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Drug-Related Eruptions Adverse drug reactions manifest more often on the skin than any other organ system. Topical drug reactions vary in severity from mild pimples over a small area to peeling of the entire skin. Skin reactions may be serious enough to cause anaphylaxis, shock, or death. Most common offending drugs are penicillin, sulfa, anticonvulsants, tetracycline, morphine, codeine, and anti-inflammatory medications. A thorough medical history including current medications can help diagnose the adverse drug reaction, and the medication can be changed. Mulvihill, Zelman, Holdaway, Tompary, and Raymond Human Diseases: A Systemic Approach, 6e Copyright ©2006 by Prentice-Hall, Inc. Upper Saddle River, New Jersey 07458 All rights reserved. Table 17-2: Common Rashes Caused By Drugs Mulvihill, Zelman, Holdaway, Tompary, and Raymond Human Diseases: A Systemic Approach, 6e Copyright ©2006 by Prentice-Hall, Inc. Upper Saddle River, New Jersey 07458 All rights reserved. Benign tumors Nevus (Mole) A small, dark skin growth that develops from pigment-producing cells or melanocytes – Moles may be flat or raised and vary in size. Most people have about 10 moles. – Moles may become malignant. – Sudden changes in moles such as enlargement with an irregular border, darkening, inflammation, and bleeding are warning signs of malignant melanoma. Nevus can be removed by excision or cryosurgery. Mulvihill, Zelman, Holdaway, Tompary, and Raymond Human Diseases: A Systemic Approach, 6e Copyright ©2006 by Prentice-Hall, Inc. Upper Saddle River, New Jersey 07458 All rights reserved. Raised nevus, or mole, on forehead. (© Custom Medical Stock Photo) Mulvihill, Zelman, Holdaway, Tompary, and Raymond Human Diseases: A Systemic Approach, 6e Copyright ©2006 by Prentice-Hall, Inc. Upper Saddle River, New Jersey 07458 All rights reserved. Benign Tumors Hemangioma A benign tumor made of small blood vessels that form a red or purple birthmark. Port wine stain is a dark red to purple birthmark appearing on the face. Strawberry hemangioma is a strawberry red, rough, protruding lesion on the face, neck, or trunk. Cherry hemangioma is a small, red, dome-shaped lesion. Some hemangioma regress on their own. Treatment options include steroids, interferon, surgery, and laser treatment. Mulvihill, Zelman, Holdaway, Tompary, and Raymond Human Diseases: A Systemic Approach, 6e Copyright ©2006 by Prentice-Hall, Inc. Upper Saddle River, New Jersey 07458 All rights reserved. Figure 17-17: Port wine hemangioma. (©Custom Medical Stock Photo.) Mulvihill, Zelman, Holdaway, Tompary, and Raymond Human Diseases: A Systemic Approach, 6e Copyright ©2006 by Prentice-Hall, Inc. Upper Saddle River, New Jersey 07458 All rights reserved. Figure 17-18: Strawberry hemangioma. (© NMSB / Custom Medical Stock Photo.) Mulvihill, Zelman, Holdaway, Tompary, and Raymond Human Diseases: A Systemic Approach, 6e Copyright ©2006 by Prentice-Hall, Inc. Upper Saddle River, New Jersey 07458 All rights reserved. Figure 17-19: Cherry hemangioma. (© Logical Images / Custom Medical Stock Photo.) Mulvihill, Zelman, Holdaway, Tompary, and Raymond Human Diseases: A Systemic Approach, 6e Copyright ©2006 by Prentice-Hall, Inc. Upper Saddle River, New Jersey 07458 All rights reserved. Skin Cancer Basal cell carcinoma Squamous cell carcinoma Kaposi’s sarcoma Actinic keratosis Malignant melanoma Mulvihill, Zelman, Holdaway, Tompary, and Raymond Human Diseases: A Systemic Approach, 6e Copyright ©2006 by Prentice-Hall, Inc. Upper Saddle River, New Jersey 07458 All rights reserved. Click on the screenshot to view a video on the topic of skin cancer. Mulvihill, Zelman, Holdaway, Tompary, and Raymond Human Diseases: A Systemic Approach, 6e Return to Directory Copyright ©2006 by Prentice-Hall, Inc. Upper Saddle River, New Jersey 07458 All rights reserved. Skin