. face (nevus of Ota) and on the shoulder (nevus of Ito). About 50 percent of these lesions are Treatment Options and Outlook congenital or appear soon after birth; most of the No treatment is necessary, although short pulsed rest appear at puberty, although a few may not lasers such as the Q-switched ruby and O-switched surface until the third decade of life. YAG lasers can lighten the lesions. See also BIRTHMARK; MOLE; NEVUS; NEVUS, BLUE; Symptoms and Diagnostic Path NEVUS, EPIDERMAL; NEVUS, HALO; NEVUS, SEBACEOUS; The two lesions are similar to a MONGOLIAN NEVUS, SPITZ; NEVUS ARANEUS; NEVUS DEPIGMENTO- SPOT with the pigment found deep in the skin, SUS; NEVUS PIGMENTOSUS; NEVUS SYNDROME, DYS- accounting for the typical blue-gray color. PLASTIC; PORT-WINE STAIN. Nevus of Ota is usually found over the cheek and temple, and is more commonly found in dark-skinned people and Asians; it affects 0.5 nevus syndrome, dysplastic An often-heredi- percent of all Japanese. Neither type fades with tary condition characterized by groups of pig- age; while both are benign, they have rarely mented skin abnormalities, which in some been associated with melanoma (usually in patients may indicate a predisposition to malig- Caucasians). nant melanoma. Such cancerous melanomas Nikolsky’s sign 257 may grow from the nevi themselves, or else- be turning malignant, check for the “ABCs”: the where on the body. blemish is asymmetrical, the border is notched or The trait usually has an autosomal dominant blurred (not smooth and distinct), and the color mode of transmission, which means that only includes mixtures of shades. one defective gene (from one parent) is needed to See also BIRTHMARK; MELANOMA, MALIGNANT; cause the syndrome. Each child of an affected per- MOLE; NEVUS; NEVUS, BLUE; NEVUS, COMPOUND; son usually has a one in two chance of inheriting NEVUS, EPIDERMAL; NEVUS, HALO; NEVUS, SEBACEOUS; the defective gene and of being affected. A patient NEVUS SPITZ; NEVUS ARANEUS; NEVUS DEPIGMENTOSUS; with dysplastic nevi with two or more primary NEVUS PIGMENTOSUS; NEVUS SYNDROME, DYSPLASTIC; family members with malignant melanoma has PORT-WINE STAIN. a very strong chance—almost 100 percent—of developing the cancer as well. newborn skin The skin of a newborn usually is Symptoms and Diagnostic Path smooth and velvety, with a greasy coating that is Dysplastic nevi are different from ordinary nevi in shed after about a week. At birth, the skin is a red- that they are bigger and usually more prevalent dish purple color, which changes rapidly to pink. (often more than 100). And while ordinary nevi The hands and feet may remain purple a little do not usually appear in adulthood, dysplastic longer, and this coloring may recur later when the nevi continue to develop throughout life. When child cries, holds its breath, or becomes chilled. researchers followed the evolution of dysplastic There are a variety of disorders that can develop nevi in 153 patients aged 12 to 73 for seven years, in newborn skin during the fi rst few weeks of they found new nevi common—even among life. Most of these are natural phenomena and adults—continuing to appear in 20 percent of resolve on their own. Knowing and understanding adults over age 50. The moles also changed appear- these disorders is essential if one is to distinguish ance, or disappeared in people of all ages. them from more signifi cant, potentially critical, problems. Treatment Options and Outlook See also BIRTHMARKS; CRADLE CAP; DIAPER RASH; Suspect nevi should be seen by a doctor and INFANT ACNE. removed. If a patient’s parent has dysplastic nevi without melanoma, the chance of the patient developing melanoma is less defi nite; however, niacin deficiency See PELLAGRA. the patient still is at higher risk than the general population. Patients with dysplastic nevi but no family his- nickel dermatitis See DERMATITIS, NICKEL. tory of melanoma have “sporadic” dysplastic nevus syndrome. If these patients have high numbers of nevi, they are still at a higher risk for developing nifedipine A drug commonly used to treat angina malignant melanoma than the general population, that is also used in the treatment of circulation dis- but less than for those in the familial dysplastic orders such as RAYNAUD’S DISEASE. nevus group. Side Effects Risk Factors and Preventive Measures Possible effects include fl uid retention and swell- Patients with multiple dysplastic nevi and a fam- ing, fl ushing, headache, and dizziness. ily history of malignant melanoma should avoid the sun and use SUNSCREEN, practice skin self- examination, and see a DERMATOLOGIST every six Nikolsky’s sign A diagnostic technique in which months. To spot signs of dysplastic nevi that may the skin sloughs off with slight lateral pressure. 258 nitrobenzenes

Nikolsky’s sign is seen in superfi cial blistering dis- world that starts in the lungs and spreads to tis- orders such as in SCALDED SKIN SYNDROME, toxic sues under the skin where fi stulas develop. This epidermal necrolysis, and in PEMPHIGUS, but it is infection is not normally found in healthy patients, not usually seen in deeper blistering diseases such and usually occurs in those with a compromised as bullous pemphigoid. immune system.

Symptoms and Diagnostic Path nitrobenzenes Hair dyes used in semipermanent Symptoms include fever and cough similar to shampoo-in hair color. The color is formulated to pneumonia that does not respond to normal last up to a month, but this depends on how often short-term antibiotics, with lung damage and brain hair is washed. ABSCESSes.

Treatment Options and Outlook nits The tiny eggs of a louse that are yellow when Sulfonamide drugs (sulfadiazine) or a combination newly laid, turning to white once they hatch. of trimethoprim-sulfamethoxazole (TMP-SMX) are effective. Drainage or resection of abscesses may be Symptoms and Diagnostic Path necessary. The prognosis is good with early diag- Nits are small, oval-shaped eggs that are “glued” nosis, before the infection spreads to the brain. at an angle to the side of the hair shaft. Nits hatch within eight days, and the empty eggshells are carried outward as the hair grows. Both head and nodule A solid mass of tissue larger than 1 cm in pubic LICE lay eggs at the base of hairs growing on diameter that may protrude from the skin or occur the head or pubic area. Nits can be seen anywhere deep underneath the surface. on the hair, especially behind the ears and at the back of the neck. Nits should not be confused with hair debris, non-ablative skin resurfacing A method to such as fat plugs or hair casts. Fat plugs are bright refresh the skin using non-wounding lasers and white irregularly shaped clumps of fat cells stuck intense pulsed light that work beneath the surface to the hair shaft. Hair casts are thin, long, cylinder- skin layer to stimulate collagen production, tone shaped segments of dandruff encircling the hair and tighten skin and improve mild to moderate shaft; they are easily dislodged. skin damage. Lice infestations are diagnosed by the presence This noninvasive approach is used to erase fi ne of nits; by calculating the distance from the base lines and skin imperfections, buffi ng the top layers of the hair to the farthest nits, it is possible to esti- of aged, discolored or irregular skin while avoiding mate the duration of the infestation. many of the side effects and extended recovery period typical of traditional resurfacing techniques. Treatment Options and Outlook Non-ablative lasers and intense pulsed light sources All nits must be removed, according to the National work by aiming light energy on the underlying skin, Pediculosis Association. Since no lice pesticide kills while leaving the surface of the skin untouched. all nits, thorough nit removal will reduce or elimi- The selective laser erases surface blemishes as the nate the need for more treatments. heat effects of treatment stimulate the production Nits can be removed with a special nit removal of new collagen deep within the skin. Non-ablative comb, with baby safety scissors, or with the therapy also helps correct irregular skin pigmen- fi ngernails. tation and improves skin texture and tone. By directly treating the layers beneath the top layer of skin, the tissue can respond by regenerating skin as nocardiosis An infection by a funguslike bacte- if it was repairing a wound. The process seems to rium (Nocardia asteroides) found throughout the stimulate collagen growth and tighten underlying NSAIDS 259 skin, improving skin tone and removing fi ne lines have (or will develop) widespread lymphoma and mild to moderate skin damage. throughout their body, their prognosis is not usu- The results from non-ablative lasers are more ally promising. subtle and gradual than a facelift or conventional laser resurfacing, improving the look of the skin after a series of treatment sessions. The advantage to these noninvasive cutaneous infections See TINEA. procedures is that patients can return to work the same day, and because the surface skin is not bro- ken, women can reapply makeup before leaving the Norwegian scabies A type of mild to severe red- doctor’s offi ce. Best results usually occur after three ness and scaling of the skin characterized by thick to fi ve treatments. Occasional retouch sessions can crusted lesions on hands, nails, and feet associ- help maintain the appearance of smooth, healthy ated with a widespread infestation of SCABIES and skin. The subtle nature of the non-ablative resurfac- mites. ing make this a favorite approach for younger men and women who want to begin preserving their Symptoms and Diagnostic Path looks before much damage is done. Mites are easily seen among the scales. Unlike Patients seeking nonablative skin rejuvenation ordinary scabies, there is little or no ITCHING. are most often treated with lasers (58 percent), The condition may be seen in retarded patients, according to the American Society for Dermato- patients with AIDS, and other individuals suffering logic Surgery. An additional 31 percent of patients from debilitating medical conditions. are treated with intense pulsed light/non-laser sources. Treatment Options and Outlook Treatment is the same as for scabies. Side Effects Mild redness may last for a few hours with non- ablative techniques, and makeup may be applied nose repair An operation (also called rhino- afterward. Four to six treatments are usually nec- plasty) that alters the nose structure to either cor- essary because the results from non-ablative tech- rect a deformity caused by injury or disease, or to niques are generally less dramatic than those with repair its appearance. In the technique, incisions are made within the nose to avoid visible scars, Er:YAG and CO2 lasers. using a local or general anesthetic. Sometimes, a bone or cartilage graft is used, and the nose is non-Hodgkin’s cutaneous lymphomas Slow- splinted in position for about 10 days. growing tumors of the lymphatic system that Risks/Complications cause skin symptoms. They may appear in patients with systemic disease or may be the fi rst sign of Rarely, complications may include recurrent nose- lymphoma. bleeds because of persistent crusting at the site of the incision, or breathing problems because of Symptoms and Diagnostic Path narrowed nasal passages. These operations usually cause considerable bruising and swelling. The fi rm smooth skin lesions may be red, blue- or plum-colored and can be found on any part of Outlook the body. They may also cause itchiness or dark Final results may not be noticeable until weeks or patches on the skin. months later.

Treatment Options and Outlook The lesions generally respond to ionizing radia- NSAIDS See NONSTEROIDAL ANTI-INFLAMMATORY tion or to chemotherapy. Because most patients DRUGS. 260 nucleic acids nucleic acids The building blocks of protein, nummular dermatitis See DERMATITIS, NUMMULAR. these specifi c chemicals act on the nucleus of cells. They cannot stimulate growth when applied to the skin’s surface or to the hair. However, like nutrition and the skin See DIET AND THE SKIN. all proteins, nucleic acids in cosmetics can form a fi lm on the skin or hair shaft to help retain moisture. Nystatin See MYCOSTATIN. O oatmeal A colloid-containing grain that soothes contact with an irritating substance. Some com- the skin and can be very helpful for itchy skin mon industrial irritants include solvents, acids conditions. Preparations containing oatmeal can and alkalies, industrial detergents, cleaning com- soothe skin irritated by sunburn or allergic reac- pounds, abrasive soaps, waterless hand cleaners, tion. Oatmeal is also included in face masks and poison ivy or oak, metallic salts, rubber antioxi- soaps because it absorbs oil from the skin’s surface dants, epoxy resins and hardeners, acrylic resins, and lessens redness of irritating ACNE-prone skin. biocidal agents, and organic dyes. Nonirritating oatmeal soaps are a good choice for Other substances encountered in the work- people with sensitive skin. place that may cause skin problems may include fragrances, cosmetic preservatives, and topical medications included in soaps, hand creams, or occupational skin disorders Because the skin fi rst-aid products. has such a large surface area accessible to the envi- ronment, it is particularly vulnerable to problems Photosensitivity related to occupational trauma and disease. In fact, Certain industrial chemicals, when present on the after traumatic injuries, skin problems represent skin and exposed to sunlight, can cause an acute almost half of all remaining occupational illnesses. SUNBURN or ECZEMA. The resulting photosensitivity As new industrial chemicals and production pro- may cause redness and swelling, with VESICLES or cesses are developed, new skin diseases and prob- BLISTERs that later weep, crust, or scale. Chemi- lems continue to appear. cals such as creosote and tar may cause burning Occupational skin diseases include systemic and stinging after sun exposure. Severe blistering diseases (caused by absorption through the skin), may occur in celery harvesters caused by toxins contact dermatitis, PHOTOSENSITIVITY DISORDERS, released by celery fungus, and certain new acrylic disorders of pigmentation, SKIN CANCER, connec- resins may produce both phototoxic and photoal- tive tissue diseases, hair and nail disorders, occu- lergic reactions. pational infections and infestations, and disorders caused by physical and mechanical agents. Acne Skin absorption is one way that many toxic sub- ACNE may be induced or aggravated by experi- stances (such as agricultural pesticides) enter the ences in the workplace as well. Tight-fi tting masks body. Some of the major industrial chemicals that may cause ACNE MECHANICA; lubricating oils or cause toxic systemic diseases by being absorbed grease may irritate the follicles and cause oil acne. in the skin include aniline dyes, arsenic, benzene, Finally, CHLORACNE is caused by exposure to spe- cyanide salts, mercury, methyl-n-butyl ketone, cifi c aromatic hydrocarbons in the workplace. polyhalogenated aromatic hydrocarbons, organic solvents, and neuromuscular insecticides. Disorders of Pigmentation About 90 percent of all skin diseases acquired The synthesis of MELANIN may be slowed down or via occupations are contact dermatitis. Most cases speeded up by a variety of occupational substances, are due to skin irritation, not allergy, through skin leading to disorders of pigmentation. Such changes

261 262 oil of bergamot in skin color may follow any contact dermatitis, oil of bergamot A type of oil contained in the and certain photosensitizers (especially tar, pitch, skin of lemons and limes that, when applied to the and furocoumarins) may also alter skin pigmenta- skin, can cause burns and BLISTERs after exposure tion. Similarly, the loss of pigment may be caused to sunlight. by exposure to a variety of industrial substances, Although lemons and limes are most notorious such as phenol. Skin discoloration has been asso- for their phototoxic reactions, many other plants ciated with heavy metal contact (especially silver and foods also contain the oil in lesser amounts— and mercury), and from dyes. carrots, celery, fi gs, parsley, parsnips, coriander, caraway, fennel, and anise. Even perfumes that Skin Cancer contain the oil can cause burns when oil-soaked Skin cancer was the fi rst type of malignancy to be skin is exposed to the sun. associated with occupational risks, when in 1775 Young children who suck on limes or lemons Percivall Potts discovered that soot caused SQUA- in the hot sun are particularly prone to skin burns MOUS CELL CARCINOMA in the scrotum of London’s and blisters, since juice of the fruit dribbles onto chimney sweeps. the face or drops onto the chest, which then causes People who work outdoors in natural sunlight, burns from the ultraviolet rays of the sun. or who are exposed to ionizing radiation, are at The chemical in oil of bergamot responsible greatest risk for the development of skin cancer. for the phototoxic reaction is PSORALEN, ironi- While coal tar and its derivatives (such as pitch cally now used for its therapeutic benefi ts. Many and creosote) may contribute to the develop- years ago, a Cairo dermatologist found out that ment of premalignant skin WARTS and keratoses indigenous people along the Nile used plants that eventually are transformed into squamous containing psoralen as a folk remedy to treat cell carcinoma, researchers have not yet proved VITILIGO, a skin disorder in which the immune that any chemical carcinogen causes malignant system attacks and destroys the skin’s pigment. melanoma. While researchers are not sure why it works, they believe that psoralen, when combined with Connective Tissue Diseases sunlight, may suppress the immune system and Diseases such as SCLERODERMA may be caused by stop the attack on the skin’s pigment, or simply on-the-job exposure to silica in mining operations. that the psoralen augments the sun’s ability to Acrosteolysis has been linked to the manufacture produce pigmentation. Psoralen plus sunlight of certain polyvinylchloride plastics. also interferes with the way cells make DNA, thus decreasing cell turnover, so it is also used to Hair Loss treat PSORIASIS (a disease featuring excessive cell Hair loss may be caused by a variety of toxic expo- turnover). sures in the workplace or by mechanical accidents. A wide variety of infections may be picked up on the job, often linked to poor hygiene or minor ointment A greasy, semi-solid substance that is abrasions and lacerations. Finally, heat, electricity, placed on the skin either to apply drugs or to pro- cold, wind, vibration, and radiation may cause a vide a protective barrier. Most ointments contain wide variety of skin problems. petrolatum or wax with an EMOLLIENT for a mois- turizing effect. Risk Factors and Preventive Measures Workers should wear protective clothing, use bar- rier creams, and practice good hygiene. Depend- onychodystrophy Malformation of a nail. ing on the job description, gloves, boots, sleeves, aprons, coveralls, and different types of face protec- tion must be worn to keep out toxic substances. onychogryphosis A curved overgrowth and See also DERMATITIS, CONTACT. thickening of the nail. The cause is unknown. onychomycosis 263 onycholysis Separation of part or all of a nail from the skin surface beneath it will not reattach— from its bed. It is a common symptom that may onycholysis only clears after new nail has replaced be associated with thyroid disorders, an injury to the affected area. It takes four to six months for the nail, exposure to chemicals, or use of nail cos- a fi ngernail to fully regrow, and twice as long for metics combined with a fungi, yeast, or bacterial toenails. Some nail problems are diffi cult to cure infection. and may permanently affect the nail appearance.

Symptoms and Diagnostic Path Risk Factors and Preventive Measures A nail that has lifted from its bed at its end can Some things will make onycholysis less likely to have an irregular border between the pink portion occur. Nails should be cut to a comfortable length of the nail and the white outside edge. Most of so that they will be less likely to endure repeated the nail is opaque, either white, yellow, green, or “tapping” trauma in everyday use. Rubber gloves discolored. Depending on the cause of onycholysis, should be worn to avoid repetitive immersion the nail may have collected thickened skin under- in water. Nails expand after they are exposed to neath the edge of its nail plate, and the nail plate moisture and then shrink while drying, a cycle may have a deformed shape with indentations in that over time can make them brittle. Keeping the nail surface, a bent nail edge, or coarse thick- nails dry will also help prevent fungal infections. ening of the nail. If the cause is trauma, the lifted Frequent exposure to harsh chemicals such as nail area is white or opaque. If it is a yeast, fungal, polish remover should be avoided. or bacterial infection, it may be yellow, green, or Because the portion of nail that has lifted away shades of black. Onycholysis caused by PSORIASIS is from its bed may catch on edges when moving usually cream or yellow. abruptly, it is a good idea to trim the nail close to If an infection is suspected as the cause of nail its separation. changes, a scraped sample of tissue from beneath the nail plate can be examined under a microscope or sent to the lab to confi rm the diagnosis. onychomalacia Softening of the nails.

Treatment Options and Outlook Onycholysis is not an urgent problem and can onychomycosis A fungal disease of the nails that be discussed with a doctor on a routine checkup. often occurs on the feet, where it may be associ- However, diabetics should seek treatment quickly ated with ATHLETE’S FOOT. It is much less common to prevent other complications. on the fi ngernails. The infection is usually caused Treatment for onycholysis depends on the cause by Trichophyton rubrum or T. mentagrophytes. of the problem. Treatment for hyperthyroidism can permit nor- Symptoms and Diagnostic Path mal regrowth of the nails. Some oral treatments The infection fi rst causes a discolored nail edge, for psoriasis that are given by mouth may improve spreading until the entire plate is discolored, nail health. Fungal nail infections can sometimes ragged, thickened, and rough. Sometimes, how- be treated with prescription medicines. However, ever, there is only a slight infection of the upper the medicines required to treat the nail condition surface of the nail, which has a chalky color. are expensive and potentially toxic. Regular clipping and application of a topical Treatment Options and Outlook antifungal such as imidazole derivative is recom- Most topical antifungals are not effective in treat- mended. Patients with Candida infection should ing fungal nail infections; fi ngernail fungal infec- avoid water. Antibiotics may help if bacteria is tions usually require systemic treatment. Systemic present. antifungals such as itraconazole are effective, Nails are slow to grow and take time to repair clearing 70 percent to 80 percent of nail fungus themselves. The portion of nail that has separated infections. The effectiveness of treatment depends 264 onychotillomania on how faithfully the patient takes the medication. Treatment Options and Outlook However, if the fungal infection returns, treatment No treatment (other than prevention of second- is far less successful because the DERMATOPHYTE ary infection) is required. The infection will heal may develop resistance to GRISEOFULVIN. spontaneously within three to six weeks; primary Infections of the toenail are more diffi cult to infection confers lifelong immunity. treat in part because it can take up to 18 months for a toenail to grow out. Risk Factors and Preventive Measures Those working with animals should watch for lesions around the mouths of sheep or goats. There onychotillomania Pulling, poking, or tearing of have been no reports of infection spreading from the nails that is a manifestation of DELUSIONS OF one human to another. PARASITOSIS. In this condition, the patient cuts down the nails in search of parasites. It may also occur as a nervous habit. orthokeratosis Normal production of keratin (KERATINIZATION). open wet dressings A type of topical prepara- tion useful in conditions characterized by VESICLES, Osler-Weber-Rendu disease A genetic disorder PUSTULES, exudates, and crusts, such as in a poison of the blood vessels in which small vessels are ivy rash. These dressings cool and dry the skin dilated in the skin and mucous membranes. The by evaporation; as they are removed, they help condition affects about one in 10,000 people, remove the crusts and exudate from the surface. both men and women from all racial and ethnic Appropriate use of open wet dressings can control groups. exudation and infl ammation. The disorder is named after several doctors who The solutions usually consist of room- studied the condition between 50 and 100 years temperature water or saline. Other agents include ago. In 1896, Dr. Rendu fi rst described this condi- silver nitrate, BUROW’S SOLUTION, potassium per- tion as a hereditary disorder involving nosebleeds manganate, 5 percent acetic acid, and sodium and characteristic red spots that was distinctly hypochlorite. different from hemophilia. Drs. Weber and Osler reported on additional features of the disease in the early 1900s. Still, a century later it is often mis- orf A viral infection with skin symptoms caused by diagnosed in affected individuals, and many doc- a subgroup of poxviruses found around the world tors do not understand all of its manifestations. in sheep and goats. Human infection is usually A patient with this condition has a tendency caused by direct contact with infected material from to form blood vessels that lack the capillaries con- animals or animal products. Veterinarians, farmers, necting an artery and vein. This means that arte- shepherds, and butchers are especially at risk. rial blood under high pressure fl ows directly into The infection is characterized by large crusting a vein without fi rst having to squeeze through the purple PUSTULES with a white center and a red edge very small capillaries. This place where an artery appearing on the hands. is connected directly to a vein tends to be a frag- ile site that can rupture and bleed. This type of Symptoms and Diagnostic Path abnormal blood vessel in which a small artery is Following an incubation period of up to a week, a attached to a small vein is called a TELANGIECTASIA. fi rm red PAPULE appears and enlarges into a large Telangiectasia tend to occur at the surface of the crusted hemorrhagic pustule. The lesions usually body, such as the skin and the mucous membrane appear alone on the fi ngers, hands, forearms, or that lines the nose. (occasionally) the face. There is sometimes an In the mid-1990s scientists discovered two accompanying low fever. genes (one on chromosome 9, one on 12) that Osler-Weber-Rendu disease 265 are responsible for most cases. There may be one and progress with age. Hemorrhage is common or more other genes that can cause this condi- and often serious. Telangiectasia of the skin of tion, but if so they are quite rare. Any individual the hands, face, and mouth are found in about will have only one of these two abnormal genes. 95 percent of all people with the disease. These Normally, these genes tell the body to produce often do not become apparent until the 30s or a substance that is involved in the formation of 40s, when they appear as small red-to-purplish blood vessels; patients make less of one of these spots or distinct areas of delicate, lacy red vessels. substances. This in turn can interfere with normal In some individuals, they become quite prominent formation of a blood vessel. The abnormal gene by late adulthood; in others they are subtle. These is usually inherited from one parent who has the telangiectasia on the skin and in the mouth can condition, which is a “dominant” disorder, mean- bleed also, but they are less likely to than those in ing it only takes one abnormal copy of the gene, the nose. Both telangiectasia of the skin and nose- from only one parent, to cause the problem. Each bleeds have a tendency to become more numerous child of a parent with the gene has a 50 percent with increasing age. But with this, too, there are chance of inheriting it. If a given child does not many exceptions. inherit the gene from a parent, they will not pass Symptoms may vary considerably, even within the gene to their children or grandchildren. How- a family. A parent may have horrible nosebleeds, ever, it is possible for an individual with the gene but no problems in an internal organ, while their to have such mild symptoms that they are not child may rarely have a nosebleed but have more recognized, or that symptoms are recognized but problems with internal organs. It is not possible not attributed to the disease. Very rarely, a new to predict how likely someone is to have one of mutation occurs in a sperm or egg cell of an unaf- the hidden, internal telangiectasias based on how fected parent and causes the disease in the child. many nosebleeds or skin lesions they have. About But in most cases, the abnormal gene has been in 95 percent of patients have recurring nosebleeds the family for generations. by the time they reach middle age. The average Currently, scientists are trying to understand age at which nosebleeds begin is 12, but they can better exactly how it is that the abnormal gene can begin as early as infancy or as late as adulthood. interfere with normal blood vessel formation. The nosebleeds can be rare or can occur daily. In a normal person, arteries carry blood under When a nosebleed occurs it can last only seconds, high pressure to all areas of the body after being or occasionally hours. The amount of blood lost pumped by the heart. Veins carry blood under low may be one or two drops, or enough to require a pressure on its way back to the heart. An artery blood transfusion. Most patients are in between does not usually connect directly to a vein; instead, the two extremes. About 25 percent of those will very small blood vessels called capillaries link an develop bleeding in the gastrointestinal tract that artery to a vein. may range from mild to severe. There is currently no test that can be done to Symptoms and Diagnostic Path determine if someone has HHT, although soon The telangiectasias occur primarily in the nose; genetic testing of a blood sample will be able to skin of the face, hands, and mouth; and the lining reveal the condition. Until then, a physician must of the stomach and intestines (GI tract), lungs, and decide whether someone has the disease based on brain. It is not currently known why they tend to symptoms and family history. Since it is so vari- occur in certain parts of the body and not others. able, and since in many individuals the symptoms Its location in the body determines what problem are so few, it can be diffi cult to be certain about a telangiectasia might cause. In most locations, the diagnosis. and at any size, a telangiectasia is more likely to The diagnosis is considered defi nite if three or rupture and bleed. more of the following four criteria are present and The lesions in this disorder may be present at “suspected” if two of the following four criteria are birth, but more often they appear after puberty present: 266 osteopoikilosis with connective tissue nevus

• Nosebleeds: spontaneous and recurrent after removing a foreign object, allergies, or a gen- • Telangiectasia: multiple, at characteristic sites, eralized skin disease. including lips, mouth, fi ngers, and nose. Malignant otitis externa is a rare (and some- times fatal) form of the disease caused by the • Internal telangiectasia: lung, brain, GI, liver, or bacterium Pseudomonas aeruginosa. This type of spinal otitis sometimes spreads into surrounding bones • Family history: parent, sibling, or child with the and soft tissue, and usually affects elderly diabetics disease. with a lowered resistance to disease.

Treatment Options and Outlook Treatment Options and Outlook Although there is not yet a way to prevent the Usually the only required treatment is a thorough telangiectasia from occurring, most can be treated cleaning and drying of the ear together with anti- once they occur. They should be treated if they biotic, antifungal, or anti-infl ammatory drugs. A are causing a signifi cant problem, such as frequent wick should be used to instill drops into the ear in nosebleeds. ear canals that are badly swollen. Patients should Telangiectasia of the skin can be treated with avoid getting the ear wet until the condition is laser therapy if they bleed to an extent that is completely healed. bothersome or are a cosmetic concern. Lesions of the skin are usually best treated by a dermatologist who has expertise in the use of lasers. otoplasty A cosmetic operation to correct over- sized or malformed ears. By the age of six, most children’s ears have reached adult size and an osteopoikilosis with connective tissue nevus See operation to repair them may be considered. In the BUSCHKE-OLLENDORFF SYNDROME. operation, an incision is made behind the ear, and excess skin is removed; at this time, the ear itself can be reshaped or recurled. The day after surgery, otitis externa An infl ammation of the outer ear bandages are removed, and smaller, lighter ban- caused by infection or the result of an infl amma- dages are applied until the sixth day, when stitches tory skin disorder (such as atopic ECZEMA or sebor- are removed. A ski headband can be worn at night rheic DERMATITIS). The condition is also known as for a month after the operation to prevent distor- “swimmer’s ear” because it can occur after swim- tions of the ear as it heals. ming in dirty or heavily chlorinated water. The risk of getting swimmer’s ear rises with the frequency of swimming, the longer the person stays in the oxytetracycline A TETRACYCLINE antibiotic used water, and the longer the head is submerged. to treat a wide variety of infections, including chla- mydia, SYPHILIS, ROCKY MOUNTAIN SPOTTED FEVER, Symptoms and Diagnostic Path cholera, and the PLAGUE. Swimmer’s ear usually causes redness and swell- ing in the ear canal, a discharge, and sometimes Side Effects eczema around the ear opening. ITCHING may Possible side effects include rash, increased skin become painful and deafness can occur if pus sensitivity to the sun, nausea, and vomiting. blocks the ear. Because oxytetracycline may discolor developing Swimmer’s ear also can be caused by excessive teeth and bones, it is not prescribed during preg- washing, perspiration, irritation of the ear canal nancy or for youngsters under the age of 12. P

PABA The abbreviation for the active ingredient Melanin defi ciency can be caused by a lack of in SUNSCREEN—PARA-AMINOBENZOIC ACID—which is exposure to the sun, or it can be the result of the very effective in blocking ultraviolet B (UVB) rays hereditary condition known as ALBINISM. of the sun. Constriction of blood fl ow to the skin is a reac- Some people are allergic to PABA and its esters, tion of the body in an effort to shunt blood to especially if they are allergic to the “-caine” group the vital organs and the brain. Constricted blood of anesthetics (lidocaine, benzocaine, and so on) vessels in the skin may be caused by severe pain, or to certain hair dyes. Allergic reactions to PABA injury, fainting, extreme cold, or excessive blood resemble SUNBURN. loss, leading to shock. Pallor may also be a symp- tom of anemia, caused by the lack of hemoglobin pigment in blood vessels in the skin. pachydermoperiostosis A rare hereditary dis- Pallor as a symptom of disease may be caused ease characterized by thickened furrows on the by kidney disorders such as pyelonephritis or renal face (especially on the forehead), with large, active failure, or from hypothyroidism. Other diseases sebaceous glands and oily skin. In addition, there that might cause pallor include lead poisoning or is often a marked folding of the scalp skin (cutis scurvy. verticis gyrata) and excessive sweating. It is an autosomal dominant disease, which means that only one defective gene (from one palmar-plantar keratosis A descriptive term for parent) is needed to cause the syndrome. Each the thickening of the horny layer of palms and child of an affected person usually has a one in soles as seen in a wide variety of acquired and two chance of inheriting the defective gene and of hereditary disorders. These include CORNS, CAL- being affected, and a one in two chance of being LUSES, WARTS, hand ECZEMA, HOWEL-EVANS SYN- unaffected. DROME, MAL DE MELEDA, and so on. pachyonychia Thickened nails that may occur as panniculitis A general term for a group of con- an inherited disease. ditions involving infl ammation of fat tissue just beneath the skin, caused by a wide variety of dis- eases. Different types of panniculitis can be divided padimate O A derivative of PABA that can block into two main types: mostly septal or mostly lobular, the damaging effects of the sun. See PABA. depending on where the infl ammation is found.

Symptoms and Diagnostic Path pallor Abnormally pale skin (especially of the Although there are many different causes, most face) that may be a symptom of a disease or a simple types of panniculitis have the same symptoms: pain, defi ciency of the skin pigment MELANIN or a con- tenderness, raised NODULEs, and sometimes large striction of blood vessels in the skin. fl at areas of thickened skin. As the skin hardens,

267 268 panthenol it forms lumps, patches, and lesions. There may specifi c type of wart. Some cause WARTS, including be a discoloration of the skin (either red or dark PLANTAR WARTS on the feet, common hand warts, brown). After the infl ammation subsides, there juvenile warts, and GENITAL WARTS. The most com- may be a slight skin depression, either temporary mon type of HPV is the basic wart on hands or feet. or permanent. These are not associated with cancer, but are very Panniculitis is diagnosed by a skin biopsy to stubborn to treat. A wide variety of benign and distinguish the different microscopic features of cancerous growths also may be associated with individual types of panniculitis. HPVs, some of which has been demonstrated to cause vulvar or cervical cancer in some women. Treatment Options and Outlook HPV is one of the most common causes of sexu- The underlying cause of the panniculitis should ally transmitted diseases in the world. About 30 be treated (if known). The affected area should be of the more than 100 different type of HPV are elevated and compression hosiery should be worn, spread through sexual contact. Some types of HPV if possible. Anti-infl ammatory medications such as cause genital warts—single or multiple bumps that aspirin or ibuprofen may be administered for the appear in the genital areas of men and women, pain; oral or injected systematic steroids may treat including the vagina, cervix, vulva, penis, and the infl ammation. Other medications may include rectum. potassium iodine or antibiotics (such as TETRACY- About 20 million people are currently infected CLINE or hydroxychloroquine). Persistent lesions with HPV, and at least half of all sexually active may need to be surgically removed. men and women acquire a genital HPV infection at some point in their lives. By age 50, at least 80 percent of women will have acquired genital HPV panthenol A VITAMIN B complex that can add infection. About 6.2 million Americans get a new strength and body to hair by fi lling in cracks on the genital HPV infection each year. There are high- shaft, thereby fi rming up the fi ber. risk and low-risk types of HPV. High-risk HPV may cause abnormal Pap smear results, and could lead to cancers of the cervix, vulva, vagina, anus, or panthothenic acid A B vitamin found in liver, penis. Low-risk HPV also may cause abnormal Pap eggs, and dried brewer’s yeast (and the ROYAL JELLY results or genital warts. of bees) that some people erroneously believe can prevent gray hair. Symptoms and Diagnostic Path Many people infected with HPV have no symptoms. A health care provider usually diagnoses warts by papilloma A generic term usually referring to visual inspection. Any woman with genital warts a nonmalignant tumor resembling a WART with should be examined for possible HPV infection of a broad base, that arises from the EPITHELIUM the cervix. If a woman has an abnormal Pap smear, (cell layer that forms the skin and mucous mem- it may indicate the possible presence of cervical branes)—most commonly on the skin, tongue, or HPV infection. A laboratory worker will examine larynx and in the urinary tract, digestive tract, cells scraped from the cervix to see if they are or breasts. cancerous.

Treatment Options and Outlook papilloma virus, human (HPV) A very common There is no known cure for HPV. There are treat- and extremely contagious virus that can cause ments to remove warts, but they often disappear abnormal warty tissue growth on the feet, hands, even without treatment. There is no way to predict vocal cords, mouth, and genitals. More than 100 whether the warts will grow or disappear. Anyone types of HPV have been identifi ed; each type who suspects genital warts should be examined infects certain parts of the body and produces a and treated, if necessary. A recently-developed para-aminobenzoic acid 269 vaccine that appears to prevent HPV infection has appears primarily in children aged two to seven; not yet been approved by the U.S. Food and Drug the disease is rare in infancy and uncommon in Administration. adulthood.

Symptoms and Diagnostic Path papovaviruses One of a group of viruses produc- The lesions appear solid instead of as a swelling, ing nonmalignant tumors in humans. Papovavi- and are sometimes indistinguishable from an ruses are divided into two types: polyomaviruses insect bite. They are generally found on exposed and PAPILLOMA VIRUS. Polyomaviruses induce areas of the skin, especially the face and arms and tumors in rodents; at least three polyomaviruses legs. In some cases, they represent an overreaction are believed to cause disease in humans; BKV, JCV, to INSECT BITES, while in others the lesions appear and SV40. Papilloma viruses induce benign tumors faraway from the insect bite site as an allergic reac- of the head and neck and several varieties of skin tion to the bite. WARTS on hands, feet, mouth, and genitals. The lesions transform into an infl ammatory, fi rm, red-brown persistent PAPULE. Extremely sensi- tive people may also experience vesicles and blisters. papular acrodermatitis See GIANOTTI-CROSTI Bacterial infection and excoriations may appear. SYNDROME. In the eastern United States, the problem appears almost exclusively in the summer when fl eas are numerous; on the West Coast the prob- papular dermatitis of pregnancy Also known as lem is found throughout the year. Spangler’s dermatitis of pregnancy, this condition is a rare, severely itchy disease that can occur at Treatment Options and Outlook any time during pregnancy. Abnormal hormone A topical steroid cream should be applied as soon levels are linked to this disorder, especially high as the itchy spots appear; antihistamine tablets at levels of gonadotrophins and low cortisol and night may be useful for severe ITCHING. Antibiotic estrogen levels. cream should be applied if the spots get infected.

Symptoms and Diagnostic Path The condition is characterized by uniform crusted, papules Small, solid slightly raised areas of the excoriated red PAPULES that appear in groups skin less than half an inch in diameter. They may of wheals. As the lesions fade, the skin may have a varied appearance: either rounded, smooth become hyperpigmented, but this will fade after or rough, skin-colored or red, pink, or brown. pregnancy. The characteristic lesion in skin conditions such as ACNE or LICHEN PLANUS is a papule. Treatment Options and Outlook Administration of systemic CORTICOSTEROIDS is recommended. Associated with 30 percent of still- papulosquamous diseases Conditions character- birth or spontaneous abortion cases, this condition ized by scaling papules or plaques, with sharply recurs with subsequent pregnancies. defi ned margins. Crusts, excoriation, or weeping are rarely seen. PSORIASIS is the most typical of the papulosquamous diseases; others include PARA- papular mucinosis See LICHEN MYXEDEMATOSUS. PSORIASIS, LICHEN PLANUS, seborrheic dermatitis, FUNGAL INFECTIONS and SYPHILIS. See DERMATITIS, SEBORRHEIC. papular urticaria A condition caused by a hyper- sensitive reaction to insect bites (especially fl eas, bedbugs, mosquitoes, and dog lice). The condition para-aminobenzoic acid See PABA. 270 parabens, sensitivity to parabens, sensitivity to A group of preservatives PARAPSORIASIS VARIOLIFORMIS ACUTA is a completely used in foods, drugs, and cosmetics that can cause different condition, and should not be classifi ed a severe redness, swelling, ITCHING, and pain in the among these diseases. skin. They also can cause anaphylactic shock in susceptible individuals. Symptoms and Diagnostic Path Foods commonly preserved with parabens The fi rst two forms of parapsoriasis are chronic and include mayonnaise, salad dressings, mustard, pro- cause no serious complications, but parapsoriasis cessed vegetables, ice cream, some baked goods, en plaques is serious and may progress to MYCOSIS jellies and jams, soda, fruit juices, syrups, and FUNGOIDES. All forms of the disease usually begin candy. Medications, with parabens include creams; with one lesion covered with a fi ne spreading SUNSCREENS; eye, ear, and nose drops; deodorants; scale, appearing fi rst on the trunk, arms, or legs. rectal and vaginal medications; cleansers; ban- Parapsoriasis guttata is characterized by fi ne dages; and local anesthetics. Cosmetics containing macules and papules resembling guttate psoriasis, parabens include foundations, powders, cover-up dusted with a fi ne silvery scale. This condition does sticks, bronzers, makeup removers, blushes, high- not respond to antipsoriasis treatment. The lesions lighters, lipsticks, quick-dry nail products, mas- appear on the trunk at any age in both men and caras, eye shadows, and eye liners. women, and may persist for years. ITCHING does However, considering how widespread para- not usually occur. bens, sensitivity to this preservative is not com- Parapsoriasis lichenoides (or retiform parapso- mon. The most commonly used parabens are riasis) is characterized by raised, dull red, scaly methylparaben, ethylparaben, p-hydroxybenzoic papules that appear on the neck, trunk, arms, and acid, propylparaben, and butylparaben. legs. The patient’s general health is not affected, and itching is not a problem. Symptoms and Diagostic Path In parapsoriasis en plaques, lesions are larger than Allergic reactions to parabens can cause severe those of either lichenoides or guttata, and they are redness, swelling, ITCHING, and pain; severe allergic fl atter than lesions in psoriasis. Plaques range from reaction in sensitive consumers may lead to ana- yellow-red to brown with a fi ne scale, found pri- phylactic shock. marily on the trunk, thighs, and buttocks. Unlike the other two types of parapsoriasis, these lesions Treatment Options and Outlook may itch and in many cases this type of parapsoria- Anyone diagnosed with a parabens allergy should sis may progress to mycosis fungoides. avoid products containing this substance. Once a sensitive person has been exposed and the reaction Treatment Options and Outlook appears on the skin, treatment is the same as for Treatment for both parapsoriasis guttata and any acute skin rash: topical corticosteroids free of lichenoides may not be necessary, since the lesions paraben preservatives, emollients, and treatment cause no problems, although sunlight (UVB and of any bacterial infection. PUVA) or topical CORTICOSTEROIDS may be helpful See also ALLERGIES AND THE SKIN; PABA. in clearing them up. Parapsoriasis en plaques may respond to topical steroids, sunlight (ultraviolet B) or PUVA. Patients with parapsoriasis en plaques parapsoriasis A hard-to-treat group of diseases should be carefully followed by a dermatologist. characterized by different-sized superfi cial scaling plaques. Resembling PSORIASIS, parapsoriasis is not related at all to that disease. parapsoriasis varioliformis acuta A disease that There are three main types of parapsoriasis: features a papular, scaly rash unrelated to other parapsoriasis guttata (small plaque parapsoria- forms of PARAPSORIASIS. It is also known as acute sis), parapsoriasis lichenoides chronica, and para- parapsoriasis, pityriasis lichenoides et varioliformis psoriasis en plaques (large-plaque parapsoriasis). acuta, or Mucha-Habermann syndrome. patch test 271

Symptoms and Diagnostic Path paronychia Swelling and infl ammation of Acute onset appears much like CHICKEN POX with infected skin at the base of the nail usually caused groups of papules, vesicles, and pustular crusted by the yeast Candida albicans. Acute paronychia is lesions that progress to a necrotic stage, leaving the result of bacteria. chicken pox–like scars. They typically form on the insides of the forearms and back of the legs. Symptoms and Diagnostic Path The condition begins with a tender red area that Treatment Options and Outlook may draw pus, and is most often found among Large doses of tetracycline, penicillin G, or ERYTH- women with poor circulation or those who must ROMYCIN are administered for a month; for chronic wash their hands often. cases this treatment may not help. While small doses of oral METHOTREXATE will control the dis- Treatment Options and Outlook ease, when the drug is stopped the lesions return. Antifungal or antibiotic drugs will cure this prob- This condition primarily occurs in patients in their lem. The hands must be kept dry. Any ABSCESSes 20s and 30s and lasts from a few weeks to years. must be surgically drained. Often, it simply disappears without treatment.

patch A fl at area of skin larger than one cm parasitic infestations A wide range of skin symp- in diameter that differs in color from the skin toms may occur with parasitic infestations, which around it. are endemic in many developing countries through- out the world where poverty, poor hygiene, and poor sanitary facilities are common. Infestation patch test A test to discover the cause of an aller- from parasites are divided into those caused by gic reaction by reproducing allergic contact derma- protozoa (single-celled animals), by helminths titis. In the test, the physician places a suspected (worms), and by arthropods (mites or ticks). ALLERGEN in contact with the patient’s unbroken Protozoal infestations that cause skin symptoms skin under occlusion for 48 hours. Positive reac- include LEISHMANIASIS, African and South Ameri- tions show redness, swelling, and/or BLISTERs. can trypanosomiasis, amebiasis, trichomoniasis, The physician can select suspended allergens and TOXOPLASMOSIS. from a screening tray of chemicals often found in Parasitic worm infestations with skin symptoms commercial products or with the products that are are divided into roundworms (class Nematoda) suspected. The chemical is placed on an adhesive- and fl atworms (class Trematoda, or fl ukes, and backed gauze pad, taped in place on the back or Cestoidea, or tapeworms). inner arm for 48 hours. The reaction is infl uenced Arthropod infestations include mites, ticks, and by the skin condition, the concentration and the insects. volume of the testing substance and the vehicle used, the length of time of the test, and the num- Symptoms and Diagnostic Path ber of readings. The standard tray of allergens is Symptoms of parasitic infections vary depending frequently updated by the International Contact on the type of parasite involved, but ITCHING and Dermatitis Research Group and the North Ameri- skin irritation are common. can Contact Dermatitis Research Group. The standard patch test covers the most com- Treatment Options and Outlook mon skin allergies, which make up about 80 Treatment for parasitic infestations depends on the percent of contact sensitivities. To test for other particular parasite involved. allergies, supplementary patch testing must be car- ried out. The type of patch test is determined by the kind of dermatitis, the history of exposure, and paresthesia See PINS AND NEEDLES SENSATION. the experience of the dermatologist. 272 Pautrier’s micro abscess

If a reaction occurs, the physician can then ness; weight loss; lethargy; depression; and describe the substance, what common products irritability. Severe attacks include bright red contain that substance, and what substitutions are weeping BLISTERs, a swollen tongue, DERMATITIS, available. diarrhea, and, in severe cases, dementia and memory loss.

Pautrier’s micro abscess A characteristic small Treatment Options and Outlook collection of leukocytes (or white blood cells— Several weeks’ supplementation with niacin and a lymphocytes) found in the top layer of skin in varied diet rich in protein and calories will reverse patients with MYCOSIS FUNGOIDES. pellagra. See also DERMATITIS, CONTACT.

pemphigoid A very rare group of autoimmune pearly penile papules See ANGIOFIBROMA. blistering diseases in which the body’s immune system mistakenly perceives as foreign one or more proteins that naturally occur in the skin or mucous peau d’orange French for “skin of an orange,” membranes. The immune system responds by pro- this is a skin symptom caused by fl uid retention ducing antibodies against itself that attack these in nearby lymph glands, dimpling the skin like an proteins. Because these proteins are responsible for orange peel. The fl uid retention may be caused keeping the skin intact, when they are damaged, it by breast cancer in the area around the nipple, in results in BLISTERs that do not heal easily. In some LICHEN MYXEDEMATOSUS, or in some types of skin cases, these blisters can cover a signifi cant portion lymphoma. of the body. Experts believe some people inherit a tendency to develop this disease, and some groups are at higher risk, but pemphigoid seems to affect pediculi See LICE. different races or genders equally.

Symptoms and Diagnostic Path pediculosis Any type of louse infestation. There are two major types of pemphigoid—bullous See also LICE. pemphigoid (BP) and cicatricial pemphigoid (CP). The type of autoantibodies produced determines which version of pemphigoid a person develops pellagra A nutritional disorder affecting the skin and in which layer of the skin the blister occurs. caused by a defi ciency of niacin (found in meat, Bullous pemphigoid This type of pemphigoid yeast extracts, and some cereals). Pellagra is found is characterized by itchy large, tense blisters on primarily in parts of India and southern Africa the skin. It usually begins with itchy red plaques, where people live mostly on corn. followed by intense blisters over several weeks or While corn has as much niacin as other cereals, months. The condition spreads across the body the niacin in corn is not absorbed by the body unless with oozing erosions that may be either painful fi rst treated with an alkali such as lime water. Corn or itchy. is also low in tryptophan, an amino acid that the Cicatricial pemphigoid Primarily a disease of body converts to niacin. This is why other diseases the elderly (between 60 and 80 years) it is rarely that increase the breakdown of tryptophan, such as seen in young adults. Lesions appear in mucous infl ammatory bowel disease, can also cause pellagra. membranes including the nose, mouth, eyes, esophagus, larynx, urethra, and anus. The gums Symptoms and Diagnostic Path are often involved, which can cause gingivitis. First signs of pellagra include ITCHING and infl am- Temporary small blisters on the head and neck mation, especially in sun-exposed sites; weak- occur in more than 20 percent of patients. penicillin and derivatives 273

Pemphigoid can be diagnosed after a visual outer skin layer. These antibodies lead to the for- examination of the skin lesions, a biopsy of mation of blisters. the lesions, and treatment of the biopsied skin sample to reveal antibodies in the skin (direct Symptoms and Diagnostic Path immunofl ourescence) and in the blood (indirect Blisters fi rst break out in the mouth and nose, then immunofl ourescence). on the skin; the precise location and type of lesions vary depending on the variety of pemphigus. The Treatment Options and Outlook easily ruptured skin lesions often form raw, pain- Prompt doses of steroids (usually prednisone or ful areas that may become infected and then form predinisolone) are needed to control pemphi- a crust. goid, which is easier to manage than PEMPHI- GUS. Patients with small areas of blisters can be Treatment Options and Outlook treated with topical or intralesional steroids, but CORTICOSTEROID drugs given over a long period of patients with more severe or widespread disease time together with immunosuppressant drugs can are prescribed systemic CORTICOSTEROIDS such as control the disease. Antibiotics may be given for prednisone. Once the disease is under control, any resulting skin infections. If the blisters appear the medications are reduced slowly to minimize over a large area, the condition can lead to second- the risk of side effects. Several other drugs are ary skin infections that may be fatal. often used in combination with prednisone, such as antibiotics, immunosuppressants, and METHOTREXATE. pemphigus, familial benign chronic See HAILEY- Up to 70 percent of patients with BP will expe- HAILEY DISEASE. rience a remission within fi ve years of diagnosis, although some patients may experience a relapse. BP lesions should heal without scarring unless pemphigus v. pemphigoid There are two types secondary infection occurs. Appropriate wound of blistering disorders caused by autoimmune care is important to promote healing and prevent problems in which a patient’s own antibodies infection and scarring. Spontaneous remissions of attack the skin cells. The attack may occur at vari- CP are rare; this disease is progressive and often ous layers of the skin. PEMPHIGUS causes a cleav- does not respond to steroids. age within the top layer of the skin, with fl accid blisters that break easily. PEMPHIGOID produces pemphigus An uncommon skin disorder fea- a split below the top layer of the skin, causing turing skin BLISTERs most often found in patients deeper, tense BLISTERs. Pemphigoid is seen most between ages 40 and 60. Pemphigus is a more often in the elderly. serious disorder than another similar condition, Both are treated with similar medications. bullous PEMPHIGOID, which features itchy blisters Severe cases may require more intensive treat- that are not normally fatal. Pemphigus appears ment. Either may recur. more often among Jews and other ethnic groups of Mediterranean and Indian descent. Pemphigus may be associated with other auto- penicillin and derivatives The fi rst group of immune diseases, such as myasthenia gravis and antibiotic drugs to be discovered (the sulfas are LUPUS ERYTHEMATOSUS. Various forms of pemphigus considered to be antibacterials); natural penicil- include pemphigus vulgaris, pemphigus vegetans, lins are derived from the Penicillium mold, but can pemphigus foliaceus, pemphigus erythematosus, also be produced synthetically. Penicillins are used and fogo selvagem. to treat a wide variety of infections, and include In pemphigus, antibodies circulate in the blood amoxicillin, ampicillin, penicillin G, penicillin V, that react against the intercellular substance of the and penicillin. 274 penicillin rash

Side Effects perforating disorders A family of several dis- Allergic reactions include skin rash, HIVES, and orders characterized by perforation of elements anaphylaxis. Any patient allergic to one type of of the DERMIS through the overlying EPIDER- penicillin should not be given any other. Side MIS. The perforating disorders include ELASTOSIS effects include vomiting and diarrhea. PERFORANS SERPIGINOSA, perforating collagenosis, See also PENICILLIN RASH. perforating FOLLICULITIS, and KYRLE’S DISEASE. Perforation has also been reported to occur in dermal diseases, including GRANULOMA ANNU- penicillin rash An allergic skin rash in response LARE, necrobiosis lipoidica diabeticorum, and to the administration of PENICILLIN and derivatives. PSEUDOXANTHOMA ELASTICUM. The red rash usually appears as HIVES or as a fi ne macular or papular rash; it can be widespread. These allergic reactions are not uncommon and perfume sensitivity See FRAGRANCE, SENSITIV- range from immediate hypersensitivity (including ITY TO. potentially fatal anaphylaxis) to SERUM SICKNESS reactions. Hypersensitivity of one type or another periarteritis nodosa An uncommon disease of to penicillin is believed to occur in about 1 or 2 small and medium-sized arteries that causes the percent of the general population. arterial wall to become infl amed and weakened, Anyone who develops such a rash should tending to form aneurysms. Many different groups immediately stop taking the medication and con- of blood vessels may be involved, including the tact a physician. Anaphylaxis should be handled as coronary arteries supplying blood to the heart, a medical emergency. and the arteries of the kidneys, intestine, skeletal muscles, and nervous system. This disorder has been linked to a poorly func- penile warts See WARTS. tioning immune system triggered by exposure to the hepatitis B virus. While it may develop at any age, it is most common among adult men. peptides A combination of two or more AMINO ACIDS that are used in shampoos, conditioners, Symptoms and Diagnostic Path and moisturizers because of their ability to retain Initial symptoms include fever and aching muscles, moisture and strengthen the hair shaft. Peptides with a general malaise, appetite and weight loss, form a fi lm on the hair shaft, making the hair seem and sometimes nerve pain. High blood pressure, thicker—they can also fi ll in cracks on the shaft muscle weakness, skin ulcers, and gangrene are and make hair shinier. On the skin, peptides form often associated with the disease. a fi lm that retains moisture. Physiologically, peptides are found throughout Treatment Options and Outlook the body’s endocrine and nervous systems. Many Large doses of CORTICOSTEROID drugs are given hormones are peptides; in the nervous system pep- together with immunosuppressant drugs. Without tides are found in nerve cells throughout the brain treatment, the condition is almost always fatal and spinal cord. within fi ve years by heart attack, kidney failure, intestinal bleeding, or complications of high blood pressure. With treatment, about half of all patients percutaneous A medical term meaning “per- survive for fi ve years. formed through the skin.” Percutaneous proce- dures include injections into veins, muscles, or other body tissues, and biopsies in which tissue or periderm The outer two layers of fetal epithe- fl uid is removed with a needle. lium (tissue that covers the external surface of permanent makeup 275 the body) that generally disappear before birth, a medical professional is better qualifi ed to handle persisting only as the cuticle. complications, many physicians do not perform the procedure. Dermapigmentation (like tattooing) is not well perifollicular fibromas Small lesions on the face regulated: Anyone may perform the procedure, made up of fi brous tissue around hair follicles. and any state or local ordinances are usually not See also ANGIOFIBROMA. well enforced. Consumers interested in the pro- cedure should fi nd out how the practitioner was trained; ask to see before-and-after photos; and periodic acid-Schiff (PAS) stain One of the most call past clients to see how pleased they were with common tests for the presence of fungi and certain the work. Clients must also understand what the microorganisms in tissue sections. end result will look like; dermapigmentation does not look like real eyebrow hairs, for example—it looks like makeup. Consumers should realize that perioral dermatitis See DERMATITIS, PERIORAL. once placed in the skin, the pigment cannot be removed. To some people, dermapigmentation on the perleche Infl ammation, dryness, and cracking sensitive eye or lip area is extremely painful, while of the corners of the mouth. Perleche is associated others dismiss it as merely uncomfortable. Physi- with the collection of moisture at the corners of cians may use injectable anesthetics (such as those the mouth, which encourages invasion by yeasts used by dentists) to numb the area, but these may and bacteria, especially Candida albicans, and cause swelling and bruising that would otherwise streptococci. In children, this is often caused by not occur. lip licking, drooling, thumb sucking, and mouth It is very important that the procedure be breathing. Adults may be troubled by age-related performed in a sterilized environment. In a skin- changes in their mouth and poorly fi tting den- care salon, the dermapigmentation area should tures. Rarely, vitamin B defi ciency can be the be separate from other rooms to protect against cause. contamination from fumes or hair. All parts of the machine that come in contact with the skin and Treatment Options and Outlook the pigment must be disposable or removable for An antifungal cream followed by a CORTICOSTEROID sterilization after each use. in a nongreasy base is usually effective. Autoclave sterilization (steam under pressure) is acceptable; dry heat sterilization is not. Because blood is drawn during the procedure, the techni- permanent makeup Also known as “dermapig- cian should wear goggles, a face shield, and double mentation,” this is a technique in which pigment gloves. is implanted in the skin to simulate the lines Pigments should be gamma-irradiated for ste- drawn with makeup pencils on eyelids, brows, or rility and approved by the U.S. Food and Drug lips. Like TATTOOING, dermapigmentation involves Administration. Common tattooing dyes, India dipping a needle into pigment that is injected ink, and vegetable dyes should never be used. Pig- into the bottom layer of the skin. Each injection ment used around the eyes must be an ophthal- leaves behind a tiny dot of pigment. The dots mologist-tested blend of iron oxide suspended in when placed closely enough together look like an glycerine and alcohol. unbroken line. While there have been no irritating reactions While the procedure is fairly straightforward, it is to eye pigments, lip lining requires an allergy test painful, it carries some risks, and it is permanent. before the operation because the ingredients used The technique is most frequently performed by to produce reddish tones often cause an allergic an aesthetician working in a skin-care salon. While reaction. 276 permethrin

To help decide on colors, the consumer should the case of an allergy, the immune system iden- bring in eye pencils and lipsticks. The pigment tifi es a normally harmless substance (called an shades would not match the pencils exactly “allergen”) as dangerous, and produces antibodies because the colors change in contact with skin to fi ght it. The allergen stems from substances in tone. Custom-mixing colors is not a good idea, the pet’s oil-producing glands, in its skin, or from because if they are improperly blended they can its saliva. Some experts also believe that cat dander separate and result in the absence of one of the also may contribute to the problem. desired hues. Placement of the pigment is critical; if placed Symptoms and Diagnostic Path only on the top layer of skin it will soon be sloughed Those allergic to cats experience an allergic reac- off. Special needle guns used in the procedure are tion, which can cause itching, puffy eyes, wheez- designed to penetrate skin only as deep as is nec- ing, rash, or shortness of breath. essary. This is particularly important around the eyes, where contact must never be made with the Treatment Options and Outlook eyeball. Occasionally eyebrow pigment is placed Antihistamines are the primary treatment for too high or with too much of a curve, but once most allergies. Repeated allergy shots may allow a applied, the color cannot be changed. patient to build up immunity over a period of sev- For more information or for a recommenda- eral months. However, because people may react tion of local dermatologists, contact the American adversely to the shots, and because repeated shots Academy of Dermatology, Box 681069, Schaum- are inconvenient, a severe cat or dog allergy is best burg, IL 60168; for a trained anesthetician, call the managed by removing the pet. Aestheticians International Association at (504) 469-1016. Risk Factors and Preventive Measures Not surprisingly, the best way to handle pet allergies is to avoid pets. But even after remov- permethrin A synthetic substance that in a 5 ing pets, it may take weeks or months for the percent cream is approved by the U.S. Food and allergens to be completely removed from carpet- Drug Administration for the treatment of SCABIES. ing and furniture. Washing the pet once a week Because of its low toxicity, it is widely prescribed, for several weeks will reduce the amount of the especially for children. In treating scabies, a single airborne allergens by 90 percent. Removing car- application of permethrin is applied to the entire peting and upholstered furniture, mopping fl oors skin surface and washed off eight to 14 hours often and vacuuming with a high-effi ciency fi lter later. will help. An effective air cleaner can remove up to 99 percent of the dust, including pet aller- gens. Pets should be kept outside as much as pernio See CHILBLAIN. possible. Because super-insulated homes have higher allergen levels, good fresh-air circulation will help. pet-borne illnesses A wide range of pet-borne See also PET-BORNE ILLNESSES. illnesses can cause skin symptoms in humans. These include allergies to pet dandruff (see PET DANDER ALLERGY), HOOKWORM, infections from petechiae Flat pinhead-sized spots of red or bites, CAT-SCRATCH FEVER, MITES, fl eas, RINGWORM, purple appearing in the skin or mucous mem- and TOXOPLASMOSIS. branes caused by a localized hemorrhage from small blood vessels. Petechiae are seen in individu- als with bleeding disorders and sometimes appear pet dander allergy Allergies to pet dander can with bacterial endocarditis (infl ammation of the cause itching and skin rash in sensitive people. In heart’s lining). photoallergy 277 petroleum jelly An inexpensive oily substance Symptoms and Diagnostic Path also known as petrolatum used in products to The syndrome is characterized by fever, a wide- treat chapped, dry, or raw skin. Derived from spread eruption consisting of red PAPULES and petroleum, it is commonly used as an ointment plaques with facial swelling, generalized tender base, a protective dressing or an emollient to swollen lymph nodes, leukocytosis, and liver soften the skin. An excellent protectant against dysfunction. water evaporation, it is very mild and has not been associated with allergies or irritation. It can, Treatment Options and Outlook however, trigger ACNE in people with oily or acne- The syndrome is reversed when medication is prone skin. stopped.

Peutz-Jeghers syndrome An inherited autoso- phlegmon Intense infl ammation of connective mal dominant disorder featuring small brown or tissue, often causing ulcers or abscesses. blue-brown spots on the lips and in the mouth. It is associated with many polyps in the small intestine; while there are often no other symp- photoallergy A condition that occurs after a toms, the polyps may occasionally produce pain person experiences an adverse reaction after or bleeding. ingesting or applying a substance (called a pho- Lesions appear early in childhood and may fade tosensitizer) and subsequently exposing the skin during adolescence. About one-third of affected to sunlight. Photosensitizers can be applied to the individuals exhibit symptoms in the fi rst 10 years skin or taken internally. Some photosensitizers of life. occur within the body; excessive porphyrin mol- ecules cause PORPHYRIA. Symptoms and Diagnostic Path Topical photosensitizers are common ingre- In addition to skin lesions, symptoms include dients of cosmetics, face creams, perfumes, abdominal pain, vomiting, and gastrointestinal after-shave lotions, and soaps. Others include bleeding. There appears to be a 2 to 3 percent medications such as coal tars and PSORALENS that chance for the eventual development of gastro- are deliberately used to induce photosensitivity intestinal cancer. Because the polyps are usually to help treat various skin disorders, or pheno- numerous and widespread, removal is not often thiazines and sulfonamides, which may produce possible. unintended photosensitivity when applied to the skin. Antibacterial agents (such as the halogenated Treatment Options and Outlook salicylanilides and related compounds) were once Bleeding polyps may be removed, but generally used in deodorant soaps; fi rst-aid creams were treatment aims at symptom management. responsible for an epidemic of photosensitivity reactions in the 1960s. Plants such as celery, wild carrots, gas plant, phenytoin hypersensitivity syndrome A type of limes, and meadow grass contain photosensitizing drug reaction causing skin symptoms in response psoralens. Industrial contaminants and air pollut- to the anticonvulsant drug used to treat epilepsy. ants such as tars and polycylic aromatic hydrocar- While fairly rare, the reaction can be severe; it bons are also potent photosensitizers. usually occurs during the fi rst week of phenytoin Commonly used photosensitizers include sul- use. Phenytoin (Dilantin) is also used occasionally fonamides, thiazide diuretics, sulfonylureas, phe- to treat migraines and to control certain types of nothiazines, and certain tetracycline derivatives arrhythmia (irregular heart beat). Cross reaction (such as doxycycline). While some of these are with other anticonvulsants is common; therefore, more potent, thiazide diuretics produce the most physicians should treat with caution. reactions because they are used most frequently. 278 photochemotherapy

Symptoms and Diagnostic Path may cause cataracts, solar keratoses, and skin The reaction is characterized by itchy papular cancer. lesions resembling POISON IVY or blistering that may extend beyond the area of exposure. Immedi- ate HIVES occur rarely. photodermatitis Skin infl ammation caused by light or ULTRAVIOLET RADIATION. Treatment Options and Outlook Prevention is the best option; patients using a known photosensitizer should avoid exposure to photophytodermatitis Skin infl ammation caused sunlight. Those who develop a reaction should avoid by plant products on the skin, activated by light or the photosensitizer. Treatment of lesions depends ULTRAVIOLET RADIATION. on the type extent and severity of response. Cool See also OIL OF BERGAMOT. tap water compresses can be applied continually or intermittently; topical application of CORTICO- STEROID cream or lotion can reduce infl ammation. photosensitivity Also known as sun sensitivity, Systemic antihistamines may lessen the itch. If the this is a toxic skin reaction to the sun that can be process is severe and extensive, systemic cortico- triggered by a variety of substances, such as some steroids (such as those used in extensive poison ivy prescription medications and consumer products— cases) may be needed. as well as some physical disorders. It often occurs because a substance (called a photosensitizer) has been ingested or applied to the skin. Examples photochemotherapy Treatments involving the of photosensitizers include certain drugs, dyes, interaction between chemicals and the sun, also chemicals in perfumes and soaps; plants such as called PUVA therapy (psoralens molecules com- buttercups, parsnips, and mustard; and fruits such bined with UVA energy). The PSORALENS (a group as limes and lemons. of photosensitizing chemical compounds) are Drugs are the primary cause of photosensitiv- taken either orally or topically followed by irradia- ity; those that are known to cause sun sensitiv- tion with long-wave ultraviolet light A (UVA) rays ity include TETRACYCLINES, furosemide (Lasix), one to two hours later, for fi ve to 10 minutes two GRISEOFULVIN, sulfonamides and nalidixic acid, or three times per week until remission. The most phenothiazine, piroxicam and naproxen, treti- common psoralen used in the United States is 8- noin (Retin-A), diphendramine, and birth control methoxy psoralen. pills. Other medications that may cause a problem Photochemotherapy in the treatment of VITI- include anticancer and photochemotherapy drugs, LIGO has been practiced since 1400 B.C. in India, antidepressants and antipsychotics, antihistamines, using plant-derived psoralens. Today, physicians antiparasitic drugs, diuretics, and hypoglycemics. use synthetic psoralens that become activated after Sun sensitivity can also be triggered by the coal they absorb UVA radiation. tars in some medicated soaps and shampoos, or This treatment has been successful in the treat- the OIL OF BERGAMOT in certain perfumes or toilet ment of a variety of conditions including PSORIASIS, soaps. vitiligo, and MYCOSIS FUNGOIDES; other diseases Photosensitivity also can be caused by some such as solar HIVES may also respond. disorders, including LUPUS ERYTHEMATOSUS and the PORPHYRIA group of blood disorders. Side Effects Fortunately, relatively few people ever become Patients who receive too much drug or UV light photosensitive; the risk is higher for those who can develop severe SUNBURN with BLISTERs and only have intermittent exposure to sunlight and swelling. The psoralen may produce nausea, vom- those who have light skin and who tend to burn iting, or light-headedness. Prolonged use of PUVA instead of tan. piebald skin 279

About 10 percent of individuals have an adverse Visible blue light is the treatment of choice for reaction to sunlight without any photosensitizing infant JAUNDICE, caused by the accumulation of bili- medications. These individuals suffer from POLY- rubin (bile pigment) as the result of a poorly devel- MORPHIC (or polymorphous) LIGHT ERUPTION, an oped liver. Experts believe the light breaks down itchy eruption characterized by red papules 24 the bilirubin in the skin, allowing it to be excreted. to 72 hours after sun exposure that last several days after the affected person avoids the sun. Fre- COMMON PHOTOSENSITIZING DRUGS quently known as “sun poisoning,” this reaction Antibiotics often develops on the fi rst sunny outing in the aureomycin (Chlortetracycline) spring or during a winter holiday to a sunny des- griseofulvin (Fulvicin) tination. It is usually mild, but the itch, swelling, minocycline (Minocin, Dynacin) and rash can be so severe that it can ruin a holiday. quinolone (Aprofl oxacin, naladoxic acid) It can be prevented by getting small amounts of sun before going on holiday, or with pretreatment sulfa drugs tetracycline (Tetracycline) (PUVA or PUVB). Antiarrythmics Symptoms and and Diagnostic Path quinidine (Cin-Quin, Duraquin, etc.) Any abnormal reaction to the sun causing exagger- Antidepressants ated SUNBURN, painful swelling, HIVES, or blistering amitriptyline (Elavil) should be considered to be a sign of photosensi- desipramine (Norpramin) tivity. A photosensitive reaction can occur in less Tranquilizers than half an hour or it can take until 48 to 72 chlordiazepoxide (Librium) hours after exposure. chlorpromazine (Thorazine) Diuretics Treatment Options and Outlook hydrochlorothiazide (Esidrix) Known photosensitizers should be avoided; sus- chlorothiazide (Diuril) ceptible people who report skin reactions without chlorathalidone (Hygroton) using any photosensitizing agents should also avoid furosemide (Lasix) exposure to the sun and should use a SUNSCREEN. triamterene (Dyrenium) Polymorphic (-ous) eruptions may be treated with systemic CORTICOSTEROIDS or antihistamines. phototoxic Pertaining to injury by ultraviolet radiation or light. phototherapy Treatment with light, including sunlight, nonvisible ultraviolet light (UVA or UVB), or visible blue light. Moderate exposure to sunlight phrynoderma Also called “toad skin,” this is an is the most common form of phototherapy and is eruption of solid, elevated palpable lesions seen in effective in treating up to 75 percent of PSORIASIS patients with severe VITAMIN A defi ciency. patients. The most recent form of phototherapy is called PUVA, which combines long-wave ultraviolet light pian See YAWS. (UVA) with a PSORALEN drug (such as METHOXSALEN) to sensitize the skin to UVA. It is especially effective in the treatment of psoriasis and some other skin piebald skin A condition of two-toned skin, diseases, such as VITILIGO and MYCOSIS FUNGOIDES. either white and black, or white and brown. It Short-wave ultraviolet light (UVB) is effective is an inherited autosomal dominant condition, in the treatment of psoriasis. which means that only one defective gene must be 280 piedra inherited from a parent to cause the disease. Each All pigment cells are produced from the neu- child has a 50 percent chance of inheriting the ral crest (except those of the retina, which come affected gene and developing the disease. from the primitive forebrain). A person’s neural crest is formed by the sixth week of gestation, Symptoms and Diagnostic Path although the precursors of pigment cells probably It is characterized by a white forlock and stable begin their migration to the skin, ears, eyes and white fl at discolorations with hyperpigmented other organs before the neural crest is completely centers; discolorations are usually found on the formed. By the eighth week of gestation, pigment trunk, face, forearms, and mid-leg (hands and feet cells can be identifi ed in the DERMIS. are not affected). See also PIGMENTATION, DISORDERS OF. Some patients with the condition are also deaf (WAARDENBURG’S SYNDROME). pigmentation, disorders of Skin color is deter- Treatment Options and Outlook mined by the MELANIN—its amount, its distri- It is diffi cult to repigment white areas, and the lack bution, its character, and its chemistry—which of MELANIN-producing cells in hair follicles next to together determine the color and hue of the skin’s affected skin means that PSORALEN and UVA (PUVA) pigmentation. therapy will not be very effective. Full thickness grafts of normal skin may result in successful Lightened Skin repigmentation. Pigment cells that are absent from an area of skin, produce too few melanosomes, or are unable to produce enough melanin, result in skin that is very piedra See TRICHOSPOROSIS. light in color. An absence of pigment cells may cause PIEBALD SKIN, WAARDENBURG’S SYNDROME, or VITILIGO. Lack of skin color may also be caused by pigmentation Color of skin, hair, and eyes deter- trauma, exposure to cold, or chemicals. Hypopig- mined by MELANIN (pigment) produced by special mentation (too little pigmentation), due to abnor- cells called melanocytes (PIGMENT CELLS). The mal formation of melanosomes, may indicate more melanin in the body, the darker the color. TUBEROUS SCLEROSIS, HYPOMELANOSIS OF ITO, NEVUS The amount of melanin any person produces is DEPIGMENTOSUS, or CHEDIAK-HIGASHI SYNDROME. the result of heredity and exposure to sunlight. Loss of pigment due to a drop in the production Three other pigments that contribute to normal of melanin may be caused by ALBINISM and TINEA skin color are oxygenated hemoglobin, reduced VERSICOLOR. PITYRIASIS ALBA is caused by a decrease hemoglobin, and carotenoids. in the transfer of melanosomes. Skin color can range from a pale white to deep Finally, there are many infections and black, and hair color ranges from white, blond, infl ammatory skin disorders that leave behind light to dark brown, black, red, or gray. Eyes can hypopigmented skin, including drug reactions, be any shade from the bluest sky blue to the very LEUKONYCHIA, and post-infl ammatory hypopig- blackest black. mentation. Patches of pale skin are also a symptom In humans, pigmented skin and hair protects of a range of disorders, including PSORIASIS and against the harmful effects of sunlight; in other PHENYLKETONURIA. animals, color may provide camoufl age against predators (as in chameleons) or act as a sexual Darker Skin attractant (as in peacocks). Some experts believe Hyperpigmentation is a common problem, espe- that the human pigmentation system may have cially among patients with dark skin. Among developed as a skin protectant for animals with those with darker skin, most skin irritations cause very little hair covering. heightened skin color. Hyperpigmentation may pilar 281 also be a sign of a serious metabolic or nutritional mucous membranes are very dark. In Caucasians, problem. Most lesions that are hyperpigmented pigmentation may not be normally visible in are benign, although some (such as MELANOMAS) mucous membranes. are cancerous. Large amounts of melanin indicate an effi - Patients may notice patches of dark and light cient effective protection against many chemical skin after an episode of ECZEMA, psoriasis, or and physical toxins. Short wave ultraviolet light, tinea versicolor. Those with CHLOASMA experi- chemical carcinogens, and phenols produce free ence dark areas on the face caused by hor- oxygen radicals within the epidermis and dermis. monal changes while taking birth control pills, It may be that a primary function of melanocytes or during pregnancy or menopause. Dark skin is to remove FREE RADICALS formed in the skin patches on the face may also be caused by during infl ammatory conditions. Melanocytes pro- some perfumes or cosmetics, especially when tect other cells of the epidermis from damage by they contain photosensitizing chemicals. These release of radical oxygens. chemically induced patches usually fade with Human pigment cells produce two types of time. Other types of skin darkening unrelated to melanin: eumelanin (black and brown) and pha- sun exposure may occur with ADDISON’S DISEASE eomelanin (red). The ratio between the two types or Cushing’s syndrome. determines a person’s skin and hair color. Permanent areas of dark pigmented skin are See also PIGMENTATION; PIGMENTATION, DISOR- usually caused by an abnormality in the melano- DERS OF. cytes, such as with a FRECKLE or MOLE. The disease ACANTHOSIS NIGRICANS is characterized by dark patches of velvety thick skin usually found in the pigmented nevi See NEVUS. skin creases. Other disorders involving hyperpigmentation include LENTIGO SIMPLEX, MULTIPLE LENTIGINES SYN- pigmented purpuric dermatosis A group of dis- DROME, NEVUS SPILUS, MONGOLIAN SPOT, NEVUS OF orders characterized by reddish brown spots or ITO AND NEVUS OF OTA, NEUROFIBROMATOSIS, heredi- patches caused by the leakage of blood through the tary cases of hyperpigmentation and Addison’s tiny capillaries the skin. Exactly why the capillaries disease. should become leaky is not known for certain, but a hypersensitivity reaction to viral infection, food Other Changes additives, and medications has been cited. Types of Still other pigment changes occur with an excess pigmented purpuric dermatosis include: of bilirubin, which turns the skin yellow, or too Gougerot-Blum syndrome (pigmented purpuric much iron, HEMOCHROMATOSIS, which turns the lichenoid dermatosis): Itchy red brown spots and skin bronze. bumps that join together to form a thickened patch Schamberg’s disease (progressive pigmented pur- pigment cells Also called melanocytes, these pura): Nonitchy, fl at brown patches with rust-col- pigment-producing cells are located in the BASAL ored spots that look like cayenne pepper CELL layer of the EPIDERMIS (top skin layer). They MAJOCCHI’S DISEASE (purpura annularis telangi- are controlled by a hormone secreted by the etoides): Similar to Schamberg’s disease, but with pituitary gland in the brain and produce MELANIN dilated capillaries arranged in rings (pigment color) by oxidizing tyrosine. Pigment Lichen aureus: Patches have a yellowish hue and cells are also found in the hair bulb and are a usually occur over VARICOSE VEINS. normal part of cells in the mucous membranes. In dark-skinned people, these pigment cells nor- mally produce large amounts of melanin, and oral pilar Pertaining to the hair. 282 pilosebaceous pilosebaceous Relating to the hair follicles and of nerve disorders called neuropathy. This condi- their sebaceous glands. tion is frequently seen in patients with diabetes.

pimples The common name for a small PUSTULE pinta A skin infection found in some remote or PAPULE, pimples are usually found on the face, tropical American villages caused by the microor- neck, and back, especially in adolescents with ganism Treponema carateum, a close relative of the ACNE. bacterium that causes SYPHILIS. It seems to affect See also ACNE, ADULT; ACNE, TREATMENT FOR; only dark-skinned people and is thought to be ACNE MYTHS; ACNE PRODUCTS, OVER-THE-COUNTER. transmitted either by direct contact or by fl ies that carry the infective spirochetes. pinch graft A small type of SKIN GRAFT used Symptoms and Diagnostic Path to cover leg ulcers. Only 4 to 10 mm thick, this Symptoms include thickening and loss of pigment graft is taken from anesthetized skin from the of the skin, particularly on the face, neck, but- upper thigh by picking up a small amount of skin tocks, hands, or feet. Up to a year after infection, with the tip of a small needle and slicing with red skin patches appear that subsequently turn a scalpel or razor blade. The grafts are kept in blue, brown, and then white. sterile saline and transferred to the wound area, leaving a 2-mm space between grafts. An adhe- Treatment Options and Outlook sive spray is then applied, followed by a semi- Rarely disabling or fatal, PENICILLIN or TETRACYCLINE permeable dressing with edges extended beyond will cure the disease, but patients may be perma- the margin of the ulcer. Gauze and an elastic nently disfi gured. dressing are used to cover the wound, which is left untouched for up to four days. Strict bed rest is required. The wound can be checked through pitted nails See NAILS, PITTED. the semipermeable dressing and accumulating fl uid can be drained. Dressings are removed in fi ve to six days. Wiping the wound with alcohol pityriasis alba A common childhood skin condi- allows it to form a scab that will come off in two tion featuring irregular, fi ne, pale scalp patches on or three weeks. As the grafts take, the grafted the cheeks caused by a mild ECZEMA. Up to a third sites grow together and cover the entire wound of children have this disorder. The skin condition site. often worsens after exposure to the sun because See also ALLOGRAFT; ARTIFICIAL SKIN; AUTOGRAFT; infl amed skin in the patches does not tan well. The HETEROGRAFT; SKIN GRAFT. disease may persist into adulthood.

