Tinea Cruris Cura

Tinea Cruris Pictures
Figure 8-33 Basal cell carcinoma. Notice the rolled, well-defined margin.
Tinea CrurisAcral Lentiginous MelanomaAcral Lentiginous Melanoma
Figure 8-38 Acral-lentiginous melanoma.

frequently in individuals who are exposed to constant sunlight, such as sailors and agricultural workers. Melanomas occur more often in rather fair-skinned individuals who experience brief, intense sun exposure, such as that occurring during vacations in the southern latitudes.

Fewer than 5% of all melanomas occur in the African-American population. The acral-lentiginous melanoma is the most common form in African Americans and occurs on the palms, soles, and nail beds. These melanomas have a short superficial growth phase and an early vertical growth phase and, as such, are associated with a poor prognosis. An acral-lentiginous melanoma on the sole of an African-American patient is pictured in Figure 8-38.

Malignant melanoma of the nail apparatus represents 2% to 3% of all melanomas in white individuals and about 20% in dark-skinned individuals. The most common pathologic type is the acral-lentiginous melanoma. It is frequently diagnosed in the sixth decade; women are affected more often than men. The thumb and the great toe are the most common sites. Figure 8-39 shows a classic malignant melanoma of the nail, with a wide longitudinal band and the variegated colors. Figure 8-40 shows a malignant melanoma of the nail bed. Notice that the band width is wider at the base than at the tip, indicating a rapidly growing lesion.

Skin Disease Nail MelanomaNail Malignant Melanoma

Figure 8-40 Melanoma of the nail bed.

Melanoma Back Muscle

Figure 8-41 Lipoma of the back.

Figure 8-40 Melanoma of the nail bed.

Figure 8-41 Lipoma of the back.

A lipoma is a benign growth of subcutaneous fat and has a rubbery appearance. The epidermis is normal. Frequently, an encapsulated lipoma may grow to a very large size and elevate the overlying dermis and epidermis, as shown in Figure 8-41; a cross section through a lipoma is illustrated in Figure 8-42. The examiner can easily push into the soft tissue tumor. Another example of a lipoma is shown on the arm of the patient in Figure 8-43.

Café au lait spots are patch lesions that are well circumscribed and brownish. They may occur as a solitary birthmark in up to 10% of the normal population. The cafe au lait macule or patch results from an increased number of functionally hyperactive melanocytes. Multiple cafe au lait patches in a patient may suggest neurofibromatosis. Figure 8-44 shows a cafe au lait patch in a patient with neurofibromatosis.

A neurofibroma is a tumor produced by a focal proliferation of neural tissue in the dermis. The epidermis is normal. Neurofibromas may appear as papules or nodules. Cutaneous neurofibromas are soft in consistency. Neurofibromatosis is a disorder in which multiple neurofibromas are present, sometimes as many as several hundred. Although the tumors are benign, the occurrence of these space-occupying lesions may produce severe disfigurement or neurologic disease. Other dermatologic features of neurofibromatosis include multiple cafe au lait patches and axillary freckling. Figure 8-45 shows several neurofibromas in a patient with

Lipoma Crosssection

Figure 8-42 Cross section through a lipoma.

Lipomas Cure Successful

Figure 8-43 Lipoma of the arm.

Figure 8-42 Cross section through a lipoma.

Figure 8-43 Lipoma of the arm.

Axillary Freckling

neurofibromatosis;a cross-sectional view is illustrated in Figure 8-46. Figure 8-47 shows axillary freckling (Crowe's sign) in a patient with neurofibromatosis. Figure 8-48 shows multiple neurofibromas on the face of another patient with neurofibromatosis.

Contact dermatitis is an inflammatory reaction of the skin that is precipitated by contact with an irritant or allergen, such as detergents, acids, alkali, plants, medicines, and solvents. Vesicles in the epidermis and perivascular inflammation result. Figure 8-49 shows contact dermatitis in reaction to poison ivy;the area is illustrated in cross section in Figure 8-50. The characteristic linear distribution of papules, vesicles, and bullae is visible on this patient's calf where the leaves of the plant touched the leg. The distribution of the bullous lesions together with their location is strongly suggestive of the diagnosis, which was confirmed by biopsy.

Psoriasis is one of the most common noninfectious skin disorders. It is frequently inherited and often chronic, and it, too, may affect the joints and nails. The rash is characterized by well-defined, slightly raised, hyperkeratotic (scaling) plaques. If the lesion is scratched, small bleeding points appear, which is a specific sign of the disease. The lesions are frequently symmetric and can be extremely itchy. The stratum corneum thickens, and erythematous plaques with silvery scales result. Within the dermis, there is capillary proliferation with perivascular inflammation. The lesions are characteristically located on the elbows, knees, scalp, and intergluteal cleft. Figure 8-51 shows the typical, symmetric lesions on the knees of an affected patient. Figure 8-52 shows the classic scaling lesions at the intergluteal cleft of another patient. Figure 8-53 illustrates a cross section through an area of psoriasis (see also Fig. 8-15). Figure 8-54 shows psoriasis of the scalp. The lesions commonly extend beyond the hair-bearing areas onto the adjacent skin. Surprisingly, this lesion rarely results in hair loss. Figure 8-55 shows severe, diffuse psoriasis involving more than 85% of the body of a 56-year-old man. This patient suffered from persistent itching, burning, and bleeding with psoriasis for more than 35 years. Psoriasis may produce several nail changes. Pitting of the nail has already been

Fungal Infection Gluteal CleftPlaque Psoriasis Skin Cross SectionFungal Infection Gluteal CleftContact Dermatitis Reaction Nicklas

Figure 8-49 Contact dermatitis: poison ivy reaction.

