Norwegian Scabies

Norwegian ScabiesScabies Diseas Testes ManScabies With Hiv
Figure 8-85 Scabies.

A month or longer may pass before the symptom of generalized pruritus develops. The diagnostic physical sign is the burrow, which is a serpiginous, palpable track about 1 cm in length that may end in a papule, nodule, or tiny vesicle. The adult female mite is present in the burrow. The extremely pruritic rash of scabies has a predilection for the web spaces of the fingers and toes, as well as the groin. The buttocks are also frequently involved, as are the genitals of men and the nipples of women. A generalized papular or urticarial eruption may ensue after localized scabies infection. The presence of papules on the genitalia in a patient with intense pruritus should raise the strong suspicion of scabies. Outbreaks of scabies are common in population groups in which HIV infection is prevalent. Figure 8-85 shows the hand of a patient with scabies. Notice the classic eruption between the fingers. Figure 18-16 shows another patient with scabies; the papular rash in the groin and on the penis is clearly seen.

Norwegian scabies is a rare, highly infectious form of scabies that is often seen in immuno-suppressed patients and patients with psychiatric illness; recently, this form of scabies has been seen in patients with AIDS. It is characterized by very thick, white hyperkeratotic scales containing thousands of mites. The dorsal aspects of the hands, the feet, and the extensor surfaces of the elbows and knees are commonly involved. Figure 8-86 shows the hand of a patient with Norwegian scabies. Figure 8-87 shows the diffuse lesions of Norwegian scabies in another patient.

Pyoderma gangrenosum is a cutaneous condition consisting of large, tender, necrotic ulcers having a violaceous, overhanging edge with a purulent base. The lesions are most frequently seen on the face, lower legs, and abdomen. Although most often associated with inflammatory

Pictures Norwegian Scabies
Figure 8-86 Norwegian scabies.
Pictures Norwegian Scabies
Figure 8-87 Norwegian scabies.

bowel disease, this condition is also seen in association with various blood dyscrasias (especially multiple myeloma), chronic active hepatitis, rheumatoid arthritis, systemic lupus erythematosus, and acute leukemias. Approximately 10% of all patients with ulcerative colitis, however, have cutaneous manifestations, especially pyoderma gangrenosum. The skin lesions of pyoderma gangrenosum are closely linked to the bowel disease;exacerbations of bowel symptoms are associated with extension of existing lesions or development of new ones. Removal of the diseased bowel often leads to improvement in the cutaneous manifestations. Figure 8-88 shows the classic shin lesions of pyoderma gangrenosum in a patient with regional enteritis. See also Figure 17-6, which shows another patient with an exacerbation of ulcerative colitis and pyoderma gangrenosum of the shin.

Insect bites are common and should always be considered when a patient complains of a pruritic rash. Papules, vesicles, and wheals amid excoriations suggest the diagnosis. Papules in a grouped or linear arrangement on an arm or face suggest bedbug bites. These insects, which live in crevices in furniture, shun the light and feed at night on exposed areas of the body. They bite and then move around only to bite again. Figure 8-89 shows the linear papules on the arm of a patient who was bitten by bedbugs. Figure 8-90 shows another patient with persistent erythematous papules as a result of bedbug bites. Flea bites were the cause of the pruritic eruption on the feet of the patient shown in Figure 8-91. Notice the excoriations. The lower legs and feet are common sites for flea bites.

Kaposi's sarcoma (KS) is a neoplasm characterized by dark blue-purple macules, papules, nodules, and plaques. The classic form of the disease is a rare, slow-growing neoplasm occurring mostly on the lower extremities, especially the ankles and soles, of elderly men of Mediterranean or Jewish eastern European descent. The male-to-female ratio is 10:1 to 15:1, and the majority of patients are 60 to 80 years of age. Figure 8-92 shows a large reddish-colored plaque, which was slow-growing, on the sole of the foot of a 60-year-old man of eastern European origin.

Currently, KS is the most frequent neoplasm occurring in patients with AIDS. Approximately 35% of patients with AIDS who acquired the disease by sexual contact are affected, as opposed to approximately 5% of patients whose infection was acquired from intravenous drug use. Overall, 24% of all patients with AIDS develop this rapidly progressive form of the disease, also known as the epidemic HIV-associated form. The widely disseminated lesions are present on the legs, trunk, arms, neck, and head. They start as light-colored papules or nodules and coalesce into larger, darker lesions. Unlike the classic form, the epidemic

Bedbug Bites
Figure 8-90 Bedbug bites.