Symptoms and Diagnostic Path pins and needles sensation The common term Symptoms include small white round or oval for paresthesia, a tingly or prickly sensation in the patches that are lighter than surrounding skin; skin that is usually associated with numbness or the borders of the rash are not clearly visible. The loss of sensation and sometimes with a burning lesions may be fl at or slightly elevated, with very feeling. small fi ne scales on the face, outer upper arms, A temporary pins and needles feeling is caused neck, and upper trunk. The lesions may get red in by a disturbance in the nerve impulses along the the sun, but they will not tan. pathway from skin to brain, such as when an arm The rash seems to worsen when the skin is dry is bent under the body during sleep. Persistent pins and may be fl akier during the winter months. and needles sensations may be caused by a group However, the rash is most obvious during the sum- plague 283 mer, when the surrounding skin gets tan and the Symptoms and Diagnostic Path patches of rash do not. Firm, pink, red, or orange follicular PAPULES may form groups of lesions that either remain localized Treatment Options and Outlook to the extensor surfaces of the skin or eventually The condition usually responds well to EMOLLIENTS cover the entire body. There may be scaling on or mild topical steroids. Patches clear but return; the scalp. When the lesions spread over the entire the lesions usually fade by adulthood. body, a few small clear areas of normal skin (“skip areas”) may be seen on the trunk. pityriasis rosea A common mild skin disorder Treatment Options and Outlook of childhood and young adulthood character- Etretinate, ISOTRETINOIN (Accutane), and METHO- ized by a single large round spot (called a herald TREXATE are the most effective treatments. Etreti- patch) on the trunk, followed days to a week nate and isotretinoin produce remission within later by slightly raised, scaly-edged, round or oval several months. Combining the retinoids with pink-to-copper colored spots on the trunk and ultraviolet B (UVB) phototherapy also may help. upper arms. The condition is not believed to be Topical creams are not usually effective. contagious. The cause of the disease is unknown, although many speculate that it is due to a virus. plague A serious infectious disease transmitted by the bites of rats or fl eas that was the scourge Symptoms and Diagnostic Path of early history. Nicknamed the Black Death dur- In addition to the above symptoms that last for ing the pandemic of the 14th century, its primary about six to eight weeks, pityriasis rosea may cause symptom is the black patches on the skin caused itching. by bleeding around swollen lymph glands. Recent outbreaks among humans have occurred in Africa, Treatment Options and Outlook South America, and Southeast Asia. Plague is also Mild ITCHING may be relieved by applying CALA- found among ground squirrels, prairie dogs, and MINE LOTION or ZINC OXIDE shake lotion; more marmots in parts of Arizona, New Mexico, Califor- severe itching may be treated with ANTIHISTAMINE nia, Colorado, and Nevada. Between one and 40 DRUGS, topical steroids, or PHOTOTHERAPY. The rash Americans contract plague during the spring and usually clears up without treatment, but a physi- summer months each year. Worldwide, more than cian should rule out other conditions that may 2800 cases are reported yearly. cause a similar rash. Fleas found on rodents throughout the world carry the bacterium Yersinia pestis that causes plague. The great pandemics of the past occurred pityriasis rubra pilaris A chronic disease of when wild rodents spread the disease to rats KERATINIZATION that can be inherited or acquired in cities, and then to humans when the fl eas and is characterized by papules with greasy plugs, jumped off dying rats. A bite from an infected generalized skin redness, and yellow thickening of fl ea leads to bubonic plague, a form of the dis- the palms and soles. ease characterized by BUBOES (swollen lymph In the inherited form, the lesions resemble PSO- glands). Pneumonic plague affects the lungs, and RIASIS, and may begin in infancy and last through- is a complication of bubonic plague; it is also out life with occasional periods of remission. The spread via infected droplets during coughing. acquired type of pityriasis rubra pilaris usually Bubonic plague causes enlarged, tender lymph appears in adulthood. The lesions disappear within nodes, fever, chills and prostration. Septicemic three years in 80 percent of cases. Treatment may plague is characterized by fever, chills, prostra- shorten that time. tion, abdominal pain, shock, and bleeding into 284 plantar wart skin and other organs. Pneumonic plague causes Occasionally, warts can spontaneously disap- fever, chills, cough, and diffi culty breathing, fol- pear after a short time, and, just as frequently, they lowed by rapid shock and death if not treated can recur in the same location. early. When plantar warts develop on the weight- bearing areas of the foot—the ball of the foot, or Symptoms and Diagnostic Path the heel, for example—they can be the source of Two to fi ve days after infection, patients experience sharp, burning pain. Pain occurs when weight is fever, shivering, seizures, and severe headaches brought to bear directly on the wart, although followed by buboes—smooth, oval, reddened, and pressure on the side of a wart can create equally very painful swellings in the armpits, groin, or intense pain. neck. Treatment Options and Outlook Treatment Options and Outlook Warts can be very resistant to treatment and have Administration of streptomycin, chloramphenicol, a tendency to recur. Self-treatment is advisable or TETRACYCLINE reduces the risk of death to less at fi rst, since over-the-counter preparations con- than 5 percent. Those in contact with anyone who taining acids or chemicals are readily available. has pneumonic plague are given antibiotics as a Self-treatment with such medications should be preventive measure at the fi rst sign of disease. avoided by people with diabetes and those with Left untreated, half of plague patients will die. If cardiovascular or circulatory disorders. blood poisoning occurs as an early complication, a Most effective treatments damage the tissue patient may die before the buboes appear. where the wart virus lives; the most effective is liquid nitrogen, a very cold liquid that is sprayed onto the wart. After treatments at least every three plantar wart A fi rm, rough-surfaced WART found weeks, the wart will clear slowly. on the sole of the foot that may appear alone or Topical treatments with acids such as trichloro- in clusters. The plantar wart is caused by an infec- acetic acid, salicylic acid, or lactic acid are painted tion with human PAPILLOMAVIRUS (HPV) often con- on or applied in a medicated bandage. When liq- tracted by walking barefoot on surfaces where the uid nitrogen cryotherapy is combined with one of virus is lurking. This virus thrives in warm, moist these medications, warts clear more quickly. environments, making infection a common occur- Plantar warts are very stubborn. It is far bet- rence in swimming pools and public showers. ter to see a physician for specialized treatment by a simple surgical procedure, performed under Symptoms and Diagnostic Path local anesthetic. Lasers have become a common Plantar warts tend to be hard and fl at, with a and effective treatment, using CO2 laser cautery rough surface and well-defi ned boundaries; warts performed under local anesthesia either in a podi- are generally raised and fl eshier when they appear atrist’s offi ce or an outpatient surgery facility. The on the top of the foot or on the toes. Plantar warts laser reduces post-treatment scarring and is a safe are often gray or brown, although the color may form for eliminating wart lesions. vary, with a center that appears as one or more pinpoints of black. Preventive Measures If left untreated, warts can grow to an inch or To avoid getting plantar warts; more in circumference and can spread into clus- ters of several warts; these are often called mosaic • avoid walking barefoot, except on sandy beaches warts. Like any other infectious lesion, plantar • change shoes and socks daily warts are spread by touching, scratching, or even • keep feet clean and dry by contact with skin shed from another wart. The wart may also bleed, which can help to spread the • avoid direct contact with warts from other peo- virus. ple or from other parts of the body poikiloderma 285 plastic and reconstructive surgery The specialty near the skin’s surface due to alcohol, heat, spicy of plastic surgery includes two branches: recon- food, and so on. More rarely, it can be caused by structive surgery and cosmetic surgery. Plastic and an excess number of red blood cells, as in polycy- reconstructive surgeons use special techniques to thema rubra vera. repair visible skin defects and problems in under- lying tissue, caused by heredity, burns, injuries, operations, aging, or disease. pockmark A term referring to the deep, pitted The word plastic, from the Greek plastikos, means scars of ACNE lesions. The appearance of pock- “to fi t for molding” or “to give form”—it does not marks can be improved by a variety of techniques, refer to the synthetic materials that are sometimes including DERMABRASION, chemical peels, or LASER used in plastic surgery. RESURFACING. Reconstructive surgery is performed on abnor- mal structures of the body, caused by congeni- tal defects, developmental abnormalities, trauma, poikiloderma Pigment changes of the skin, caus- infection, tumors, or disease. It is generally per- ing a dappled or mottled appearance with areas of formed to improve function, but also may be done both increased and decreased color. Poikiloderma to approximate a normal appearance. This includes is a word that means “varied, multicolored skin” procedures done to repair birth defects, such as from the Greek poikilos (mottled) and -derma (skin). cleft lip and palate repair, and deformities caused by The exact cause is unknown, but it is clear that the accidents or disease, such as facial reconstruction sun is the major factor causing this condition. In following cancer surgery, burn care, reattachment some cases, a substance in cosmetics sensitizes the of limbs, and breast reconstruction following mas- skin to the Sun’s ultraviolet light. In others, it is tectomy. The average plastic surgeon spends 60 per- simply caused by excess sun exposure. The neck cent of the time performing reconstructive surgery. area under chin that is usually shaded from the Cosmetic surgery is performed to reshape nor- sun is spared. Contributing factors include fair mal structures of the body in order to improve skin, accumulated sun exposure, and in women, the patient’s appearance. This includes procedures hormonal factors. such as FACE-LIFTS, nose reshaping, and other pro- cedures done to improve appearance and enhance Symptoms and and Diagnostic Path the patients’ quality of life. Symptoms include mottled changes that have A variety of techniques are used to provide skin brown hyperpigmentation, a netlike proliferation cover for damaged areas, including SKIN GRAFTS, of fi ne red vessels, intermingled with white skin. skin and muscle fl aps, Z-plasty, and TISSUE EXPAN- It is commonly known as “red neck,” from which SION. These techniques may be performed in addi- the derogatory term redneck derives. Fair-skinned tion to grafts or implants. farmers and outdoor workers who spend hours a Since the early 1990s, the practice of plastic sur- day outside over many years develop diffuse red- gery has become more complex through the use ness of the neck, which is sometimes combined of microsurgical techniques to join blood vessels, with brown discoloration of a permanent tan. allowing the transfer of blocks of skin and muscle from one part of the body to the other. Treatment Options and Outlook More than 1 million plastic and reconstructive sur- The results of treatment are encouraging. Patients geries are performed in hospitals each year, accord- should protect themselves from the sun, use a ing to the National Center for Health Statistics. daily broad spectrum SPF 30+ SUNSCREEN, and See also COSMETIC SURGERY; Z-PLASTY. avoid all perfumes on the affected area, including those in soap. Hydroquinone-containing prepara- tions may help fade the pigmentation. Pulse-dye plethora A fl orid, bright red fl ushed complexion LASER TREATMENT (and some other vascular lasers) that may be caused by dilation of blood vessels are very effective at decreasing the overall red 286 poison ivy color and sometimes even the brown color after a object. Urushiol remains active for up to one year, series of treatments. A combination of sun avoid- so any equipment that touches poison ivy must be ance, lightening agents, and laser treatments can washed. Even the smoke from burning poison ivy dramatically improve poikiloderma. is toxic and can irritate the lungs, since urushiol See also ROTHMUND-THOMSON SYNDROME. can be carried in smoke. Therefore, individuals should never burn poison ivy plants as a way to get rid of them; the smoke given off by these burn- poison ivy (Toxicodendron radicans; Rhus ing plants is particularly dangerous and can enter toxicodendron) Sensitivity to this plant’s oil (uru- the nasal passages, throat, and lungs of anyone shiol) is the most common allergy in the country, who breathes it. affecting almost half of all Americans at one time As the leaves die in the fall, the plant draws or another. In a few cases, it can be quite serious; certain nutrients and substances (including the oil) if symptoms such as swelling appear within four to into the stem. But the oil remains active, so even 12 hours, patients should seek immediate medical in winter if broken stems are used as fi rewood treatment. kindling or as vines on a Christmas wreath they One of the most common poisonous plants may cause a rash. in the United States, its leaves may be notched or smooth, and almost always grow in groups of Symptoms and Diagnostic Path three—two leaves opposite each other and one While not every person is allergic to poison ivy, at the end of the stalk. However, according to about seven out of 10 people are sensitive to uru- some experts there are exceptions, and leaves shiol and will develop contact dermatitis if exposed may sometimes appear in groups of fi ve, seven, to a large enough dose. or even nine. In early fall, the leaves sometimes Children rarely have allergic reactions to uru- turn bright red. While it usually grows as a long, shiol, primarily because it usually takes several hairy vine (often wrapping itself around trees), it exposures to develop a sensitivity to the resin. can also be found as a low shrub growing along Symptoms vary from one person to the next; fences or stone walls. Poison ivy has waxy yellow- some people exhibit only mild itching while others green fl owers and greenish berries, which can experience severe reactions, which may include help identify the plant in late fall, winter, and terrible burning and itching with watery BLISTERs. early spring before the leaves appear. Poison ivy The skin irritation, swelling, blisters, and itching is found throughout the United States, although may appear within hours or days, usually develop- it is most common in the eastern and central ing within 24 to 48 hours in a sensitized person. states. The skin becomes reddened, followed by watery The ITCHING and blistering is caused by the blisters, peaking about fi ve days after contamina- reaction of the body’s blood vessels to the plant’s tion and gradually improving over a week or two, urushiol oil. Sensitivity to this oil ranges from even without treatment. Eventually, the blisters nonexistent to severe, and an allergy can spring break and the oozing sores crust over and then up in previously immune people at any time. The disappear. urushiol oil that causes the rash is a colorless or Despite a common misconception, poison ivy is slightly yellow resin, whose name comes from not spread by scratching open blisters or by skin- a Japanese word meaning lacquer. The entire to-skin contact, but by the oil (urushiol) found in plant contains this oil, and is therefore poisonous: the plant. Anything that brushes against this oil is leaves, berries, stalk, and roots. contaminated and can cause poison ivy if it con- Urushiol is easily transferred from an object to a tacts the skin. person, so anything that touches poison ivy (cloth- However, doctors recommend not scratching ing, gardening tools, a pet’s fur, athletic equip- blisters, since any remaining urushiol that has not ment) can be contaminated with urushiol and been washed off can be transmitted to another part cause poison ivy in anyone who then touches the of the body. In addition, scratching the blisters may poison ivy 287 cause a skin infection from bacteria present on the Colloidal oatmeal (such as Aveeno, available at fi ngernails. drugstores) will dry up oozing blisters, and can be Animals can also transmit poison ivy from their applied with a cloth or used in the bath, which also fur to their owners’ skin. Any animal suspected of eases itching. coming in contact with poison ivy should be given Widespread, severe poison ivy is treated by der- a bath. matologists with topical steroids; if quite severe, Allergy to poison ivy may also indicate that a systemic steroids may be administered. person is also sensitive to related plants, including cashews, pistachios, mangos, and Chinese or Japa- Risk Factors and Preventive Measures nese lacquer trees. Most important is proper protection—gloves, long A small percentage of sensitive individuals are sleeves, heavy socks, and pants tucked into boots. seriously allergic, and will begin to develop a rash Before going out and working in a poison ivy- and swelling in only four to 12 hours after con- infested area, consumers should spray deodorant tact (as opposed to the normal 24 to 48). One of or antiperspirant on arms, legs, clothes, and pets. the few real emergencies in dermatology, such an Deodorant sprays contain activated clay known as extreme sensitivity should be immediately treated organoclay, and antiperspirants contain the clay at the hospital as soon as possible; a shot of CORTI- and aluminum chlorohydrate, both of which have COSTEROIDS will lessen swelling. been found to neutralize urushiol oil. Antiperspi- rant contains both oil-fi ghting ingredients, but it Treatment Options and Outlook is also irritating and should not be sprayed on the If it is not possible to wash off the oil before the face or in body folds. allergic reaction begins, the best nonprescription Short of avoiding the plant, the best method treatment is generally considered to be CALAMINE for preventing a rash from exposure to poison lotion, a soothing skin protector that cools the ivy before the allergic reaction takes hold is to skin and absorbs the oozing, forming a protec- immediately wash off the oil—fi rst with alcohol, tive crust that keeps the skin from sticking to followed by water (soap is not necessary). Or, clothes. wash the affected area immediately after con- Because the cooling effect of calamine shrinks tact (within 10 minutes, if possible) with yellow the blood vessels, this also helps stop the blister laundry soap (such as Castile) and cold water, formation. Patients should stop using calamine lathering several times and rinsing the area in once the oozing stops, so as not to dry the skin too running water after each sudsing. Do not scrub much and worsen itching again. with a brush. Itching also can be treated with compresses Any clothing that might have come in contact soaked in cold water. Products containing local with urushiol must be washed several times. If the anesthetics (such as benzocaine) should be avoided urushiol is washed off, there is little or no further because they themselves cause a contact dermati- treatment of mild cases of the rash. tis. Some experts recommend cooling counterir- Anyone who comes in contact with poison ivy ritants such as phenol or menthol, which may be out in the wild should wash in a cold running effective, although they may sting and may not be stream. If no water is available, there are a host strong enough to stop the discomfort. of other possibilities, including rinsing with paint Nonprescription oral antihistamines (such as thinner, acetone, horse urine, ammonia, and meat Chlor-Trimeton or Benadryl) also may be effec- tenderizer. Organic solvents (paint thinner or ace- tive; systemic antihistamines do not work against tone) work very well in washing off the urushiol the rash, although their sedative action may oil, but they should not be used on a regular basis. help the patient sleep. Nonprescription cortisone (Regular skin contact with solvents can cause a creams, however, are too weak to be very effec- rash). Solvents are recommended for eliminating tive, although they may provide minor relief for the poison ivy on garden tools, car upholstery, and minimal itching. so on. 288 polyarteritis nodosa

Other products designed to prevent poison ivy polymorphic light eruption An allergic reaction and poison oak are presently being investigated by to certain wavelengths of the Sun that affects 10 the Food and Drug Administration. percent of the population, causing bumpy, scaling, Extremely sensitive individuals may be desen- blistering, itchy, or red patches hours or days after sitized to the effects of poison ivy with allergen exposure to the sun. More women than men are extracts, although results have been disappointing affected by this condition, which usually appears sometimes and often do not last longer than one between adolescence and the 30s. season. The vaccine is given by mouth or injec- tion. The procedure requires a great deal of time Symptoms and Diagnostic Path (three to six months). Adverse reactions to the The eruption is characterized by red MACULES, PAP- desensitization include swelling, dermatitis, gas- ULES, plaques, and BLISTERs, and begins anywhere troenteric disturbances, fever, and infl ammation between an hour and 24 to 36 hours after expo- at the injection site. Because of these problems, sure to the sun, and lasts three to fi ve days. The immunization is only recommended for those itch can be quite severe. sensitive people who live or work near the ivy. Convulsions have occurred in children follow- Treatment Options and Outlook ing oral administration of the plant’s extract. No Patients should avoid the sun and always use cream, lotion, or spray has been proven effective a SUNSCREEN of at least SPF 15; patients tend to as protection against the allergen, although stud- improve as the summer progresses. Slow exposure ies are continuing. to the sun can increase tolerance. Nonprescription Alternatively, recent research suggests a differ- topical steroids or prescription steroids and ANTI- ent vaccine may be available for millions of Ameri- HISTAMINES also may be effective. cans tormented each summer with the itchy rash. See also SOLAR URTICARIA; PHOTOSENSITIZING Researchers at the University of Mississippi have DISORDERS. developed an experimental vaccine that seems to prevent an allergic reaction and may lessen the painful symptoms after the rash appears. polymyositis-dermatomyositis A rare systemic Researchers explain the vaccine works best as an connective tissue disease characterized by infl amed, injection, and probably would be most helpful for weak muscles that may cause a rash. The disor- those who are highly sensitive to the plants. The der may affect children under age 10 and adults agent has been tested on animals, but has not yet between ages 40 and 60. There have been reports been tested on humans. Researchers at the univer- of cases associated with cancer in up to 40 percent sity have been studying the oily compounds of the of adult cases. plants that make the skin blister and itch to create The course of this disease varies and is unpre- less-toxic forms of the oil, which allow the body to dictable, lasting for many years or sometimes lead- tolerate the plants in the laboratory. ing to death within 12 months.

Symptoms and Diagnostic Path polyarteritis nodosa See SYSTEMIC NECROTIZING Reddish purple discolored swollen eyelids, scaly VASCULITIDES. red fl ush over the cheeks and forehead, red PAP- ULES over the surfaces of fi nger joints, and a dusky red rash on the arms and upper back, plus pigment polychondritis, relapsing See RELAPSING changes of the skin (POIKILODERMA). POLYCHONDRITIS. Treatment Options and Outlook CORTICOSTEROIDS may be given in the early stages; polycystic ovary syndrome See STEIN-LEVENTHAL the disease may be chronic, requiring therapy for SYNDROME. years. In those who fail to respond to steroids, porokeratosis 289 immunosuppressive drugs (such as METHOTREXATE, water does not open pores, and cold water does cyclophosphamide, azathioprine, and chlorambu- not close them. cil) may be effective. A combination of CORTICOSTE- It is possible to make pores appear smaller by ROIDS and methotrexate is probably most effective, using an alcohol-base astringent that contains especially in childhood dermatomyositis. aluminum chloride or aluminum hydroxide. This will temporarily reduce oiliness and minimize light refl ection, which can magnify pore size. In addi- polymyxins A group of antibiotics derived from tion, Retin-A and prescription strength GLYCOLIC the bacterium Bacillus polymyxa used to treat infec- ACID can refi ne the skin’s texture, which may also tions of the skin. These drugs, which include colis- help pores look smaller. tin and polymyxin B, are often given as drops or in Women can also use a water-based foundation ointment form and are often used in antibiotic eye and powder to make pores look smoother and drops or skin ointments. Taken orally, colistin is more even. associated with pseudomembranous enterocolitis— a severe, life-threatening type of diarrhea some- times caused by antibiotics. porokeratosis A disorder of KERATINIZATION that includes three separate autosomal dominant syn- dromes, all featuring a lesion with a raised border pompholyx The appearance of BLISTERS on the and central furrow or depression; the center may hands or feet without known cause. Once called be scaly or atrophic. “Autosomal dominant” means dyshidrotic pompholyx, this term is no longer used that only one defective gene must be inherited since the SWEAT GLANDS play no part in the dis- from a parent to cause the disease. Each child has ease’s cause. Pompholyx means “bubble” in Greek a 50 percent chance of inheriting the affected gene and the words simply denote a blistering ECZEMA and developing the disease. of the palms and soles, respectively. Symptoms and Diagnostic Path Symptoms and Diagnostic Path In porokeratosis of Mibelli, the lesions—craterlike In general the blisters are found on the sides of patches with a raised border that enlarge to form the fi ngers, spreading to the central palms and the lesions—may appear anywhere on the body, either soles of the feet that may merge into large blisters. alone or in groups arranged in a line or in seg- Itching is intense and secondary infection is com- ments. This rare, chronic progressive skin disorder mon (especially on the feet). is seen usually in males and fi rst appears in early childhood (usually before age 10). Lesions slowly Treatment Options and Outlook enlarge as the child grows older. Low- or mid-potency steroids are often not very Disseminated superfi cial actinic porokeratosis is an effective; high potency steroids are required. Soak- autosomal dominant skin disorder occurring on ing the hands in a potassium permanganate solu- sun-exposed areas in fair-skinned individuals tion, normal saline, or BUROW’S SOLUTION for 10 or (usually women) over age 16. It is characterized 15 minutes followed by wet dressings (0.05 per- by many brownish red MACULES with depressed cent silver nitrate solution or shake lotions) gives centers and sharply-ridged borders. The palms rapid relief. However, the silver nitrate or potas- and soles are spared. Unlike the Mibelli form, the sium permanganate may stain the hands. border of the lesion is less distinct, the centers of the lesions are not as atrophied and they are often itchy. Number of lesions will increase with time. pore The tiny opening of the oil or SWEAT GLANDS The lesions of porokeratosis plantaris, palmaris et at the skin’s surface. The size of a pore is regulated disseminata are most similar to those of dissemi- by heredity, and contrary to popular opinion, it is nated superfi cial actinic porokeratosis, although not possible to shrink large pores. In addition, hot they occur at an earlier age (in the second decade) 290 porphyria and lesions fi rst appear on palms and soles. The on by a variety of drugs, including barbiturates, number of lesions will increase with time. phenytoin, birth control pills, and TETRACYCLINES. Porphyria cutanea tarda causes blistering skin, but Treatment Options and Outlook there are no abdominal or nervous system prob- Because of the small danger of the development lems. In this variety, wounds are slow to heal and of SQUAMOUS CELL CARCINOMA (especially in the the urine may be pink or brown. Protoporphyria Mibelli type), physicians should follow this dis- often causes mild skin symptoms after exposure ease closely. FLUOROURACIL 2 percent or 5 percent to sunlight, such as burning and stinging without cream applied twice daily for three weeks may be blister formation. useful in some patients. In the Mibelli form, surgical removal of small Treatment Options and Outlook lesions (especially on arms and legs) may be Specifi c treatment depends on the variety of effective. porphyria. For porphyria cutanea tarda, avoiding Patients with the disseminated superfi cial actinic causative agents such as alcohol and estrogen and form should avoid sunlight and use SUNSCREENS. treatment with phlebotomy and/or antimalarials Lesions (if not too numerous) may be treated with such as hydroxychloroquine is recommended. LIQUID NITROGEN.

Portuguese man-of-war sting See JELLYFISH porphyria A group of rare inherited disorders STINGS. that cause a rash or skin blistering that in some instances is brought on by sunlight, as a result of abnormalities of the metabolism of chemicals in port-wine stain The common name for the body called porphyrins. The diseases result in nevus fl ammeus, a permanent large purple-red the increased production and excretion of porphy- BIRTHMARK. rins; each type has distinct clinical, biochemical, and genetic features. Symptoms and Diagnostic Path Porphyrins are involved in the manufacture of Present at birth, port-wine stains are usually heme, a component of hemoglobin (the oxygen- sharply outlined and fl at, although the surface carrying pigment in the blood). When blocks occur may sometimes have a pebbly feel. Most com- in the chemical process that produces heme, por- monly appearing on the face, they can range in phyrins build up. size from a few millimeters in diameter to half the Porphyria includes the more common types of body’s surface. They do not enlarge, but they do acute intermittent porphyria, variegate porphyria, increase in size proportionately as the child grows, and porphyria cutanea tarda, and rare varieties, becoming darker over time. Three out of every including hereditary coproporphyria, protopor- 1,000 people will be born with a port-wine stain. phyria, and congenital erythropoietic porphyria. Port-wine stains may appear alone or as part of Estimates of the combined prevalence of the a multisystem disorder, such as STURGE-WEBER SYN- disease in the United States are about one per DROME, which also features seizures and eye abnor- 10,000 to 50,000. malities such as glaucoma. There are a normal number of vessels that are larger than normal. Symptoms and Diagnostic Path Blood vessels in port-wine stains have an Porphyrias with skin symptoms include variegate abnormal nerve supply, which may account for the porphyria and hereditary coproporphyria, both vessels’ enlargement over time. of which cause blistering of sun-exposed skin, together with abdominal pain, cramps in the arms Treatment Options and Outlook and legs, muscle weakness, psychiatric distur- A simple port-wine stain, when it does not occur as bances, and so on. Attacks also may be brought part of another syndrome, is more than a cosmetic post-herpetic neuralgia 291 problem. If treated early in childhood, the psycho- Typically, the onset of shingles is heralded by an logical burden on the child may be relieved. attack of skin pain, followed by the development The most successful method of removal is the of a painful skin rash within several days. The rash PULSED DYE LASER, popular because it has a low rate usually fades away within two to four weeks, but of scarring and its effectiveness is not as depen- the nature, severity, and duration of the continu- dent on an operator’s experience. Total clearing ing pain vary considerably among individuals. with pulsed dye laser treatment is uncommon, but Because the nerves have been damaged after dramatic lightening after a series of treatments is a shingles attack, they can produce strong pain not unusual. Pulsed dye laser treatment decreases impulses that may last for months or years after the solid color mass, thins thickened lesions, and the shingles blisters heal. Not everyone with lightens all types of port-wine stains. By treating shingles will develop post-herpetic neuralgia, patients early in their lives, the psychological bur- but the older the patient and the more severe den is eased, the risk of darkening and thickening the shingles, the more likely that post-herpetic is reduced, and the risk of bleeding and infection neuralgia may occur. As many as 75 percent of eliminated. patients aged over 70 years have pain a month Pulsed dye laser treatment has become the gold after the rash heals, and 50 percent are still hav- standard of treatment. Since it was introduced, ing pain a year later. the pulsed dye laser has been modifi ed several Four additional risk factors have been identifi ed times to lengthen the wavelength and the pulse for the development of post-herpetic neuralgia duration, two changes that have enhanced results signifi cantly. • greater acute pain severity Until the late 1980s, the ARGON LASER was the • greater rash severity treatment of choice for these birthmarks. The laser • abnormal sensitivity in the affected skin during works by emitting light that is absorbed by the the acute phase hemoglobin in the dilated blood vessels that make up the birthmark. However, this therapy is limited • the presence of a painful feeling before the rash because of its substantial rate of scarring—the occurs (prodome) continually delivered laser energy dissipates into the surrounding dermis, causing thermal damage. Less-than-optimum treatment can result in pale, Symptoms and Diagnostic Path immature port-wine stains. In addition, the extent Post-herpetic neuralgia pain usually occurs only of clearing and the rate of scarring is highly depen- in the area affected by the rash, and may come dent on the skill and experience of the operator. and go with a burning, throbbing, or sharp and Choosing a wavelength that is more selectively shooting nature. Allodynia (pain provoked by absorbed by hemoglobin and delivering it in a normally harmless stimuli) is common. Some pulse shorter than the cooling time of the abnor- patients experience marked allodynia without mal vessel produces better results. numbness, while others have marked sensory Excision and grafting for smaller lesions, or tat- loss in the affected area with minimal allodynia. tooing for larger ones, are best avoided, consider- There also may be areas of scarring or loss of skin ing how effective laser treatment is. CAMOUFLAGE pigmentation. COSMETICS also may be used to mask lesions. Use of antiviral drugs such as ACYCLOVIR, fam- cyclovir, or valacyclovir to treat the acute shingles seems to reduce the risk of developing post-herpetic post-herpetic neuralgia A chronic pain syn- neuralgia and the overall duration of pain. Thus, drome experienced by between 9 percent and 34 with widespread use of these antiviral drugs, it is percent of patients following an attack of SHINGLES likely that less than 22 percent of patients with that is often diffi cult to treat and can persist for acute shingles will experience pain for three months years. or more after the beginning of the rash. 292 post-infl ammatory pigmentation

Researchers are studying whether the use of post-inflammatory pigmentation A discolor- drugs such as TCAs, gabapentin, oxycodone, and ation left on the skin after an underlying trauma, tramadol or nerve block during acute shingles may skin infection, ECZEMA, or a drug reaction has reduce the risk of developing post-herpetic neural- healed. gia. Administration of the chicken pox vaccine is also being studied as a way to prevent shingles in Symptoms and Diagnostic Path the fi rst place. In people with dark skin, the color tends to be more intense and last for a longer period. Treatment Options and Outlook Simple measures such as use of cold packs for Treatment Options and Outlook short-term pain relief or occlusion with cling fi lm Bleaching agents such as those containing hydro- may be suffi cient in some instances, but many quinone may be used, and a mild steroid may help. patients require drug treatment. Research suggests The pigmentation tends to clear with time, and that starting treatment as soon as possible after the normal skin color should return slowly within a beginning of the rash may be a key in preventing few months. Further trauma to the area (and sun post-herpetic neuralgia. exposure) should be avoided. Tricyclic antidepressants have been regarded as fi rst-line treatments for some time; recent research has shown nortriptyline to be the potassium iodide A simple chemical that has preferred drug of this class. The anticonvul- been used for a century to effectively treat lym- sant gabapentin, sustained-release oxycodone, phatic SPOROTRICHOSIS (chronic fungal skin infec- and topical lidocaine patches are also used as tion). In saturated solution, it is prescribed on a fi rst-line treatments for post-herpetic neuralgia slowly increasing dose until adverse effects appear, Lidocaine patches may be preferred for patients or until a response is noted. Potassium iodide is not with signifi cant pain from normally nonpainful effective against any other fungal infection. sources (allodynia), or occasional intermittent pain, whereas nortriptyline is a suitable option Side Effects for those patients with depressive symptoms in Common side effects include ACNE-like lesions, addition to pain. Trial and error may be required nausea and vomiting, and hypothyroidism. to fi nd the most suitable treatment for each indi- vidual patient. Cognitive-behavioral therapies, including relax- potassium para-aminobenzoate A chemical ation training, biofeedback, and hypnosis, can help once used to treat LICHEN SCLEROSIS ET ATROPHICUS manage chronic pain. Pain management centers and SCLERODERMA. However, there is little scien- offer a multidisciplinary approach that usually tifi c evidence that it works. incorporates such measures, with the aim of improving function and improving quality of life, as well as reducing pain. potassium permanganate An antiseptic drug For patients who do not respond to any of with an astringent effect on the skin useful in the fi rst-line treatments, alternative treatment treating infl ammation (DERMATITIS). It is applied approaches that may be considered include tra- directly to the skin as a dressing or dissolved in madol, selective serotonin reuptake inhibitors water for a soak. (particularly paroxetine or citalopram), anticon- Once a popular remedy for dermatitis, its ten- vulsants other than gabapentin (such as sodium dency to stain skin, nails, and clothing purple has valproate or carbamazepine), transcutaneous elec- caused this drug to lose favor among physicians. trical nerve stimulation (TENS), topical capsaicin, Moreover, if not fully dissolved, potassium per- lidocaine infusion followed by oral mexiletine, and manganate can cause a chemical burn on contact nerve blocks. with skin. pregnancy and the skin 293 poultice A warm pack made of a soft, moist sub- Ordinary FRECKLES, some scars, and many stance such as kaolin (white clay) spread between MOLES may also darken. These are harmless, but layers of soft fabric as a way of providing moist since malignant melanomas and premalignant heat to the skin. In the past, poultices were widely DYSPLASTIC NEVI are sensitive to hormonal change, used to reduce pain or infl ammation and improve any suspicious-looking moles should be brought circulation in a particular area, or to soften the to the attention of a physician. HYPERPIGMENTATION skin to allow matter to be expressed from a boil. is usually most pronounced among dark-haired, Poultices containing kaolin retain heat for a long dark-skinned women and usually begins in the period of time. fi rst trimester, continuing throughout the nine months and usually fading after the birth. Gen- erally, however, the sites that became darkened precancerous conditions Conditions in which never return to their exact pre-pregnancy color. cancer has a tendency to develop. Precancerous conditions of the skin include ACTINIC KERATOSES, Melasma DYSPLASTIC (or atypical) NEVI, LENTIGO MALIGNA, Called the “mask of pregnancy,” or chloasma, this BOWEN’S DISEASE, and SQUAMOUS CELL CARCINOMA is a special type of hyperpigmentation affecting in-situ. the face that may appear in up to 75 percent of all pregnancies. It is more common in dark-skinned women, is often worsened by sun exposure, and pregnancy and the skin A wide variety of skin also occurs in up to one-third of women on birth changes can be brought about by pregnancy. control pills. It has been suggested that this condi- While it is true that many women notice an tion may be hereditary. improvement in the condition of their skin dur- ing pregnancy, some annoying skin problems also Pruritus Gravidarum can occur. Changes during pregnancy may also be This common disorder is characterized by ITCHING, associated with preexisting skin conditions such as which in some is mild and in others is generalized ACNE, ATOPIC DERMATITIS, and PSORIASIS. and severe. It occurs in the third trimester and Some of the many skin changes that arise dur- disappears after the birth, but tends to recur with ing pregnancy include itchiness, stretch marks, subsequent pregnancies or with the administration blood vessel overgrowth and broken blood vessels, of birth control pills. Symptoms include itching mole growth or darkening, and skin darkening in over the entire body, loss of appetite, nausea, and patches or all over the body. vomiting.

Normal Skin Changes PUPPP A certain number of physiological changes occur Another common disorder is PRURITIC URTICARIAL in the skin because of hormonal changes that PAPULES AND PLAQUES OF PREGNANCY (PUPPP), take place during pregnancy. While they do not which appears during the third trimester only in affect health, they may be psychologically dis- fi rst pregnancies and is characterized by itching tressing. About 90 percent of pregnant women and red papules that resemble HIVES. They usually experience an increase in pigmentation, usually begin on the abdomen and later spread onto the a mild darkening of areas of the body that are thighs, buttocks, and arms. There is no increase already darkly pigmented (such as the under- in fetal problems or death associated with this arms, the nipple and areolae, vulva, anus, and syndrome. Patients usually respond to antihista- inner thighs). A dark line often appears in the mines and topical CORTICOSTEROIDS, although some middle of the abdomen from the pubic bone to women need a brief course of oral corticosteroids the belly button. (This line is already present on to control the itching. The disease does not reap- the skin, but does not really become visible until pear after birth, nor is there a recurrence with pregnancy). birth control pills or subsequent pregnancies. 294 pressure injuries

Papular Dermatitis and weight loss. Skin symptoms include red mac- Spangler’s dermatitis of pregnancy is a rare, severely ules followed by sterile pustules, especially in body itchy disorder that may begin at any time during folds and mucous membranes. The individual the nine months. It is associated with a 30 per- lesions may itch and burn. Treatment is the same cent chance of stillbirth or spontaneous abortion. as for pustular psoriasis, except that antimetabo- The disorder, which can recur during subsequent lites or ETRETINATE are avoided. pregnancies, may be characterized by red papules that become crusted and excoriated, followed by a Jaundice darkening of skin after the lesions fade. The disor- This yellowing of the skin may appear during the der is treated with oral corticosteroids. last trimester, caused by obstruction of liver ducts. It is not usually a serious problem and resolves Immune Progesterone Dermatitis of Pregnancy quickly after delivery. This rare disorder of the fi rst three months of pregnancy is characterized by PAPULES and PUS- Blood Vessel Lesions TULES on the arms, legs, and buttocks that may Vascular spider angiomas caused by circulating resemble acne or psoriasis. The problem may recur estrogens appear in the fi rst or second trimester, with subsequent pregnancies. Administration of but most (75 percent) have already faded seven estrogens can suppress the lesions, which may be weeks after the birth. Spider veins and varicose brought on by the administration of birth control veins may also occur. pills with progesterone.

Herpes Gestationis pressure injuries Continuous pressure on the This unusual autoimmune blistering disorder is skin can cause several different problems, including similar to bullous pemphigoid. It appears in one in CORNS, CALLUSES, and BEDSOREs (pressure sores). 50,000 pregnancies, can occur at any time during A corn appears when there is focal pressure pregnancy and is characterized by blistering and over a bony prominence or a bone spur. Although itching. It is treated with topical and sometimes they are most common on the foot, calluses, which systemic steroids. There is no conclusive proof are larger and less focal than corns, can form on that it is associated with an increased risk for fetal any surface where there is recurrent pressure or injury and death. There is a tendency for the con- friction (such as the soles of runners’ feet, the dition to recur, with increased severity, in subse- fi ngers of guitar players, or the middle fi nger of quent pregnancies. people frequently holding a pencil or pen). The initial thickening of the STRATUM CORNEUM Prurigo Gestationis of Besnier is an attempt by the skin to protect itself; pain and This third-trimester disorder is characterized by fi ssures may develop if the pressure continues. small papules that are crusted and excoriated on Eliminating this pressure or friction usually pro- the arms, backs of hands, tops of feet, thighs, legs, duces a permanent cure, but sometimes surgical and trunk. It is not associated with any fetal or removal may be necessary. Special inserts in shoes, maternal problems. wearing two pairs of socks, and wearing well-fi t shoes may help to prevent the cause of sores. Impetigo Herpetiformis Pressure sores may form over any bony promi- This type of pustular psoriasis occurs primarily nence (especially on the heels, base of the spine, during the third trimester and may occur during and elbows) and are caused by continual pressure subsequent pregnancies. It is thought to be associ- on the skin, which interferes with blood fl ow in ated with a signifi cant increase in death rates for patients who are unconscious, bedridden, or who mother or child. Associated with hypoparathyroid- have abnormal sensations. The process is affected ism, it is characterized by symptoms such as fever, by a person’s age, nutrition, and general physical chills, prostration, vomiting, diarrhea, convulsions, shape. progeria 295

Risk Factors and Preventive Measures in the heat will also help prevent the problem. Skilled, vigilant nursing care can prevent most Frequent cool showers and sponging the area will of these ulcers from forming; any reddened relieve the itching. CALAMINE lotion and dusting area should receive special attention. Bedrid- powder may also ease the discomfort. Clothing den patients should be turned every two hours should be clean, dry, starch-free, and loose to to distribute their weight, and the skin should help sweat evaporate. Sweating from fever can be be kept clean and dry. Urine and feces should be reduced with drugs such as acetaminophen. promptly removed before they irritate the skin; dusting powder may also help. Other preventive aids include sheepskins, water and air mattresses, procarbazine (Trade name: Matulane) A che- and foam rings. motherapy drug used to treat certain cancers of the skin, among other conditions. It inhibits growth of cancer cells by preventing cell division. pressure sores See BEDSORES; PRESSURE INJURIES. Side Effects In addition to typical anticancer drug side effects, pretibial fever See LEPTOSPIROSIS. which include nausea and vomiting, procarbazine may cause a sudden rise in blood pressure if taken with certain foods or drinks (such as cheese or red prickle cell layer See STRATUM SPINOSUM. wine), which can be fatal. prickly heat An irritating skin rash also known progeria A rare autosomal recessive disorder as heat rash that is associated with obstruction of characterized by premature old age, including the SWEAT GLANDS and accompanied by aggravat- excessive wrinkling of the skin. The condition ing prickly feelings. The medical term for prickly is usually diagnosed at six to 12 months of age. heat, miliaria rubra (“red millet seeds”) refers to Cells taken from affected patients show only a few the appearance of the rash. A milder form of the generations of cell division before they stop repro- condition, miliaria crystallina, sometimes appears ducing, instead of the 50 generations that occur in fi rst as clear, shiny, fl uid-fi lled BLISTERs that dry up cells from healthy youngsters. without treatment. While physicians are not completely sure of the Symptoms and Diagnostic Path mechanism behind the development of prickly There are two forms of the disease, both of which heat, it is thought to be associated with sweat that are rare. In Hutchinson-Gilford syndrome, aging is trapped in the skin. starts around age four; within eight years the affected child has all the external features of old Symptoms and Diagnostic Path age, including sagging skin on the face and body, Numerous tiny, red itchy spots occur, covering baldness, loss of fat, and internal degenerative mildly infl amed parts of the skin where the sweat changes. In WERNER’S SYNDROME (or adult proge- collects (especially the waist, upper trunk, armpits, ria), the condition begins in early adult life and and insides of the elbows). With prickly heat it is follows the same rapid progression. comfortable to sleep only in cool surroundings, and lack of sleep and intense skin irritation can Treatment Options and Outlook make the patient irritable. There is no treatment, and the outlook is not good for either type of this condition. Patients Treatment Options and Outlook with Hutchinson-Gilford syndrome typically die at Slow acclimation to hot weather will reduce the puberty. Patients with Werner’s syndrome die in chance of prickly heat. Avoiding heavy activities early adulthood. 296 progressive systemic sclerosis progressive systemic sclerosis See SCLERODERMA. tions, including LEISHMANIASIS, trypanosomiasis, amebiasis, TRICHOMONIASIS, and toxoplasmosis. See also PARASITIC INFECTIONS. prolidase deficiency A rare inherited disease in which the enzyme prolidase is absent. Skin symp- toms include chronic recurrent ulcers of the lower prurigo The general term for several itchy skin legs, diffuse spider veins (TELANGIECTASIA), and eruptions consisting of dome-shaped PAPULES and shallow scarring with darkened skin color over nodules. face and buttocks. Other skin symptoms include See also PRURIGO NODULARIS. fragile skin; purple papules (PURPURA); gray hair; reddened fi ssures of hands and feet; papular lesions on face, arms, and legs; and dry crusted prurigo nodularis A skin condition characterized areas on face and buttocks. by intense ITCHING. Experts believe that the disease Other symptoms associated with this enzyme may represent some problem with skin sensory defi ciency include nose abnormalities, jaw prob- nerves. It primarily affects middle-aged women lems, multiple dental cavities, mental retarda- and drives affected individuals to pick and dig at tion, joint problems, and recurrent ear and sinus their skin. Repeated picking produces nodular infections. lesions. There is no treatment. Symptoms and Diagnostic Path Lesions, which are found most often on the upper promethazine An ANTIHISTAMINE drug used to back, back of the neck, arms, and shins, are skin- relieve itching in a variety of skin conditions, colored with a warty, rounded surface topped by including HIVES and ECZEMA. The drug is also used a crust. to relieve nausea and vomiting, and as a premedi- cation sedative. Treatment Options and Outlook There is no one specifi c treatment for this con- Side Effects dition but picking must be stopped. Topical or Dry mouth, blurred vision, and drowsiness. intralesional steroids are often administered, while some patients respond slowly to a modifi ed GOECKERMAN REGIMEN of tar ointments and daily Propionibacterium acnes A type of bacterium exposure to ultraviolet-B light (UVB). CRYOTHER- that is one of the more important factors in the APY also may be helpful in treating the lesions. development of ACNE. P. acnes is found deep in the sebaceous follicle. While it is important in the development of infl ammatory acne, acne is not a pruritic urticarial papules and plaques of bacterial infection; instead, infl ammation probably pregnancy (PUPPP) A common disorder that stems from the effect of the byproducts of this bac- appears during the third trimester of pregnancy terium within the cell. characterized by ITCHING and red papules resem- bling HIVES. The disorder, which appears in one out of every propylene glycol A substance used to improve 300 fi rst-time pregnancies, does not occur in spreadability of a topical cosmetic product which repeat pregnancies. can worsen ACNE. The cause of PUPPP is not known, but studies show that between 4 percent and 10 percent of patients with the condition are pregnant with protozal infections Infection caused by single- twins, which suggests a relationship between celled animals account for a number of skin condi- skin distension and the development of PUPPP. pseudofolliculitis barbae 297

Most studies also have found patients with Symptoms and Diagnostic Path higher weight gain developed PUPPP when com- ITCHING that is localized at fi rst and then spreads pared to normal pregnancies, further supporting over the entire body may be associated with the role of increased skin distension. One large anorexia, nausea, and vomiting and, rarely, JAUN- series of cases revealed an infant male/female DICE. The liver may be enlarged and tender; stools ratio of 2-to-1. Investigators have recently iden- are clay-colored and urine dark. tifi ed fetal DNA in the skin of mothers with PUPPP. Treatment Options and Outlook While the itching can be severe, it virtually always Symptoms and Diagnostic Path stops after the birth. OATMEAL baths and ANTIHIS- Lesions may fi rst appear in the abdominal area, TAMINES are effective, although more aggressive and spread to the thighs, buttocks, and arms. The treatment may be necessary, involving cholestyr- lesions usually fade away within one or two weeks amine and vitamin K. Phenobarbital can help pro- after the birth. There is no evidence of death of mote bile excretion. either the fetus or the mother. See also PREGNANCY AND THE SKIN.

Treatment Options and Outlook ANTIHISTAMINES (for ITCHING) and topical CORTICO- pruritus Itching. STEROIDS are effective, although initial control may require a brief course of oral corticosteroids. The condition fades away within a week of delivery. pseudoacanthosis nigricans See ACANTHOSIS The disorder does not reappear after birth, nor NIGRICANS. does it recur with subsequent pregnancies or with the use of birth control pills. See also PREGNANCY AND THE SKIN. pseudofolliculitis barbae A condition of ingrown hairs in the beard area that is very common among African-American patients, occurring in either sex pruritis gravidarum This common itchy con- on any shaved part of the body. Shaving increases dition, also known as intrahepatic cholestasis the chances of this problem by sharpening the free of pregnancy, appears in up to 2.4 percent of hair end. Short, curly hairs are more likely to pen- pregnancies during the last trimester and disap- etrate the skin than long straight ones. pears after birth. This reversible condition, which appears to have a genetic component, causes Symptoms and Diagnostic Path itching without producing primary skin lesions. Numerous infl ammatory papules and pustules It tends to recur with subsequent pregnancies or (ranging from just a few to hundreds) in any hairy with birth control pill use. area together with darker skin color. The disease While the health of the mother is not affected disappears if the beard or other hair is allowed to by this condition, its effect on the fetus is more grow. While early lesions include reddened papules controversial. Some experts report premature with pustules, those who have had the problem for births and intrauterine asphyxia among infants a long time have fi rm, hyperpigmented PAPULES. whose mothers have the condition, but most argue that there is no fetal risk. Treatment Options and Outlook Cause is unknown, but lab studies reveal ele- The best treatment is to discontinue shaving, vated bilirubin (a bile pigment); the itchiness is which will slow the appearance of new lesions, proportional to the concentration of bile acid in ultimately allowing some of the embedded hairs the skin. Placental estrogens and progestins are to be released from the skin. As the beard grows, believed to interfere with the liver’s excretion of warm-water compresses should be applied for 10 bile acids. minutes, three times daily to smooth lesions and 298 pseudoxanthoma elasticum remove crusts. The beard may be trimmed dur- tissue, causing the elastic fi bers of the skin to frag- ing this time, but not shorter than half an inch. ment and calcify. There are four different forms of Ingrown hairs should be released each day with a pseudoxanthoma elasticum: two caused by autoso- clean toothpick or sterile needle; they should not be mal recessive inheritance (the most common) and plucked, since this may cause more irritation when the two caused by autosomal dominant inheritance. A hair breaks through the hair follicle. After releasing genetic autosomal dominant trait means that only the hair, a topical CORTICOSTEROID lotion should be one defective gene (from one parent) is needed to applied. If there is infection, systemic antibiotics cause the syndrome. may be prescribed. One of any of the four types of this condition If the beard must be shaved, a close shave can appear in one out of every 40,000 live births. should be avoided to stop the immediate penetra- tion by sharpened hairs. Symptoms and Diagnostic Path Before shaving, the face should be washed with Skin symptoms include stiff, thickened, yellow- an abrasive soap and rough washcloth to loosen tan skin in mucous membranes of the mouth, embedded hairs. Then, areas of ingrown hairs cheek, and inner lips, in the armpits, groin, the should be massaged with a toothbrush. Warm- navel, and the neck. Other general characteristics water compresses should be applied for several of the disorder include vision problems caused by minutes. A single-blade razor (not a double blade) hemorrhages in the retina, persistent high blood should be used with the grain, in one direction, pressure, severe chest pain, and dizzy spells. There using short, even strokes. Some people fi nd relief are also speech problems and brief, minor strokes, with special razors designed to prevent a close with abdominal pain and severe pain in the calf shave, and some electric shavers are also designed muscle. to prevent close shaving. The skin should not be Lesions are usually distributed equally on the pulled tight, since the released skin falls on the left and right sides of the body, and may group stubble and causes more shaving bumps. Any together to affect a larger area of skin. Some ingrown hairs should be released after shaving, people have described these areas as having a followed by a nonirritating aftershave. If the lotion “chicken skin” or “cobblestone” appearance or causes any itching or burning, a prescribed topical have described the neck as appearing unwashed. corticosteroid lotion should be applied. The areas of lesions tend to progress downward Alternatively, chemical hair-removers may be from the neck, affecting the underarm, the inside effective. For some people, topical Retin-A (treti- of the elbow, the groin, and the back of the knee. noin) or glycolic acid is effective over the long Sometimes the navel and inner lip are affected. term, although heightened irritation may occur Generally, the progression of skin lesions is slow. at fi rst. In late stages of the disease, the skin may develop Laser hair removal has revolutionized the treat- loose and saggy folds. ment of pseudofolliculitis barbae. A series of treat- A skin biopsy by a dermatologist can reveal ments permanently decreases hair growth and elastic fi bers of the skin that are clumped and converts remaining dark, thick hairs into fi ner, fragmented, and include small amounts of cal- lighter-colored ones. By doing so, the cause of cium. Both the age of onset and the age of detec- pseudofolliculitis is removed. With no terminal tion vary greatly from one individual to another, thick hairs to cause infl ammation, the disease as does the extent of skin involvement. In some ends. All skin types, even very dark skinned indi- individuals, there is no apparent skin involve- viduals, can be treated with long-pulse diode and ment, whereas in others, skin involvement may Nd:YAG lasers. be extensive. Once PXE is diagnosed, the affected individual should consider all the ramifi cations of this dis- pseudoxanthoma elasticum A chronic heredi- ease. A detailed history should be taken by the tary disease involving abnormalities in connective dermatologist and the patient should obtain a psoralens 299 referral to an ophthalmologist and a cardiologist. plants containing OIL OF BERGAMOT as a folk rem- PXE can cause diffi culties in the eyes, cardiac, vas- edy to treat VITILIGO, a skin disorder in which the cular, and gastrointestinal systems. There may be immune system attacks and destroys the skin’s special issues for women and pediatric patients. pigment. While researchers are not sure why it works, they believe that psoralens, when com- Treatment Options and Outlook bined with sunlight, may suppress the immune There is not yet a treatment for the disease, but system and stop the attack on the skin’s pigment there are several treatments for complications. while stimulating melanin production. Psoralens Cosmetic surgery may be used to tighten the skin also stops cells from making DNA, eventually kill- if this effect is considered unsightly. The outcome ing them, which may explain why it helps those of the cosmetic surgery is usually good, although with disorders characterized by rapid cell replica- stretched scars have been reported in some cases. tion, such as PSORIASIS. Aerobic exercise and good diet low in fat and Psoralens, together with ultraviolet light-A cholesterol may help. All exercise should be safe (UVA), is the most commonly used form of pho- from the risk of head trauma or increasing pres- tochemotherapy. Called psoralen-UVA (or PUVA), it sure in the eye (this would exclude football, soc- became available in the mid-1970s. PUVA therapy cer, weight lifting, and so on). Patients should consists of oral or topical administration of a pso- avoid smoking or becoming overweight and should ralen and irradiation of the skin with UVA light. try to lose weight if obese. Patients with mitral The most widely used psoralen in the United valve prolapse should take prophylactic antibiotics States is 8-methoxypsoralen, administered orally before dental work and avoid nonsteroidal anti- followed by a one-hour exposure to UVA. PUVA infl ammatory drugs (such as aspirin or ibuprofen) may interfere with the migration of infl amma- since they may cause gastric irritation or encour- tory cells to the skin, and is effective in managing age bleeding. psoriasis (it alleviates the problem in almost 90 Patients should visit a doctor on a regular basis percent of cases). It may also be used in the treat- in order to monitor pulses in the extremities, blood ment of other forms of psoriasis, for cutaneous pressure, and cholesterol. In addition, an ophthal- T-cell lymphomas, atopic dermatitis, LICHEN PLA- mologist should monitor any retinal changes. NUS, and vitiligo. The life expectancy of people affected by PXE is Psoralen alone may produce ITCHING and nau- the same as the general population. However, life- sea in a small number of patients, and the risks of threatening complications can occur as a result of PUVA can be either acute or chronic. SUNBURN-like involvement of major arteries. redness may occur together with BLISTERs. These There is no way to predict the rate of progres- effects can be prevented by carefully assessing sion or the extent of skin involvement, nor is there dose. However, the chronic long-term toxicity is any evidence regarding the effect of environment not yet determined. PUVA is carcinogenic in exper- or diet on the progression or the extent of skin imental situations. Hyperpigmentation occurs in involvement. most patients, and some experience lentigines and mottling of skin color. There is also a risk of premature aging of the skin, ACTINIC KERATOSES, psoralens Organic compounds found in many BOWEN’S DISEASE, and SQUAMOUS CELL CARCINOMA. plants such as limes, lemons, celery, and parsnips Prior skin cancer, previous exposure to ionizing that stimulate the formation of MELANIN in com- radiation, arsenic ingestion, and (perhaps) the bination with ultraviolet light (UVA). Capable of previous use of tar preparations may increase the inducing phototoxic reactions in the skin when chance of abnormal growths in those patients. The exposed to sunlight, this substance is now being formation of cataracts is another risk, although studied for its therapeutic benefi ts. there have been few reports of premature cataracts Many years ago, a Cairo dermatologist found in those patients treated with PUVA without eye out that indigenous people along the Nile used protection. 300 psoriasiform psoriasiform A medical term meaning “like PSO- While anyone can develop psoriasis, there also RIASIS.” It refers to any sharply-marginated plaque seems to be a hereditary link, and a family associa- with thick scales. tion, in one out of three cases. If one parent has psoriasis, each child has a 10 to 25 percent chance of developing the condition. If both parents have psoriasis A chronic skin disorder affecting more psoriasis, each child has a 50 percent chance. It is than 4.5 million men and women, producing sil- not known whether just one gene, or a collection very, scaly plaques on the skin. The most common of genes, predisposes a person to the condition. type of psoriasis is called plaque psoriasis (or pso- Experts do believe that one gene modifi ed by oth- riasis vulgaris), characterized by raised, infl amed ers in combination with certain environmental lesions covered with silver-white scales. Other, factors produce the condition. far less common forms include pustular, guttate, Skin trauma, emotional stress, and some kinds inverse, and erythrodermic psoriasis. In eryth- of infection may trigger the development of psoria- rodermic psoriasis, red scaly involvement of the sis. The condition sometimes forms at the site of a entire skin makes temperature and fl uid control surgical incision or after a drug reaction. Psoriasis diffi cult, placing a signifi cant strain on internal that appears after trauma is known as the “Koeb- organs such as the heart and kidneys, that may ner phenomenon.” Alcohol abuse makes psoriasis require hospitalization. more aggressive and more diffi cult to treat and Psoriasis usually begins between 15 and 35, control. affecting 2.1 percent of the population but it can begin at any age. Rarely, even some infants Symptoms and Diagnostic Path develop the condition. The condition is considered The fi rst lesions of plaque psoriasis appear as red, mild if less than 10 percent of the body is affected; dots that can be very small; these eruptions slowly more than 10 percent indicates a severe problem. get larger, producing a silvery white surface scale About 30 percent of patients have moderate to that is shed easily. When forcibly removed, the severe cases. scales may leave tiny bleeding points known as the The location of the symptoms, more than the AUSPITZ’S SIGN. The plaques, which often appear in extent, infl uences how disabling the condition the same place on the right and left sides of the may be. Psoriasis only on the palms and soles of body, often cover large areas of skin, merging into the feet can be physically disabling, while psoriasis one another. The most common sites are elbows, on the face can be emotionally disabling. scalp, and genitals. Lesions vary in size and shape Normally, a person with psoriasis experiences from one person to another. cycles of improvement and fl are-ups; the disease Certain races seem more susceptible to develop- can go into remission for a periods ranging from ing psoriasis. Caucasians have the highest percent- one to 60 years. age, although East Africans are also at risk; African The cause of psoriasis is unknown, although Americans have a low incidence of the disease, researchers believe that some type of biochemical probably because their origins are primarily West stimulus triggers the abnormal cell growth in the African. epidermis. While normal skin cells take a month The most common places to fi nd the scaly to mature, patients with psoriasis have skin cells patches are on the scalp, elbow, knees, and trunk, that overmultiply, forcing the cells to move up although they can be found anywhere on the body. to the top of the skin in only seven days. As the Patches spread over wide expanses of skin can lead number of cells builds up, the epidermis thickens to intense itching, skin pain, dry or cracking skin, and the extra cells pile up in raised, red and scaly and swelling; body movement and fl exibility may lesions. The white scales covering the red lesions also be affected. is made up of dead cells that are continually shed; Potentially more disabling than the physical the infl ammation is caused by the buildup of blood discomfort of psoriasis is the emotional impact of a needed to feed the rapidly dividing cells. disfi guring disease. Psoriasis can be unsightly and psoriasis 301 erode self-confi dence, inducing depression, guilt, For more severe cases, the topical treatments or anger. above will be combined with psoralen plus UVA, Between 10 and 30 percent of patients develop chemotherapy (METHOTREXATE), and oral retinoid psoriatic arthritis. Mild cases are milder than rheu- medications (such as Tegison). Treatments for matoid arthritis but in several cases can be very severe psoriasis are toxic and must be weighed disabling. Psoriatic arthritis causes infl ammation against their potential risks. and stiffness, often affecting the fi ngers and toes. A new treatment for localized psoriasis involves About 1 million Americans have psoriatic arthri- using a laser to target small psoriatic plaques. The tis (about 0.5 percent of the country). Psoriatic laser produces high-intensity UVB light at the arthritis usually develops between the ages of 30 wavelengths most effective for clearing psoriasis. and 50, but it can develop at any time. Although Because the light is so intense and the laser can psoriasis typically appears before psoriatic arthritis, be aimed just at the spot of psoriasis, clearing can arthritis can develop even without the character- occur in just six to eight treatments. Cleared areas istic skin lesions. may remain clear for six to eight months. Psoriasis is usually diagnosed by observation. DERMATOLOGISTs usually begin with the mild- There are no blood tests for the disease, although est therapy and work up to the one that is most physicians sometimes examine a skin biopsy under effective in clearing up the skin problem. No single the microscope to confi rm the diagnosis. Some- treatment works for everyone, and each patient times small pits in the fi ngernails, yellow discolor- reacts differently to the drugs. Systemic medi- ation of the nail, or collections of scaly skin under cations are prescription medications that affect the nail can help to diagnose the condition. the entire body. They are usually used only for patients with moderate to severe psoriasis who do Treatment Options and Outlook not respond to or who are not eligible for topical There is no cure for psoriasis, but there are treat- medications or ultraviolet (UV) light treatments. ments that can clear plaques or signifi cantly “Biologics” are medications developed from improve the skin’s appearance. Treatment is aimed cells rather than combinations of chemicals like at slowing the excessive cell division, resulting in traditional drugs. They block or eliminate immune remissions lasting up to a year or more. Once the system cells involved in psoriasis and psoriatic treatment is effective, it is discontinued until the arthritis. Biologics that have been approved include psoriasis returns. Type of treatment depends on the Amevive, the fi rst approved biologic medication; type of psoriasis, its location and severity, patient Enbrel; and Raptiva. Remicade has been approved age, and medical history. Experts suspect that pso- to treat psoriatic arthritis and is being studied for riasis is caused by a malfunctioning immune sys- treating psoriasis. tem that allows skin cells to grow too fast, resulting Other systemic medications for these diseases in dry, red, scaly patches. Topical medications slow can also affect the immune system in a more gen- down the excessive cell reproduction and ease eral way. Cyclosporine is a prescription systemic infl ammation associated with psoriasis. There are medication used to treat psoriasis; it has been many effective topical treatments. While many can available since 1995 to help prevent organ rejec- be purchased over the counter, others are available tion in transplant patients. In 1997 Neoral (one by prescription only. brand name of cyclosporine) was approved as a Topical medications (EMOLLIENTS, steroids, VITA- psoriasis treatment. MIN D or A derivatives, ANTHRALIN, salicylic acid, Methotrexate is a systemic medication, usually and COAL TAR preparations) are used for mild to sold as a generic, that was fi rst used to treat cancer; moderate psoriasis. These may be used alone or in researchers discovered in the 1950s that it could combination with each other or with ultraviolet clear psoriasis, and it was eventually approved for light (UVB). Regular sunbathing may help clear up this use in the 1970s. a case of psoriasis for some patients because of the Soriatane (acitretin) is a prescription oral RETI- exposure to natural UVB. NOID (a synthetic form of vitamin A). Synthetic 302 pulsed dye laser retinoids were introduced as experimental drugs darker, thicker lesions such as port-wine stains in the mid-1970s and were approved in the United may need six to 12 or more sessions. States in the 1980s. Soriatane is currently the only oral retinoid approved specifi cally to treat Risks and Complications psoriasis. There are few signifi cant risks with this procedure. Other systemic medications sometimes used Patients may notice a tingling or burning sensation to treat psoriasis include Hydrea, mycophenolate for a few hours after treatment. mofetil, sulfasalazine, and 6-Thioguanine. Two types of treatment settings are used. If pur- pura (bruising settings) are selected, immediately after the treatment, a purple discoloration appears pulsed dye laser A type of laser tuned to a spe- at the treatment site, which lasts for fi ve to 10 cifi c light wavelength that uses fl ashes of light days. As this color fades, the treated area may still that are only a few millionths of a second long. look red, but will slowly fade to normal skin color Its bright light is well absorbed by blood vessels, over the next few weeks. Crusting may develop which are then destroyed without harming sur- in the fi rst several days and last up to two weeks. rounding skin. Some patients may experience a temporary brown In use with blood vessels, only yellow light is discoloration of the skin for several months. used to target hemoglobin—the substance that If non-bruising settings are used, the treated gives blood its red color. As a result, when used area gets red and a bit swollen for a few hours to a to treat birth defects of blood vessels, only the few days, but bruising does not develop. Applica- abnormal blood vessels are destroyed; surround- tion of ice for 10 minutes every hour on the day ing tissue is left undamaged by the laser light. In of treatment reduces the amount and duration of treating pigment disorders such as liver spots and swelling. CAFÉ-AU-LAIT MACULES, green light is chosen to target the melanin. Outlook and Lifestyle Modifi cation This type of laser is particularly effective in A soothing ointment (such as Aquaphor Healing removing BIRTHMARKS such as PORT-WINE STAINS Ointment) may be applied immediately after treat- at a very low risk of side effects. It is also effective ment. Patients should limit sun exposure before in treating facial redness, ROSACEA, broken blood the treatment, because tanned skin will absorb the vessels in the face, STRETCH MARKS, and SCARs, laser light and make the treatment less effective, as well as a variety of blood vessel tumors. The and it also will increase the risk for temporary pulsed dye laser has revolutionized treatment brown discoloration to occur after treatment. of many of these conditions. Until the 1980s, Treated skin also may be sensitive to the sun and port-wine stains could be treated but the risk of should not be exposed for several weeks. A SUN- scarring was great. With the pulsed dye lasers, SCREEN of SPF 30 is suggested. port-wine stains can be lightened drastically with a risk of scarring signifi cantly less than 1 percent. Other blood vessel problems can all be treated PUPPP See PRURITIC URTICARIAL PAPULES AND with the pulsed dye laser. PLAQUES OF PREGNANCY. During the treatment, the physician holds a handpiece against the skin and pulses the laser; patients say the light feels like a rubber band snap- purpura A group of disorders characterized by ping and stinging against the skin. Although most purplish or reddish brown areas of discoloration, adults tolerate the procedure without anesthesia, visible through the skin and caused by bleeding some children may need an anesthetic or medica- within underlying tissue. “Purpura” also refers tion to relax during treatment. Some lesions (such to the discolored purple areas themselves, which as a spider angiomas or dilated blood vessels) may range from the size of a pinhead to an inch require only one to three treatments, while larger, in diameter. Smaller bleeding points are called PUVA 303

PETECHIAE; larger areas of discoloration are called The main organisms that form pus include BRUISES or ecchymoses. staphylococci, streptococci, pneumococci and Esch- erichia coli. Some bacteria (pseudomonas aeruginosa) Symptoms and Diagnostic Path produce blue-tinged pus. Common purpura (or senile purpura) is the most common of all bleeding disorders. It affects mostly middle-aged or elderly women, causing large dis- pustule A small pus-containing skin blister found colored areas on the thighs but especially on backs on skin that may or may not be caused by infec- of the hands and forearms, the result of thinning tion. They are often found at the opening of hair of the tissues supporting blood vessels beneath the follicles (folliculitis). Staphylococcus aureus is a fre- skin. Bleeding may also be seen in the membrane quent cause of bacterial FOLLICULITIS, while the lining the mouth. pustules in ACNE are not infectious. Purpura caused by a lack of platelets in the blood, called thrombocytopenia, is usually the result of a disease of the bone marrow such as leu- PUVA The combination of the oral or topical kemia or aplastic anemia, or a side effect of drugs photosensitizing chemical PSORALEN (either triox- or excessive radiation. salen or methoxsalen) plus long-wave ultraviolet Henoch-Schonlein purpura (or anaphylactoid light-A (UVA), the most commonly used form of purpura) is caused by infl ammation of blood ves- photochemotherapy helpful in treating PSORIASIS, sels in the skin, and is associated with infl amma- VITILIGO, MYCOSIS FUNGOIDES, and several other tion of blood vessels in the gut, joints, and kidney skin disorders. Only becoming clinically useful in as well. the mid-1970s, PUVA therapy consists of oral or Other types of purpura can be found in SCURVY, topical administration of a psoralen and irradia- resulting from a VITAMIN C defi ciency, and in cer- tion of the skin with UVA light. Treatments (which tain infections, autoimmune disorders, blood poi- last fi ve to 10 minutes) are given two or three soning, or blood chemical disturbances. times a week until remission, when the therapy is reduced to once a week or every other week. The Treatment Options and Outlook most widely used psoralen in the United States is Common purpura is diffi cult to treat. Avoidance 8-methoxysoralen, administered orally followed of systemic and topical steroids are advised as they by a one-hour exposure to UVA. thin the skin even further. Avoiding trauma (even The exact reason why PUVA works is not a slap on the wrist) is essential. Henoch-Schonlein known, but it leads to a decrease in the rate of purpura responds only to immunosuppressant DNA synthesis, which may explain why it helps drugs and systemic CORTICOSTEROIDS. In severe those with disorders characterized by rapid cell cases, plasmapheresis (removal of blood, replace- replication (such as psoriasis). PUVA also may ment of plasma and retransfusion) can be effec- interfere with the migration of infl ammatory tive. Platelet defi ciency is treated by curing the cells to the skin. PUVA is highly effective in the underlying cause. Autoimmune thrombocytope- management of psoriasis (it clears the problem nia purpura is usually treated with corticosteroid in almost 90 percent of the time). It also may be drugs or a splenectomy. used in the treatment of other forms of psoriasis, for cutaneous T-cell lymphomas, atopic dermatitis, LICHEN PLANUS, and vitiligo. pus The product of infl ammation, this is a pale yellow or green creamy fl uid composed of millions Side Effects of dead white blood cells, fl uid, partly digested tis- Patients who receive too much drug or ultra- sue, bacteria, and other substances found at the violet light can develop severe SUNBURNS. Psoralens site of a bacterial infection. A collection of pus in alone may produce itching and nausea in a small solid tissue is an ABSCESS. number of patients, and the risks of PUVA can be 304 pyoderma either acute or chronic. Sunburnlike redness may Treatment Options and Outlook occur together with BLISTERs; these effects usu- Pyoderma gangrenosum can be very diffi cult to ally can be prevented by carefully assessing doses. treat, and the underlying disease must be identi- However, the chronic long-term toxicity is not yet fi ed. Treatment of such underlying disease often determined; PUVA is known to be carcinogenic in helps to heal and prevent new ulcers. experimental situations. HYPERPIGMENTATION occurs Treatment may involve topical and systemic in most patients, and some experience lentigines CORTICOSTEROIDS, DAPSONE, SULFAPYRIDINE, anti- and mottling of skin color. There is a risk of prema- cancer drugs, MINOCYCLINE, and CLOFAZIMINE. The ture aging of the skin, ACTINIC KERATOSES, BOWEN’S lesions should be protected from injury and any DISEASE, and SQUAMOUS CELL CARCINOMA. Prior skin underlying disease should be treated. cancer, previous exposure to ionizing radiation, arsenic ingestion, and (perhaps) the previous use of tar preparations may increase the chance of abnor- pyogenic granuloma A non infectious capillary mal growths in those patients. The formation of tumor, that may appear anywhere on the skin but cataracts is another risk, although there have been is frequently seen on the lips, gums, digits, arms, few reports of premature cataracts in those patients legs, or trunk (often after trauma). treated with PUVA without eye protection. Symptoms and Diagnostic Path The solitary lesion usually begins as a small pyoderma A purulent (containing or character- red PAPULE that quickly grows; as it develops, it ized by pus) condition of the skin. becomes friable and bleeds easily. The condition is common in pregnant women (granuloma gravi- darum), especially in the gums. pyoderma gangrenosum A rare ulcerative condi- tion characterized by ulcers that are surrounded by Treatment Options and Outlook bluish gray discolored skin; it is found in about 5 Surgical excision by electrosurgery or CURETTAGE percent of patients with underlying disease such AND ELECTRODESICCATION, or laser (argon, CO2 as infl ammatory bowel diseases (ulcerative colitis and dye lasers have all been successful.) Some and Crohn’s disease), rheumatoid arthritis, chronic pyogenic granulomas recur after surgery and may active hepatitis, and Wegener’s granulomatosis. require treatment.