Figure 8-50 Cross section through an area of contact dermatitis. Note the perivascular inflammation in the dermis, as well as the vesicles and bullae in the epidermis.

Figure 8-49 Contact dermatitis: poison ivy reaction.

discussed (see Fig. 8-14). There are several other nail changes: oily patches, onycholysis, sub-ungual hyperkeratosis, and splinter hemorrhages.

Tinea corporis is "ringworm" infection. Fungal infections of the skin produce a scaling, ery-thematous patch, often with a reddened, raised, serpiginous border. The term tinea indicates the fungal cause, and the second word denotes the area of the body involved: tinea corporis is infection in the body;tinea pedis, in the foot; tinea faciale, in the face; tinea barbae, in the beard and moustache area in men; tinea cruris, in the groin; and tinea capitis, in the head. In all cases, the epidermis is thickened, and the stratum corneum is infiltrated with fungal hyphae.

Tinea Cruris

Figure 8-51 Psoriatic lesions on the knees.

Psoriatic Lesions Face

Figure 8-52 Psoriatic lesions on the intergluteal cleft.

Figure 8-51 Psoriatic lesions on the knees.

Figure 8-52 Psoriatic lesions on the intergluteal cleft.

Cruris Area Tinea Periternial
Figure 8-56 Cross section through an area of tinea corporis. Note the thickened stratum corneum, which is infiltrated by the fungus.

Figure 8-57 Tinea corporis.

The underlying dermis displays mild inflammation. Figures 8-56 and 8-57 illustrate the classic annular lesion of tinea corporis with its raised erythematous border and central clearing. Another example of tinea corporis is pictured in Figure 8-58. Tinea faciale in a child is pictured in Figure 8-59. Tinea cruris is pictured in Figure 8-60. This common pruritic lesion is seen commonly in young men; it is unusual in women. It spreads outward from the groin, down the thigh, leaving postinflammatory pigmentation. The advancing border is well defined, red, scaly, and slightly raised. If untreated, the eruption can spread onto the lower abdomen, as shown, and the buttocks. The foot of a patient with tinea pedis is pictured in Figure 8-61. Notice the maceration with erosions and scaling.

Pityriasis rosea is a common, acute, self-limiting inflammatory disease of unknown cause that usually occurs during the spring. The generalized eruption is preceded by a ''herald patch,'' which is a single lesion resembling that of tinea corporis. In several days, the generalized eruption appears. Papulosquamous plaques appear over the trunk and rarely on the face and distal extremities. Although patients may complain of mild itching, they feel quite well. The full-blown picture develops slowly over 5 to 10 days and lasts for approximately 3 to 6 weeks. Slight hyperkeratosis of the epidermis with moderate dermal perivascular infiltration occurs. Figure 8-62 shows a herald patch and the characteristic lesions of pityriasis

Herald Patch

Figure 8-59 Tinea faciale.

Figure 8-58 Tinea corporis.

Figure 8-59 Tinea faciale.

Figure 8-61 Tinea pedis.

rosea;Figure 8-63 illustrates a cross-sectional view. Notice the delicate scale at the border of the annular lesion. Secondary syphilis may manifest with a similar eruption. It is therefore important to order a serologic test for syphilis in any individual with pityriasis rosea.

Herpes zoster, or shingles, is an intraepidermal vesicular eruption occurring in a dermatomal distribution. Bullae and multinucleated giant cells are present in the epidermis, with perivas-cular inflammation of the dermis. The condition is caused by activation of the varicella-zoster virus. Groups of vesicles and bullae on erythematous bases are present along the distribution of peripheral nerves. Severe pain often precedes the eruption. Figure 8-64 shows herpes zoster lesions along the T3 distribution in two patients. Usually, the distribution occurs along the spinal or cranial nerves, but it can become generalized, as pictured in Figure 8-65; Figure 8-66 illustrates a cross section. Figure 8-67 is a close-up photograph of the typical vesicles on an erythematous base in a dermatomal distribution.

Herpesvirus infections are frequently encountered in patients with HIV infection;approxi-mately 25% to 50% of these patients have some form of herpetic disease during the course of their illness. Herpesvirus infections are thought to be predictive of future progression from HIV

Figure 8-63 Cross section through a lesion of pityriasis rosea.

Figure 8-62 Pityriasis rosea. Note the herald patch.

Figure 8-63 Cross section through a lesion of pityriasis rosea.