Cancer Basal Cell Carcinoma Most common skin cancer is basal cell carcinoma Slow-growing, generally nonmetastasizing Generally develops on the face of people with light skin Lesion begins as a pearly nodule with rolled edges that may bleed and form a crust. Ulceration occurs and size increases if it is neglected. Treatment: surgical removal, cauterization, or radiation therapy Mulvihill, Zelman, Holdaway, Tompary, and Raymond Human Diseases: A Systemic Approach, 6e Copyright ©2006 by Prentice-Hall, Inc. Upper Saddle River, New Jersey 07458 All rights reserved. Figure 17-20: Basal cell carcinoma. (© Calienda / Custom Medical Stock Photo.) Mulvihill, Zelman, Holdaway, Tompary, and Raymond Human Diseases: A Systemic Approach, 6e Copyright ©2006 by Prentice-Hall, Inc. Upper Saddle River, New Jersey 07458 All rights reserved. Figure 17-21: Kaposi’s sarcoma on the bottom of the foot. (Courtesy of the CDC / Dr. Steve Kraus, 1981.) Mulvihill, Zelman, Holdaway, Tompary, and Raymond Human Diseases: A Systemic Approach, 6e Copyright ©2006 by Prentice-Hall, Inc. Upper Saddle River, New Jersey 07458 All rights reserved. Figure 17-22: Malignant melanoma is a serious skin cancer that arises from melanocytes. Mulvihill, Zelman, Holdaway, Tompary, and Raymond Human Diseases: A Systemic Approach, 6e Copyright ©2006 by Prentice-Hall, Inc. Upper Saddle River, New Jersey 07458 All rights reserved. Figure 17-23: Malignant melanoma on a foot. (© Caliendo / Custom Medical Stock Photo.) Mulvihill, Zelman, Holdaway, Tompary, and Raymond Human Diseases: A Systemic Approach, 6e Copyright ©2006 by Prentice-Hall, Inc. Upper Saddle River, New Jersey 07458 All rights reserved. Squamous Cell Carcinoma More serious than basal cell carcinoma because it grows more rapidly, infiltrates underlying tissues, and metastasizes through lymph channels Squamous cell carcinoma is a malignancy of the keratinocytes in the epidermis of people who have been excessively exposed to the sun. Lesion is a crusted nodule that ulcerates and bleeds Develops in any squamous epithelium of the body Treatment: should be completely excised surgically or treated with radiation Mulvihill, Zelman, Holdaway, Tompary, and Raymond Human Diseases: A Systemic Approach, 6e Copyright ©2006 by Prentice-Hall, Inc. Upper Saddle River, New Jersey 07458 All rights reserved. Kaposi’s Sarcoma Purplish neoplasm of the lower extremities Lesions are classically described as red-to-purple lesions varying from macules to nodules. The etiological agent of Kaposi’s sarcoma is the human herpes virus 8 Has been epidemic in persons with AIDS and is one of the indicator diseases for the diagnosis of AIDS Herpes virus has been found in lesions and may play a part in etiology Treatment includes sugery, chemotherapy, and radiation Mulvihill, Zelman, Holdaway, Tompary, and Raymond Human Diseases: A Systemic Approach, 6e Copyright ©2006 by Prentice-Hall, Inc. Upper Saddle River, New Jersey 07458 All rights reserved. Actinic Keratosis Caused by excessive exposure to the sun; more common in middle-aged fair-skinned individuals Multiple wart-like lesions on areas of the body exposed to the sun such as the face, arms, and legs Treatment may include topical medications such as Retin-A, and surgical removal of the lesions Mulvihill, Zelman, Holdaway, Tompary, and Raymond Human Diseases: A Systemic Approach, 6e Copyright ©2006 by Prentice-Hall, Inc. Upper Saddle River, New Jersey 07458 All rights reserved. Malignant Melanoma Most serious skin cancer Arises from the melanocytes of the epidermis Highly malignant and metastasizes early – Melanoma sometimes develops from a mole that changes its size and color and becomes itchy and sore. Treatment: It is usually excised with the surrounding lymph nodes to reduce metastasis. Radiation and chemotherapy follow. Prognosis depends on the depth of infiltration, previous spread, and