Symptoms and Diagnostic Path

Lesions begin as pustules that quickly progress to pyridoxine deficiency See VITAMIN B6 DEFICIENCY. a necrotic (composed of dead tissue) ulcer; lesions often enlarge several centimeters each day. In about a third of cases, injury to the skin precedes pyrilamine An ANTIHISTAMINE drug used to treat the onset of the lesion. The blue-gray necrotic edge HIVES. Unlike other antihistamines, this drug rarely of the ulcer is characteristic of this disease. causes drowsiness. Q quartz lamp A vacuum lamp of melted quartz Treatment Options and Outlook glass used as a source of ULTRAVIOLET RADIATION. Specifi c antibiotics and administration of fl uids and electrolytes are recommended, as well as prompt treatment of the associated high fever. Queensland tick typhus A disease in the spotted TETRACYCLINE and chloramphenicol are effective, fever group caused by ticks infected with the Rick- responding within 24 hours. Therapy should be ettsia australis organisms. continued for two weeks after the onset of fever. Treatment with CORTICOSTEROIDS has been effective Symptoms and Diagnostic Path for neurological complications of this infection. The fi rst sign of this disease is usually a lesion at the site of the tick bite that becomes an ulcer of deadened skin up to 5 mm across with a red quick-tanning lotions See SELF-TANNING PRODUCTS. areola, also called the tache noir (“black spot”).

305 R racket nail One of the most common con- Other skin tumors (KAPOSI’S SARCOMA and genital nail deformities. It is caused by a problem MYCOSIS FUNGOIDES) may also be treated with with the thumb, which is shorter than normal, superfi cial radiation. producing a nail that is very short and wide. This Electromagnetic radiation includes a spec- is an autosomal dominant trait, which means trum of wavelengths, beginning with the shortest that only one defective gene (from one parent) (X-rays and gamma rays), followed by ultraviolet is needed to cause the syndrome. Each child (UV), visible light, infrared, microwave, and radio of an affected person usually has a one in two waves. chance of inheriting the defective gene and of Ionizing radiation (as produced by X-rays) pro- being affected. The condition, which occurs most duces FREE RADICALS in tissue, which lead to dam- often in women, can affect either one or both age and structural changes in cells, delaying the thumbs. growth and eventually killing the cells. See also BASAL CELL CARCINOMA; DERMATITIS, RADIATION; RADIATION ERYTHEMA; RADIATION THER- radiation dermatitis See DERMATITIS, RADIATION. APY FOR SKIN CANCER; RADIODERMATITIS. radiation and the skin In the fi rst half of this radiation erythema Also known as Roentgen century, an X-ray machine was commonly found erythema, this is a brief reddening of the skin with in every dermatologist’s offi ce. With the dawn of varying amounts of swelling following exposure to other treatments, including antibacterials, anti- radiation of between 300–400 cGy. The transient fungals, CORTICOSTEROIDS, chemotherapy, and redness lasts between 24 and 72 hours; a longer- improved surgical treatment, and as the long-term lasting reddening follows in a week, and may consequences of radiation therapy became better last for another week. It appears to be an early known, radiotherapy became less frequently used. response to injury to the EPIDERMIS and DERMIS Today, it is confi ned largely to the treatment of (fi rst and second layer of skin). Darkening of the malignant tumors. skin caused by the excess production of MELANIN The penetration of X-ray radiation varies. The follows. There is usually no signifi cant pain associ- shorter the wavelength, the deeper it can pen- ated with this level of radiation exposure. etrate tissue. X-rays must be chosen to match See also DERMATITIS, RADIATION; RADIATION AND tissue penetration. Superfi cial X-ray radiation is THE SKIN; RADIATION THERAPY FOR SKIN CANCER; primarily used to treat BASAL CELL and SQUAMOUS RADIODERMATITIS. CELL CARCINOMA of the face. While most of these cancers are treated by surgical excision, in some patients radiation is the treatment of choice (it radiation therapy for skin cancer Treatment is nontraumatic and better preserves cosmetic of BASAL CELL or SQUAMOUS CELL CARCINOMA by appearance). X-ray radiation is also used to treat X-rays that produce ionizing radiation. As the eyelid cancers. radiation passes through disease tissue, it destroys

306 RAST test 307 the abnormal cells. If the correct dosage of radia- Acute radiodermatitis can be expected follow- tion is given, normal cells suffer little or no dam- ing radiation therapy for cancer; it may also age. Radiation, which is usually passed through occur following accidental exposure to radiation. diseased tissues by X-rays (or electrons) produced In this acute form, the skin reddening does not by a linear accelerator, cures most SKIN CANCERS. disappear after a week, but instead progresses to an infl ammatory reaction by the second week, Side Effects characterized by blistering, crusting, and pain. As Radiation for the treatment of skin cancer may the infl ammation begins to heal over the ensuing produce fatigue, nausea and vomiting, and hair months, a nonpigmented scar and TELANGIECTA- loss from the affected area. Skin reddening and SIAS appear; hair and sweat glands may be perma- blistering after treatment are common and may be nently destroyed. alleviated with CORTICOSTEROID drugs. Long-term Chronic radiodermatitis can appear years after side effects may include skin cancer in areas of extensive radiation exposure, characterized by chronic RADIODERMATITIS (atrophy of the skin and atrophy of the skin, with telangiectasias and mot- loss of hair and/or sweat glands). tling. The skin becomes dry and easily injured, healing slowly. There is no hair on the exposed area, and sweat and sebaceous glands may be radioallergosorbent test See RAST TEST. destroyed. There is an increased risk of SKIN CAN- CER (most commonly BASAL CELL CARCONIMA). When SQUAMOUS CELL CARCINOMA develops, it is radiodermatitis A mottled increase and decrease often more aggressive than this type of cancer in skin pigment caused by exposure to ionizing induced by sun exposure. radiation. The area usually has no hair and is cov- ered with dilated blood vessels over the thin sur- Treatment Options and Outlook face of the patch. Radiodermatitis is considered to Acute radiodermatitis should be treated with cool be a precancerous condition that may eventually tap water and protective dressings; ITCHING can be progress to a malignant skin tumor. relieved with emollients, shake lotions, or witch The skin may have been exposed to ionizing radi- hazel. Mild analgesics may relieve pain; the area ation either by accident, or deliberately during radia- should not be rubbed. Secondary infection is tion therapy; in either case, the radiation energy treated with antibiotics. Topical steroids are not either injures or kills the individual cells, or causes a effective with this type of skin condition. DNA mutation. The degree of radiation that reaches There is no treatment for chronic radiodermati- the cells depends on the type of radiation (X-rays, tis, other than protecting the area from injury or gamma rays, or neutrons); high-energy radiation exposure to the sun and watching carefully for used to treat deep tumors may actually cause less early signs of skin cancer. total energy to the skin than lower-energy radiation See also RADIATION AND THE SKIN; RADIATION ERY- of X-rays. Temporary hair loss may follow 300–400 THEMA; RADIATION THERAPY FOR SKIN CANCER. cGy of superfi cial radiation to the skin; hair loss may be permanent following larger doses. rash The popular term for a group of spots or Symptoms and Diagnostic Path red, infl amed skin that is usually temporary and is Radiation erythema causes a temporary reddening only rarely a sign of a serious underlying problem. of the skin that lasts up to 72 hours, followed by It may be infl ammatory, infectious, cancerous, or a longer-lasting redness that appears in about a it may represent an underlying disease. week and may take another week to fade. Hyper- pigmentation due to excess MELANIN production follows. There is no discomfort associated with this RAST test The abbreviation for radioallergosorbent type of radiodermatitis. test, used to diagnose allergies. The principle behind 308 rat-bite fever these tests is that there is a specifi c antigen for every blue; upon being reheated, the skin turns red. antibody. Any antibody will bind only to its own Feelings of tingling, numbness, or burning may antigen. This test detects antibodies to antigens. occur during an attack.

Treatment Options and Outlook rat-bite fever A condition following the bite of a Hands and feet of affected individuals should be rat that causes two similar type diseases—sodoku, kept as warm as possible. Cigarette smoking fur- caused by Spirillum minus, and septicemia caused ther constricts the blood vessels and can worsen by Streptobacillus moniliformis. Spirillus minus causes the condition, and thus should be avoided. Vasodi- skin ulcers and recurrent fever; Streptobacillus lator drugs may be administered to relax the blood moniliformis causes skin infl ammation, muscular vessel walls and help prevent vasoconstriction. pain, and vomiting. Following the rat bite, the In severe cases, sympathectomy (cutting of the wound heals but after one to three weeks, it nerves controlling the caliber of arteries) may be becomes tender and swollen. Skin lesions appear, effective. together with enlarged lymph nodes, general mal- Patients with Raynaud’s phenomenon should aise, loss of appetite, and joint pain. wear the proper clothes for the temperature. Per- spiration is more responsible for cold hands and Treatment Options and Outlook feet than cold temperatures, so it is important to Intravenous administration of PENICILLIN G is effec- wear fabrics that soak up excess sweat and keep tive in both cases. it from contacting the body. Hands and feet are especially prone to getting cold because they are natural areas of perspiration, which is why woolen Raynaud’s phenomenon A disorder of blood socks and fl eece boots make a person sweat and vessels that causes the skin of the fi ngers to turn feel cold instead of warm. white in the cold; in rare cases, the blood fl ow is This condition can occur in any season and is permanently decreased, leading to ulceration or related to changes in temperature, so that grocery gangrene at the tips of affected fi ngers and toes. shopping or going to an air-conditioned theater in On exposure to cold, the blood vessels of people summer can provoke Raynaud’s phenomenon. with Raynaud’s phenomenon suddenly contract, cutting off blood fl ow. Fingers of young women are most often affected. razor bumps The common name for PSEUDOFOL- Possible causes of Raynaud’s phenomenon LICULITIS BARBAE. include arterial diseases (Buerger’s disease, ath- erosclerosis, embolism, and thrombosis), con- nective tissue disease (rheumatoid arthritis, reactive perforating collagenosis A rare skin dis- SCLERODERMA, and systemic LUPUS ERYTHEMATO- ease characterized by small papules with a central SUS), and medications (ergotamine, methysergide, plug of oily material. They are caused by seeping and beta blockers). of abnormal COLLAGEN through the overlying EPI- Raynaud’s phenomenon is also a recognized DERMIS (top layer of skin). This hereditary condi- occupational disorder in some people who use tion usually appears in childhood. The lesions are pneumatic drills, chain saws, or other vibrating usually found on the backs of the hands, forearms, machines; it is also sometimes seen in typists, elbows, and knees. pianists, and those whose fi ngers suffer repeated trauma. Treatment Options and Outlook No treatment is needed, since the lesions usually Symptoms and Diagnostic Path disappear on their own, but removing the lesions During exposure to cold, the skin of the digits by freezing with LIQUID NITROGEN or ELECTRODESIC- turns white. As blood fl ow returns, the skin turns CATION may be effective. resorcinol 309 von Recklinghausen’s disease See NEUROFIBRO- ear.” There are a number of other symptoms MATOSIS. affecting other areas of the body; death can occur from aneurysms and cardiac valve disease. reconstructive surgery See PLASTIC SURGERY. Treatment Options and Outlook Topical steroids do not work, but high doses of sys- temic CORTICOSTEROIDS can control or ease infl am- reduction mammoplasty See MAMMOPLASTY. mation. Because of the frequent spontaneous remissions and recurrences, it is hard to evaluate response to therapy. DAPSONE, which may be safer Refsum’s disease A rare genetic metabolic dis- than steroids, has been effective for some patients, ease caused by a lack of the enzyme phytanic acid but it also can cause serious side effects. oxidase that causes mild scaling of the skin on the About 30 percent of patients usually die within trunk, arms, and legs similar to ICHTHYOSIS. This four years, usually as a result of obstruction or results in a buildup in many organs of phytanic collapse of the airway. Even if heart and bronchial acid, a compound chiefl y of dietary origin. tube defects do not occur, the disorder can cause The disorder is an autosomal recessive trait, deformities of the ears and nose. which means that a defective gene must be inher- ited in a double dose to cause the abnormality. Generally, both parents of an affected person are renal failure and skin symptoms See KIDNEY DIS- unaffected carriers of the defective gene. Each of the EASE AND SKIN SYMPTOMS. children has a one in four chance of being affected, and a two in four chance of being a carrier. Renova See TRETINOIN. Symptoms and Diagnostic Path In addition to the skin symptoms, the disease is characterized by night blindness, cataracts and reportable skin diseases Skin conditions (CHICKEN other eye problems, skeletal abnormalities, kidney POX, MEASLES, SYPHILIS, TUBERCULOSIS, and RUBELLA) or heart problems, and hearing problems. that must be reported to local health authorities by the physician responsible for care of the affected Treatment Options and Outlook person. In turn, local health authorities must Eating a low-phytanic acid diet is recommended. report some of these diseases to the national Cen- Some patients fi nd relief with plasma exchange ters for Disease Control. (a procedure that reduces the concentration of Notifi cation of certain potentially harmful infec- unwanted substances in the blood). tions is important because it enables public health offi cials to take the necessary steps to control the spread of infection. Reporting also provides valu- relapsing polychondritis A rare chronic autoim- able statistics on the incidence and prevalence mune infl ammatory disease in which cartilage in of the disease, which can be used to formulate the ear, nose, joints, eyes, blood vessels, trachea, health policies such as immunization programs and bronchial tubes may be destroyed. and improvements in sanitation.

Symptoms and Diagnostic Path Skin signs are characterized by abnormal cartilage resorcinol (Trade name: Rezamid) An ointment in the outer ear, which is large, swollen, tender, that causes the skin to peel, which is used to treat and red, lasting for one or two weeks before it fades ACNE, DERMATITIS, and fungal infections, and con- and then recurs. Recurrent attacks will eventually tained in hair lotions for DANDRUFF. Its mechanism destroy the cartilage, and result in “caulifl ower of action is unknown. 310 Restylane

It is available in concentrations of 2 percent or light, and maintenance of soft mucous tissue. Reti- less. In preparations of 3 percent and higher, local nol (the alcohol of retinoic acid) and refi ned pal- swelling, dermatitis, ITCHING, and peeling may mitate are both often found in skin-rejuvenating occur. More seriously, there is also the possibility creams. While less effective than retinoic acid of systemic toxicity; if the drug is absorbed into the (Retin A), these two substances likely do help body, it can cause a decrease in activity of the thy- to slow the skin aging process and do reverse at roid gland, and convulsions. For this reason, prod- least some of the changes caused by sun damage. ucts containing resorcinol should not be applied to Their greatest benefi t is that they are less irritat- broken skin or to large areas of the body. In addi- ing than retinoic acid and are available without a tion, resorcinol may discolor dark or black skin. prescription. Resorcinol is usually added to sulfur as an acne treatment; although resorcinol by itself is not con- sidered to be effective against acne, it appears to retinyl palmitate A form of VITAMIN A that some enhance the action of sulfur. The U.S. Food and studies suggest may be transformed into retinoic Drug Administration allows a combination of 8 acid in the skin. Retinyl palmitate is less irritat- percent sulfur with 2 percent resorcinol, or 8 per- ing than retinoic acid, but many experts believe cent sulfur with 3 percent resorcinol monacetate. that commercial skin care products do not contain Resorcinol is considered to be a rather old-fash- enough of this substance to prevent or reduce ioned agent and is no longer commonly used. aging. See also RETINOIDS.

Restylane See HYALURONIC ACID GEL. rhinophyma Bulbous deformity and redness of the nose found almost exclusively in men over age retinoic acid See TRETINOIN. 40, usually as a complication of severe ROSACEA (a skin disorder of the cheeks and nose). As nose tis- sue thickens, small blood vessels enlarge and the retinoids Synthetic or naturally occurring deriv- sebaceous glands become overactive, making the atives of VITAMIN A that have a range of effects on nose excessively oily. the skin, including wound repair, inhibiting tumor promotion, and so on. Today, retinoids are widely Symptoms and Diagnostic Path used in the treatment of stubborn cases of ACNE, This condition causes the nose to thicken and PSORIASIS, prevention of SKIN CANCER, reversal of become reddened and bulbous, with a waxy, yel- aging, and disorders of KERATINIZATION (the depos- lowish appearance. iting of KERATIN within the cell). Physicians can usually diagnose this condition Primary dietary sources of vitamin A are the by visual inspection alone, although a skin biopsy beta-carotenes in the yellow and green leafy veg- may be needed to confi rm the diagnosis in unusual etables and also in some animal fats and fi sh oils. cases. Vitamin A (RETINOL) is sent to the liver, where more than 90 percent of the body’s stores are stockpiled. Treatment Options and Outlook They may be used topically as in retinoic acid Rhinophyma can be treated with a variety of sur- or systemically as in ISOTRETINOIN, the generic form gical procedures, with a laser, scalpel, or derma- of Accutane, or ETRETINATE, the generic term for brasion. Skin grafting is not necessary, since the Tegison. remaining tissue rapidly regenerates. Some physi- cians have found that the ACNE medication ISOTRET- INOIN (Accutane) offers good results. Although the retinol The principal form of VITAMIN A found in condition can be corrected surgically, the problem the body. It is essential for growth, vision in dim may recur. rickettsial infections 311 rhinoplasty See NOSE REPAIR. Treatment Options and Outlook A diet low in tyrosine and phenylalanine is advised. If diagnosed early enough, it is possible to rhinoscleroma A chronic bacterial infection prevent some of the problems (including mental caused by Klebsiella rhinoscleromatis that is common retardation) associated with the disease. in rural areas throughout the third world.

Symptoms and Diagnostic Path rickettsial infections Diseases caused by the bite The disease begins with increased nasal secretion or feces of parasites called rickettsiae. The infec- and crusting, followed by an enlargement of the tions can be grouped as the spotted fevers (ROCKY nose, upper lip, palate, or neighboring areas. If the MOUNTAIN SPOTTED FEVER, RICKETTSIAL POX, other infection spreads to the respiratory tract, breathing tickborne fevers); the TYPHUS group (epidemic or may become diffi cult and a tracheotomy may be louseborne typhus, endemic or murine typhus, necessary. and scrub typhus); Q fever; and trench fever. Rickettsiae are microorganisms that share fea- Treatment Options and Outlook tures of both bacteria and viruses. Like bacteria, This progressive disease is diffi cult to treat, but rickettsiae have enzymes and cell walls, use oxy- systemic antibiotics such as gentamicin and tobra- gen, and can be controlled or destroyed by antibi- mycin have been effective. Alternatively, oral otics. Like viruses, rickettsiae can live and multiply administration of ciprofl oxacin may help, although only inside cells. Rickettsiae normally live in ticks, this drug has not been widely studied as a therapy mites, fl eas, and lice, and they can be spread to for this condition. The condition may be fatal due humans by the bites of these bloodsucking insects. to breathing obstructions or continuing infection. In people, rickettsiae usually live inside the cells lining small blood vessels, causing the blood ves- sels to become infl amed or blocked or to bleed into rhytidectomy See FACE-LIFT. the surrounding tissue.

Symptoms and Diagnostic Path Richner-Hanhart syndrome The common name A rickettsial infection may cause a fever, a skin for tyrosinemia type II, a hereditary metabolic dis- rash, and a feeling of illness. Because the charac- ease caused by the absence of the enzyme tyrosine teristic rash often does not appear for several days, aminotransferase. an early diagnosis is diffi cult. Flea or lice infesta- The condition is an autosomal recessive trait, tion or a prior tick bite, particularly in a geographic which means that a defective gene must be inher- area where a rickettsial disease is common, is a ited from both parents to cause the abnormality. helpful clue in making the diagnosis. Generally, both parents of an affected person are The diagnosis of a rickettsial infection can be unaffected carriers of the defective gene. Each confi rmed by identifying the organism in special child of parents who both carry the defective gene cultures of blood or tissue specimens, by identify- has a one in four chance of being affected, and a ing the organism under a microscope using certain two in four chance of being a carrier. stains, or by identifying antibodies to the organism in a blood sample. Symptoms and Diagnostic Path The skin erodes on fi ngers, palms, and soles of Treatment Options and Outlook the feet in symmetric lines, becoming crusted and A rickettsial infection responds promptly to early wasted. The lesions may be so painful that they treatment with the antibiotics chloramphenicol or interfere with movement. Other signs of the con- TETRACYCLINE, both of which are taken by mouth. dition include mental retardation, excess tearing, Improvement usually takes 24 to 36 hours, and and eye problems. fever usually disappears in two to three days. 312 rickettsial pox

When treatment is not so prompt, improvement ROCKY MOUNTAIN SPOTTED FEVER and various forms is slower and the fever lasts longer. Antibiotics of TYPHUS. should be continued for at least 24 hours after the See also RICKETTSIAL INFECTIONS; RICKETISIAL fever disappears, and may be given intravenously POX. to people who are too ill to take them orally. If a person is severely ill and in a late stage of disease, a CORTICOSTEROID may be taken for a few days in rifampin An antibacterial drug used to treat addition to the antibiotic to relieve serious toxic LEPROSY that is usually prescribed with other anti- symptoms and help relieve the infl ammation of bacterials because some strains of bacteria quickly blood vessels. develop resistance to rifampin alone. It is also used See also RICKETTSIA RICKETTSII. to eradicate Staphylococcus aureus from nasal cavi- ties. Because it is so expensive, it is typically used as an adjunct treatment. rickettsial pox An urban disease transmitted by mites on common house mice that has been Side Effects reported in cities since 1946. The responsible Harmless, orange-red discoloration of urine, saliva, microorganism is Rickettsia akari, which belongs to and other body secretions; muscle pain; nausea the spotted fever group of these parasites. and vomiting; diarrhea; JAUNDICE; fl ulike symp- toms; rash and ITCHING. Symptoms and Diagnostic Path A local lesion develops between one and three weeks after a mite bite, beginning as a red papule ringworm The popular term for TINEA, a superfi - that breaks down into an area of dead crusted cial fungal infection of the skin. skin, at which time it may be associated with local swelling of lymph nodes. Within a week after the lesion appears, fever, chills, headache, and myal- Ritter’s disease The former name for staphlococ- gias occur, followed in a few more days by a rash cal SCALDED SKIN SYNDROME. over the body. This rash develops into an eruption similar to CHICKEN POX. Rocky Mountain spotted fever A rare infec- Treatment Options and Outlook tious disease caused by the Rickettsia parasite Treatment involves antibiotics (TETRACYCLINEs (similar to a bacteria), characterized by a spot- or chloramphenicol), fl uid and electrolytes, and ted rash. Transmitted to rabbits and other small prompt treatment of complications. The lesions mammals primarily by tick bites, it is found most may not be very severe, and the disease itself is often in wooded areas along the Atlantic coast, mild and self-limiting. but it gets its name from its original occurrence See also RICKETTSIAL INFECTIONS. in the Rocky Mountain states. The incidence of the disease has been rising steadily since 1980; there are more than 1,000 cases reported each Rickettsia rickettsii A type of intracellular para- year. Diagnosis may be diffi cult because the sitic microorganism that looks like a small bacte- disease has symptoms resembling several other rium but that can reproduce only by invading cells infections. Lab tests on blood and tissues are of another life form. These parasites live primar- needed to confi rm the diagnosis. Rocky Moun- ily off insects and insectlike animals such as lice, tain spotted fever has been a reportable disease fl eas, ticks, and mites. In turn, these insects can in the United States since the 1920s. In the last transmit the parasite to rodents, dogs, or humans 50 years, between 250 and 1,200 cases have through saliva or feces. Human diseases spread by been reported each year, although it is likely that different types of these microorganisms include many more cases go unreported. rosacea 313

Symptoms and Diagnostic Path and, less commonly, disfi gurement and enlarge- Mild fever, muscle pain loss of appetite, nausea ment of the nose. and vomiting, and slight headache may develop Rosacea affects about 14 million Americans slowly about a week after a tick bite. Sometimes, (about one in 20), typically between ages 30 however, symptoms appear suddenly with high and 60. While it is sometimes called “adult acne” fever and prostration. Two to fi ve days after symp- because the pimples usually appear during the 30s toms appear, small pink itchy spots appear on and 40s, rosacea is actually a different condition, wrists and ankles, spreading centrally over the rest and the pimples are not usually associated with of the body. The illness subsides after about two BLACKHEADs and WHITEHEADs. weeks. The typical red, spotted rash occurs in only The condition affects fair-skinned patients more 35 to 60 percent of patients with Rocky Mountain often than those with dark complexions, although spotted fever. In those who have a rash it may also it can affect all skin types. Most rosacea patients appear later in the course of the disease on the have a history of blushing more often and easily. palms or soles in up to 80 percent of patients. On Rosacea also may affect members of the same fam- the other hand, up to 15 percent of patients never ily because of similar skin conditions or genetic pre- develop a rash. disposition. Rosacea occurs at a particularly high Rocky Mountain spotted fever can be tough to rate among Irish Americans, although other nation- diagnose in its early stages, even by experienced alities—English, Scots, or Eastern Europeans— physicians familiar with the disease because the also may develop this conspicuous condition. symptoms are so common to many other infec- While women are more likely to develop rosa- tious and noninfectious diseases. cea, men are more likely to develop RHINOPHYMA (the large, bulbous nose associated with the con- Treatment Options and Outlook dition). Rosacea is not linked with alcoholism, Antibiotic drugs TETRACYCLINE or chloramphenicol although alcohol may worsen the condition; tee- usually cure the disease. Untreated cases with very totalers may also develop rosacea. high fever may end in death from pneumonia or Doctors do not know exactly what causes rosa- heart failure. cea, but most suspect that some people inherit a tendency to develop the disorder. People who Risk Factors and Preventive Measures blush frequently also may be more likely to People in tick-infested areas should use insect develop rosacea. Some researchers believe that repellent and examine themselves daily for ticks. people who have rosacea have blood vessels that See also RICKETTSIAL INFECTIONS; RICKETTSIA dilate too easily, triggering fl ushing and redness. RICKETTSII. Other theories suggest that the condition may be triggered by bacteria, mites, or fungal infection, but no link has been proven between rosacea and rodent ulcer The popular term for BASAL CELL bacteria or other organisms on the skin, in the hair epithelioma (tumor of the covering of the internal follicles, or elsewhere in the body. and external surfaces of the body) that has become Different people experience fl are-ups caused by large and eroded. different triggers, which may include any of the following: alcoholic beverages, emotional stress, heat (including hot baths), menopause, spicy foods Rogaine See MINOXIDIL. and drinks, strenuous exercise, sunlight, wind, very cold temperatures, and long-term use of topi- cal steroids on the face. rosacea A chronic disorder affecting facial skin of the nose, cheeks, chin, or forehead that may Symptoms and Diagnostic Path include redness, pimples, PUSTULES, solid raised Rosacea develops slowly and usually gets worse lesions, dilated blood vessels (TELANGIECTASES), unless treated. In most patients, the condition 314 roseola infantum waxes and wanes repeatedly for no apparent rea- or a laser may also be used to eliminate enlarged son. Earliest signs include a red face (especially blood vessels, and also decrease the overall red- on cheeks and nose) that may come and go. This ness, thus improving appearance. redness is caused by enlarged blood vessels under In addition, a DERMATOLOGIST may recommend the skin that looks like a blush or SUNBURN. Gradu- specifi c moisturizers, soaps, sunscreens, or other ally, the redness becomes permanent and more products as needed to improve the condition of noticeable; facial skin also becomes very dry. As the skin. Only very mild soaps or cleansers should the redness gets worse, pimples may appear. Thin be used; alcohol or irritating ingredients and red lines (called telangiectases), which are really excessive cleaning of the skin should be avoided. enlarged blood vessels, may appear on the surface High-quality moisturizers should be applied only of the skin. In the most advanced stages (especially after the topical medication has dried. Sunscreens in men) the nose may become lumpy and swollen of SPF 15 or higher are often recommended when from excess tissue. prolonged sun exposure is expected. Rosacea is aggravated by sun, hot liquids, spicy foods, alcohol, vigorous exercise, heat, cold and wind, fl uorinated steroids, menopause, endocrine roseola infantum A common infectious disease disturbances, and emotional stress. of early childhood also known as exanthema subitum It can be diagnosed visually by a dermatologists. (Latin for “sudden rash”) that can affect youngsters aged six months to six years. The disease, is caused Treatment Options and Outlook by the human herpes virus 6 and 7. There is no cure for rosacea, but treatment can control the condition and improve the skin’s Symptoms and Diagnostic Path appearance. The treatment of choice for the diffuse The disease is characterized by the abrupt onset of redness and dilated blood vessels is laser surgery, irritability and a fever, which may climb as high which may improve the skin’s appearance with as 105° F. By the fourth or fi fth day, the fever very low risk. breaks, suddenly returning to normal. At about Topical and oral medications can control red- the same time, a rash appears on the trunk, often ness and reduce papules and pustules; a combina- spreading quickly to the face, neck, and limbs, tion of topical and oral forms of prescription drugs fading within hours and disappearing within two may be recommended. The most widely prescribed days. Other symptoms may include sore throat, therapy for rosacea is topical metronidazole, which enlarged lymph nodes, and, occasionally, a febrile has been proven effective in clinical studies. Oral seizure. antibiotics such as TETRACYCLINE, minocycline, ERYTHROMYCIN, or doxycycline are also commonly Treatment Options and Outlook used; they tend to produce better results and work There are no serious complications, and there is no more quickly than topical medications. Still, it usu- specifi c treatment other than acetaminophen for ally takes several weeks for drugs to take effect, the fever. A single attack appears to confer perma- and they may have to be taken regularly to keep nent immunity. rosacea under control. Up to 80 percent of patients can expect signifi cant improvement from oral or topical therapy, or a combination of both. Rothmund-Thomson syndrome (RTS) An ex- Prescription and nonprescription mild topical tremely rare inherited multisystem disorder that steroids are occasionally used on a short-term basis is usually apparent during early infancy, typically to help control redness; long-term use of topical characterized by distinctive abnormalities of the steroids is not recommended. skin, defects of the hair, clouding of the lenses Surgery may be used to correct the nose of the eyes, short stature and other skeletal ab- enlargement in RHINOPHYMA. A fi ne electric needle normalities, malformations of the head and face, rubber sensitivity 315 and other physical problems. In rare cases, mental percent risk of having both RTS genes and the dis- retardation may be present. The range and sever- ease. The RTS gene has been mapped and is found ity of symptoms may vary from case to case. RTS on chromosome 8. is also known as POIKILODERMA congenita and The disease gets its name from Dr. August von poikiloderma atrophicans. Rothmund, a German ophthalmologist (1830– 1906), who in 1868 reported having seen a Symptoms and Diagnostic Path familial disorder with cataracts, saddle nose, and During early infancy, individuals with Rothmund- skin atrophy in an isolated inbred Alpine village. Thomson syndrome develop abnormally red, Matthew S. Thomson was a British dermatologist infl amed patches on the skin accompanied by (1894–1960) who in 1923 and 1936 described abnormal accumulations of fl uid between layers “A hitherto undescribed familial disease” and of tissue under the skin. The patches typically fi rst termed it poikiloderma congenita. Today, it is gener- appear on the cheeks. In most cases, additional ally thought that Thomson’s fi nding was the same areas of the skin may then become involved to a disease that was seen in the Alps long before by lesser degree, such as the skin of the ears, fore- Rothmund. head, chin, hands, forearms, lower legs. Infl ammation eventually tends to recede, and Treatment Options and Outlook the skin of affected areas develops a condition Patients should use broad-spectrum SUNSCREENS. known as poikiloderma, characterized by abnormal TELANGIECTASES can be treated with pulsed-dye widening of groups of small blood vessels (telangi- laser therapy. Keratolytics and RETINOIDS have ectasia); skin tissue degeneration; and patchy areas been somewhat successful in treating the skin of abnormally decreased pigmentation (DEPIGMEN- lesions. TATION) and/or unusually increased pigmentation Ophthalmology evaluation in early years for (HYPERPIGMENTATION). In many cases, additional detection and management of cataracts is neces- skin abnormalities also may occur. Patients are sary, together with dental, orthopedic, endocrine, usually short, with either baldness or abnormal and hematology referrals for care depending on hair growth. There is an early onset of cataracts related symptoms. and an abnormally low bridge of the nose (“saddle The prognosis for survival, barring such compli- nose”). Teeth tend to be underdeveloped and the cations as bone cancer, is fairly good. jaw protrudes. There may be bone defects from birth and con- tractures of soft tissue involving the limbs. The royal jelly A substance secreted from the diges- bone defects may include abnormally small hands tive system of worker bees that some people mis- and feet, and underdevelopment or absence of takenly believe improves skin condition. Royal the thumbs or bones in the forearm. Underactiv- jelly is fed to male bees and worker bees for a ity of the ovaries in females or testes in males few days after they are born. Because the queen can lead to irregular menstruation and delayed bee eats royal jelly throughout her life, royal jelly sexual development in boys and girls. There is a became associated with health and long life. tendency to anemia and an increased risk of bone Studies have shown that royal jelly does not cancer. prevent aging in humans. Rothmund-Thomson syndrome is inherited genetically as an autosomal recessive trait. This means that both parents have one RTS gene but rubella See GERMAN MEASLES. do not have the disease. Each of their children stands a 25 percent chance of not having either RTS gene, a 50 percent chance of having one RTS rubber sensitivity See ALLERGIES AND THE SKIN; gene (and, as the parents, being normal) and a 25 LATEX ALLERGY. 316 rubeola rubeola Another name for MEASLES. (rough, scaly skin), dark, warty growths (ACAN- THOSIS NIGRICANS), excess sweating of palms and soles, epilepsy, hair loss, deformed teeth, mental rubor Redness. retardation, seizures, and hypogonadism.

Rud’s syndrome A rare congenital syndrome characterized by mild to fairly severe ICHTHYOSIS S

St. Anthony’s fire The common name for ERY- ethnic groups—primarily African Americans, but SIPELAS, a potentially fatal streptococcal infection also Scandinavians, Irish, and Puerto Ricans. of the skin characterized by deep swellings on Despite decades of research, scientists still know the face, with severe headache and blistering. very little about the disorder, and its cause remains Severe cases require hospitalization and intrave- unknown. nous antibiotics. An unusual form of the disease, called Lofgren’s disease, is characterized by a very rapid onset, with a HIVE-like skin rash and acute lung problems, salicylic acid A drug used to treat a variety of enlarged lymph nodes and fever. This condition skin disorders, including DERMATITIS, ECZEMA (topi- usually disappears as quickly as it came. cally), PSORIASIS, ICHTHYOSIS, ACNE, and WARTS. The drug is also sometimes used for fungal infections. Symptoms and Diagnostic Path Salicylic acid pads or solutions can be very The typical symptom of the disease is the sar- effective for the treatment of warts. It is impor- coidal granuloma. Its most common symptom tant to avoid treating normal surrounding skin to involves lung disease, but in the acute form of the prevent its irritation. This can be avoided by coat- disease purplish swellings on the legs may occur ing the rim of the wart with zinc oxide paste or with fever, generalized aches, and lymph node PETROLEUM JELLY. enlargement. Chronic sarcoidosis may cause a variety of Side Effects symptoms, including a purple facial rash, painful This drug may cause infl ammation and even skin joints, bloodshot eyes, and numbness. However, ulceration if used for a long period of time or if about a third of affected people have no symp- applied to a large area of skin. It is poisonous and toms at all; in these people, X-rays reveal enlarged should never be ingested. lymph nodes in the center of the chest. Finally, about one patient in 20 will experience scarring and thickening of the lungs, abnormally salmon patch See STORK BITE NEVUS. high blood levels of calcium, and kidney damage. Sarcoidosis initially may be confused with tuberculosis or a deep fungal infection. The con- salve A healing, soothing (often medicated) oint- dition is often diagnosed by fi rst ruling out these ment for the skin. other problems.

Treatment Options and Outlook sarcoidosis A rare disease characterized by About 90 percent of patients recover completely infl ammation in the skin and other tissues through- within two years with or without treatment. out the body (especially the lungs) that occurs pri- However, the remainder develop a chronic form marily in young adults. Often appearing abruptly, of the disease. Oral CORTICOSTEROID drugs (such its incidence is highest among widely disparate as prednisone) may relieve ERYTHEMA NODOSUM,

317 318 sarcoma fever, and lung or eye problems. Steroids are given rows into the skin and lays its eggs. Mites are usu- because their anti-infl ammatory effects suppress ally passed during close body contact. the sarcoid granulomas often found in the disease. The mite is transmitted by direct, prolonged, This treatment usually produces a rapid reduction skin-to-skin contact with a person already infested of symptoms within weeks, although it still takes with scabies. Contact must be prolonged (a quick about a year for the disease to disappear. Hydroxy- handshake or hug is not enough). Infestation is chloroquine is sometimes prescribed to treat skin easily spread to sexual partners and household abnormalities. members, and by sharing clothing, towels, and For the very seriously ill patient with life- bedding. People with weakened immune systems threatening complications, more potent anti- and the elderly are at risk for a more severe form infl ammatory drugs (such as the anticancer drug of scabies, called Norwegian or crusted scabies. METHOTREXATE) may be administered. Deprived of the human body, mites do not sur- In symptom-free patients, the disorder will fade vive more than 48–72 hours, but on a human an away with or without treatment in about two adult female mite can live up to a month. years. In another third, the condition responds to Pet scabies Humans cannot become infested drug therapy, but these patients may require treat- by catching the mites from pets, because animals ment for many years. have a different kind of scabies mite. If a pet is infested with scabies (also called mange), and they are in close contact with a human, the pet’s mites sarcoma Cancer of the connective tissue, blood may infest human skin and cause ITCHING and vessels, or the tissue surrounding and supporting skin irritation. However, the mite will die in a few organs. Examples of sarcoma include KAPOSI’S days and cannot reproduce. The mites may cause SARCOMA (mainly affecting the skin, and common itching for several days, but the human does not in AIDS patients), and osteosarcoma and chondro- need to be treated with special medication to kill sarcoma (both affecting bones). the mites. However, until the pet is successfully treated, mites can continue to burrow into the skin and cause symptoms. Sarcoptes scabiei The mite responsible for the skin infestation of SCABIES. Symptoms and Diagnostic Path A person who has never been infested with scabies may develop symptoms within four to six weeks. scab A crust that forms on a healing superfi - A person who has had scabies before may develop cial skin wound or infected area, composed of symptoms within several days. It is not possible to dried fi brin and serum leaked from the wound, become immune to a scabies infestation. Symp- along with pus, skin scales, and other skin debris. toms include tiny red scaly PAPULES on the skin Another name for a scab associated with burns is between the fi ngers, on wrists and genitals, and ESCHAR. in armpits that cause intense itching (especially at night). Reddish lumps may appear later on arms, legs, and trunks. scabicides Insecticides (such as LINDANE) designed The infestation can be diagnosed by a physi- to treat SCABIES by killing the mites that cause the cian by visual inspection of the skin. In addition, a infestation. These lotions usually kill the mites, but doctor may take a skin scraping to look for mites, itching may continue for up to two weeks. eggs, or fecal matter. However, a false negative from a skin scraping is possible, because there are often fewer than 10 mites on the entire body of an scabies A highly infectious skin infestation infested person, which makes it easy for an infesta- caused by the mite SARCOPTES SCABIEI, which bur- tion to be missed. scaling disorders of infancy 319

Treatment Options and Outlook tender, and the skin around the mouth becomes Insecticide lotion (such as LINDANE, gamma ben- reddened, weeping, and crusting in a way that zene hexachloride, or permethrin) should be resembles potato-chip scales. The trunk may also applied to all skin, which kills the mites (although become involved. In some patients, the rash sta- itching may continue for up to two weeks later). bilizes, while in other cases fl accid blisters begin The insecticide is usually left on overnight for eight to develop all over the skin within 24 to 48 hours. hours, and occasionally treatment is repeated the Large areas of skin slough off, and hair or nails following night. Bedclothes and intimate apparel may be lost. should be washed twice to prevent reinfection. All members of a family and close friends should be Treatment Options and Outlook treated at the same time. Prompt administration of antibiotics and fl uids Itching may persist for two or three weeks after are generally given in the hospital. Patients often treatment, which does not mean that mites are still appear very ill, with low fl uid levels and risk of alive. Alternative medication can relieve severe secondary infection. The skin is treated with wet itching. No new burrows or rashes should appear dressings for crusted sites and antibiotic ointments after one or two days of treatment. such as bacitracin. Patients usually heal without scarring within a week. The death rate in children is very low (between scald A burn on the skin caused by steam or hot 1 and 5 percent) unless the child has a blood infec- liquid. tion or a serious underlying medical condition. The death rate in adults is higher (between 20 to 30 percent). scalded skin syndrome, staphylococcal (SSSS) A syndrome of acute exfoliation of the skin following a reddened skin infection (CELLULITIS) most com- scaling disorders of infancy It is completely mon in children and neonates, and rare in adults. normal for newborns to shed their skin, and it is SSSS is caused by an exotoxin from a staphylococ- particularly noticeable in babies who have gone cal infection. beyond full term. However, excessive scaling may First recognized as a distinct condition in the indicate one of the ichthyoses, a group of disorders mid-1800s, this disease has been incorrectly called featuring dry, rough, and scaly skin caused by a by many different names, including Ritter’s dis- defect in KERATINIZATION (the process by which ease, toxic epidermal necrolysis, and PEMPHIGUS skin cells become horny as they move upward neonatorum. Only recently was its cause discov- toward the outer layer of skin). ered to be a toxin-producing strain of Staphylococcus There are four major types of ICHTHYOSIS, aureus. three of which occur during the neonatal period: Epidemics have occurred in contaminated nurs- X-linked ichthyosis, lamellar ichthyosis (nonbul- eries, and the strain of bacteria may be transmitted lous congenital ichthyosiform erythroderma), and by a carrier who has no symptoms. The condition epidermolytic hyperkeratosis. The fourth type of has also been reported among adults, most of scaling disorder, ichthyosis vulgaris, rarely devel- whom had poorly functioning immune systems. ops before age three months and most commonly occurs in older children. In addition, COLLODION Symptoms and Diagnostic Path BABY and HARLEQUIN FETUS describes the skin con- Symptoms usually begin with evidence of a pri- dition of some of these affected infants. mary staph infection, of the nose, throat, skin, or GI tract, including IMPETIGO, conjunctivitis, Symptoms and Diagnostic Path ear infection, or sore throat with fever, malaise, In X-linked ichthyosis, up to a third of the affected or irritability. The center of the face becomes male infants are born scaly, and the rest begin to 320 scar show the signs by three months of age. This con- A KELOID is a large, irregular scar that grows dition is characterized by dirty brown scales that beyond the site of initial surgery. This type of scar usually cover the entire body, except for the face, is most common among African Americans and palms, and soles of the feet. Female carriers may Asians, and tends to run in families. have certain eye abnormalities, but they show no A HYPERTROPHIC SCAR is an overgrown scar that skin symptoms. remains within the confi nes of the initial injury Babies with lamellar ichthyosis are born with red, or cut. The tendency toward the development of scaly skin over their body, including the palms, hypertrophic scars may be inherited. Hypertrophic soles, and fl exible surfaces. As the baby ages, the scars are usually pink and relatively fi rm. redness fades and yellow-to-brown thick scales There is not always a clear-cut difference appear over the body, especially in areas of the between keloids and hypertrophic scars, since body that are fl exed. These infants may suffer with both are characterized by the same type of fi brous secondary infections due to the large areas of moist connective tissue. However, keloids tend to keep broken skin. The disorder is usually inherited in growing, whereas hypertrophic scars tend to an autosomal recessive way, which means that a reach a certain size, level off, and spontaneously defective gene must be inherited in a double dose regress. to cause the abnormality. Generally, both parents of an affected person are unaffected carriers of the Treatment Options and Outlook defective gene. Each of their children has a one in Surgical excision of both types of scars is generally four chance of being affected, and a two in four not very effective. They tend to recur and they can chance of being a carrier. become larger and more unattractive than before In epidermolytic hyperkeratosis (bullous congeni- the operation. Prolonged application of pressure tal ichthyosiform erythroderma), affected infants by special appliances after surgical removal may develop crops of blisters over large areas of their prevent recurrence, but it is frequently impracti- body during the neonatal period. This causes dry, cal. Newer treatments, however, have improved eroding, reddened skin, together with frequent the ability to deal with raised scars. Intralesional secondary infection. Sepsis (blood poisoning) may injections of CORTICOSTEROIDS, silicone gel dress- follow, especially in young infants. In this condi- ings, or laser therapy are effective treatments for tion, the scales are wartlike and fl ake off easily in at least some scars. great numbers. Palms of the hands and soles of the feet are usually unaffected. Risk Factors and Preventive Measures Other scaling conditions found in infancy Because wounds that heal quickly and neatly are include atopic eczema, seborrheic dermatitis (see less likely to scar, all wounds should be cleaned DERMATITIS, SEBORRHEIC), and PSORIASIS. and kept slightly moist during healing. Scabs should not be picked, which would increase the likelihood of scarring. scar An area of fi brous tissue left behind on To minimize scarring without stitching, a but- the skin after damaged tissue has healed. When terfl y bandage (available at most drugstores) can tissue is damaged, the body repairs the wound be applied. This helps keep the wound closed. Eat- by increasing production of the tough protein ing a balanced diet, especially rich in the mineral COLLAGEN at the wound site. The collagen helps ZINC, also can help heal wounds quickly. construct new connective tissue to repair the To help prevent keloids, earlobe piercing and defect. If the edges of the wound are brought excision of nevi and other lesions on keloid-prone together during healing (such as after the surgical areas should be done with caution in young people excision), the scar is narrow and pale; if the edges (especially those with dark skin). To help prevent remain wide apart (such as after a BURN), the scar hypertrophic scars, injury to the skin (especially in is more extensive. early adulthood) should be avoided. Schamberg’s disease 321 scarlet fever An infectious bacterial childhood 104°F, accompanied by a severe sore throat. The disease characterized by a skin rash, sore throat, face is fl ushed and the tongue develops a white and fever, that is much less common and dangerous coating with red spots, rather like a white straw- than it used to be. No longer a reportable disease, berry. The patient may seem tired and fl ushed. experts do not know exactly how many cases occur Twelve to 18 hours after the fever, a rash appears today in the United States, although it is believed as a mass of rapidly-spreading tiny red spots on that the disease has been on the increase for the the neck and upper trunk. The scarlet fever rash is past several years. Once a very serious childhood unique in that it feels rough, like fi ne sandpaper, disease, scarlet fever now is easily treatable. and is quite distinctive. Scarlet fever is caused by infection with Group Other common symptoms include headache, A streptococcus. Scarlet fever strains of group A strep chills, and vomiting, and tiny white lines around produce toxins that are released in the skin, caus- the mouth, as well as fi ne red striations in the ing a bright red rash the consistency of sandpaper. creases of the elbows and groin. After a few days, In the past, the disease was associated with poor the tongue coating peels off, followed by a drop in living conditions. In 1737, a scarlet fever epidemic fever and a fading rash. Skin on the hands and feet in Boston killed 900 people; another epidemic in often peel. New York City in the late 1800s killed 35 percent of children who contracted the disease; that same Treatment Options and Outlook year, 19 percent of Chicago children who got the A 10-day course of antibiotics (usually penicillin or disease perished. ERYTHROMYCIN), with rest, liquids, and acetamino- Inexplicably, by the 1920s the death rate of the phen is effective. disease dropped to 5 percent for reasons that are still Children are contagious for a day or two after not completely understood. It is believed that the they begin treatment, but after that they can return scarlet fever bacteria underwent a natural mutation to school. Alternatively a shot of long-acting peni- that made it less virulent. The introduction of PENI- cillin that slowly releases the antibiotic over several CILLIN reduced the death rate even more. weeks may be effective. Today, most cases occur in middle-class suburbs, As with other types of sore throat caused by the not in inner cities. Because it is possible to get a streptococci bacteria, untreated infection carries streptococcal infection and scarlet fever more than the risk of rheumatic fever or glomerulonephritis once, and because the incidence of all strep infec- (infl ammation of the kidneys). tions is rising, prompt medical attention when streptococcus infection is suspected is important. A child with a sore throat or skin rash should be scarlatina Another name for SCARLET FEVER. brought in for medical evaluation. Anyone can develop scarlet fever, but most cases are found among children aged four to eight. Resembling SCARLATINA, the deli- Scarlet fever bacteria are spread in droplets dur- scarlatiniform cate red rash of SCARLET FEVER. ing coughing or breathing, or by sharing food and drink. When bacterial particles are released into the air, they can be picked up by others close by. For this reason, some experts advise children to avoid Schamberg’s disease The common name for drinking fountains. The hallmark rash is caused by progressive pigmented PURPURA, one of several a toxin released by the bacteria. subtypes of PIGMENTED PURPURIC DERMATOSIS that share the symptom of rust-colored MACULES and Symptoms and Diagnostic Path PAPULES (especially on the lower legs). The red pig- After an incubation period of two to four days, ment changes are caused by the leaking of blood the fi rst signs of illness is usually a fever of 103˚ to into tissues. 322 schistosomiasis, visceral

Symptoms and Diagnostic Path Treatment Options and Outlook In this subtype, there is no ITCHING; the small The drug praziquantel has revolutionized the treat- macular spots and brown pinhead-sized macules ment of this form of schistosomiasis since the are found on the lower part of the leg. The red 1980s; one dose can kill the fl ukes and prevent fur- color and tiny size give these lesions their common ther damage. Alternative drugs are oxamniquine name—CAYENNE PEPPER SPOT. and metriphonate.

Treatment Options and Outlook Risk Factors and Preventive Measures There is no really satisfactory treatment, but the There is no vaccine to prevent the disease, and visi- condition is more of a cosmetic problem than tors to the tropics should assume that all lakes and a medical one, since internal organs are not rivers are unsafe for swimming. involved and the lesions do not itch. Patients may fi nd support stockings helpful. While sys- temic CORTICOSTEROIDS are usually effective, their scleroderma A general term for several chronic risk is usually greater than any benefi t that would autoimmune conditions (also called systemic scle- accrue from their use. Topical CORTICOSTEROIDS rosis) that involve the abnormal growth of connec- (especially under wet dressings) may help. tive tissue. In some forms of scleroderma, patients experience only hardened, tight skin, but in other forms, the problem goes much deeper, affecting schistosomiasis, visceral A parasitic disease blood vessels and the heart, lungs, and kidneys. (also called bilharziasis) that causes an itchy Scleroderma is considered to be both a rheumatic rash where fl ukes (fl atworms) have penetrated and a connective tissue disease. Rheumatic diseases the skin. The disease, found in most tropical are characterized by infl ammation and pain in the countries, affects more than 200 million people muscles, joints, or fi brous tissue. A connective around the world. tissue disease affects the major substances in the The disease is caused by one of three types of skin, tendons, and bones. It is twice as common in fl ukes (schistosomes) acquired from bathing in women, especially between the ages of 40 and 60. infested lakes and rivers in the Far East, West Scleroderma’s cause is unknown, but it is not Indies, Africa, South and Central America, and infectious or transmittable. Studies of twins also the Middle East. The fl ukes penetrate the skin, suggest it is not inherited. Instead, scientists suspect where they develop within their host into adults. that scleroderma may be the result of infl amma- Their eggs provoke infl ammatory reactions. tory activity, a type of noninherited genetic activity, environment, or hormones. Symptoms and Diagnostic Path Abnormal immune or infl ammatory activity While it also causes problems in other organs, Scientists believe scleroderma is an autoimmune the skin symptoms of this condition include disease, which occurs when a patient’s own immune DERMATITIS, HIVES, and skin lesions, due to the system for some reason attacks its own cells. The deposits of eggs in the skin. The relatively minor immune system of scleroderma patients may stim- skin symptoms of this form of schistosomiasis ulate certain cells to produce too much COLLAGEN, is quite different than the marked skin infl am- which then forms thick connective tissue around mation in SWIMMER’S ITCH (the second form of the cells of the skin and internal organs. In milder schistosomiasis). forms, this buildup is limited to the skin and blood About one to two months after the penetra- vessels, but in more serious forms it also interferes tion of the skin, hives again appear. Skin lesions with normal function of skin, blood vessels, joints, caused by the egg deposits may appear in the and internal organs. genital and perineal (the region of the body Genetic makeup While genes may put certain between the anus and the urethral opening) people at risk for scleroderma, the disease is not areas. passed from parent to child as some genetic diseases scleroderma 323 are. However, some research suggests that having sweat very little and have little hair growth. children may increase a woman’s risk of sclero- Patches appear most often on the chest, stomach, derma. When a woman is pregnant, cells from and back, although they also may appear on the her baby can enter her bloodstream and remain face, arms, and legs. in her body for many years. Recently, scientists Morphea can be either localized or generalized, have detected fetal cells from former pregnancies but both types of morphea generally fade out in the in the skin lesions of some women with sclero- three to fi ve years, although people are often left derma. Experts suspect that these fetal cells may with darkened skin patches and, in rare cases, mus- either trigger an immune reaction to the woman’s cle weakness. Localized morphea typically involves own tissues or set off a response by the woman’s only one or a few reddish patches from about a immune system to remove those cells. Either way, half-inch to 12 inches in diameter. The condition the woman’s healthy tissues may be damaged in sometimes appears on areas treated by radiation the process. Further studies are needed to fi nd out therapy. Generalized morphea spreads over the if fetal cells play a role in the disease. entire body with darker, harder patches. Environmental triggers Research suggests that Linear scleroderma is characterized by a single exposure to some environmental factors such as line or a band of thickened or abnormally colored viral infections, adhesive and coating materials, skin that appears down an arm or leg, or down the and organic solvents such as vinyl chloride or tri- forehead. chloroethylene may trigger the disease in people Systemic scleroderma This type of scleroderma genetically predisposed to it. affects the skin, but also penetrates into the tissues Hormones By the end of the childbearing years beneath, affecting the blood vessels and major (ages 30 to 55), women develop scleroderma at a organs. Systemic sclerosis is typically broken rate seven to 12 times higher than men, which leads down into diffuse and limited disease. People with scientists to suspect that there must be something systemic sclerosis often have all or some of the unique to women (such as the hormone estrogen) symptoms that some doctors call CREST, which that is linked to the disease. However, the role of stands for Calcinosis, RAYNAUD’S PHENOMENON, female hormones has not yet been proven. Esophageal dysfunction, Sclerodactyly, and Tel- angiectasias. Symptoms and Diagnostic Path The formation of calcium deposits in the connec- There are two basic groups of scleroderma diseases— tive tissues is called calcinosis, which can be detected localized and systemic. It is the localized type of by X-ray. These deposits are often found on the fi n- scleroderma that primarily affects the skin and gers, hands, face, and trunk and on the skin above related tissues and, in some cases, the muscle elbows and knees; they can break through the skin, below. Internal organs are not affected by localized causing painful ulcers. Raynaud’s phenomenon is scleroderma as they are in the systematic variety, a condition in which the small blood vessels of the and will never progress to the systemic form. hands and/or feet contract in response to cold or Localized scleroderma Often the skin lesions in anxiety, so that hands or feet turn white and cold, localized scleroderma improve or go away on their and then blue. As blood fl ow returns, they become own over time, although the skin damage that red. Fingertip tissues may suffer damage, leading occurs when the disease is active can be permanent. to ulcers, scars, or gangrene. Esophageal dysfunc- However, for some people, localized scleroderma is tion impairs the function of the esophagus so that serious and disabling. There are two generally rec- swallowing is diffi cult, causing chronic heartburn ognized types of localized scleroderma—morphea or infl ammation. Sclerodactyly results in thick, and linear scleroderma (and some people have tight, shiny, darkened skin on the fi ngers because both types of localized scleroderma). of excess collagen deposits within skin layers. The Morphea is characterized by reddish patches of condition makes it diffi cult to bend or straighten skin that thicken into fi rm, ovalshaped areas, with the fi ngers. TELANGIECTASIAS are small dilated blood a center of ivory with violet borders. These patches vessels on the hands and feet. 324 scorpion stings

Limited scleroderma Limited scleroderma typi- cal problems. A scorpion sting produces severe pain cally begins slowly, affecting the skin only on the and swelling at the site of the sting; a nontoxic fi ngers, hands, face, lower arms, and legs. Many scorpion sting will swell and become discolored, people with limited disease have Raynaud’s phe- forming a BLISTER. These symptoms may last for nomenon for years before skin thickening starts, eight to 12 hours. If the sting was from C. exilicauda, while others experience initial skin problems cov- the sting will be followed by a PINS AND NEEDLES ering the body, which then slowly improves, leav- SENSATION at the sting site. The area of the sting ing only the face and hands with tight, thickened would not get swollen or discolored, but within skin. This is typically followed by the development one to three hours may trigger itching eyes, nose, of telangiectasias and calcinosis. and throat; tightness of the jaw muscles, speech Diffuse scleroderma This type of scleroderma problems, extreme restlessness, numbness, froth- begins abruptly, as skin suddenly thickens and ing at the mouth, nausea and vomiting, inconti- tightens over much of the body, symmetrically nence, drowsiness, muscle twitching and painful affecting the hands, face, upper arms, upper legs, spasms, irregular heartbeat, breathing problems chest, and stomach. Internally, the disease can (including respiratory paralysis), and sometimes damage the heart, lungs, and kidneys. People with convulsions. Death is rare because toxicity is dose diffuse disease often feel tired, lose appetite and related, but the smaller the victim, the higher the weight, and have painful joint swelling. risk of a fatal sting. After the fi rst three to fi ve years, the disease often stabilizes, and skin thickness and appearance Treatment Options and Outlook remain about the same, while little internal dam- Medical attention is usually necessary only for age occurs and symptoms subside. Gradually, the infants and the elderly, or if the person is having skin starts to change again, so that the last areas to trouble breathing. An antivenin is available for thicken become the fi rst to begin softening. Some severe reactions. Local anesthetics and powerful patients’ skin returns to almost normal, while oth- painkillers may be administered. ers have thin, fragile skin and neither hair nor Fatalities have occurred as long as four days sweat glands. More serious damage to heart, lungs, after a sting, but it is not true that any scorpion will or kidneys is unlikely to occur. be fatal. In fact, only one out of a thousand stings People with diffuse scleroderma face a serious is fatal. long-term outlook if they develop severe kidney, lung, digestive, or heart problems, but less than a Risk Factors and Preventive Measures third of patients with diffuse disease develop these Scorpions would not run after a human and attack, problems. but they will sting if they are picked up or stepped on. They prefer moist, dark places and often hide Treatment Options and Outlook in clothing or shoes. Residents in endemic areas There is no effective treatment. Symptoms may be should always shake out all shoes, bedding, and controlled with antihypertensives, physical ther- clothing before using and should modify the area apy, dialysis, and CORTICOSTEROID drugs. surrounding a house, moving trash, logs, boards, stones, bricks, and any other objects, mowing the grass, and pruning overhanging bushes and tree scorpion stings The sting of most species of scor- branches. Garbage cans should be stored off the pion cause pain similar to a bee sting, but the more ground, and fi rewood should never be brought toxic varieties can cause sweating, restlessness, diar- inside the house unless it is placed immediately rhea, and vomiting—and can be fatal to children. onto a fi re. Homeowners also should add weather- stripping inside and out around doors, baseboards, Symptoms and Diagnostic Path and windows, and plug any holes in the walls with Symptoms that appear within two to four hours steel wool, pieces of nylon scouring pad, or small after a toxic scorpion sting indicate a serious medi- squares of screen. sea bather’s eruption 325 scratch A skin mark caused by the stroking of the Sea bather’s eruption was fi rst described in 1949 skin with fi ngernails or a sharp instrument. as an itchy rash occurring in bathers off the eastern coast of Florida. Sea bather’s eruption is a hypersensitivity skin scrofuloderma See TUBERCULOSIS SKIN. reaction to the larval form of the thimble jellyfi sh, L. unguiculata. The rash typically occurs underneath a bathing suit, which is believed to trap the jel- scurvy A disease caused by inadequate intake of lyfi sh larvae against the skin. It remains uncertain VITAMIN C that results in skin hemorrhages, causing whether the discharge of venom by the trapped widespread bruising. It is rare today in developed larvae may play an important role in the appear- countries because of widespread consumption of ance of the rash. fresh fruit and vegetables; body stores of the vita- Factors that promote the discharge of venom min can protect against scurvy for about three by the larvae include wearing bathing suits months. However, it is still seen in developed coun- for long periods after swimming, exposure to tries among the elderly who have poor diets. It has freshwater through showering, and mechanical primarily been associated with sailors, who used to stimulation. suffer from scurvy because of a lack of fresh fruit Due to seasonal variation in the concentrations during long sea voyages. of thimble jellyfi sh larvae in endemic areas, there The body’s normal production of COLLAGEN is is an increased incidence of sea bather’s erup- disrupted by inadequate supplies of VITAMIN C; as tion during May through August, with a peak the collagen production becomes unstable, it weak- in May/June. This coincides with the warm Gulf ens small blood vessels and slows wound heal- streams running along the Atlantic coastline of ing. Hemorrhages and widespread bruising occur, Florida and the corresponding spawn of thimble together with bleeding gums and loosening of jellyfi sh larvae, which results in the high seasonal teeth. Pain results from bleeding into muscles and concentration of the jellyfi sh. The occurrence of joints. Follicular purpura of the skin is classical. sea bather’s eruption in Palm Beach saltwater The disease is especially serious in children, swimmers in May has been estimated to be 16 since bleeding into the membranes around the long percent. bones may interfere with growth. Fatal hemor- Similar rashes have been reportedly linked to rhages in and around the brain may also occur. the larvae of the sea anemone Edwardstella lineata in an outbreak of sea bather’s eruption on Long Treatment Options and Outlook Island. Various types of larvae in other waters likely Large doses of vitamin C will stop bleeding within can produce similar rashes. 24 hours, quickly easing bone and muscle pain. Symptoms and Diagnostic Path Risk Factors and Preventive Measures Apparently, some people are more susceptible to The body can obtain enough vitamin C through the condition than others, since in any group of modest consumption of fruit (especially citrus fruit) swimmers only certain people will experience sea and vegetables; other sources of vitamin C include bather’s eruption. Relatively rare signs and symp- milk, liver, kidneys, and fi sh. toms of sea bather’s eruption include nausea, head- ache, sore throat, cough, diarrhea, and abdominal pain. sea bather’s eruption A rash of red bumps that Children more commonly demonstrate body- appear on the skin creases covered by a bathing wide symptoms, including fever, nausea, abdomi- suit after swimming in salt water. The symptoms nal pain, and diarrhea. These symptoms may be usually become noticeable within several hours of mistaken for viral gastritis. swimming, and last for several days before clear- Diagnosis of sea bather’s eruption is made based ing up. on history of exposure and physical examination. 326 sea urchins

Laboratory studies and skin biopsy are sebaceous cyst A nonspecifi c term for a harm- unnecessary. less large, smooth nodule under the skin, usually found on the face, ear, scalp, trunk, or genitals (a Treatment Options and Outlook CYST on the scalp is called a wen). These cysts may Patients with sea bather’s eruption require only grow very large and may become red and infl amed symptomatic or supportive therapy. High-potency either spontaneously or after trauma. The infl am- topical steroids in combination with oral ANTIHISTA- mation is usually the result of disruption of the cyst MINES are typically used to treat the rash. Systemic wall, causing the contents (usually a mixture of CORTICOSTEROIDS should be reserved for patients KERATIN) to leak out. These cysts are often wrongly with severe rash or pronounced associated sys- thought to be infected because of their appearance, temic symptoms. and antibiotics are incorrectly administered. Alternative remedies made with vinegar, rub- bing alcohol, sodium bicarbonate, sugar, urine, Treatment Options and Outlook olive oil, and meat tenderizer may help. Incision and drainage is recommended. Large or bothersome cysts should be removed surgi- Risk Factors and Preventive Measures cally under local anesthetic; if the entire cyst wall Studies suggest that the risk of developing sea is removed, recurrence is rare. Infl amed cysts bather’s eruption in patients exposed to high sea- should not be excised until the infl ammation has sonal concentrations of larvae while swimming in subsided. salt water can be reduced if bathers shower with the bathing suit off, regardless of length of time in the water or timing of showers. sebaceous glands Tiny glands that secrete a lubricating substance called SEBUM either into hair follicles or directly onto the skin’s surface. Most sea urchins The spines of sea urchins can break of these glands are located on the scalp, face, and off in or underneath the skin, causing an immedi- around the anus; none are found on the hands or ate burning, swelling or ITCHING, and redness or a soles of the feet. The production of sebum is partly delayed reaction featuring a fl esh-colored nodule controlled by male sex hormones. Problems with appearing several months after being stung.

