Disorders of Skin

OVERVIEW
Through a requirement of patients to remove superficial clothing, you will see a
great deal of patients skin, perhaps more so than when they visit their GP. This
provides an opportunity to identify serious skin disorders that require rapid
therapeutic intervention, e.g. malignant melanoma. In some cases patients don't
even know they are there, or may not appreciate the seriousness of
the condition, or do so, but are reluctant to seek medical help as they fear the worst.

It is very important to be able to recognise the common disorders of skin. In practice,

this difficult as a number resemble each other and patients may often not present as the 'textbook case'.
Very helpful in this differential diagnosis, however, are details obtained from the case history.

Some skin disorders, e.g. malignant melanoma require immediate medical treatment
and are contraindications to non-allopathic intervention as they may be metastases in
bone. Others, e.g. scabies are infectious and failure to recognise them may result in a
spread to other patients and thus prohibit health care practice for a period. Some
disorders are associated with tissue or joint pain, e.g. Herpes zoster and psoriasis,
which may be the reason a patient seeks treatment; others are
associated with systemic disease, e.g. diabetes or other endocrine conditions.

A knowledge of skin disorders precludes asking unnecessary questions, such as 'What's that?'

See also notes on sexually transmitted diseases.

INTRODUCTION
Important to note are:

a) How long the symptoms have been present? (Onset and Duration)
b) The anatomical distribution of the lesions. Where did it first appear?
c) Is there a pattern to the symptoms, e.g. day/night, weekends, seasonal?
d) Are they itchy, painful, scaly?
e) The general medical history of the patient, e.g. diabetes, immunosuppression
f) The family history of the patient - do other members of the family have similar symptoms?
g) Contacts - Do close family friends have similar symptoms?
h) Is the patient on medication and if so what and what are the possible side effects?
i) What are the patient’s hobbies?
j) Have they traveled abroad, if so where and when?
k) What is the patient’s occupation?
l) Do they use of deodorants, after shave, perfume, soap.
m) What is directly on the skin e.g. watch strap, bra strap.

TERMINOLOGY
Macule A flat circumscribed area of altered colour, e.g. freckle, birth mark
Papule A small, solid circumscribed elevation
Pustule A collection of pus, e.g. acne, boil
Vesicle Small (less then 5mm), circumscribed, fluid-containing elevation, e.g. a
blister, shingles
Nodule An elevation that arises beneath the surface
Wheal A slightly raised lesion, pale at the centre with a pink margin and
transient
Bulla A large vesicle
Scale A detached fragment of the stratum corneum
Crust Dried exudates
Plaque A flat-topped lesion
Lichenification (Acanthosis, Hyperkeratosis). An increased thickness of the
epidermis

INFECTIVE DISORDERS

A. Bacterial infections
Refer to the lecture on Biological Basis of Dysfunction.

Impetigo
A superficial, contagious, cutaneous infection due to Staphylococci (especially S. aureus), or
Streptococci. Latter especially in the elderly. Pus accumulates superficially in the epidermis of the hands
and face to produce pustules that rupture easily and leave a thick, golden crust that looks stuck on and
breaks to reveal an red (erythematous) base. It fades without scarring.

Associated with poor hygiene, overcrowding, particularly of children in the same household or institution.
Now relatively rare. It is easily spread by touch. It may be caused by scratching due to eczema, scabies or
head louse infection.

It can be easily treated with antibiotics, but Streptococci can result in post-infective kidney damage
(glomerulonephritis) due to cross-reacting antibodies.

Cellulitis (‘Erysipelas’)
Due to Streptococcus pyogenes that gain entry through breaks in the skin and spread due to an enzyme
that digests connective tissue.

Abrupt onset, unilateral, dermal lesions occur with sharp boundaries that are bright red, hot oedematous,
painful and spreading. Usually with fever. The patient may feel unwell and the elderly confused.

Occurs on the face and occasionally legs.

Treated with antibiotic, bed rest, cold compresses.
Necrotising fasciitis is extensive tissue necrosis, with several bacteria present and can be fatal. Wrongly
described as a ‘flesh-eating virus’.

Folliculitis
Staphylococcus aureus infection of superficial hair follicles. Follicles become blocked and infected.
Clusters of small red papules become yellow pustules on a red base.
Transmitted from infected razors, towels, shaving brushes, or due to in-growing hair.

Boils (feruncles)
Acute pyogenic inflammation of hair follicles due to Staphylococcus aureus that results in painful,
subcutaneous abscess. Source may be nostrils or the perineum. Area around boils are contaminated with
bacteria which can be spread by soft tissue work.

A mass of them is a 'Carbuncle'. Occur especially in elderly men, diabetics and with those with debility.
At the back of the neck, deep seated infection may result in scars.
 Primary and Secondary syphilis
A systemic disease from the start. primary syphilis results in a painless nodule
(chancre) at the site of infection, 1-4 weeks later, that is a granuloma (chronic
inflammation). Secondary syphilis occurs 4-8 weeks later, typically causing a symmetrical, coppery rash,
evident also on the palms and soles, but it is 'a great deceiver' and can be confused with other disorders.

