Skin Disease

Boil

-Symptoms:

A boil is a localized infection deep in the skin. A boil generally starts as a reddened,
tender area. Over time, the area becomes firm, hard, and tender. Eventually, the center of the
boil softens and becomes filled with infection-fighting white blood cells from the bloodstream
to eradicate the infection. This collection of white blood cells, bacteria, and proteins is known
as pus. Finally, the pus "forms a head," which can be surgically opened or spontaneously drain
out through the surface of the skin. Pus enclosed within tissue is referred to as an abscess. A
boil is also referred to as a skin abscess.

There are several different types of boils. Among these are:

 Furuncle or carbuncle: This is an abscess in the skin caused by the

bacterium Staphylococcus aureus. A furuncle can have one or more openings onto the skin
and may be associated with afever or chills. The term carbuncle is sometimes reserved for an
abscess that involves a group of hair follicles. The condition of having chronic, recurring boils
is referred to as furunculosis or carbunculosis.
 Cystic acne: This is a type of abscess that is formed when oil ducts become clogged and
infected. Cystic acne affects deeper skin tissue than the more superficial inflammation from
common acne. Cystic acne is most common on the face and typically occurs in the teenage
years.
 Hidradenitis suppurativa: This is a condition in which there are multiple abscesses that
form under the armpits and often in the groin area. These areas are a result of local
inflammation of the sweat glands. This form of skin infection is difficult to treat with
antibiotics alone and typically requires a surgical procedure to remove the involved sweat
glands in order to stop the skin inflammation.
 Pilonidal cyst: This is a unique kind of abscess that occurs in the crease of the buttocks.
Pilonidal cysts often begin as tiny areas of infection in the base of the area of skin from which
hair grows (the hair follicle). With irritation from direct pressure, over time the inflamed area
enlarges to become a firm, painful, and tender nodule that makes it difficult to sit without
discomfort. These frequently form after long trips that involve prolonged sitting.
-The causes:

There are many causes of boils. Some boils can be caused by an ingrown hair. Others
can form as the result of a splinter or other foreign material that has become lodged in the skin.
Others boils, such as those of acne, are caused by plugged sweat glands that become infected.
The skin is an essential part of our immune defense against materials and microbes that
are foreign to our body. Any break in the skin, such as a cut or scrape, can develop into an
abscess should it become infected with bacteria.
-The treatment:
Home treatment is an option for most simple boils. Ideally, treatment should begin as
soon as a boil is noticed since early treatment may prevent later complications.
The primary treatment for most boils is heat application, usually with hot soaks or hot
packs. Heat application increases the circulation to the area and allows the body to better fight
off the infection by bringing antibodies and white blood cells to the site of infection.
As long as the boil is small and firm, opening the area and draining the boil is not
helpful, even if the area is painful. However, once the boil becomes soft or "forms a head" (that
is, a small pustule is noted in the boil), it can be ready to drain. Once drained, pain relief can be
dramatic. Most small boils, such as those that form around hairs, drain on their own with hot
soaks. On occasion, and especially with larger boils, medical treatment is required. In this
situation, the boil will need to be drained or "lanced" by a health-care practitioner. Frequently,
these larger boils contain several pockets of pus that must be opened and drained.
Antibiotics are often used to eliminate any accompanying bacterial infection, especially
if there is an infection of the surrounding skin. However, antibiotics are not needed in every
situation. In fact, antibiotics have difficulty penetrating the outer wall of an abscess well and
often will not cure an abscess without additional surgical drainage.
-Preventing:
There are some measures that you can take to prevent boils from forming. Good
hygiene and the regular use of antibacterial soaps can help to prevent bacteria from building up
on the skin. This can reduce the chance for the hair follicles to become infected and prevent the
formation of boils. In some situations, your health-care practitioner may recommend special
cleansers such as phisoderm to even further reduce the bacteria on the skin. When the hair
follicles on the back of the arms or around the thighs are continually inflamed, regular use of an
abrasive brush (loofah brush) in the shower can be used to help break up oil plugs and buildup
around hair follicles.
Pilonidal cysts can be prevented by avoiding continuous direct pressure or irritation of the
buttock area when a local hair follicle becomes inflamed. At that point, regular soap and hot
water cleaning and drying can be helpful.
For acne and hidradenitis suppurativa (see above), antibiotics may be required on a long-term
basis to prevent recurrent abscess formation. As mentioned above, surgical resection of sweat
glands in the involved skin may be necessary. Other medications, such
as isotretinoin (Accutane), can be used for cystic acne and have been helpful in some patients
with hidradenitis suppurativa. Recurrences are common in patients with hidradenitis
suppurativa.
Finally, surgery may occasionally be needed, especially for pilonidal cysts that recur but also for
hidradenitis suppurativa. For pilonidal cysts, surgically removing the outer shell of the cyst is
important to clear the boil. The procedure is typically performed in the operating room. For
hidradenitis suppurativa, extensive involvement can require surgical repair by a plastic surgeon.