Treatment Options and Outlook Cross Section of Skin Revealing Sebaceous Gland For an immediate reaction, the wound should be placed in extremely hot water for at least a half hour to relieve pain; spines must be surgically removed in an emergency room to eliminate the risk of infection. Even so, some spines will remain lodged and will take several months to be ejected by the body’s defenses. Sweat Gland seaweed A plant whose gelatin-like substance is used as the main ingredient in peel-off masks. Sebaceous Seaweed is also used in face creams and lotions to Gland help provide body to the products.

seaweed dermatitis See DERMATITIS, SEAWEED. Hair Bulb self-tanning products 327 the sebaceous glands may lead to excessively oily skin and scalp) and may lead to seborrheic DERMA- skin (SEBORRHEA), ACNE, RHINOPHYMA, or sebaceous TITIS or ACNE. hyperplasia.

sebum-suppressive agents The only medication seborrhea Excess SEBUM secretion, causing known to suppress SEBUM production is ISOTRETI- increased facial oiliness and a greasy scalp. While NOIN (Accutane), which works by suppressing the the exact cause of this excess production is not sebaceous glands. Topical agents may be used to understood, male sex hormones (androgen hor- defat the skin, but sebum activity is not affected and mones) do play a role in the problem. Not surpris- within minutes, the skin’s oiliness returns. ingly, therefore, the problem is most common in adolescent boys and men. self-tanning products A cosmetic product Symptoms and Diagnostic Path designed to produce an “artifi cial” tan without Symptoms include excessive oiliness of the skin, requiring exposure of the skin to the sun. The especially of the scalp and face, without redness or main ingredient in most topical products is DIHY- scaling. Patients with seborrhea may later develop DROXYACETONE (DHA), a chemical that acts only seborrheic dermatitis, which is characterized by on the skin’s superfi cial cell layers. When the DHA both redness and scaling. combines with certain amino acids and KERATIN in the skin’s outer layer, it produces a natural Treatment Options and Outlook golden color. However, as the skin sheds its dead Seborrhea usually disappears by adulthood with- cells, the tan fades—usually within a few days of out treatment, but people with seborrhea are also application. more likely to have other skin problems such as Some self-tanning products also include a SUN- ACNE vulgaris and seborrheic DERMATITIS. Sebor- SCREEN up to 15 SPF; others contain no sunscreens rhea is very diffi cult to treat. Washing the face at all. Topical self-tanning products should be frequently and the use of acne products reduce applied at least several hours before going out in skin oiliness only temporarily. The only medica- the sun, and preferably the night before. Sunscreen tion known to reduce sebaceous gland activity is should then be applied at least an hour before ISOTRETINOIN (Accutane), which reduces the size of going outside. the glands during treatment and for several months For best results, users should exfoliate before afterwards. The side effects of Accutane usually application because the DHA may be absorbed preclude its use for seborrhea. unevenly in areas where there is a thick layer of dead cells—especially hands, elbows, and knees. The depth of color is determined by how often the seborrheic dermatitis See DERMATITIS, SEBORRHEIC. product is reapplied, not by how much is applied at one time. It can take between three to fi ve hours for a self-tanner to develop fully. seborrheic keratoses See KERATOSES, SEBORRHEIC. Most self-tanning formulations have a short shelf-life once opened because DHA degrades quickly, and should be used up within three sebum An oily substance produced by the SEBA- months of opening. CEOUS GLANDS in the skin. Composed of fat and Tanning pills are another self-tanning prod- wax, sebum lubricates the skin and protects it uct, but these drugs are available only outside from becoming soggy when wet, or cracked when the United States and are not recommended by exposed to hot, dry temperatures. Sebum also DERMATOLOGISTS. There are two types; one type helps protect the skin from bacteria and fungi. of drugs contain canthaxidine, a chemical that Oversecretion of sebum causes SEBORRHEA (oily colors the skin but can damage the eyes and liver. 328 Senear-Usher syndrome

The second contains PSORALEN, also available as a or women can be highly reactive to a variety of psoralen-containing cream. Neither is available in irritants. the United States, and both are considered danger- Some of the most common irritants are cold air, ous by dermatologists because of the potential for dry air, water, and ultraviolet light. Other non- severe SUNBURNS. environmental irritants that can induce contact Several self-tanning synthetic hormones that dermatitis include primary and secondary irritants. color the skin and also seem to protect against sun Primary irritants can cause the skin to react the damage are currently under investigation. very fi rst time they contact the EPIDERMIS. (This group includes strong acids or alkalies that burn the skin.) Secondary irritants are milder, and pro- Senear-Usher syndrome The common name for duce an irritation only after the skin has become the blistering disease PEMPHIGUS erythematosus. sensitized to the substance over time. For example, these could include soaps, detergents, moisturizers, Symptoms and Diagnostic Path SUNSCREENS, and so on. Symptoms are usually limited to the face, where it “Hypoallergenic” cosmetics and products are appears as a butterfl y rash over the nose and cheeks. designed for the consumer with sensitive skin. Its severe scales and crusts may also appear on the This may indicate that a product has no added scalp and the upper areas of the chest and back. fragrance or that the manufacturer has avoided certain compounds known to be irritating. Unfor- Treatment Options and Outlook tunately, when a person has become sensitive to Topical medications including cleansing baths using a range of ingredients, it can become harder and BUROW’S SOLUTION or silver sulfadiazine cream, harder to fi nd products that do not trigger an aller- and application of topical CORTICOSTEROIDS may gic response. This group of patients is not neces- ease symptoms. Systemic corticosteroids are the sarily allergic to agents, but they may more easily primary method of treatment, beginning with develop irritant reactions. doses high enough to completely stop the forma- See also DERMATITIS, IRRITANT; DERMATITIS, CON- tion of new BLISTERs. Immunosuppressive therapy TACT; DERMATITIS, ALLERGIC. together with corticosteroids improves control of the disease. Most patients on long-term systemic cor- serum sickness A brief illness featuring a skin ticosteroids develop side effects, such as high rash that develops about 10 days after an injection blood pressure, weight gain, infection, potassium with an antiserum derived from animals (such as loss, gastrointestinal bleeding, osteoporosis, and anti-rabies serum obtained from horses). Antisera cataracts. can be obtained from either human or animal blood that contains specifi c antibodies (substances that play a role in immunity), and may be given to senile keratoses See KERATOSES, SENILE. protect against dangerous infections. When an antiserum is prepared from animal blood, a protein in the serum may be identifi ed sensitive skin Some people appear to have by the body’s immune system as a potentially skin that is extraordinarily sensitive, easily ITCH- harmful foreign substance (called an antigen). In ING, burning, chafi ng, stinging. This type of skin serum sickness, the person’s immune system pro- is also called problem-sensitive skin. Individu- duces antibodies that combine with the antigen als with sensitive skin often develop diffi culties to form particles called immune complexes. They while using cosmetics. While popular myth holds are deposited in various tissues, stimulating more that fair or thin-skinned women have the most immune reactions and leading to infl ammation sensitive skin, in fact any type of skin in men and other symptoms. Serum sickness is different shampoo 329 from anaphylactic shock, another type of hyper- shake lotion A suspension of powder in a liquid, sensitivity reaction in response to antiserums. such as water or oil. Anyone who has ever had serum sickness should remember the injection to which they are sensitive and warn medical personnel against its shampoo Liquid hair cleaner designed to wash future use. away dirt and oil. All shampoos clean hair by removing oil (produced from the oil glands in Symptoms and Diagnostic Path the scalp) and debris the oil attracts to the hair About a week after exposure to the antiserum, an shaft. Inexpensive shampoos may be about 90 itchy rash may appear, followed by enlarged lymph percent water with added detergent cleansing nodes, painful joints, and fever. In severe cases, a agents—usually either SODIUM LAURETH SULPHATE, state similar to shock develops. Symptoms usually SODIUM LAURYL SULFATE, ammonium laureth sul- fade within a few days. fate, and ammonium lauryl sulfate. More expen- sive products vary from 30 to 50 percent solids. Treatment Options and Outlook Other shampoo ingredients include slip agents or Soothing lotions may help with the itching; non- oils such as dimethicone, lecithin, cyclomethicone, steroidal anti-infl ammatory drugs may relieve joint and mineral oil, with thickeners and ingredients to pain and an antihistamine may curtail the illness add lubrication and texture, such as stearyl alcohol, period. In severe cases, systemic CORTICOSTEROIDS cetyl alcohol, or protein; detangling agents such as may be prescribed. tricetylmonium chloride, benzalkonium chloride, or quaternium 1 through 80; foaming agents (lin- oleic DEA or cocamide DEA); preservatives, color- Sezary syndrome A rare T-cell lymphoma caus- ing agents, and/or fragrances. Many manufacturers ing total body redness (with scaling), because of an add other ingredients, including aloe vera, amino abnormal overgrowth of lymphoid cells in the skin, acids, COLLAGEN, vitamins, herb or fruit extracts, liver, spleen, and lymph nodes. Sezary syndrome and a variety of unusual oils. primarily affects middle-aged and elderly patients. The formulation of shampoos for various types of hair is very complex; even the addition of .1 Symptoms and Diagnostic Path percent of an active ingredient can change the The patchy redness appears fi rst, followed by hair formula. Therefore, it is diffi cult to judge any loss, thickening of the palms and soles, and dis- product’s performance based on the label ingredi- torted nail growth. Malignant T-cells also accumu- ents alone, since performance is determined by the late in the bloodstream. concentration of ingredients and how they function when mixed with other ingredients. Even expert Treatment Options and Outlook cosmetic chemists cannot judge the performance Treatments include topical and systemic antican- of a product based on reading label ingredients cer drugs, electron beam radiation, and PUVA alone. therapy. Low doses of METHOTREXATE also has been Some manufacturers have begun to add SUN- reported to help a group of patients, and does not SCREENS in shampoo, but they are not given an cause secondary leukemia. Also benefi cial may be SPF rating, because rating is based on the ability photopheresis—giving the PSORALEN methoxsalen of a sunscreen to allow greater sun exposure to followed by irradiation of the blood with UVA. an individual without producing a sunburn. Since a sunburn is evaluated by skin redness, the test is impossible to do on hair. Instead, manufacturers shagreen patch A sign of TUBEROUS SCLEROSIS have proposed establishing measures of “hair pro- that involves large area of protruding skin on the tective factors” as a way of measuring a product’s lower back. ability to protect hair. Hair is very susceptible to 330 shaving and the skin damage from ultraviolet light, especially if it has because they can cause a photosensitivity reaction been colored or permed. Sunscreen for hair is most in the sun. effective when included in conditioners or fi nishing Blades should be changed after three to six sprays. shaves. A light touch with smooth, even, long strokes along the grain produces the closest, least- How to Use irritating shave. In the case of nicks, a styptic pencil Shampoo should be applied to the scalp, especially (aluminum chloride) can help. if the user has long or chemically treated hair. Hair After shaving, cool water or a mild after-shave near the scalp will be oilier, and looks fl at and lotion should be used to tighten pores and smooth sticky with oil buildup; hair at the ends does not skin. Talcum powder after shaving does not really get nearly the lubrication. Those with seriously provide much benefi t, but applying a mild moistur- damaged or dry hair should never apply shampoo izer after shaving may be helpful. to the ends of the hair shaft; enough shampoo will reach this area as the hair is rinsed. Shampoo must be thoroughly rinsed out of the shingles A viral infection caused by the VARI- hair, or it will make the shafts look dull and fl aky CELLA-ZOSTER VIRUS, a virus of the herpes family with residue. that causes a painful, red blistering of the nerves Anyone with coarse, permed, color-treated, or that supply certain areas of the skin. The problem damaged hair should not use a combination sham- begins during a CHICKEN POX attack (usually in poo and conditioner. A shampoo and conditioner’s childhood); after the spots fade, the virus lies dor- uses are actually opposite; the shampoo is designed mant in sensory nerves for many years. For reasons to clean oil off the hair, while the conditioner coats that aren’t entirely clear, the virus may reemerge the hair. and cause an episode of shingles. This is found Those with oily hair should not use conditioner most often in those over age 50. unless the hair is colored or permed, since con- Although rarely fatal, shingles has been the ditioners add lubricants and coatings to the hair, scourge of the elderly and the immunocompro- which is already struggling with excess oil. mised because it causes such terrible pain; each For those with chemically treated hair, con- year, the condition affects 500,000 people each year ditioners designed for oily hair (these products in the United States about one in 544. Researchers use little or no oils and lighter weight lubricants) believe that current population trends will bring should be applied only to the ends of the hair, more cases of shingles as the numbers of elderly avoiding the scalp. and those with failing immune systems increases. After washing, hair should not be scrubbed dry with a rough towel; it should be dried gently by a Symptoms and Diagnostic Path blotting or gentle squeezing motion. Rough treat- The fi rst sign of shingles is an excessive sensitivity ment on wet hair can damage the cuticle. in an area of skin, followed by pain. After about fi ve days a rash appears, turning fi rst into tense BLISTERs, and then yellow lesions within three shaving and the skin Daily shaving exfoliates the more days. The blisters then dry out and crust over, skin. The best way to get a nondamaging shave is gradually dropping off, leaving small pitted scars to fi rst soften the hair with warm water; hot water behind. Because the nerves have been damaged can infl ame the skin. Shaving soap or cream helps after the shingles attack, once the blisters heal the hold moisture, softening and lifting the hairs. Gel nerves constantly produce strong pain impulses and cream-containing moisturizing shaving creams that may last for months or years. The older the help individuals with dry or easily irritated skin. patient and more severe the rash, the more likely Shaving creams that contain OIL OF BERGAMOT the pain (called POST-HERPETIC NEURALGIA) will (found in some lime scents), should be avoided persist. sickle-cell ulcers 331

Shingles often affects a belt of skin over the ribs production of a chemical necessary for pain impulse on one side, which is where herpes zoster gets its transmission between nerve cells. It should not be name (zoster is the Greek word for belt). Sometimes applied to active shingles blisters; as a counterirritant, the disease affects the lower part of the body or the Zostrix is designed to be used on unbroken, healed upper half of the face on one side. The common skin that hurts, not for open, oozing infections. name for the disease—shingles—comes from the For severe pain from shingles, some experts Latin word for belt—cingulus. recommend injecting a sympathetic nerve block in the appropriate place to block the nerves supplying Treatment Options and Outlook the area of pain. This block typically relieves pain Prompt use of antiviral drugs—such as ACYCLOVIR in up to 80 percent of patients. In some cases, it (Zovirax), famciclovir (Famvir), and valacyclo- can permanently end shingles pain. Prompt inter- vir (Valtrex) can shorten the rash and lessen the vention by a pain specialist can sometimes head off chance of pain later. These drugs are most effec- post-herpetic neuralgia. tive if used within 72 hours after the rash appears; patients should seek medical help at the fi rst sign Risk Factors and Preventive Measures of shingles. Both drugs slow reproduction of the Recent studies have found that a stronger version virus and shorten the course of the infection. There of the chicken pox vaccine was able to cut the is some evidence that the drugs may also decrease incidence of shingles in half. In April 2005 the U.S. the chances for nerve pain following an attack. Food and Drug Administration received a license Doctors often prescribe various pain medica- application from the manufacturer for the zoster tions for people with shingles. Because the pain of vaccine. If approved for use, the vaccine has the shingles can be so intense, some researchers have potential to prevent hundreds of thousands of cases looked for other ways to block the pain. of shingles in the United States each year. It works When the herpes zoster virus infl ames nerves, by boosting the type of immunity necessary to hold they pump out a chemical messenger called glu- the virus in check. tamate. Glutamate then travels to receptors on nearby cells, which transmit pain signals to the brain. Shingles triggers such a fl ood of glutamate shock, electrical See ELECTRICAL BURN; ELECTRI- that some cells stop functioning, while others CAL INJURY. become hypersensitive. This probably explains why shingles patients can feel great pain even when skin is touched only lightly. sickle-cell ulcers Skin symptoms occur in about There are drugs that can block the receptor sites half of patients with sickle-cell anemia, a heredi- where glutamate lands, and researchers are study- tary disease that affects African Americans char- ing whether these drugs will help relieve shingles acterized by the production of an abnormal type pain. In 1999, the U.S. Food and Drug Administra- of hemoglobin. The skin ulcers associated with tion approved a patch form of the anesthetic lido- this condition usually appear between ages 10 and caine. The patch, called Lidoderm, provides pain 20 and appear on the lower legs, with recurrent relief for some people with shingles. Because Lido- attacks of fever and pain in the anus, legs, and derm is applied to the skin, it has less risk of side abdomen. They are caused by partial obstruction in affects than pain medications taken in pill form. the blood vessels and decreased oxygen in certain A cold, wet compress applied to the blisters and areas caused by abnormal hemoglobin. avoiding direct heat on the lesions may help. The medication Zostrix (active ingredient: CAPSAICIN, a Symptoms and Diagnostic Path red pepper derivative) may help relieve the post- The sickle-cell lesions look like well-defi ned herpetic neuralgia, once all the blisters have disap- punched-out skin defects that are painful and heal peared. Experts believe the capsaicin blocks the slowly; they may be complicated by infection. 332 silica

Treatment Options and Outlook Today, while the FDA has not formally Affected limbs should be elevated and immobilized. approved silicone gel-fi lled breast implants, they The ulcers should be cleaned with antibacterial have allowed their continued use under certain solutions; the wounds also should be debrided in guidelines. The FDA also concluded that the order to promote healing. Blood transfusions may implants were of signifi cant benefi t for reconstruc- be necessary. tive patients, and ruled that the implants should be available to those who want them. However, only a small number of women who want the gel-fi lled silica A mineral included in face and body pow- implants for cosmetic augmentation are allowed ders and paste-type masks. Silica is soothing and to have them; these women must be part of a forms a moisture-retaining fi lm on the skin. research study and their names must be recorded in a registry. The FDA also requires manufactur- ers to conduct more studies to prove the device’s silicone implant A synthetic implant once widely safety and effectiveness. used in cosmetic surgery because it was resistant to Women who have an “urgent need” for an body fl uids, permeable to oxygen, and not rejected implant have immediate access to the device; by the body. The implants have been used in breast these include women who have expanders, whose reconstruction or breast enlargement for several implants have ruptured, or who are facing mastec- million American women. Medical-grade silicone tomy and who want reconstruction with silicone. is included in more than 500 products, includ- However, critics continue to insist that silicone ing a range of over-the-counter medications, and often leaks from the gel-fi lled devices, causing in hair spray, processed foods, skin creams, and cancer and neurological diseases despite a lack of cosmetics. supporting scientifi c data. As a result, more than 90 percent of the U.S. market now uses saline- History fi lled implants, although silicone implants have Silicone gel-fi lled breast implants have been avail- remained available for women who have under- able since 1963 and were originally made out of gone mastectomies. a thick, smooth envelope of silicone rubber fi lled In July 2005 silicone gel-fi lled breast implants with a silicone gel. In the early 1980s, the shell was moved a step closer to being reintroduced to reformulated to minimize the amount of certain the general U.S. market after the FDA issued an types of silicone that “bled” through the envelope. “approvable with conditions” letter to one manu- Among the more than 2 million women who facturer (Mentor Corp.) for its implants. However, have had breast implants containing a soft polymer this letter does not mean that the device is approved called polydimethylsiloxane (PDMS), reported ill- for marketing in the United States at this time. Fed- nesses from reactions to the implants include auto- eral law prohibit the government from discussing immune disorders such as LUPUS ERYTHEMATOSUS, the letter’s specifi c contents, but an approvable let- rheumatoid arthritis, and chronic fatigue. In some ter is one of several intermediate steps in the FDA’s cases, silicone invaded the surrounding tissue or review process for new products. implant capsule. In 1992, based on complaints that the implants Procedure ruptured or caused systemic disease, the U.S. Food Surgical insertion of the device can be performed and Drug Administration (FDA) called for a vol- under local or general anesthesia, and is usually untary moratorium on the use and distribution an outpatient procedure. It can be placed either of silicone gel-fi lled breast implants. This call fol- directly beneath the breast tissue or under the lowed a 1991 advisory panel ruling that found “no muscles. For reconstructive surgery after mastec- evidence that these implants are unsafe” but noted tomy, the existing surgical incision is usually used, that “there is also insuffi cient evidence to prove and the implant can be placed at the time of mas- safety.” tectomy or at a later date. silicone implant 333

Side Effects on a mammography or by physical examination, There have been a variety of different problems although neither method is 100 percent success- that women have experienced, which has led the ful. If this should happen, the free gel will usually FDA to crack down on silicone implants. be kept within the scar-tissue capsule around the Hardening of the implant The most common implant. side effect is called “capsular contraction.” Nor- A rupture should be suspected if the breast mally a surgical pocket is created for the implant changes in appearance or texture. Rarely, an acci- that is larger than the device itself. A membrane dent can tear the scar envelope itself, and push the called a capsule forms around the implant, and gel into subcutaneous areas such as the chest wall, under the best circumstances, it maintains its origi- down into the abdomen, the arm, or the breast nal dimensions, allowing the implant to rest inside tissue. it. However, for reasons that seem to be related to a Within two to six weeks, gel that has escaped is person’s individual characteristics, the scar capsule surrounded by new scar tissue and can form granu- shrinks in some women and squeezes the implant, lomas, which can either mask or mimic a tumor. causing the implant to become hard. These levels This is one reason why direct injection of silicone of contracture are measured on a scale of one to into the breast is not recommended. four (one so soft as to be undetectable, and four Cancer An FDA advisory panel in 1991 con- to be as hard as a grapefruit). The contraction may cluded that the potential risk from cancer from occur right after surgery, or only many years later, polyurethane-coated implants is probably less than in one or both breasts. Some researchers believe one in 1 million. Studies of women who have had that a low-grade bacterial contamination may trig- implants for 10 or 20 years have found no higher ger this process. incidence of breast cancer in this group than in This hardening is not hazardous to the health, those women without implants. but it can interfere with the cosmetic result and Other experts are concerned that the implants cause discomfort or pain. If it becomes trouble- may block the detection of breast tumors via mam- some, a physician may recommend surgically mography. The American College of Radiology, scoring the tight capsule of scar tissue or surgically the American Cancer Society, and the American removing it. However, hardening can recur. Society of Plastic and Reconstructive Surgeons For some women who have developed hard- agree that a woman with breast implants should ened implants, a “closed capsulotomy” can provide have routine mammography at the same rate as a dramatic immediate relief. In this procedure, a woman without implants but that she should be forceful squeeze of the breast can tear the scar cap- referred to mammographic facilities accredited by sule, allowing additional space for the implant and the American College of Radiology who are famil- restoring softness. This simple procedure causes iar with the special “Eklund” views required for very little pain and—when it works—the relief is adequate evaluation of the breast. If possible, these immediate, eliminating the necessity for surgery. women should return to the same place for all However, in some women excessive force is future mammograms. This type of mammography required to tear the capsule, which can be pain- is more expensive, since a minimum of four X-rays ful and sometimes ruptures the implant. The is required to adequately evaluate the breast; thus, FDA states that a closed capsulotomy should not the amount of radiation is also higher. be performed, although some physicians feel the Rheumatic disorders Some experts have spec- procedure is appropriate for some patients. If the ulated that there may be an association between implant does break, a closed capsulotomy can push silicone and autoimmune or rheumatic disorders, the loose gel into nearby tissues. especially SCLERODERMA and LUPUS ERYTHEMATOSUS. Rupture Sometimes the implants break on Since scleroderma, lupus, and similar diseases are their own. This could happen in the wake of a car not commonly found in the population, it is dif- accident or normal breast movement and compres- fi cult to research and compare the link between sion. This type of “silent rupture” may be detected them and implants. 334 Silvadene

Silvadene See SILVER SULFADIAZINE. cells are produced in lower layers of skin. After these new cells have grown and divided, they begin to migrate over a two-week period up to the sur- silver nitrate A salt of silver that is applied in face, where they replace older cells. creams or solutions to destroy WARTS and treat The hair and nails are extensions of the skin wounds and BURNS. It is also used in eyedrops and are primarily made up of KERATIN, the main to prevent a serious form of conjunctivitis in all constituent of the top layer of the skin. newborns. There are two layers of skin—the EPIDERMIS and DERMIS. The epidermis is the top skin layer, whose Side Effects thickness varies from about a ½ inch on soles of Silver nitrate may cause irritation or pain and if feet and palms to 1⁄25 inch over the eyelids; most used for a long time, it may cause permanent blue- of the epidermis is no thicker than a page in this black skin discoloration. It is extremely poisonous book, made up of about 20 overlapping layers when ingested. near the skin surface. The epidermis is good at holding water, which helps make the skin elastic and maintains the body’s balance of fl uid and silver sulfadiazine An antibacterial cream used electrolytes. to prevent infections in skin grafts or second- and A small proportion of epidermal cells are called third-degree burns. It is especially helpful in keep- Langerhans cells, and are located in the mid-zone ing burn sites sterile, thereby reducing the chance of the stratum spinosum, the middle layer of the of secondary infection. epidermis. They are also found in the dermis, lymph nodes, and thymus, and they are important Side Effects in recognizing and presenting antigens to keratino- Possible side effects include allergic reactions (with cytes and to lymphocytes. They serve as the early RASH, ITCHING, or burning). Although rare, long- warning system of the body’s immune system, term use may produce serious blood disorders or picking up antigens in the skin and circulating to kidney damage. It is not recommended for patients the draining lymph areas via the dermal lymphatics who are sensitive to sulfonamide drugs, nor should in order to elicit an immune reaction. it be used for newborns or premature infants. The epidermis is also divided into three layers— the basal layer (named because its cells form the base of the epidermis)—is also referred to as the skin The outermost covering of body tissue that Stratum germinativum because this layer of cells is weighs twice as much as the brain—about six to always producing—or germinating—new cells. The nine pounds, stretching over 18 square feet. It is second subdivision of epidermis is called the prickle also a sensory organ, and contains many cells sen- cell layer (or Stratum spinosum), composed of squa- sitive to touch, temperature, pain, pressure, and mous cells. The topmost layer is called the “horny itching. The skin protects the internal organs and layer” (Stratum corneum). The basal layer is also keeps the body at the correct temperature—not too home to the class of cells called MELANOCYTES, the warm and not too cold. pigment-producing cells that give birth to MELANIN When the body is hot, the SWEAT GLANDS in the (responsible for giving color to the skin). One out skin perspire, cooling the body, and helping the of every six cells in the basal layer is a melanocyte. blood vessels in the dermis to dilate, dissipating Production of the melanin is under the control of the heat. If the body gets cold, the blood vessels in a hormone secreted from the hypothalamus of the skin constrict, conserving the body’s heat. The the brain called melanocyte-stimulating hormone skin also takes in oxygen and secretes waste, and (MSH). It is believed that melanin is capable of manufactures hair, nails, and VITAMIN D. absorbing ultraviolet light and thus protecting The skin completely renews itself every 30 days; against the harmful effects of the ultraviolet rays as older cells are sloughed off on the surface, new that occur with suntanning. skin, cleansing 335

Cross Section of Skin sebum that makes the skin waterproof, allowing a person to sit in a tub without soaking up water like a sponge. Blood vessels, lymph vessels, and Hair nerves are also found throughout the dermis. Hair Horny Pore (Dead) and sweat glands are actually epidermal append- Layer ages that migrate into the dermis during fetal development. Epidermis Basal Cell Layer skin, cleansing Skin should be cleansed daily to Dermis remove dirt and grease, bacteria, and odor. Soaps Sweat are the products used for these purposes. There are Gland differences in the types of soaps that may be used on the skin, and they differ in outward appearance, Subcutaneous fragrance, cost, and composition. Layer For example, superfatted soaps, which are designed to improve mildness, contain excess fatty Hair Blood material and leave an oily residue on the skin. Folicle Transparent soaps contain glycerin and varied amounts of vegetable fats. Other soaps may be produced for specifi c purposes, such as oatmeal Differences in skin color are due to genetically soap for skin that tends to break out. The choice of determined differences in how much melanin a proper soap depends on a person’s age, skin tex- there is, and where it is found in the body. In gen- ture, skin problems, and personal needs. All soaps eral, the darker the skin the more melanin in the are good at cleansing, but because of age, heredity, epidermal cells, and the more densely arranged. climate, and skin texture, there are many different Sunlight stimulates this melanin production, and a methods of proper skin cleansing. suntan simply means that more melanin has been produced as a way of protecting the skin against Infancy the harmful effects of the sun. While the culture In infancy, the skin’s oil glands are not very active, may consider a suntan to be a characteristic of although the SWEAT GLANDS are quite active. Tepid attractiveness, to the body it means a protective water is recommended for bathing, and a mild response to injury. soap may be used sparingly to remove skin oil. The epidermis is modifi ed in different areas of The diaper area requires special attention: Soiled the body; it is thick over the palms of the hands diapers should be changed frequently to avoid the and soles of the feet, and contains more keratin. harsh irritant potential of urine and feces. Removal This contrasts with the thin epidermis over most of fecal material may require gentle rubbing with of the rest of the body. The epidermis can get even a cotton ball soaked in warm water. Soap should thicker with use, and can result in a callus on not be used if an irritating rash appears—in fact, a hands or feet. great deal of soap is not required at this early age. It The junction where epidermis and dermis meet is not necessary to wash the skin after removing a is an area of many furrows called rete ridges, which diaper soaked in urine only, since an infant’s urine anchors the epidermis with the dermis and allows is sterile. the exchange of nutrients between the two. The dermis is the second layer of skin, made Childhood up of connective tissue and various specialized As the child gets older, the need for soap increases, structures like HAIR FOLLICLES, sweat glands, and but if a rash appears, then the soap should be dis- SEBACEOUS GLANDS that produce oily SEBUM. It is the continued. It may be particularly diffi cult to use 336 skin, congenital absence of soap on a child who has ATOPIC DERMATITIS, an bulbs, which enable fi ne body hairs to act as a sort inherited dry, scaly condition of the skin. Preteens of sensing antenna. have a greater need for daily soap and bathing, as There are three types of special nerve end- the sweat and oil glands are now functioning with ings found in the skin—Meissner’s touch corpus- more effi ciency and can withstand repeated use of cles, pacinian corpuscles, and hederiform endings. soap. Meissner’s touch corpuscles are composed of oval coils of terminal axons within COLLAGEN fi bers, Teenagers found mostly on the palms and soles of the feet During puberty (13 to 19 years) the oil glands and thought to be associated with touch. Pacinian function at peak capacity—especially on the scalp, corpuscles are composed of an axon core inside forehead, face, and upper chest. Some degree of a capsule found in the deep protein of the feet ACNE and an oily complexion are quite common, and palms; they may be especially tuned to detect and routine showering or bathing should become vibration. a habit. While frequent washing may appear to Hederiform (“ivy-shaped”) endings include the decrease oiliness, it will not alleviate acne by Merkel cells, found alone or in groups in the basal itself. epidermis, which may function as touch receptors, although their exact function is not clear. Adulthood As the skin continues to age, the oil glands secrete much less oil, and soap may begin to cause drying. skin, newborn At birth, the skin of an infant may While some people may continue to cleanse with be covered by a soft, cheesy, white material called soap for a long time without any adverse effects, vernix that serves to protect young skin; in the others will experience excess dryness. Seasonal past this was almost always immediately removed, variations affect the skin, too, and must be taken but lately more physicians assume it may have a into consideration. Cold, wind, sunlight, and protective benefi t. other environmental factors play a role in skin Many babies are born with skin marks, splotches, dryness. or rashes that are quite normal and temporary. If soap is used too often in later life, skin disease Some newborns have ACNE, as a result of the may develop; it may be better to cut down on the mother’s hormones still in the baby’s system; these use of soap, especially on the lower extremities— fade away in a few months. There may be scratch especially during the colder months. Cleansing marks, superfi cial bruises, or a purplish mottling of creams or lotions may be good substitutes, although the skin due to a temporary instability of the blood certain areas of the body may continue to require vessels. Such blisters on the lips, feet, or hands are soap. It’s especially important to cleanse the body normal, and will fade away. folds with soap. More than half of all babies and up to 80 percent of premature infants experience JAUNDICE, a yellow discoloration of the skin due to a buildup of biliru- skin, congenital absence of See APLASIA CUTIS. bin (a product released normally when blood cells are broken down). It may be that an infant’s liver is not ready to handle the job, but there is not usually skin, nerves of The skin is fi lled with a vast web cause for concern. Bilirubin levels may normalize of nerves that have considerable functional over- on their own, or the baby may need to rest under lap, producing sensitivity to temperature, touch, special blue lights for a few days or refrain from pressure, itch, and pain. The nerve endings are nursing until the levels drop. found within the papillary and reticular dermis— BIRTHMARKS are often apparent, and in most some extend into the lower portion of the EPIDER- cases should be left alone. However, some experts MIS (outer layer of the skin). Great collections of believe that a MOLE (or congenital nevus) present sensory nerves also surround hair follicles and hair at birth should be removed to forestall the potential skin cancer 337 later transmutation into a malignant melanoma. The wedge (incisional) biopsy involves a narrow A STORK BITE NEVUS (a type of HEMANGIOMA) is a incision that extends deep into a nodule or subcu- harmless small, fl at, pink skin blemish found in up taneous tissue that is used when it is important to to half of all infants, usually around the eyes, that assess the subcutis. This type of biopsy may be used disappears within the fi rst year of life. Those around to diagnose panniculitis, large vessel vasculitis, or a the nape of the neck may persist indefi nitely. deep fungal infection. While the technique is simi- See also NEVUS, CONGENITAL. lar to an excisional biopsy, the incision is usually narrower and extends more deeply. skin biopsy The most common procedure in der- matology that involves cutting a small piece of skin skin cancer Skin cancer is the most common of for analysis and requires only a local anesthetic. It all cancers; basal cell and squamous cell cancers is used to establish a diagnosis by providing spe- affect more than one million Americans each cifi c, reliable information about the problem. The year—a number that is rising rapidly. Another biopsy will include all of the skin and some subcu- 59,580 people will be diagnosed with malignant taneous tissue that is large enough to contain hair melanoma in 2005. But it is also the easiest cancer complexes and sweat glands. to cure if diagnosed and treated early. Prolonged Most commonly, the sample will be taken exposure or intermittent overexposure to sunlight for histopathologic examination by routine light is the primary cause of skin cancers. In fact, about microscopy, but special studies (immunofl uores- 90 percent of all skin cancer is related to sun expo- cence microscopy or electron microscopy) may be sure, and most skin cancers are found on parts of performed. It may also be processed for a bacterial, the body exposed to sunlight. fungal, or viral culture. Because ultraviolet light can damage DNA, DERMATOLOGISTs commonly use four different exposing the skin to sunlight increases the risk that techniques—punch, shave, excisional, or wedge an individual will develop skin cancer. (incisional) biopsy. The punch (trephine) biopsy is Skin type is also a very important factor in the most commonly used by dermatologists for a rou- development of skin cancer, since fair-skinned tine diagnostic biopsy. It is used to remove a portion individuals who tend to burn easily and tan poorly of a larger lesion, to remove small lesions com- are at greatest risk and dark skinned people are at pletely, or to sample a representative area involved a reduced risk. in widespread disease. French scientists have discovered they can deter- Shave biopsy is a simple technique used to remove mine a person’s skin cancer risk by measuring a lesions (or parts of them) protruding above the specifi c mutation in a tumor-suppressor gene called skin’s surface. This technique is quick and easy and p53. They found specifi c changes in the building provides good cosmetic results afterward. However, blocks for this gene in three-quarters of samples it does not allow for the sampling of the DERMIS taken from sun-exposed skin of cancer patients, underlying the lesion. This type of biopsy is often according to scientists at the International Agency used to rule out cancer in SEBORRHEIC KERATOSES for Research on Cancer in Lyon. Almost no DNA and cutaneous horns. It is rarely used to diagnose from nonexposed skin of these patients—or the an infl ammatory skin disease. skin of those who spend less time outdoors—had Excisional biopsy is occasionally used to excise an this mutation. entire lesion, especially in the case of malignant melanoma and DYSPLASTIC NEVI, since the appear- Symptoms and Diagnostic Path ance of the cells may differ widely within one There are three basic types of skin cancer: basal lesion in these conditions. Excision also allows for cell, squamous cell, and melanoma. BASAL CELL a much bigger chunk of tissue than a punch biopsy. CARCINOMA usually appears as a small, shiny However, this type of biopsy carries greater risk of bump on sun-exposed areas, such as the face, signifi cant scars, bleeding, and infection. neck, chest, upper back, and hands, primarily in 338 skin care for infants fair-skinned people (especially those who burn ognized early, DERMATOLOGISTs recommend that easily). The lesions gradually grow and may crust, individuals examine the skin twice yearly, using bleed, or ulcerate, although they usually do not a full-length and a hand-held mirror. When spread. Local destruction of the skin and under- doing a self-exam, examiners should look for the lying tissues may be considerable if this type of early warning signs (see box) but also look for cancer is left untreated. any changes in the skin. Coupled with yearly skin SQUAMOUS CELL CARCINOMA usually appears as exams by a physician, self-exams are the best way a red, scaly patch. It grows slowly, occasion- to ensure early detection and treatment of skin ally becoming a nodule and frequently becoming cancer. crusted and eroded. Bleeding is common. Basal cell and squamous cell cancers are almost certainly Treatment Options and Outlook related to cumulative sun exposure, occurring Most skin cancers (even malignant melanoma) can mostly on exposed places. Unlike basal cell carci- be cured if discovered early enough, which is why noma, squamous cell cancers grow and may spread attention to symptoms and regular self-examination (metastasize). is highly recommended. When cancers of the Basal and squamous cell cancers account for skin are discovered early, there are a variety of about 1 million new cases each year; cure rates are treatment possibilities, depending on the type of excellent if these lesions are discovered and effec- tumor, size, location, and other factors affecting the tively treated early. patient’s general health. A biopsy is often studied Malignant melanoma is the third type of cancer, before a defi nitive therapy is selected. the most deadly of the three. Melanoma is the Malignant melanoma causes 75 percent of all most common cancer among people aged 25 to deaths from skin cancer. 29. Melanomas are usually small brown, black, or multicolored patches, plaques, or NODULES with an Risk Factors and Preventive Measures irregular outline. They may crust on the surface Because exposure to the sun seems to be the most or bleed, and many of them appear in preexisting important environmental factor in causing skin moles. Melanoma is much more dangerous than cancer, avoiding the sun or protecting against it other forms of skin cancer because of its tendency can help prevent skin cancer. Ultraviolet (UV) to spread rapidly to vital internal organs as the radiation is also a factor in the development of lip lungs, liver, and brain. cancer, so protecting the lips against the sun is also important. SKIN CANCER WARNING SIGNS Consumers also should realize that UV rays from Any spot (or sore or growth) that: artifi cial sources of light, such as tanning beds and sun lamps, are just as dangerous as those rays from • changes color the sun, and should also be avoided. • increases in size or thickness In addition to avoiding excess sun exposure, • changes in texture scientists have found that some foods and nutrients • is irregular in outline may counteract the development of melanoma: • is bigger than 6mm (the size of a pencil eraser) best choices are fi sh with omega-3 fatty acids, and • appears after age 21 antioxidants (including VITAMIN E, VITAMIN C, and • continually itches, hurts, crusts, scabs, erodes, or bleeds beta carotene). • does not heal See also MELANOMA, MALIGNANT. • increases in size and appears pearl-colored, translucent, tan, brown, black, or multicolored skin care for infants When babies are born, their Because the skin is so easily visualized, skin pigment production is not complete; even children cancer can be easier to spot than internal malig- who will go on to have dark eyes and hair are nancies. To make sure that skin cancer is rec- fairly light at birth. Slowly, as the child gets older skin care for infants 339 the skin color changes and begins to correspond Unscented sunscreens are a better choice because more closely to that of the parents. While young they do not attract insects. The sun protection fac- skin heals faster than older skin, it is also less able tor (SPF) should be at least 15, manufactured by to protect itself from injury (including injury from a major drug company, and purchased at a store the sun). with a large turnover. Some sunscreens are avail- A child’s skin should be examined regularly, able without PABA, which can cause skin irritation while diapering, bathing, and dressing. Any change in some people. (MOLE, growth, spot, or sore) should be pointed No matter how safe and effective the product out to the pediatrician or DERMATOLOGIST. While it seems, it is a good idea to test it on a child’s skin is normal for toddlers to develop new moles and before regular use. Normally, creamy products other brown spots, ones that continue to change work best on youngsters because they don’t dry the should be checked by a doctor. skin and can be easily seen. Some medications make skin ultra-sensitive— The sunscreen should be applied on all exposed when prescribed, ask the physician if the sun areas, and under thin clothing, 15 to 30 minutes should be avoided. before exposure (it takes that long for the ingredi- ents to penetrate the skin). Preventing Sunburn in Infants For a baby under one year, sunburn should be It may take several years until an infant’s MELANIN treated as a medical emergency. If the child is over production is fully developed; until then, the skin age one, the doctor should be called if there is is especially vulnerable to the sun—even darker pain, blistering, decreased urine output, lethargy, skin. or fever above 101°F. Because a baby’s skin constitutes a larger per- centage of total body mass than an adult’s, they Treatment Options and Outlook are especially vulnerable to anything affecting the In case of sunburn, water or juice can replace skin. A bad SUNBURN can cause serious fl uid and fl uids, especially if the child is not urinating; acet- electrolyte loss, fever, faintness, delirium, shock, aminophen is given for fever over 101°F. The skin low blood pressure, and irregular heart beat. should be soaked in tepid, clear water, followed by Under six months As SUNSCREENS have not a light moisturizing lotion. Dabbing plain CALAMINE been approved for their age group, infants under lotion may help. six months of age should be kept out of the Alcohol should not be used, and no medicated sun entirely, under carriage hoods, canopies, and cream (such as hydrocortisone or benzocaine) tightly woven umbrellas. Since sand, concrete, should be used unless a baby’s pediatrician pre- snow, and water refl ect ULTRAVIOLET RADIATION, it is scribes it. The child should be kept completely out better to park a baby carriage on grass instead of a of the sun until the burn is healed. patio; even on overcast days, as much as 80 percent of the sun’s harmful radiation can still penetrate Sunscreen Recommendations the clouds. A sunscreen for children should have an SPF of 15 Over six months Babies over age six months or higher, and SPF 15 lip balm for face and hands— should avoid the hours from 10 A.M. to 3 P.M. when the waxy form stays on and does not sting or taste the sun is most intense. A broad-brimmed hat will bad. Toddlers can even apply it themselves. shade ears, nose, and lips, and may reduce a baby’s The child’s skin should be coated well, rub- chance of cataracts in later life. The sun can pen- bing on hands, ears, nose, lips, and areas around etrate some fabric (even cotton undershirts, which the eyes. Contact with eyes or eyelids should be only have an SPF of about 8)—so clothes alone avoided. won’t provide protection. Limit time spent in the Sunscreen should be applied before going into sun, regardless of hour or season. the sun, and every two hours thereafter, or more After a baby reaches six months of age, experts often if the child plays in water or is perspiring. agree on the importance of using sunscreen. Children should be taught to use sunscreen early, 340 skin care product allergy so they will be more likely to use it regularly as ter. One suggestion is to use a humidifi er or pan adults. of water indoors during winter to keep indoor air Zinc oxide on the nose and lips may give more moisturized. protection. Baby oil should never be placed on the Combination skin Most people with this type child before going outdoors—it makes the skin of skin have basically trouble-free complexions translucent, letting the sun’s rays pass through with a supple, fl exible smooth texture. Some areas more easily. of the skin may be dry (such as forehead and eyes) and other parts may be oily (such as the nose). People with this type should use products designed skin care product allergy Allergic reactions to for normal skin, but use specially designed prod- skin care products are rare (only 210 for every 1 ucts on spots that are oily or dry. million applications), but they can develop after years of trouble-free use. The perfuming agents in creams, soaps, and cosmetics are often the cause skin color There are three pigments that give skin (even some products called “unscented” con- its color—MELANIN, which provides brown tones; tain tiny amounts of fragrance to hide chemical carotene, which produces yellow tones; and hemo- odors). globin, the red pigment in blood that provides red See also COSMETIC ALLERGY. and pink color. A person’s skin is actually a blend of the various pigmentations, and the healthy “rosy glow” comes primarily from hemoglobin. In some skin characteristics A description of a person’s people, lack of this healthy rosy color is caused by skin (oily, dry, or in-between) often referred to as low hemoglobin levels or impaired circulation of “skin type” among consumers and cosmetician. the blood in the skin. Oily skin People with this type of skin usually See also BLEACHING CREAMS; PIGMENTATION; PIG- have enlarged pores, a shiny nose, and a tendency MENTATION, DISORDERS OF; PIGMENT CELLS. to have breakouts, ACNE, or BLACKHEADS. People with an oil problem should keep their skin clean, while not scrubbing too hard, which can stimulate skin cream Lotions designed to retain moisture the overproduction of oil. and keep skin smooth and soft. These products Only products formulated for oily skin should usually include at least one of the following: be used; in the oiliest areas, an astringent or toner LANOLIN, petrolatum, COLLAGEN, mineral oil, and with a high alcohol content is a good idea. Oil-free squalene. moisturizers may be used, and women with oily Many products also include preservatives that skin should use only water-based makeup. keep the product stable and fresh. The most On the positive side, people with oily skin are common preservatives include PARABENS (ethyl-, less likely to experience premature aging lines, methyl-, and butyl-), quaternium-15, and imidaz- although eventually even the oiliest skin becomes olidinyl urea. In addition, because many fragrances drier, causing WRINKLES and lines. can cause allergies, many skin creams and other Dry skin People with this type of skin usually products also offer fragrance-free products. have invisible pores and a tendency to itch, fl ake, get chapped, and develop tiny premature wrinkle lines around mouth or eyes. skin disorders Despite its surprising resiliency, This type of skin should be cleaned with soaps any number of things can go wrong with the that moisturize; transparent soaps are a good skin: it can become irritated and infl amed; it can choice, but their added alcohol may leave skin dry, be burned. The skin is also prey to production so be sure to follow with a moisturizer. Lips may problems—too little or too much oil, MELANIN, or need special protection against chapping in win- skin cells. skin fi llers 341

In fact, skin-related complaints account for up include pemphigus, BULLOUS PEMPHIGOID, HERPES to 10 percent of all ambulatory patient visits in this GESTATIONIS, EPIDERMOLYSIS BULLOSA, DERMATITIS country. Since the skin mirrors the general condi- HERPETIFORMIS, and HAILEY-HAILEY DISEASE. tion of the patient, many systemic conditions may be accompanied by dermatologic manifestations. Trauma And because disorders of the skin are so readily vis- The skin’s role as protector of vital underlying ible, dermatologic complaints are often the primary organs means that it is vulnerable to injury itself. reason for patient visits. Injuries may be due to cold (CHILBLAINS, IMMER- SION FOOT, or FROSTBITE), to heat (BURNS or eryth- Congenital Skin Conditions romelalgia), or to pressure (CALLUSES, CORNS, or BIRTHMARKS are pigmented skin blemishes present BEDSORES). at birth that include MOLES, MONGOLIAN SPOTS, and HEMANGIOMAS. Occupational Skin Conditions Injuries excluded, dermatoses account for nearly Infection/Infestations half of all remaining occupational illnesses. They The skin can be infected with either viruses, bacte- can include systemic disease due to skin absorp- ria, or fungi. Viral infections include CHICKEN POX, tion, contact dermatitis, PHOTOSENSITIVITY DISOR- WARTS, HERPES SIMPLEX, MOLLUSCUM CONTAGIOSUM, DERS, ACNE, PIGMENT disorders, tumors; connective and HERPES ZOSTER. Bacterial infections include tissue disease, granulomatous reactions, and disor- BOILS, CELLULITIS, ERYSIPELAS, and IMPETIGO. Fun- ders of the hair or nails. gal infections include ATHLETE’S FOOT, JOCK ITCH, and RINGWORM. Parasites include SCABIES, worms, Disorders of Structure/Function FLEAS, TICKS, and LICE. These can include inherited skin diseases, disorders of keratinization (ICHTHYOSIS, REFSUM’S DISEASE, Tumors (Neoplastic Disorders) FOLLICULAR HYPERKERATOSES, ACANTHOSIS NIGRICANS, Noncancerous tumors are very common skin prob- and so on), disorders of pigmentation (LENTIGO lems, and include seborrheic keratoses and most SIMPLEX, NEVUS SPILUS, NEUROFIBROMATOSIS, FRECK- types of NEVI. Types of skin cancer are BASAL CELL LES, MELASMA), diseases of the dermis (CUTIS LAXA CARCINOMA, SQUAMOUS CELL CARCINOMA, MALIGNANT or PROGERIA), disorders of the subcutaneous tissue MELANOMA, PAGET’S DISEASE OF THE NIPPLE, MYCOSIS (such as POLYARTERITIS NODOSA), ACNE or ROSACEA, FUNGOIDES, and KAPOSI’S SARCOMA. disorders of hair (such as ALOPECIA), disorders of the nails (such as PACHYONYCHIA), MAST CELL DIS- Autoimmune Disorders EASES (such as URTICARIA PIGMENTOSA), and diseases Caused when the body attacks its own tissues, of nutrition and metabolism (such as VITAMIN A these skin disorders include LUPUS ERYTHEMATO- DEFICIENCY or PHENYLKETONURIA). SUS, VITILIGO, DERMATOMYOSITIS, MORPHEA, SCLERO- DERMA, PEMPHIGOID, and PEMPHIGUS. skin fillers Substances that replace components Disorders of Hypersensitivity of the skin to erase WRINKLES and other imper- A wide range of skin symptoms can occur because fections. The top fi llers are HYALURONIC ACID of hypersensitivity. These include contact dermati- GEL (Restylane and Hylaform), human collagen, tis, HIVES and anaphylaxis, reactive erythemas, drug bovine collagen, and Sculptra. Wrinkles are caused reactions, vasculitis, and photosensitivity diseases. by the loss of three skin components—collagen, ELASTIN, and HYALURONIC ACID. DERMATOLOGISTs Scaling and Bullous Disorders can replace collagen and hyaluronic acid that are Although uncommon, the bullous diseases are a lost as the skin ages and one day may be able to dramatic and serious group of skin diseases. They replace elastin, as well. Although doctors cannot 342 skin fi llers reverse aging, they can erase its effects by using scars, or to replace fat pads in the cheeks. This tech- injectable soft tissue fi llers, which are designed nique may require follow-up visits to achieve the to produce a smoother, more youthful appear- desired effects. Results last longer than with bovine ance with minimal recovery time and maximum collagen—typically over one year. safety. Potential side effects with this method are Injectable soft tissue fi llers are used to improve unlikely, although sometimes lumps can develop the appearance of fi ne lines and wrinkles, fi ll out around the lips or the eyes, where body fat does hollow cheeks, lighten scars, lessen deep folds, and not naturally occur. repair other facial fl aws. Results are often imme- diate, however, it may take more than one treat- Human-based collagen ment to achieve the desired effect. The length of Two products containing human-based collagen time and results will vary. In the past, doctors have (COSMODERM and COSMOPLAST) were approved used bovine (cattle) collagen and the patient’s own in March 2003 for the correction of facial wrin- body fat to safely diminish wrinkles and give the kles, acne scars, restoration of the lip border, face a more youthful appearance. Today, human and other soft-tissue contour problems. Allergy collagen and hyaluronic acid promise to be a better testing is not required with this method. Side solution. effects are usually limited to temporary redness and swelling around the injection site. As with Bovine collagen bovine collagen, results are noticeable almost The oldest and best-known fi ller is purifi ed bovine right away, and last about four to eight months. collagen, which dermatologists use to fi ll in fi ne Multiple treatments may be needed to achieve lines around the eyes and deep lines from the nose the desired effects. to the corners of the lips, as well as enlarge lips ALLODERM is another soft tissue fi ller made of and erase acne scars. Typically, a series of injections human tissue donated in much the same way as will help fi ll out the imperfections and give almost other transplantable organs and approved by the immediate results, each session lasting about 10 U.S. Food and Drug Administration for cosmetic to 30 minutes. However, while these methods are use. It may be used to enhance the lips or to fi ll in effective, the fi llers are not a long-term solution; lines and creases that develop with aging. they require frequent offi ce visits to maintain the AlloDerm is processed from donated human youthful look. The procedure must be done again cadaver tissue prepared in such a way that it within three or four months, depending on the retains its underlying structure. It has been used size of the area treated, how much collagen was for a variety of surgical reconstructive procedures injected, and how healthy the fi lled skin was. The to replace lost, damaged, or diseased tissues, and procedure often causes some redness, swelling, is now used to fi ll in facial wrinkles, where it is or bruising around the injection site, which usu- considered stable and may last from one to two ally disappears in a few days. Patients risk possible years. allergic reactions. A micronized form of AlloDerm, called CYME- TRA, is also available. This material is rehydrated Body Fat with lidocaine in the physician’s offi ce before injec- Dermatologists have been successfully injecting tion so the procedure is much less painful. the patient’s own body fat into wrinkles for years, Because it is human derived, no skin test is which eliminates potential allergic reactions and required. Studies so far have found no evidence avoids the need for allergy testing. of allergic reactions, although temporary bruising, In this procedure, the dermatologist transfers redness, and swelling occurs in a few patients. the patient’s own fat from a part of the patient’s AlloDerm is obtained from tissue banks, which body with excess fat to an area that has lost fat as surgically remove a thin layer of skin from deceased a result of aging. Typically, the fat is used to plump donors, using sterile operating room techniques. up deep creases around the nose and mouth, to fi ll The skin is placed into a antibiotic solution and skin fi llers 343 processed to remove the top layer of skin cells and and adds volume to easily fi ll in larger folds of all of the cells in the deepest layer. The remaining skin around the mouth and cheeks. Patients notice material—the AlloDerm—is a collagen framework an immediate plumping of the skin in the treated that provides strength to the skin, but without any areas. components left to cause the rejection or infl am- Approved in 2005, hyaluronic acid gels mation. Therefore, when transplanted to a patient, (Restylane and Hylaform), are injected into facial the AlloDerm graft gradually becomes a natural tissue to smooth wrinkles and folds, especially in part of the patient’s own tissue. the folds around the nose and mouth. Hyaluronic AlloDerm was fi rst used in 1992 to treat burn acid is a protective, lubricating, and binding gel patients and in 1994 for periodontal and plastic substance that is produced naturally by the body. surgery. Currently, more than 50,000 patients have Restylane and Hylaform work by temporarily received AlloDerm grafts. adding volume to facial tissue and restoring a AlloDerm is the only available product capable smoother appearance to the face for an effect that of regenerating normal soft tissue. Since it is lasts for about six months. human tissue, it does not trigger an infl amma- They are injected by a doctor into areas of facial tory or allergic reaction, and the pretreatment tissue where moderate to severe facial wrinkles skin testing required with bovine collagen is not and folds occur. The gels temporarily add vol- needed. In addition, patients report that the graft ume to the skin and can give the appearance of a does not feel hard the way other synthetic mate- smoother surface. They will help smooth moderate rials do. When AlloDerm is used as an implant, to severe facial wrinkles and folds. In one study, it completely eliminates any need to transplant most patients needed just one injection to smooth donor fat or skin from one part of the body to out the wrinkles; about one-third of patients another area. needed more than one injection to get a satisfac- Although AlloDerm appears to be long last- tory result. ing, there have been reports of a small number of One of the main advantages of hyaluronic acid patients completely absorbing the AlloDerm within gels are that they do not trigger allergic reactions, six months. AlloDerm lip enhancement is irrevers- nor is there a risk of transmitting animal diseases ible after a period of seven to eight weeks. by injection as there is with bovine collagen. Since a skin check for allergies is not required with hyal- Hyaluronic acid gels uronic acid gel, patients can be treated on their fi rst Although human collagen was an improvement visit to the dermatologist. In addition, hyaluronic over bovine collagen because it did not trigger acid treatments last about four to six months and allergies, dermatologists still needed a fi ller that require less volume to fi ll wrinkles and hard-to- could safely and effectively replace hyaluronic acid, treat skin folds compared to collagen. the other primary component lost in aging skin. These gels do have side effects, and pain is a Several new fi llers have been approved by the FDA problem. Since hyaluronic acid get does not con- that can replace the skin’s hyaluronic acid lost dur- tain the anesthetic lidocaine, injections can be ing aging. These products work by fi lling as well painful. In addition, there is usually temporary as by pulling water into the skin, plumping up the infl ammation that produces swelling and redness skin, and adding volume. following injection with hyaluronic acid gel— Dermatologists have known for a long time especially in the lip area. that wrinkles are caused by the loss of three skin Some dermatologists combine hyaluronic acid components—collagen, elastin, and hyaluronic and collagen for the most benefi ts with each fi ller. acid. Today, doctors can replace two of these com- Injecting collagen fi rst numbs and supports the ponents (collagen and hyaluronic acid). Hyaluronic area, stabilizing the skin to prevent bruising. Then acid holds together collagen and elastin, providing hyaluronic acid gel is injected painlessly. Using a framework for the skin. When injected into the these fi llers together replaces two of the skin com- skin in gel form, hyaluronic acid binds to water ponents that are lost with skin aging. 344 skin graft

Silicone in place until it disperses after injection, leaving the Until it was banned by the FDA in 1992, injectable spheres behind to plump up the wrinkles. These silicone was used in the United States for many spheres stimulate the body’s own production of years to successfully treat wrinkles and acne scars collagen, which then forms around the spheres. as well as enhance lips, cheekbones, and the chin. The primary benefi t of polymethylmethacrylate However, problems emerged when medical-grade is that it is a permanent solution, which also can silicone was diluted with foreign substances, such be a problem if it is not injected properly. Other as mineral oil, and when it was injected in large side effects include temporary swelling and redness volumes. (especially in the lips) and permanent or long-term What makes silicone unique is that the results lumps. are permanent. Studies are showing that once the Hydroxylapatite with a methylcellulose vehi- desired results are achieved, there is no need for cle Patients interested in a more permanent solu- future treatments unless it becomes necessary as tion than collagen but who want to avoid the the patient ages or disease processes continue. permanent results of polymethylmethacrylate may Unfortunately, side effects may include delayed someday soon be able to choose hydroxylapatite reactions that trigger redness and lumpiness as the with a methylcellulose vehicle, which is currently body rejects the silicone. In the past, more prob- approved for other purposes. It is now being stud- lems were reported with silicone breast implants. ied as an injectable skin fi ller. This fi ller contains However, side effects are rare when silicone is calcium hydroxylapatite beads (a substance now injected by a dermatologic surgeon skilled in the used to replace missing bones). Hydroxylapatite microdroplet technique, in which tiny amounts of with a methylcellulose vehicle temporarily corrects silicone are injected at four- to eight-week intervals wrinkles and may last about a year, although its until the desired effects is achieved. exact length of improvement has not yet been fully studied. However, if not injected properly, the cal- Fibroblasts cium beads might cling together and could exhibit Harvesting the patient’s own collagen-producing a lumpy treated area. cells (FIBROBLASTS) holds promise for fi lling fi ne facial lines, enhancing lips and correcting scars. Results reportedly last a bit longer than bovine col- skin graft A technique used by both dermatolo- lagen, and side effects are minimal. However, the gists and plastic surgeons to repair areas of lost or procedure is time-consuming. First, a dermatologist damaged skin in which the healthy skin is removed must remove a small amount of skin tissue and from one part of the body and reattached to the close the area with adhesive or sutures; the tissue damaged area. If successful, new cells grow from is shipped to a company that cultures the fi bro- the graft and cover the damaged area with fresh, blasts, using its patented process. In six weeks, the new skin. harvested cells are delivered to the dermatologist’s Skin used for a graft may be removed from offi ce; the patient must return for skin testing another part of the patient’s body, or taken from because the substance in which the cells are grown an identical twin; otherwise, skin from anyone else can cause an allergic reaction. If the patient does is rejected as foreign by the recipient’s body. (Skin not develop an allergic reaction within two weeks, from an unrelated donor may provide temporary treatment can begin. cover, however). Although all skin grafts leave scars, a skin graft is performed when the damaged New fi llers area is too large to be stitched together or because Polymethylmethacrylate One of the newest an ungrafted area would result in unsightly or permanent injectable skin fi llers awaiting FDA restrictive scarring. approval, this is mixture of micronized plastic There are two types of skin grafts—split thick- spheres and bovine collagen. When injected into ness and full thickness grafts. A split-thickness graft is the skin, the collagen holds the synthetic spheres used when large areas (such as burns) must be cov- skin scams 345 ered; the area that has been “harvested” will regen- MEASLES, GERMAN MEASLES, RUBEOLA, FIFTH DISEASE, erate in a few days to weeks and can provide more AIDS, and so on. donor skin. Full-thickness grafts include a deeper, Fungal infections can be noninvasive, invasive thicker section of the skin, and are often used for and systemic. They include RINGWORM (tinea), CAN- facial grafts because the transferred skin looks more DIDA infection, CHROMOMYCOSIS, CRYPTOCOCCOSIS, normal. They have a more natural color and tex- and so on. ture, and contrast less than split-thickness grafts. Rickettsial infections are conveniently grouped However, full-thickness grafts are less likely to suc- as the spotted fevers (ROCKY MOUNTAIN SPOTTED cessfully attach themselves. In addition, donor sites FEVER, RICKETTSIAL POX, and so on), the typhus cannot be reharvested, and must be stitched closed group (TYPHUS), Q FEVER, and TRENCH FEVER. after the graft section has been removed. Split- Parasitic infections are endemic in many devel- thickness grafts are usually cut from the abdomen oping countries, where poverty, poor hygiene and or thigh; full-thickness grafts are often taken from inadequate sanitary facilities create favorable condi- behind or in the crease in front of the ear. tions for infection. The infections enter the United Pinch grafts may be used in an attempt to treat States with the immigration of foreign students, leg ulcers when there is good granulation tissue. In diplomats, and immigrants. Protozoal infections this procedure, grafts are taken from anesthetized include LEISHMANIASIS and AMEBIASIS; helminthic skin (usually the upper thigh) by pinching a small infections (worms) include PINWORMS, HOOKWORMS, amount of skin with a needle and slicing it with a STRONGYLOIDIASIS, CUTANEOUS LARVA MIGRANS, FILA- scalpel or razor blade. The grafts are transferred to RIASIS, and so on. Ectoparasite (a parasite that lives the ulcer bed with a small space between grafts, on the outside of the host) infections include SCA- sprayed with an adhesive and covered with a semi- BIES and LICE. permeable dressing with edges extending beyond See also SKIN DISORDERS. the margin of the ulcer. Gauze and an elastic dress- ing cover the wound, which is left in place for three or four days. Strict bed rest is required. The physi- skin patch Also called a transdermal patch, this cian can examine the pinch graft through the semi- is multilayered disk ranges in size from that of a permeable dressing, draining accumulated fl uid small coin to several square inches. It introduces a when necessary. Dressings may be removed in fi ve controlled release of a medication into the system or six days, or left in place if there is no infection. through the skin. The patches are painless and usu- Cleansing with alcohol helps the wound to form a ally do not irritate the skin. The patch works by fi rm crust that will fall off in two or three weeks. maintaining a reservoir of the drug and releasing The grafts will extend to the skin of the adjacent it through the skin via an adhesive-coated polymer graft and fi ll up the ulcer. membrane. Effective drug levels can be maintained this way for some time. Patches have been used to deliver scopolamine; skin infections Because the skin represents the nitroglycerin and other nitrates to treat heart outer barrier to the world, it is responsible for disease; hormones for birth control in women; defending the interior of the body against a wide and nicotine to people trying to stop smoking. range of attackers, including bacteria, viruses, Researchers have found ways to introduce estra- insect venom, and fungi. Skin infections can range diol to postmenopausal women who need estrogen from a local superfi cial problem (such as IMPETIGO) replacement, and to administer timolol and cloni- to a wide-spread and possibly fatal infection. dine hydrochloride to treat high blood pressure. Examples of bacterial skin infections include IMPETIGO, ECTHYMA, FOLLICULITIS, BOILS, CARBUN- CLES, ERYSIPELAS, SCARLET FEVER, CELLULITIS, and so skin scams Many beauty products promise to on. Viral infections with skin symptoms include “reverse the tracks of time” by removing wrinkles. HERPES SIMPLEX, CHICKEN POX and SHINGLES, WARTS, Unfortunately, this is something no skin cream can 346 skin tags do. Terms like antiaging, rejuvenation, and cellular skin tuberculosis See TUBERCULOSIS, SKIN. renewal sound wonderful, but they do not perma- nently alter the characteristics of aging skin. In truth, these skin products simply moisturize the skin, skin tumor, benign A group of skin tumors that plumping it up so lines and creases are less noticeable. are not cancerous. These include Cutaneous SKIN Experts say the special wrinkle-fi ghting ingredients in TAGS, SEBORRHEIC KERATOSES, ACTINIC KERATOSES, the supercream formulas are of limited value. BIRTHMARKS, LIVER SPOTS, MOLES, KELOIDS, and COLLAGEN, for example, is commercially manu- WARTS. factured from animal protein with the idea that, applied topically, it will enhance the production of a person’s own collagen. But collagen molecules skin tumor, malignant See SKIN CANCER. are just too large to be absorbed into the skin. Other anti-aging skin formulas include RNA and DNA, super-oxide dismutase, and glycosphingo- skin type While the phrase “skin type” has come lipid, which some claim can “rejuvenate” cells. to mean the skin’s characteristics (whether the skin None of them has been shown to have any effect is oily, dry, or in-between), dermatologists use the on internal body chemistry, experts say. term “skin type” to indicate a person’s relative sen- According to the U.S. Food and Drug Adminis- sitivity to sun exposure. Because a person’s skin tration, if skin products alter the structure or func- characteristics can vary from one part to another, tion of the skin, they are regarded as drugs, not dermatologists prefer to treat specifi c areas and cosmetics. Manufacturers would have to submit conditions of each area of the skin. Skin char- data to demonstrate that these products were safe acteristics tend to become more oily in summer, and performed their intended function—something under stress, during adolescence and in hot, humid not now required of cosmetics. climates. Other products with little value include quail Skin type, according to DERMATOLOGISTS, is clas- egg omelettes for the face, seaweed cleansers, sifi ed into six groups, according to the skin’s ten- moisturizers with bee jelly, and oils squeezed from dency to sunburn. turtles, sharks, and minks. SUNBURN TYPE skin tags Known medically as acrochordons, these TYPE I: Always burns, never tans. Very fair with red or blond hair and FRECKLES. common lesions are small brown or fl esh-colored fl aps of skin that usually occur spontaneously and TYPE II: Burns easily, tans minimally. Usually fair-skinned. tend to run in families. TYPE III: Sometimes burns, gradually tans. They are found most often in middle-aged TYPE IV: Minimum burning, always tans. Usually white with women, on the neck, under the arm, under the medium pigmentation. breasts, and on the eyelids. TYPE V: Very seldom burns, always tans. Medium to heavy pigmentation. Skin tags do not usually cause problems, TYPE VI: Never burns but tans darkly. Blacks as well as others although they may be irritated by rubbing clothing with heavy pigmentation. or jewelry. Anal tags often occur as a complication of anal fi ssures or hemorrhoids. Skin tags appear to be more common in overweight individuals. SLE See SYSTEMIC LUPUS ERYTHEMATOSUS. Treatment Options and Outlook Skin tags can usually be removed with electro- surgery or by cryosurgery. Larger lesions may be smallpox A highly infectious viral disease caus- removed with scissors or a scalpel, followed by ing skin rash and fl ulike symptoms that has been electrodesiccation or cauterization. totally eradicated since 1980. soap and the skin 347

A medical scourge of the 19th century, smallpox (scented bars of soap were excavated from Pom- was characterized by a rash that spread over the peii, and Phoenicians were milling soap 700 years body, turning into PUS-fi lled BLISTERs that crusted before that), and the majority of Americans still and sometimes left deeply pitted scars. Complica- turn to a bar of soap to clean their skin. tions included blindness, pneumonia, and kidney The downside of soap is that some skins are irri- damage, and there was no effective treatment tated by heavily perfumed products, and deodorant for the disease, which killed up to 40 percent of soaps may be troublesome to others. Moreover, affected individuals. some people with very dry skin or with ECZEMA Smallpox was eradicated through a cooperative may fi nd that soap’s fatty acids are too irritating; international vaccination program that was suc- for them, a soapless cleanser or detergent (acid cessful because the disease affected only humans. rather than alkaline) is a good choice. (Soaps are Patients were easily recognized and infectious only made from natural animal fat, while detergents are for a short time. As a result of the eradication pro- synthetic). gram, smallpox vaccination certifi cates are no lon- ger required for international travel. Most countries Antibacterial Soap have stopped vaccinating because the vaccine itself Dermatologists note that there is a place for the is now more dangerous than the disease, since the antibacterial cleanser such as Dial, Safeguard, or vaccine can cause encephalitis and there is now no Liquid Lever 2000, a mild product that contains chance of contracting smallpox. moisturizer in addition to deodorant and antibac- However, after the events of September and terial agents and that is safe for children over the October 2001, the U.S. government took precau- age of 18 months. Antibacterial soap is ideal for tions to deal with a possible bioterrorist attack cleaning the fi ngers before inserting contact lenses, using smallpox as a weapon. The risk for smallpox after handling suspicious things, or after being occurring as a result of a deliberate release by ter- around people with coughs and colds. However, rorists is not known, but the government considers these cleansers are no better at killing bacteria it very low. Still, by the end of 2002, the govern- than plain soap and hot water. ment had stockpiled about 286 million doses of smallpox vaccine—enough to vaccinate every per- Old-Fashioned Soap son in the United States. Soap used to be made by combining an alkali with The virus responsible for smallpox is still main- fat (such as vegetable oil) and water. Soaps such tained at laboratories at the Centers for Disease as Ivory come under this heading, but many other Control in Atlanta and at a research institute in products that seem like soap are really detergents. Moscow. A recent suggestion to destroy the virus was met by such criticism among the scientifi c com- Detergent Soap munity, who value the virus for scientifi c purposes, While many consumers assume that “detergent” that any attempt to do so has been postponed. is synonymous with “household cleaner” and is therefore too harsh for the skin, in fact many com- panies add extra emollients to detergent formulas soap and the skin Soap is an emulsifi er that to make their products milder. Still, detergents do attaches to water molecules and to oil and dirt mol- tend to be harsher than soap. Dove is an example ecules, pulling them together. This is why soap is of a soap that is really a detergent. better at washing away oily dirt than water alone. Many people choose to clean their skin with Superfatted Soap soap (in fact, Americans take more than 60 billion A cleansing product with extra oils or fats (such as showers and baths each year) and the choices of coconut or mineral oil, LANOLIN, or COLD CREAM) soap are almost limitless—from 100 percent pure, included in the formula. In addition, excess fatty hard-milled, and scented to translucent bars or acids are added to ensure that the pH is not too liquids. Soap has been around for quite some time alkaline. These products tend to leave an oily fi lm. 348 sodium laureth sulfate

Glycerin Soap alkaline. Therefore, no matter what a particu- Usually transparent, these soaps contain the lar company may claim, a soap cannot truly be humectant GLYCERIN as an ingredient. Examples pH-balanced. include Basis and Neutrogena. How to Use Soap Castile Soap It is important not to over-clean the skin; even those Often advertised as being especially pure, the real with oily or problem skin should wash with soap difference between castile and other soaps is that just twice a day (or once in the evening if skin is castile products are made with olive oil instead of very dry). Experts recommend 10 rinses to ensure other fats. that the skin is free of residue. If the skin has a tight, drawn feeling after washing, most likely the Medicated Soap skin has been overcleansed or too strong a soap has This cleansing product, which includes antibacte- been used. rial ingredients, is considered to be a drug and A person’s skin condition may change drasti- is therefore subject to drug regulations. In fact, cally with the seasons. In cold, harsh weather the some medicated soaps, such as soaps containing skin is prone to dryness and chapping. Hot, humid salicylic acid or benzoyl peroxide, are sold only by weather may lead to more washing, which could prescription. irritate the skin. See also CLEANSING PRODUCTS. Deodorant Soap These cleansing products contain ingredients that fi ght body odor by killing bacteria. They are not sodium laureth sulfate Cosmetic detergents that recommended as facial cleansers. exert liquefying action, removing oil and soil from Whatever kind of soap is used, it must be com- the hair and skin. This ingredient produces eye pletely rinsed off the skin or the resulting residue and skin irritation in experimental animals and in can dry the skin and attract dirt. some human test subjects; irritation may occur in Old beauty advice held that any type of soap some users of cosmetic formulations containing the was bad for the skin. The reasoning was that no ingredient. The irritant effects are similar to those matter how mild or pure, soap was still too drying. produced by other detergents, and the severity Formerly, people were advised to use a nonsoapy of the irritation appears to increase directly with cosmetic cleanser containing no alcohol or grains, concentration. followed by a toner or astringent. Sodium laureth sulfate may induce eye and skin Today many skin care experts note that there irritation, but it is considered safe as presently used are plenty of mild, non-drying soaps available that in cosmetic products. are fi ne for everyone, such as glycerin or superfat- ted soaps. A consumer should select the mildest product that is effective. sodium lauryl sulfate (SLS) A detergent cleanser Despite the plethora of fancy “beauty bars,” fea- and emulsifi er in creams and lotions that may turing exotic ingredients such as milk and honey, cause allergic reactions in some people. essence of eucalyptus, pear nectar, and freesia, all The longer this ingredient stays in contact with soaps still contain sodium or potassium salts. It may the skin, the greater the likelihood of irritation, not be glamorous, but soap works by emulsifying which may or may not be evident to the consumer. surface oils, carrying dirt away in the foam. Sodium lauryl sulfate appears to be safe in formu- All soaps by defi nition are alkaline, and strip lations designed for brief use followed by thorough the skin of its outside oily layer. Some soaps have rinsing from the surface of the skin. In products a neutral or slightly acid pH, until they come intended for prolonged contact with skin, concen- in contact with water, whereupon they become trations should not exceed 1 percent. Solumbra 349 soft tissue augmentation See SKIN FILLERS. ous ultraviolet light that will reach the Earth’s surface at noon the next day. The scale is generally from 1 to 11+. The higher the number, the greater solar keratoses See ACTINIC KERATOSES. the level of radiation from the sun. The goal of the warnings, is to remind people of the danger of the sun to their skin so they will use solar lentigo A condition in which the skin dark- SUNSCREENS, sunglasses, and reduce exposure to ens because of an excess of MELANOCYTES (MELANIN- themselves and their children. Damage from sun producing cells). Solar lentigo appears in patients exposure accumulates over time, and much of the with fair skin who have a history of chronic sun injury is done when people are youngsters. exposure; the lesions usually appear after age 40.