B. Viral infections
Tend to occur in the metabolically active, rapidly dividing cells of the basal layer.

Herpes simplex virus (HSV)

Type I causes 'cold sores' especially around the mouth. Type II causes 'Genital Herpes'. The distinction,
however, is not so clear cut.

Oral Herpes is present in 50-100% of the population, depending on socio-economic

Status. Many people are carriers and are antibody positive.

The incubation period is one week (but variable). It is heralded by a sensation (tingling, burning, itching,
numbness, discomfort) on and around the lips and chin. A few hours later, red papules or vesicles appear
that coalesce and burst to form a shallow ulcer about 1 cm diameter with a red margin that persists for 7-
10 days.

It is spread by personal contact-even from people without vesicles, saliva (e.g. on a treatment couch),
towels and cutlery. It can also be transmitted in contact sports, e.g. rugby, wrestling (‘scrum pox’, ‘herpes
gladiatorum’).

It often first occurs age 2-3 due to infected adults kissing children. Children often refuse to eat and are
irritable.
The majority of primary infections are sub-clinical, but with atopic eczema it can be extensive on head
and neck and with lymphadenopathy and be life threatening. It can be so severe, especially in
immunosuppressed patients, to require hospitalisation and may spread to other organs, e.g. liver, brain
and can cause corneal scarring. Some 50-100 cases occur annually in UK of encephalitis due to Herpes.

Like other Herpes infections it remains dormant to be reactivated later. As the facial
area is innervated by the Trigeminal Nerve (V), it remains within the Trigeminal
ganglion.

It is present for life. Many adults have recurrent Herpes, though the frequency of occurrence declines with
age.

It is often associated with the common cold or fever, hence termed 'fever blisters' and also reactivated by
bright sunlight, trauma, menstruation, emotional stress, fatigue,
pregnancy, infections, i.e. whenever general health declines.

Herpetic whitlows occur due to inoculation in finger pulps.

Treatment: Keep area clean and dry. Rehydrate body. Zovirax (Acyclovir) useful in
early stages.

Genital Herpes is a common sexually transmitted disease, implicated in the aetiology of cervical
carcinoma.
Herpes zoster
Causes chicken pox that reactivates as shingles (Latin: cingulum = girdle), due to breaking through
immune restraints, probably involving stress, immunosuppression, UV light. Once mostly seen in the
elderly, it now also occurs in young adults (20+) (due to changes in life-style, stress?).

Remains latent in dorsal root ganglia, or ganglia of cranial nerves. Occur unilaterally with a dermatomal
distribution usually on the chest and abdomen (T3-L2), The Trigeminal nerve (CNV) is the commonest
cranial nerve to be affected and if along ophthalmic branch can cause corneal scarring and blindness. Can
also affect sacral ganglia and vesicles appear on genitals.

Prodromal (i.e. before the event) pain or paraesthesia (tingling) occur, occasionally fever. Pain
may proceed the rash by a week and may be reason the patient seeks treatment. 3-4 days later clusters of
oval, firm vesicles appear on an red (erythematous) base, resembling chicken pox, in which the virus is
present for about one week. Vesicles then dry up to form dry crusted lesions that resolve in 2 weeks
(longer in the elderly), but usually with some residual scarring.

Note the vesicles may initially not be along the entire spinal nerve, but as a small
patch. Always bear this in mind if a patient complains of localised chest pain.

Pain may be excessive and last several weeks (post-herpetic neuralgia) especially in
the elderly.

Secondary infection and lymphadenopathy may occur.

Serious in the immunosuppressed, leukaemia, steroid therapy-can spread to other

organs including the brain.

Treatment: Bed rest, simple analgesics, maintain fluid balance, good nutrition, topical
lotion, e.g. calomine. Possibly Acyclovir in early stages.

Best avoid massage/soft tissue work as it may worsen the condition.

Warts
Benign epidermal neoplasms-Squamous cell papillomas caused by the Human Papilloma Virus (HPV).
Appearance depends on the type and location. Some 90 sub-types. Those that cause genital warts
different from skin warts.

Common - most people have them at some time, especially in childhood or early adulthood. Transmitted
by direct contact or shed skin - encouraged by moisture, e.g. swimming baths, showers, saunas, or in
certain occupations-butchers, fish mongers. Genital and anal warts are transmitted by sexual contact.

Most disappear in time. They can be removed with salicylic and lactic acid ('salactol'), or cryoptherapy
(liquid nitrogen), but satellite warts may then occur. Problem in the immunosuppressed.

The common wart occurs as a raised cauliflower-like, hyperkeratotic, firm papules at the site of trauma
(Köbner phenomenon), single or scattered, occur anywhere, but especially on the knees and hands.

Plane warts are flat topped, flesh-coloured plaques and occur on the face and back of the hands. They are
difficult to treat and best left to resolve.

Plantar warts (Verrucae) occur on the soles of the feet, solitary, scattered or grouped and grow inwards
because of the pressure. They can be very painful. Transmitted especially in showers i.e. common in
sports people. Small black dots evident are thrombosed capillaries.
Genital warts Large and fleshy. The incidence has increased in the last decade, particularly in those
under 24 years of age. Implicated in the aetiology of cervical cancer.