how completely the tumor is excised. Mulvihill, Zelman, Holdaway, Tompary, and Raymond Human Diseases: A Systemic Approach, 6e Copyright ©2006 by Prentice-Hall, Inc. Upper Saddle River, New Jersey 07458 All rights reserved. Melanoma on calf. (© Custom Medical Stock Photo.) Mulvihill, Zelman, Holdaway, Tompary, and Raymond Human Diseases: A Systemic Approach, 6e Copyright ©2006 by Prentice-Hall, Inc. Upper Saddle River, New Jersey 07458 All rights reserved. Sebaceous Gland Disorders Acne vulgaris Seborrheic dermatitis Sebaceous cysts Acne rosacea Mulvihill, Zelman, Holdaway, Tompary, and Raymond Human Diseases: A Systemic Approach, 6e Copyright ©2006 by Prentice-Hall, Inc. Upper Saddle River, New Jersey 07458 All rights reserved. Acne Vulgaris Blackheads, pimples, and pustules About 80% of the population between the ages of 12 and 25 develop some form of acne. Noninflammatory: the mild form Inflammatory acne: a constant breakout of pus-filled pimples and cysts that cause deep pitting and scarring. Etiology: hormonal changes that occur at puberty increase production of sebum by sebaceous glands – Blackhead: oxidized sebaceous secretion – Whitehead: pyogenic bacteria accumulation under the skin Treatment: Topical agents, oral agents, condition is self- limiting Mulvihill, Zelman, Holdaway, Tompary, and Raymond Human Diseases: A Systemic Approach, 6e Copyright ©2006 by Prentice-Hall, Inc. Upper Saddle River, New Jersey 07458 All rights reserved. Figure 17-24: A patient with severe acne. (© Custom Medical Stock Photo.) Mulvihill, Zelman, Holdaway, Tompary, and Raymond Human Diseases: A Systemic Approach, 6e Copyright ©2006 by Prentice-Hall, Inc. Upper Saddle River, New Jersey 07458 All rights reserved. Click on the screenshot to view a video on the topic of acne. Mulvihill, Zelman, Holdaway, Tompary, and Raymond Human Diseases: A Systemic Approach, 6e Return to Directory Copyright ©2006 by Prentice-Hall, Inc. Upper Saddle River, New Jersey 07458 All rights reserved. Seborrheic Dermatitis (Chronic Dandruff) The cause of dandruff is similar to that of acne – Excessive secretion of sebum from the sebaceous glands – Oily scalp and excessive secretion of sebum forms the familiar scales of dandruff. – May spread to the face and ears, and the eyebrows are often affected. Treatment: Frequent shampooing, particularly with medicated shampoo Mulvihill, Zelman, Holdaway, Tompary, and Raymond Human Diseases: A Systemic Approach, 6e Copyright ©2006 by Prentice-Hall, Inc. Upper Saddle River, New Jersey 07458 All rights reserved. Metabolic Skin Disorder Psoriasis Characterized by red, cracked, and bleeding scales on the scalp, knees, elbows, and trunk Psoriasis is characterized by an abnormal rate of epidermal cell production and turnover. Etiology: overactive T cells – Scales seen in psoriasis are not the cause, but the effect. Treatments for psoriasis include coal tar, application of emollient cream, ultraviolet light, the cancer drug methotrexate, and the organ transplant rejection drug cyclosporine Mulvihill, Zelman, Holdaway, Tompary, and Raymond Human Diseases: A Systemic Approach, 6e Copyright ©2006 by Prentice-Hall, Inc. Upper Saddle River, New Jersey 07458 All rights reserved. Figure 17-26: Psoriasis covering the arm of a patient. (Courtesy of the CDC / Dr. N.J. Flumara, 1976.) Mulvihill, Zelman, Holdaway, Tompary, and Raymond Human Diseases: A Systemic Approach, 6e Copyright ©2006 by Prentice-Hall, Inc. Upper Saddle River, New Jersey 07458 All rights reserved. Sebaceous Cysts Sebaceous cysts form when a sebaceous gland duct becomes blocked, and the sebum accumulates under the surface of the skin, forming a lump. Sebaceous cysts are not considered serious, but they can rupture, allowing bacteria to enter the body. These cysts can be incised and drained, although they tend to recur, or they can be removed