Symptoms and Diagnostic Path THE GENERAL CATEGORIES OF HAZARD ARE: Symptoms include moderately dark brown, large Minimal (index of 0–2): Fair-skinned people may burn in 30 minutes; those with darker skin may be safe up to two spots (called “age spots” or “liver spots”) with irregu- hours. lar borders. The outer skin layer is atrophied with Low (3–4) Fair-skinned people may burn in 15 to 20 minutes; fi ne, paperlike wrinkles. Like LENTIGO SIMPLEX, solar others may be safe from 75 to 90 minutes. lentigo does not fade in the winter or darken in the Moderate (5–6) Fair people may burn in 10 to 12 minutes; summer. others may be safe for 50 to 60 minutes. High (7–9): Fair people may burn in 7 to 8½ minutes; others Treatment Options and Outlook may be safe for 33 to 40 minutes. The most important part of treatment is to avoid Very high (10 and up): Fair people may burn in 4 to 6 min- any further skin darkening by avoiding the sun, utes; others may be safe for 20 to 30 minutes. and applying SUNSCREENS or sunblocks before going outside. Bleaching creams applied every day for The Environmental Protection Agency prepared up to a year may be effective. More aggressive the index in collaboration with the National Oce- treatment includes LIQUID NITROGEN cryotherapy anic and Atmospheric Administration and the or short pulsed laser treatment such as Q-switched Centers for Disease Control and Prevention. The ruby lasers. index is available online at: http://www.epa.gov/ sunwise/uvindex.html. solar urticaria The medical term for sun-induced HIVES, this is an allergic reaction to certain wave- Solumbra A type of 30+ SPF sun-protective lengths of the sun that appears immediately after clothing that can provide medically accepted sun exposure. protection. The Solumbra products are regulated as medical devices and have been evaluated in Treatment Options and Outlook medical research. Solumbra material is soft and The treatment of choice is a nonsedating antihista- lightweight and offers head-to-toe sun protection. mine such as terfenadine. It is available in hats, shirts, pants, and accessories See also POLYMORPHIC LIGHT ERUPTION. for adults and children. A typical 30 SPF SUNSCREEN, even though it may claim to provide UVA protection, may still allow solar UV index A daily warning index forecasting UVA rays to penetrate the skin. Solumbra blocks the ultraviolet (UV) light radiation exposure for the more than 97 percent of both UVA and UVB rays, United States designed to help people avoid SKIN far better than a typical 30 SPF sunscreen or typical CANCER. The index is issued daily by the National summer shirt. Weather Service to predict the amount of danger- See also CLOTHES AND SUN PROTECTION. 350 sore sore The common term for a skin lesion. be called right away. Antivenin is available, but most people can be managed without it. Healthy people should recover rapidly in two to fi ve days, SPF See SKIN PROTECTION FACTOR. but people under age 16 or older than 60, espe- cially those with a heart condition, may require a hospital stay. A tetanus shot may be needed. spider angioma See NEVUS ARANEUS. Brown Recluse Spider The brown recluse is by far the most dangerous spider bite Although most of the 50,000 species of the U.S. species, with a range from Texas and of spiders in the United States have poison glands Arkansas to as far north as Massachusetts. This connected to their fangs, only a few are capable brown, half-inch-long spider gets its name from a of piercing human skin, and only two—the black shy habit of hiding in dresser drawers, closets, folds widow and the brown recluse—are harmful to of clothing, garages, attics, and sheds, where they humans. In general, most spider attacks occur will not try to bite unless they are trapped. The when someone disturbs the nest while working venom of females is more deadly than males. outside. The physical reaction to a BROWN RECLUSE SPIDER BITE depends on how much venom was Black Widow Spider injected and the person’s sensitivity to it. Some One of only two truly poisonous spiders found in people are unaffected by a bite, whereas oth- the United States, all six species of black widow ers experience immediate or delayed effects as spider are venomous, although none are usually the venom kills the tissues at the site. Typically, fatal. Reluctant to bite humans, these spiders are most people do not feel much pain at fi rst, but responsible for only about three deaths in the within eight hours the pain becomes severe and United States every year. The venom of the black the area begins to turn red. Any area on the skin widow spider is 15 times as deadly as the venom that the spider has bitten will begin to die and of the prairie rattlesnake, but because they inject slough off, because the venom contains a sub- only a small amount they are not usually very stance that is very destructive to skin. This leads dangerous. to a large, spreading sore that will eventually The bite of the black widow is not especially become a dark, hard BLISTER within a few days. painful, and may produce just a bit of swelling In some cases, this blister turns deep purple, and with two tiny puncture marks, followed by a dull within two weeks becomes an open ulcer. As this numbing pain that gets worse as time passes. The ulcer develops, it often becomes infected, and in pain peaks within three hours, but continues for a small number of people the ulcer takes a very another two days. Within 40 minutes after the long time to heal. bite, the venom begins to attack the nerves, caus- The bite also may cause a number of body-wide ing abdominal or chest muscles to get tight. At the reactions, including fever, chills, weakness, nau- same time, there may be stomach pain and muscle sea and vomiting, joint pain, and RASH. Fatal bites spasms in the arms and legs, along with breath- usually kill within two days, as a result of kidney ing problems, chills, urinary retention, sweating, failure. convulsions, paralysis, delirium, nausea and vom- There is no specifi c antivenin, but ANTIHISTA- iting, drooping eyelids, headache, and fever. In MINES, muscle relaxants, and steroids may help. rare cases, cardiac failure leads to death, but most The surgical removal of affected skin was once patients recover without complication. standard procedure, but now experts believe this The wound should be kept clean and cool, with slows down wound healing. Some physicians the affected limb elevated to heart level. Aspirin or administer high doses of systemic steroids, or oral Tylenol may used to relieve minor symptoms. A DAPSONE to reduce the degree of tissue damage, but doctor or Poison Control (800-222-1222) should an effective treatment has not yet been found. squamous cell carcinoma 351

Risk Factors and Preventive Measures tericin B and fl ucytosine have also been used to Homeowners should be careful when working treat the chancriform sporotrichosis. Itraconazole around areas where spiders may live, and should has also been found to be effective. wear gloves and pay attention. To eradicate these Systemic sporotrichosis does not respond well spiders, homeowners should remove all materials to iodide treatment. In this case, amphotericin B is where these spiders might hide, knocking down usually necessary. Systemic sporotrichosis in par- the webs and their round egg sacs with a stick and ticular may be fatal. crushing them underfoot. Removing or destroying the egg sacs helps control the population. spun-glass hair See UNCOMBABLE HAIR SYNDROME. spongiform pustule An accumulation of white blood cells between epidermal cells that may lead squamous cell KERATIN-producing cells that make to a spongy appearance and the appearance of fl uid up most of the EPIDERMIS, lying above the BASAL between the cells. It is characteristic of PSORIASIS. CELL layer. See also SQUAMOUS CELL CARCINOMA. spongiosis Swelling between the epidermal cells. It is a hallmark of ECZEMA. squamous cell carcinoma The second most com- mon SKIN CANCER (after BASAL CELL CARCINOMA) that affects more than 200,000 Americans each year. sporotrichosis A chronic fungal infection of the This type of cancer begins in the SQUAMOUS CELLS skin that often follows trauma caused by the fungus that compose most of the upper layer of skin. Squa- Sporothrix schenckii, characterized by the formation mous cell cancers may be found on all areas of the of painful ABSCESSES and ulcers. The fungus affects body, including the mucous membranes, but they both men and women around the world who come are most often found on areas exposed to the sun. in contact with the fungus through soil, vegetation, While squamous cell carcinomas start in the top untreated plants, or decaying vegetables. layer of skin, they can eventually spread to under- lying tissues if untreated. Rarely, they spread to dis- Symptoms and Diagnostic Path tant tissues and organs; this can be fatal. Squamous There are several forms of the disorder; 80 per- cell carcinomas that metastasize most often begin cent of patients develop the acute chancriform or from chronic infl ammatory skin conditions or on lympho-cutaneous type of sporotrichosis. In this the mucous membranes, lips, or ears. form, numerous scaly papules that erode and form Chronic exposure to sunlight causes most cases chronic ulcers usually form in a line starting at the of squamous cell cancer, which is why tumors are initial site of injury, spreading up the limb. usually found on areas of the body that are exposed A disseminated systemic form invades the eye, to sunlight. The rim of the ear and the lower lip are nervous system, or other organs in a true systemic particularly prone to this type of cancer. fungal infection. The skin lesions that may accom- Squamous cell cancers also may appear on skin pany this type of musculoskeletal sporotrichosis that has been injured by burns, scars, long-standing are more chronic, and the outlook may not be so sores, sites previously exposed to X-rays, or chemi- positive. cals (such as arsenic and petroleum byproducts). In addition, chronic skin infl ammation or medical Treatment Options and Outlook conditions that suppress the immune system for Specifi c treatment depends on the form of spo- long periods of time may encourage squamous cell rotrichosis. In the skin form, iodides (given as an carcinoma. oral solution of potassium iodide) are the preferred Sometimes squamous cell carcinoma begins method of treatment for up to six weeks. Ampho- spontaneously on what seems to be normal, healthy 352 squamous cell carcinoma skin. Some researchers believe this type of cancer This technique is repeated several times to make may be hereditary. sure the tumor has been completely removed. Anyone with a long history of sun exposure can With CRYOSURGERY, the physician does not develop squamous cell cancer, but those with fair cut the growth but instead freezes the lesion by skin, light hair, and blue, green, or gray eyes are applying LIQUID NITROGEN with a special spray or at highest risk. Dark-skinned individuals are far a cotton-tipped applicator; this method doesn’t less likely to develop any form of skin cancer, but require anesthesia and produces no bleeding. more than two-thirds of all skin cancers in African It is easy to administer and is the treatment of Americans are squamous cell carcinomas found choice for those who have bleeding disorders or most often on sites of preexisting infl ammatory are intolerant to anesthesia. Patients experience skin conditions or burn injuries. redness, swelling, or blistering, and crusting after There are some skin conditions that are associ- this treatment. ated with eventual development of squamous cell LASER SURGERY is used to focus a beam of light carcinoma. These conditions include ACTINIC KERA- onto the lesion either to excise it or destroy it by TOSIS, actinic cheilitis, LEUKOPLAKIA, and BOWEN’S vaporization. The major advantage of this tech- DISEASE. These “precursor” conditions, if properly nique is that it seals blood vessels as it cuts. treated, can be prevented from developing into a In radiation therapy, X-rays are directed at the squamous cell carcinoma. malignant cells. It usually takes several treatments several times a week for a few weeks to totally Symptoms and Diagnostic Path destroy a tumor. Radiation therapy is most often Symptoms include a persistent, scaly red patch used with older patients or with those in poor with irregular borders that sometimes crust or health. Radiation may be less traumatic for the bleed; an elevated growth with a central depres- elderly. sion that sometimes bleeds; a wartlike crusting Mohs’ surgery (microscopically controlled sur- growth that may bleed; an open persistent sore gery) involves the removal of very thin layers of that bleeds and crusts. The lesions usually look like the malignant tumor, checking each layer thor- rough, thick, scaly patches that bleed if bumped. oughly under a microscope. This is repeated as They often look like warts, and sometimes an often as necessary until the tissue is free of tumor. open sore will develop with a raised border and This method saves the most healthy tissue and has a crusty surface. A diagnosis is made after physi- the highest cure rate. It is often used for tumors cal exam and biopsy (removal and examination that recur, for large tumors, or for areas where of a piece of tissue). If tumor cells are found, the recurrences are most common (nose, ears, and physician will outline possible treatment based on around the eyes). type, size, and location of the tumor and on the When removed early, squamous cell carcinomas patient’s age and health. are easily treated, but the larger the growth the more extensive the treatment. While squamous Treatment Options and Outlook cell carcinoma does not spread to vital organs very The most frequently used treatment is excision of often, if it does it can be fatal. Since removal of the entire growth and an additional border of nor- a tumor scars the skin, large tumors may require mal skin as a safety margin (excisional surgery). reconstructive surgery and skin grafts. The site is then stitched closed and the tissue is sent If a patient is diagnosed with one squamous cell to the lab to determine if all malignant cells have carcinoma, there is a greater chance of developing been removed. other squamous cell carcinomas in the future. Hav- A physician may use electrosurgery (curettage ing had a BASAL CELL CARCINOMA also makes it more and electrodesiccation) in which cancerous tissue is likely that a squamous cell cancer will develop. No scraped from the skin with a curette while an elec- matter how carefully a tumor is removed, another tric needle burns a safety margin of normal skin can develop in the same place (or nearby), usu- around the tumor at the base of the scraped area. ally within the fi rst two years after surgery. If the Stewart-Treves tumor 353 cancer recurs, the physician may recommend a Stevens-Johnson syndrome A rare condition different type of treatment the second time. It is involving the skin and mucous membranes (ery- therefore important to examine the surgical site thema multiforme major) characterized by fever periodically. and a variety of skin lesions, including red PAPULES, See also MELANOMA, MALIGNANT. erosions, and BLISTERs. When the condition affects only the skin, it is called erythema multiforme minor, or simply erythema multiforme. The condi- staphylococcal infections A group of infections tion is most often caused by drug reactions, and caused by staphylococci bacteria that are a com- while it may occur at any age, it is most common mon source of skin conditions. Staphylococcal in children and young adults. bacteria are normally found on the skin of most people, but if the bacteria accumulate within Symptoms and Diagnostic Path the skin, they can cause a wide variety of skin A fever and malaise may precede by several days infections (PUSTULES, BOILS, IMPETIGO, FOLLICULITIS, the appearance of skin lesions, and there may be ABSCESS, STY, or CARBUNCLE). extensive involvement of the skin, lips, oral areas, One strain of the bacteria produces a toxin and mucous membranes. that can cause a severe blistering rash in newborn babies called staphylococcal SCALDED SKIN SYN- Treatment Options and Outlook DROME. Another produces the toxin responsible for Painkillers and sedatives may relieve the pain; TOXIC SHOCK SYNDROME. while Stevens-Johnson patients usually respond to treatment, they may become seriously ill if shock or infection set in. Patients usually survive with staphylococcal scalded skin syndrome See also some scarring, eye problems, and nail dystrophy. SCALDED SKIN SYNDROME. Controversy exists over whether systemic steroids are indicated in this condition. See also ERYTHEMA MULTIFORME. Stein-Leventhal syndrome An endocrine disor- der causing excess hairiness also known as poly- cystic ovary syndrome. In this disorder, the ovaries Stewart-Treves tumor A type of tumor that increase testosterone production, increasing blood is closely related to angiosarcoma, which often levels of the male hormone. About 20 percent of appears in the upper extremities after radical women with this problem have ACNE. mastectomy for breast cancer. The tumor, which is unrelated to the breast cancer, usually appears Symptoms and Diagnostic Path about 10 years after the original surgery and after This disorder is characterized by incomplete devel- long-standing swelling in the lymph nodes in the opment of follicles in the ovary due to inadequate upper extremity. secretion of luteinizing hormone; the follicles fail to ovulate and remain as multiple cysts, distending Symptoms and Diagnostic Path the ovary. Hormone imbalance results in obesity Onset of this tumor is usually fairly quick, with and hairiness (HIRSUTISM), and the sufferer becomes the appearance of a blue-purple patch on the infertile due to the lack of ovulation. upper arm followed by red-blue or purple NODULES or BLISTERs. Larger lesions may spread quickly, Treatment Options and Outlook through the lymph system and blood vessels, to the Administration of antiandrogens such as spirono- lungs, pleura, and thoracic wall. lactone, cimetidine, or cyproterone acetate and the oral contraceptive pill to suppress gonadotropic Treatment Options and Outlook hormones. A wedge resection of the ovaries may There is no truly effective treatment; the tumors and help some women. lesions usually recur even after radical surgery. 354 sting sting An injury caused by a plant or animal toxin the pigment-forming cells of the skin that produce introduced into the skin. MELANIN, responsible for giving skin its color.

stork bite nevus A type of vascular malforma- stratum granulosum A part of the EPIDERMIS, the tion, this is a harmless small, fl at, pink skin blemish stratum granulosum consists of two or three rows found around the nape of the neck in up to 50 per- of cells lying directly below the STRATUM LUCIDUM, cent of newborn babies. It may persist indefi nitely. which lies below the STRATUM CORNEUM. Salmon patches are similar blemishes found around the eyes in a similar percentage of new- borns. These blemishes usually disappear within stratum lucidum The epidermal cell layer the fi rst year. between the STRATUM CORNEUM and the STRATUM GRANULOSUM. stratum corneum Latin for the “horny layer,” the top layer of EPIDERMIS that consists of dead cells. stratum malpighii The major layer of the EPIDER- Because the surface of this layer is acidic, it is some- MIS, consisting of six to 10 layers of keratinocytes. times also referred to as the acid mantle. The stratum corneum gets its name from the fact that when tightly compacted, its cells toughen, like an animal’s horn stratum spinosum The middle layer of the EPI- (and mammal horns are made of the same protein DERMIS, also known as the SKIN’s “prickle cell layer” material that makes up the stratum corneum). because of its spiny, hairlike prickly projections The cells of this SKIN layer are constantly sloughed linking the cells in this area. The cells within this from the skin’s surface and are completely replaced thickest part of the epidermis are called SQUAMOUS about every two weeks by cells migrating upward CELLS (basal cells that have matured and migrated from below. If for some reason horny cells accu- upward through the epidermis). mulate on the skin surface, the result will be fl aky skin. This is a particular problem for those with dark skin because of the sharp contrast between strawberry birthmark A bright red, raised, lumpy the gray fl akes and the surrounding skin. BIRTHMARK, also called strawberry nevus, straw- This layer of the skin provides the major physi- berry HEMANGIOMA, or, the correct term, superfi - cal barrier of the body, and also serves as a shield cial HEMANGIOMA. About 2 percent of all infants to the sun’s harmful ultraviolet rays. It also blocks develop this type of birthmark. the penetration of most substances that touch the skin. Normally only substances smaller than Symptoms and Diagnostic Path a water molecule can easily penetrate the horny They typically appear at about one to four weeks layer, which means that the skin cannot “drink up” of age and may quickly grow over the new few vitamins, nutrients, COLLAGEN, or ELASTIN because months; they stop growing between six and 12 their molecular structure is larger than water. months and gradually disappear over the next few years. Experts cannot predict what will happen to a strawberry birthmark; some will disappear by age stratum germinativum The base of the EPIDER- two and about 60 percent will be gone by age fi ve. MIS also known as the basal layer where SKIN cells Between 90 and 95 percent will have disappeared are constantly germinated anew. New cells are by age nine. constantly produced in the basal layer, eventually migrating upward through the epidermis to the Treatment Options and Outlook surface of the skin. The basal layer is composed Because these birthmarks eventually disappear on not only of basal cells, but also of MELANOCYTES, their own, treatment is not always recommended. stress and the skin 355

Data show a good response to the pulsed dye Symptoms and Diagnostic Path laser. The PULSED DYE LASER is effective at slowing Once exposed, a person can get sick within three growth during the proliferative phase, and may days and can pass the infection to others for up to help to speed resolution of an already-regressing two or three weeks, even if there are no symptoms. hemangioma. After 24 hours of antibiotic treatment, the patient DERMATOLOGISTs recommend that most super- is no longer able to spread the germs. fi cial hemangiomas be left untreated. However, Some types of group A strep bacteria cause severe treatment should be started early if the heman- infections, including BACTEREMIA, toxic shock syn- gioma is on the face, or near the eyes, nose, or drome, and necrotizing fasciitis. According to the mouth, or if it grows rapidly or interferes with Centers for Disease Control and Prevention, 4,844 function of vital organs. Treatment of rapidly grow- cases of severe group A streptococcal disease were ing hemangiomas is performed every two weeks. reported in 2003. All severe group A strep infec- Once growth has stabilized, treatment is given tions can cause shock, organ failure, and death. every four weeks. These infections can be diagnosed with blood counts, urine tests, or cultures of blood or fl uid from a wound site. streptocerciasis A type of infection caused by a roundworm (Dipetalonema streptocerca) found only Treatment Options and Outlook in the tropical rain forests of western and central Antibiotics used to treat these severe infections Africa that causes a chronic DERMATITIS similar to include PENICILLIN, ERYTHROMYCIN, and CLINDAMY- onchocerciasis (a tropical skin disease caused by a CIN. In severe cases of strep infection, a health care parasitic worm). provider may need to remove the tissue surgically or amputate the limb. streptococcal infections A group of infections caused by bacteria of the streptococcus family, stress and the skin The SKIN is the “window to among the most common bacteria that affect the mind,” and to an astonishing degree, it can humans. reveal a person’s emotional state. Humans blush Group A streptococcus is a bacterium respon- when they are embarrassed; blanch when they are sible for a variety of health problems ranging from afraid, and turn red when angry. mild skin infection or “strep throat” to severe, It is not surprising that stress, which can have a life-threatening conditions such as TOXIC SHOCK profound impact on the emotions and the physical SYNDROME and NECROTIZING FASCIITIS (fl esh-eating health of the body, also can cause profound effects disease). Experts estimate that more than 10 mil- on the skin. In fact, experts believe a wide range lion mild throat and skin infections occur every of skin problems (ACNE, ECZEMA, ROSACEA, HERPES, year. Other strep infections responsible for a wide PSORIASIS, and HIVES) can be worsened or even trig- range of skin problems include ERIPSIPELAS, CELLU- gered by stress. LITIS, ECHTHYMA, and SCARLET FEVER. In addition to Stress can make new skin lesions appear, or strep throat and superfi cial skin infections, group make already existing skin problems worse. In fact, A strep bacteria can cause infections in tissues at people who are most at risk for developing stress- specifi c body sites, including lungs, bones, spinal related skin problems are those who have problem cord, and abdomen. skin to start with. This is most likely due to the fact Strep infections can be spread by direct contact that when people are under stress, they may work with saliva or nasal discharge from an infected long hours, eat unhealthy meals, neglect their person, usually not as a result of casual contact exercise or sleep needs. but from a crowded environment such as a dormi- Abusing ALCOHOL also can damage the skin, tory or institutional setting. There also have been since alcohol increases the fl ow of blood to the reports of contaminated food causing infection. skin. Alcohol use is particularly troubling to skin 356 stretch marks conditions such as rosacea, hives, fl ushing, and marks are new and still pink. Retin-A dose not psoriasis. Nicotine, on the other hand, constricts work on stretch marks that have turned white. blood vessels, which reduces the supply of blood to Caution: Pregnant women and nursing mothers the skin. This is one reason why the skin of chronic should not use Retin-A, because it crosses the placenta smokers looks pale and deeply lined, leading to the and is also found in breast milk. For both red (early) “smoker’s mask.” and white (late) stretch marks, lasers are the treatment of choice. The pulsed-dye laser and the Treatment Options and Outlook intense pulsed light source are two of several laser If stress is worsening the condition of the skin, and light sources that improve stretch marks. individuals should:

• avoid picking or scratching skin striae See STRETCH MARKS. • use a noncomedogenic moisturizer that clog pores, but will combat dryness strongyloidiasis An intestinal infestation of tiny • avoid exotic ingredients that could cause an parasitic roundworms that cause itching and raised allergic reaction red patches on the skin where the worms enter. • drink lots of water to improve the skin’s tone The disease, caused by Strongyloides stercoralis, is and texture found throughout the tropics, especially in the Far • try relaxation techniques, biofeedback, and so on East. to lessen stress The worms are picked up by walking barefoot on soil contaminated with feces. The larvae enter the skin of the feet and migrate to the small intes- tines where they develop into adulthood, burrow- stretch marks Also known medically as “striae,” ing into the intestinal walls and producing larvae. these lines on the skin are caused by thinning and loss of elasticity in the underlying skin area. Symptoms and Diagnostic Path After infestation, the worms cause redness, swell- Symptoms and Diagnostic Path ing, itching, or HIVES, fading within two days. If Stretch marks fi rst appear as red, raised lines the larvae penetrate the perianal area, skin lesions that turn purple, fl atten, and fade to form shiny begin to radiate from the anus down the thigh or streaks between a quarter-inch and a half-inch across the buttocks or abdomen as itchy bands. wide. These marks may strike during adolescence, While the individual lesion may fade away within appearing on thighs and hips of young girls dur- a few days, an infestation may continue in the host ing their growth spurt. They are also common in for many years and cause recurrent problems. pregnancy; about 75 percent of pregnant women experience the marks on breasts, thighs, and lower Treatment Options and Outlook abdomen. In addition, purple stretch marks may Thiabendazole administered for two days is the occur in patients with Cushing’s syndrome and treatment of choice. Rarely, death may occur from in those using excess CORTICOSTEROID hormones, blood poisoning or meningitis many years after the which suppress the formation of collagen (skin infestation occurs. fi ber), causing COLLAGEN to waste away.

Treatment Options and Outlook Sturge-Weber syndrome (SW) A rare congenital TRETINOIN (Retin-A) has been found to help fade condition (also called trigeminal angiomatosis) that red early stretch marks signifi cantly, and in some affects the skin and brain. Sturge-Weber syndrome cases even make them disappear, as long as the is caused by a spontaneous genetic mutation; it is sulfonamide drugs 357 not transmitted by parents who carry the gene. subcutaneous A medical term referring to the How often the condition occurs in babies is not area beneath the SKIN. known, and because it is not often diagnosed it is diffi cult to estimate how many people currently have the disease. subcutaneous fat, atrophy of See FAT ATROPHY.

Symptoms and Diagnostic Path The most obvious symptom is a facial PORT-WINE subcutaneous fatty tissue Also known as sub- STAIN birthmark present at birth, usually over one cutis, this is the bottommost layer of skin, found side of the face, including at least one upper eyelid under the DERMIS. This layer serves as a cushion and the forehead. However, each case of Sturge- for internal organs and also as a storage site for Weber is unique and symptoms vary. reserve energy. The amount and distribution of this Neurological problems include unusual blood fatty tissue throughout the body is believed to be vessel growths on the brain (angiomas) that usu- governed largely by heredity and by how much a ally cause seizures beginning before age one, and person eats. worsening with age. Convulsions usually appear on the side of the body opposite the port wine stain and vary in severity. subcutis See SUBCUTANEOUS FATTY TISSUE. About 30 percent of patients with Sturge-Weber also develop glaucoma in the eye affected by the port-wine stain. Enlarging of the eye also can occur subungual hematoma A blood-fi lled bruise under in the eye that is involved with the stain. In some the fi ngernail caused by direct trauma, such as cases, strokes can occur. slamming the fi nger in a door. The pain can be Treatment Options and Outlook eased by puncturing the nail plate with a drill or fi ne scalpel blade; otherwise, the nail may be shed. Visible light lasers (argon, dye, and heavy metal If the injury affects the matrix of the nail, it may lasers) are the treatments of choice for children as form permanent deformity of the nail, with ridging young as 12 months, although lesions respond vari- ably according to their color, thickness, size, and site. or a split. The birthmark can be hidden with specially designed masking makeup. Seizures can be controlled with anticonvulsant drugs, and in severe cases, surgery sulfapyridine A long-acting sulfa drug used may be performed on the affected part of the brain to treat blistering diseases such as DERMATITIS to treat glaucoma and other eye problems. HERPETIFORMIS. See also CAMOUFLAGE COSMETICS. Side Effects This drug can cause severe allergic reactions, ane- sty A small PUS-fi lled ABSCESS (also called a hor- mia, and a decrease in the number of white cells deolum) near the eyelashes caused by an infection in the body. To prevent kidney problems, patients with Staphylococcus aureus. should drink plenty of liquids.

Treatment Options and Outlook Warm compresses administered for 20 minutes, sulfonamide drugs The fi rst available anti-bacte- four times daily, may help eliminate the pus, rial drugs. These medications are used to treat skin reduce swelling, and decrease pain. An antibiotic infections, among other things. Before the devel- ointment designed for the eyes can help prevent a opment of PENICILLIN drugs, the sulfonamides were recurrence. widely used to treat other infections. 358 sulfones

The sulfa drugs are usually given by mouth, and Many studies suggest that a combination of most are quickly absorbed from the stomach and BENZOYL PEROXIDE and sulfur is more effective than small intestines. sulfur used alone. Sulfur is thought to dissolve the top layer of dry dead cells and slow down oil-gland Side Effects activity, which is why it is used in acne soaps, A variety of side effects may occur, including nau- lotions and dandruff SHAMPOOS. sea, vomiting, headache, and appetite loss. More The highest concentration of sulfur in over-the- severe side effects include blood disorders, skin counter medication is 10 percent. Sulfur may cause rashes, and fever. Patients taking sulfa drugs should a mild sensitivity and allergic reactions, and can avoid sun exposure. irritate the eyes. Discontinue use if skin sensitivity occurs. While most experts consider benzoyl peroxide sulfones One of a group of drugs closely related and sulfur safe when used as single ingredients, to the sulfa drugs in their structure and the products that combine the two increase the possi- way they act. Sulfones are powerful agents in bility of sensitivity to benzoyl peroxide. Therefore, the fi ght against bacteria that cause LEPROSY. The combination products are not available without two sulfones most often used in dermatologic prescription. practices are DAPSONE and SULFAPYRIDINE. Other In addition, sulfur is sometimes added to RESOR- skin diseases in which sulfones are used include CINOL (a drug that causes skin to peel) as an acne subcorneal pustular dermatosis, acne conglobata, treatment, although experts aren’t sure why this PYODERMA GANGRENOSUM, BULLOUS PEMPHIGOID, cic- combination works. Resorcinol by itself is not con- atricial pemphigoid, chronic bullous dermatosis of sidered to be effective against acne, but it appears childhood, erythema elevatum diutinum, relapsing to enhance the action of sulfur. Because resor- POLYCHONDRITIS, GRANULOMA ANNULARE, granuloma cinol in concentrations above 3 percent appear to faciale, bullous eruption of systemic lupus erythe- be toxic, products with this ingredient are only matosus, leukocytoclastic vasculitis, actinomycotic mycetoma, alopecia mucinosa, pustular psoriasis, available over-the-counter in concentrations of 2 percent and less. Products containing resorcinol HERPES GESTATIONNIS, PEMPHIGUS, Weber-Christian should not be applied to broken skin or to large PANNICULITIS, BROWN RECLUSE SPIDER BITES, and HAILEY-HAILEY DISEASE. areas of the body. In addition, resorcinol may dis- Patients who take these drugs require fre- color dark or black skin. quent evaluation, including complete blood counts Sulfur is not the same as sulfa, an abbreviation with differential white counts, a chemistry profi le for a group of antibacterial agents including sulfa- (including liver and kidney tests), urine tests, and diazole and sulfathiazole. methemoglobin level.

sun blocks See SUNSCREENS. sulfur An important mineral component of vita- min B1 and of several essential amino acids. Sulfur is particularly necessary for the body’s production sunburn Infl ammation of the skin as a result of of COLLAGEN, which helps to form connective tis- overexposure to the sun. Sunburn occurs when sue. Sulfur is also a component of KERATIN, the the ultraviolet rays of the sun destroy skin cells chief ingredient in hair, skin and nails. in the outer layer of the skin, damaging tiny In addition, sulfur is one of the oldest of the blood vessels underneath. Sunburn is a particular modern drugs and a popular ACNE treatment, problem in light-skinned individuals whose skin although its action is still not well understood. does not produce much MELANIN, the protective Researchers believe that it is effective by control- pigment that can guard against damage from the ling bacteria and exfoliating the skin. sun. sun protection factor 359

Symptoms and Diagnostic Path SPF of 30; typical clothing is only about as effective Sun-exposed skin turns red, becomes very painful as SPF 6. and may develop BLISTERs; if the BURN is severe, See also SUN PROTECTION FACTOR; CLOTHES AND the individual may also experience symptoms of SUN PROTECTION; MELANOMA, MALIGNANT. sunstroke, including vomiting, fever, and collapse. Several days after the skin has burned, the skin may shed its dead cells by peeling. Repeated exposure to sun poisoning A common term for a temporary sunlight over the years may result in prematurely condition of red, itchy bumps caused by sun sen- aged skin and SKIN CANCER; blistering sunburns sitivity. Some of the causes include POLYMORPHIC before age 20 increase the risk of melanoma. LIGHT ERUPTION, photocontact DERMATITIS involving an agent applied to the skin (such as PABA or oxy- Treatment Options and Outlook benzone in SUNSCREENS), and photosensitivity to a The best idea is to avoid getting sunburned in the systemic drug (such as TETRACYCLINE). The bumps fi rst place, because once the skin is burned it has should disappear within a week. Patients should become damaged. While there are many so-called see a doctor if weeping, oozing blisters develop, sunburn remedies, none are highly effective. Com- since this may indicate a possible infection. presses may help, using a variety of ingredients such as skim milk and water, aluminum acetate Treatment Options and Outlook baths (as contained in Buro-Sol antiseptic powder Cool compresses and over-the-counter hydrocorti- or Domeboro’s powder), oatmeal, or witch hazel. sone cream or oral antihistamines. Cool (not cold) baths may also be soothing, See also SOLAR WARNING INDEX; SUNBURN; SUN- especially if enhanced with one cup of white vin- SCREEN; SKIN CANCER. egar, Aveeno powder (made from oatmeal), or bak- ing soda. Soap or bubble baths should not be used on sunburned skin (they can irritate tender fl esh). sun protection factor (SPF) A rating system for After a compress or a soaking bath, moisturizer SUNSCREEN products that measures how effectively should be applied immediately afterward. it works; the higher the SPF, the greater the amount Other home remedies include application of a of protection from the sun. For example, an SPF of cornstarch paste, raw cucumber or potato slices, 15 means that an individual using the sunscreen yogurt, or tea bags soaked in cool water. The oil could spend up to 15 times longer in the sun with- from the aloe plant may be applied directly to the out burning. An SPF value is assigned by manufac- skin for sunburn relief, but the skin should fi rst be turers of sun protecting cosmetics for items such as tested for allergies. sunscreens, creams, lipsticks, cosmetic milks, and lotions. Most SPF rating only apply to UVB rays. A Risk Factors and Preventive Measures burn is caused by ultraviolet-B (UVB) rays, which Exposure to strong sunlight should be limited to are strongest between the hours of 10 A.M. and 4 15 minutes on the fi rst day, especially for those P.M. However, it is the ultraviolet-A (UVA) rays with fair skin, increasing exposure slowly each day. that age the skin, causing WRINKLES, sagging skin, Until the skin has tanned, it should be protected and brown spots. Standardized ratings for blocking with a high-protection SUNSCREEN of at least 15 UVA rays are being developed, which is why there SPF. Fair-skinned individuals and those who are are few SPF ratings for UVA numbers on sunscreen photosensitive should use a sunscreen with an bottles. SPF of 29 or higher. The sun should be avoided Experts suggest that sunscreen should have a between the hours of 10 A.M. and 3 P.M. minimum SPF of 15 to avoid the burning, drying, Aspirin and nonsteroidal anti-infl ammatory and wrinkling that results from overexposure to drugs (NSAIDs) can prevent sunburn only if taken the harmful rays, which are the single most damag- before exposure to the sun. New types of protective ing element to the skin. On the other hand, experts clothing are now available that are equivalent to an at the U.S. Food and Drug Administration criticize 360 sunscreens sunscreens with SPFs up to 50, charging that con- both ultraviolet-A (UVA) and UVB. Sunscreens sumers may have a false sense of security by using are used primarily to avoid SUNBURN and suntan- products with very high SPF values. ning, although they can also be used to prevent An SPF of 50 implies that a person can tolerate the rash in patients’ PHOTOSENSITIVITY. They also 50 times the amount of sun that it would normally prevent skin cancer and the aging effects of the take to burn, which is not necessarily true. And sun on the skin. even a sunscreen with an SPF of 50 lets some UVB While some skin exposure to sunlight is nec- rays through, so using it does not allow a person to essary for the body to produce VITAMIN D, over- bake for hours in the sun without any risk of cancer exposure can have a range of harmful effects, or wrinkling, according to some DERMATOLOGISTs. especially in fair-skinned people. Most sun- In addition, the higher the SPF number, the faster screens, including those preparations containing the proportional increase in protection diminishes. para-aminobenzoic acid (PABA) or benzophe- For example, the difference between an SPF of 45 none, work by absorbing ultraviolet rays of the and one of 30 is only a few percentage points. Most sun. Products containing other substances (such SUNBURNS can be prevented by using a product with as TITANIUM DIOXIDE, an uncolored relative of ZINC an SPF of 30. OXIDE) refl ect the sun’s rays. There are still some physicians and sunscreen Sunscreens are designed to protect against UVB manufacturers who believe that higher SPFs should light, the type of radiation that causes sunburn. No be available for those who choose to use them. sunscreens screen out all UVA rays, another kind of Sweating heavily, swimming, or participating in ultraviolet light produced by the sun that can dam- other water activities reduces the SPF because age the skin and may play a role in malignant mel- sweat or water on the skin will lessen the amount anoma simply because sunlight contains so much of protection the sunscreen provides. Sunscreen of it. (Think UVA-aging, UVB-burn plus aging). needs to be reapplied more frequently during these Some sunscreens may advertise protection from activities. UVA rays; there is no standardized rating for UVA For overseas travelers, it is important to realize protection. that not all SPFs are the same. In Europe, the SPF The best sunscreens offer a broad spectrum of is called DIN (Deutsches Institut fur Normung, the protection, and include such ingredients as oxy- company that developed the system). The DIN uses benzone, titanium dioxide, zinc oxide, or Parsol lower numbers than the American SPF system for 1789. But while sunscreens are not perfect, they equivalent sun protection. For example, an SPF 12 do prevent sunburn, future freckling and brown is equal to DIN 9; SPF 19 is DIN 15. spots, ACTINIC KERATOSES (precancerous lesions), and SKIN CANCER. A French blocker called Mexoryl SX, made by sunscreens Products that protect the skin from the French skin care giant L’Oreal, and shown to the harmful effects of sunlight’s harmful radia- be effective in several studies, is contained in some tion; all sunscreen products protect against ultra- European and Canadian sunscreens, but is not yet violet-B (UVB); some products protect against approved in the United States. However, some con-

SAFE EXPOSURE TIMES USING SUNSCREENS PROTECTION FACTOR 4 8 15 SKIN TYPE SAFE EXPOSURE TIME Fair 10 minutes 40–80 minutes 1.5–2 hours Medium 50–80 minutes 2–2.5 hours 5–5.5 hours Dark 1.5–2 hours 3.5–4 hours all day Black 4 hours all day all day sunscreens 361 sumers are ordering the product online from out of can be applied less often, but experts recommend the country and buying it on auction sites because an extra application after swimming if there is any it blocks both UVA and UVB light and provides bet- uncertainty about the need for more. ter and longer UVA protection than other products Sunscreen should be applied before going out- available in the United States. side (even in cloudy weather, since 80 percent of Sunscreens containing this blocker are available the Sun’s rays break through the clouds). in Europe, Asia, and Latin and South America. Consumers can still develop sun-induced aging Sunscreen Allergies and skin cancer even if they do not get a sunburn. Some people are allergic to the chemicals con- The only way to completely protect against aging tained in sunscreens and can develop a skin rash. and skin cancer is to avoid the sun. The most common ingredients to cause an allergic reaction are PABA and oxybenzone. SPF Fortunately, new chemical-free sunscreens are Sunscreen products are labeled with a SUN PRO- now being developed that contain physical sun- TECTION FACTOR (SPF), which is a measure of how blocks (such as titanium dioxide and talc) broken effectively the sunscreen works; the highest factor down into tiny particles that can be formulated indicates the greatest amount of protection. Sun- into clear, invisible lotions instead of the white screen with a minimum SPF of 15 should be used zinc-oxide creams. The nonchemical sunscreens to avoid burning, drying, and wrinkling that results block both UVA and UVB rays far better than most from chronic overexposure. An SPF of 15 means chemical sunscreens. that individuals using the sunscreen could spend up to 15 times longer in the sun without burning Other Protective Factors than if they weren’t wearing it. However, the SPF A more controversial approach to sunscreen devel- applies only to UVB; no effective rating for UVA opments is the addition of other protective fac- currently exists. tors, such as VITAMINS E and C (antioxidants that An SPF 15 blocks 94 percent of UVB rays and neutralize free radicals, which are unstable oxygen an SPF 30 blocks 98 percent. However, since many molecules that damage skin). The goal is to prevent people skimp when applying sunscreen or apply it or delay damage to skin cells by screening out some unevenly, experts rationalize that skimping when of the premature-aging effects of sunlight while applying SPF 15 might mean the consumer ends up allowing the triggering of vitamin D, but many with the equivalent of an SPF 6, whereas skimping dermatologists are skeptical. when using an SPF of 30 or higher still provides Because the wavelength of light that stimulates adequate protection. A full ounce should be applied vitamin D production in the skin is UVB, some each time. have voiced concern regarding the overuse of The U.S. Food and Drug Administration (FDA) UVB sunscreens. However, since it takes only 15 revised sunscreen labeling to include a maximum minutes two or three times a week to spur vitamin SPF 30 on all sunscreens, the use of the terms D synthesis in the skin, very few people have to “water-resistant” and “very water resistant” instead worry about not getting enough sun exposure. of “waterproof,” charts to match skin types with the appropriate SPF numbers, and stricter guide- Rating Sunscreens lines on anti-aging claims. The Skin Cancer Foundation rates sunscreens; consumers should look for their seal of approval on How to Apply all sunscreen products. Sunscreens that have the Experts suggest that adults should use an ounce of foundation’s “seal” on the label have met stringent sunscreen (about a shot glass full) to properly pro- criteria that exceed those of the FDA; in order to tect an average-sized person. Sunscreens should be rate the foundation’s approval, the product must reapplied every two hours, and again after swim- prove that it helps prevent sun-induced damage to ming; waterproof or water-resistant sunscreens the skin. The product must have an SPF of 15 or 362 sunstroke higher and include substantiation for any claims Even with frequent applications of SUNSCREEN, that a sunscreen is waterproof, water-, or sweat- sunbathers may be at risk for developing skin can- resistant. The seal is also granted to SELF-TANNING cer, including melanoma (the most serious form PRODUCTS that include a sunscreen; this sunscreen of skin cancer). Newest fi ndings have found that must meet the same requirements as regular sun- not only ultraviolet-B (UVB) light (rays that cause screen. Clothing is still considered to be the best sunburn, between 280 and 320 nanometers) but protection against sun-induced skin aging and skin also light with longer wavelengths—including cancer of all types. ultraviolet-A (UVA) light—can fuel a series of changes in skin cells. Protective Clothing In the past several years, scientists began to It is a good idea to wear some type of sun-protective agree that UVA light does indeed play a greater role clothing specially designed to block the harmful in causing some skin disorders. Although experts rays of the sun, such as SOLUMBRA. still believe that UVB is responsible for much of the See also PABA; SUN POISONING; SOLAR WARNING sun-related skin damage (especially SUNBURN) UVA INDEX. is important in making the skin look aged (with wrinkles, brown spots) and to a lesser extent, SKIN CANCERS. sunstroke Also called heatstroke, this condition is About 65 percent of melanomas and 90 per- caused by excess exposure to heat and the sun, and cent of basal and squamous cell skin cancers are is characterized by feelings of dizziness and nausea. attributed to UV exposure. Although the exact However, in some people (especially the elderly) it wavelengths of UV light that contribute to the can involve a very high body temperature and lack development of skin cancer is unknown, it is most of sweating followed by loss of consciousness. For likely a UVB wavelength. Most sunscreens do a these individuals, this condition is potentially fatal good job blocking UVB, but fewer sunscreens fi lter unless treated quickly. out most of the UVA. Controversy about how well sunscreen protects Treatment Options and Outlook against cancer occurs because experts do not know Quick cooling is the most important aspect of whether melanoma and other skin cancers are treatment for sunstroke. An ice bag or crushed ice caused by exposure to UVB, UVA, or both. Since should be applied; alternatively, the patient should most sunscreens protect only against UVB, using be wrapped in a wet sheet and hosed down with a sunscreen may be of no value if cancer is caused cold water until emergency medical help arrives. by UVA. Moreover, people using a UVB-only sun- See also SUNBURN. screen may stay out longer than they would have in the sun, thus potentially increasing their risk. The Sun’s rays do not just stay on the surface of suntan The result of the body’s attempt at pro- the skin; they also penetrate deep beneath the skin, tecting itself from the damage of the Sun’s ultra- where they can damage the COLLAGEN network, the violet rays. During exposure to the Sun, the skin springy web of fi bers that support and strengthen begins to produce more of the dark pigment called skin. This damage actually can be reversed in part MELANIN to absorb the damaging rays. The result is by staying out of the sun and by long-term use of a darkened skin tone. Retin-A. While a suntan is widely considered to be See also CLOTHES AND SUN PROTECTION; MELA- desirable, it is in fact a sign that the skin has been NOMA, MALIGNANT; SUNBURN; SUN PROTECTION FAC- damaged. Melanin provides some protection from TOR; TANNING BEDS. skin damage and is the reason why dark-skinned individuals usually get fewer WRINKLES than fair- skinned individuals given the same amount of sun suppuration The formation of pus at the site of exposure. bacterial infection. The pus may also accumulate, sweat glands, disorders of 363 forming an ABSCESS (in solid tissue) or a BOIL or referred to a physician, since such sweating may be PUSTULE on the skin. Open sores often weep pus a sign of hormonal imbalance. like this, especially when they do not heal well, because the exposed tissue gets reinfected with bacteria again and again. sweat glands Sweat glands are spread out all across the body in varying concentrations that are designed to produce perspiration. Each gland surfer’s nodules Lesions caused by repeated fric- has a tube for secreting sweat and a narrow pas- tion of the tops of the feet and the knees against sage that carries sweat to the skin’s surface. Most a surfboard. This condition will disappear if the people have about 3 million sweat glands in two patient stops surfi ng; otherwise, local injections of types—apocrine and eccrine glands. a low-dose cortisone will help. Apocrine glands lie heavily coiled in mostly hairy areas (the armpits, the nipples, genital, and anal areas, and around the navel), located deep within sweat Sweating is the body’s way of keeping its the fatty tissue. This is the gland that secrets the internal temperature at a constant 98.6°. When the type of sweat associated with body odor, mostly body’s temperature rises, the body’s SWEAT GLANDS under the armpits. Apocrine glands secrete a milky are stimulated to start producing water to cool off sweat into the upper portion of the HAIR FOLLICLE, the body. When this happens, sweating is heaviest and from there to the skin surface. This sweat is on the forehead, upper lips, neck, and chest. broken down by bacteria on the skin, causing body Sweat is made primarily of water and some tiny odor. While it is believed that the apocrine glands amounts of other substances (such as salt). Perspi- in other mammals serve as a sexual stimulant, their ration itself, regardless of the type of sweat gland function in humans is not known. Like SEBACEOUS from which it originates, is odorless—the smell GLANDS, the apocrine glands do not mature and occurs when sweat mixes with bacteria (especially begin secreting until puberty. in the armpits). Eccrine glands are the most common (especially Sweating is an involuntary process, a response on hands and feet), and like apocrine glands they to the environment or to psychological factors such are heavily coiled in the fatty tissue layer. Eccrine as embarrassment or stress. People who experi- glands secrete clear, watery sweat through their ence excess sweating (HYPERHIDROSIS) need to be own pores, not along hair follicles. Exercise, hot weather, fever, and emotional stress can stimulate Cross Section of Skin Showing Sweat Glands eccrine sweating over the entire surface of the body (but concentrated on the soles of the feet, fore- head, palms, and armpits). They appear to be more Hair strongly linked to stimulation by emotional stress than by heat. Eccrine glands are mostly water and do not cause body odor; they serve to regulate body temperature and to help eliminate waste salts. See also HYPERHIDROSIS; SWEAT GLANDS, DISOR- Eccrine Sweat Gland in DERS OF. Sweat Cross section Gland sweat glands, disorders of There are a number Subcutaneous of disorders that can affect the sweat glands. The Layer most common is PRICKLY HEAT, an intense, irritat- ing skin rash caused by blocked sweat glands. Less Hair Bulb commonly, the sweat glands may be affected by HYPERHIDROSIS, a type of profuse sweating that 364 swimmer’s ear often requires medical treatment and can cause phenate. A thick coating of grease or tightly woven highly embarrassing social problems. HYPOHIDRO- clothes can protect against infestation. Bathing SIS (reduced sweating), a less common problem, with a hexachlorophene soap before swimming occurs in ectodermal dysplasia syndrome. may help to some degree. Briskly rubbing the skin with a towel after swimming may help remove some organisms. swimmer’s ear See OTITIS EXTERNA.

swimming pool granuloma A disorder of the swimmer’s itch The common name for cutane- skin caused by a mycobacterium in swimming ous SCHISTOSOMIASIS, or cercarial dermatitis, this is pool water characterized by ABSCESSES on the an itchy skin infl ammation caused by bites from hands, over the fi ngers, or on the knees. The fl atworms. This disorder features a distinctive problem is also found in those who own tropi- papular eruption after swimming in or having cal fi sh tanks; if a person cleans the tank and contact with freshwater populated by ducks and scratches a hand against objects in the tank, the snails. organism can penetrate the abrasion; weeks later, This type of dermatitis is a potential risk when- a lesion may form. ever people use an aquatic area with animals and A swimming pool granuloma results when water mollusks who harbor the schistosomes. In the contains an infectious organism, Mycobacterium United States, the worst outbreaks occur in the marinum, enters a traumatized area of skin and pro- lake regions of Michigan, Wisconsin, and Min- duces a localized infection called a granuloma. nesota. A more serious tropical disease is visceral schistosomiasis. Symptoms and Diagnostic Path Swimming pool granulomas appear approximately Symptoms and Diagnostic Path six to eight weeks after exposure to the organism, After exposure to water containing schistosomes, appearing as reddish bumps that slowly enlarge a prickling or itchy feeling begins that can last up into purplish NODULES. The nodules may break to an hour while the fl ukes enter the skin. Small down and ulcerate, leaving an open sore. red MACULES form, but there may be swelling or The lesions generally disappear over a period of wheals among sensitive people. Also these lesions months to more than a year. There is no evidence begin to disappear, they are replaced after 10 or 15 of systemic disease associated with M. marinum, but hours by discrete, very itchy PAPULES surrounded this organism may pose a threat to immunocom- by a red area. VESICLES and pustules form one promised people. or two days later; the lesions fade away within The condition is diagnosed with a biopsy of a week, leaving small pigmented spots. Different the lesion, and a culture of lesion demonstrating symptoms depend on how sensitive the patient is M. marinum. A PPD tuberculin skin test will usually to the schistosome. Each reexposure causes a more be positive. severe reaction. Treatment Options and Outlook Treatment Options and Outlook Treatment includes local heat therapy and CALAMINE lotion or oral ANTIHISTAMINES may help minocycline. control the itch until the lesions begin to disappear on their own. sycosis vulgaris See BARBER’S ITCH. Risk Factors and Preventive Measures The best way to alleviate the problem is to destroy the snails by treating the water with copper sul- syphilis A sexually transmitted infection found fate and carbonate, or with sodium pentachloro- around the world that causes (among other symp- systemic disease, skin symptoms of 365 toms) a skin sore and rash. Also present as an infec- and brain damage (neurosyphilis) leading to insan- tion at birth, syphilis was fi rst recorded as a major ity and paralysis. epidemic in Europe during the 15th century. Today, the infection is transmitted almost exclu- Treatment Options and Outlook sively by sexual contact. Since the 1970s and early PENICILLIN is the drug of choice for all forms of 1980s, the incidence of syphilis in the United States the disease; early syphilis can often be cured by a has been on the rise. single large injection; later forms of the disease may Syphilis is caused by a spirochete Treponema require a longer course of the drug. More than half pallidum that enters broken skin or mucous mem- of syphilis patients treated with penicillin develop branes during sexual intercourse, by kissing, or by a severe reaction within six to 12 hours caused by intimate bodily contact with an infected person. the body’s response to the sudden killing of large The rate of infection during a single contact with numbers of spirochete. an infected person is about 30 percent. Risk Factors and Preventive Measures Symptoms and Diagnostic Path Infection can be avoided by maintaining monoga- During the fi rst (or primary) stage, a sore appears mous relationships; condoms offer some protec- between three to four weeks after contact; the sore tion, but they are not absolutely safe. People with has a hard, wet painless base that heals in about a syphilis are infectious during the primary and month. In men, the sore appears on the shaft of secondary stages, but not in the late latent and the penis. In women it can be found on the labia, tertiary stages. although it is often hidden so well that the diag- nosis is missed. In both sexes, the sore also may be seen on the lips or tongue. syringomas Benign growths of the sweat ducts Six to 12 weeks after infection, the patient enters that look like small skin-colored lumps on the the secondary stage, which features a skin rash that eyelids, trunk, and cheeks; they may occur among may last for months. The rash has crops of pink or several family members. pale red round spots, but in black patients the rash is pigmented and appears darker than normal skin. Symptoms and Diagnostic Path The eruption can be mistaken for PITYRIASIS ROSEA. These harmless painless lumps, which are really In addition, the lymph nodes may be enlarged, enlarged, underdevelop SWEAT GLANDS, typically and there may be backache, headache, bone pain, appear during adolescence and adulthood. appetite loss, fever, fatigue, and sometimes men- ingitis. The hair may fall out and the skin may Treatment Options and Outlook exhibit gray or pink patches (condylomata) that They can be removed by minor surgery for cos- are highly infectious. The secondary stage may last metic reasons, but many individuals choose to up to a year. ignore these skin growths. The latent stage may last for a few years or until the end of a person’s life. During this time, the infected person appears normal; about 30 percent systemic disease, skin symptoms of In many of these patients will develop tertiary syphilis. ways, the skin can be a window into the health of Tertiary syphilis (end stage) usually begins about the body, mirroring internal disease. Changes can 10 years after the initial infection, although it may appear in thickness, color, texture, or sensation. appear after only about three years or as late as Problems with immune function or with blood 25 years later. The person’s tissues may begin to fl ow can trigger the appearance of HIVES, PURPURA deteriorate (a process called “gumma formation”), (purple skin patches), BLISTERs, or deadened areas involving the bones, palate, nasal septum, tongue, of skin. skin, or any organ of the body. The most serious Skin fi ndings may be important in diagnosing complications in this stage include heart problems, cancer and a host of systemic diseases affecting 366 systemic lupus erythematosus any of the body’s organ systems, such as the gas- tion, therapy, dietary changes, and lifestyle changes trointestinal tract, eye, kidneys, lungs, heart, blood (such as avoiding the sun, wearing sunblock, and vessels, cardiovascular system, musculoskeletal, or avoiding stress). endocrine system. Nonsteroidal anti-infl ammatory drugs (NSAIDS) Generalized itching is one skin symptom that are used to relieve achy joints and arthritis in mild may be associated with systemic disease. If there lupus when pain is limited and organs are not are no other skin diseases to explain it, itching of affected. Antimalarial drugs such as hydroxy- unknown origin (or “idiopathic” itching) may be cholorquine are often prescribed for arthritis or associated with Hodgkin’s disease, polycythemia skin problems. CORTICOSTERIODS such as pred- rubra vera, liver or kidney disease, thyroid disease, nisone are used for major organ involvement. hypoparathyroidism, infections, or drug reactions. The dosage prescribed will depend on the type of organ involvement, symptoms, and blood test results. Immunosuppressive agents such as AZA- systemic lupus erythematosus (SLE) The more THIPRINE (Imuran), METHOTREXATE, CYCLOPHOSPHA- serious and potentially fatal form of the chronic cir- MIDE, CYCLOSPORINE, and mycophenolate mofetil culatory disease LUPUS ERYTHEMATOSUS that affects (CellCept), are strong drugs that help control the many systems of the body, including the skin. (The overactive immune system, helping to limit dam- milder form is DISCOID LUPUS ERYTHEMATOSUS, or age to major organs. However, these powerful DLE.) drugs carry potentially serious side effects and SLE is probably not one, but several, conditions; complications. although typically a disease of young women, it The prognosis for patients with SLE depends can affect either sex and all age groups without on which organs are involved; kidney or central regard to race. The disease commonly waxes and nervous system involvement implies a poor prog- wanes, and its etiology is affected by heredity, nosis. In most patients the disease is chronic; more autoimmunity, certain drugs, sex hormones, ultra- than 90 percent of patients survive for at least 10 violet light, and viruses. years. The relationship between DLE and SLE is con- troversial. Between 2 and 20 percent of patients who are fi rst diagnosed with DLE go on to develop systemic necrotizing vasculitides A group of SLE. It is not uncommon for typical SLE to go infl ammatory diseases of the small and medium- into remission, leaving lesions of chronic DLE. On size arteries causing palpable NODULES, ulcers, the other hand, DLE may spontaneously subside, purple patches (PURPURA), or plaques. This group of remain constant, worsen, or progress to active SLE diseases includes polyarteritis nodosa and WEGEN- after some stress. ER’S GRANULOMATOSIS. The survival rate for untreated polyarteritis Symptoms and Diagnostic Path nodosa is 13 percent; CORTICOSTEROID treatment Typically there is a red scaly rash on the face, affect- improves the survival rate to 48 percent and a com- ing the nose and cheeks, arthritis, and progressive bination approach using corticosteroids and immu- kidney damage; the heart, lungs, and brain may nosuppressive agents hikes the rate to 80 percent. also be affected by progressive attacks of infl amma- In a variety of polyarteritis nodosa, cutane- tion followed by the formation of scar tissue. In the ous polyarteritis nodosa, patients do not usually milder form (DLE) only the skin is affected. develop systemic signs and their prognosis is quite good. Treatment Options and Outlook Treatment depends on how active the disease is, Symptoms and Diagnostic Path and can range from nonprescription pain relievers Skin symptoms include palpable purpura (see LEU- and anti-infl ammatories to prescription medica- COCYTOELASTIC VASCULITIS), tender nodules, purple systemic sclerosis 367 patches, LIVEDO RETICULARIS, and ulceration. There Treatment Options and Outlook are a wide variety of nonskin symptoms, includ- A combination of corticosteroids (prednisone) and ing fever, malaise, weight loss, joint or muscle cyclophosphamide is the treatment of choice for problems, kidney problems, nausea and vomiting, both diseases, together with a careful control of abdominal pain, congestive heart failure, high high blood pressure. In addition, additional treat- blood pressure, strokes, and neuropathy. ment with aspirin, sulfapyridine, and DAPSONE may Symptoms of Wegener’s granulomatosis include be considered. ulcers, papules and plaques on legs, with ulcers in the mouth. “Saddle nose” may appear as a result of destruction of the cartilage in the nose. systemic sclerosis See SCLERODERMA. T tachyphylaxis The rapid decrease of response to burning experienced at the beginning of treatment topical steroids. Patients treated with topical COR- is worth the discomfort. TICOSTEROIDS after only one or two weeks but usu- ally after several weeks may fi nd that the product seems to have stopped working. After a week-long tan See SUNTAN. rest of that specifi c corticosteroid, however, the drug usually begins working again. Substituting one corticosteroid for another type tanning booths/beds A special booth or bed that with a slightly different chemical structure may emits ultraviolet (UVA) rays that cause the skin eliminate this problem. to tan. While an estimated 2 million Americans still aim for a rich golden tan from a bed or booth, experts have concluded that the practice is neither tacrolimus (Protopic) A nonsteroidal topical oint- safe nor foolproof. In fact, researchers have found ment for the treatment of ECZEMA (atopic dermati- that people who use tanning devices have 2.5 times tis) that represents an advance in the development the risk of SQUAMOUS CELL cancer and 1.5 times the of topical steroids. It acts at the site of the immune risk of BASAL CELL cancer. imbalance to help stop the redness and itching of These devices were once billed as a way to get eczema infl ammation. The 0.1 percent concentra- a “safe” tan because the artifi cial ultraviolet light tion of tacrolimus ointment was approved for the they emit is made up of primarily UVA rays, not treatment of adults, while the lower 0.03 percent UVB rays (the main component of sunlight). How- concentration was approved for the treatment of ever, research suggests that in fact, both types of both children (ages two and above) and adults for ultraviolet light are dangerous. short-term and intermittent long-term therapy. Research suggests that tanning beds may pro- Protopic’s safety and effectiveness was evalu- mote aging of the skin and SKIN CANCER. Many ated in 28 worldwide trials with more than 4,000 consumers do not realize that just 30 minutes in a adults and children, including those as young as 24 tanning bed is equal to six to eight hours of non- months. Research indicates that both concentra- stop sunning on the beach. tions of Protopic signifi cantly improved or cleared Experts also caution that there is no such thing the signs and symptoms of the condition in more as a “safe” tan, and a tan from a bed is just as dam- than two-thirds of the subjects. Many subjects aging as a tan acquired at the beach. exhibited marked improvement after one week. Only 21 states have laws regulating indoor tan- ning, and there are no government standards for Side Effects how much exposure time is safe for different skin About 70 percent of patients experience burning types. Furthermore, many salons are staffed by and ITCHING with the application of Protopic; how- part-time attendants who are poorly trained in safe ever, the incidence of these events decreased as the tanning-bed procedures. disease improved. The results of treatment are so The World Health Organization in 2005 called dramatic, even in the worst cases, that the initial for a ban on tanning beds and warned that the

368 tar compounds 369 increasing popularity of tanning beds could result reason they are used, they should only be used in an “epidemic” of skin cancer within a decade. with close medical supervision. For that reason, the United Nations health agency is The U.S. FDA does not approve the sale of pills urging governments around the world to pass laws that contain beta-carotene and/or canthaxanthin, regulating their use and banning them for all people both relatives of VITAMIN A (although beta-carotene under age 18. Still, the use of tanning beds and sun is available by prescription). According to both the lamps is largely unregulated around the world, with FDA and the Skin Cancer Foundation, some of France, Belgium, and Sweden among the few coun- the ingredients in these pills can have toxic side tries that have legislation on their use. In the United effects. States, some states (including California, Texas, Beta-carotene is a natural component of many Tennessee, Illinois, and Wisconsin) have passed fruits and vegetables (such as oranges, carrots, and laws to keep children from using tanning beds. tomatoes) and is sometimes used as a food additive Finally, many prescription drugs are photosensi- in butter or cheese to add color. However, the pills tizing, including some antibiotics (such as TETRACY- may do the same thing to human skin, turning it CLINE) and thiazides (blood pressure pills). Anyone yellow or orange instead of a handsome tan. In taking photosensitizing medication can experience combination with the canthaxanthin, beta-carotene severe consequences as a result of using a tanning accumulates in the skin and colors it. At the same bed. time, it forms deposits in the blood, fatty tis- sue, liver, and other organs, sometimes becoming toxic. tanning pills Sometimes called “French bronzing Another kind of tanning pill contains 5- or 8- pills,” these are drugs designed to provide an arti- methoxypsoralen, a form of PSORALEN that is used fi cial tan. They are sold outside the United States to treat PSORIASIS, ALOPECIA AREATA, and VITILIGO. (and occasionally by mail order or through health Physicians have sometimes prescribed this chemi- food stores in this country). The drugs contain cal for those with sensitive skin as a way to resist beta-carotene and/or canthaxanthin, chemicals sun damage on the theory that the chemical may that color the skin but also can damage the eyes thicken the skin and accelerate MELANIN produc- and possibly the liver. They are not recommended tion. It has been prescribed for those who are aller- by DERMATOLOGISTs. gic to sunblocks, but can not avoid the sun. Although canthaxanthin is approved by the U.S. It is recommended that it be used only under Food and Drug Administration (FDA) for use as a close medical supervision. It is available in other color addictive in foods in small amount, its use countries, and it does produce a deep, protective in tanning pills is not approved. Imported tanning tan—but the risk of bleeding is signifi cant. pills containing canthaxanthin may be automati- cally seized as products containing unsafe color additives. tar compounds Crude and refi ned tars are an Although at least one company applied for effective treatment for psoriasis, and are used approval of canthaxanthin-containing pills as a either alone or in combination with ultraviolet tanning agent, it withdrew the application when light therapy. Tar decreases the turnover of the side effects (such as crystals in the eye) were dis- top-most layer of skin, and helps to reduce scal- covered. This is a common adverse effect associ- ing and fl akiness. However, the color and smell of ated with canthaxanthin use. Other side effects these products do not make them popular choices. reportedly included nausea, cramping, diarrhea, Tar is usually applied to the skin a few hours before severe ITCHING, and welts associated with the use light therapy. of tanning pills. Tar is a mixture of hundreds of compounds; a Some tanning pills are advertised as a safe more cosmetically acceptable tar compound is liquor method of tanning, while others are designed to carbonis detergens (LCD) usually mixed with COLD bolster resistance to sun damage. Regardless of the CREAM in a 5 percent to 10 percent concentration. 370 tattooing

LCD is a distillate of crude coal tar not dissimilar into the bottle. The tattooist should wear latex to road tar. Other tar preparations are available as gloves and should change gloves if the tattooing SOAPS, GELS, or SHAMPOOS. There are lots of newer procedure is interrupted for other activities such as cosmetically acceptable preparations, such as LCD answering the phone or leaving the room. tar-gel or fragrant clear shampoo. Tattoos can be removed using short pulsed Tar shampoos are one of the treatments of lasers including the Q-switched ruby, Ng:YAG, choice for scaly scalp conditions such as seborrheic alexandrite, and 510 nanometer pulsed dye laser. dermatitis DANDRUFF, or PSORIASIS. Amateur tattoos can usually be entirely removed, See also DERMATITIS, SEBORRHEIC as can black professional tattoos. Multicolored professional tattoos are more diffi cult to remove and require several different wavelengths for the tattooing The process of instilling permanent different colors. colors into the skin, usually to create words or a design. Practiced for thousands of years as a form of identifi cation or tribal marking, today tattoos are Tegison The trade name for ETRETINATE. almost always used just for decoration. Even when performed by professionals, however, tattooing can be dangerous, leading to AIDS or hepatitis if the telangiectasia An abnormal dilation of capillary tattoo artist does not follow strict sterile procedures blood vessels that often forms into an ANGIOMA (a to clean needles that inject the dyes. tumor made of mostly of blood vessels). Telangiec- A “professional” tattoo is applied by an artist tasias may occur in ROSACEA, certain diseases such who may or may not be licensed, using non–FDA- as SCLERODERMA, or in long-term therapy with topi- approved pigments at a studio. A tattoo may be cal fl uorinated CORTICOSTEROIDS. Most causes are applied with or without consent from a parent or unknown. Telangiectasia also may occur as a result guardian, depending on state or local regulations. of an inherited disorders, such as hereditary hem- Tattoo artists use an electrically powered, verti- orrhagic telangiectasia or LOUIS-BAR SYNDROME. cal vibrating instrument to inject the tattoo pig- ment 50 to 3,000 times per minutes into the second layer of the skin (DERMIS), at a depth of 1/64 to telogen The resting stage of the hair growth cycle. 1/16 of an inch. A single needle outlines the tattoo and the design is then fi lled in with fi ve to seven needles in a needle bar. telogen effluvium Generalized hair shedding, State regulations of tattooing range from pro- often after an acute illness or pregnancy. Normally, hibiting tattooing to no regulations at all; in some healthy adults lose between 75 and 100 hairs daily, states with no regulation, local cities have estab- but certain events can prompt an increase in hair lished their own standards. The law for any specifi c loss by inducing the hair follicles to enter the telo- state may be obtained from state, country, or local gen (resting) phase of hair growth. health departments. About 95 percent of women develop some Because tattooing carries the risk of transmitting degree of hair loss after giving birth or after stop- a blood-borne disease or infection, needles must ping birth control pills. Other causes may include be sterilized before use and should not be reused. high fever, surgery and psychiatric stress, bulimia, Tattooists should use an autoclave to heat sterilize dieting, malnutrition, blood loss, and shock. equipment between customers. Packaged, steril- ized tattoo needles should be used only once and Treatment Options and Outlook then thrown away in a special biohazard container. No treatment is needed, since new hairs replace Leftover tattoo ink should be thrown away after those falling out. If hair loss persists for longer than each procedure; ink should never be poured into three months, patients should see a dermatologist. the bottle, and needles should never be inserted See also ALOPECIA AREATA. Tinactin 371 tetracycline A group of antibiotic drugs used to thyroid disorders, skin symptoms of A range of treat a range of conditions with skin symptoms, skin symptoms accompany thyroid disorders. including ACNE, SYPHILIS, and ROCKY MOUNTAIN Hyperthyroidism is characterized by fi ne, thin SPOTTED FEVER. hair, red palms, increased sweating, onycholysis, diffuse darkening of skin, and ITCHING. Side Effects Hypothyroidism includes dry, lax skin; thick lips Possible problems include nausea and vomiting, and tongue; cool skin; thinning hair; carotenemia; diarrhea, photosensitivity rash, and ITCHING. Tet- itching; xerosis; brittle nails. racyclines may increase the overgrowth of yeasts Hashimoto’s thyroiditis is associated with several in the vagina and interfere with the absorption of other auto-immune conditions such as VITILIGO, over-the-counter drugs taken concurrently. They ALOPECIA AREATA, DERMATITIS HERPETIFORMIS, PEM- may also discolor developing bones and teeth, PHIGOID, LUPUS ERYTHEMATOSUS, and SCLERODERMA. and are not prescribed for youngsters under age 12 or for pregnant women. Tetracyclines also may worsen kidney disease in patients with kidney ticks and disease Ticks are not so much a primary problems. cause of skin disease as carriers of infectious agents that produce diseases with skin symptoms, such as ROCKY MOUNTAIN SPOTTED FEVER, LYME DISEASE, and thalidomide The infamous antinausea drug never TULAREMIA. approved for use in the United States that caused Ticks bury their heads into the skin to feed, widespread birth defects in other parts of the world become engorged with their host’s blood, and swell when given to pregnant women. to many times their size. In 1998 the U.S. Food and Drug Adminis- tration (FDA) approved thalidomide for use in Symptoms and Diagnostic Path treating LEPROSY symptoms. Studies are also Sometimes generalized HIVES may develop. While being conducted to determine the effectiveness a tick bite itself does not usually cause problems, of thalidomide in treating symptoms associ- it may result in persistent NODULEs or PAPULES ated with AIDS, Behcet disease, lupus, Sjogren after forced removal of the tick. Other skin reac- syndrome, rheumatoid arthritis, infl ammatory tions to tick bites include papular HIVE-like lesions, bowel disease, macular degeneration, and some patchy scalp hair loss, painful local swelling, ulcer- cancers. ation, and erythema chronicum migrans in Lyme disease. theque An island of MELANIN-producing cells situ- Treatment Options and Outlook ated at the junction of the DERMIS and EPIDERMIS, or Gently pulling the tick parallel to the skin can often within the dermis. remove it completely. Infl ammatory papules and nodules caused by a tick bite can be treated with a topical CORTICOSTE- thrush The common name for candidiasis, a ROID cream. Excision of nodules may be necessary, superfi cial fungal infection of the mucous mem- although persistent reactions have occurred in spite branes of the mouth. of excision. See also CANDIDA INFECTION. Risk Factors and Preventive Measures Low concentrations of bug repellents such as Deet thymol An antiseptic derived from PHENOL that do not work very well at repelling ticks. used to be used to treat ECZEMA, PSORIASIS, and ACNE. It is an effective drying agent for the treat- ment of PARONYCHIA. Tinactin See TOLNAFTATE. 372 tinea tinea The medical term for RINGWORM, a group tinea barbae RINGWORM infection of the skin of common fungus infections of the skin, hair, or under the beard, caused primarily by Tinea mentag- nails caused by various species of the fungi Micros- rophytes or T. verrucosum. porum, Trichophyton, and Epidermophyton that affect See also TINEA. humans and animals. Ringworm is highly conta- gious and can be spread either by direct contact or via infected material. Infections can be contracted tinea capitis The medical term for RINGWORM from other people, and from animals, soil, or an of the scalp, this fungal infection causes several object (such as a shower stall). round, itchy patches of hair loss on the scalp. It is The term tinea is often followed by the part of most commonly found in children who are sub- the body affected by the fungus, such as tinea pedis ject to crowded conditions where the fungi spread (ATHLETE’S FOOT). more easily.

Symptoms and Diagnostic Path Treatment Options and Outlook Symptoms vary according to the part of the Antifungal drugs, usually taken by mouth for four body affected by the infection. The most com- to six weeks, will cure the infection. mon affected area is the foot (ATHLETE’S FOOT), with cracking, itchy skin between the toes. Tinea cruris (JOCK ITCH) is more common in males, and tinea corporis The medical term for RINGWORM produces a red, itchy area from the genitals out- of the body, this fungal infection is characterized ward over the inside of the thighs. TINEA CORPORIS by itchy round patches with raised edges. Tinea (ringworm of the body) is characterized by itchy corporis is found throughout the world, occurring circular skin patches with a raised edge. TINEA more often in hot, humid climates. Tinea rubrum CAPITIS (ringworm of the scalp) causes round, is the most common infectious agent. In HIV- itchy circles of hair loss found most commonly in positive or other immunocompromised patients, children living in large cities or in overcrowded signifi cant symptoms of ITCHING or pain may conditions. Tinea unguium (ringworm of the develop, and, rarely, deep ABSCESSes or dissemina- nails, or ONYCHOMYCOSIS) is characterized by thick tion may occur. white or yellow nails. Ringworm can also affect Tinea corporis occurs in both men and women; the skin under a beard (TINEA BARBAE) or the women of childbearing age may be more frequently facial skin. infected because they are more likely to come into contact with infected children. Treatment Options and Outlook Infection may occur through contact with Antifungal drugs as creams, lotions, or ointments infected humans, animals, or inanimate objects. can successfully treat most types of tinea. For wide- The person may have had on-the-job exposure spread infection (or those affecting hair or nails), or environmental and recreational exposure dur- systemic treatment is usually required. Treatment ing gardening, contact sports, or use of sports should continue after symptoms have faded to facilities. ensure the fungi have been destroyed. Mild infec- The most common cause of tinea corporis is tions on the surface of the skin may be treated for T. rubrum, although M. canis, T. mentagrophytes, and four to six weeks. T. tonsurans are also known to cause infection. Toenail infections may require treatment with terfenebrin or itraconazole for months, but with Treatment Options and Outlook the new drugs three-month treatment may be Topical treatment is recommended for localized suffi cient. Until recently, the standard treatment cases, applied to an area at least 2 cm beyond the was GRISEOFULVIN. It is relatively effective for skin edge of the identifi ed lesion once or twice a day and hair fungal infections but of limited use in the for at least two weeks, depending on which agent treatment of nail infections. is used. ECONAZOLE, KETOCONAZOLE, clotrimazole, tissue expansion 373

MICONAZOLE, oxiconazole, sulconazole, and sys- in a circular pattern. It may mimic malignant temic azoles (fl uconazole, itraconazole, ketocon- melanoma azole) can be effective. Allylamines (naftifi ne, terbinafi ne) and the related benzylamine buten- Treatment Options and Outlook afi ne also may be prescribed. Most infections respond to topical antifungals such Oral therapy may be indicated for tinea corporis as Whitfi eld’s ointment, topical imidazoles or allyl- cases that are extensive, involve immunocompro- amines, Keralyt gel, or 40 percent urea. Removal mised patients, or are not responsive to topical by scraping with an emery board may be helpful. therapy. Other drugs may include oral doses of Recurrence is rare. micronized GRISEOFULVIN, ketoconazole, fl ucon- See also MELANOMA, MALIGNANT. azole, itraconazole, or terbinafi ne.

tinea pedis See ATHLETE’S FOOT. tinea cruris See JOCK ITCH.

tinea unguium See ONYCHOMYCOSIS. tinea manuum RINGWORM infection most often caused by Tinea rubrum, often found together with a foot infection. tinea versicolor A common skin condition (also known as pityriasis versicolor) characterized by Symptoms and Diagnostic Path patches of white, brown, or salmon-colored fl aky The condition is characterized by thickened scaly skin on the trunk and neck. It primarily affects skin of palms and fi ngers, especially in the creases young and middle-aged adult men, and is not of the skin. contagious. A yeast living on the skin causes the condition, Treatment Options and Outlook when it colonizes the dead outer layer of skin. Topical antifungal preparations such as imidazole or allylamine antifungals are preferred. Topical Treatment Options and Outlook agents may not be enough to cure this problem; Thorough application of antifungal cream or lotion therefore, an oral antifungal drug (such as GRISEO- from ears to knees for several consecutive nights FULVIN or KETOCONAZOLE) is usually required and after shampooing with an anti-yeast SHAMPOO, should be taken for two to three months. such as one containing selenium sulfi de or KETO- CONAZOLE, will eradicate the fungus, provided not one spot is missed. It is also important to wash tinea nigra palmaris A superfi cial RINGWORM underwear and night clothes and sheets thor- infection of the palms, although the soles of the oughly. The treatment will cure the condition, but feet may also be affected. While the condition is it may take many months for the skin patches to found throughout the world in both men and return to a normal color. Relapses are frequent. A women of all ages, it is uncommon in North simpler approach requires taking an anti-yeast pill, America. Compared to other types of fungal infec- ketoconazole, for just two doses. tions, the incidence of tinea nigra palmaris is low, even in South America where it is most often found. tissue expansion A technique of plastic surgery that uses neighboring skin to cover birth defects, Symptoms and Diagnostic Path injuries, or cosmetically displeasing areas by slowly The condition is characterized by the appearance stretching the skin. on the palm or sole of a single brown-black MACULE This procedure began to gain popularity in the with sharply defi ned margins that tends to spread early 1980s and was fi rst used to reconstruct breasts 374 toad skin after mastectomy. Today it is also used to cover and vomiting, inner ear deafness, headache, and birth defects, areas of skin after tumor removal, itchy rash. skin damaged by trauma, as well as for breast enlargement and creation of new, hair-bearing scalp for bald men. toe web infection Disorders of the spaces between In the past, the only way to replace skin marred the toes are usually called ATHLETE’S FOOT, and most by defects or injuries was to cut a fl ap of healthy are caused by fungal infections. Although the fl esh from elsewhere on the body and transplant it fungus is the primary cause of tissue destruction, over the problem area. Unfortunately, this caused subsequent bacterial infi ltration can contribute to scarring in both the donor and recipient area of the problem and interfere with treatment success. the skin, as well as a mismatch between skin type. Independent bacterial infection also produces toe For example, the skin from the abdomen or back web infection. looks very different from the fl esh on the breast or face in the color, thickness, texture, and ability to Symptoms and Diagnostic Path grow hair. Maceration, cracking, discomfort, foul smell, and With the tissue expansion technique, a small oozing in the spaces between toes. expander is implanted beneath the skin. After the incisions have healed, the balloon is gradually fi lled Treatment Options and Outlook by injection with saline solution until the skin has Because so many different types of organisms are expanded enough to cover the desired area. This involved in toe web infections, several different types expansion process takes from six weeks to four of treatment must be used in order to be effective. months depending on the location and size. When If the lesions are dry and scaly, topical antifungal the skin has been expanded enough, the balloon is agents (such as imidazoles or allylamines) are effec- withdrawn, any deformed tissue is removed, and tive. For soft, wet lesions, treatment must include the newly stretched skin is positioned and sutured removal of excess moisture, daily compresses with into place. A permanent saline-fi lled implant may be saline or albumin subacetate (BUROW’S SOLUTION), inserted during a breast reconstruction procedure. broad-spectrum topical antimicrobial agents, long- Studies have shown that during expansion, the term use of antifungals, and oral GRISEOFULVIN. outer layer of skin (the EPIDERMIS) actually thickens as the cells multiply in reaction to the pressure. In contrast, the underlying connective tissue, tolnaftate (trade names: Aftate, Tinactin) An which is squeezed between the epidermis and the antifungal treatment for some types of TINEA expanding balloon, becomes thinner. The body (including ATHLETE’S FOOT). It is available without a also forms a membrane of scar tissue around the prescription as a cream, powder, or aerosol. expander, adding to the look of fullness. Side Effects In rare cases, it may cause skin irritation or rash. toad skin See PHRYNODERMA.

topical medications Drugs that are applied to tobramycin (trade names: Nebcin, Tobrex) An the skin surface (instead of being injected or swal- antibiotic drug used to treat severe skin infections, lowed). Topical drugs also include suppositories usually given by injection in combination with inserted into the vagina or rectum, and drugs PENICILLIN. administered to the ear canal or surface of the eye.