Molluscum contagiosum
'White warts' caused by a pox virus, usually in children under 5. Reddish, or pearly
white/pink papules occur with a keratin plug and small central depression and 'cheesy' core, often on face,
neck, occasionally the trunk and often grouped. Can occur in adults, especially if immunosuppressed, as
large pedunculate lesions. Genital occurrence now commoner.
Best left to resolve.

C. Fungal infections
‘Athelete’s foot,’ ‘Ring worm’,'Tinea'
Several genera and species of fungus that live in the upper, keratinised layer of skin
(hence termed Dermatophytes). They spread outwards as a red, scaly ring.

'Athlete's foot (Tinea pedis) occurs particularly if areas sweaty, or damp, e.g. clothes or shoes prevent
sweat evaporation, swimmers, leaky shoes.
High incidence in school children and the military.
Fungus can survive and proliferate off the human body, e.g. on floors, in shoes, i.e. indirect
contamination from infected keratin usual.

Commonly between 4th and 5th toe. The skin becomes moist and white (blotting paper skin), itchy and it
may spread to soles and occasionally dorsally on foot. Secondary infection common that causes redness
and itching and fissuring of the skin.

‘Ringworm’ occurs elsewhere on the body due to scratching an infected area, especially body folds, groin
(Tinea cruris), or axilla.
The area has clear raised, red, advancing edge, with paler (healing) centre.

May occur on the scalp (Tinea capitis), especially in puberty when the sebum is rich in fatty acids. There
is patchy hair loss and scaling.

Also infects palms and nails. Toe nails may become thickened and friable and painful on touch.

Treated with Imidazole and related fungicides. Hygiene is also important.

Candida
A yeast that lives as a commensal in mucus membranes and the gut, but can live on the skin.

It occurs in the axilla, groin, mammary folds and fat aprons of the obese (Intertrigo), especially if poor
hygiene, as glazed, brick-red lesions. Painful fissures may develop.
Produces napkin candidosis in babies.

Occurs in nails and nail folds (paronychia) of those who occupationally have their hands immersed in
water for long periods, e.g. dishwashers, fish mongers.

Orally and vaginally it causes ‘thrush’ in some individuals, especially in the elderly and the
immunosuppressed, e.g. those on steroid therapy and those on broad spectrum antibiotics. Its presence
warrants suspicion of diabetes. It may also be associated with pregnancy or oral contraceptives.
Orally: As white patches which bleed if scraped.
Vulvo-vaginally: May result in itching and burning sensations and severe 'cottage
cheese' discharge, especially in those pregnant, on oral contraceptives, or diabetic.

Causes inflammation on the foreskin and glans of uncircumcised men.

Treatment: Keep dry and clean. Fungicidal cream.

Pityriasis versicolor
A yeast-like infection, normally commensal in hair follicles of young adults, resulting in persistent,
usually asymmetrical, café-au-lait, brownish, or depigmented patches on upper trunk and upper arms with
fine scales. Pigmentation varies with skin colour, hence name. Asymptomatic.

Associated with hot humid weather in the UK, and commoner in the tropics.

Treated with fungicidal cream.

D. Animals
Scabies
Causes by a mite - Sarcoptes, which burrows in the epidermis but results in an inflammatory,
hypersensitivity reaction in the dermis. Females lay eggs and a new generation emerges 14 days later.

Spread by direct contact, e.g. holding hands, massage/soft tissue work, as it requires prolonged skin to
skin contact, but also in sheets and blankets through sharing beds (treatment couches?).

4-6 weeks after infection, a severe itching occurs, especially at night or after a hot bath. Severity of
symptoms depends on extent of allergic reaction to the mite faeces.

Tortuous burrows evident up to 1.5cm long with mite at the end as a white vesicle.
Burrows appear erythematous due to allergic reaction. A rash occurs as small papules which is an allergic
reaction. Between fingers, flexor aspects of wrist, elbow, anterior axillary fold, periumbilical around
waist, buttocks, inner thigh and ankles, but occasionally buttocks, genitals in males, around nipples in
females. Very rare on chest, back, or head. Secondary infection may be present.

Mite paralysed by cold (less than 16C). Treated with Malathion (‘Qualada’) lotion, or benzyl benzoate
(cheap, but an irritant). Applied head to toe, 2-3 times, 24 hours apart. Other people in the household
should be treated.

Lice
Body lice live in seams of clothing and feed of the body and important in transmitting typhus. Common
where poor hygiene and poverty.
Head lice commoner in those with long hair. They have now ‘climbed the social ladder’. Eggs attached to
hairs as 'nits'.

Pubic lice Location depend on hair spacing, i.e. can occur in body hair, beards and eyelashes.
Spread by sexual contact. Result in an itch, small, purple macule at site of feeding, reddish/black spots on
underwear (blood). Feeling of being 'lousy'. Treated as for scabies.

Other arthropods: bites of fleas, bed bugs, mosquitoes, ticks. Pustules occur in 3s: ‘breakfast, lunch and
dinner’.