surgically. Mulvihill, Zelman, Holdaway, Tompary, and Raymond Human Diseases: A Systemic Approach, 6e Copyright ©2006 by Prentice-Hall, Inc. Upper Saddle River, New Jersey 07458 All rights reserved. Acne Rosacea Appears during or after middle age in persons with fair skin. The cheeks, chin, and nose develop tiny pimples and broken blood vessels that eventually thicken and give the nose a bulbous appearance. Etiology: not known, although this condition responds well to topical antibiotic treatment Mulvihill, Zelman, Holdaway, Tompary, and Raymond Human Diseases: A Systemic Approach, 6e Copyright ©2006 by Prentice-Hall, Inc. Upper Saddle River, New Jersey 07458 All rights reserved. Figure 17-25: Acne rosacea is more common in the middle-aged to older adult. It causes changes in skin color, enlarges pores, and in some cases, thickening of the soft tissues of the nose. Mulvihill, Zelman, Holdaway, Tompary, and Raymond Human Diseases: A Systemic Approach, 6e Copyright ©2006 by Prentice-Hall, Inc. Upper Saddle River, New Jersey 07458 All rights reserved. Pigment Disorders Albinism Vitiligo Ephelis Lentigo Melasma Mulvihill, Zelman, Holdaway, Tompary, and Raymond Human Diseases: A Systemic Approach, 6e Copyright ©2006 by Prentice-Hall, Inc. Upper Saddle River, New Jersey 07458 All rights reserved. Melanin Interspersed among other cells in the epidermis Skin color varies from light to dark depending on the number of melanocytes present. Melanin production normally increases with exposure to sunlight causing tanning. Hypopigmentation is an abnormally low amount or absence of melanin. – The skin may be pale white to various shades of pink caused by blood flowing through it. Mulvihill, Zelman, Holdaway, Tompary, and Raymond Human Diseases: A Systemic Approach, 6e Copyright ©2006 by Prentice-Hall, Inc. Upper Saddle River, New Jersey 07458 All rights reserved. Albinism Rare inherited disorder in which no melanin is formed White hair, pale skin, and pink eyes. Because melanin protects the skin from the sun, albinos are prone to sunburn and skin cancer. Mulvihill, Zelman, Holdaway, Tompary, and Raymond Human Diseases: A Systemic Approach, 6e Copyright ©2006 by Prentice-Hall, Inc. Upper Saddle River, New Jersey 07458 All rights reserved. Vitiligo A loss of melanin Resulting white patches of skin may cover large parts of the body Hypopigmentation is most striking in dark-skinned persons. As in albinism, the unpigmented skin is prone to sunburn. Etiology: unknown Treatment: no cure – Small areas of skin may be covered with tinted make-up, and sunscreen should always be applied to the skin to prevent sunburn. Other options include steroids, psoralen, and UV light therapy, depigmentation therapy, and laser treatments. Mulvihill, Zelman, Holdaway, Tompary, and Raymond Human Diseases: A Systemic Approach, 6e Copyright ©2006 by Prentice-Hall, Inc. Upper Saddle River, New Jersey 07458 All rights reserved. Figure 17-27: Vitiligo. (© Custom Medical Stock Photo.) Mulvihill, Zelman, Holdaway, Tompary, and Raymond Human Diseases: A Systemic Approach, 6e Copyright ©2006 by Prentice-Hall, Inc. Upper Saddle River, New Jersey 07458 All rights reserved. Ephelis Freckles indicate skin damage due to sunburn. – Melanocytes in a freckle area are hyper- reactive to sunlight and the excess melanin they produce causes the freckle. – Bleaching creams can be used to lighten freckles. Mulvihill, Zelman, Holdaway, Tompary, and Raymond Human Diseases: A Systemic Approach, 6e Copyright ©2006 by Prentice-Hall, Inc. Upper Saddle River, New Jersey 07458 All rights reserved. Lentigo Lentigo (liver spots) are small brown lesions occurring on the face, neck, and back of the hands. Lentigo are not due to aging but are due to excessive sun exposure. Bleaching creams can be used to lighten liver spots. Mulvihill, Zelman, Holdaway, Tompary, and Raymond Human Diseases: A Systemic Approach, 6e Copyright ©2006 by Prentice-Hall, Inc. Upper Saddle River, New Jersey 07458 All rights reserved. Figure 17-28: Lentigo. (© Zuber / Custom Medical Stock Photo.) Mulvihill, Zelman, Holdaway, Tompary, and Raymond Human Diseases: A Systemic Approach, 6e Copyright ©2006 by Prentice-Hall, Inc. Upper Saddle River, New Jersey 07458 All rights reserved. Melasma Melasma occurs due to hormonal changes in some women during pregnancy or from oral contraceptive use. Patches of darker skin develop on the face especially over the cheeks. The patches disappear after childbirth or when oral contraceptive use is discontinued. Mulvihill, Zelman, Holdaway, Tompary, and Raymond Human Diseases: A Systemic Approach, 6e Copyright ©2006 by Prentice-Hall, Inc. Upper Saddle River, New Jersey 07458 All rights reserved. Pressure Injury of Skin Decubitus ulcer Corns and calluses Pressure injuries to the skin occur when pressure decreases blood flow to an area of the skin. Mulvihill, Zelman, Holdaway, Tompary, and Raymond Human Diseases: A Systemic Approach, 6e Copyright ©2006 by Prentice-Hall, Inc. Upper Saddle River, New Jersey 07458 All rights reserved. Decubitus Ulcer Affects the bony areas of the body such as the hips, heels, elbows, and ankles Shiny, red skin appears over a bony area that eventually includes blisters, erosions, necrosis, and ulceration. If the ulcer becomes infected, a foul-smelling, purulent discharge is present. Etiology: Immobility, confinement to the bed Treatments include gelatin sponges, antiseptic irrigation, debriding agents, antibiotics, repositioning to decrease pressure and increase blood flow to irritated area Mulvihill, Zelman, Holdaway, Tompary, and Raymond Human Diseases: A Systemic Approach, 6e Copyright ©2006 by Prentice-Hall, Inc. Upper Saddle River, New Jersey 07458 All rights reserved. Click on the screenshot to view a video on the topic of decubitus ulcer. Mulvihill, Zelman, Holdaway, Tompary, and Raymond Human Diseases: A Systemic Approach, 6e Return to Directory Copyright ©2006 by Prentice-Hall, Inc. Upper Saddle River, New Jersey 07458 All rights reserved. Figure 17-29: Decubitus ulcers. (© Caliendo / Custom Medical Stock Photo.) Mulvihill, Zelman, Holdaway, Tompary, and Raymond Human Diseases: A Systemic Approach, 6e Copyright ©2006 by Prentice-Hall, Inc. Upper Saddle River, New Jersey 07458 All rights reserved. Click on the screenshot to view an animation showing pressure ulcer. Mulvihill, Zelman, Holdaway, Tompary, and Raymond Human Diseases: A Systemic Approach, 6e Return to Directory Copyright ©2006 by Prentice-Hall, Inc. Upper Saddle River, New Jersey 07458 All rights reserved. Corns and Calluses Areas of the skin that have grown thick in response to repeated pressure and friction Corns have a glassy core, are small, found on the feet, and are usually due to an improperly fitting shoe. Can be painful or protective If found on the palms of the hands, they are usually due to manual labor Treatment: excision if painful, preventative measures, and comfort pads and soaks Mulvihill, Zelman, Holdaway, Tompary, and Raymond Human Diseases: A Systemic Approach, 6e Copyright ©2006 by Prentice-Hall, Inc. Upper Saddle River, New Jersey 07458 All rights reserved. Thermal Skin Injury (Burns) Fire, steam, hot water, sunlight, chemicals, and electricity can burn skin. Burns are classified by the depth of skin involved First-degree or superficial burns affect the epidermis and are caused by sunburn or a low intensity flash. Second-degree or partial thickness burns are caused by scalds or flash flame and affect the dermis or true skin. Recovery requires 2 to 3 weeks and some scarring and depigmentation usually occurs. Mulvihill, Zelman, Holdaway, Tompary, and Raymond Human Diseases: A Systemic Approach, 6e Copyright ©2006 by Prentice-Hall, Inc. Upper Saddle River, New Jersey 07458 All rights reserved. Thermal Skin Injury (Burns) (continued) Third-degree or full thickness burns result from fire and prolonged exposure to hot liquids. Subcutaneous tissue is affected and the burn appears pale or charred. – Broken skin exposes underlying fat tissue. – Symptoms of shock – Healing requires time and grafting is necessary. Scarring and loss of contour occur. Mulvihill, Zelman, Holdaway, Tompary, and Raymond Human Diseases: A Systemic Approach, 6e Copyright ©2006 by Prentice-Hall, Inc. Upper Saddle River, New Jersey 07458 All rights reserved. Figure 17-30: First degree burn. Mulvihill, Zelman, Holdaway, Tompary, and Raymond Human Diseases: A Systemic Approach, 6e Copyright ©2006 by Prentice-Hall, Inc. Upper Saddle River, New Jersey 07458 All rights reserved. Figure 17-31: Second degree burn. Mulvihill, Zelman, Holdaway, Tompary, and Raymond Human Diseases: A Systemic Approach, 6e Copyright ©2006 by Prentice-Hall, Inc. Upper Saddle River, New Jersey 07458 All rights reserved. Figure 17-32: Third degree burn. Mulvihill, Zelman, Holdaway, Tompary, and Raymond Human Diseases: A Systemic Approach, 6e Copyright ©2006 by Prentice-Hall, Inc. Upper Saddle River, New Jersey 07458 All rights reserved. Frostbite Frostbite is the freezing of tissue and is most common on the fingers, toes, and ears. The skin appears white in color and is painless. Treatment for frostbite includes rapid warming in warm water baths. When warmed, the skin turns red and becomes painful. Tissue affected by severe frostbite may become necrotic and require surgery or amputation. Mulvihill, Zelman, Holdaway, Tompary, and Raymond Human Diseases: A Systemic Approach, 6e Copyright ©2006 by Prentice-Hall, Inc. Upper Saddle River, New Jersey 07458 All rights reserved. Age-Related Diseases of Skin Structure and function of skin changes Touch sensation of the skin decreases with age making burns and frostbite more likely. Xerosis or dry skin is a major problem in older adults. The epidermis becomes thinner with age and therefore retains less water. Sebaceous glands do not function as well, adding to the xerosis. Mulvihill, Zelman, Holdaway, Tompary, and Raymond Human Diseases: A Systemic Approach, 6e Copyright ©2006 by Prentice-Hall, Inc. Upper Saddle River, New Jersey 07458 All rights reserved. Age-Related Diseases of Skin (continued) Loss of elasticity Nails become thicker and difficult to trim. Hair becomes brittle, thin, gray, and may be lost. Seborrheic keratosis is a benign overgrowth of epithelial cells that is very common in older adults. The lesions are brown and appear to be pasted on. The cause of seborrheic keratosis is unknown, but the lesions do not become malignant. The lesions can be removed by curettage. Mulvihill, Zelman, Holdaway, Tompary, and Raymond Human Diseases: A Systemic Approach, 6e Copyright ©2006 by Prentice-Hall, Inc. Upper Saddle River, New Jersey 07458 All rights reserved. Diagnostic Procedures for Skin Diseases Identified by visual examination Scrapings from lesions can be cultured or blood tests for antibodies may be used to identify the causative organism in infectious skin diseases. Complete medical history including prior outbreaks and locations of outbreaks may help identify the allergen. Sensitivity testing or blood tests for antibodies may be used to identify the allergen. Biopsies are used to diagnose benign tumors and skin caner. Types of biopsies performed include punch, incisional, or total excisional. Mulvihill, Zelman, Holdaway, Tompary, and Raymond Human Diseases: A Systemic Approach, 6e Copyright ©2006 by Prentice-Hall, Inc. Upper Saddle River, New Jersey 07458 All rights reserved. Figure 17-33: Seborrheic keratosis. (Courtesy of the CDC / Dr. Steve Kraus, 1981.) Mulvihill, Zelman, Holdaway, Tompary, and Raymond Human Diseases: A Systemic Approach, 6e Copyright ©2006 by Prentice-Hall, Inc. Upper Saddle River, New Jersey 07458 All rights reserved.