Ringworm
Definitions:

The term ringworm or ringworms refers to fungal infections that are on

the surface of the skin. The name is derived from the early belief was that the infection was due
to a worm, which it is not. Ringworm is a fungal infection in the skin. Nevertheless, the name
ringworm has stuck. Some of these fungi produce round spots on the skin but many do not. On
the other hand, many round spots on the skin are not due to a fungal infection. A physical
examination of the affected skin, evaluation of skin scrapings under the microscope, and culture
tests can help doctors make the appropriate distinctions. A proper diagnosis is essential to
successful treatment.
The medical term for ringworm istinea. (Tinea is the Latin name for a growing worm.)
Doctors add another word to indicate where the fungus is located. Tinea capitis, for instance,
refers to scalp ringworm, tinea corporis to fungus of the body, tinea pedis to fungus of the feet,
and so on.
-The Causes:
Although the world is full of yeasts, molds, and fungi, only a few cause skin problems.
These agents are called the dermatophytes, which means "skin fungi." An infection with these
fungi is sometimes known as dermatophytosis. Skin fungi can only live on the dead layer of
keratin protein on top of the skin. They rarely invade deeper into the body and cannot live on
mucous membranes, such as those in the mouth or vagina.
Scientific names for the most common of the dermatophyte fungi include Trichophyton
rubrum, Trichophyton tonsurans, Trichophyton interdigitale, and/or Trichophyton
mentagrophytes, Microsporum canis, and Epidermophyton floccosum.
-Kind of Ringworm:
Among the types of ringworm, or tinea, are the following:

1. Tinea barbae: Ringworm of the bearded area of the face and neck, with swelling and
marked crusting, is often accompanied by itching, sometimes causing the hair to break
off. In the days when men went to the barber daily for a shave, tinea barbae was called
barber's itch.
2. Tinea capitis: Ringworm of the scalp commonly affects children, mostly in late childhood
or adolescence. This condition may spread in schools. Tinea capitis appears as scalp
scaling that is associated with bald spots (in contrast to seborrhea ordandruff, for
instance, which do not cause hair loss)
3. Tinea corporis: When fungus affects the skin of the body, it often produces the round
spots of classic ringworm. Sometimes, these spots have an "active" outer border as they
slowly grow and advance. It is important to distinguish this rash from other even more
common rashes, such as nummular eczema. This condition, and others, may appear
similar to ringworm, but they are not due to a fungal infection and require different
treatment.
4. Tinea cruris: Tinea of the groin ("jock itch") tends to have a reddish-brown color and to
extend from the folds of the groin down onto one or both thighs. Other conditions that
can mimic tinea cruris include yeast infections, psoriasis, and intertrigo, a chafing rash
which results from the skin rubbing against the skin.
5. Tinea faciei (faciale): ringworm on the face except in the area of the beard. On the face,
ringworm is rarely ring-shaped. Characteristically, it causes red, scaly patches with
indistinct edges.
6. Tinea manus: ringworm involving the hands, particularly the palms and the spaces
between the fingers. It typically causes thickening (hyperkeratosis) of these areas, often
on only one hand. Tinea manus is a common companion of tinea pedis (ringworm of the
feet). It is also called tinea manuum.
7. Tinea pedis: Athlete's foot may cause scaling and inflammation in the toe webs,
especially the one between the fourth and fifth toes. Another common form of tinea
pedis produces a thickening or scaling of the skin on the heels and soles. This is
sometimes referred to as the "moccasin distribution." In still other cases, tinea causes
blisters between the toes or on the sole. Aside from athlete's foot, tinea pedis is known
as tinea of the foot or, more loosely, fungal infection of the feet. Tinea pedis is an
extremely common skin disorder. It is the most common and perhaps the most
persistent of the fungal (tinea) infections. It is rare before adolescence. It may occur in
association with other fungal skin infections such as tinea cruris (jock itch).
8. Tinea unguium: Finally, fungal infection can make the fingernails and, more often, the
toenails yellow, thick, and crumbly. This is referred to as fungal nails or onychomycosis.