DISORDERS OF TISSUE GROWTH

Malignant disorders
Malignant melanoma
Malignant tumours of melanocytes, but some lack pigment. Really a melanocarcinoma. Occur on skin,
but also in the CNS, e.g. the retina as melanocytes present there.

Sun exposure important in aetiology, but not directly related to hours of exposure. Short intense episodes
important.

High incidence in fair skinned people (fair or red hair; blue or green eyes), living near tropics, frequent
holidays in the sun, young emigrants, with family history of it. Increase in incidence (incidence doubling
each decade) due to increase in sunny holidays and sunbathing and use of sun beds.

Increasing incidence. High proportion young adults, more so than other skin cancers.
Twice as commoner in females.

Commoner if many melanocytic naevi. 30-50% from a preceding naevus.

Several types. Mostly as a Superficial spreading melanoma. Flat, brown, black or bluish, irregular nodule,
with colour variation. Radial growth before invasion.

May become U-, or crescent shaped. Irregular pigmentation and may bleed. Occur anywhere, but
especially legs of women and trunk of men. Other types are nodular, or occur on the soles of the feet in
China and Japan. Can occur around nails, where it is often mis-diagnosed.

High potential to metastasise once they spread to lymphatics and blood vessels in the dermis. Metastasise
via lymphatics to lymph nodes. Haematogenous spread to other organs, e.g. liver, lung, brain, gut and
elsewhere in the skin.

Lethal - early diagnosis is important.

ABCDE Features:
A Asymmetrical -outline and surface
B Border (irregular)
C Colour: variable
D Diameter (More than 0.6cm - i.e. blunt end of pencil)
E Elevated

Another diagnosis is based on 3 or more of the following:

1. Getting bigger
2. Irregular outline
3. Irregular pigmentation
4. Greater than 1cm diameter
5. Inflamed/reddish border
6. Oozing or crusting
7. Itches or hurts

Treatment by excision at the earliest opportunity following diagnosis. The deeper it is, the worse the
prognosis. Prevention better. ‘Slip (on a shirt), Slap (on a hat), Slop (on sun block lotion). Avoid
sunburn. Avoid the midday sun (11-3)’.

Basal cell carcinoma (‘Rodent ulcer’)

Commonest form of skin cancer. Despite its name, there is uncertainty from
which cell type the tumour is derived.

Occur mostly on the face, occasionally shoulders and back.

Takes several forms. Often as a small glistening semi-transparent pearly papule with blood vessels (i.e.
bleeds easily). Grows slowly (0.5cm a year). Central necrosis then occurs forming a shallow ulcer with a
rolled edge. Growth continues to produce
extensive local damage to soft tissue and bone resulting in hideous facial deformity if not treated.

Differs from squamous cell carcinoma in that it grows slower, ulcerates and
with a raised, pearly border, rather than white and opaque and the centre is crusty rather than scaly.

UV exposure important in the aetiology - common in fair-skinned Europeans in tropics and subtropics,
e.g. Australia, South Africa, particularly if working outdoors.

Mostly in elderly - over age 40 (can occur earlier) in both sexes equally.
Rarely metastasizes, but highly invasive.

Squamous cell carcinoma

Four - five times less common than basal cell carcinoma.

Malignant tumour derived from keratinocytes, usually on lower lip, ears, cheek, scalp. Less commonly
elsewhere.

Commonest cause is UV (sun) damage in the elderly, but also tar, machine oils, X ray,
immunosuppression. Smoking (mouth tumours) and genital warts (genital tumours) also important in the
aetiology.

Starts as a nodule with a warty or scaly surface, which after 2-3 months
reaches 1-2 cm diameter. It is rough, hyperkeratotic, expanding and ulcerated.
Can appear as a cherry-red nodule 4-5cm diameter.

Metastasis, relatively late and uncommon, to lymph nodes. Treated by excision.

Premalignant Disorders and Carcinoma in-situ

Bowen's carcinoma
Low grade dysplasia and squamous cell carcinoma in situ. Elderly. Seldom invasive. Once associated
with arsenical 'tonics'. Occurs as well demarcated, erythematous, or brownish solitary scaly patch that
expands slowly. Resembles psoriasis. Often associated with solar keratosis.

Senile, actinic or solar keratosis

Epidermal dysplasia due to UV light over long periods, e.g. in Queensland Australia.
Commoner in fair- haired people who tan poorly but burn easily and those with outside occupations, or
recreations. (‘farmer's skin’, ‘seaman's skin’)

On sun-exposed sites, e.g. face, back of hands, forearms, lower legs, bald scalp.
Lesions, small (up to 1cm),often multiple (100s can occur). Rough, pigmented hyperkeratotic surface.
Red scaly patches wax and wane.

Have low grade malignancy potential.

Keratoacanthoma
Large, symmetrical keratotic, crater-like tumour on sun-exposed sites in the elderly.
Base often red and inflamed and may be painful. Resembles a squamous cell carcinoma, but does not
invade deeply and never metastasises.