Side Effects Possible side effects when giving tobramycin in toxic epidermal necrolysis See NECROLYSIS, TOXIC high doses may include kidney damage, nausea EPIDERMAL. tretinoin 375 toxic shock syndrome An uncommon condition photoaging (the long-term effects of sun on the characterized by a distinctive skin rash resembling skin that cause wrinkling and blotchy pigmen- SUNBURN on the palms and soles of the feet that tation). Retinoin in the United States has been peels within one or two weeks. approved formally for the treatment of acne, but it The condition, fi rst recognized in the 1970s, is is also widely used to treat sun-damaged, wrinkled associated with the use of certain brands of highly skin. Renova (a 5 percent emollient cream) has absorbent tampons (no longer available). About been approved to treat photoaging. 70 percent of cases occur in women who are using Although tretinoin is in the same family as tampons when symptoms begin. Most recent cases vitamin A, the two are not the same. For many have been related to staphylococcal infections years, different compounds of vitamin A have been unrelated to tampon use. included in cosmetics (as retinol, retinyl, retinyl- The condition is caused by a toxin produced by acetate, or retinyl palmitate) because these ingre- Staphylococcus aureus. dients are not considered to be drugs by the U.S. Food and Drug Administration. Tretinoin, the acid Symptoms and Diagnostic Path of vitamin A, has unique properties and because it In addition to the skin rash, symptoms include sud- is available by prescription only in this country, it is den high fever, vomiting and diarrhea, headache, not included in any cosmetic skin-care product. It muscular aches and pains, dizziness, and disorien- is available without a prescription in Mexico. tation. Blood pressure may drop rapidly and shock The fi rst reports of tretinoin’s ability to smooth may develop. Death occurs in about 3 percent of out wrinkles appeared in the Journal of the American cases, usually due to a prolonged drop in blood Medical Association in 1988, when researchers at the pressure or lung problems. University of Michigan reported that subjects with sun-damaged skin showed signifi cant improve- Treatment Options and Outlook ment in number of WRINKLES after applying it. Up Antibiotic drugs and IV infusion (to prevent shock), to that time, dermatologists used tretinoin mostly plus treatment for any complications as they occur. for acne patients until Albert Kligman, M.D., a Recurrence is common. prominent dermatologist at the University of Penn- sylvania, noted his acne patients’ reports and began Risk Factors and Preventive Measures using tretinoin on sun-damaged skin. Women who have had toxic shock syndrome Many studies have now shown that tretinoin should not use tampons, cervical caps, diaphragms, is effective in removing facial wrinkles, smooth- or vaginal contraceptive sponges. ing coarse skin, and improving LENTIGINES. It is not effective for improving coarse wrinkles. It is also extremely effective in the treatment transforming growth factor (TGF) beta A bio- of acne, although—as with the case of wrinkles— logical compound produced by the body that is there is a lag time before it becomes effective. Some essential for the normal production of COLLAGEN individuals even notice their skin becomes worse and ELASTIN. It lies beneath the skin and makes it after the fi rst two or three weeks. At the beginning, supple. One of the newest compounds currently tretinoin can cause dryness and irritation. being studied, TGF may one day be available as a Two types of SKIN CANCER, SQUAMOUS CELL can- daily beauty treatment to slow down the physical cer and BASAL CELL cancer, are caused by sun expo- signs of aging and keep skin young. sure and an individual’s own risk factors. Cancer in the skin develops when cellular development goes awry; retinoids improve cellular differentia- tretinoin (Retin-A, Renova) A synthetic form of tion, so experts think these medications may help VITAMIN A (RETINOIC ACID) used as a prescription prevent cancer. In fact, tretinoin does slow down ACNE medication and wrinkle cream; it also may the development of precancerous skin lesions such prevent skin and cervix cancer. It is used to treat as ACTINIC KERATOSES. Individuals might choose to 376 triamcinolone use tretinoin as a cancer preventive if they have a if the potential benefi t outweighs the potential history of heavy sun exposure and previous sun- risk to the baby. Women who want to use treti- related lesions that were removed from their skin. noin during pregnancy should consult with their doctors. How to Apply See also ACTINIC CONDITIONS; AGING AND SKIN; The higher the concentration of tretinoin, the ALPHA HYDROXY ACIDS; EXFOLIANTS; ISOTRETINOIN; faster and more signifi cant the results. It is often PHOTOSENSITIVITY; STRETCH MARKS. irritating, however, and for this reason many doc- tors start patients with the milder forms available: 0.025 percent to 0.05 percent cream every other triamcinolone (Trade names: Aristocort, Aristo- night, slowly increasing the strength and frequency span, Kenalog, Triacet, Triamolone) A CORTICO- of application. STEROID hormone used to treat skin infl ammations, Consumers should fi rst wash the skin thor- with uses similar to cortisone. It reduces infl amma- oughly with a gentle cleanser, pat dry, and then tion but does not cause water retention. wait 15 minute. Then a tiny amount of cream is spread over the entire face. Tretinoin may be Side Effects applied under the eyes. At fi rst the skin may be Dizziness, headache, muscle weakness, and low pink and fl aky; it takes three to six months before blood pressure may be evident. benefi ts are apparent. On less sensitive areas (such as the backs of the hands) it can be started more quickly and used every night. trichauxis An increase in the size and number Renova is a similar product containing retinoic of hairs. acid in a moisturizing base. It is considered less irritating but as effective as tretinoin and is used in the same way. trichiasis Eyelashes that grow toward the eyeball instead of outward as they normally would. If the Side Effects lashes grow to the point where they touch the eye- Tretinoin is a powerful drug, and side effects can ball, they can cause severe pain and may damage include burning eyes and peeling or reddening of the cornea. the skin that lasts for weeks; this reaction is most common in women who sunburn easily and who Treatment Options and Outlook normally have very sensitive skin. Benefi ts often Temporary treatment consists of removing the do not appear until between six and 12 months. In eyelashes that are growing the wrong way, but the study groups, some users experience results so dis- lashes will regrow. Permanent treatment requires tressing that they drop out, but these people were the destruction of the growth follicles of the way- using a 0.1 percent cream twice a day. ward eyelashes via ELECTROLYSIS. Ironically, tretinoin makes the skin more vul- nerable to ultraviolet light, causing users to sun- burn more easily. Users should always layer a high trichosporosis Also known as piedra, this is a SPF block under makeup (even during winter) to fungal condition in which the hair shafts are coated protect from harmful exposure, wear protective with hard masses of white (Trichosporon cutaneum hats and avoid the sun. or T. beigelii) or black (Piedraia hortai) fungus. The The drug should be used under the supervision black fungus appears as small dark nodules along of a physician. Incorrect use of tretinoin can lead the hair shaft, visible to the naked eye and under to extreme irritation so consumers should see a the microscope. It occurs primarily in the Tropics. dermatologist to obtain a prescription. The white variety is found around the world, and Tretinoin is a class “C” drug, which means that is characterized by soft NODULES on primarily facial pregnant women should use this medication only and pubic hair. tuberous sclerosis 377

Treatment Options and Outlook decreasing in prevalence in developed countries Removal of the affected hairs by clipping or until the past few years. Recently, there has been a shaving. resurgence in TB cases, especially in urban areas.

Symptoms and Diagnostic Path trichotillomania The habit of pulling out one’s There are two basic forms of this type of TB: local- hair, often associated with psychological stress and ized and disseminated. sometimes mental illness or psychotic illness (such The localized form may develop after the intro- as schizophrenia). Hair-pulling also may take place duction of the tubercle bacilli into a wound in among children who are anxious and frustrated. patients who have never been exposed to TB. Typically, the patient pulls, twists, or breaks off It begins as an infl ammatory nodule (called the chunks of hair, leaving bald spots. Children some- “tuberculous chancre”) and is followed by swell- times eat the removed hair, which may lead to a ing of the lymph nodes. In those who are immune hairball in the stomach. or partially immune, two types of lesions may appear: tuberculosis verrucosa and lupus vulgaris. Treatment Options and Outlook In tuberculosis verrucosa, the bacilli leads to local- Psychotherapy and/or antipsychotic drugs are ized solid elevated lesions. Lupus vulgaris begins sometimes used. in early life, with patchy lesions studded with what look like soft yellowish brown “apple jelly” nodules, when compressed with a glass slide. This tuberculin test A skin test used to determine is followed by swelling, ulcers, and hypertrophy. whether or not a person has been infected with In temperate climates, most lupus lesions are on tuberculosis. The test is used to diagnose suspected the face, while those of tuberculosis verrucosa are cases of tuberculosis prior to vaccination against on the hands; the distribution may be different in the disease. tropical areas. During the test, the skin is fi rst disinfected, Scrofuloderma is another form of localized skin usually with an alcohol swab, and a small dose of TB, in which tuberculosis of the lymph nodes tuberculin (a protein extract of the tuberculosis extends into the skin, causing the development of bacilli) is introduced into the skin in one of a variety ulcers and fi stulas beneath ridges of bluish skin. of ways. In the Mantoux test, the extract is injected In the disseminated form, bacteria spread by into the skin with a needle—in the Sterneedle test, patients with fulminating TB result in miliary the extract is dropped on the forearm as a spring- tuberculosis of the skin. Lesions that resemble ACNE loaded instrument circled with a sharp prong forces appear on the face and arms and legs; these lesions the tuberculin into the skin. end in CHICKEN POX–like scars. After two days, the skin is inspected at the site; if the skin is unchanged, the reaction is negative, indi- Treatment Options and Outlook cating the person has never been exposed to tuber- Treatment usually combines three or four antibiot- culosis and has no immunity. Skin that becomes ics in combination over six to nine months. red, fi rm, and raised after the injection indicates See also TUBERCULIN TEST. that the person has been exposed to tuberculosis, either through vaccination or infection. See also TUBERCULOSIS, SKIN. tuberous sclerosis A genetic disorder that causes benign tumors (tubers) to form in many different organs, especially the skin, brain, eyes, heart, kid- tuberculosis, skin Tuberculosis of the skin is ney, and lungs. It is called both tuberous sclerosis characterized by breakdown of the skin over PUS- (TS) and tuberous sclerosis complex (TSC); the fi lled tuberculous glands, forming irregular-shaped term TSC is used in scientifi c literature to distin- ulcers tinged with blue. TB was uncommon and guish tuberous sclerosis from Tourette syndrome. 378 tuberous sclerosis

The true prevalence of TS is unknown, but sci- 1 percent to 3 percent. At this time, there is no entists estimate it occurs once in every 6,000 live simple way to determine whether an unaffected births; this means approximately 25,000 to 40,000 parent of a child with TS has germline mosaicism. individuals in the United States have TS. It occurs Although some individuals may inherit the in both sexes and in all races and ethnic groups. It disorder from a parent with TSC, most cases occur is often fi rst recognized in children who have sei- as spontaneous mutations. In these situations, zures and developmental disabilities, but the symp- neither parent has the disorder or the faulty gene. toms of TS vary greatly and may often not appear Instead, a faulty gene fi rst occurs in the affected until later in life. There are presently no cures and individuals. there is no way to predict how severely or mildly First described in the 1880s, TS affects only an individual may be affected by TS. some organs in most individuals. Mutations in one of two genes, TSC1 and TSC2, have been identifi ed as the cause of tuberous Symptoms and Diagnostic Path sclerosis. In some genetic conditions such as TS, The skin, face, body, and nails are places where a mutation in one copy of the gene is enough to many people with TS experience symptoms. In cause the condition. About a third of people with some cases, skin growths can become obtrusive, TS inherit it from a parent who also has TS. If a but in most cases, the growths themselves are parent has TS and passes on the copy of the gene harmless. Skin lesions may include patches of with the mutation, then the child will also have TS. skin lighter than the surrounding skin that can be If the parent passes on the copy of the gene with- any size or shape (or may be the classic “ash-leaf” out the mutation, the child will not have TS. Thus, shape), a shagreen patch (a patch of skin that is there is a 50 percent chance with each pregnancy tough and dimpled like an orange peel), fi brous for a parent with TS to have a child with TS. This growths that appear around the fi ngernails and is true regardless of the sex of the parent or the sex toenails, and benign tumors of the face. Fibrous of the child. In the remaining two-thirds of people plaques sometimes appear on the forehead of indi- with TS, neither parent shows any symptoms or viduals with TS. There may also be fi brous, hairless signs of TS. Instead, one of the normal genes from scalp plaques surrounded by thin white tufts of one parent changes to the abnormal form, leading hair. to a new occurrence of TS in the child. Normally, Occasionally an individual with TS will have these parents do not have another child with TS CAFÉ-AU-LAIT MACULES (areas of skin darker than because the mutation was sporadic, not inher- the surrounding skin, but lighter and usually larger ited. However, some families have more than one than a mole), but these skin lesions are not related child with TS, even though neither parent showed to TS. A child with three or more or an adult symptoms or fi ndings of TS. with fi ve or more café-au-lait spots may be diag- Scientists have determined that a small number nosed with NEUROFIBROMATOSIS, another genetic of physically unaffected parents of a child with TS condition. actually have TS mutations in some of their cells. In most cases the fi rst clue to recognizing TSC is Because the mutation is limited to a small portion the presence of seizures or delayed development. of all of the body’s cells, these individuals show no In other cases, the fi rst sign may be white patches signs of TS, but if a portion of the egg or sperm cells on the skin (hypomelanotic MACULES). of a parent carries the TS mutation, that parent A physician will use a Wood’s lamp (an ultra- can have more than one affected child, possibly at violet light) to better visualize the white patches on the same 50/50 chance that people with TS have. the skin that often are diffi cult to see, especially on A person who carries cells with TS mutations in infants and people with very pale skin. The entire egg or sperm supply has germline mosaicism. The body should be examined, including the skin (for occurrence of germline mosaicism has led geneti- the wide variety of skin symptoms), the teeth for cists to estimate a recurrence risk ranging from dental pits, and the eyes for dilated pupils. Some turban tumor 379 of the skin signs may not be present at birth; the mia can be fatal in 5 percent of cases. The disease facial tumors do not usually appear until between confers permanent immunity. the ages of three and fi ve at the earliest, and the fi brous growths do not usually occur until much Risk Factors and Preventive Measures later in life. A vaccine is available for those at high risk, such as Other diagnostic tests include computed tomog- hunters, trappers, game wardens, or lab workers. raphy (CT) or magnetic resonance imaging (MRI) of the brain and an ultrasound of the heart, liver, and kidneys. tumbu fly bites A fl y bite that causes myiasis (skin infestation with fl y larvae). It most com- Treatment Options and Outlook monly occurs in South Africa. Facial tumors can be removed using dermabrasion or laser treatment when they are small, before they enlarge and become fi brous. They most likely will tumefaction A swelling. recur and need further treatment, but they will be milder than if left untreated. Some cosmetic com- panies also manufacture makeup to cover light- tunable dye laser Dye lasers use colored solids ened skin patches if they are large or in exposed dissolved in organic solvents to produce laser light. areas of the skin. The color of the laser light emitted depends on the Most people who are mildly affected by TS lead color of solid material chosen. By changing the dye, active and productive lives, but it is important to the wavelength (or color) can be altered. Dye lasers realize that TS is a life-long condition. are used for the treatment of blood vessel abnor- malities (yellow light), and pigmented disorders (green light). tularemia An infectious disease of wild animals See also PULSED DYE LASER. occasionally transmitted to humans, characterized by a red spot at the site of infection that eventually forms an ulcer. Tunga penetrans A species of fl eas found in tropi- Humans may contract the disease through direct cal and subtropical America, commonly referred to contact with an infected animal (most commonly a as jiggers, sand fl ies, or chigoes. rabbit, squirrel, or muskrat). The bacteria enter the body through a cut or scratch in the skin, or may be acquired following a bite from a tick, fl ea, fl y, or turban tumor Multiple benign growths called louse or (rarely) by eating infected meat. cylindromas that cover the scalp, giving the patient A few hundred cases occur in North America, the appearance of a person wearing a turban. some parts of Europe, and Asia each year. Although the tumors are usually benign, they can become very large, ulcerated, or infected, Symptoms and Diagnostic Path requiring surgery to replace the affected areas with In addition to the skin lesion, symptoms include skin grafts. Turban tumors are more common in enlarged lymph nodes, fever, headache, muscle women; the male to female ratio ranges between pains, and malaise. Sometimes the eyes, throat, 6 to 1 to 9 to 1. digestive tract, and lungs are affected. Researchers have discovered the gene that causes multiple turban tumors on chromosome Treatment Options and Outlook 16q12-q13. The gene codes for proteins that coor- Antibiotics (such as streptomycin, TETRACYCLINE, or dinate the attachment of structures inside the cell. intravenous gentamicin) treat the disease, with a Solitary cylindromas This type of turban tumor less than 1 percent fatality rate. Untreated, tulare- usually occurs in middle and old age, affecting the 380 turtle oil face and scalp. This type of tumor does not seem mins and—as all oils—it forms a fi lm on the skin to be inherited. The solitary form usually begins as that helps retain moisture. It has no other value in a slow-growing, rubbery nodule with pink, red, or skin-care products. sometimes blue coloring, ranging in size from a few millimeters to several centimeters. Multiple cylindromas This type of turban tylosis Callus formation. tumor may cover almost the entire scalp, causing the disfi guring turban appearance and requiring extensive plastic surgery. The multiple form has Tyndall light phenomenon The refl ection of light numerous masses of pink, red, or blue NODULES, by particles suspended in a gas or liquid that sometimes resembling bunches of grapes or small imparts a blue tinge to objects. In skin, MELANIN tomatoes (sometimes called “tomato tumor”). particles found at levels of the dermis give the skin Multiple tumors, which are not as common as varying degrees of a bluish tinge. This is the same single tumors, are inherited in an autosomal domi- process as the scattering of particles in the atmo- nant mode and may occur on the body, arms, and sphere that makes the sky appear blue. legs, as well as the head and neck. They usually begin in early adulthood and may progress over time. The inherited condition is known as familial typhus Any of a group of infectious diseases with cylindromatosis, and the cause appears to be due to similar symptoms, characterized by a measleslike a defect in a gene that is a tumor suppressor. rash, severe headache, back and limb pain, high Malignant cylindromas These tumors are very fever, confusion, prostration, weak heartbeat, and rare and appear to arise out of solitary cylindromas delirium. or—more often—as a complication of the mul- In the past, epidemic typhus spread by body lice tiple type. While the vast majority of cylindromas was the most serious type of this disease. Epidemics remain benign, at least 14 reports exist of malig- swept across the world, killing hundreds of thou- nant transformation. sands of people during war, famine, and natural The prognosis is not good with malignancy, disaster. It is rare today, except in some areas of since this type of cancer often spreads. A cylin- Africa and South America. droma occasionally will erode through the skull, Typhus is caused by rickettsiae (microorgan- causing hemorrhage and meningitis. isms much like bacteria); in epidemic typhus, they are ingested by LICE from the blood of infected Treatment Options and Outlook patients. The lice deposit feces containing the rick- For solitary lesions, treatment is by excision or ettsiae on another person’s skin. When a person electrosurgery. For small cylindromas, a CARBON scratches the skin, the microorganisms enter the DIOXIDE LASER may be used. Multiple cylindromas bloodstream. usually require extensive plastic surgery, progres- Endemic (or murine) typhus is found in rats; it is sively removing a group of nodules in multiple spread to humans through fl ea bites. Scrub typhus procedures. is spread by mites in India and Southeast Asia. Because of the tendency for new lesions to develop and because of the risk of cancer, Treatment Options and Outlook follow-up of patients with multiple cylindromas is Antibiotic drugs (TETRACYCLINES) treat typhus fever; recommended. other treatment is aimed at relieving symptoms. It may take a long time to recover from the dis- ease. In the past, epidemic typhus was prevalent turtle oil One of the oldest products used in skin in crowded, unsanitary places and had a mortality care, whose effectiveness was discredited as early rate close to 100 percent. as 1934. Extracted from the genitals and muscles Untreated, a patient may die from blood poison- of the giant sea turtle, the oil does have some vita- ing, heart or kidney failure, or pneumonia. Tzanck smear 381

Risk Factors and Preventive Measures Tzanck smear Examination of cells from the fl oor Epidemic typhus may be prevented by vaccination of a BLISTER. It is used to diagnose HERPES VIRUS and control of lice via insecticides. Other types of infections and some blistering disorders such as typhus may be prevented by wearing protective PEMPHIGUS. A DERMATOLOGIST removes the top of clothes to prevent tick, mite, and fl ea bites. the blister and scrapes the jellylike material from the base of the blister onto a microscope slide. The results from this type of smear is better than in a tyrosine An amino acid that is used to produce culture of the virus in VARICELLA-ZOSTER virus infec- MELANIN (skin pigment). Tyrosine is also used in tions, but less clear than that of a culture in herpes some tan accelerators. simplex. However, the test is inexpensive and very reliable. tyrosinemia type II See RICHNER-HANHART SYNDROME. U ulcer An open sore on the skin caused by the are recommended, because sun exposure and destruction of surface tissue. Skin ulcers, typi- heat increase the fl ushing and may promote the cally caused by inadequate blood fl ow, may be redness. found anywhere on the body; the site is often helpful in a diagnosis. Leg ulcers are mainly caused by inadequate blood fl ow or poor blood ultraviolet light warning badge A self-adhesive return to the heart. Skin cancer can ulcerate, as waterproof badge that can be worn on clothing or can trauma or burns. More rarely, ulcers may be on the skin that changes color with accumulated caused by BASAL CELL CARCINOMA. Genital ulcers UV exposure. Watching the color changes on the may be caused by sexually transmitted diseases, badge helps even a child understand when excess including SYPHILIS, gonorrhea, chancroid, and exposure has occurred. HERPES simplex. See also ULTRAVIOLET RADIATION. ulerythema A rare, harmless skin disease causing ultraviolet radiation The energy that comes to atrophy and scarring, usually of the face, and hair the Earth from the Sun is emitted as radiation of loss. Typically, a portion of the eyebrow is affected various wavelengths, called the electromagnetic and is lost. This disorder mainly affects children spectrum. Included in this spectrum are radio and young adults, affecting boys and girls equally. waves, X-rays, infrared rays, visible light, and It is usually sporadic, although a few cases may be ultraviolet radiation. inherited in an autosomal dominant pattern. This Infrared radiation is experienced as heat, rep- means a defective gene inherited from just one par- resenting 45 percent of the Sun’s total energy. ent causes the disease. Each child has a 50 percent Another 49 percent of the total energy reaching chance of inheriting the affected gene and develop- the Earth makes up the visible light spectrum, which ing the disease. is perceived as color. Ultraviolet radiation makes up the rest of the total Symptoms and Diagnostic Path energy from the Sun reaching the Earth—radiation Symptoms include a red color on the central part strong enough to cause photochemical reactions of the face, especially the cheeks and on eyebrows, and penetrate the skin. and occasionally with the loss of eyebrow hair later There are three types of ultraviolet radiation in life. The affected areas may feel rough, like fi ne emitted from sunlight: UVA, UVB, and UVC. UVC sandpaper, and there may be scattered open and is toxic to human, plant, and animal life but it closed comedones and MILIA. Less often, similar is absorbed by the Earth’s atmosphere before it lesions may be seen on the arms and legs. reaches the Earth. UVB (0.5 percent of the total energy reaching Earth) is responsible for inducing Treatment Options and Outlook skin redness and burning by penetrating the top Successful treatment with the PULSED DYE LASER two layers of the skin. UVB has been considered has been reported. SUNSCREENS and sunblocks to be more dangerous than UVA, and is believed

382 uncombable hair syndrome 383 to be the direct cause of a range of major skin and over much of the world, but it is not clear how UV eye problems. levels at the Earth’s surface have changed, because Until recently, UVA radiation was believed to no worldwide measurement network exists. be fairly harmless because it has a much lower Interestingly, polluted air has been found to pro- intensity than UVB. But this type of ultraviolet tect citizens from the ultraviolet radiation stream- radiation can penetrate the DERMIS (the third layer ing through the Earth’s damaged ozone layer. of the skin), and since UVA represents 5.5 percent Studies found that levels of UV light were nearly of the total energy reaching the Earth, it has grave twice as high in the relatively clean air of New potential for damage. Zealand as they were in the more polluted area Ultraviolet radiation stimulates melanocytes to of Germany. Similarly, measurements in the Alps produce brown pigment called MELANIN, which acts show a strengthening of UV intensity; those in the as a natural defense mechanism against ultraviolet United States show a weakening. radiation and gives skin a tanned look. It is ultraviolet radiation that is responsible for both immediate and long-term damage to the skin uncombable hair syndrome A rare hereditary from the sun. This radiation can cause anything hair-shaft defect characterized by coarse, curly, tan- from a tan to a painful SUNBURN. It causes skin to gled hair. Also known as spun-glass hair, it mostly sag and wrinkle, brings out “sun spots,” and ulti- affects children aged three to 12. In some cases, mately can lead to SKIN CANCER. the inheritance is autosomal dominant, whereas in The amount of ultraviolet radiation people others, the genetics are not clear. receive depends on how close they are to the equa- tor, what time of day it is, what season it is, their Symptoms and Diagnostic Path elevation, and the type of surrounding terrain. The The hair of the head has a shaggy aspect, will not potential for damage is greater at high altitudes lie fl at against the scalp, and cannot be combed or because less atmospheric fi ltration occurs. brushed. Dry and rough to the touch, the color The closer to midday and the equator, the more is characteristically silver-blond. The eyebrows or damage from the Sun because of the position of eyelashes can be normal or thin. Slow hair growth the Sun in the sky: When the Sun is directly over- and increased fragility are uncommon but have head, its rays reach the Earth vertically instead of been reported. Uncombable hair syndrome is quite at an angle, lessening the distance they must travel rare, with only about 60 cases reported between through Earth’s protective atmosphere. 1973 and 1998. Seasonal changes also affect the ozone layer; the Onset may be in infancy or delayed until puberty, ozone layer is thinner and more dangerous, allowing after which spontaneous improvement may occur. more of the Sun’s rays to penetrate the atmosphere. Hair loss is possible because the hair is not Snow can be very hazardous because it refl ects the always anchored in the hair follicle properly; also, Sun more effectively even than sand and water. the brittle nature of the hair means the hair is While clouds and pollution obstruct some ultraviolet easy to break off. Problems with nails have been radiation, they do not entirely eliminate it. reported in association with uncombable hair syn- The ozone layer in Earth’s stratosphere fi lters drome. The nails can be short, brittle, and easy to out most of this harmful radiation, but scientists split. Teeth may have problems, such as enamel warn that UV levels will climb as chemicals break defects. This is not surprising, since both nails and down the ozone layer. Because the ozone layer is teeth have many similarities in basic structure with being depleted, higher concentrations of both UVA hair follicles. an UVB radiation are now reaching Earth, which The examination of the shaft under light micros- has signifi cantly increased the risk of skin cancer copy may be normal, but under a scanning electron among all people. microscope, the cross section appears triangular in In the last several years, instruments have shape (pili trianguli) but may be kidney-shaped detected signifi cant thinning of stratospheric ozone or oval. One or more depressions running along 384 ungual the length of the hair shaft resembling canals (pill urticaria, contact An acute localized allergic canaliculi) may be seen. The cuticle is normal. reaction characterized by HIVES after direct contact with an allergen, usually occurring within minutes Treatment Options and Outlook after contact. It can be triggered by contact with a Spontaneous improvement occurs without treat- variety of antigens in food (especially fi sh or meat), ment as the child enters adolescence. drugs, cosmetics, and textiles. It also can be set off by other mechanisms, such as jellyfi sh, nettles, and chemicals. ungual Relating to the nail. Symptoms and Diagnostic Path A red swollen area will appear at the point of con- Unna’s boot A dressing of gelatin and ZINC OXIDE tact with a substance to which a person is sensitized. paste applied to the foot and leg to help to heal leg It usually fades away within an hour or two. It can ulcers and other infl ammatory skin conditions. be confi rmed by performing a skin prick test.

Treatment Options and Outlook Urbach-Wiethe disease A rare hereditary meta- Antihistamines and anticholinergic drugs may bolic disease involving the skin as well as other sometimes provide relief. tissues and organs. The condition is an autosomal recessive trait, which means that a defective gene Risk Factors and Preventive Measures must be inherited from both parents in order to Avoiding a known irritant is the only prevention. cause the abnormality. Generally, both parents of See also URTICARIA, SOLAR. an affected person are unaffected carriers of the defective gene. Each of their children has a one- in-four chance of being affected, and a two-in-four urticaria, solar A rare allergic response to sun- chance of being a carrier. light characterized by the appearance of HIVES within minutes of exposure. The lesions last from Symptoms and Diagnostic Path a few minutes to an hour, depending on the In the fi rst two years of life, skin symptoms include intensity of the exposure as well as the sensitivity PUSTULES or BLISTERs on the face and exposed areas of the individual. This condition may be chronic. of the arms and legs that heal, leaving behind white Solar urticaria sometimes develops in patients scars. Subsequent skin lesions include NODULEs and who are taking a drug (aspirin and morphine-like waxy yellow PAPULES on the face, back of the neck, medicines) or are exposed to a particular chemi- hands, and fi ngers. Another characteristic sign is cal. When exposed to sunlight, the skin cells of a line of lesions along the eyelids resembling a someone with solar urticaria release HISTAMINE, and string of beads. In addition, there may be red warty other infl ammatory substances which widens the plaques on elbows, knees, fi ngers, buttocks, and blood vessels and allows fl uid to leak out, collecting face. Some patients develop a general yellow thick- within the skin. ened skin and lose hair on the scalp, beard area, eyebrows, and eyelashes. Symptoms and Diagnostic Path Symptoms include itchy skin covered with swollen Treatment Options and Outlook red patches resembling weals or a rash that can There is no known treatment. Tracheostomy may take only a few minutes to longer than an hour to be required for patients whose trachea becomes appear after exposure to light. Within an hour or blocked with cartilage. so, they disappear, typical of hives. However, if a large area of the body is affected, the loss of fl uid into the skin could cause light-headedness, pallor, urticaria See HIVES. and nausea. UV light 385

A dermatologist who specializes in sun-sensitive hives or even anaphylaxis; PUVA therapy is helpful conditions can diagnose the condition with blood in some patients. tests or an instrument that studies the effects of light on the skin. In this test, different doses of ultraviolet and visible wavelengths are shone on urushiol oil The active ingredient in POISON IVY the skin of the back to measure a person’s sen- that is one of the most potent external toxins sitivity to each part of the light spectrum, with known. The amount necessary to cause a rash in a the response compared to that seen in normal sensitive person is measured in nanograms (a nano- subjects. gram is one billionth of a gram). This means that the amount of urushiol oil equal to the size of the period Risk Factors and Preventive Measures at the end of this sentence is enough to affect 500 Susceptible patients should avoid exposure to the people. Urushiol oil is also long-lasting; specimens of sun by wearing protective clothes and opaque sun- poison ivy several centuries old have been known to blocks. SUNSCREENS are not of much help. Gradual trigger a reaction in sensitive individuals. daily exposure to more and more sun will control the disease in many people, but this type of therapy is very diffi cult to carry out because of recurrent UV light See ULTRAVIOLET LIGHT. V vaccinia A viral cattle disease (cowpox) inocu- varicella virus vaccine live (VariVax) The lated in humans to produce an antibody against CHICKEN POX vaccine approved in 1995 for all SMALLPOX. infants, children, teens, and young adults who have not had the disease. One dose is needed for children up to age vaginal warts See WARTS. 12 (ideally given between 12 and 18 months of age); teenagers and adults need two shots, four to eight weeks apart. High-risk, susceptible patients valacyclovir (Valtrex) An antiviral drug used to may also obtain passive immunization with VZV treat HERPES infections. Easily absorbed and con- immune globulin, which can abort or modify verted in the body to ACYCLOVIR, it is available in infection if administered within three days of concentrations three to fi ve times greater than exposure. that of acyclovir. The drug works by interfering The vaccine is about 70 percent to 90 percent with viral reproduction. Several large studies have effective in preventing chicken pox, and 95 percent shown that it is safe and well tolerated. effective at preventing a moderate or severe case. In treating SHINGLES, Valtrex reduces the lesions, The vaccine is made from a live, weakened virus shortens the duration of the infection, and shortens that works by creating a mild infection similar to the pain. However, it is not clear whether it can natural chicken pox, but without related problems. reduce pain that lingers once the shingles clear. The mild infection spurs the body to develop an Although valacyclovir will not cure shingles or immune response to the disease. These defenses genital herpes, it does help relieve the pain and are then ready when the body encounters the discomfort and helps the sores heal faster. Vala- natural virus. cyclovir works best if it is used within 48 hours The vaccine is considered to be safe, but it is not after the fi rst symptoms of shingles or genital yet known how long immunity will last in children herpes (for example, pain, burning, or BLISTERs) who have received the chicken pox vaccine. Current begin to appear. For recurrent outbreaks of geni- studies suggest immunity lasts at least 20 years, since tal herpes, valacyclovir works best if it is used children who have received the vaccine 20 years within 24 hours after the symptoms begin to ago are still immune. Although there has been no appear. evidence of impaired immunity, if the vaccine should wear off later in life adults could then be vulnerable Side Effects to infection at an age when chicken pox can be more Side effects are rare. Valacyclovir can cause nausea serious. It is not currently believed that children will and headache; the drug may damage the kidneys if need a booster dose of the chicken pox vaccine. patients are severely dehydrated. Because of poten- If given within 72 hours after an exposure to tial kidney problems, people with existing kidney someone with chicken pox, the vaccine may help damage should use valacyclovir only under the to prevent the disease in a child who has not been close supervision of a physician. vaccinated. People should not get chicken pox vac-

386 varicose veins 387 cine if they have ever had a life-threatening allergic A person’s immune system usually can success- reaction to gelatin, the antibiotic neomycin, or a fully keep the virus from reactivating until later previous dose of chicken pox vaccine. People who in life, when the patient’s immunity to VZV may are sick at the time the shot is scheduled should deteriorate. At that time, the virus replicates within usually wait until they recover before getting the the ganglia, and causes shingles. Why and how the vaccine. Pregnant women should wait to get the virus replicates is not well understood. In younger vaccine until after they have given birth, and they people shingles often may appear during periods should not get pregnant for one month after get- of stress. It is much more likely, however, to affect ting chicken pox vaccine. people over age 50. Some people should check with their doctor about whether they should get chicken pox vac- cine, including anyone who has HIV/AIDS or varicose veins Twisted, swollen veins just below another disease that affects the immune system, the skin’s surface, most often found in the legs. is being treated with drugs that affect the immune When valves in the leg veins become defective, system (such as steroids) for two weeks or longer, they cause blood to pool in the superfi cial veins of or who has any kind of cancer or is undergoing the legs, which become swollen and distorted. Obe- cancer treatment with X-rays or drugs. People who sity, hormones during pregnancy or menopause, recently had a transfusion or were given other deep vein thrombosis, phlebitis, or pelvic vein blood products should ask their doctor when they pressure can all accelerate the formation of vari- may get chicken pox vaccine. cose veins. About 15 percent of adults suffer from varicose veins, which are more common among Side Effects women and run in some families. Mild problems or side effects that can occur after receiving the chicken pox vaccine include sore- Symptoms and Diagnostic Path ness or swelling where the shot was given, fever, If backfl ow of blood from varicose veins is severe and mild rash, which can occur for up to a month enough to cut off oxygen and nourishment to later. Rarely, it is possible for other people to catch tissue, the skin over the veins may become thin, a mild chicken pox infection from being in contact tight, dry, scaly, and discolored, which can lead to with this rash. ulcers. Bumping a large varicose vein may cause Moderate problems can include fever-related severe bleeding, which can be stopped by tying a seizures. It is very rare for someone to have a clean handkerchief around the leg to apply moder- serious problem after receiving the chicken pox ate pressure and raising the affected leg. vaccine, but side effects can also include acute cerebellar ataxia, pneumonia, and possibly (but Treatment Options and Outlook unproven) severe brain reactions or a low blood In many cases, wearing elastic support stockings, and/or platelet count. exercising regularly, elevating the legs, and stand- ing still as little as possible will alleviate the prob- lem. SCLEROTHERAPY (injecting an irritant solution varicella-zoster virus A member of the family into the veins to scar and block them, forcing other of HERPES viruses named after the two illnesses it healthy veins to take over) also is effective. causes—varicella (CHICKEN POX) and zoster (SHIN- If they are very painful or if the overlying skin GLES). The virus fi rst enters the upper respiratory ulcerates, the veins may be removed using a surgi- tract of a nonimmune host in childhood, and pro- cal technique known as stripping. The patient must duces the skin lesions of chicken pox. The virus then keep the affected area bandaged for several then becomes dormant in the nerve cells that weeks to help heal the wound. transmit messages from the central nervous system Two techniques are replacing surgical stripping. to the skin. Either a laser or a radiofrequency probe can be 388 variola placed into the vessel. As it is slowly withdrawn, The diagnosis is based on a patient’s medical his- energy is applied to the vessel, causing it to col- tory, symptoms, a complete physical examination, lapse. These techniques, described as endovascular and the results of special lab tests. laser, are very promising. Treatment Options and Outlook Treatment depends on the disease severity and the variola Another name for SMALLPOX. patient’s general health; many cases do not require treatment. For example, an occasional few spots on the skin may not require any treatment. VariVax See VARICELLA VIRUS VACCINE LIVE. If treatment is chosen, physicians typically administer steroids such as prednisone, prednis- olone, or methylprednisolone (Medrol). Some vascular tumors Tumors related to or supplied people with severe conditions that do not respond with blood from blood vessels. They include HEM- well will need to be treated with cytotoxic (“cell- ANGIOMAS (including superfi cial strawberry hem- killing”) drugs to destroy the cells that are causing angioma, deep [cavernous] hemangioma, cherry the infl amed blood vessels. The two most common angioma, pyogenic granuloma); ANGIOKERATOMAS, are AZATHIOPRINE (Imuran) and cyclophosphamide spider nevi, lymphangiomas, GLOMUS TUMORS, (Cytoxan). These are often used together with ANGIOSARCOMAS, STEWART-TREVES TUMORS, and prednisone and are often effective. PORT-WINE STAINS. Other, experimental procedures that may help include: plasmapheresis, intravenous gammaglobu- lin, and CYCLOSPORIN, a medication used to prevent vasculitis Infl ammation of blood vessels that organ rejection in transplant patients. usually leads to narrowed, blocked blood vessels, Many patients whose vasculitis is confi ned to which eventually destroy the surrounding tissues the skin may live a normal life, albeit with an supplied by those damaged vessels. This is the annoying skin condition. Most people will fi nd that underlying basic disease process in a number of treatment is at least partially successful. diseases such as SCLERODERMA, LUPUS, PERIARTERITIS NODOSA, ERYTHEMA NODOSUM, HENOCH-SCHONLEIN PURPURA, SERUM SICKNESS, temporal arthritis, and venereal warts See WARTS. Buerger’s disease. Symptoms depend on the size of vessel involved and their body location. Vasculitis is caused in some cases by immune vernix The pale cheesy substance covering new- complexes in circulating blood. While these born skin consisting of fatty secretions and dead immune complexes would normally be destroyed cells. It protects and insulates the baby’s skin before by white blood cells, in certain disease states they birth. settle in the blood vessel walls where they cause severe infl ammation. verruca The medical term for WART. Symptoms and Diagnostic Path Skin symptoms include red or purple dots on the legs; larger sports that may look like bruises are vesicle A small skin BLISTER (usually fi lled with called PURPURA. These are the most common vascu- clear fl uid). litis skin lesions, but HIVES, itchy lumpy rash, and painful or tender lumps may appear. Areas of dead skin can look like ULCERS, and there may be small viral diseases with skin symptoms Viral diseases black spots at the end of the fi ngers or around the are a common cause of skin symptoms. Some of fi ngernails and toes, or GANGRENE of fi ngers or toes. these skin symptoms (such as WARTS) are infec- vitamin D 389 tions of the skin, whereas others (such as MEASLES vitamin B2 (riboflavin) deficiency Defi ciency of and CHICKEN POX) are the symptoms of systemic this vitamin may cause chapped lips and a sore disease. tongue, or sores in the mouth corners. While a Other viral diseases with skin symptoms include balanced diet usually provides adequate amounts dengue, erythema infectiosum (HHV-6), EXAN- of ribofl avin, some people are susceptible to a defi - THEM SUBITUM, HERPES simplex (HSV-1 and HSV-2), ciency. This includes those taking phenothiazine SHINGLES, MILKER’S NODULE, ORF, PAPULAR ACRODER- antipsychotic drugs, tricyclic antidepressants, oral MATITIS, RUBELLA, and COXSACKIE (hand, foot, and contraceptives, and those with malabsorption disor- mouth disease). ders or severe alcohol dependence. Defi ciency also Other viral infections that cause only mild skin may result from serious illness or injury, or surgery. symptoms include Epstein-Barr virus (infectious mononucleosis), hepatitis, and retroviruses (such as HIV). vitamin B6 (pyridoxine) deficiency Defi ciency of this vitamin causes a variety of skin conditions, infl ammation of mouth and tongue and cracked vitamin A The vitamin necessary to maintain lips. This vitamin plays a vital role in the activi- healthy skin. Many foods contain this vitamin, ties of various enzymes and hormones involved but particularly good sources include liver, fi sh in keeping skin healthy. Good dietary sources of liver oils, egg yolk, milk and other dairy prod- vitamin B6 are found in liver, chicken, pork, fi sh, ucts, margarine, and a wide range of fruits and whole grains, wheat germ, bananas, potatoes, and vegetables. dried beans. A balanced diet will provide suffi cient Defi ciency of this vitamin is rare in developed amounts of this vitamin, which is also produced in countries, but a serious lack or excess intake small amounts by intestinal bacteria. can both cause dry, rough skin, among other People who are at risk for developing a vitamin problems. B6 defi ciency include breast-fed infants, people Contrary to popular belief, ingesting too much with poor diets and those with malabsorption dis- carotene (by eating huge amounts of carrots) does orders, severe alcoholics, and patients taking cer- not cause excess levels of vitamin A; however, it tain drugs (including penicillamine, hydralazine, or can produce carotenemia (high blood levels of birth control pills). carotene), which colors the skin deep yellow. Synthetic vitamin A-like compounds called RETI- NOIDS, such as TRETINOIN, applied directly to the vitamin C Also known by its chemical name skin have been used to treat ACNE and skin WRIN- (ascorbic acid), this vitamin plays an important KLING and mottled pigmentation caused by chronic role in healing wounds in the skin and in prevent- sun exposure. Used systemically, retinoids such as ing SCURVY. The primary dietary source includes ISOTRETINOIN (Accutane) and ETRETINATE treat acne fresh fruits and vegetables, especially citrus fruits, and help to prevent SKIN CANCER in those at very tomatoes, green leafy vegetables, potatoes, green high risk. peppers, strawberries, and cantaloupe. A balanced diet usually provides enough vitamin C, but slight defi ciencies may occur after surgery, vitamin A acid See RETINOIC ACID. fever, constant inhalation of carbon monoxide in tobacco smoke and traffi c fumes, serious injury, or use of oral contraceptives. vitamin A deficiency The earliest signs of vita- min A defi ciency appear in the eyes, causing night blindness, dry eyes, and corneal ulcers. Skin symp- vitamin D A naturally-occurring substance pro- toms of vitamin A defi ciency include dryness, fi ne duced by the interaction of sunlight with chemicals scaling, and FOLLICULAR HYPERKERATOSIS. in the skin that helps the body absorb calcium from 390 vitamin E the intestinal tract and provides for the healthy used more and more in skin preparations as a way development and growth of bones. About 15 min- to fend off this damage. utes outdoors a day is enough to meet the body’s Although topical use of vitamin E has few requirements for the vitamin, although it is also negative consequences other than the potential found in many foods. A defi ciency of vitamin D, for allergic reaction, oral vitamin E overdoses can either through a poor diet or lack of sunlight, can block the absorption of other fat-soluble vitamins lead to rickets. Vitamin D has been added to milk such as A and D. since the 1930s as a way to reduce the incidence Vitamin E defi ciency is extremely rare, and of rickets. when it occurs it is usually caused by a disease Many other foods are fortifi ed with vitamin D, that blocks its absorption from the gastrointestinal and supplements are also available. Other good tract. This vitamin is found naturally in vegetable dietary sources of vitamin D include oily fi sh, liver, oils, including wheat germ oil; most people get an dairy products, and egg yolks. However, sunlight’s adequate supply by eating a typical American diet. interaction with the skin can provide enough vita- min D unless children drink no milk at all. Elderly people who do not drink milk and don’t get out vitamins and the skin Experts have known for into the sunshine do have a potential risk for vita- some time that vitamins affect the skin. Lack of min D defi ciency. vitamins can make skin lifeless, blotchy, dry, or Vitamin D is considered to be an antioxidant (see oily. Healthy skin requires a variety of vitamins to ANTIOXIDANT BEAUTY PRODUCTS) and anticarcinogen, keep it resilient; specifi cally, VITAMIN A (found in and may play a role in skin pigmentation. Since it carrots, broccoli, leafy green vegetables, asparagus, can be absorbed by the skin, applying this vitamin cantaloupe, apricots, peaches, and sweet potatoes) topically can have an effect on the skin’s health. and VITAMIN E (in whole grain breads, wheat germ, Vitamin D is toxic in very large amounts oatmeal, and eggs). (between 5,000 and 10,000 IU daily for several Furthermore, vitamins E and C (found in citrus months for D3 or D4), and megadoses should be fruits and vegetables) are the simplest forms of avoided. Sunbathing, however, will not result in ANTIOXIDANT. Antioxidants may help prevent skin an overdose. damage from free radicals, a dangerously mutant form of oxygen that in large doses (from pollu- tion, sunlight, and so on) can break through the vitamin E (tocopherol) This vitamin has a long membrane that protects the skin’s cells and cause history of usefulness in skin problems such as infl ammation, visible lines, and WRINKLES, among bruises, cuts, skin irritations, and to help heal other damage. WRINKLES. Scientifi cally, it has never been shown to Vitamin A may help prevent sun damage, and be effective when used topically as anything other VITAMIN C may accelerate skin healing. There is also than a MOISTURIZER, since vitamin E cannot pen- some evidence that vitamin C may pass through etrate the outer skin’s layers. Some studies have the layers of skin and help heal tissue damaged by found that this vitamin can actually irritate the skin burn or injury, although some experts dispute this. of the face, especially when it is used with an ACNE Vitamin D, absorbed through the skin’s outer lay- product that has a peeling effect. When spray-on ers, may help heal the skin when applied topically, vitamin E is forced through the layers of the skin it especially when combined with vitamin A. can lead to severe allergic reactions. Vitamin E is an antioxidant that can help pre- vent FREE RADICAL damage. Based on the observa- vitiligo A common disease in which the skin loses tion that skin damage caused by sunlight and by pigment due to the destruction of pigment cells other environmental agents are induced by free (melanocytes). In this condition, areas of the skin radicals, there is the possibility that vitamin E may become white, especially in areas such as the groin be effective in preventing skin damage. It is being or armpits, around body openings, and exposed vitiligo 391 areas like the face or hands. The unpigmented areas develop vitiligo; in many of these cases, vitiligo are extremely sensitive to ultraviolet radiation, and seems to stop the cancer from spreading. are especially obvious in dark-skinned people. Between 2 to 5 million Americans have this Symptoms and Diagnostic Path condition, which occurs more often in people with Vitiligo often starts with a rapid loss of pigment, thyroid conditions and some other metabolic dis- which may be followed by several months when the eases. However, most people who have vitiligo are skin color does not change. The number and size of in good health and suffer no symptoms other than the light areas become stable and may remain so for areas of pigment loss. a long time. Later, the pigment loss may resume, About half of the people who develop this skin especially if the patient has suffered physical trauma disorder experience some pigment loss before or stress. Many vitiligo patients report that initial or the age of 20, and about one-third of all vitiligo later episodes of pigment loss are followed by periods patients say that other family members also have of physical or emotional stress, which seem to trig- this condition. ger depigmentation in those who are predisposed. Medical researchers are not sure what causes vit- Sometimes, depigmented areas may spontaneously iligo. Some researchers think the body may develop repigment. The loss of color may continue until for an allergy to its pigment cells; others believe that unknown reasons it suddenly stops. Cycles of pig- the cells may destroy themselves during the process ment loss, followed by periods of stability, may con- of pigment production. MELANIN is the substance tinue indefi nitely. However, it is rare for a patient that normally determines the color of skin, hair, with vitiligo to regain skin color. Most patients who and eyes. This pigment is produced in cells called say that they no longer have vitiligo may actually melanocytes. If melanocytes cannot form melanin have become totally depigmented and are no lon- or if their number decreases, skin color will become ger bothered by contrasting skin color. While such lighter or completely white—as in vitiligo. patients appear to be “cured,” they really are not. A combination of genetic and immunologic fac- People who have vitiligo all over their bodies do not tors is of major importance in most cases. In more look like albinos because the color of their hair and than half the cases, there is a family history of viti- eyes may not change. ligo or early graying of hair. Many patients do not In severe cases, the pigment loss extends over realize that anyone in the family has had vitiligo, the entire body surface. The degree of pigment loss either because they don’t know that premature can also vary within each vitiligo patch, and a bor- gray hair is a sign of vitiligo or because the affected der of abnormally dark skin may encircle a patch of area is hidden by clothing. In many cases of viti- depigmented skin. ligo, there is no family history of the disorder, and many vitiligo patients don’t have either children or Treatment Options and Outlook grandchildren with symptoms of pigment loss. There is no cure for this disease, but the symp- Many people report pigment loss shortly after a toms can be treated, although treatment may not severe SUNBURN. Others relate the onset of vitiligo be completely satisfactory. There are two basic to emotional trauma associated with an accident, methods: Try to restore the normal pigment (repig- death in the family, or divorce. Patients with mentation), or try to destroy the remaining pig- vitiligo appear to have normal pigment cells. An ment cells (depigmentation). Current treatment increase in something such as nitric oxide may be options for vitiligo include medical and surgical toxic for pigment cells or there may be a lack of options, along with camoufl age cosmetics. Medi- growth factors that are required for normal pig- cal therapies include topical and oral PSORALEN ment cells to be viable. photochemotherapy, topical steroid therapy, and DEPIGMENTATION. Surgical therapies include skin Vitiligo and Cancer grafts from a person’s own tissues, SKIN GRAFTS Vitiligo is neither a cancerous nor a precancer- using BLISTERs, micropigmentation (TATTOOING), ous condition. People with skin cancer sometimes and laser therapy. 392 vitiligo

Repigmentation The most common method A dermatologist’s supervision is required during of repigmenting is a combination of a drug called all aspects of repigmentation therapy. Patients with PSORALEN (applied to the skin or taken orally) and vitiligo should always protect their skin against regulated doses of sunlight. Some clinics use pso- excessive sun exposure by wearing protective ralen and indoor ultraviolet light treatments. When clothing, staying out of the sun at peak periods psoralen drugs are activated by ultraviolet (UVA) except during treatment time, and applying SUN- light called PUVA, they stimulate repigmentation SCREEN lotions and creams. Patients with vitiligo by increasing the availability of color-producing should use a sunscreen with an SPF of 15 or higher, cells at the skin’s surface. The response varies except during the hours of treatment. During treat- among patients and body sites. The psoralen treat- ment, an SPF of 8 to 10 protects against SUNBURN ment is not always successful, but many patients but does not block the UVA needed for treatment. fi nd that it can help restore some degree of pig- Sunscreens should be reapplied after swimming mentation to areas of the skin. About 75 percent or perspiring. To prevent potential damage to the of the patients who undergo psoralen–UVA light eyes, special sunglasses with protective lenses therapy respond to some extent, but complete should be worn during sunlight exposure and for repigmentation rarely occurs. the remainder of the day on which the psoralen The psoralen drugs used for repigmentation drug is taken. therapy are trimethylpsoralen and 8-methyoxy- Another method of psoralen treatment, used psoralen. A patient takes the prescribed dose by occasionally for patients with small, scattered viti- mouth two hours before lying in the sun or under ligo patches, involves the application of a solu- artifi cial UVA light. The ideal time for natural sun- tion of the drug directly to the affected skin. The light is between 11 A.M. and 1 P.M. when the sun health expert applies a thin coat of psoralen to the is highest. Treatment every other day is recom- patient’s depigmented patches about 30 minutes mended. Too much ultraviolet light can be harm- before direct sun exposure, which then turns the ful. Treatment schedules can be adjusted for each affected area pink. The dose of UVA light is slowly patient. If the day is cloudy or if sun exposure is increased over many weeks. Eventually, the pink not possible on a scheduled treatment day, then the areas fade and a more normal skin color appears. patient does not take any medication because the After each treatment, the skin is cleansed with soap drug does not work without appropriate sunlight. and water and a sunscreen applied. In northern United States, patients usually begin There are two main problems with topical therapy in May and continue until September. psoralen-UVA (PUVA) therapy—severe sunburn Moderate repigmentation should take place during and blistering and excess darkening of the treated this time. Treatment is usually discontinued during patches, or of the normal skin surrounding the viti- the winter. Although artifi cial sources of UVA light ligo (HYPERPIGMENTATION). Patients can lessen the can be used throughout the year, patients should chances of sunburn if they avoid exposure to direct consult their DERMATOLOGIST to determine whether sunlight after each treatment. Hyperpigmentation such treatments are desirable. UVA light systems is usually a temporary problem and eventually dis- for home use are expensive and treatment can be appears when treatment is stopped. time consuming. Ordinary sunlamps are not effec- However, such topical treatment makes a person tive with the psoralen medications, since only UVA very susceptible to severe burn and blisters with light produces the desired interaction. too much sun exposure. After the initial two to three weeks of exposure Hydrocortisone-type compounds when applied to sunlight, patients will look worse since the con- to the skin slow the process of depigmentation and trast between light and tanned skin increases. With sometimes even enhance repigmentation. How- time, repigmentation will begin, and the appear- ever, the weak cortisones that are sold without a ance of the skin improves. If patients stop the ther- prescription (such as 1.0 percent hydrocortisone) apy in winter, most will retain at least half of the are too weak to help. On the other hand, very color they achieved during the summer months. potent cortisones when used daily for a long time vitiligo 393 produce side effects, such as thinning of the skin. son’s own tissues, removing skin from one part of a Under the care of a dermatologist it is usually pos- patient’s body and attaching it to the depigmented sible to adjust the treatment with topical hydrocor- section. Possible complications include infections, tisones so that side effects are at a minimum. scarring, a cobblestone appearance, or spotty pig- Not everyone is a good candidate for repigmen- mentation. Sometimes the graft fails to repigment tation. The ideal person should have lost pigment at all. Grafting is expensive and time-consuming, no more than fi ve years ago. In general, chil- so most people fi nd it unacceptable. dren and young adults respond better than older Tattooing (micropigmentation) Tattooing people. Patients should be at least 10 years old. places pigment into the skin with a special surgi- While treatment is safe for younger children, the cal instrument, which works best for the lip area, method is tedious, and better results are achieved particularly in people with dark skin; however, it is when the child is interested in treatment. In addi- diffi cult for the doctor to match perfectly the color tion, patients should be healthy, and no one with of the skin of the surrounding area. Tattooing tends a sensitivity or allergy to sunlight can be treated. to fade over time, while tattooing the lips may trig- Pregnant women should not be treated because ger episodes of herpes simplex blister outbreaks. of the potential harmful effects of the drug on the Experimental procedures In an autologous developing baby. melanocyte transplant procedure, the doctor tries Depigmentation People with vitiligo over more to grow pigment cells (melanocytes) from a sample than half of the exposed areas of the body are not of the patient’s normal pigmented skin. When the candidates for repigmentation. Instead, these peo- melanocytes in the culture solution have multi- ple may want to try removing the pigmentation of plied, the doctor transplants them to the patient’s the remaining skin so the patient is an even color. depigmented skin patches. This procedure is still However, total depigmentation is tried only in very experimental. severe cases of vitiligo. Laser treatment The newly developed 308 The drug for depigmentation is monobenzyle- nanometer excimer laser (XTrac) is a high- ther of hydroquinone. Many patients with vitiligo frequency source of UVB light that shows promise are at fi rst apprehensive about the idea of depig- in repigmenting patches of vitiligo. Treatments mentation and reluctant to go ahead, but those are required two to three times a week for several who achieve complete depigmentation are usually months. satisfi ed with the end results. Unfortunately, some Cosmetics Most patients, even if they are people become allergic to the medication and must responding well to treatment, would like to make discontinue therapy. the vitiligo less obvious. Many fi nd that a com- The major side effect of depigmentation ther- bination of cosmetics can deemphasize the skin apy is skin infl ammation, with ITCHING or dry disorder. Cosmetics are not just for women, nor skin. Depigmentation is permanent and cannot be are they only for the face. Anyone can wear them reversed. Further, a person who undergoes depig- anywhere on their body. Over-the-counter cosmet- mentation will always be abnormally sensitive to ics exist in a wide range of skin tones; many are sunlight. waterproof and do not rub off. Skin grafts using blisters In this procedure, the There are also special dermatological cosmetics doctor creates blisters on the patient’s pigmented that patients even with severe vitiligo fi nd use- skin with heat, suction, or cold. The tops of the ful. Dermablend, Lydia O’Leary, Clinique, Fashion blisters are then cut out and transplanted to a Flair, Vitadye, and Chromelin offer makeup or dyes depigmented skin area. Blister grafting can cause that can help cover depigmented patches. a cobblestone appearance, scars, or a lack of repig- Vitiligo may spread to other areas, but there mentation, but there is less risk of scarring with this is no way of predicting whether or where it will procedure than with other kinds of grafting. spread. When vitiligo begins and how severe the Skin grafts In patients with small patches of pigment loss will be, differs with each patient, vitiligo, the doctor may take a skin graft from a per- but illness and stress can result in more pigment 394 Voigt’s line(s) loss. Light-skinned people usually notice the pig- (French for “veils”) are based on a water-in-oil ment loss during the summer, as the contrast emulsion and are helpful for consumers with dry between the vitiliginous skin and the suntanned skin who fi nd alcohol-based fragrance to be too skin becomes distinct. People with dark skin may drying. The oil in the formulation helps skin retain observe the onset of vitiligo at any time. moisture.

Voigt’s line(s) Also known as Futcher’s lines, volar melanotic macules A condition primar- these normal color patterns are seen in dark- ily affecting the skin of African Americans, char- skinned people (especially African Americans and acterized by darker MACULES on palms and soles dark Japanese) in which the border between the resulting from local accumulation of MELANIN. The darker segment of skin (usually on the upper arms) discoloration lasts throughout life and requires no and the lighter area of skin is marked by a line. treatment. voiles A type of spray-on fragrance that is non- drying because of a lack of alcohol. The voiles W

Waardenburg’s syndrome A hereditary disorder used to freeze a wart and form a blister that lifts off of pigmentation and hearing loss that was fi rst the growth. Sometimes a blister-producing liquid described in 1951. (cantharidin) or a corroding acid liquid or plaster is The disorder is genetically transmitted to off- used. The last two product groups usually contain spring in a dominant manner, and carries a 50 per- SALICYLIC ACID, lactic acid, or trichloracetic acid. cent risk that siblings may be born with a variation of the syndrome. Still, only a few people who have the abnormal form of the gene show all the fea- warts Harmless, contagious growths on the skin tures of the syndrome. Researchers believe there or mucous membranes caused by any of more may be a connection between the development of than 50 varieties of PAPILLOMAVIRUS. Warts appear pigmentation and hearing during pregnancy. only on the very top layer of skin, without roots or branches. Occasionally, warts contain small black Symptoms and Diagnostic Path spots, which are capillaries that have become clot- Symptoms include a white forelock of hair with a ted due to the rapid skin growth caused by the triangular white area of skin on the forehead (60 virus. While all warts are basically the same type percent); piebald spots on extremities or trunk (5 of growth, they may look different depending on percent to 10 percent); medial folds of the eyes where on the body they appear. associated with fl attening of the root of the nose (66 percent), and possibly two different colored Symptoms and Diagnostic Path eyes. About 50 percent of patients may have a Common warts are fi rm, well-defi ned growths up to nonprogressive sensorineural hearing loss ranging a quarter-inch wide, often with a rough surface. from mild to severe in one or both ears. They usually appear in areas that are frequently injured, such as the hands, fi ngers, feet, toes, knees, Treatment Options and Outlook and face, especially in young children. They often Therapy for the depigmentation of the skin is the appear in crops, and can disappear spontaneously. same as for PIEBALDISM. Attempts to repigment the Flat warts are fl at-topped, sometimes itchy PAP- white areas of the skin with conventional methods ULES found mainly on the wrists, backs of hands, (such as ultraviolet light and PSORALENS) have gen- legs and face. erally been unsuccessful. It is possible to surgically Digitate warts are dark-colored growths with correct the problem with punch autografts, epider- fi nger-like projections. mal suction grafts, and thin split-thickness grafts. Filiform warts are long, slender growths found in Repigmentation does occur, and the appearance is the armpits, on eyelids, or the neck in middle-aged often satisfactory. Opaque cosmetics can be used to or overweight people. conceal the more obvious depigmented areas. Plantar warts are found on the soles of the feet, fl attened by the pressure of the body on the bottom of the feet, forcing them to grow inward. wart removal preparations Substances that Genital warts are transmitted through sexual remove WARTS from the skin. LIQUID NITROGEN is contact, and are characterized by pink or brown,

395 396 waxing

fl at, or raised caulifl owerlike groups of growths on cases, adjacent digits may be completely fused (called the genitals. This type of wart needs prompt diag- syndactyly). Webbing may have a genetic origin. nosis and treatment, since there is evidence that some of these warts infecting a woman’s cervix may predispose her to cervical cancer. It is impor- weeping Oozing of clear fl uid from a superfi cial tant that both partners be checked and rechecked, since infl ammation of the EPIDERMIS. When the ooze the infection can be passed back and forth between them. dries, it forms a crust. Condoms can prevent the transfer of warts. Warts present around the genitals of young children may be a sign of sexual abuse. Wegener’s granulomatosis See GRANULOMA, LETHAL MIDLINE; SYSTEMIC NECROTIZING VASCULITIDES Treatment Options and Outlook (VASCULITIS). About half of all warts disappear on their own between six months to a year after they appear. In many cases they can be left untreated to spontane- Weil’s disease See LEPTOSPIROSIS. ously resolve. Common, fl at and plantar warts may be removed with liquid nitrogen or a blister-producing agent, Werner’s syndrome A rare connective tissue dis- corroding acids, or plasters. Surgical removal with a order in men and women associated with prema- scalpel, electric needle, or laser also may be used. ture aging and hardening of the skin, mottled skin Genital warts may be removed by surgery or by color, and spidery veins in the skin. Other symp- the application of podophyllin. Recurrence rates toms include a distinctive appearance with short with this type wart are very high and there is no stature, beaked nose, premature gray hair, diabetes specifi c treatment available. All treatments are mellitus, hypogonadism, and leg ulcers. destructive and not that effective. The disease usually starts in the 20s and 30s and See also WART REMOVAL PREPARATIONS. is transmitted as an autosomal recessive trait, which means that a defective gene must be inherited from both parents to cause the abnormality. Generally, waxing A technique used to remove unwanted both parents of an affected person are unaffected hairs (usually from the legs, bikini area, and upper carriers of the defective gene. Each of their children lip) by stripping them from their root. In the proce- has a one in four chance of being affected, and a dure, solid wax and resin mixtures are heated until two in four chance of being a carrier. they melt, and are applied to the hairy areas. As the This syndrome usually is associated with an wax cools, it traps the hair; when the wax is pulled increased risk of cancer, for which there is no off, the hair comes off with it. known treatment. Death usually occurs as a result Alternatively, tacky material on strips of cloth of accelerated hardening of the arteries (atheroscle- or paper may be used to remove hair on the body rosis), generally when the patient is in the 40s. or face. Waxing is most often performed in beauty salons. When performed on the upper lip or legs wheal A HIVE—a smooth, raised area of skin that around the hair follicle it may cause FOLLICULITIS, is usually itchy. an infl ammatory reaction.

Whipple’s disease A rare disorder found most webbing A fl ap of skin present at birth, located often among middle-aged men that causes (among between toes or fi ngers that may affect two or more other things) abnormal skin pigmentation. digits. Although mild webbing is harmless, surgery The cause in unknown, but is probably due to may be performed for cosmetic reasons. In severe an unidentifi ed bacterial infection. Wiskott-Aldrich syndrome 397

Symptoms and Diagnostic Path Wilson’s disease An inborn defect of copper Symptoms include abnormal skin color, malabsorp- metabolism characterized by excess amounts of tion, diarrhea, abdominal pain, progressive weight copper deposits in the liver (causing JAUNDICE and loss, joint pain, swollen lymph nodes, anemia, and cirrhosis) or the brain (causing mental retardation fever. and parkinsonism).

Treatment Options and Outlook Symptoms and Diagnostic Path Antibiotics for at least one year is the typical Known medically as hepatolenticular degener- treatment. ation, skin symptoms include skin darkening (hyperpigmentation) along the front portion of the legs; blue-colored nails, spider ANGIOMAS, whitehead Also known as an open comedone, and jaundice. Other symptoms include tremor, this is a very common superfi cial dilated closed psychiatric problems, hepatitis or cirrhosis, dis- pore fi lled with debris and some white cells seen colored corneal membrane, bony abnormalities, typically in patients with ACNE. Left untreated, and so on. some whiteheads progress to infl ammatory pus- The gene that causes the disease prevents the tules, which may then clear spontaneously. liver from removing the excess copper ingested See also MILIA. in food; eventually, the copper accumulates in the body, damages the liver, and leaks into the brain. Whitmore’s disease The common name for meli- oidosis, a bacterial infection of rodents caused Treatment Options and Outlook by Pseudomonas pseudomallei, which is endemic in Administration of D-penicillamine for life. For Southeast Asia and Australia. The disease, which those who cannot tolerate this drug, trientine is a is also found in pigs, cattle, sheep, and horses, can safe alternative. If treated early, patients can expect be acquired by humans who breathe the bacteria to live a normal lifespan. Untreated patients even- or come into contact with the bacteria via broken tually develop a fatal failure of many organs. skin. The bacteria are also found in soil and water (especially rice paddies). winter itch Itchy, dry skin related to the cold Symptoms and Diagnostic Path winter season. In humans, the disease takes three forms—an acute septicemic (blood poisoning) with diarrhea; a typhoidal form with local abscess formation and Wiskott-Aldrich syndrome This rare hereditary severe HIVES; and a chronic variety. The disease disease is characterized by skin irritation that may be milder and more common than had been resembles atopic DERMATITIS, recurrent infections, thought. and a reduced number of platelets in the blood. The disease is an X-linked recessive trait, which Treatment Options and Outlook means that it is caused by a defect on the X chro- ABSCESses must be surgically drained; antibiotics mosome, usually leading to problems in males (TETRACYCLINE with chloramphenicol, piperacillin, only. Women can be carriers of the defect, and half gentamicin, or doxycycline) are administered. of their sons may be affected.

Symptoms and Diagnostic Path Wickham’s striae Pale network of whitish lines The fi rst sign of this disease is usually a bleeding on the surface of the PAPULES of LICHEN PLANUS. The irritation or infection; eventually, other infections lines are also highly visible in the mouth. appear, often followed by cancers. 398 witch hazel

Treatment Options and Outlook gauze and covered with a bandage. After four or Infections are treated by replacement of immuno- fi ve days, if there is no sign of infection, the wound globulins and blood platelets; bone marrow trans- can then be closed. Otherwise, the wound will be plants have helped some patients. This condition is left open to heal on its own. often fatal. Cuts and scrapes heal best when treated with See also DERMATITIS, ATOPIC. a broad-spectrum antibacterial ointment and a proper bandage. It is best to keep cuts and scrapes clean and witch hazel An extract of the leaves and bark of moist and not exposed to the air, which forms scabs the Hamamelis virginniana plant used as an effective that cut down on cell growth. Bandages that keep astringent. It can dry out spots, reduce oil on the the wound moist (such as those impregnated with skin, and soothe bruises and sprains. Puffy eyes can petroleum jelly) enable cells to regenerate rapidly. be refreshed with refrigerated witch hazel–soaked pads. wrinkles A crease or furrow in the skin caused by the natural process of aging or by excessive Woronoff ring A skin symptom of PSORIASIS in exposure to the Sun’s damaging rays. Wrinkles are which a white halo forms at the periphery of skin caused by reduced COLLAGEN production and sub- lesions. It is thought to be related to vasoconstric- sequent loss of elasticity in the skin. tion of vessels surrounding psoriatic plaques caused by the elaboration of prostaglandins. Symptoms and Diagnostic Path While wrinkles are most obvious on exposed areas, they occur all over the body. “Expression lines” wound Damage to the skin and/or underlying tis- may be caused by the contraction of facial muscles sue resulting from an accident or surgery. Wounds during smiling or frowning; when these muscles in which the skin is broken are called open wounds; contract, they pull the skin in, causing a line. The wounds associated with unbroken skin are called muscles controlling frown lines between the brows closed wounds. may contract even when the muscle is resting, causing deep lines. Symptoms and Diagnostic Path Incised wounds involve skin that is cleanly cut or sur- Treatment Options and Outlook gically incised; an abrasion is a graze in which the Treatments aimed at reducing wrinkles do not surface skin is scraped away; a laceration involves permanently restore skin elasticity. These treat- torn skin. A penetrating wound, which penetrates ments include adding things to the skin to fi ll the all skin layers, would include a stab or gunshot wrinkles (such as collagen, silicone, fat, or Gortex) wound, and a contusion is a bruise caused by a blunt and removing tissue to smooth the surface (DERM- instrument that damages underlying tissue. ABRASION, chemical peels, LASER RESURFACING, and FACE-LIFTS). Newer methods involve injections of Treatment Options and Outlook BOTOX to paralyze facial muscles and ease frown Many minor wounds may be treated with fi rst aid, lines. While all of these treatments are considered but deeper wounds require professional care. Any permanent solutions, they work best on fi ne, shal- foreign material or dead tissue must be removed. low wrinkles. The wound should be cleaned with an antiseptic Laser resurfacing with a pulsed CO2 laser or solution to decrease the chance of infection. erbium YAG (Er:YAG) is a good technique for the Clean, freshly incised wounds may be stitched treatment of medium-to-fi ne wrinkles, emitting a closed, and usually heal with little scarring. Con- very brief pulse of high-intensity light that is fast taminated wounds are not usually stitched shut. enough to limit heat damage in the skin, yet strong Instead, they are usually fi lled with layers of sterile enough to vaporize tissue cleanly. Since the heat wrinkles 399 penetrates the skin no deeper than half the thick- lines, fi lling in deep vertical wrinkles between the ness of a human hair, it can remove the wrinkled eyebrows, deep wrinkles running from mouth skin layer by layer without scarring. The procedure to nose, and forehead wrinkles. Results last only can be done on an outpatient basis, and takes on between three and 18 months. The entire treat- average about one to two hours. ment may take up to only about 10 minutes, and Less expensive than a face-lift, laser resurfacing patients recover in two to three hours. Afterward, does not cause bleeding and does not require gen- there may be some redness lasting up to 10 days. A eral anesthesia. While face-lifts are good for sagging few patients experience bruising, temporary sting- skin, they are not ideal for too much sagging skin. ing or burning, faint redness, swelling, or exces- While laser resurfacing cannot replace a face-lift, sive fullness. Others may have no reaction. Risks it can improve the appearance after a face-lift has include contour irregularities, infection, or local been performed by removing the fi ne lines that ABSCESSes. Like all cosmetic procedures, its success may remain. depends on the skill of the physician: Ill-placed Unlike other cosmetic techniques, most patients collagen can leave a bumpy surface. report little or no pain during the pulsed CO2 or A face-lift can smooth out wrinkles by stretch- Er:YAG laser treatment. Areas of the skin that ing the skin, but the effects only last for fi ve to can be completely anesthetized, such as the skin 10 years. In face-lifts and brow lifts, excess skin is around the mouth, are usually pain free. After the removed at the edge of the face, leaving stretched, technique, the skin may ooze and become puffy, tighter skin behind. crusting, and red. The skin remains reddened for BOTOX (Botulinum toxin), a purifi ed form of about six weeks, but can be covered completely by the toxin that causes botulism, also can lessen makeup after the fi rst few days. Full healing takes wrinkles. Injected into the face, the substance tem- place within about three months. porarily and partially paralyzes the muscles under- Many dermatologists today believe the pulsed neath frown lines, giving the face a smoother, less CO2 or Er:YAG lasers are a better way to treat wrin- furrowed look. While experts report up to a 90 kles than either dermabrasion and chemical peels percent reduction in wrinkling, the cost is high. because it allows for better control and safety. Dermabrasion is the surgical removal of the top Risk Factors and Preventive Measures layer of skin by high-speed sanding; it can leave Anything that protects the skin from sun exposure the skin smooth and soft, but it also carries a risk of can help prevent wrinkles. scarring and pigment changes. In an age of blood- SOLUMBRA, a type of 30+ SPF sun-protective borne infections such as AIDS, dermabrasion can clothing, can provide medically accepted sun be risky to health care workers since the technique protection. tends to spray a great deal of blood. A typical 30 SPF SUNSCREEN, even though it may Deep chemical peels also are more risky than laser claim to provide UVA protection, may still allow treatment since the extent of the burn can be dif- UVA rays to penetrate the skin. Solumbra blocks fi cult to control and the fi nal appearance of the more than 97 percent of both UVA and UVB rays, skin may appear artifi cial. A chemical peel causes a far better than a typical 30 SPF sunscreen or typical deep, controlled second-degree burn using caustic summer shirt. chemicals; at least one of the chemicals (phenol) may adversely affect someone with poor liver, Wrinkles in Men heart, or kidney function. Wrinkle-reducing products are also marketed to Collagen injections, although temporary, is one of male consumers, because a man’s skin tends to be the less painful and more conservative methods to thicker and oilier than a woman’s and therefore temporarily reduce the appearance of facial wrin- needs unique skin-care products. Men’s products kles. The procedure involves the injection of tiny tend to be more oil-free and concentrated. drops of human collagen into the skin to minimize X xanthelasma See XANTHOMA. xenograft See HETEROGRAFT. xanthogranuloma, juvenile A benign disorder of xeroderma pigmentosum This rare inherited skin infancy characterized by red-yellow NODULES that disease causes an extreme sensitivity to light, so that gradually grow larger and then fade away. They fi rst the skin (normal at birth) becomes dry, wrinkled, appear in the fi rst six months of life, but they also can freckled, and prematurely old by age fi ve, with vari- occur in older children and adults. ous types of benign and malignant skin tumors. It is often accompanied by eye disorders such as photo- Treatment Options and Outlook phobia and conjunctivitis. These lesions usually require no treatment. The condition is caused by the lack of an enzyme present in normal individuals that corrects light- induced DNA damage. In affected patients, the lack xanthoma A yellow deposit of fatty material in the of this enzyme causes cells to reproduce abnormally, skin that may indicate a disorder of triglycerides or leading to vast numbers of SKIN CANCERS. cholesterol. Symptoms and Diagnostic Path Symptoms and Diagnostic Path Infants or young children exposed to sunlight develop There are several types of xanthomas, depending on a prolonged skin redness, FRECKLES, and telangiecta- the lipid abnormality. Xanthelasmas are yellowish sia. Skin hardening causes distortions of eyes, nose, plaques on the eyelids that are related to lipid abnor- and mouth, and eye problems from damage caused mality in 50 percent of patients. by the sun. In some forms of the disease, there also Xanthomas may appear over joints such as elbows may be microcephaly, mental retardation, and tes- or knees (tuberous xanthomas) or scattered in show- ticular hypoplasia. ers over the trunk (eruptive xanthomas). Treatment Options and Outlook Symptoms and Diagnostic Path Patients must avoid exposure to sunlight by wearing These soft, yellowish bumps are located under the skin protective clothing and using SUNSCREENS with an with a fl at surface and sharply defi ned margins. The SPF of at least 15. Skin cancer is treated by surgical diagnosis is primarily on how the skin growth looks, removal or with anticancer drugs. especially if there is a history of an underlying disor- BASAL CELL CARCINOMA, SQUAMOUS CELL CARCI- der. A biopsy of the growth will show a fatty deposit. NOMA, KERATOACANTHOMAS, and malignant mela- noma are common at an early age and may be fatal. Treatment Options and Outlook See also MELANOMA, MALIGNANT. Dietary changes and agents that lower blood lipid levels can be effective for tuberous and especially eruptive xanthomas. Eruptive xanthomas usually xerosis Abnormal dryness of the skin. disappear as triglyceride levels return to normal.