-The Treatment:
Ringworm can be treated topically (with external applications) or systemically (for
example, with oral medications):
 Topical treatment: When fungus affects the skin of the body or the groin, many
antifungal creams can clear the condition in around two weeks. Examples of such preparations
include those that contain clotrimazole(Cruex cream, Desenex cream, Lotrimin cream, lotion,
and solution), miconazole(Monistat-Derm cream), ketoconazole(Nizoral cream), econazole
(Spectazole),naftifine (Naftin), and terbinafine (Lamisil cream and solution). These treatments
are effective for many cases of foot fungus as well.
Systemic treatment: Some fungal infections do not respond well to external
applications. Examples include scalp fungus and fungus of the nails. To penetrate these areas
and in cases of particularly severe or extensive disease, oral medications can be used.
For a long time, the only effective antifungal tablet was griseofulvin (Fulvicin, Grifulvin,
and Gris-PEG). Now, other agents are available that are both safer and more effective. These
include terbinafine, itraconazole (Sporanox), and fluconazole (Diflucan). Oral medications are
usually given for a three-month course.
-Preventing:
Conventional wisdom holds that minimizing sweat and moisture can help prevent fungal
infections. Common recommendations along these lines are for men to wear boxer shorts, for
women to avoid panty hose, and so forth. Whether these measures, some of which are quite
difficult to implement, are really worth all of the effort is open to question.

Shingles (Herpes)
-What is shingles?
Shingles is a skin rash caused by the same virus that causes chickenpox. This virus is
called the Varicella zoster virus (VZV) and is in the herpes family of viruses. After an individual
has chickenpox, this virus lives dormant in the nervous system and is never fully cleared from
the body. Under certain circumstances, such as emotional stress, immune deficiency (from AIDS
or chemotherapy), or with cancer, the virus reactivates and causes shingles. In most cases of
shingles, however, a cause for the reactivation of the virus is never found. Anyone who has ever
had chickenpox is at risk for the development of shingles, although it occurs most commonly in
people over the age of 60.
The herpes virus that causes shingles and chickenpox is not the same as the herpes
viruses that causes genital herpes (which can be sexually transmitted) or herpes mouth sores.
Shingles is medically termed herpes zoster.
-Symptoms:
Before a rash is visible, the patient may notice several days to a week of burning pain
and sensitive skin. When the characteristic rash is not yet apparent, it may be difficult to
determine the cause of the often severe pain. Shingles rash starts as small blisters on a red
base, with new blisters continuing to form for three to five days. The blisters follow the path of
individual nerves that come out of the spinal cord in a specific "ray-like" distribution (called a
dermatomal pattern) and appear in a band-like pattern on an area of skin. The entire path of
the affected nerve may be involved, or there may be areas in the distribution of the nerve with
blisters and areas without blisters. Generally, only one nerve level is involved. In a rare case,
more than one nerve will be involved. Eventually, the blisters pop, and the area starts to ooze.
The affected areas will then crust over and heal. The duration of the outbreak may take three to
four weeks from start to finish. On occasion, the pain will be present but the blisters may never
appear. This can be a very confusing cause of local pain.
-The Treatment:
There are several effective treatments for shingles. Drugs that fight viruses (antivirals),
such as acyclovir (Zovirax), valacyclovir(Valtrex), or famciclovir (Famvir), can reduce the severity
and duration of the rash if started early (within 72 hours of the appearance of the rash). In
addition to antiviral medications, pain medications may be needed for symptom control. Both
nonsteroidal anti-inflammatory medications and narcotic pain control medications may be used
for pain management in shingles.
 The affected area should be kept clean. Bathing is permitted, and the area can be
cleansed with soap and water. Cool compresses and anti-itching lotions, such ascalamine lotion,
may also provide relief. An aluminum acetate solution (Burow's orDomeboro solution, available
at your pharmacy) can be used to help dry up the blisters and oozing.
-Preventing:
The vaccine, known as Zostavax, is approved for use in adults ages 60 and over who
have had chickenpox. The shingles vaccine contains a booster dose of the chickenpox vaccine
usually given to children. Tests over an initial four-year period showed that the vaccine
significantly reduced the incidence of shingles in these older adults. The single-dose vaccine
was shown to be more than 60% effective in reducing shingles symptoms and it reduced the
incidence of postherpetic neuralgia (PHN, see above) by at least two-thirds. Studies are ongoing
to evaluate the effectiveness of the vaccine over a longer term.
People with weakened immune systems due to immune-suppressing medications,
cancer treatment, HIV disease, or organ transplants should not receive the shingles vaccine
because it contains live, weakened viral particles.
Since vaccination against VZV is now recommended for children, the incidence of
chickenpox has been reduced. This is also expected to reduce the incidence of shingles in adults
as these children age.