Rapidly growing. In 2-3 weeks grows to 2-3 cm, reaching maximum size in 6-8 weeks. Develops
necrotic centre. Clears spontaneously, but leaves a scar.

Benign Disorders

Seborrhoeic warts/keratosis (Basal cell papilloma)

Common, especially in the elderly. Not a disorder of the sebaceous glands. Dark,
nodule/plaque with a roughened, surface and look stuck on and greasy/granular. Itchy. Pale to deeply
pigmented. Single or multiple. Large numbers associated with malignancy.
Occur on the head, neck, back of hands, forearm, trunk and become inflamed if scratched. Can reach 3cm
diameter. Removed for cosmetic reasons.

Skin tags
Pedunculate, benign tumours, often around the axilla or neck, possibly due to friction
on the skin. Predisposed by obesity and age.

DERMATITIS AND ECZEMA

The terms are often used interchangeably.

The principal symptom is itching. Look for scratch marks and polished fingernails, as if varnished.

3 clinical appearances:
a) Acute: red, swollen, oozing, hot, painful, vesicles present.
b) Subacute: red and swollen, but dry, crusty/scaly centre and itchy
c) Chronic: skin thickened and fissured, scaly and itchy. Only slightly oedematous.

Atopic eczema/dermatitis
Type I Hypersensitivity reaction. Family history associated with elevated IgE.
Scaly lesions, often symmetrical. Secondary infection common, e.g. bacteria, Herpes. Latter can lead to
severe illness (see above).

Increasing in developed World in recent years. Predominant symptom is an intense itch. Often starts in
first year of life.

Irritant dermatitis
Acids, alkalis, detergents, petroleum products, e.g. ‘Housewife’s hand’ with dry skin and painful fissures,
due to shampoo (hairdressers), machine oil (engineers mechanics).

Juvenile plantar dermatosis

In children wearing socks of synthetic material. It occurs on the weight-bearing areas of the soles.

Contact dermatitis
Due to a Type IV (delayed hypersensitivity) reaction.

Direct contact with substances that damage the skin barrier, particularly
occupationally related: clothes washing, hairdressers, potters, cleaners, fish industry.
Skin becomes painful and itchy and secondary infection often occurs.
May be due to:
Nickel in jewelry, zips, coins, cutlery, suspenders, jean studs, watches
Rubber: shoes, condoms, latex gloves
Resin in Elastoplast
Dyes: hair dye, tattoo dye
Chemicals, e.g. chromates in cement, leather tanning
Medication, e.g. neomycin
Plants, e.g. poison ivy

It may show a distribution of that of the irritant, e.g. where a watch was worn, or
where perfume applied.

Eczema of the hands and feet

Chronic symmetrical eczema may occur on palms and soles.
Papules look like sago grains or frog spawn, deep set more easily palpated than seen. Often in Summer
months and reoccur annually. Secondary infection is common.
Associated with excess sweat production and stress.
In Pompholyx there are tense, fluid-filled blisters which are intensely itchy and last several days (up to a
month).

Asteatotic eczema
Dry, irritable skin. Large scales with crazy paving appearance, mainly on legs, occasionally lower
abdomen and arms.
Common in elderly. Due to a decrease in lipid content of the stratum corneum, e.g. due to too frequent
hospital baths, soap not washed off.

‘Seborrhoeic’ dermatitis
Misnomer as not related to sebaceous glands. Scaly and itchy. Associated with increased yeasts in skin.
Predominantly males. Occurs on the face, scalp, chest, upper back and flexures. On scalp it presents as
severe, persistent dandruff. Produced glazed lesions on trunk. May occur in infancy as 'cradle cap'.
Especially severe in AIDS.

Stasis dermatitis (varicose eczema)

Associated with venous insufficiency. Often precedes ulceration. Occurs on inner aspect of lower leg, as
an ill-defined red, very itchy, scaly area.

Neurodermatitis
Well demarcated area that occurs. Stress or emotionally initiated. Itch scratch itch cycle results in its
persistence. Clue: location relates to whether person is right or left
handed. Occurs usually on the back of the neck, below the elbow, hands, inner thigh, anus, genitals.

PHOTOSENSITIVITY
Photocontact dermatitis (Photoallergy)
Abnormal response to UV light and occasionally visible light. Evident on light-exposed areas of the skin,
i.e. related to clothing worn.

Photophobic dermatitis (phototoxicity) a photosensitising agent on skin, e.g. plant contact, chemicals
in soap, causes eruption on light-exposed areas.

Polymorphic Light eruption

('sun allergy') Common. 10-15% develop it of people at some time in their lives, often initially aged 8-15.
Occurs as an itchy eruption papules or plaques on some sun-exposed sites, e.g. hands and face, often in
spring and decreases with increasing sun exposure. Occasionally with secondary infection.

Sunlight may exacerbate disorders, e.g. seborrhoeic dermatitis, atopic eczema,

Herpes simplex, but benefits psoriasis.

DRUG REACTIONS
Especially to antibiotics, NSAIDs, anti-convulsants. May involve any of the 4 types of Hypersensitivity.
May result in a rash (measles-like), purpura, erythema, or exfoliation.