HIV-associated form is commonly associated with visceral involvement, frequent oral lesions, and lymphadenopathy. The average length of patient survival from the onset of the disease is 18 months. The skin lesions of epidemic HIV-associated KS are shown in Figure 8-93. Figure 8-93A shows the typical lesions on the arm and chest;Figure 8-93B shows the widely disseminated plaque lesions varying in color from dark red to violet;Figure 8-93C shows a violaceous lesion on the lateral aspect of the lower eyelid;Figure 8-93D shows a large confluent plaque of KS on the hard palate;Figure 8-93E shows a purplish-red, nodular lesion of KS on the gingiva and an infiltrative, violaceous lesion of the nose.

Figure 8-94 demonstrates the rapidity of the growth of epidemic KS. The initial manifestation (Fig. 8-94A) on the back of a 36-year-old gay man was only a few macular lesions of KS;a follow-up photograph, taken only 6 months later, shows the widely disseminated, purplish plaques of KS (Fig. 8-94B).

Kaposi Sarcoma Stages Nose

Figure 8-92 Kaposi's sarcoma: a classic plaque.

Figure 8-91 Flea bites.

Figure 8-92 Kaposi's sarcoma: a classic plaque.

Scabies Gay Man

Figure 8-93 Kaposi's sarcoma: epidemic human immunodeficiency virus (HIV) associated. A and B, Plaque lesions. C, Violaceous lesion affecting the lateral lower eyelid. D, Confluent plaque on the hard palate. E, Nodular lesion on the gingiva and the nose.

Figure 8-93 Kaposi's sarcoma: epidemic human immunodeficiency virus (HIV) associated. A and B, Plaque lesions. C, Violaceous lesion affecting the lateral lower eyelid. D, Confluent plaque on the hard palate. E, Nodular lesion on the gingiva and the nose.

Scleroderma, also known as progressive systemic sclerosis, is an important rheumatic disease characterized by hardening of the skin. Vascular changes occur with visceral involvement and involve the microvessels and small arteries. The onset of the disease is often heralded by the development of Raynaud's phenomenon, which is discussed in Chapter 15, The Peripheral Vascular System. The cutaneous manifestations of scleroderma involve tightening of the skin, especially on the face and hands. As a result of tendon contractures, flexion of the fingers results. The fingers of a patient with scleroderma are shown in Figure 8-95; notice that the skin is bound tightly and obscures the superficial vasculature. Skin lines are absent. Figure 8-96 shows the face of the same patient. Notice the tightening and wrinkling of the skin around her mouth and the fixed, expressionless countenance as a result of flattening of the nasolabial folds. The patient had great difficulty in opening her mouth. The skin around the mouth has many furrows radiating outward, creating a mouselike appearance known as mauskopf.

Kaposi Sarcoma White Man Back
Figure 8-94 A, Early lesions of Kaposi's sarcoma on the back. B, Follow-up photograph, 6 months later, showing rapid development of purplish plaques of Kaposi's sarcoma.

Erythema nodosum is a common reaction associated with streptococcal infections, sarcoido-sis, tuberculosis, inflammatory bowel diseases, and fungal diseases. It is infrequently associated with rheumatic disorders. Patients, primarily young women, seek medical attention after the appearance of extremely painful, erythematous nodules on the lower legs, especially over the anterior tibia. The lesions range in size from 1 cm to several centimeters in diameter. The lesions can then coalesce and spread over the entire leg. The lesions of erythema nodosum begin to regress after 1 to 2 weeks. As they disappear, they undergo a series of characteristic color changes: bright erythema to shades of purple, yellow, and green. Figure 8-97 shows the

Sklerodermie Haut Gesicht
Figure 8-95 Scleroderma: hands.

Figure 8-96 Scleroderma: face.

early lesions of erythema nodosum in a 33-year-old woman in whom sarcoidosis was diagnosed 3 months later.