Hives

-What is Hives?
Hives (medically known as urticaria) are red, itchy, raised areas of skin that appear in
varying shapes and sizes. They range in size from a few millimeters to several inches in
diameter. Hives can be round, or they can form rings or large patches. Wheals (welts), red
lesions with a red "flare" at the borders, are another manifestation of hives. Hives can occur
anywhere on the body, such as the trunk, arms, and legs.
It is estimated that 5% of all people will develop urticaria at some point in their lives.
Hives are more common in women than in men. Of those with chronic hives (those lasting six
weeks or more), some 80% are idiopathic, the medical term which means that no cause, allergic
or otherwise, can be found.
 One hallmark of hives is their tendency to change size rapidly and to move around,
disappearing in one place and reappearing in other places, often in a matter of hours. Individual
hives usually last two to 24 hours. An outbreak that looks impressive, even alarming, first thing
in the morning can be completely gone by noon, only to be back in full force later in the day.
Very few, if any other skin diseases occur and then resolve so rapidly. Therefore, even if you
have no evidence of hives to show the doctor when you get to the office for examination, he or
she can often establish the diagnosis based upon the history of your symptoms. Because hives
fluctuate so much and so fast, it is helpful to bring along a photograph of what the outbreak
looked like at its worst.
Swelling deeper in the skin that may accompany hives is called angioedema. This may be
seen on the hands and feet as well as on mucous membranes (with swelling of the lips or eyes
that can be as dramatic as it is brief.)
-The Causes:
Hives are produced by histamine and other compounds released from cells called mast
cells, which are a normal part of skin. Histamine causes fluid to leak from the local blood
vessels, leading to swelling in the skin.
Hives are very common. Although they can be annoying, they usually resolve on their
own over a period of weeks, and are rarely medically serious. Some hives are caused by
allergies to such things as foods, medications, and insect stings, but the large majority of cases
are not allergic, and no specific cause for them is ever found. Although patients may find it
frustrating not to know what has caused their hives, maneuvers like changing diet, soap,
detergent, and makeup are hardly ever helpful in preventing hives and for the most part are
not necessary. Having hives may cause stress, but stress by itself does not cause hives.
In rare cases (some hereditary, others caused by bee stings or drug allergy), urticaria
and angioedema are accompanied by shock and difficulty breathing. This is calledanaphylaxis.
Ordinary hives may be widespread and disturbing to look at, but the vast majority of cases of
hives do not lead to life-threatening complications.

- Kinds of Hives:
Almost all hives fall into two categories: ordinary urticaria (ordinary hives) and physical
urticaria (physical hives).

Ordinary urticaria (ordinary hives)

Symptoms of ordinary hives

Ordinary hives flare up suddenly and usually for no specific reason. Welts appear, often in
several places. They flare, itch, swell, and go away in a matter of minutes to hours, only to
appear elsewhere. This sequence may go on from days to weeks. Most episodes of hives last
less than six weeks. Although that cutoff point is arbitrary, hives that last more than six weeks
are often called "chronic."