PSORIASIS
(See sessions on disorders of joints)

Chronic relapsing and remitting, scaling disorder.

One of commonest skin disorders (2% of pop) males and females equally. Any
Age.

In classical psoriasis there are sharply defined slightly elevated, red areas (plaques), often as discs several
cms in diameter, with asymmetrical distribution, single or multiple, but can almost cover the body.
Abrupt transition into 'normal' skin. Healing at centre.

Covered in large, adherent, silvery scales which result in pin-point bleeding when
rubbed off (diagnostic) as capillaries almost reach the surface.

Lesions tend to develop at sites of trauma (Köbner phenomenon), i.e. especially extensor surfaces,
elbows, knees, hands, scalp, lumbo-sacral area.
Often itchy.
May be stable, or slowly grow, or resolve, often latter in response to sunlight.

Strong genetic component, but with environmental triggers

Commoner in colder countries and among fair-haired people.
Worse in spring and autumn.
Triggers: Trauma, infection, possibly stress
Episodic. Flare ups. Varies over months, years.

Increase in keratinocyte proliferation rate, i.e. epidermal thickening (acanthosis) occurs (due to cytokines)
with increase in mitosis in the basal layer and the transit
time of keratinocytes to the surface is shorter, such that the cells are not fully matured and with nuclei and
shed in large clumps.

Why do some areas remain normal?

Scalp: resembling sebaborrhoeic dermatitis, but lesions can be felt. Cause variable hair loss.
Nails: pitting and nail plate lifts off (onycholysis) and becomes yellow or brown and with ‘greasy’ spots

5-10% have arthropathy (see disorders of joints)

UV light (phototherapy) is helpful, i.e. holidays abroad, or sun lamp therapy. It is also treated with topical
and systemic drugs, methotrexate, coal tar.
LICHEN PLANUS
A chronic inflammatory disorder.
Acute eruption of polygonal, itchy papules, violet, shiny and flat-topped and slightly scaly. Resembles
drug eruption.
Fine white streaks or dots in early stages is diagnostic.
Pea-sized, but may fuse into larger areas.

Occur on flexor aspects of the wrist, palms, soles, often at sites of trauma, e.g.backs of the hands (Köbler
phenomenon), but also on genitalia and oral cavity, where they may appear as white spots or streaks, or a
bald area of the tongue.

Commoner in middle years, but any age after 10. Psychological factors and trauma
may be important in aetiology. Possibly has immunological basis.

Acute type appears rapidly, covers a large area, intensely itchy, but rapidly disappears. Chronic type
begins insidiously and progresses slowly.

Spontaneous resolution usually 3 months to 2 years.

Two-thirds of cases it clears by 15 months to leave an area of skin with increased or decreased pigment.
May be treated with steroids.

BLISTERING DISEASES
Fluid accumulation in epidermis. If <5mm= a vesicle; >5mm = a bulla.

Causes:
a) Genetic (Rare)
b) Physical: friction, heat, cold. Commonest
c) Invasion, e.g. carcinoma
d) Inflammatory, e.g. Herpes simplex and zoster, Streptococci, Staphylococci
e) Drug reaction, e.g. aspirin, barbiturates, paracetamol
f) Insect bites
g) Metabolic, e.g. diabetes
h) Associated with coeliac disease. Small, intensely itchy blisters occur on extensor surfaces of
young adults (Dermatitis herpetiformis)
i) Autoimmune

Pemphigus
Loss of adhesion of epidermal cells close to basal layer, or higher. In 50% it involves the mouth, but can
occur anywhere. Blisters rupture and heal slowly. Pathognomonic is that edge of blister slides when
pushed. Middle aged and elderly. Has high mortality.

Bullous Pemphigoid
the split is at the dermal-epidermal junction (See autoimmune disorders). More than 80% are over 60.
Commoner than pemphigus. Generally self-limiting and associated with pruritus.

DISORDERS OF SKIN DERIVATlVES

Pilosebaceous follicles: hair and sebaceous glands
Sweat glands
Melanocytes
Nails
Disorders of pilosebaceous follicles
Acne vulgaris
One of commonest skin disorders. (80% of people sometime). Due to blocked follicles.

Pathophysiology
i) Excess sebum secreted by overactive sebaceous glands, due to testosterone secretion.
ii) It is unable to escape from the follicles due to plugged orifice.
iii) Hyperkeratosis occurs due to abnormal keratinisation and hyperplasia
of duct cells.
iv) Infection by obligate anaerobes that proliferate, break down sebum into irritant chemicals that leak
into the dermis
v) Inflammation

Effect is pimples (Comedones), either closed (whiteheads) or open (blackheads), papules and pustules,
where sebaceous glands abundant on face, chest, upper back. The skin becomes thick and greasy and
complexion 'muddy', nodules may occur, cysts and scars.

Highest incidence age 10-20 (but exceptions).

Both sexes affected, but occurs earlier in girls, where it may vary in severity with the menstrual cycle, but
rather more persistent in boys. May be mild, moderate, or severe. Fluctuates and may be worse on stress.
Usually (not always) settles in 2-3 years.