Lichen planus is a relatively common skin disorder of unknown cause. The primary lesion is a polygonal, shiny, flat-topped papule with a violaceous hue. The pruritic lesions can be seen on any part of the body but have a predilection for the front of the wrists and forearms, the backs of the hands, the ankles, the shins, the genitalia, and the lumbar areas. The lesions range in size from 2 mm to more than 1 cm. Figure 8-98A shows the characteristic rash on the arm. Fine reticulated scales are visible (see Fig. 8-98B). Oral lesions are seen in 50% of all patients with lichen planus and consist of a white, lacy network on the buccal mucosa. On occasion, involvement of the mouth may be the only manifestation of lichen planus. The patient usually experiences severe pain as the lesions ulcerate. Figure 12-15 depicts lichen planus of the buccal mucosa. Lichen planus may also involve the genitalia. Figure 8-99 shows lichen planus of the penis. Note the reticular markings on the penis. Figure 18-10 depicts another case of lichen planus of the penis. Note again the fine reticular markings.

Seborrheic dermatitis is a papulosquamous disorder associated with epidermal hyperplasia and scaling. The lesions have a greasy-looking scale in a seborrheic distribution: scalp, eyebrows, nasolabial fold, perioral area, midchest, and groin. Seborrheic dermatitis is one of the most common skin conditions associated with HIV infection; it is estimated that 85% of patients infected with HIV have this skin lesion at some time. In some patients, the development of seborrheic dermatitis is the first sign of HIV infection. Figure 8-100 shows the typical greasy scales of seborrheic dermatitis on the face of a patient with AIDS.

Seborrheic warts are common, benign skin tumors, seen in light-skinned individuals; they occur more frequently with advancing age. Also known as seborrheic keratosis (Fig. 8-101), seb-orrheic warts may be solitary or multiple lesions. They occur in any area of the body exposed to ultraviolet light. The lesions are well defined and raised and have a fissured surface. The lesions result from a failure of keratinocytes to mature normally, which produces an accumulation of immature cells in the epidermis. Sometimes the lesions may be pedunculated. A similar condition known as dermatosis papulosis nigra is seen in African Americans. Figure 8-102 is a close-up photograph of the characteristic appearance of a seborrheic wart.

A keloid is a hyperproliferative response of fibrous tissue to injury, inflammation, or infection. It has a smooth appearance with a shiny surface and is raised and firm to palpation. It is more commonly seen in dark-skinned individuals. The lesion characteristically spreads beyond the site of the initiating factor. Figure 8-103 shows an extensive keloid on the shoulder.

Nevi are common, localized abnormalities of the skin that may be present at birth or appear within the first few decades of life. Sometimes called ''moles,'' nevi may arise from almost any area of the skin. They are well defined, with a smooth surface and a round shape (Fig. 8-104). Hair may sometimes project from the surface. A strawberry nevus is a vascular tumor or heman-gioma that occurs shortly after birth and is red and raised. These grow rapidly and are often seen on the face of a child. They may bleed and ulcerate. Fortunately, most strawberry nevi involute by 6 or 7 years of age. Figure 24-8 shows a strawberry nevus in a child. Figure 24-9 shows a hemangioma in another child.

Blistering, or vesiculobullous, diseases of the skin are rare but important to recognize. Pemphigus vulgaris, pemphigus vegetans, and bullous pemphigoid are autoimmune diseases that affect skin and mucosal surfaces. Pemphigus vulgaris is a vesiculobullous disease of

Eczema Genitals
Figure 8-100 Seborrheic dermatitis.

Figure 8-101 Seborrheic keratosis.

Figure 8-103 Keloid.

middle age, seen more commonly in Jewish people. The lesions are superficial, flaccid blisters that break easily, leaving the skin denuded and eroded. The broken bullae may crust but do not heal spontaneously. These lesions are nonpruritic but are painful. The disease is caused by the production of antibodies to the intercellular junctions of the epidermis. The defective junctions lead to the formation of traumatic fissures and bullae. Figure 8-105A shows pemphigus vulgaris and broken bullae. Figure 8-105B shows pemphigus vegetans. The lesions may be present on any area of the skin, especially the trunk, umbilicus, intertriginous areas, and scalp. The lesions are frequently found in the mucous membranes of the oral cavity, pharynx, and genitalia. Figure 8-106 shows pemphigus vegetans of the lips.