Causes of ordinary hives

As noted above, many cases of ordinary hives are "idiopathic," meaning no cause is known.
Others may be triggered by viral infections. A few may be caused by medications, usually when
they have been taken for the first time a few weeks before. (It is uncommon for drugs taken
continuously for long periods to cause hives or other reactions.) When a medication is
implicated as a cause of hives, the drug must be stopped, since no skin or blood test will prove
the connection. In most cases, drug-induced hives will go away in a few days. If a drug is
stopped and the hives do not go away, this is a strong indication that the medication was not in
fact the cause of the hives.
Some medications, like morphine, codeine, aspirin, and other nonsteroidal anti-inflammatory
drugs (NSAIDs, such as ibuprofen [Advil]), cause the body to release histamine and produce
urticaria through non-allergic mechanisms.
Despite the reputation hives have for being "allergic," when there is no obvious connection
between something new that a person has been exposed to and the onset of hives, allergy
testing is not usually helpful.

Chronic hives
Chronic hives (defined as lasting six weeks or more) can last from months to years. Allergy
testing and laboratory tests are hardly ever useful in such cases.

Physical urticaria (physical hives)

The term physical urticaria refers to hives produced by direct physical stimulation of the skin.
By far the most common form is dermographia, which literally means "skin writing." This is an
exaggerated form of what happens to anyone when their skin is scratched or rubbed: a red welt
appears at the line of the scratch. In dermographia, raised, itchy red welts with adjacent flares
appear wherever the skin is scratched or where belts and other articles of clothing rub against
the skin, causing mast cells to leak histamine.

Another common form of physically induced hives is called cholinergic urticaria. This produces
hundreds of small, itchy bumps. These occur within 15 minutes of exercise or physical exertion,
or a hot bath or shower, and are usually gone before a doctor can examine them. This form of
hives happens more often in young people.
Other forms of physical hives are much less common. Triggers for these include cold, water,
and sunlight.
-The Treatment:
 The goal of treating most cases of ordinary urticaria is to relieve symptoms while the
condition goes away by itself. The most commonly used oral treatments areantihistamines,
which help oppose the effects of the histamine leaked by mast cells. The main side effect of
antihistamines is drowsiness.
Many antihistamines are available withoutprescription, such
as diphenhydramine(Benadryl), taken in doses of 25 milligrams and chlorpheniramine (Chlor-
Trimeton), taken in a dose of 4 milligrams. These can be taken up to three times a day, but
because these medications can cause drowsiness, they are often taken at bedtime. Those who
take them should be especially careful and be sure they are fully alert before driving or
participating in other activities requiring mental concentration.
Loratadine (Claritin, 10 milligrams) is available over the counter and is less likely to
cause drowsiness. Also approved for over-the-counter use is cetirizine (Zyrtec, 10 milligrams),
which is mildly sedating. Some antihistamines are available in combination preparations with
decongestant medication (Claritin-D, Zyrtec-D). The decongestant component is not needed to
treat hives.
Antihistamines that require a prescription include hydroxyzine (Atarax, Vistaril)
andcyproheptadine, both of which tend to cause drowsiness. Prescription antihistamines that
cause little sedation are fexofenadine (Allegra) and levocetirizine (Xyzal). Sometimes physicians
combine these with other types of antihistamines called H2 blockers, such as ranitidine (Zantac)
and cimetidine (Tagamet). This antihistamine list is not exhaustive. Physicians individualize
treatment plans to suit specific patients and modify them depending on the clinical response.
Oral steroids (prednisone, [Medrol]) can help severe cases of hives in the short term,
but their usefulness is limited by the fact that many cases of hives last too long for steroid use
to be continued safely. Other treatments have been used for urticaria as well,
including montelukast (Singulair), ultraviolet radiation, antifungal antibiotics, agents that
suppress the immune system, and tricyclic antidepressants (amitriptyline [Elavil,
Endep], nortriptyline [Pamelor, Aventyl], doxepin [Sinequan, Adapin]). Evidence to support the
benefit of such treatments is sparse. In ordinary cases, they are rarely needed.
Topical therapies for hives include creams and lotions which help numb nerve endings
and reduce itching. Some ingredients which can accomplish this are camphor,
menthol,diphenhydramine, and pramoxine. Many of these topical preparations require no
prescription. Cortisone-containing creams (steroids), even strong ones requiring a prescription,
are not very helpful in controlling the itch of hives.