400 Y yaws One of the world’s most prevalent infections, ics, oral steroids, or birth control pills, or in diabet- this is a childhood skin disease found throughout ics and the overweight. Age or sex has no effect on the poorer subtropical and tropical areas of the these infections. world, caused by a spirochete similar to the one responsible for SYPHILIS. Yaws, also known as fram- Symptoms and Diagnostic Path besia, pian, or bouba, is found between the tropics This type of yeast causes THRUSH (white patches on of Cancer and Capricorn, where more than 50 mil- the inside of the cheeks), cheesy vaginal discharge, lion people have been treated with PENICILLIN in an monilial intertrigo (damp red eruptions under the effort to eradicate the disease. As a result, its inci- breasts, the foreskin, and under-body folds in the dence has been reduced in many areas, although it obese). It also causes CANDIDA PARONYCHIA (redness still occurs in many communities. It is transmitted and swelling around the nails). by direct contact with infected persons, their cloth- ing, and possibly by a fl y. The spirochetes enter Treatment Options and Outlook through skin abrasions. Yeast infections respond to specifi c systemic agents designed to fi ght yeasts (such as Nystatin or Symptoms and Diagnostic Path KETOCONAZOLE). About a month after infection, a highly contagious, itchy tumor with yellow crusts appears on hands, face, legs, and feet. Scratching spreads the infec- yellow fever A short-acting infectious disease tion, leading to development of more growths on that gets its name from the jaundiced yellow skin other parts of the skin that may deteriorate into that is its most striking symptom. deep ulcers. The yellow fever virus is transmitted by mos- quitoes that spread the disease from monkeys to Treatment Options and Outlook humans. Today it can be contracted only in Cen- A single dose of penicillin will cure this disease. tral America or Africa. In urban areas, the disease Without treatment, growths heal slowly over about is transmitted between humans by Aëdes aegypti six months, but recurrence is common. About 10 mosquitoes. percent of untreated patients experience widespread tissue loss leading to destruction of skin, bones, and Symptoms and Diagnostic Path joints of the legs, nose, palate, and upper jaw. Between three and six days after infection there is a sudden fever and headache accompanied by nausea and nosebleeds. Sometimes the patient yeast infections Skin infections caused by types recovers within three days, but often in more seri- of yeast, the most important of which is Can- ous cases there is severe headache and neck, back, dida albicans. Candida can normally be found in and leg pain, followed by liver and kidney damage, the mouth, vagina, and large intestine, but for jaundice, and kidney failure. This may be followed unknown reasons it can cause infection in its by agitation, delirium, coma, and, in 10 percent of host—most commonly in those who take antibiot- cases, death.

401 402 Yersinia (Pasteurella) pestis

Treatment Options and Outlook A single injection of the vaccine gives protec- No drug is effective against the yellow fever virus, tion for up to 10 years, but children under age one so treatment is aimed at maintaining blood volume should not be vaccinated. In addition, eradication via transfusion of fl uids. In mild or moderate cases of the mosquito from populated areas has greatly the prognosis is excellent. Relapses do not occur reduced the incidence of the disease. and one attack confers lifelong immunity.

Risk Factors and Preventive Measures Yersinia (Pasteurella) pestis A small gram-nega- Vaccination confers long-lasting immunity and tive bacterium that causes PLAGUE and is transmit- should always be obtained before traveling through ted from rodents to humans. Streptomycin is the affected areas. A vaccination certifi cate is required antibiotic of choice in combatting the bacterium. for entry to many countries. Z zinc For many years, zinc has been used as an skin conditions (such as ECZEMA, DIAPER RASH, and astringent, an antiseptic, and a skin protectant. How- BEDSORES) and is an ingredient in diaper rash oint- ever, a recent advisory panel of the U.S. Food and ment. It also can ease the pain and itch of INSECT Drug Administration has determined that zinc salts BITES and stings and hemorrhoids, and will block (ZINC OXIDE, zinc stearate, and zinc sulfi de) have no the ultraviolet rays of the Sun. An inert ingredient, established effectiveness in the treatment of ACNE. it is often used to thicken lotions and creams. Some dermatologists, however, recommend zinc to their patients for its anti-infl ammatory effect, theorizing that zinc releases VITAMIN A, which may Zostrix An ointment whose active ingredient is normalize cells, and suggesting patients add zinc-rich CAPSAICIN, a red pepper derivative used to make food to their diet (lean beef, cheese, and chicken). chili powder, used to ease the pain of SHINGLES. ZINC OXIDE also is an effective sunblock. Defi ciency of this element may cause skin infl ammation and hair loss, diarrhea, and low zinc Z-plasty A plastic surgical technique used to blood levels. Skin symptoms are very similar to change the direction of a scar so it can be hidden those of ACRODERMATITIS ENTEROPATHICA. Zinc is a in natural skin creases or to relieve skin tension trace element essential for normal wound healing. caused by a skin CONTRACTURE. It is especially help- Small amounts are found in a wide variety of foods, ful in reducing unsightly scars on the face, and for including lean meat, wholegrain breads and cere- releasing scarring across joints (such as on the fi n- als, dried beans, and seafood. gers or armpits) that restrict movement. A common cause of zinc defi ciency is tube feed- In the operation, a Z-shaped incision is made ing without adequate zinc replacement, usually with the central arm of the Z along the scar; two after the second or third month of tube feeding. V-shaped fl aps are created by cutting the skin away Zinc supplements rapidly reverse the defi ciency. from underlying tissue. The fl aps are then trans- posed and stitched. zinc oxide An ingredient in many skin prepara- tions that has a mild astringent action and soothing Zyderm See COLLAGEN. effect. It can be used to treat painful, itchy, or moist

403

APPENDIXES

I. Cosmetic Ingredients

II. Color Additive Terms

III. Cosmetic Ingredients to Avoid

IV. Types of Lesions

V. Organizations

VI. Professional Organizations APPENDIX I COSMETIC INGREDIENTS

ABRASIVE AGENT ANTISEPTIC kaolin pumice balsam lemon benzalkonium chloride nettle potassium alum ACNE TREATMENT benzoin boric acid quercus benzoyl peroxide chamomile rose biotin colloidal sulfur sage birch eucalyptus salicylic acid ergocalciferol geranium thyme horsetail zinc sulfate ANTIBACTERIAL juniper BLEACHING AGENT methylbenzethonium chloride lemon menthol ascorbic acid myrrh fennel ANTI-INFLAMMATORY phenol (carbolic acid) hayfl ower AGENT pine needle hydrogen peroxide coltsfoot propylene glycol hydroquinone elder resorcinol lemon hypericum thyme linden juniper zinc phenolsulfonate orange restharrow parsley ANTIWRINKLE phosphoric acid wild lettuce ANTIOXIDANT orange rose ascorbyl palmitate royal jelly CLEANSER BHA tocopherol acetone BHT turtle oil ether hydrogen peroxide isoprophyl alcohol propyl gallate ASTRINGENT mineral oil salicyclic petrolatum sodium ascorbate ammonium alum SD alcohol sodium bisulfate apricot sodium laureth sulfate tricosan bentonite birch yarrow boric acid ANTIPERSPIRANT coltsfoot CONDITIONING AGENTS aluminum chlorohydrate hectorite alanine sage horse chestnut amino acid

406 Appendix I 407 amniotic liquid apricot kernel oil poilyoxypropylene 15 stearyl aspartic acid avocado oil ether benzoin beeswax P.P.G. (followed by a number) carrageenan benzoin propylene glycol stearate chondroitin sulfate butyl stearate purceline collagen caprylic/capric triglyceride sesame oil cysteine carnauba silicone cystine carrot spermaceti elastine castor oil squalane glutamic acidglutathione ceresin stearic acid hydrolized animal proteins cetearyl alcohol steryl alcohol lysine cetearyl octanoate vegetable oils menthionine cetyl alcohol wheat germ P.E.G. 2 stearyl quaternium 4 cocoa butter proteins cocoanut acid EMULSIFIER tyrosine cocoanut oil acetamide M.E.A. coltsfoot ammonium laureth sulfate DEPILATORY diisopropyl adipate ceteareth glycerin glyceryl thioglycolate ceteth glyceryl monostearate choleth hexyl alcohol disodium monolauryl DETERGENT hexylene glycol sulfosuccinate benzalkonium chloride isocetyl stearate disodium phosphate sodium laureth sulfate isopropyl isostearate glyceryl stearate isopropyl myristate isopropyl (lanolate, linoleate, DISINFECTANT isopropyl palmitate myristate, oleate, palmitate benzoyl peroxide isostearic acid or stearate) laneth isosteareth 20 lanolin lanolinamide DEA DRAWS SKIN IMPURITIES lanolin alcohol lauramide DEA TO THE SURFACE lanolin hydrogenate laureth almond bitter oil lard lauroyl sarcosine bentonite lauryl alcohol linoleamide hectorite lauryl lactate magnesium lauryl sulfate kaolin lecithin nonoxynol magnesium aluminum silicate magnesium lanolate octoxy glyceryl palmitate titanium dioxide microcrystalline wax octoxynol silica mineral oil oleamide DEA zinc oxide mink oil oleth myristyl alcohol pareth DRYING AGENT myristyl lactate poloxamer oleic acid polysorbate benzoyl peroxide oleyl alcohol quaternium kelp olive oil sodium borate palm oil sodium cocoyl isethionate EMOLLIENTS petrolatum sodium isostearoyl 2 lactylate acetamide polyethylene sorbeth (followed by a number) almond sweet oil polyethylene glycols sorbitan althea polyoxethylene lauryl ether steareth 408 Appendix I stearic acid royal jelly boric acid stearoyl sarcosine sorbitol solution butylparaben sucrose stearic acid disodium EDTA urea ethylparaben HEALING, SOOTHING AGENT fructose allantoin MISCELLANEOUS imidazolidinyl lactic acid allantoin acetyl methionine chlorhexidine (skin activity methylparaben aloe booster) parabens (ethyl-, methyl- and apricot dimethicone (silicone) butyl-) arnica folic acid (essential for cell potassium sorbate azulene growth) propylparaben balm mint ginseng (promotes cell growth) quaternium-15 biotin papaya (natural exfoliant) sodium chloride birch pyridine (helps synthesize sodium dehydroacetate boric acid vitamins) sorbic acid calendula pyridoxine (helps metabolize fat) coltsfoot resorcinol (peels dead cells) cucumber retinol (improves dry skin) SEBACEOUS GLAND elder rosemary (tonic, antispasmodic) REGULATOR honey salicylic acid (peels dead skin camphor hops cells) eucalyptus horsetail sodium bicarbonate (increases hops hypericum pH of a cosmetic) lime mallow sodium xexameta phosphate linoleic acid menthol (water softener) menthol peach titanium dioxide (whitens methionine peppermint powders) myrrh restharrow tocopherol (slows rosemary ribofl avin formation of dark spots) royal jelly spearmint thyme thyme PIGMENTS tocopherol witch hazel bismuth oxycholoride SOLVENTS chromium oxide green acetone D&C and FD&C HUMECTANTS alcohol erric ammonium ferrocyanide ascetic acid amniotic liquid ferric ferrocyanide ether butylene glycol iron oxides ethoxydiglycol cholesterol manganese violet isopropyl alcohol diethylene glycol mica toluene glycerin titanium dioxide (white glycol (usually followed by pigment) STABILIZERS/VISCOSITY another name) ultramarine blue lactic acid BUILDERS laneth amphoteric PRESERVATIVES, lavender cholesterol lecithin ANTIOXIDANTS, AND glycol lime CHEMICAL STABILIZERS lecithin P.P.G. (followed by a number) benzylparaben phosphoric acid (stabilizer) propylene glycol benzoin sodium laureth sulfate Appendix I 409

STIMULANT agaraluminum stearate thiamine H.C.I. anise carbomer turtle oil apricot kernel oil cellulose witch hazel chamomile dextrin gelatin dandelion VASO-CONSTRICTOR gentian glutam gum camphor juniper hydrated silica elder matricaria potassium alginate geranium myrrh potassium carrageenan horsetail parsley rosin lime thyme xanthan menthol sunscreen TONER mint cetyl dimethyl paba (escalol) pine needle cucumber althea witch hazel dihydroxyacetone balsam homosalate hops matricaria horse chestnut myrrh hydrolized animal proteins para-aminobenzoic acid (PABA) lavender matricaria mint THICKENING/STIFFENING/ pine needle SUSPENDING AGENTS quercus acacia rose acrylate/acrylamide copolymer spearmint APPENDIX II COLOR ADDITIVE TERMS

A variety of color additives may be included in FD&C A prefi x designating that a certifi ed color cosmetics. The following describe some of the most can be used in foods, drugs, or cosmetics common: indigotine The common name for uncertifi ed allura Red AC The common name for uncerti- FD&C Blue No. 2 fi ed FD&C Red No. 40 lakes Water-insoluble forms of certifi able col- certifi able color additives Colors manufac- ors that are more stable than straight dyes and tured from petroleum and coal sources listed in the ideal for product in which leaching of the color is Code of Federal Regulations for use in foods, drugs, undesirable (coated tablets and hard candies, for cosmetics, and medical devices example) coal-tar dyes Coloring agents originally derived permanent listing A list of allowable colors from coal sources determined by tests to be safe for human consump- D&C A prefi x designating that a certifi able color tion under regulatory provisions has been approved for use in drugs and cosmetics provisional listing A list of colors, originally erythrosine The common name of FD&C Red numbering about 200, that the Food and Drug No. 3 Administration allows to continue to be used pend- exempt color additives Colors derived primar- ing acceptable safety data ily from plant, animal, and mineral (other than straight dye Certifi able colors that dissolve in coal and petroleum) sources that are exempt from water and are manufactured as powders, granules, Food and Drug Administration certifi cation liquids, or other special forms (used in beverages, Ext. D&C A prefi x designating that a certifi able baked goods, and confections, for example) color may be used only in externally applied drugs tartrazine A common name for uncertifi ed and cosmetics FD&C Yellow No. 5

410 APPENDIX III COSMETIC INGREDIENTS TO AVOID

CONDITIONERS LOTIONS SHAVING CREAMS Irritants: Quaternium 15, Irritants: Lanolin, beeswax, Allergens/irritants: Lanolin Benzalkonium chloride, propylene glycol, parabens, Carcinogens: Cocamide DEA, stearalkonium chloride some preservatives TEA Carcinogens: DEA Carcinogens: TEA SOAPS DEODORANTS MOISTURIZERS Allergens/irritants: Almond, coconut, lavender, oak moss, Irritants: Fragrance, lanolin, Irritants: Beeswax, cocoa butter, potassium hydroxide parabens, propylene glycol, PABA, propylene glycol, Carcinogens: DEA triclosan parabens, preservatives Carcinogens: Cocamide DEA Carcinogens: Polyethylene gly- col, TEA, octyle dimethyl PABA SUNSCREENS Irritants: PABA, octyl LIPSTICKS methoxycinnamate, lanolin, Allergens/irritants: Synthetic SHAMPOO cocoa butter, coconut oil colors Allergens/irritants: Sodium Carcinogens: TEA; padimate-0 Carcinogens: Some synthetic lauryl sulfate, preservatives or octyl-dimethyl PABA may colors, octyl dimethyl PABA Carcinogens: Cocamide DEA be carcinogenic

411 APPENDIX IV TYPES OF LESIONS

ABNORMAL KERATIN ERYTHRODERMA Metabolic disorders FORMATION Allergic contact dermatitis Molluscum contagiosum Acanthosis nigricans Atopic dermatitis Rosacea Actinic keratosis Congenital ichthyosiform Sarcoidosis Ichthyosis erythroderma Secondary syphilis Keratosis of soles and palms Dermatoleukemia Tuberculosis Keratosis follicularis Lymphoma Warts Warts Psoriasis PUSTULES BLISTERS HIVES Acne Burns Cold, warmth, or irradiation Folliculitis barbae Chemical warfare Food or drug allergies Fungal infections Dermatitis herpetiformis Insect bites Mercury dermatitis Drug eruption Pustular psoriasis Pyodermas Epidermolysis bullosa MACULES Reiter’s disease Erythema multiforme Drug eruptions Frostbite Infectious exanthemas Herpes gestationis VESICLES Impetigo Allergies NODULES Pemphigoid Contact dermatitis Pemphigus Erythema nodosum Dermatitis herpetiformis Phototoxicity Granuloma annulare Duhring’s disease Plant allergies Leishmaniasis Fungal infections Porphyria Leprosy Herpes simplex Toxic epidermal necrolysis Lymphomas Miliaria Toxic dermatitis Nodular vasculitis Mycosis Sarcoidosis Nummular eczema DEPOSITS Tumors Shingles Amyloid: systemic amyloidosis Calcinosis: scleroderma, PAPULES dermatomyositis Atopic dermatitis Cholesterol: xanthoma and Leishmaniasis xanthelasma Leprosy Mucus: mucinosis, diffuse Lichen planus myxedema, pretibial Localized neurodermatitis myxedema Lymphocytoma

412 APPENDIX V ORGANIZATIONS

ALLERGIES National Alopecia Areata Foundation P.O. Box 150760 Asthma and Allergy Foundation of America San Rafael, CA 94915-0760 1233 20th Street, NW, Suite 402 710 C Street Washington, DC 20036 Suite 11 (202) 466-7643 San Rafael, CA 94901 [email protected] (415) 472-3780 http://www.aafa.org/ http://www.alopeciaareata.com A nonprofi t organization founded in 1953 for people A support group for individuals with alopecia areata, with asthma and allergies. AAFA provides practical infor- that develops public awareness, provides a support network, mation, community-based services, and a national network raises funds for research, maintains a medical advisory of chapters and support groups. AAFA organizes state and board, and offers research grants. Founded in 1981, the national advocacy efforts and funds research. group publishes a bimonthly newsletter covering treatment, American Latex Allergy Association research, and development (including wig and cosmetic 3791 Sherman Road tips). The foundation also sponsors an annual conference. Slinger, WI 53086 888-972-5378 (tollfree) BEHCET’S SYNDROME [email protected] http://www.latexallergyresources.org American Behcet’s Association A national nonprofi t organization that provides infor- P.O. Box 19952 mation about latex allergy and supports latex-allergic Amarillo, TX 79114 individuals. The association offers education and provides (800) 7 BEHCETS support to individuals with latex allergy. http://www.behcets.com A support group for Behcet’s syndrome. The associa- ALOPECIA tion conducts educational programs, maintains a speakers' bureau, and publishes a quarterly newsletter, brochures, American Hair Loss Council and pamphlets. 125 Seventh St. Suite 625 BIRTHMARKS Pittsburgh, PA 15222 http://www.ahlc.org Klippel-Trenaunay Support Group A group of dermatologists, plastic surgeons, cosmetolo- 5404 Dundee Road gists, barbers, and interested lay members that provides Edina, MN 55436 information regarding treatments for hair loss in both (612) 925-2596 men and women. The group facilitates communication http://www.k-t.org and information exchange between specialists in different The Klippel-Trenaunay Support Group was founded areas, maintains a library, conducts educational pro- in 1986; its Web site has been established to provide infor- grams, offers children’s services and a placement service, mation about the group and about Klippel-Trenaunay and compiles statistics. syndrome.

413 414 Appendix V

BURNS logical ramifi cations of burn disfi gurement, and disseminates information on burns and trauma and their treatment. The Burns United Support Groups society conducts school programs for burned children return- P.O. Box 36416 ing to class and presents the Heroism Award to burn rescu- Detroit, MI 48236 ers. It maintains a speakers’ bureau and contains books on (313) 881-5577 burn recovery, fi lms, and videocassettes. A support group for burn survivors and their families that provides support services and information on burn care CANCER and prevention. The group conducts educational programs and children’s services and operates a speakers' bureau. American Cancer Society International Society for Burn Injuries 1599 Clifton Road, NE http://www.worldburn.org Atlanta, GA 30329 The ISBI was founded in the city of Edinburgh, Scotland, in (404) 320-3333; (800) 227-2345 1965 to establish a permanent organization to reduce the inci- http://www.cancer.org dence of burns and improve patient care, especially in develop- The American Cancer Society is a nonprofi t organization ing countries, and to stimulate prevention in the fi eld of burns. dedicated to eliminating cancer. This nationwide, commu- nity-based voluntary health organization has state divisions National Burn Victim Foundation and more than 3,400 local offi ces. 32-34 Scotland Road Orange, NJ 07050 Cancer Care Inc. National Offi ce (973) 676-7700 275 7th Avenue (973) 267-8660 New York, NY 10001 A professional group for anyone interested in burns, fi re (212) 302 2400 prevention, and burn care that maintains a 24-hour emer- (800) 813-HOPE (4673) gency burn referral service and crisis intervention team to http://www.cancercare.org/ provide counseling to burn victims and their families. The Cancer Care is a national nonprofi t organization that group provides free blood services to burn victims, sponsors provides free professional support services to anyone affected a self-help group, and conducts burn care seminars and by cancer. workshops for health-care experts. Look Good . . . Feel Better The group also provides private helicopters to transport (800) 395-LOOK medical teams to disaster sites. It offers consultation and http://www.lookgoodfeelbetter.org evaluation services regarding suspected child abuse or A free public service program of classes taught by makeup, neglect to the Division of Youth and Family Services and hair, and nail aestheticians to help cancer patients cope with to law enforcement agencies, and presents burn awareness the cosmetic crises that may accompany chemotherapy or and prevention programs to schools, civic organizations, other treatments, such as loss of hair, eyelashes and eyebrows; and day-care centers. It also maintains speakers’ bureaus, uneven skin tone and texture or fragile fi ngernails. The pro- compiles statistics, and conducts specialized education, chil- gram was founded by the Cosmetics, Toiletry and Fragrance dren’s services, and research programs. Association Foundation in partnership with the American The foundation offers videos and publishes the quarterly Cancer Society. newsletter Update. Skin Cancer Foundation Phoenix Society for Burn Survivors 245 Fifth Avenue 1835 R. W. Behrends Drive, SW Suite 1403 East Grand Rapids, MI 49519 New York, NY 10016 (800) 888-BURN (2876) 1-800-SKIN-490 (616) 458-2773 [email protected] [email protected] http://www.skincancer.org http://www.phoenix-society.org The only international organization concerned solely A self-help service organization for burn survivors and with skin cancer. The nonprofi t foundation conducts educa- their families that works to ease the psychosocial adjustment tion programs and provides support for medical training of severely burned and disfi gured persons during and after and research. hospitalization. The group offers a training program for vol- The major goals of the foundation are to increase public unteers, educates the public about disfi gurement, discourages awareness of the importance of preventive sun overexpo- concealment of disfi gurement, conducts research on psycho- sure and to publicize the warning signs of skin cancer. Appendix V 415

It distributes brochures, posters, books, newsletters, and (800) 448-6389; (410) 357-9932 audiovisual materials. http://www.hht.org The foundation publishes an annual journal (the Skin A support group that promotes research into the treat- Cancer Foundation Journal) and a quarterly newslet- ment, causes, and cure of hereditary hemorrhagic telangi- ter (Sun & Skin News). It also grants its Seal of Recom- ectasia (HHT), also known as Osler-Weber-Rendu disease. mendation to sunscreens of SPF15 or higher that meet its Founded in 1991, the foundation publishes the quarterly stringent criteria. HHT Newsletter. DYSTROPHIC EPIDERMOLYSIS BULLOSA HERMANSKY-PUDLAK SYNDROME Dystrophic Epidermolysis Bullosa Research Association of America Hermansky-Pudlak Syndrome An association for people with epidermolysis bullosa One South Road and their families that raises funds to support research into Oyster Bay, NY 11771 the cause, nature, and treatment and to provide practical (516) 922-3440 or (800) 789-9HPS advice, guidance, and support. [email protected] http://www.medhelp.org/web/hpsn.htm ECTODERMAL DYSPLASIA A volunteer nonprofi t support group for those dealing with Hermansky-Pudlak syndrome. Founded in 1992, National Foundation for Ectodermal Dysplasias the network provides education and research, publishes 401 East Main Street a newsletter and a pamphlet, and maintains a bibliogra- Box 114 phy of materials. The group promotes research activities Mascoutah, IL 62258 and is involved in research. (618) 566-2020 http://www.nfed.org A support group for families of ectodermal dysplasia ICHTHYOSIS patients and the medical community. The group helps physi- Foundation for Ichthyosis and Related Skin Types cians acquire information, locates treatment facilities and makes referrals, provides funds to qualifi ed applicants for care, (F.I.R.S.T.) conducts educational meetings, helps with research projects, 1601 Valley Forge Road and establishes regional centers for diagnosis and treatment. Lansdale, PA 19446 The group also provides children’s services, compiles statistics (215) 631-1411 and publishes a number of brochures and newsletters. http://www.scalyskin.org An educational foundation for persons suffering from EPIDERMOLYSIS BULLOSA ichthyosis, a group of rare hereditary diseases that cause the skin to be thick, dry, taut, and scaly. Dystrophic Epidermolysis Bullosa Research The group provides information about the technical, social, Association of America and psychological aspects of the disease. Its publications include 5 West 36th Street booklets and a quarterly, Ichthyosis Focus. Suite 404 New York, NY 10018 (212) 868-1573 KLIPPEL-TRENAUNAY SYNDROME http://www.debra.org Klippel-Trenaunay Syndrome Support Group The only national nonprofi t organization dedicated to 5404 Dundee Road both promoting research to fi nd new treatments and a cure Edina, MN 55436 for epidermolysis bullosa and providing information and support for people with EB and their families. (616) 925-2596 http://www.k-t.org A support group for individuals affected by Klippel- HEREDITARY HEMORRHAGIC TELANGIECTASIA Trenaunay syndrome and for their families. The support Hereditary Hemorrhagic Telangiectasia (HHT) group acts as a clearinghouse of information and corre- Foundation International spondence between members. Founded in 1986, the group P.O. Box 329 publishes a quarterly K-T newsletter and holds a biennial Monkton, MD 21111 conference. 416 Appendix V

LEPROSY A nonprofi t organization established to build awareness about head lice and to standardize head lice control policies American Leprosy Foundation nationwide. The NPA seeks to dispel myths about pediculosis 11600 Nebel Street while encouraging research and development for safer and Suite 210 more effective management procedures. Its program of edu- Rockville, MD 20852 cation, prevention, and early detection work is an effort to (301) 984-1336 raise pediculosis as a public health priority for the protection http://www.userserols.com/lwm-alf of American children and their families. A health and research foundation concerned with micro- biological research of leprosy, conducting research programs LUPUS ERYTHEMATOSUS in the United States and the Philippines. The foundation supports clinical and basic lab research and epidemiological The American Lupus Society surveys and sponsors an exchange program. 260 Maple Court Suite 123 American Leprosy Missions Ventura, CA 93003 1 ALM Way (800) 331-1802 Greenville, SC 29601 A support group for those interested in information on (800) 543-3135; (864) 271-7040 lupus erythematosus, a noncontagious disease that may http://www.leprosy.org affect the skin, alone or in addition to other symptoms. The An international medical Christian mission for those society offers patients support, funds research, holds patient with leprosy supporting more than 100 programs in 30 seminars, and publishes the quarterly newsletter The countries with antileprosy drugs, surgical intervention, American Lupus Society—Lupus Today. training, research, public information, and physical and vocational rehabilitation assistance. The group collaborates L.E. Support Club with member agencies of the International Federation of 8039 Nova Court Anti-Leprosy Associations. As leprosy treatment becomes North Charleston, SC 29420 integrated with community health care, ALM includes (803) 764-1769 those who are disabled from causes other than leprosy in A patient support group designed to aid people with its rehabilitation programs. Founded in 1906 by Protestant lupus erythematosus and other autoimmune diseases that missionaries, the group works closely with committees of offers support and self-help education via newsletters the World Health Organization and with the U.S. Public and personal interchange and also provides information Health Service Hospital in Carville, Louisiana. ALM also on nutrition and medication. Founded in 1984, the club supports training and research centers in India, Ethiopia, contributes to lupus research and publishes the bimonthly and Brazil. The group also publishes a quarterly newsletter newsletter LE Beacon. (Word & Deed), pamphlets, reports, and brochures. Lupus Foundation of America Damien Dutton Society for Leprosy Aid 2000 L Street 616 Bedford Avenue Suite 710 Bellmore, NY 11710 Washington DC 20036 (516) 221-5829 (202) 349-1155 A group of religious leaders and laypeople interested in http://www.lupus.org helping sufferers of leprosy that provides relief, research, A nonprofi t voluntary health foundation serving and recreation to patients all over the world. Founded in patients with lupus erythematosus by providing patient 1944, the society has 30,000 members and publishes the education, services, and support and education to the medi- quarterly newsletter Damien-Dutton Call. cal community and the public. The foundation offers a fel- lowship grant for lupus research and publishes the Lupus News three times a year, together with other publications. LICE Lupus Network National Pediculosis Association 230 Ranch Drive 50 Kearney Road Bridgeport, CT 06606 Needham, MA 02484 (203) 372-5795 (781) 449-NITS An informational group for educators, medical profession- http://www.headlice.org als, and individuals suffering from systemic lupus erythema- Appendix V 417 tosus. Established in 1985, the group publishes the quarterly Foundation dedicated to providing information and sup- newsletter Heliogram, pamphlets, and reprints. port to people living with pemphigus and pemphigoid.

MAFFUCCI’S SYNDROME PEUTZ-JEGHERS SYNDROME

Ollier/Maffucci Self-Help Group Network for Peutz Jeghers an Juvenile Polyposis 1824 Millwood Road Syndrome Sumter, SC 29150 http://www.epigenetic.org~pjs/homepage.html (803) 775-1757 Online information site dedicated to Peutz-Jeghers and A nonprofi t group established in 1998 for individuals juvenile polyposis syndrome, with information, related Web with Olliers/Maffucci’s syndrome, their families, and phy- sites, a support group, and genetic information. sicians. The group supports research, helps families cope, provides information, and offers a geographic database of PLASTIC/RECONSTRUCTIVE SURGERY physicians and hospitals with expertise in Maffucci’s. The group also offers a newsletter, videos, and brochures. Children’s Craniofacial Association 13140 Coit Road NECROTIZING FASCIITIS FOUNDATION Suite 307 Dallas, TX 75251 National Necrotizing Fasciitis Foundation (214) 570-8811; (800) 535-3643 180 Lafayette Avenue http://www.ccakids.com Suite 10-D A national nonprofi t organization dedicated to improving Passaic, NJ 07055 the quality of life for people with facial differences and their http://www.nnff.org families. CCA addresses the medical, fi nancial, psychosocial, The foundation tries to educate the public about recogni- emotional, and educational concerns relating to craniofacial tion of symptoms and preventive measures, offers resources, conditions. CCA’s mission is to empower facially disfi gured and offers support for those affected by necrotizing fasciitis. children and their families. National Foundation for Facial Reconstruction NEUROFIBROMATOSIS 317 East 34th Street Room 901 Children’s Tumor Foundation New York, NY 10016 95 Pine Street (212) 263-6656 16th Floor http://www.nffr.org/ New York, NY 10005 The mission of the National Foundation for Facial (800) 323-7938 Reconstruction (NFFR) is to enable people (primarily http://www.nf.org children) with craniofacial conditions to lead productive, A foundation that helps provide surgical and rehabilita- fulfi lling lives. The NFFR supports the Institute of Recon- tion service programs for patients suffering facial disfi gure- structive Plastic Surgery at the New York University Medi- ments who are unable to afford private care. The group cal Center. Its programs include comprehensive surgical also trains health professionals, encourages research, and rehabilitation; medical research and professional training; educates the public. The group maintains a patient referral help with social, psychological, and fi nancial needs; and service; founded in 1951, the group publishes an annual programs to change attitudes. newsletter and offers brochures. PORPHYRIA PEMPHIGUS American Porphyria Foundation International Pemphigus Foundation P.O. Box 22712 1540 River Park Drive Houston, TX 77227 Suite 208 (713) 266-9617 Sacramento, CA 95815 http://www.porphyriafoundation.com (916) 922-1298 A support group for anyone interested in the treatment of http://www.pemphigus.org/ porphyria, a class of seven rare (usually inherited) metabolic 418 Appendix V disorders that affect either the skin or the nervous system. The SCLERODERMA foundation provides fi nancial support for research, offers edu- cational programs, and maintains a lending library of vid- Scleroderma Foundation eotapes, papers, and pamphlets. Founded in 1981, the group 12 Kent Way sponsors an annual meeting and physician lecture series. Suite 101 Byfi eld, MA 01922 (800) 722-4673; (978) 463-5843 PSEUDOXANTHOMA ELASTICUM http://www.scleroderma.org A professional organization that promotes medical PXE International, Inc. research to fi nd a cure for scleroderma. It provides infor- 4301 Connecticut Avenue, NW mation and referrals to local organizations and medical Suite 404 specialists, offers encouragement and consultation services, Washington, DC 20008 a speakers’ bureau, and publishes a range of brochures (202) 362-9599 and the quarterly Scleroderma Voice. http://www.pxe.org A nonprofi t organization offering services for individuals Scleroderma International Foundation with pseudoxanthoma elasticum and their families, includ- 704 Gardner Center Road ing a quarterly newsletter and support group meetings. PXE New Castle, PA 16101 International, Inc. was founded in 1995 to initiate, fund (724) 652-3109 and conduct research; support affected individuals and their International organization for individuals with sclero- families; and provide resources to clinicians. derma, family and friends of patients, and health-care workers. It sponsors research into the cause, cure, and con- trol of the disease, and provides information and a quarterly PSORIASIS newsletter, pamphlets, and other brochures. Scleroderma Research Foundation National Psoriasis Foundation 2320 Bath Street 6600 S.W. 92nd Avenue Suite 315 Suite 300 Santa Barbara, CA 93105 Portland, OR 97223 (805) 563-9133 (503) 244-7404; (800) 723-9166 http://www.srfcure.org http://www.psoriasis.org A support and research group for interested individu- A professional organization for people suffering from pso- als with fi rsthand experience of scleroderma that supple- riasis, their families and friends, and health-care workers. The ments medical research on the cause, treatment, and foundation supports research, makes physician referrals, offers cure of the disease. The foundation also seeks to develop a pen-pal program, and sponsors group sessions. The group a national network of support centers for patients and provides information to schools, libraries, and the media and their families; informs the medical community and public supplies members with samples of new nonprescription prod- about symptoms; and encourages donations, bequests, ucts. Established in 1968, the foundation maintains a library and memorials. It publishes a quarterly newsletter, the of major medical journals and personal histories of psoriasis Advance, and the quarterly Advance Research and patients. Publications include an annual report, a bimonthly Treatment. newsletter, pamphlets, brochures, and fl yers. International Scleroderma Network ROSACEA/ACNE 7455 France Avenue South Suite 266 National Rosacea Society Edina, MN 55435 USA 800 South Northwest Highway (800) 564-7099 Suite 200 (952) 831-3091 Barrington, IL 60010 http://www.sclero.org (888)-No-Blush A nonprofi t organization operating a Web site, publishing http://www.rosacea.org a book series, and supporting research. It also manages the An educational organization that provides information Scleroderma Webmaster’s Association, which provides links on rosacea to physicians, patients, and the public. to many scleroderma resources. Appendix V 419

SHINGLES STURGE-WEBER SYNDROME Varicella Zoster Virus Research Foundation Sturge-Weber Foundation 24 East 64th Street P.O. Box 418 5th Floor Mt. Freedom, NJ 07970 New York, NY 10021 (973) 895-4445; (800) 627-5482 (212) 371-7280 http://www.sturge.weber.com [email protected] A support group for patients with Sturge-Weber syn- http://www.vzvfoundation.org drome and their families that serves as an information Nonprofi t organization dedicated to funding research into clearinghouse on the syndrome, port-wine stains, and shingles and the VZV virus. Klippel-Trenaunay Weber syndrome. The group, founded in 1986, provides information, offers support, maintains a SJOGREN’S SYNDROME speakers’ bureau, compiles statistics, and funds research. The foundation publishes Branching Out. National Sjogren’s Syndrome Association P.O. Box 22066 TUBEROUS SCLEROSIS Beachwood, OH 44122 (800) 395-NSSA; (216) 292-3866 Tuberous Sclerosis Alliance http://www.sjogrenssyndrome.org 801 Roeder Road The association promotes public awareness of Sjogren’s Suite 750 syndrome and encourages research into the cause and cure Silver Spring, MD 20910 of the disorder, sponsors support groups, offers informa- (301) 562-9890; (800) 225-6872 tion to the medical community, conducts educational and http://www.tsalliance.org research programs, and maintains a speakers’ bureau. A nonprofi t organization founded in 1974 to provide fel- Its publications include the quarterly Patient Education lowship, generate awareness, and provide hope to those who Series, the quarterly Sjogren’s Digest, and the guide shared the common bond of tuberous sclerosis. The group also Learning to Live with Sjogren’s Syndrome. supports research and offers a range of brochures and books. Sjogren’s Syndrome Foundation 8120 Woodmont Avenue VITILIGO Bethesda, MD 20814 National Vitiligo Foundation (516) 933-6365; (800) 4 sjogren 700 Olympic Plaza Circle http://www.sjogrens.com Suite 404 Tyler, TX 75701 SKIN DISORDERS (903) 595-3713 http://www.vitiligofoundation.org National Institute of Arthritis and Musculoskeletal A professional group for physicians, patients, and sup- and Skin Diseases porters that provides information and counseling to vitiligo 9000 Rockville Pike patients and their families. Founded in 1985, the group Building 31, Room 4C02 raises funds for scientifi c and clinical research on the cause, 31 Center Drive MSC 2350 treatment, and care of vitiligo. Bethesda, MD 20892 (301) 496-8190 http://www.nih.gov/niams The mission of the institute is to support research into the causes, treatment, and prevention of arthritis and musculo- skeletal and skin diseases; the training of basic and clinical scientists to carry out this research; and the dissemination of information on research progress in these diseases. APPENDIX VI PROFESSIONAL ORGANIZATIONS

American Academy of Allergy, Asthma and the American Academy of Dermatology, and the monthly Immunology Journal of the American Academy of Dermatology. 555 East Wells Street American Academy of Facial Plastic and Milwaukee, WI 53202 Reconstructive Surgery (414) 272-6071; (800) 822-2762 310 South Henry Street http://www.aaaai.org Alexandria, VA 22314 A professional society of specialists in allergy and aller- (703) 299-9291 gic diseases. The group conducts research and educational programs, maintains a speakers’ bureau, bestows annual http://www.facemd.org grants and research awards, operates a placement service, A professional association for physicians specializing in and compiles statistics. Founded in 1943, the academy facial plastic surgery that promotes research and study in publishes the annual journal, a quarterly newsletter, the fi eld, maintains a speakers' bureau, conducts education and a monthly journal. and charitable programs, and compiles statistics. Founded in 1964, the academy is the world’s largest specialty asso- American Academy of Cosmetic Surgery ciation whose members are board-certifi ed surgeons with 737 North Michigan Avenue a focus on surgery of the face, head, and neck. Suite 2100 Chicago, IL 60611 American Association of Plastic Surgeons (312) 981-6760; (800) 221-9808 900 Cummings Center http://www.cosmeticsurgery.org Suite 221-U A professional group that represents practitioners of der- Beverly, MA 01915 matology, ophthalmology, otorhinolaryngology, plastic and (978) 927-8330 reconstructive surgery, oral surgery, general surgery, and http://www.aaps1921.org cosmetic dentistry. The group seeks to encourage high-quality A professional group of plastic surgeons founded in 1921. cosmetic medical and dental care, provides continuing educa- Formerly the American Association of Oral and Plastic tion for cosmetic surgeons, and promotes research. The acad- Surgeons, the group sponsors an annual scientifi c program emy also compiles statistics, operates the American Board of each spring. Cosmetic Surgery, and is the nation’s largest organization American Board of Dermatology representing cosmetic surgeons. Henry Ford Health System American Academy of Dermatology 1 Ford Place P.O. Box 4014 Detroit, MI 48202 930 North Meacham Road (313) 874-1088 Schaumburg, IL 60168 http://www.abderm.org (847) 330-0230 The examining and certifying body for U.S. dermatolo- http://www.aad.org gists offers board certifi cation to those who meet its require- The world’s largest society representing dermatologists, ments and pass its examination. The board establishes which conducts educational programs, provides placement ser- requirements of postdoctoral training and creates and con- vices, bestows awards, and compiles statistics. Its publications ducts an annual comprehensive examination to determine include the bimonthly Bulletin, the biennial Directory of the competence of physicians who meet the requirements.

420 Appendix VI 421

American Board of Plastic Surgery ence, advisory, and consulting services. Founded in 1958, 7 Penn Center the association publishes brochures, the quarterly newsletter Suite 400 Electrolysis World and the semiannual Journal of the 1635 Market Street American Electrology Association, and the semiannual Philadelphia, PA 19103 Medical/Professional News. (215) 587-9322 American Osteopathic College of Dermatology http://www.abplsurg.org 1501 East Illinois Street A group established in 1937 and offi cially recognized in P.O. Box 7525 1941 as the only specialty board responsible for certifying Kirksville, MO 63501 plastic surgeons, the board has 20 directors who meet twice (660) 665-2184; (800) 449-2623 a year to judge the education, training, and knowledge of http://www.aocd.org plastic surgeons. Certifi cation by the board is not required A professional association for osteopaths or those involved to practice plastic surgery, but it is a status that plastic sur- in dermatology that conducts specialized education pro- geons voluntarily obtain as an indication of competence. grams and improves the standards of dermatology practice. Requirements for certifi cation include graduation from an accredited medical school; at least three years of clini- American Society for Aesthetic Plastic Surgery cal training in general surgery, completion of an approved 11081 Winners Circle residency in orthopedic surgery, or certifi cation by the Suite 200 American Board of Otolaryngology; at least two years Los Almitos, CA 90720 of approved residency training in plastic surgery in the (800) 364-2147; (562) 799-2356 United States or Canada; and successful completion of the http://www.surgery.org certifi cation examination. The leading organization of board-certifi ed plastic sur- American Burn Association geons specializing in cosmetic plastic surgery. Active member 625 North Michigan Avenue plastic surgeons are certifi ed by the American Board of Plas- Suite 2550 tic Surgery or the Royal College of Physicians and Surgeons Chicago, IL 60611 of Canada. The Web site offers information on tummy tuck, (312) 642-9260 breast augmentation, breast lift, breast reduction, brow lift, http://www.ameriburn.org eyelid surgery, face-lift, liposuction and rhinoplasty; non- A professional organization for anyone interested in the surgical cosmetic procedures, including laser hair removal, care of burn injuries dedicated to improving the care and skin resurfacing; and injectable treatments such as Botox treatment of burns. Founded in 1967, the association pub- and collagen. lishes an annual book of abstracts, a directory of burn care American Society for Dermatologic Surgery services in North America, and a bimonthly Journal of 930 North Meacham Road Burn Care and Rehabilitation. Schaumburg, IL 60204 American Dermatological Association (847) 330-9830 P.O. Box 554 http://www.asds-net.org Millwood, NY 10546 A professional organization for physicians specializing in (914) 923-8540 dermatologic surgery that seeks to maintain the highest pos- http://www.amer-derm-assn.org sible standards in medical education, clinical practice, and Founded in 1876, this professional society of physicians patient care. The group promotes high standards in allied specializing in dermatology promotes teaching, practice, health professions and maintains an audiovisual library. and research in dermatology. Founded in 1970, its publications include the monthly Journal of Dermatologic Surgery. The group can pro- American Electrology Association vide consumers with a list of local physicians qualifi ed to 106 Oakridge Road perform dermatologic laser surgery. Trumbull, CT 06611 http://www.electrology.com American Society for Laser Medicine and Surgery A professional group for electrologists interested in edu- 2404 Stewart Square cation, professional advancement, and uniform legislative Wausau, WI 54401 standards. The association sponsors the International Board (715) 845-9283 of Electrologist Certifi cation and maintains referral, refer- http://www.aslms.org 422 Appendix VI

A professional group for physicians, physicists, and Dermatology Foundation other scientists, nurses, dentists, podiatrists, veterinar- 1560 Sherman Avenue ians, paramedical personnel, technicians, and commercial Suite 870 representatives concerned with the medical application of Evanston, IL 60201 lasers. The society exchanges information about lasers and (847) 328-2256 publishes the bimonthly journal Lasers in Surgery and http://www.dermfnd.org Medicine. A foundation for members of national and regional der- American Society of Dermatopathology matological societies and board-certifi ed dermatologists that 930 North Meacham Road raises funds to help control skin cancer and disease through Schaumburg, IL 60173 research, improved education, and better patient care. (847) 330-9830 Established in 1964, the foundation’s publications include http://www.asdp.org the quarterly Dermatology Focus, the quarterly Progress A professional association that seeks to improve the in Dermatology, and an annual report, Stewardship quality of dermatopathology. The group provides informa- Report. tion, supports continuing education and research, conducts International Guild of Professional Electrologists seminars and courses, and bestows awards. Founded in 803 North Main Street 1962, it hosts an annual scientifi c conference and an annual Suite A meeting in conjunction with the International Academy of High Point, NC 27262 Pathology. Its publications include the bimonthly Journal (800) 830-3247 of Cutaneous Pathology and its annual membership http://www.igpe.org directory. A professional organization for electrologists, electrology American Society of Plastic and Reconstructive schools, and manufacturers and suppliers of electrolysis Surgeons equipment that works to improve the image of electrolysis 444 East Algonquin Road and promote it as an acceptable allied health profession. Arlington Heights, IL 60005 It establishes standards for practice, promotes licensing, (708) 228-9900; (800) 635-0635 compiles statistics, provides a referral service, and con- http://www.plasticsurgery.org ducts seminars and research programs. The organization A professional organization founded in 1931 to promote publishes brochures, a quarterly newsletter, and biennial quality care for plastic surgery patients, provide educational conference reports. programs, and support the activities of its members. To become a member, each plastic surgeon must be certifi ed by International Society for Burn Injuries the American Board of Plastic Surgery. In addition to its http://www.worldburn.org professional activities, the society maintains a patient refer- A professional society for those who treat or research ral service to help patients choose a plastic surgeon and a burns that seeks to disseminate knowledge and stimulate speakers bureau. prevention in the fi eld. The society promotes scientifi c, clini- cal, and social research in burns; promotes fi rst aid, nurs- Cosmetic, Toiletry and Fragrance Association ing, and other types of education in all phases of burn care; 1101 17th Street, NW and offers awards for research. Affi liated with the World Suite 300 Health Organization, the society was founded in 1965 and Washington, DC 20036 publishes the monthly journal Burns. (202) 331-1770 http://www.ctfa.org International Society of Dermatology The leading U.S. trade association for the personal-care 930 North Meacham Road products industry, with about 600 member companies. Schaumburg, IL 60173 Founded in 1894, the CTFA works to protect the freedom (847) 330-9830 of the industry to compete in a fair and responsible market- http://www.intsocdermatol.org place. CTFA also supports the cosmetic ingredient review, An international organization of dermatologists and a program it helped establish in 1976 that assesses the general physicians that promotes interest, education, and safety of ingredients used in cosmetics in an unbiased, inde- research in dermatology. The group was founded in 1960 pendent forum with an expert panel composed of world- and publishes a biennial directory and a monthly, Interna- renowned physicians and scientists. tional Journal of Dermatology. Appendix VI 423

Interplast Society for Clinical and Medical Hair Removal, Inc. 300-B Pioneer Way 2810 Crossroads Drive Mountain View, CA 94041 Suite 3800 (650) 962-0123 Madison, WI 53718 http://www.interplast.org (608) 443-2470 A professional group of medical professionals that sends homeoffi [email protected] volunteer teams into developing countries to perform free http://scmhr.org reconstructive surgery on patients with burns, birth defects, An international nonprofi t organization with mem- or other deformities. An estimated 37,000 free surgeries bers in the United States, Canada, Australia, Japan, and have been performed in Ecuador, Peru, Peru, Honduras, beyond. SCMHR supports all methods of hair removal and Nepal, Mexico, Brazil, China, Thailand, Vietnam, and the is dedicated to the research of new technology that will keep Philippines. The group also conducts teaching programs its members at the pinnacle of their profession, offering during visits to these countries. safe, effective hair removal to clients. The society also pro- vides information on the newest technology in hair removal National Foundation for Facial Reconstruction and offers the only national certifi cation for physicians, 317 East 34th Street nurses, and medical estheticians. Suite 901 New York, NY 10016 Society for Investigative Dermatology (212) 263-6656; (800) 422-FACE 820 West Superior Avenue http://www.nffr.org Suite 340 Cleveland, OH 44113 North American Clinical Dermatologic Society (216) 579-9300 Mayo Clinic http://www.sidnet.org 4500 San Pablo Road A professional society promoting research in dermatology Jacksonville, FL 32082 and allied subjects. Founded in 1937, the society publishes (908) 223-2000 the monthly Journal of Investigative Dermatology. http://www.nacds.com Society for Pediatric Dermatology Plastic Surgery Educational Foundation 5422 North Bernard 444 E. Algonquin Road Chicago, IL 60625 Arlington Heights, IL 60005 (773) 583-9780 (708) 228-9900; (888) 475-2784 http://www.spdnet.org http://www.plasticsurgery.org A professional organization of pediatricians, dermatolo- A professional group for plastic and reconstructive sur- gists, pediatric or dermatologic house offi cers, manufactur- geons that sponsors demonstrations, lectures, educational ers of children’s skin products, and researchers in pediatric seminars, symposia, and workshops focusing on plastic biomedicine. Founded in 1975, the group conducts research surgery techniques and procedures. Founded in 1948, the programs and bestows awards. Publications include the group publishes the Plastic and Reconstructive Surgery quarterly Society for Pediatric Dermatology. journal, booklets, and Plastic Surgery News. Plastic Surgery Research Council 45 Lyme Road Suite 304 Hanover, NH 03755 (603) 643-2325 http://www.ps-rc.org A professional group designed to foster fundamental research in the fi elds of plastic and reconstructive surgery.

GLOSSARY

abdominoplasty A tummy tuck. atrophy Wasting away. abrasion A slight loss of epithelium (usually caused by Auspitz’s sign Pinpoint bleeding when the scale of a a scrape) that causes oozing and crusting. psoriatic lesion is removed. abscess A clearly defi ned walled-off infl ammatory area axillary Referring to the armpit area of the body. (usually caused by infection) that contains pus. basal cells Cells found along the bottom layer of the actininc Relating to sunshine. top layer of the skin. actinic keratosis Rough slightly raised, pink, or red benign Not malignant. papules that appear singly or in groups on sun-dam- blackhead A darkened plug of sebum and keratin aged skin. blocking the outlet of a sebaceous (oil-forming) gland acute condition A condition that appears suddenly. in the skin. (Another name for open comedo.) adnexa Term that refers to hair, nails, sweat, and oil blanch To make white or pale. glands. bromhidrosis Foul-smelling sweat produced by the apo- allergen Substance that causes allergic reactions. crine sweat glands, caused by bacterial decomposition. alopecia Hair loss. bubo Enlarged, infl amed lymph node (especially under anagen Growth phase of hair. the arm or in the groin) caused by infections (such as anaphylactic shock A severe life-threatening reaction plague, tuberculosis, or syphilis). that occurs in people with an extreme sensitivity to a bulla A fl uid-fi lled blister. particular substance that causes the release of massive café-au-lait macules Medium brown-colored patches amounts of histamines and other infl ammatory chemi- that may appear without an underlying disorder or in cals that affect body tissues. The dilation of blood vessels patients with neurofi bromatosis. cause a drop in blood pressure; other symptoms include callus Area of skin that is thickened in certain areas hives, constriction of the airway, leading to breathing (especially on the hands and feet), in response to fric- problems, abdominal pain, and swelling of the tongue. tion or pressure. androgen Male hormone. canker sore A small painful ulcer usually found in the angioedema A soft tissue swelling of skin caused by mouth or on the lips. excess fl uid. carbuncle A deep-seated infection involving clustered angioma A tumor comprising blood or lymph vessels. hair follicles. anhidrosis Absence of the ability to sweat. carcinoma A malignant growth of cells. annular Ring-shaped. carcinoma in situ Limitation of cancer to its place of antifungal A substance that destroys or suppresses the origin. growth/reproduction of fungi. carotenemia Yellowed skin (similar to jaundice) antigen Any substance foreign to the body’s system caused by too much carotene in the skin. It is most that causes an immune response. often caused by eating too many carrots. antihistamine A drug that counteracts the action of cavernous hemangioma A vascular tumor of large histamine. blood vessels found in the deep dermis (middle layer aplasia Lack of development of a tissue or organ. of the skin), extending into the subcutaneous fat. apocrine A gland that releases cellular material and cellulitis Infl ammation of tissues of the skin usually fl uid. It usually applies to the type of sweat gland caused by bacterial infection. found only in hairy areas of the body and that develop chancre A papule or ulcer at the site of infection in the after puberty. skin caused by diseases such as syphilis or tuberculosis.

425 426 Glossary cold sore The common term for a herpes simplex eruption Visible rash or production of lesions. infection (usually on the lips). erythema Red, warm skin usually caused by infl am- collagen The primary supportive protein of the skin. mation due to infection or injury. comedo Thick secretion of dead skin cells and oily sub- erythroderma Generalized redness of the skin. stances that plug a pore or follicle. When open, it is eschar Crusted dead skin produced by burns, corrosive called a blackhead; when closed, a whitehead. agents, or gangrene. corn A tender, horny, thickened growth produced by exfoliative Diffuse scaling. friction or pressure, resulting in a cone-shaped mass factitial Produced artifi cially. pointing into the middle layer of skin (dermis). fi broma A tumor of fi brous or mature connective corticosteroids A group of anti-infl ammatory drugs tissue. similar to hormones produced by the adrenal glands. fi ssure Crack or split in the skin. crust Outer layer of solid material caused by drying of fl ush Redness and warmth (usually of the face and a secretion by the body. neck). curettage The removal of skin tissue with a curette. follicle A sac, cavity, or depression. curette An instrument with a tip shaped like a spoon fungus Simple parasitic life forms that make up a plant or loop used to remove abnormal tissue or growths. phylum (including yeasts, rusts, molds, smuts, mush- cutis The skin. rooms, mildews, and so on). cyst A sac containing either a liquid or semisolid. granular The presence of granules or grains. depigmentation Loss of pigment (usually melanin). granuloma A chronic, proliferative lesion of cells often dermabrasion Surgical removal by mechanical associated with chronic infl ammation anywhere in methods of the epidermis (outermost layer of skin) the body. and as much of the dermis (middle skin layer) as hemangioma A benign tumor composed of blood necessary. vessels. dermatitis Skin infl ammation. hematoma A localized accumulation of blood (usually dermatofi broma A benign skin nodule found most clotted) in skin caused by a rupture of a blood vessel often on the arms and legs. wall. dermis Part of the skin lying directly under the epider- hidradenitis Infl ammation of a sweat gland (usually mis, made up primarily of connective tissue. an apocrine gland). diaphoretic A substance that produces or increases histamine A chemical found in cells all over the body perspiration. that is released during an allergic reaction; it is one of ecchymosis Bruise. the substances responsible for infl ammation. eccrine The name for the common sweat gland and its hives An eruption of itchy wheals (raised white lumps related structures. surrounded by red areas) on the skin (also called edema Collection of excess fl uid in the skin leading to urticaria). swelling. hyperhidrosis Excessive sweating. elastosis Degeneration of elastic tissue. hyperpigmentation An abnormal excess of pigmen- electrodesiccation Dehydration and destruction of tation (or darkening) of the skin. skin tissue using a high-frequency electric current. hyperplasia An increase in the number of keratocytes emollient A substance used to moisten, soften, or that cause a thickened epidermis (topmost layer of smooth the skin. the skin). emulsifi er A substance that binds two dissimilar sub- hypersensitivity A condition of heightened reactivity stances together (such as the mixture of an egg, oil, in that the body responds with an exaggerated reac- and vinegar to make mayonnaise). tion to a foreign substance. emulsion One liquid broken down into globules and hypertrichosis Excess hair growth. distributed throughout a second liquid. hypertrophic scar Enlarged or thickened scar. ephelis Freckle (plural: ephelides). hypertrophy Thickened epidermis (topmost skin epidermis The very thin outer layer of the skin that layer) caused by the increase in keratinocyte size. covers the dermis; it contains the stratum basal, stra- hypopigmentation A reduction of pigment resulting tum spinosum, stratum granulosum, stratum lucidum, in a lightening of skin. and stratum corneum. integument The skin. erosion A superfi cial ulcer, resulting in loss of epider- keloid A sometimes tender scar that is sharply elevated mis (outer skin layer) that heals without scars. and larger than the original wound. Glossary 427 keratin The principal protein constituent of epider- porphyria A group of diseases caused by dysfunction mis, hair, and nails. in porphyrin metabolism, characterized by increased keratinization The process by which the epidermal production and excretion of porphyrins. cells (outer layer of the skin) turn into keratin. poultice A moist hot pack applied to the skin. kerion A deep fungal infection of hair-bearing skin prurigo An itchy area of skin. that produces a nodular swelling covered with pus- pruritus Itching. tules. purpura The generic term for hemorrhage into tissue. laceration Torn, ragged skin wound. It may appear as pinpoint bleeding (petechiae) or lanugo The fi ne hair covering the fetus. larger areas (bruise). lentigo Pigmented macule on the skin (liver spot). pus A liquid caused by infl ammation consisting of leu- lichenifi cation Thickened epidermis with exagger- kocytes, dead tissue, and fl uid. ated normal markings. pustule A raised skin lesion (papule), usually less than liniment Oily liquid preparation. 1 cm, containing pus. lipoma A benign tumor composed of mature fat cells. pyoderma A condition of the skin involving pus-fi lled lotion A liquid preparation in suspension or disper- lesions. sion for external application to the body. rash Skin eruption. macerate Soften by wetting or soaking. scale The thin cells that build up on the outer layer of macule Nonpalpable area of skin that has a different the skin due to abnormal formation and shedding of color or texture from surrounding skin, but fl ush the top layers. with surrounding skin. schlerosis Hardening. malignant Cancerous. seborrhea Excess secretion of sebum. melanin Dark pigment contained in special cells in sebum The oily secretion produced by the oil (seba- the hair and skin. ceous) glands, consisting of fats and waxes designed melanocyte Melanin-producing cells found in the to lubricate the skin and keep it supple. bottom layer of the top skin layer (epidermis). shake lotion A suspension of a powder in a lotion. mesoderm The middle layer of the three primary squamous cell Flat cell that makes up most of the top germ layers of the embryo. skin layer (epidermis). milia Small white cysts. systemic Affecting many or all of the organs or sys- mole A nevocellular nevus. tems of the body. morbilliform Eruption resembling measles. telangiectasia Dilation of small group of blood vessels mycosis Any disease caused by a fungus. that look like small red lines. necrosis Death of cells. tinea Superfi cial fungal skin infection of skin, hair, or ointment A greasy semisolid preparation applied to nails. the skin. topical medication Drugs that are applied directly to papule Raised pimple that is smaller than a pea. the surface of the skin. petechia A tiny non-blanchable red spot caused by a tumefaction Swelling. capillary hemorrhage. ulcer An erosion or loss of skin layers from the surface pH A measure of acidity or alkalinity using a scale from of the skin downward. 0 to 14 (the lower the number, the more acidic; the urticaria The medical term for hives or wheals. higher the number, the more alkaline). Vinegar has vascular Related to blood vessels. a pH of 2.3; the skin has a slightly acid pH (between verruca A wart. 5.5 and 6.8). Most soaps are pH 8 to 10. vesicle A small blister less than .5 cm in diameter. pilar Pertaining to the hair. wheal Solid, distinct raised lesion formed by swelling poikiloderma Dappled, mottled with areas of hypo- welt that may be white to dark pink. and hyperpigmentation and atrophy. xerosis Skin dryness.