Bullous pemphigoid is a blistering disorder seen more frequently in elderly patients. It is more common than pemphigus vulgaris. There is no racial predilection, and the disease is not

Pemphigus Vegetans
Figure 8-105 A and B, Pemphigus vulgaris. B, A vegetative form sometimes called pemphigus vegetans.

as serious as pemphigus. The lesions are intensely pruritic, tense bullae often on an erythem-atous base and are symmetric on the limbs, inner aspects of the arms, thighs, and trunk. Oral and mucosal lesions are rarer than those of pemphigus. Figure 8-107 depicts generalized bullous pemphigoid. Figure 8-108 shows bullous pemphigoid in another patient. Notice the tense bullae, which help differentiate this disease from pemphigus. Figure 8-109 is a close-up photograph of the tense bullae of bullous pemphigoid in yet another patient.

Atopic dermatitis, a form of eczema, is a common disease associated with other atopic diseases such as asthma and allergic rhinitis. It is characterized by itchy, dry, inflamed skin. The symptoms of atopic dermatitis often begin at a young age. Infants and young children may have eczematous patches on the face, scalp, and extensor surfaces of the extremities. These patches may erode and ooze. Scaling erythematous plaques often develop. As the child grows older, the atopic dermatitis begins to involve the flexural areas such as the neck, antecubital

Images Excoriation Neonates
Figure 8-106 Pemphigus vegetans of the lips.
Ancylostoma Caninum
Figure 8-107 Bullous pemphigoid.

fossae, and popliteal fossae. The pruritic lesions result in excoriations; thickening and lichen-ification of the skin with increased skin markings are common. In the adult, oozing, weeping, and excoriated plaques may become generalized. Although the pathogenesis of atopic dermatitis is unknown, many patients have elevated levels of serum immunoglobulin E. Since the 1970s, the incidence of atopic dermatitis has increased from 4% to 12%;the reasons are unclear. Immune dysregulation appears to play an important role in atopic dermatitis. Up to 50% of children with atopic dermatitis may have evidence of a food sensitivity. Emotional stressors do not cause atopic dermatitis but do exacerbate the symptoms. Figure 8-110 shows classic lesions of atopic dermatitis in the axilla. Figure 8-111 shows atopic dermatitis in another patient. Notice the oozing lesions and excoriations.

Lyme disease is an infection caused by the spirochete Borrelia burgdorferi that is transmitted by the usually asymptomatic bite of certain ticks of the genus Ixodes. Lyme borreliosis occurs in northeastern, mid-Atlantic, north-central, and far western regions of the United States. Erythema migrans is the clinical, distinctive hallmark of Lyme disease. It is a dynamic lesion

Atopicd Dermatitis Figure
Figure 8-110 Atopic dermatitis. Figure 8-111 Atopic dermatitis.

whose appearance can change dramatically over a period of days. The rash is recognized in 90% of patients with objective evidence of B. burgdorferi infection. The erythema begins as a red macule or papule at the site of the tick bite that occurred 7 to 10 days earlier. The rash expands as an annular erythematous plaque as the spirochetes spread centrifugally through the skin. Central clearing may or may not be present. Local symptoms of pruritus or tenderness are hardly noticeable. Systemic symptoms are common and include fatigue (54%), myalgia (44%), arthralgia (44%), headache (42%), fever and chills (39%), and stiff neck (35%). Neurologic symptoms are also common. The most common sign is regional lymphadenopathy (23%). Figures 8-112 and 8-113 show the classic erythema migrans of Lyme disease. Note the central lesion in Figure 8-113, which was the area of the tick bite.

As indicated previously in this chapter, there are many cutaneous manifestations of AIDS. Three of these common lesions are shown on the face of a patient with AIDS in Figure 8-114. The umbilicated, white papules on and around the lips, nose, and cheek are lesions of mol-luscum contagiosum. The verrucous papule on the upper lip is a wart. The violaceous lesions of KS are present on the lips and chin.

Fungal infections of the nails and hair are very common. The main fungi responsible for hair and nail diseases are dermatophytes of the genera Trichophyton, Microsporum, and

Tick Bite Lip
Figure 8-113 Erythema migrans of Lyme disease: site of the tick bite.
Erythema Migrans
How To Deal With Rosacea and Eczema

How To Deal With Rosacea and Eczema

Rosacea and Eczema are two skin conditions that are fairly commonly found throughout the world. Each of them is characterized by different features, and can be both discomfiting as well as result in undesirable appearance features. In a nutshell, theyre problems that many would want to deal with.

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