Not related to diet (sweets, fatty foods), hygiene, exercise, use of cosmetics, hormone imbalance, or
sexual behaviour. Not contagious.

Rosacea
Relatively common. Any age. Especially in middle-aged women, but also in men.

Over responsive blood flow to follicles. Demodex mite often found in the follicles.
Erythema on face, spreading to neck which then becomes persistent. Papules and pustules develop.

If sebaceous glands undergo hyperplasia, it leads to Rhinophyma of the nose, which can be severe in men.
Treated with tetracyclines.

Change in hair texture

Brittle hair in hypothyroidism, iron deficiency, hairdressing techniques, women who have had chemicals
on their hair long term.

Excessive hair growth

a) Hirsutism (Hirsuties)
Hair has post-pubertal male distribution in females, i.e. on face etc. In post-menopausal women it is due
to adrenal androgens not being balanced by ovarian oestrogens. Fine body hair converted into coarse
hair, e.g. Mediterranean women. Can cause distress.

Due to excessive androgen secretion from ovaries or adrenals in females, or due to increased sensitivity
of follicles to androgens, consequential to adrenal or pituitary or other tumours, Cushing's disease,
polycystic ovaries, drugs.
Endocrine assessment therefore needed. Check family history, drug history, e.g. steroids, contraceptive
pill, or precocious puberty.
b) Hypertrichosis
Not restricted to male pattern of hair distribution, e.g. spina bifida occulta

Hair Loss (Alopecia)

Numerous causes

i) Male pattern baldness. Commonest. Hair loss from temples and crown. Testosterone-dependent in
genetically susceptible individuals. Increases with age. Occurs in a small proportional of post
menopausal
women.
ii) Pregnancy. Increase hair growth during pregnancy that is shed after 4-9 months after childbirth.
iii) Syphilis - secondary syphilis there is a 'moth eaten' pattern of hair loss.
iv) Endocrine disorders Hypothyroidism and hypopituitarism.
v) Nutritional: generalised malnutrition, protein deficiency, iron deficiency,
zinc deficiency, fatty acid deficiency, excess vitamin A.
vi) Drug induced, e.g. beta blockers, Warfarin, chemotherapy (anti-mitotic agents).
vii) Congenital disorders
viii) Psychological- compulsory desire to pull out hair (trichotillomania) -
shows unilaterally and evidence of broken hair ends
ix) Traction alopecia- tight hair styles, over brushing
x) Fungal infection -ringworm
xi) Severe liver or renal impairment
xii) Fever, haemorrhage, surgery, emotional stress
xiii) Autoimmune (Alopecia areata) sudden area of baldness in childhood or early adolescence
xii) Poisoning

Sweat Glands
Excess sweat production (Hyperhydrosis)
May be local or general. Due to heat or emotional factors.

In Miliaria ('Prickly heat') there is sweat gland obstruction, with secondary infection.
Itchy eruption.

Apocrine glands in arm pits and groin may succumb to deep-seated inflammation
with pustules and abscess that result in deep scarring.

Melanocytes
Lack of pigmentation

a) Albinism
Autosomal recessive disorder. See genetic basis of disorders. Due to absence of the enzyme required for
melanin production.

b) Vitilago
Acquired depigmentation in a small or large area, often symmetrical, over hands or around mouth or eyes.
May be autoimmune destruction of melanocytes, preceded by melanin loss from them.
May be a family history and/or other autoimmune disorders present.
May be associated with some systemic disorders, e.g. diabetes.
Sometimes no known cause (idiopathic)
Köbner phenomenon evident.
c) Drugs and chemicals, e.g. hydroquinone used to lighten skin.

Increased pigmentation

a) Freckles
Melanocytes produce an abnormal amount of melanin in fair people, especially if red-haired,
consequential to a hyper-responsiveness to UV radiation.

b) Chloasma
Increase in melanisation that is hormonally induced, e.g. pregnancy, contraceptive pill. Often forehead,
cheeks, around eyes, in response to sunlight or spontaneous.

c) Addison's disease
Cortisol deficiency, i.e. Increase in MSH and ACTH (both derived from the same molecule-POMC).

Naevi
The term has several meanings.

a) Melanocytic naevi (moles)

Very common. Melanocytes fail to mature and migrate properly. First appear in second decade. Average
white-skinned person has 20-50.

i) Banal or acquired naevi

Very common. Uniform brown. 2-3mm diameter. Most appear in first 20 years of life and develop to
40s and usually disappear. May darken and elevate with age, or become skin tags. An excessive number
may be a risk factor for melanoma, which develops in them and they may be confused with it.

ii) Congenital melanocytic naevi

Seen in 1% of babies. Usually less than 5cm diameter. There is an increased risk of melanoma,
especially with Giant 'bathing trunk' naevi

b) Deep capillary naevus

Port wine stain. Usually on head and neck and unilateral in the territory of the Trigeminal nerve. My
darken and thicken with age and develop nodules. Treated by laser or cosmetics.

c) Strawberry (cavernous) naevi

Arise shortly after birth, especially on head and neck and napkin area, Grow rapidly to become dome
shaped, red-purple and may be large and unsightly. 50% resolve by 5; 70% by age 7.