Figure 8-64 A and B, Herpes zoster lesions in T3 distribution.
Cross Section Pimple

Figure 8-68 Cross section through an area of acne. Note the rupturing of the sebaceous gland in the dermis as a result of a plugged hair follicle, which results in dermal inflammation.

infection to AIDS;the rate of this association with progression is 23% at 2 years and up to 73% at 6 years. When CD4+ T cell counts fall below 100 cells/mm3, the likelihood of a herpesvirus infection approaches 95%. Herpes zoster infections may be severe and fulminant in immuno-compromised patients, such as in the patient shown in Figure 10-58.

Acne is a pustular disease affecting the hair follicles and sebaceous glands. In this condition, pustules, papules, and comedones are the primary lesions. There are collections of intradermal and intrafollicular neutrophils. Within the dermis, the hair follicle is occluded by a collection of keratin, sebum, and inflammatory cells. The hair follicle often ruptures into the dermis as a result of increasing pressure, which leads to further dermal inflammation (Figs. 8-68 to 8-71).

Tinea versicolor is a common superficial, noninflammatory, noncontagious fungal skin infection of young adults occurring most often during the summer. Pregnancy, warm climate, corticosteroids, and debilitation seem to be predisposing factors. Persons older than 40 years are rarely affected. The lesion consists of very fine, scaly patches that coalesce as they enlarge. The hypopigmented lesions are frequently seen on seborrheic areas of the body: the neck, the upper trunk, the upper arms, the shoulders, and, on occasion, the groin. The lesions are usually

Figure 8-69 Acne.

Figure 8-70 Acne.

Figure 8-71 Acne.

Tinea Versicolor Figure

asymptomatic but may be mildly pruritic. Figure 8-72 shows the back of a patient with the classic hypopigmented patches of tinea versicolor. Figure 8-73 shows another patient with tinea versicolor.

A ganglion cyst is a chronic, painless lesion on the dorsum of the wrist or ankle. It results from leakage of synovial fluid through the tendon sheath of the capsule of the joint. This fluid eventually becomes encapsulated, and a cyst results. Figure 8-74 shows a ganglion in the wrist, the typical location.

A spider angioma is a common pale red lesion, usually less than 2 cm in diameter, with a pulsating, central arteriole, often raised, surrounded by erythema and radiating ''legs.'' If pressure is exerted on the central body, blanching of the spider's legs occurs. These benign lesions are commonly seen on the face, neck, arms, and upper trunk;they are rarely seen on the lower extremities. Although seen in normal individuals, spider angiomas are found more commonly in pregnant women and in patients with liver disease or vitamin B deficiency. These angiomas frequently become more evident during various times of a woman's menstrual cycle. Figure 8-75 shows a spider angioma on the face of a young woman. Notice the central arteriole with the peripheral blush.

Tinea Versicolor Knees
Figure 8-73 Tinea versicolor.

Vitiligo consists of patches of lightened skin resulting from decreased melanin pigmentation. Vitiligo is essentially a large macule that is totally depigmented. The epidermis manifests a complete absence of pigment, whereas the dermis is normal. Vitiligo can occur in any area, but it is commonly found on the neck, knees, elbows, and back of the hands. Figure 8-76 shows extensive vitiligo on the face and neck;a cross section is shown in Figure 8-77. Diffuse vitiligo is pictured in Figure 8-78.

Urticaria is a common condition. The primary lesion is the wheal, or hive. In urticaria, the epidermis is normal. The dermis demonstrates papillary edema. Inflammatory cells may be found surrounding dilated blood vessels. Itching is a common complaint. There are several mechanisms for the development of urticaria, which include both immunologic and nonim-munologic causes. Regardless of the cause, the common factor is the release of substances, such as histamine, that change the vascular permeability and produce dermal edema. Figure 8-79 shows urticaria, and Figure 8-80 depicts the cross section.

Erythema multiforme is an immunologic reaction in the skin triggered by various causative agents, including viruses, bacteria, drugs, and x-radiation. In many cases, the agent cannot be identified. As the name implies, the condition includes a variety of lesions: papules, bullae, plaques, and ''target lesions.'' Target lesions are the diagnostic lesions and have three zones of color: A central, tense bulla, or dark area, is surrounded by a zone of relative pallor that is rimmed by a thin area of erythema. Typically, target lesions are seen on the palms and soles (Fig. 8-81). The epidermis is usually normal. In the dermis, there is a subepidermal separation with inflammatory cells in the papillary dermis. Penicillin and sulfonamides are the drugs most commonly implicated as the cause of this condition. The most severe form of erythema multiforme involves the mucous membranes and is called Stevens-Johnson syndrome. The classic skin lesions of erythema multiforme are shown in Figures 8-82 and 8-83; Figure 8-84 illustrates a cross-sectional view.

Scabies is a common, intensely pruritic skin disorder caused by a mite, Sarcoptes scabiei var. hominis. The female mite burrows into the stratum corneum of the skin and lays her eggs.

Erythema Multiforme Information SheetPapillary Genital Warts
Figure 8-81 Target lesions on palms and hands in a patient with erythema multiforme.
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