BIBLIOGRAPHY

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Page numbers in bold- of 3 acne products, over-the- adipose nevi 13 face indicate extensive drug-induced 5 counter 9 adipose tissue 13 treatment of a topic. hormones and 2–4, acne vulgaris 5, 9 adnexa of skin 13 7, 181 acral lentiginous mela- adrenal insufficiency A infant 5, 336 noma 232, 234 12–13 ABC/ABCD assessment isotretinoin for vii, 3, acrochordon 346 Advil (ibuprofen) 187 257 6–7, 192 acrocyanosis 9 African American(s) abdominoplasty 1 moisturizers and 242 acrodermatitis, papular dermatitis papulosa ablative lasers 204 myths about 9 158–159 nigra in 113–114 abrasion 1 occupational expo- acrodermatitis entero- infundibulofolliculitis abrasive cleansers/pads sure and 261 pathica 10 in 190 80 oil 5–6 acroparesthesia 10 Mongolian spot in abscess 1 pathogenesis of 2 acropustulosis, infantile 243, 253–254 AIDS and 17 pockmark from 285 189–190 pomade acne in 6 amebic 25 pomade 6 actinic 10 pseudofolliculitis bar- absorption, skin 261 prevention of 8 actinic cheilitis 10 bae in 297–298 acantholysis 1 resorcinol for 3, 6 actinic conditions 10 sickle-cell ulcers in acanthosis 2 risk factors for 8 actinic keratosis viii, 331–332 acanthosis nigricans 2, salicylic acid for 3, 10–11, 13–14 Aftate. See tolnaftate 207, 281 6, 53 actinic lentigo 210 age spots 13–14, 24 Accutane. See isotreti- sulfur for 3, 6, 358 Actinomyces israelii 11 aging and skin 14–16, noin surgical techniques actinomycin D, and 398–399 acid-balanced shampoo for 7 acne 5 alpha hydroxy acids 168 symptoms of 3 actinomycosis 11 for 14, 24–25, 75, acid burns 88 systemic therapy acupuncture, cosmetic 160 acid mantle 2 for 7 89 beta hydroxy acids for acne 2–4 topical applications acyclovir 12, 35 50–51 adult 4 for 7 for chicken pox 12, biological implants androgens and 4–5, treatment and out- 77 for 51 26 look for 3–4, 6–8 for cold sore 83 Botox for xii, 58–59, antibiotics for 3, 6–7, types of 3t for eczema herpeti- 399 31, 81 whitehead in 2, 8, cum 125 chemical peels for bacteria and 2, 6, 49, 397 for herpes simplex xii, 74–75 81, 296 acne conglobata 3t infection 12, 179 collagen injection for behavior to avoid in acne detergens 3t, 8 for shingles 12, 331 x–xi, 14–16, 84, 7–8 acne excoriée 3t, 8 side effects of 12 341–343 benzoyl peroxide for acne fulminans 8 adalimumab viii fillers for x–xi, 14– 3, 6–7, 31, 49–50, acne keloidalis 8–9, 113 adapalene xiii 16, 21, 341–344 53, 358 acne mallorca 3t Addison, Thomas 12 hyaluronic acid gel blackheads in 2, 8, acne mechanica 3t, 9, Addison’s disease 12–13, for 15–16, 182– 52–53 261 281 183, 341, 343 in boys versus girls 2 acne medicamentosa adenoma sebaceum 27 lifts for xi–xii, 138– cosmetic 4 3t, 5 adenosine monophos- 140 cystic 4–5 acne neonatorum 3t, phate (AMP) 13 microdermabrasion diagnostic pathology 5, 336 adenovirus 13 for 238–239

439 440 Index

relaxers for xii alopecia areata univer- anhidrotic ectodermal apocrine glands 363 risk factors and pre- salis 23 dysplasia 28 apocrine miliaria 148 vention 16 alopecia totalis 23 aniline hair dye 170 Arachnia propionica 11 smoothers for xii–xiii alpha hydroxy acids animal bites 28 arginosuccinic aciduria treatment and out- (AHA) 14, 24–25, 75, ANSI sunglass standard 36 look for x–xiii, 160 28 argon laser 36, 291 14–16 aluminum acetate. See anthralin preparations Aristocort (triamcino- AIDS Burow’s solution 23, 28–29 lone) 376 and bacterial infec- aluminum chloride anthrax, cutaneous Aristospan (triamcino- tions 17 hexahydrate (Drysol) 29–31 lone) 376 and bruises 60 34, 122, 184 anthrax vaccine 30–31 Artecoll 36–37 and fungal infections aluminum oxide crystal antibacterial drugs 31 arthritis, psoriatic 301 17, 152 microdermabrasion antibacterial soap 347 arthropod infections 271 and hair problems 17 xii–xiii antibiotic drugs 31–32, artificial skin 37 and Kaposi’s sarcoma ambergris 92 42. See also specific drugs ascorbic acid. See vita- 196 amebiasis 17, 25 and uses min C and nail problems 17 Amevive 301 allergic reactions to ashy dermatosis 37, and parasitic infec- amino acids 25 19 131–132 tions 17 aminoglycosides 31–32 side effects of 32 Asian(s), Mongolian spot and skin disorders ammonia, for jellyfish types of 31–32 in 243, 253–254 16–17 sting 195 anticoagulation syn- aspirin, contraindicated and skin tumors 17 ammoniated mercury drome 32, 177 in chicken pox 76–77 and viral infections 25, 53 antifungal/anti-yeast asteatotic dermatitis 105 16–17, 178 amoxicillin 31–32, 273 agents ix, 32, 152. See asteatotic eczema 125 air travel and skin 17 for Lyme disease 222 also specific agents and astringents 37, 81 albendazole, for gnathos- amphotericin B 25, 32 applications ataxia telangiectasia tomiasis 161 for cryptococcosis 96 side effects of 32, 152 219–220 albinism 17–18, 177– for mucormycosis types of 32 athlete’s foot 37–38 178, 186, 267, 280 245 antihistamines 32–33. atopic dermatitis 106, Albright’s syndrome 18 ampicillin 273 See also specific agents 251 alcohol (topical) 18 amyloidosis 25–26 and uses atopic eczema 125 alcohol and skin 355– anaphylaxis 19, 26, 207 anti-inflammatory drugs atrophic papulosis, 356 Ancobon. See flucytosine 33, 190 malignant 101 alcohol and skin cancer Ancylostoma duodenale nonsteroidal 33 atrophie blanche 38 18 180 side effects of 33 attar of roses 38 Aldara. See imiquimod Anderson, R. xii types of 33 atypical nevi 38–39 cream Anderson-Fabry disease antimalarial drugs 33 augmentation mam- alefacept viii 28, 139, 199 antioxidant(s), and skin moplasty 227–228, Alibert, Jean-Louis 115 androgen(s) cancer prevention 235, 332–333 alkalizers 88 and acne 4–5, 26 338 aurothioglucose 39, 161 alkaptonuria 18 and hair loss 43–44, antioxidant beauty prod- Auspitz’s sign 39 allergens 18 171 ucts 33–34, 149–150 autograft 39–40 allergies and skin 18–21, androgenetic alopecia antiperspirants 34 autoimmune disorders 89–90, 340 22, 171 allergic reaction to 340 allergy tests 271–272 anergy 27 108 Autologen 40 AlloDerm 21, 342–343 angioedema 27 Drysol 34, 122 autologous fat transplant allograft 22 hereditary 27, 180 antipruritic agents 34 40 aloe vera 22 angiofibroma 27 antiseptic cleaners Avon’s Skin-so-Soft 245 alopecia angiokeratoma 27–28 34–35 azathioprine 40–41 androgenetic 22, 171 angiokeratoma corporis antiviral agents 35 for Behcet’s syndrome friction 22 diffusum of Fabry 28 aplasia cutis 35 49 traction 22, 172 angioma 28, 36, 55, APLIGRAF 35–36 azelaic acid 41, 103 alopecia areata 22–24, 75–76, 255, 294 apocrine bromhidrosis AZT. See zidovudine 43, 169–172, 248–249 anhidrosis 28 59 azulene 41 Index 441

B Behcet’s syndrome strawberry 52, 172, botulinum toxin B xii baby shampoo 168 48–49 254, 354–355 bouba 401 Bacillus anthracis 29–30 benzocaine treatment and out- bovine collagen xi, bacitracin 31 allergic reaction to look for 52 14–15, 84, 342 bacterial skin infections 121 bisulfites 52 Bowen’s disease 59 42, 340. See also specific for canker sore 69 bite(s). See also specific breast augmentation types benzoic acid 49 types 227–228, 332–333 AIDS and 17 benzoyl peroxide 49–50 human 182 breast lift 230 Bactroban. See mupirocin for acne 3, 6–7, 9, insect 52, 191 breast reduction 227– bags under eyes 42 31, 49–50, 53, 358 bites and infestations 52 228 baking soda 42 for blackheads 53 bithionol 91 breast reshaping 230 for chicken pox 76 for chloracne 79 blackhead 2, 8, 52–53, bromhidrosis 59 for jellyfish stings side effects of 49–50 79, 85, 137 delusion of 102 195 bergamot oil 106–107, black widow spider 350 bromides, and acne 5 baldness 22, 42, 171– 262, 278, 299 bleaching, of hair 169 bromoderma 59 173 berloque dermatitis bleaching creams 53–54, bronze diabetes 176 female-pattern 42–43 106–107 103, 183 brown recluse spider male-pattern 43–44, beta-carotene 50, 71, bleb 54 bites 59–60, 191, 350 171 119 bleomycin 54, 99 Brugia malayi 128 balloon cell nevus 254 as antioxidant 33–34, blepharochalasis 97 Brugia timori 128 balneotherapy 44 149–150 blepharoplasty 42, 138 bruise 60–61, 123 bamboo hair 44–45, 251 for erythropoietic blister 54, 412 bubble bath 61 bandages (dressings) protoporphyria with burn injury bubo 61, 283–284 120 135 63–64 bubonic plague 61–62, barber’s itch 45 for melanoma pre- blistering disorders 55 283–284, 402 Barraquer-Simmons dis- vention 235 Bloch-Sulzberger syn- Buckholderia mallei 159 ease 140–141 in tanning pills 369 drome 55 bulla 62 Bartonella henselae 71–72 beta hydroxy acids blood vessel disorders bullous disorders 340 basal cell 45, 129, 281 50–51 and skin 55 bullous impetigo 189 basal cell carcinoma bichloracetic acid 157 blood vessel lesions, in bullous pemphigoid 272 45–46, 337–338 bilharziasis 322 pregnancy 294 bull’s-eye rash, of Lyme diagnostic pathology bilirubin 183, 194 Bloom’s syndrome disease 222 of 45 biologic agents viii–ix, 55–56 burns 62–65 radiation therapy for 51, 301 blue nevus 253, 254 chemical 74, 88 46, 306–307 biological implants 51 bluing rinse 170 complications of symptoms of 45 biopsy, skin 337 blush 56 64–65 treatment and out- bioterrorism 29–31 blusher 56–57 effects of 63–64 look for 46 biotin deficiency 51 Bockhart’s impetigo 189 electrical 63 basal cell epithelioma birth control pills body lice 213–215 extent of 63 313 51–52 boil 42, 57, 70, 152–153 first-degree 62, 64 Bateman’s purpura 96 and acne 2–4, 8 borate 57 fourth-degree 63 bath oil, as insect repel- and condylomata borax 57–58 risk factors and pre- lent 245 acuminata 86 boric acid 58 vention 65 Bazex syndrome 46–47 and hair loss 172 for miliaria 240 scald 319 beard, ingrown hairs of birthmarks 52, 336–337, Borrelia burgdorferi scars from 65 297–298 340 221–223 second-degree 62, 64 Beau’s lines 47 adipose nevi 13 Botox xii, 58–59, 399 severity of 62–63 bedbugs 47, 191 collagenomas 84–85 for hyperhidrosis skin grafts for 39–40, bedsores 47–48, 101, hemangiomas 52, 55, 59–60, 184 64–65 208, 294 176, 254 procedure for 58–59 third-degree 63–65 bee and wasp stings 48 nevus 253–254 risks and complica- treatment and out- bee royal jelly 268, 315 port-wine stains 26, tions of 59 look for 64–65 beeswax 48 28, 52, 55, 200, botulinum toxin A. See Burow’s solution 42, 65, Behcet, Hulusi 48 254, 290–291, 357 Botox 68, 264, 289, 328 442 Index burrow 65 carbon dioxide laser xii, chemical pollutants and citronella 80 Buschke-Lowenstein 27, 70, 86, 179, 204– skin 75 clavus. See corn tumor. See wart(s) 205, 284, 398–399 cherry angioma 13, clay 80, 228–229 Buschke-Ollendorff syn- carbuncle 42, 70 75–76 cleansing, skin 335– drome 65 carmine 92 chicken pox 76–77, 387 336 buttermilk 228–229 carnauba wax 70–71 acyclovir for 12, 77 cleansing cream 94 butyl stearate 65 carotenemia 71 diagnostic pathology cleansing products cartilage-hair hypopla- of 76 80–81 C sia 71 risk factors and pre- climatotherapy 81 café-au-lait macule 66, casein 71 vention 77 clindamycin 81 251–252, 378 castile soap 348 symptoms of 76 for acne 6–7, 31, 81 calabar swelling 219 castor oil 71 treatment and out- for perioral dermatitis calamine 66 catagen 71 look for 76–77 111 for chicken pox 76 cat scratch fever 71–72 vaccine against clofazimine 81 for contact dermatitis causalgia 72 76–77, 292, 331, for leprosy 81, 212 108 cavernous hemangioma 386–387 closed comedo 2 for insect bites 52, 176 chigger bites 77–78, 241 Clostridium botulinum 58 191, 244 cayenne pepper spots chilblains 78 Clostridium welchii 154 for itching 193 72, 322 chin augmentation 78 clothes and sun protec- for jellyfish stings cefaclor 31–32 chloasma 52, 78, 281, tion 81–82, 175, 349, 195 ceftriaxone, for Lyme 293 362 for miliaria 240 disease 222 chloracne 3t, 5, 78–79, clotrimazole 32 for poison ivy 287 cefuroxime, for Lyme 261 for erythrasma 135 for seaweed dermati- disease 222 chlorhexidine 34 for jock itch 195 tis 112 cellulite 72 chlorine, and green hair for Majocchi’s granu- calcinosis 323 cellulitis 17, 42, 72 164 loma 226 calcinosis cutis 66 cement dermatitis 19 chlorine bleach, as insect cloxacillin 82 calcium dioxide 88 centrofacial lentiginosis repellent 245 coal tar derivatives 82 callus 66, 87, 294 245–246 chloroacetamide 90 Cockayne-Touraine syn- camouflage cosmetics cephalexin 31–32 chlorofluorocarbon pro- drome 82 66–67, 147–148, 291 cephalosporins 31–32 pellants 91 cocoa butter 82 Campbell De Morgan’s cerate 73 chloroform 91 coconut oil 82 spots 13 cestodes 176, 271 chlorophyll 79 cod liver oil, and acne 5 camphor 67, 83 chalazion 73 chloroquine 33 colchicine, for Behcet’s cancer, skin. See skin chamomile 41–42, 73 chromium/chromate syndrome 49 cancer chancre allergy 18–19, 107 cold cream 82 cancer vaccine 234 syphilitic 73 chromoblastomycosis 79 cold exposure 78, Candida albicans 68, 401 tuberculous 377 chromomycosis 79 150–151 candida infection 68, chapped skin 73 chromosomal defects and cold sore 82–83, 141, 151, 174, 275, 371, 401 Chediak-Higashi syn- skin disease 79–80 178 nails in 248–249, drome 73–74, 186 Chrysops 219 versus canker sore 69 263, 271 cheilitis 74 chrysotherapy 39, laser therapy and candida paronychia cheiloplasty 74 161–162 205 68–69 chemabrasion. See chem- cicatricial pemphigoid collagen 83 candidiasis 68 ical face peel 272 exercise and 137 canker sore 69 chemical(s), corrosive ciclopirox. See cyclopirox stimulation of, Fibrel cantharidin 395 88 ciclopiroxolamine. See for 141 canthaxidine 327–328, chemical burns 74, 88 cyclopiroxolamine vitamin C and 118 369 chemical exposure and cimetidine 80 collagen diseases 83–84 capsaicin 69, 331, 403 skin 74 cinnamate 80 collagen injection x–xi, carbamide peroxide 69 chemical face peel xii, ciprofloxacin (Cipro) 80 14–16, 84, 341–342, carbaryl, for lice 214 74–75, 399 for anthrax 30 399 carbenicillin 70 chemically induced cirrhosis, skin symptoms allergic reaction to carbolic acid 70 depigmentation 102– of 155 xi, 19, 84 carbolic soap 70 103 citric acid 80 Autologen 40 Index 443

bovine versus human- contracture 87 cream, cleansing 94 cutis marmorata telan- derived xi, 14–15, corn 66, 87, 294 cream eye shadow 226 giectatica congenita 84, 342 corn oil 87 creeping eruption 180– 97–98 CosmoDerm or Cos- cornstarch 87–88 181, 203 cyanosis 98 moPlast 93 corrosive chemicals 88 CREST phenomenon cyclophosphamide 98, 99 procedure for 84 corticosteroids 33, 94–95, 323 for lichenification 215 risks and complica- 88–89 Cronkhite-Canada dis- cyclopirox 32 tions of 84 cortisone 89 ease 95 cyclopiroxolamine 98 collagenomas 84–85 for acne 4 Cross-McKusick-Breen cyclosporine 98–99 collagenosis, reactive for contact dermatitis syndrome 95 for alopecia areata 24 perforating 308 108 crotamiton cream 95 cylindromas 379–380 collodion baby 85, 319 Corynebacterium diphthe- cyclopirox 32 Cymetra xi, 21, 99, 342 colloid milium 85 riae 96 cyclopiroxlamine 98 cyst(s) 99 cologne 20, 123 Corynebacterium minutis- cryogen sprays xii dermoid 99 color additives 91–92, simum 134–135 cryosurgery 95 epidermal 129, 239 146, 410 cosmeceutical 89 for actinic keratosis epidermoid 129 combination skin 340 cosmetic(s) 92–93, 226 11, 13–14 meibomian (chala- comedo 2, 85 allergic reaction to for basal cell carci- zion) 73 compact powder 226 19, 340 noma 46 pilar 129 composite cultured skin blush 56 liquid nitrogen for sebaceous 129, 326 (CCS) 85 camouflage 66–67, 218 cystic acne 4–5 compound nevus 254 147–148, 291 for molluscum conta- cytotoxic drugs concealing creams choosing 93 giosum 243 for skin diseases 99 66–67 contamination of for wart removal 86, skin side effects of 99 conditioner 67, 168 92–93 144, 157, 284, 395 Cytoxan. See cyclophos- conditioning shampoo diethanolamine cryptococcosis 95–96 phamide 168 (DEA) in 119 Cryptococcus neoformans condylomata acuminata federal regulation of 95 D 16, 86 146–147 Ctenocephalides canis 144 dandruff 100 congenital absence of ingredients of 92, Ctenocephalides felis 144 dandruff shampoo 168 skin 35 406–409 cucumber 96 dapsone 100–101 congenital disorders of ingredients to avoid curettage and electrodes- for brown recluse spi- skin 87 411 iccation 96 der bites 60 congenital nevus 254 prohibited ingredients for actinic keratosis for dermatitis herpeti- connective tissue disease 91–92, 146 11 formis 113 83–84 for vitiligo 393–394 for basal cell carci- for infantile acropus- mixed 220 Cosmetic, Toiletry, and noma 46 tulosis 190 occupational expo- Fragrance Association for condylomata acu- for leprosy 100, 212 sure and 262 (CTFA) 90 minata 86 for relapsing poly- connective tissue nevus cosmetic acupuncture 89 cutaneous atrophy 96 chondritis 309 65, 87, 254–255 cosmetic allergy 89–90 cutaneous diphtheria side effects of 100– Conradi’s disease 87 Cosmetic Ingredient 96–97 101 contact dermatitis 107– Review (CIR) Expert cutaneous larva migrans Darier’s disease 101 108 Panel 50–51, 90 180–181, 203 Darier’s sign 101 diagnostic pathology cosmetic labeling 92 cutaneous lymphoid darkened skin 185, of 108 cosmetic surgery 93 hyperplasia 224 280–281 drug-induced 19, 121 CosmoDerm 15, 84, 93, cuticle 97 Darwin, Charles 123– hand 109 342 care of 249 124 irritant 110 CosmoPlast 15, 84, 93, inflammation of DEA (diethanolamine) occupational expo- 342 (paronychia) 271, 119 sure and 261 coumarin (Coumadin) 68–69, 248–249 decubitus ulcers 47–48, symptoms of 108 necrosis 32, 93 cutis 97 101, 208, 294 treatment and out- Cowden’s disease 94 cutis hyperelastica 97, deer ticks 221–222 look for 108 crabs (lice) 213–215 125–126 DEET 52, 244–245 contact urticaria 384 cradle cap 94 cutis laxa 97 Degos’ disease 101 444 Index delusion of bromhidrosis exfoliative 108–109 DHA (dihydroxyacetone) dysplastic nevi 38–39, 102 hand 109–110 119 256–257 delusions of parasitosis immune progester- diabetes mellitus 207– dysplastic nevus syn- 102 one, of pregnancy 208 drome 256–257 Demodex folliculorum 294 diaper rash 117–118 102 nickel 20, 110 diascope 118 E deodorant 102 nummular 110–111 dicloxacillin 42 ear repair 266 deodorant soap 348 occupational expo- for ecthyma 123 eau de cologne 20, 123, depigmentation 102 sure and 261 for impetigo 188–189 148 chemically induced papular, of pregnancy diet and skin 118–119 eau de toilette 148 102–103 269, 294 diethanolamine (DEA) ecchymosis 123 congenital 103 perioral 111 119 eccrine glands 363 post-traumatic 103 pigmented purpuric Diflucan. See fluconazole econazole 32, 123 for vitiligo 53, 391, lichenoid 162 digitate warts 395 Ecostatin. See econazole 393 radiation 307 dihydroxyacetone (DHA) ecthyma 123 depigmentation disorder seaweed 111–112 119, 327 ecthyma, AIDS and 17 103 seborrheic 112 DIN 119 ectoderm 123 depigmenting agents dermatitis artefacta dioxin 5 ectodermal dysplasia 53–54, 103 112–113 Dipetalonema streptocerca (ED) 123–124 depilatory 103–104, dermatitis herpetiformis 355 ectoparasite 124 173 113 diphenhydramine 119– ectothrix 124 deposits 412 dermatitis papillaris cap- 120, 121 eczema 124–125 depression, isotretinoin illitii 8–9, 113 diphenylcyclopropenone asteatotic 125 and 193 dermatitis papulosa nigra (DPCP) 23–24 atopic 125 dermabrasion 104–105, 113–114 diphtheria, cutaneous diagnostic pathology 399 dermatofibroma 114 96–97 of 125 for actinic keratosis dermatofibrosarcoma discoid eczema 125 discoid 125 11 protuberans 114 discoid lupus erythe- dyshidrotic 289 for angiofibroma 101 dermatoglyphics 114– matosus (DLE) 120, endogenous 125 for Darier’s disease 115 220–221 evening primrose oil 101 dermatographia 115 disseminated superficial for 136 for lichenification dermatologic surgeon actinic porokeratosis nummular 125 215 115 289–290 occupational expo- for multiple lentigines dermatologist 115 Down syndrome 79 sure and 261 syndrome 246 dermatologist-tested doxycycline 31–32 pimecrolimus cream dermal fillers. See skin 89–90 for anthrax 30 for viii fillers dermatology 115–116 for Lyme disease 222 seborrheic 125 Dermalogen xi dermatome 116 for rosacea 314 symptoms of 125 dermal stimulator 105 dermatomyositis 116 dressings 120, 264 tacrolimus for viii, dermapigmentation dermatopathology 116 drug(s), photosensitizing 368 275 Dermatophagoides 241 278–279 treatment and out- dermaplaning 105 dermatophagy 116 drug eruptions, lichenoid look for 125 dermatitis 105 dermatophyte 116–117, 215 varicose 125 AIDS and 17 129, 174, 263–264 drug-induced acne 5 eczema craquele 105 allergic 18–21 dermatophytid 117 drug-induced hypopig- eczema herpeticum 12, asteatotic 105 dermatophytosis 117 mentation 186 125, 179 atopic 106, 251 dermatosis, ashy 37 drug-induced lupus 220 eczematous dermatitis berloque 106–107 dermatosis cinecienta drug reactions 19, 121 125 cologne and 20 117 dry gangrene 154 efulizumab viii contact 19, 107–108, dermis 117, 334–335 dry skin 121–122, 340 egg 125 109, 261 dermoid 117 Drysol 34, 122, 184 Ehlers-Danlos syndrome contact irritant 110 dermoid cysts 99 Duhring’s disease 113 97, 125–126 diaper 117–118 desquamation 117 dyshidrotic eczema 289 elastic fibers 126 drug-induced 19, 121 developers (hair dye) dyskeratosis congenita elastin 126, 341 eczematous 125 117 122 elastomas 126 Index 445 elastosis 126 erythema annulare cen- evening primrose oil filariasis 143, 219 elastosis perforans ser- trifugum 131 136, 136 filiform warts 143, piginosa 79, 126–127 erythema chronicum exanthem subitum 136 395–396 electrical burns 63 migrans. See Lyme excimer laser ix, 393 fillers. See skin fillers electrical injury 127 disease excisional biopsy 337 finasteride, for baldness electrodesiccation 127. erythema dyschromi- excoriation 136 44 See also curettage and cum perstans 37, 117, exercise and skin 137 fingernails. See nail(s) electrodesiccation 131–132 exfoliation 137–138 fingerprints 114–115 electrolysis 127, 173 erythema gyratum exfoliative dermatitis fissure 143 electroporation 127– repens 132 108–109 Flagyl. See metronidazole 128 erythema marginatum exudate 138 flap 143, 149 electrosurgery, for basal 132 eye(s), bags under 42 flat warts 143–144, cell carcinoma 46 erythema multiforme eyebrow(s) 167 395–396 electrothermal burns 132–134 eyebrow pencil 226 fleas 144, 191 63 erythema nodosum 134 eyelashes 167 flesh-eating bacteria elephantiasis 128, 143 erythema toxicum neo- eyelid lift xi–xii, 138 250–251 Elidel (pimecrolimus) natorum 134 eyeliner 226 fluconazole 32, 152 viii erythrasma 134–135 eye shadow 226 flucytosine 144 emollients 128, 193 erythroderma 108, 135, for cryptococcosis 96 emotion and skin 128– 412 F flukes 176, 271, 322 129, 355–356 erythrokeratodermia Fabry’s disease 28, 139, fluocinolone 144 Enbrel 301 variabilis 235 199 fluorescent lights and en cutem penetrans erythromycin 31–32, face-lift xi–xii, 139–140, skin 144 201 135 285, 399 fluoroquinolones 144– endothrix 129 for acne 3, 6–7, 31 face powder 226 145 Entamoeba histolytica 25 for ecthyma 123 facial 140 fluorouracil 145 entoderm 129 for erythrasma 135 factitial dermatitis 112– for actinic keratosis ephelis 129, 149 for impetigo 188–189 113 11 epidermal cyst 129, for Lyme disease 222 Fair Packaging and for genital warts 157 239 for parapsoriasis Labeling Act 146 flush 145 epidermal nevus 255 varioliformis acuta famcyclovir (Famvir) malar 226–227 epidermis 129, 334– 271 35, 140 fly bites 52, 191, 219, 335 for perioral dermatitis Farber’s lipogranuloma- 379 epidermoid cysts 129 111 tosis 140 Flynn-Aird syndrome epidermolysis bullosa for rosacea 314 fat atrophy 140–141 145 85, 129–130 side effects of 135 fat distribution, aging follicle, hair 166, 171 epidermolytic ichthyosis for staph infections 42 and 14 follicular hyperkeratoses 319–320 erythroplasia 135 fat transplant xi, 15 145 Epidermophyton 116– erythropoietic protopor- autologous 40 follicular orifice (pore) 117 phyria 135–136 for fat atrophy 141 289 Epidermophyton floccosum eschar 136 fatty acids, essential 136 folliculitis 42, 145–146 226 essential fatty acids female-pattern baldness AIDS and 17 epidermotropism 130 (EFAs) 136 42–43 Demodex 102 epiloia 130 essential oils 136 fever blisters 141. See Food, Drug and Cosmetic epinephrine, for angio- estrogen 136 also cold sore Act of 1938 146–147 edema 27 and acne 2–4, 7–8 Fibrel 141 food additives 147 epithelioma 130, 313 etanercept viii fibroblasts 16, 141, 163, Food and Drug Adminis- epithelium 130 ethoxyethanol 90 343 tration (FDA) 146–147 epsom salts 130 ethoxyethanol acetate fibroma, perifollicular food reactions 19, 147 erasers xii–xiii 90 275 footwear, allergic reac- erbium laser xii ethylenediamine, allergic fibrosis 141 tion to 19 erbium:YAG laser 204 reaction to 121 fibrous dysplasia 18 formaldehyde, sensitivity erysipelas 42, 130, 317 etretinate 136, 370 fibroxanthoma of skin to 147 erythema 130–131 eumelanin 231, 281 141 Fort Bragg fever. See lep- erythema ab igne 131 Eurax lotion 95 fifth disease 141–143 tospirosis 446 Index foundation (cosmetic) Gardner-Diamond syn- gnathostomiasis 160–161 anatomy of 166– 66–67, 147–148 drome 154 Goeckerman regimen 167 Fox-Fordyce disease 148 Gardner’s syndrome 161, 296 appearance of 167 fragrance 154–155 gold sodium thiomalate bamboo 44–45, 251 allergic reaction to gas gangrene 154 161 bleaching of 169 19–20, 340 gastrointestinal bleeding, gold therapy 39, 161– care of 167–169, as cosmetic ingredient skin symptoms of 155 162 329–330 146 Gaucher’s disease 155 gooseflesh 162 color of 167 eau de cologne 123, gel 155 Gougerot-Blum syn- conditioner for 67, 148 generalized lentiginosis drome 162, 281 168 and skin 148 209, 246 graft(s). See skin grafts disorders of 169. See frambesia 401 generalized lipodystro- graft-versus-host disease also specific types freckles 24, 129, 149 phy 140–141 (GVHD) 162 excess (hirsutism) free-flap surgery 149 genetic disorders of skin gramicidin 31 180 free radicals 33–34, 74– 155–156 granular cell tumor 162 gray 169–170 75, 149–150, 281, 306 genital deodorant allergy granulation tissue 163 green 164 fresheners 81 20 granuloma(s) 163 growth stages of 71, fresh issue technique genital herpes 178 lethal midline 163 166, 370 ix–x emotion and 129 Majocchi’s 226 trauma to 168 friction alopecia 22 genital warts 86, 156– pyogenic 304 types of 166–167 frostbite 150–151 158, 268–269, 395–396 sarcoid 317 uncombable 383– frostnip 150, 151 diagnostic pathology swimming pool 364 384 fruit acids 24 of 156–157 granuloma annulare 163 white 169 fucosidosis 151 epidemiology of 156 granuloma faciale 163– hair dye 170–171 Fulvicin. See griseoful- imiquimod for viii 164 allergic reactions to vin risk factors and pre- granulomatous disease 20, 170 fungal infections 151– vention 158 164 and cancer 171 152, 340. See also specific symptoms of 156–157 granuloma tricofitico developers in 117 types treatment and out- 226 metallic 170 AIDS and 17, 152 look for 157–158 gray hair 169–170 permanent 170 diagnostic pathology genodermatosis 158 green hair 164 semipermanent 170 of 151–152 gentamicin 31–32, 158 Grenz ray therapy 164 synthetic (aniline) risk factors and pre- Geopen (carbenicillin) Grenz zone 164 170 vention 152 70 Grisactin. See griseofulvin vegetable 170, 176– subcutaneous 151 German measles 158 griseofulvin 32, 152, 177 superficial 151 Gianotti-Crosti syndrome 164–165 hair follicle 166, 171 symptoms of 151– 158–159 for kerion 199 hair loss 22–24, 42–44, 152 gigantism, in Law- for lichen planus 215 171–173 treatment of ix, 25, rence-Seip syndrome for nail fungus 248, in alopecia areata 32, 152 207–208 264 22–24, 171–172 Fungizone. See ampho- Gillis W. Long Hansen’s side effects of 165 concealing 172 tericin B Disease Center 212 ground itch (hookworm) future research on fungus 152 ginseng 159 180–181 173 furuncle 152 glanders 159 group B streptococci hairpieces for 172, furunculosis 153 glomangioma 159 infections 165 173 Futcher’s line 394 glomangiosarcoma Grover’s disease 165 medical disorders 159–160 guanine 92 causing 172 G glomus tumor 159–160 medical treatment of H gabapentin, for post-her- glutamic acid 160 173 petic neuralgia 292 glycerin 160 Hailey-Hailey disease minoxidil for 22–23, gamma benzene hexa- glycerin soap 348 166 43–44, 173, 241 chloride 319 glycolic acid 24–25, 74, hair occupational expo- gamma linoleic acid 136 160, 298 aging and 14, 169– sure and 262 gangrene 154 Gnathostoma spinigerum 170 surgical treatments Gardner, Eldon 155 160 AIDS and 17 for 172–173 Index 447

tissue expansion for hemolytic jaundice 194 with dermatographia hydropic degeneration 44, 374 henna 170, 176–177 115 183 treatment and out- Henoch-Schonlein pur- diphenhydramine for hydroquinone 53, 102– look for 172–173 pura (HSP) 177, 303 119–120 103, 183 hairpieces 172, 173 heparin necrosis 177 drug-induced 121 for chloasma 78 hair removal 173 hepatocellular jaundice with filariasis 143 for poikiloderma depilatory for 103– 194 with food reactions 285 104, 173 hepatolenticular degen- 147 for vitiligo 393 electrolysis for 127, eration 397 with insect bites 191 hydroxychloroquine 33 173 herald patch 177 with penicillin allergy hydroxylapatite with laser 203–204 hereditary disorders of 274 methylcellulose vehicle waxing for 173, 396 skin 155–156 sun-induced 349 344 hair transplants 22, Hermansky-Pudlak syn- treatment and out- hydroxyurea 183 43–44, 172, 173–174 drome 177–178 look for 180 Hylaform. See hyaluronic hair weaving 174 herpes gestationis 178, homograft (allograft) 22 acid gel haloderma 174 294 hookworm 180–181, hyperbilirubinemia 183 halogenated salicylani- herpes simplex infection 203 hypergranulosis 183 lides 91 178–179 hordeolum 357 hyperhidrosis 183–184, halo nevus 255 acyclovir for 12, 179 hormones and acne 181 363–364 haloprogin (Halotex) 174 AIDS and 16, 178 horn, cutaneous 181 Botox for 59–60, halothane, and acne 5 cold sore 82–83, 178 Horner’s syndrome 181 184 hand, foot, and mouth diagnostic pathology Howel-Evans syndrome Drysol for 122, 184 disease 174 of 178–179 181–182 surgery for 184 hand cream 174 eczema herpeticum HPV. See human papil- hyperkeratosis 184 hand dermatitis 109– 125, 179 loma virus hyperkeratosis follicu- 110 emotion and 129 human bites 182 laris et parafollicularis hangnails 174, 249 erythema multiforme human-derived collagen 201 Hansen, Armauer 210 132–133 xi, 14–15, 84, 342 hyperpigmentation 185, Hansen’s disease. See genital 129, 178 human papilloma virus 280–281 leprosy prodrome in 178 (HPV) 86, 156–158, in pregnancy 52, 72, harlequin color change risk factors and pre- 268–269, 284 281, 293 174 vention 179 humectant 182 hyperplasia 185 harlequin fetus 175, 319 symptoms of 178– Hunter’s syndrome 182, hypersensitivity 340. See Hartnup disease 175 179 245 also allergies and skin Hashimoto’s thyroiditis treatment and out- Hutchinson-Gilford syn- hyperthyroidism 249– 371 look for 35, 179 drome 295 250, 263, 371 hats and sun 175 type 1 (HSV1) 178 Hutchinson’s freckle hypertrichosis 185 HC Blue No. 1 90 type 2 (HSV2) 178 182, 210 hypertrophic scars 65, head lice 213–215 herpes zoster. See shingles hyaluronic acid gel xi, 185, 320 heat disorders 175–176 heterograft 179 15–16, 182–183, 341, hypoallergenic 89–90, heat rash 176 hexachlorophene 35, 343 328 heatstroke 362 91, 179 hydralazine, and lupus hypochondria, cutane- hederiform endings 336 hidradenitis suppurativa 220 ous 8 helminthic infections 179 Hydrea (hydroxyurea) hypohidrosis 185, 364 176, 271 systemic biologics for 183 hypohidrotic ectodermal hemangioma(s) 52, 55, viii hydrocortisone dysplasia 185 176, 254 hidrocystoma 179–180 for contact dermatitis hypomelanosis of Ito cavernous 176 hirsutism 180 108 185, 186 stork bite 337, 354 histamine 32, 34, 180, for seaweed dermati- hypopigmentation 185– strawberry 52, 176, 190 tis 112 186, 280 254, 354–355 histiocytoma cutis 114 for seborrheic derma- azelaic acid and 41 hematoma, subungual hives 180, 412 titis 112 congenital 186 357 antipruritic agents for vitiligo 392–393 drug-induced 186 hemochromatosis 176, for 34 hydrogen peroxide 34, post-inflammation 281 cimetidine for 80 183 186 448 Index hypopituitarism and skin symptoms of 188 iron therapy, for erythro- jock itch 195 color 186 treatment and out- poietic protoporphyria juvenile melanoma 232 hypothalamus, and ther- look for 188–189 135 mal regulation 175 impetigo herpetiformis irritant dermatitis K hypothyroidism 371 294 contact 110 kairo cancer of Japan Imuran. See azathioprine hand 109 131 I incisional biopsy 337 isoniazid, and acne 5 kange cancer of China iatrogenic atrophy 187 incontinentia pigmenti isopropyl myristate, and 131 ibuprofen 187 55 acne 4 kangri cancer of India ice packs 187 infant(s) isotretinoin 192–193 131 ichthyosis 175, 187, skin care for 338–339 for acne vii, 3, 6–7, kaolin 228–229 316, 319–320 skin diseases of 190 192 Kaposi’s sarcoma 17, 196 AIDS and 17 sun protection for for chloracne 79 Kawasaki disease 196– diagnostic pathology 339–340 for Darier’s disease 197 of 187 infant acne 5, 336 101 keloids 65, 197, 320 epidermolytic 319– infantile acropustulosis and depression 193 Kenalog (triamcinolone) 320 189–190 discovery of vii 376 isotretinoin for 192 inflammation 190 duration of effects Kennedy, John F. 12 lamellar 85, 187, infliximab viii vii, 7, 192 Keralyt gel, for berloque 202, 319–320 infrared light 190 mechanism of action dermatitis 107 symptoms of 187 infrared radiation 382 vii, 192, 327 keratin 166, 197, 248 treatment and out- infundibulofolliculitis for pityriasis rubra keratin formation, look for 187 190 pilaris 283 abnormal 412 X-linked 319–320 ingrown hair 169 for rhinophyma 310 keratinization 197 ichthyosis linearis cir- ingrown toenail 191 side effects of vii, 7, disorders of 197. See cumflexa 251 insect bites 191. See also 192–193 also specific types ichthyosis vulgaris 187, specific types teratogenicity of vii, keratinocytes 166, 319 insect repellent 52, 3, 192 197–198 icterus. See jaundice 80, 219, 223, 241, itching 34, 193 keratitis-ichthyosis-deaf- imaginary acne 3t 244–245 with bites and infes- ness syndrome 199 imidazole, for candida insulin lipoatrophy tations 52, 244 keratoacanthoma 198 paronychia 68 140–141 emotion and 129 keratoderma 198 imiquimod cream viii, insulin-resistant diabe- with food reactions keratohyaline granules 187 tes, and Lawrence-Seip 147 198 immersion foot 188 syndrome 207–208 with mosquito bites keratolysis 198 immune progesterone intense pulsed light xii 244 keratolytic drugs 198 dermatitis of pregnancy interferon with otitis externa keratosis 294 for basal cell carci- 266 dermatitis papulosa immunity and sunlight noma 46 in pregnancy 293, nigra 113–114 188 for genital warts 297 palmar-plantar 267 immunologic drugs viii 157 itraconazole ix, 32, 152 seborrheic 198 immunomodulators, interferon alpha (IFN-a) ivermectin, for loiasis keratosis follicularis 101 topical viii viii, 191 219 keratosis pilaris 198–199 immunotherapy 188 for condylomata acu- Ixodes pacificus 221 kerion 199 impetigo 42, 188–189 minata 86 Ixodes scapularis 221 ketoconazole 32, 152, AIDS and 17 for Kaposi’s sarcoma 199 Bockhart’s 189 196 J drug interactions of bullous 189 intertrigo 191–192 Jarisch-Herxheimer reac- 199 diagnostic pathology iodides, and acne 5 tion 194 for Majocchi’s granu- of 188 iodine, dietary 119 jaundice 194, 279, 294 loma 226 risk factors and pre- iodine antiseptics 34–35 hemolytic 194 for seborrheic derma- vention 189 iontophoresis, for hyper- hepatocellular 194 titis 112 staphylococcal 188– hidrosis 184 obstructive 194 side effects of 199 189 iris nevi 252 jellyfish stings 194–195, for tinea versicolor streptococcal 188 iron excess 176, 281 325–326 199 Index 449 kidney disease and skin excimer ix, 393 lentiginosis profusa 209, lidocaine, for post- symptoms 199 long pulse 204 246 herpetic neuralgia 292 KID syndrome 199 Nd:YAG 205, 298, lentigo (pl. lentigines) lifts xi–xii, 138–139, kissing bug bites 199– 398–399 13, 149, 209 285, 399 200 non-ablative xii, actinic 210 lightened skin 185–186, Kligman, Albert 375 204–205, 258–259 multiple, syndrome of 280 Klinefelter’s syndrome pulsed dye xii, 36, 245–246 light treatment. See pho- 80 52, 200, 285–286, solar 349 totherapy Klippel-Trenaunay syn- 291, 302, 355 lentigo maligna 182, limes and skin 262, 299 drome 200 ruby 205 209, 210 lindane 216–217 Koebner’s phenomenon tunable dye 379 lentigo maligna mela- FDA warning on 200 laser hair removal noma 232–233, 234 214, 216–217 koilonychia 200 203–204 LEOPARD syndrome for lice 214, 216 kwashiorkor 200–201 laser resurfacing 24, 245–246 for scabies 214, 216, Kwell. See lindane 204–205, 398–399 leprosy 210–212 318–319 Kyrle’s disease 201 non-ablative 204– clofazimine for 81, linear scleroderma 323 205, 258–259 212 lipoatrophy, insulin L outlook and lifestyle dapsone for 100, 140–141 laceration 202 modification with 212 lipodystrophy Lac-Hydrin, for keratosis 205 diagnostic pathology generalized 140–141 pilaris 199 risks and complica- of 212 partial 140 lactic acid tions of 205 epidemiology of 210 lipoma 217 for keratosis pilaris laser skin renewal xii, history of 211 liposuction xi, 217–218 199 159 lepromatous 211 versus abdominoplasty for mal de Meleda laser treatment 205–206 multidrug therapy for 1 227 for actinic keratosis 212 outlook and lifestyle for plantar warts 284 11 symptoms of 212 modification with LAMB syndrome 245– for basal cell carci- transmission of 210– 218 246 noma 46 211 risks and complica- lamellar dystrophy of for flat warts 144 treatment and out- tions of 218 nails 202 for genital warts 157 look for 212 traditional 217 lamellar ichthyosis 85, for hidrocystoma tuberculoid 211 tumescent technique 187, 202, 319–320 179 leptin, for Lawrence-Seip 217–218 Lamisil. See terbinafine for plantar warts 284 syndrome 208 ultrasound-assisted Langerhans cell 202, for poikiloderma leptospirosis 212–213 218 334 285–286 lesions, types of 412 lipstick 226 Langer’s lines 202 for port-wine stain lethal midline granuloma liquid nitrogen 95, 218 lanolin 202–203 291 163 for actinic keratosis and acne 4 pseudofolliculitis bar- leukonychia 213 11, 13–14 allergic reactions to bae in 298 leukoplakia 192, 213 for basal cell carci- 20, 107 for psoriasis 301 levamisole, for Behcet’s noma 46 for lichen sclerosis for spider angioma syndrome 49 as bleaching agent 54 216 55 lice 213–215, 258 for molluscum conta- for miliaria 240 for squamous cell car- lichen aureus 281 giosum 243 lanugo 166–167, 203 cinoma 353 lichenification 215 for wart removal larva migrans, cutaneous for vitiligo 393 lichen myxedematosus 144, 157, 284, 395 180–181, 203 latex allergy 20–21, 215, 272 Listeria 165 laser(s) 206–207 lichenoid drug eruptions lithium, and acne 5 ablative 204 Lawrence-Seip syndrome 215 livedo reticularis 218 argon 36, 291 207–208 lichen planus 215, liver spots 13, 149 carbon dioxide xii, leg ulcers 208 248–249 Lofgren’s disease 317 70, 86, 204–205, leishmaniasis 208–209 lichen sclerosis et atro- van Lohuizen’s disease 284, 398–399 lemon 209, 262, 299 phicus (LSEA) 215– 97–98 erbium xii lentiginosis, generalized 216, 292 loiasis 219 erbium:YAG 204 209, 246 lichen simplex 216 long pulse laser 204 450 Index loofahs 219 malar flush 226–227 melanocyte system, methotrexate 237 Loprox (ciclopiroxol- Malassezia furfur 174 tumors of 232 for parapsoriasis amine) 98 malathion, for lice 214 melanoma, malignant varioliformis acuta lotions 80–81, 219 mal del pinto (pinta) 282 233–235, 337–338 271 Lotrimin 38 mal de Meleda 227 acral lentiginous 232, for pityriasis rubra Louis-Bar syndrome male-pattern baldness 234 pilaris 283 219–220 22, 43–44, 171 alcohol and 18 for polymyositis- lubricants 220 malignancy, internal, awareness of x dermatomyositis lunula 220 skin signs of 227 azelaic acid for 41 288–289 lupus erythematosus malignant melanoma. See diagnostic pathology for psoriasis 301 199, 220–221, 273 melanoma, malignant of 233–234 for Sezary syndrome discoid 120, 220–221 malnutrition 118–119, early detection of x 329 drug-induced 220 200–201 epidemiology of side effects of 237 severe flares of 221 mammoplasty 227–228, 233 methoxsalen 237, 279 systemic 220–221, 332–333 genetics of 233 4-methoxy-m-phenyl- 366 manicures 249 juvenile 232 enediamine 90 lupus vulgaris 221 Mantoux test 377 lentigo maligna 232– 4-methoxy-m-phenyl- lycopenia 221 Marie-Antoinette, Queen 233, 234 enediamine HCl 90 Lyell’s syndrome 133 169 moles and 233–234, 4-methoxy-m-phenyl- Lyme disease 221–223, mascara 226 243 enediamine sulfate 90 371 mask 228–229 nevi and 38–39, methylene chloride 91 diagnostic pathology mask of pregnancy 78, 256–257 methyl paraben 237 of 222 281, 293 nodular 234 metronidazole 237–238 risk factors and pre- masoprocol, for actinic risk factors and for amebiasis 25 vention 222–223 keratosis 11 prevention x, for rosacea 237, 314 symptoms of 222 mast cell diseases 229 234–235 side effects of 238 transmission of 221– mastocytomas 229–230 sentinal node biopsy Metryl. See metronida- 222 mastocytosis 229, 230 of x zole treatment and out- mastopexy 230 superficial spreading Mexoryl SX 360–361 look for 222 Matulane (procarbazine) 234 miconazole 32, 238 vaccine against 222 295 symptoms of 233– for Majocchi’s granu- LYMErix 222 measles 230–231 234 loma 226 lymphangitis 223 mumps, and rubella treatment and out- microdermabrasion xii– lymphocytoma cutis vaccine 158, 231 look for 234 xiii, 238–239 223–224 mebendazole, for hook- Melanotan 235 microlipoinjection xi. lymphoma worms 181 melasma 52, 78, 293 See also skin fillers AIDS and 17 mechlorethamine 231 melioidosis 397 Microsporum 116–117 non-cutaneous Hodg- meclocycline, for acne melphalan 99 milia 85, 239 kin’s 259 31 Mendes da Costa syn- miliaria 148, 239–240 medicated soap 348 drome 235 miliaria crystallina M Mees’ lines 231 meningitis 235 239–240 macule 225, 412 meibomian cyst 73 meningococcal infections miliaria profunda 239– Maffucci’s syndrome Meissner’s touch cor- 235–236 240 225 puscles 231, 336 Menkes’ kinky-hair syn- miliaria rubra 239–240 magnesium aluminum melanin 231–232, 280– drome 236 milker’s nodule 241 sulfate 225 281, 334–335, 340 menthol 108, 229, 236, mineral oil 241 Majocchi, Domenico in hair 167, 169 240 Minocin. See minocycline 226 lack of (albinism) mercury, ammoniated minocycline 241 Majocchi’s disease 225– 17–18 25, 53 for acne 3, 7 226, 281 melanocyte(s) 231, 281, mercury compounds, in for rosacea 314 Majocchi’s granuloma 334 cosmetics 91 minoxidil 22–23, 43–44, 226 aging and 14 Merkel cell(s) 336 173, 241 makeup 226. See also melanocyte-simulating Merkel cell cancer 236 mites 102, 241, 259 cosmetic(s) hormones (MSH) 186, metabolic disorders, skin mixed connective tissue permanent 275–276 231, 232, 334 signs of 237 disease 220 Index 451

Mohs, Frederick E. ix, mupirocin 246 neomycin 31–32, 251 stork bite 337, 354 242 for impetigo 188 allergic reaction to vascular 254 Mohs’ microscopically Mycifradin. See neomy- 108, 121 nevus araneus 255 controlled excisions cin Neosar(cyclophosphami nevus depigmentosus ix–x, 242 Myciguent. See neomycin de) 98, 99 186, 256 for basal cell carci- mycobacterial infection, nerves of skin 336 nevus elasticus of noma 46 AIDS and 17 Netherton’s syndrome Lewandowsky 254 for Bowen’s disease Mycobacterium leprae 210 44, 251 nevus flammeus. See 59 Mycobacterium marinum neuralgia, post-herpetic port-wine stain for dermatofibrosar- 364 291–292, 330–331 nevus lipomatosus coma protuberans mycoses. See fungal neurocutaneous disor- superficialis Hoffmann 114 infections ders 251 and Zurhelle 13 for squamous cell car- mycosis fungoides 231, neurodermatitis (lichen nevus of Ito 256 cinoma 353 237, 272 simplex) 216 nevus of Ota 256 moisturizer 121–122, Mycostatin 32 neurofibroma 251 nevus pigmentosus 256 242 Myobloc xii neurofibromatoses 66, nevus spilus 256 moles 52, 242–243, 253, 251–253, 378 nevus syndrome, dys- N 336–337. See also nevus bilateral acoustic plastic 256–257 ABCD assessment of naftifine (Naftin) 32, 252 newborn skin 257, 243 247 diagnostic pathology 336–337 and melanoma 233– nail(s) 248 of 252–253 niacin deficiency 272 234, 243 AIDS and 17 symptoms of 252– nickel dermatitis 20, in pregnancy 293 care of 248–249 253 110 molluscum contagiosum disorders of 249–250. treatment and out- nicotine and skin 356 16, 243 See also specific types look for 253 nifedipine 257 Mongolian spot 243, lamellar dystrophy type 1 (NF1) 252 Nikolsky’s sign 257–258 253–254 of 202 type 2 (NF2) 252 nitrobenzenes 258 monilethrix 243 pitted 250 neurotic excoriations nitrogen. See liquid moniliasis 68 racket 306 253 nitrogen monobenzone 243 sculptured 249 nevus (pl. nevi) 242– nitrogen mustard 231 monobenzoyl ether of nail biting 247 243, 253–254 nits 214–215, 258 hydroquinone 53, 103, nail discoloration 247 amelanotic 254 Nizoral. See ketocon- 393 nail fungus ix, 247–248, atypical (dysplastic) azole monochloroacetic acid 263–264 38–39 Nocardia asteroides 258 243 nail hardeners 248 balloon cell 254 nocardiosis 258 morbilli. See measles nail-patella syndrome blue 253, 254 nodule 258, 412 More, Sir Thomas 169 199, 248 compound 254 non-ablative skin resur- Morgan’s lines 243 nail polish 248 congenital 254, facing xii, 204–205, morphea 243–244, 323 nail products, allergic 336–337 258–259 mosquito bites 52, 128, reactions to 20 connective tissue non-Hodgkin’s cutane- 191, 244–245 NAME syndrome 245– 65, 87, 254–255 ous lymphoma 259 Motrin (ibuprofen) 187 246 dysplastic 256–257 noninvasive cutaneous Moynahan’s syndrome narrow band UVB ix epidermal 255 infections. See tinea 245–246 Nebcin (tobramycin) halo 255 nonsteroidal anti- Mucha-Habermann syn- 374 iris 252 inflammatory drugs drome 270–271 Necator Americanus 180 melanocytic or pig- (NSAIDs) 33, 190 mucinoses 245 necrobiosis 250 mented 254 Norwegian scabies 259 mucocutaneous lymph necrotizing fasciitis and melanoma 38– nose repair 259 node syndrome 196– 250–251 39, 256–257 nucleic acids 260 197 Neisseria meningitidis 235 Mongolian spot 243 nummular dermatitis mucopolysaccharidoses nematodes 271 in pregnancy 293 110–111 182, 245 neodymium:yttrium sebaceous 255 nummular eczema 125 mucormycosis 245 aluminum garnet (Nd: spindle and epithe- Nuprin (ibuprofen) 187 multiple lentigines syn- YAG) laser 205, 298, lial cell 255 nutrition 118–119 drome 245–246 398–399 Spitz 232, 255 Nystatin 32 452 Index

O pachydermoperiostosis Pasteurella pestis. See Yer- periderm 274–275 oatmeal 76, 108, 261, 267 sinia pestis perifollicular fibromas 287, 297 pachyonychia 267 patch 271 275 obstructive jaundice 194 pacinian corpuscles 336 patch test 271–272 periodic acid-Schiff stain occlusive dressings 120 padimate O 267 Pautrier’s micro abscess 275 occupational skin disor- pallor 267 272 perioral dermatitis 111 ders 261–262, 340 palmar-plantar keratosis pearly penile papules 27 perleche 275 oculocutaneous albinism 267 peau d’orange 229, 272 permanent makeup 186 panniculitis 267–268 pediculi. See lice 275–276 oil(s), essential 136 panthenol 268 pediculosis 272. See also permanent wave solu- oil acne 5–6 pantothenic acid 268 lice tions 168–169 oil of bergamot 106– papilloma 268 Pediculus humanus capitis permethrin 276, 319 107, 262, 278, 299 papilloma virus(es) 269, 213 pernio 78 oily skin 340 395 Pediculus humanus corporis pet-borne illnesses 276 ointment 262 papilloma virus, human 213 pet dander allergy 276 old-fashioned soap 347 86, 156–158, 268–269, pellagra 272 petechiae 276 omega-3 fat 235, 338 284 pemphigoid 272–273 petroleum jelly 277 onychodystrophy 262 papovaviruses 269 bullous 272 with anthralin use 29 onychogryphosis 248– papular acrodermatitis cicatricial 272 for carbuncle 70 249, 262 158–159 pemphigus versus 273 for cold sore 83 onycholysis 249, 263 papular dermatitis of pemphigus 273 Peutz-Jeghers syndrome onychomalacia 263 pregnancy 269, 294 acantholysis with 1 277 onychomycosis 247– papular mucinosis 215 azathioprine for 40 phenol 74, 83, 102–103 248, 263–264 papular urticaria 269 familial benign phenytoin, and acne 5 onychotillomania 264 papule(s) 269, 412 chronic 166 phenytoin hypersensitiv- open comedo 2 papulosis, malignant gold therapy for 39, ity syndrome 277 open wet dressings 264 atrophic 101 161 pheomelanin 231, 281 oral contraception. See papulosquamous dis- Nikolsky’s sign in phlegmon 277 birth control pills eases 269 258 photoallergy 21, 277– oral hairy leukoplakia para-aminobenzoic acid versus pemphigoid 278 16–17 267, 360 273 photochemotherapy orf 264 parabens, sensitivity to penicillin(s) 31–32, 42, 278. See also PUVA organizations 20, 107–108, 121, 270 273–274 photodermatitis 278 advocacy/support paradihydroxybenzene. allergic reaction to photophytodermatitis 413–419 See hydroquinone 19, 274 278 professional 420–423 paraphenylenediamine for anthrax 30 photorejuvenation xii orthokeratosis 264 20, 170 for erysipelas 130 photosensitivity 278– Osler-Weber-Rendu dis- parapsoriasis 270 for Lyme disease 222 279 ease 264–266 parapsoriasis en plaques side effects of 274 occupational expo- osteopoikilosis with con- 270 penicillin G 273 sure and 261 nective tissue nevus parapsoriasis guttata 270 for meningococcal phototherapy 279. See 65 parapsoriasis lichenoides infection 236 also PUVA otitis externa 266 chronica 270 for parapsoriasis for pityriasis rosea otoplasty 266 parapsoriasis variolifor- varioliformis acuta 283 overlap syndrome 220 mis acuta 270–271 271 for pityriasis rubra oxacillin 31–32 parasitic infections 271, penicillin rash 274 pilaris 283 oxycodone, for post-her- 340 penicillin V 31–32, 273 for psoriasis ix petic neuralgia 292 parasitosis, delusions of Penicillium 273 photothermolysis, selec- oxytetracycline 31–32, 102 penile papules, pearly 27 tive xii 266 paresthesia 282 peptides 274 phototoxic 279 paronychia 68–69, 248– percutaneous 274 phrynoderma 279 P 249, 271 perforating disorders Phthirus pubis 213 p53 tumor suppressor Parrish, J. xii 274 p-hydroxyanisole 90 gene 337 Parsol 1789 360 perfume 148, 340 pian 401 PABA 267, 360 parvovirus B19 141–143 periarteritis nodosa 274 piebald skin 279–280 Index 453 piedra 376–377 poikiloderma atrophi- pramoxine, for infantile prurigo gestationis of Piedraia hortai 376 cans 315 acropustulosis 190 Besnier 294 pigmentation 280 poikiloderma congenita praziquantel, for schisto- prurigo nodularis 296 disorders of 185–186, 315 somiasis 322 pruritic urticarial papules 280–281. See also poison ivy 286–288, 385 precancerous conditions and plaques of preg- specific types pollutants 75 293 nancy (PUPPP) 293, occupational expo- polyarteritis nodosa 366 pregnancy 296–297 sure and 261–262 polychondritis, relaps- immune progesterone pruritus 297 post-inflammatory ing 309 dermatitis of 294 pruritus gravidarum 292 polycystic ovary syn- isotretinoin contra- 293, 297 in pregnancy 52, 72, drome 353 indicated in vii, pseudoacanthosis nigri- 281, 293 polymethylmethacrylate 7, 192 cans 2 pigment cells 231, 281, xi, 344 itching in 293, 297 pseudofolliculitis barbae 334 polymorphic light erup- mask of (chloasma) 297–298, 308 pigmented purpuric der- tion 279, 288 52, 78, 281, 293 Pseudomonas aeruginosa matosis 162, 225, 281 polymyositis-dermato- papular dermatitis of 266 pigmented purpuric myositis 288–289 269, 294 Pseudomonas pseudomal- lichenoid dermatitis polymyxin(s) 289 pruritic urticarial pap- lei 397 162 polymyxin B 31, 289 ules and plaques pseudoxanthoma elasti- pilar 281 polyomaviruses 269 of 293, 296–297 cum 298–299 pilar cyst 129 pomade acne 6 and skin 293–294 psoralen(s) 232, 237, pilosebaceous 282 pompholyx 125, 289 stretch marks in 356 262, 299 pimecrolimus cream viii pore 289 premature gray hair for psoriasis 262 pimozide, for delusions porokeratosis 289–290 169–170 in tanning pills 328, 102 porokeratosis of Mibelli premenstrual acne 3t 369 pimples 282. See also 289–290 preservatives, allergy for vitiligo 262, acne porokeratosis palmaris to 20 391–392 pinch graft 282, 345 et disseminata 289– pressure injuries 47–48, psoralen-UVA therapy. pins and needles sensa- 290 294–295 See PUVA tion 282 porokeratosis plantaris prickle cell layer 334 psoriasiform 300 pinta 282 289–290 prickly heat 239, 295, psoriasis 300–302 pitch acne 3t porphyria 135–136, 277, 363 adalimumab for viii pityriasis alba 186, 280, 290 procainamide, and lupus AIDS and 17 282–283 porphyria cutanea tarda 220 alefacept for viii pityriasis lichenoides 290 procarbazine 295 anthralin preparations et varioliformis acuta Portuguese man-of-war prodrome, in herpes for 28–29 270–271 195 infection 178 biologic agents for pityriasis rosea 177, 283 port-wine stain 28, 36, progeria 295 51, 301 pityriasis rubra pilaris 52, 55, 200, 254, 290– progressive pigmentary capsaicin for 69 283 291, 357 purpura 72 diagnostic pathology etretinate for 136 post-herpetic neuralgia progressive systemic scle- of 300–301 plague 61–62, 283–284, 291–292, 330–331 rosis. See scleroderma efulizumab for viii 402 post-inflammatory pig- prolidase deficiency 296 emotion and 129 plantar wart 284, mentation 292 promethazine 296 epidemiology of 300 395–396 post-traumatic depig- Propecia (finasteride) 44 etanercept for viii plastic and reconstruc- mentation 103 Propionibacterium acnes 2, etiology of 300 tive surgery 285. See potassium hydroxide 6, 49, 81, 296 etretinate for 136 also specific procedures (KOH), in fungus test- propylene glycol 296 excimer laser therapy platyhelminths 176 ing 152 Proscar (finasteride) 44 for ix plethora 285 potassium iodide 292 Protopic. See tacrolimus Goeckerman regimen plucking, for hair potassium para-amino- Protostat. See metroni- for 161 removal 173 benzoate 292 dazole gold therapy for 161 pockmark 285 potassium permanganate protozoal infections 271, infliximab for viii podophyllin 396 292 296 laser treatment for poikiloderma 285–286 poultice 293 prurigo 296 301 454 Index

location of symptoms Q resorcinol 309–310 rubber allergy 20–21, 300 Q fever 311 for acne 3, 6, 9, 310, 107, 206–207 methotrexate for 301 quartz lamp 305 358 rubella (German mea- methoxsalen for 237 Queensland tick typhus for chemical face peel sles) 158 nails in 248–249, 263 305 74 rubeola 316. See also psoralen for 262 quicklime 88 and yellowing of hair measles symptoms of 300– quick-tanning products 170 rubor 316 301 119, 327–328, 369 Restylane. See hyaluronic ruby laser 205 treatment and out- quinacrine 33 acid gel Rud’s syndrome 316 look for 301–302 Retin-A. See tretinoin S ultraviolet light ther- R retinoids xiii, 310, 349 apy for ix racket nail 306 retinol 310 saddle nose 315 Psoriatec. See anthralin radiation retinyl palmitate 310 St. Anthony’s fire 130, preparations infrared 382 Retrovir. See zidovudine 317 psoriatic arthritis 301 and skin 306 Reye’s syndrome 77 salicylanilides, haloge- pubic lice 213–215 ultraviolet 382–383 Rezamid. See resorcinol nated 91 Pulex irritans 144 radiation erythema 306, rhinophyma 310, salicylic acid 317 pulsed dye laser xii, 36, 307 313–314 for acne 3, 6, 9, 53 52, 176, 200, 285–286, radiation therapy rhinoplasty 259 for blackheads 53 291, 302, 355 for lichenification rhinoscleroma 311 as cosmetic ingredient purpura 302–303 215 Rhus toxicodendron 286 50–51 common or senile side effects of 307 rhydectomy xi–xii, for dandruff 100, 168 303 for skin cancer 46, 139–140 for itching 34 Henoch-Schonlein 306–307 riboflavin for perioral dermatitis 177, 303 radioallergosorbent test and acne 5 111 purpura annularis telan- 307–308 deficiency of 389 for plantar warts 284 giectodes 225–226 radiodermatitis 307 Richner-Hanhart syn- for seborrheic derma- pus 303 rash 307 drome 311 titis 112 pustule 303, 412 RAST test 307–308 Rickettsia akari 312 side effects of 317 spongiform 351 rat-bite fever 308 rickettsial infections salmon patch 354 PUVA 278–279, 299, Raynaud’s phenomenon 311–312 salve 317 303–304 9, 257, 308 rickettsial pox 311, 312 sand-fly bite 208–209 for alopecia areata razor bumps 308 Rickettsia rickettsia 312 sarcoidosis 317–318 24 reactive perforating col- rifampin 212, 312 sarcoma 318 for dermatitis her- lagenosis 308 for leprosy 212 Sarcoptes scabiei 318 petiformis 113 recessive dystrophy ringworm 312. See also Satric. See metronidazole etretinate with 136 epidermolysis bullosa tinea scab 318 for lichen planus (RDEB) 85 Ritter’s disease 312 scabicides 318 215 von Recklinghausen dis- Rocky Mountain spot- scabies 65, 241, 318–319 for Sezary syndrome ease 252 ted fever 311–312, AIDS and 17 329 redneck 285 312–313, 371 crotamiton cream side effects of 303– red tints, and acne 4 rodent ulcer 313 for 95 304 Reeve, Christopher Roentgen erythema 306 diagnostic pathology for vitiligo 392 47 Rogaine. See minoxidil of 318 pyoderma 304 refining lotions 81 rosacea 237, 310, lindane for 214, pyoderma gangrenosum Refsum’s disease 309 313–314 318–319 viii, 51, 304 relapsing polychondritis roseola infantum 136, Norwegian 259 pyogenic granuloma 309 314 permethrin for 276, 304 relaxers xii Rothmund, August von 319 Pyopen (carbenicillin) Remicade 301 315 pet 318 70 Renova. See tretinoin Rothmund-Thomson symptoms of 318 pyridoxine deficiency repigmentation, for viti- syndrome (RTS) 314– treatment and out- 389 ligo 391–393 315 look for 319 pyrilamine 304 reportable skin diseases roundworms 176, 355 scald 319 pyrocatechol 90 309 royal jelly 268, 315 scalded skin syndrome, Index 455

staphylococcal 258, sea urchins 326 shingles 76, 330–331, sentinal node biopsy 312, 319 seaweed 326 387 of x scaling disorders 340. seaweed dermatitis acyclovir for 12, 331 squamous cell 262, See also ichthyosis 111–112 AIDS and 16 337–338, 351–353 of infancy 319–320 sebaceous cyst 129, diagnostic pathology squamous cell in situ scalp reduction 44, 172 326 of 330–331 (Bowen’s disease) scams 345–346 sebaceous glands 326– emotion and 129 59 scar(s) 320 327 neuralgia with 291– symptoms of 337– with burn injury 65 sebaceous nevus 255 292, 330–331 338 camouflage cosmetics seborrhea 100, 327 risk factors and pre- treatment and out- for 66–67 seborrheic dermatitis vention 331 look for 338 dermabrasion for 112 symptoms of 330– tretinoin as preven- 104–105 seborrheic eczema 125 331 tion 375–376 dermaplaning for seborrheic keratoses 13 treatment and out- vitiligo with 391 105 seborrheic keratosis look for 331 warning signs of hypertrophic 65, 198 valacyclovir for 331, 338 185, 320 sebum 327, 335 386 skin care for infants keloid 65, 197, 320 sebum-suppressive shock 338–339 laser resurfacing for agents 327 electrical 127 skin care product allergy 204–205 selective photothermoly- therapeutic 194 340 microdermabrasion sis xii sickle-cell ulcers 331– skin characteristics 340, for 238–239 selective serotonin reup- 332 346 pockmark 285 take inhibitors, for silica 332 skin color 340 scarlatina 321 post-herpetic neuralgia silicone 16, 168, 343 skin cream 340 scarlatiniform 321 292 silicone implant 227– skin disorders 340–341. scarlet fever 321 selenium sulfide, for 228, 332–333 See also specific types Schamberg’s disease dandruff 168 procedure for 332 skin fillers x–xi, 14–16, 281, 321–322 self-tanning products side effects of 333 341–344 schistosomiasis, visceral 119, 327–328 skin 334–335 AlloDerm 21, 342– 322, 364 Senear-Usher syndrome cleansing of 335–336 343 scleroderma 243–244, 328 nerves of 336 Artecoll 36–37 322–324 senile purpura 303 newborn 257, 336– Autologen 40 diagnostic pathology sensitive skin 328 337 autologous fat trans- of 323–324 sensitizers, topical, for skin absorption 261 plant 40 diffuse 324 alopecia areata 23–24 skin biopsy 337 biological implants etiology of 322–323 sentinal node biopsy x skin cancer 337–338. See 51 limited 324 septicemia, rat bite and also specific types collagen injections linear 323 308 albinism and 17 x–xi, 14–16, 84, localized 323 serum sickness 328– alcohol and 18 341–343, 399 occupational expo- 329 awareness of x Cymetra xi, 21 sure and 262 setting solutions, for hair azelaic acid for 41 hyaluronic acid gel symptoms of 323– 168–169 basal cell 45–46, 15–16, 182–183, 324 Sezary syndrome 329 337–338 341, 343 systemic 323–324 shagreen patch 329 diagnostic pathology ideal, characteristics treatment and out- shake lotion 329 of 337–338 of x look for 292, shampoo 168, 329–330, early detection of x skin grafts 344–345 324 348 erythema ab igne and allograft 22 scorpion stings 324 acid-balanced 168 131 autograft 39–40 scratch 325 baby 168 occupational expo- for burns 39–40, scrofuloderma 377 conditioning 168 sure and 262 64–65 sculptured nails 249 dandruff 168 prevention of x full-thickness 345 scurvy 118, 303, 325, for lice 214 radiation therapy for pinch graft 282, 345 389 shave biopsy 337 46, 306–307 split-thickness 344– sea bather’s eruption shaving 173 risk factors and pre- 345 111, 325–326 and skin 330 vention 338 for vitiligo 393 456 Index skin infections 345. See squamous cell cancer stork bite nevus 337, sulfones 358 also specific types in situ (Bowen’s dis- 354 sulfur 358 skin patch 345 ease) 59 stratum corneum 129, for acne 3, 6, 358 skin scams 345–346 squamous cell carcinoma 334, 354 for dandruff 100, 358 skin tags 346 337–338, 351–353 stratum germinativum for perioral dermatitis skin tumor(s) 17, 49, diagnostic pathology 334, 354 111 340 of 352 stratum granulosum 354 for seborrheic derma- benign 346 erythema ab igne and stratum lucidum 354 titis 112 malignant. See skin 131 stratum malpighii 354 sulindac, for Gardner’s cancer occupational expo- stratum spinosum 334 syndrome 155 skin type 346 sure and 262 strawberry birthmark sun, allergic reactions to “slapped cheeks” disease porokeratosis and 52, 176, 254, 354–355 21, 277–278 141–142 290 Streptobacillus moniliformis sunburn 62, 358–359 smallpox 346–347 radiation therapy for 308 aloe vera for 22 smoothers xii 306–307, 353 streptocerciasis 355 in infants, prevention soap(s) 80–81 risk factors and pre- streptococcal infections and treatment of and skin 347–348 vention 354 31, 42, 355 339–340 soap-free cleansers 81 symptoms of 352 ecthyma 123 and melanoma 233 sodium laureth sulfate treatment and out- erysipelas 130 occupational expo- 329, 348 look for 352– erythema margin- sure and 261 sodium lauryl sulfate 353 atum 132 skin types and 346 329, 348 squaric acid dibutyl ester erythema nodosum sun exposure sodoku 308 (SADBE) 23–24 134 clothes and 81–82, soft tissue augmentation. staphylococcal infections group B 165 349, 362 See skin fillers 31, 42, 353 human bite 182 and freckles 149 solar keratosis 10–11 barber’s itch 45 impetigo 188 of hair 167–168 solar lentigo 349 carbuncle 70 necrotizing fasciitis hats and 175 solar urticaria 349, ecthyma 123 250–251 and immunity 188 384–385 folliculitis 145–146 scarlet fever 321 and skin cancer 46 solar UV index 349 furunculosis 153 streptomycin 31–32 sunglass standard, ANSI Solumbra 349, 399 human bite 182 for glanders 159 28 sore 350 impetigo 188–189 for plague 284 Sun Guard 82 Soriatane, for psoriasis rifampin for 312 stress and skin 128–129, sunless tanners 119 301–302 toxic shock syndrome 355–356 sun poisoning 359 SPF 81, 359–360, 361 375 stretch marks 356 sun protection factor spider angioma 36, 55, staphylococcal scalded striae 356 (SPF) 81, 359–360, 255, 294 skin syndrome 258, strongyloidiasis 356 361 spider bite 59–60, 191, 312, 319 Sturge-Weber syndrome sunscreens 360–362 350–351 Staphylococcus aureus 31, 28, 52, 290, 356–357 allergies to 361 spindle and epithelial 45, 70, 153, 182, 189, sty 357 application of 361 cell nevus 255 312, 375 subcutaneous 357 for cancer prevention Spirillum minus 308 Staphylococcus epidermidis subcutaneous fatty tis- x, 235, 338 Spitz nevus 232, 255 240 sue 357 cinnamate in 80 spongiform pustule 351 Stein-Leventhal syn- subcutis, aging and 14 for infants 339–340 spongiosis 351 drome 353 subsurface remodeling PABA in 267, 360 spoon nails 200 steroid(s) 33, 88–89 xii rating of 361–362 Sporanox. See itracon- steroid acne 3t, 5 subungual hematoma titanium dioxide in azole Stevens-Johnson syn- 357 x, 360 Sporothrix schenckii 351 drome 132–134 sugaring, for hair sunstroke 362 sporotrichosis 151, 292, Stewart-Treves tumor removal 173 suntan 362 351 353 sulconazole, for Majoc- superfatted soap 347 spun-glass hair 383– stick eye shadow 226 chi’s granuloma 226 super-wet technique, of 384 stimulator, dermal 105 sulfapyridine 357 liposuction 217–218 squalene 92 sting 353. See also specific sulfonamide drugs 31, suppuration 362–363 squamous cell 351 types 357–358 surfer’s nodules 363 Index 457 sweat 363 tattooing 370 thyroid disorders, skin transposition flaps absence of (anhidro- for vitiligo 393 symptoms of 249–250, 172–174 sis) 28 tazarotene, for aging 263, 371 trauma 340 excessive (hyperhi- skin xiii ticks and disease 221– trematodes 176, 271 drosis) 59–60, Tegison (etretinate) 136, 222, 305, 311–312, 371 trench fever 311 122, 183–184, 370 Tinactin. See tolnaftate trench foot 188 363–364 telangiectasia 370 tinea 116, 151, 372 Treponema carateum 282 foul-smelling (brom- in Osler-Weber- nails in 248–249 Treponema pallidum 365 hidrosis) 59, 102 Rendu disease tinea barbae 372 tretinoin 375–376 reduced (hypohidro- 264–266 tinea capitis 372 for acne 3, 6, 53, sis) 185, 364 in rosacea 313–314 tinea corporis 226, 375–376 sweat glands 334, 363 in Rothmund- 372–373 for aging skin xiii, disorders of 363–364 Thomson syn- tinea cruris (jock itch) 14 swimmer(s), green hair drome 315 195 for berloque dermati- of 164 in scleroderma 323 tinea manuum 373 tis 107 swimmer’s ear 266 telogen 370 tinea nigra palmaris 373 for blackheads 53 swimmer’s itch 111, telogen effluvium 43, tinea pedis 37–38 for chloasma 78 322, 364 370 tinea unguium. See ony- for chloracne 79 swimming pool granu- terbinafine ix, 32, 152 chomycosis for Fox-Fordyce dis- loma 364 terminal hair 167 tinea versicolor 186, ease 148 sycosis vulgaris 45 tertiary syphilis 365 280, 373 for Grover’s disease syphilis 364–365 testosterone, for lichen azelaic acid effects 165 AIDS and 17 sclerosis 216 in 41 for keratosis pilaris chancre of 73 tetracycline(s) 31–32, ketoconazole for 199 199 Jarisch-Herxheimer 371 tissue expansion 44, Triacet (triamcinolone) reaction in 194 for acne 3, 6–7, 31 373–374 376 syringomas 365 for glanders 159 titanium dioxide x, 360 triamcinolone 376 systemic biologics viii–ix for Lyme disease toad skin 279 Triamolone (triamcino- systemic diseases, skin 222 tobramycin 374 lone) 376 symptoms of 365–366 for parapsoriasis Tobrex (tobramycin) trichauxis 376 systemic lupus erythe- varioliformis acuta 374 trichiasis 376 matosus (SLE) 220– 271 tocopherol. See vitamin E trichloroacetic acid 221, 366 for perioral dermatitis toenail, ingrown 191 as bleaching agent systemic necrotizing vas- 111 toe web infection 374 53–54 culitides 366–367 for plague 284 tolnaftate 32, 374 for chemical face peel systemic vasculitis 199 for Queensland tick toners 37, 81 74 typhus 305 topical immunomodula- for wart removal T for rickettsial infec- tors viii 157, 284 tache noir 305 tion 311–312 topical medications 374 Trichophyton 116–117 tachyphylaxis 368 for Rocky Mountain allergies to 21, 107– Trichophyton mentagro- tacrolimus viii, 368 spotted fever 313 108 phytes 226, 263 Tagamet (cimetidine) for rosacea 314 toupees (hairpieces) Trichophyton rubrum 226, 80 thalidomide 371 172, 173 263 talc 87–88 theque 371 toxic epidermal necroly- trichorrhexis invaginata tan 362 therapeutic shock 194 sis (TEN) 133, 258 44, 251 tanning booths/beds thiabendazole, for cuta- Toxicodendron radicans Trichosporon beigelii 376 368–369 neous larva migrans 286 Trichosporon cutaneum tanning pills 327–328, 203 toxic shock syndrome 376 369 thiamine chloride, as 375 trichosporosis 376–377 tanning products 119, insect repellent 245 traction alopecia 22, 172 trichotillomania 377 327–328 thiouracil, and acne 5 transdermal patch 345 tricyclic antidepressants, tapeworms 176 thiourea, and acne 5 transforming growth fac- for post-herpetic neu- tar compounds 369 thrush 68, 118, 151, tor beta 375 ralgia 292 tar sulfur, for dandruff 371, 401 transient acantholytic trigeminal angiomatosis 168 thymol 371 dermatosis 165 356–357 458 Index trimethadione, and acne ultraviolet light warning visible light spectrum repigmentation for 5 badge 382 382 391–393 trimethoprim-sulfa- Ultraviolet Protection vitamin(s), and skin 390 skin grafts for 393 methoxazole, for Factor (UPF) 81–82 vitamin A 118, 389, 390 tattooing for 393 nocardiosis 258 ultraviolet radiation deficiency of 118– Voigt’s line 394 trisomy 8 79 382–383 119, 389 voiles 394 trisomy 10 79 uncombable hair syn- derivatives of xiii, volar melanotic macules trisomy 21 (Down syn- drome 383–384 349 394 drome) 79 ungual 384 and hair loss 172 Trombidioidae 77–78 Unna’s boot 384 for leukoplakia 213 W tropical acne 3t Urbach-Wiethe disease for miliaria 240 Waardenburg’s syn- tuberculin test 377 384 vitamin B drome 395 tuberculoid leprosy 211 urticaria. See also hives deficiency of 118– wart(s) 395–396 tuberculosis, skin 377 contact 384 119, 389 AIDS and 16 tuberculous chancre 377 papular 269 and premature gray cimetidine for 80 tuberous sclerosis 130, solar 349, 384–385 hair 169 common 395–396 186, 248–250, 329, urticaria pigmentosa vitamin B12 digitate 395 377–379 229–230 and acne 5 filiform 143, 395– tularemia 371, 379 urushiol oil 286, 385 deficiency of 389 396 tumbu fly bites 379 UVB narrow band ix vitamin B6 deficiency flat 143–144, 395– tumefaction 379 389 396 tumescent liposuction V vitamin C 389, 390 genital viii, 86, 217–218 vaccinia 386 as antioxidant 33–34, 156–158, 268–269, tunable dye laser 379 valacyclovir (Valtrex) 149–150 395–396 Tunga penetrans 379 35, 386 and bruises 60–61 occupational expo- turban tumor 379–380 varicella virus vaccine for Chediak-Higashi sure and 262 turf (peat) fire cancer of live (Varivax) 76–77, syndrome 73–74 plantar 284, 395–396 Ireland 131 386–387 deficiency of 118, wart removal prepara- Turner’s syndrome 79–80 varicella-zoster virus 303, 325, 389 tions 395 turtle oil 380 76–77, 330–331, 387 for melanoma pre- wasp stings 48 tylosis 380 varicose eczema 125 vention 235 waxing 173, 396 Tyndall light phenom- varicose veins 200, for miliaria 240 weaving, hair 174 enon 380 387–388 vitamin D 389–390 webbing 396 typhus 305, 311–312, variola 388 vitamin E 390 wedge biopsy 337 380–381 vascular tumors 388 as antioxidant 33–34, weeping (oozing) 396 tyrosine 381 vasculitides, systemic 149–150 weeping burn 63 tyrosinemia type II 381 necrotizing 366–367 for leukoplakia 213 Wegener’s granulomato- Tzanck smear 381 vasculitis 199, 388 for melanoma pre- sis 366, 396 vellus hair 167 vention 235 Weil’s disease 212–213 U verapamil, for jellyfish vitiligo 390–394 Werner’s syndrome 295, ulcer(s) 382 stings 195 and cancer 391 396 leg 208 vernix 388 cosmetics for 393– wet dressings 120, 264 rodent 313 verruca 388 394 wet gangrene 154 sickle-cell 331–332 vesicle 388, 412 depigmentation for wheal 396. See also hives ulerythema 382 vinblastine, for Kaposi’s 53, 391, 393 Whipple’s disease 386– ultrasound-assisted lipo- sarcoma 196 excimer laser therapy 397 suction 218 vinegar, for jellyfish sting for ix white hair 169 ultraviolet A (UVA) 195 experimental proce- whitehead 2, 8, 397 382–383 vinyl chloride 91 dures for 393 Whitmore’s disease 397 with psoralen. See viral diseases 340. See methoxsalen for Wickham’s striae 397 PUVA also specific types 237 Willan, Robert 115 ultraviolet B (UVB) AIDS and 16–17 monobenzone for Willett, G. E., leprosy 382–383 with skin symptoms 243 of 211 ultraviolet C (UVC) 388–389 psoralen for 262, Wilson’s disease 397 382–383 treatment of 35 299, 391–392 winter itch 105, 397 Index 459

Wiskott-Aldrich syn- xanthoma 400 Yersinia pestis 61, 283– Zostrix 331, 403 drome 397–398 xenograft 179 284, 402 Zovirax. See acyclovir witch hazel 398 xeroderma pigmentosum yogurt 68 Z-plasty 403 Woronoff ring 398 400 Yushchenko, Viktor 5 Zyderm 84 wound 398 xerosis 400 Zyplast 84 Z wrinkles 398–399. See X-linked ichthyosis also aging and skin 319–320 zidovudine 17, 35, Wuchereria bancrofti 128 196 Y zinc 83, 168, 245, 403 X yaws 401 zinc oxide x, 29, 118, xanthelasma 400 yeast infections 68–69, 283, 360, 403 xanthogranuloma, juve- 401 zirconium-containing nile 400 yellow fever 401–402 complexes 91