Nails
Congenital: absent or rudimentary nails.
Beau's lines Transverse ridges or depressions after severe disease, e.g. pneumonia
Spoon shaped nails (Koilonychia) iron deficient anaemia (also car mechanics due to
oil, rickshaw pullers.
Convex nails in finger clubbing consequential to chronic diseases of the heart, lungs, liver, gut
Splinter haemorrhages, e.g. bacterial endocarditis.
Infection, e.g. fungi- nail elevated from bed.
Malignant tumours-bleeding pigmented nodule at periphery.
Pitting in Psoriasis and eczema.
Ill-fitting footware
In-growing toe nails
SKIN DISORDERS CONSEQUENTIAL TO SYSTEMIC DISORDERS

Vascular Autoimmune Collagen disorders

Infection Endocrine Nutritional

a) Vascular

Leg ulceration
Mostly venous ulcers (70-80's) and occur on the lower leg of the elderly. Very common. Often
precipitated by minor local trauma. Associated with varicose veins and varicose eczema. Due to venous
stasis

Arterial leg ulcers result in severe pain and poor foot pulse and claudication. Have
a punched-out appearance. Often on legs of diabetics and in severe atheroma.

Vasculitis
Inflammation of walls of small and medium-sized blood vessels, e.g.
chilblains. Dusky red, round or oval intensely itchy areas on fingers,
toes, especially in cold, damp weather.

Telangectasias
Capillary dilation. Seen in the elderly, prolonged steroid therapy, liver failure.

Erythema nodosum
Painful palpable dusky blue-red blotches on calves and shins (occ
forearms). Often fever, joint pain, malaise present. Common in women.
Due to drugs, or infection.

Purpura
Haemorrhaging (See Blood disorders).

Urticaria (‘hives’, ‘wheals’ , ‘nettle rash’)

Recurrent, transient, dermal oedema. Lesions appear rapidly as an
itchy weal or plaque and then disappear. In most cases cause unknown.
May be drug reaction (e.g. aspirin, penicillin), food allergy, food preservatives, contact dermatitis, insect
sting, heat, cold. If in mouth or upper respiratory tract can be life-threatening.

b) Autoimmune disorders
e.g. SLE: butterfly rash; Scleroderma: tight atrophic skin and calcified
nodules.

c) Collagen disorders
Ehlers-Danlos Syndrome. Genetic. Results in hyperelasticity.
Rheumatoid disease-nodules.

d) Infection
Rash associated with measles, rubella, secondary syphilis.

e) Endocrine
 Diabetes
Some nine different conditions occur, e.g. Pruritus and skin becomes shiny and atrophic.
Red or yellow plaques with marked blood vessels (Necrobiosis lipoidica).
Ulceration of feet.

Myxoedema
Dye to hypothyroidism. Skin dry.
Pre-tibial myxoedema-Raised red, waxy plaque at front of tibia, with
prominent follicles: Graves’ disease.

Hyperthyroidism (increased sweating and hair loss)

Cushing's syndrome (cutaneous striae, hirsutism, thin skin etc).
Addison's disease (melanisation, hair loss).
Acromegaly (acne).

f) Nutritional
Vitamin C deficiency causes scurvy, e.g. ‘tea and toast diet’ of the elderly.
Bleeding gums and bruise easily.
Pellagra due to nicotinic acid deficiency results in dermatitis (and
diarrhea and dementia).

g) Others

Sarcoidosis
Blue/red nodules (= granuloma) may occur in the skin (Lupus pernio) of
nose, hands face.

Hyperlipidaemia
White or yellow plaques of cholesterol in skin around eye (Xanthelasma)
Yellow or pink areas over tendons due to hyperlipidaemia (Xanthoma).

Neurofibromatosis
Cafe au lait patches with multiple skin tags. 40% may develop
neurological complications, e.g. acoustic neuroma. Careful neurological
examination needed. Family history.

Gout
Tophi of uric acid.

Raynaud’s Disease/Phenomenon
While some people define these differently, others use the terms interchangeably. A better distinction is
between:
Primary: No underlying cause
Secondary: Systemic disease present (10-50%)
May precede evidence of systemic disease by 20 years

Cold-related disorder. Episodic digital ischaemia due to vasospasm provoked by cold and emotional
factors, resulting in pallor of digits, followed by cyanosis and then redness due to a reactive hyperaemia.
Gangrene can result.
May also affect the tips of the nose, tongue and ears and evidence it also affects the heart, kidneys and
lungs
Other stimuli may provokes it, e.g. trauma, tobacco smoke
It is also associated with the use of vibrating tools, vinyl chloride, cold food industry, weapons in the
cold, beta blockers.

5-10% of the population (10 million in the UK)

9 times commoner in women
Usually developed by age 40

Systemic diseases it is associated with include:

Collagen vascular diseases, e.g. rheumatoid arthritis, systemic sclerosis, SLE
Obstructive arterial disease, e.g. atherosclerosis, thoracic outlet syndrome, emboli
Hypothyroidism

© Martin Collins, 2014