Biopsy with immunofluorescence is often indicated to exclude keratosis, chronic ulcerative stomatitis with stratified epitheliumspecific antinuclear antibodies, lichen sclerosus, lupus erythematosus, malignancy and other disorders. Counters may be made from many different potentially allergenic materials, including natural rubber, formaldehyde resins, biocides and pine oil. If the same allergen provokes an equally strong reaction on both sides, it is an indication of contact allergy alone; if it is significantly stronger on the irradiated side, then combined allergy and photocontact allergy may be occurring. A proportion of these infants have been hypothermic, and occasionally sclerema has been described as a complication of neonatal cold injury [4]. In cases where systemic involvement such as renal impairment or liver function disturbance is noted, appropriate supportive care such as intravenous fluids and careful haemodynamic monitoring should be employed. No specific treatment is available for infectious mononucleosis, but supportive care is important, not only because of the potential for airways obstruction but also because of the associated lassitude. Acute inflammation of the scrotum in patients with familial Mediterra nean fever can occur [38]. Of 49 patients with acute ocular involvement, 31 went on to develop chronic eye disease; the severity of the acute ocular involvement was found to be the only significant risk factor for late eye complications [38]. Sporting activities can exacerbate preexisting skin disease, such as atopic eczema, psoriasis, acne and other skin diseases. Viral respiratory infections, overwork and fatigue, smoking or immune defects may precede the onset of disease, suggesting depression of immunity as a predisposing cause. Second line In a doubleblind, placebocontrolled study of 16 patients with secondary Raynaud phenomenon, sildenafil 50 mg twice daily demonstrated significant improvement in mean attack rates and duration [18]. Management Conservative management includes taking measures to keep the hands and feet warm and reducing cold exposure and also emotional stress. Care must always be taken in prescribing an antihistamine systemically if the patient is known to have been exposed to the same or a chemically similar drug topically. Labels on medicated foot powders and talcs generally acknowledge it as an ingredient, but specific enquiries may be necessary to establish its presence in some topical medicaments and disinfectants. Predisposing factors the precise cause is unestablished, but a variety of insults appear to have contributed in individual cases. Halogenated aromatic hydrocarbons [2,3,4,5,6,7] are the most potent acnegenic agents. Allergic contact dermatitis is markedly inflamed and may have an ill-defined spreading border. Partially cured epoxy resin dusts from sanding and drilling may induce dermatitis with a similar distribution. Alternatively, they may have developed a secondary allergic or photoallergic contact sensitivity to their sunscreen or to one of their other medicaments. In severe and longstanding staphylococcal blepharitis, trichiasis (misdirection of eyelashes towards the eye), poliosis (depigmentation of the eyelashes), madarosis (loss of eyelashes), eyelid ulceration, and eyelid and corneal scarring may occur [3]. Most patients presenting to dermatologists will therefore be those that require further investigations or treatments that cannot be undertaken or prescribed by the nurse. However, depending on the degree of sensitivity, penetration and other factors, this may vary from a few hours to many days. Painless, shaggy or folded white lesions typically affect the buccal mucosa bilaterally but may also involve other areas, although rarely the gingival margins [1,2]. However, both drugs should be used with caution in patients with hepatic or renal impairment. Hairy leukoplakia regresses on treatment with antivirals but fails to resolve with antifungals, despite the frequent presence of Candida species. Epidemiology Clinical features Sex Fungal infection in the genital area is more common in men. The natural history is of proliferation in the first few months of life, and involution over a matter of years. Many types of foreign body elicit a granulomatous response, seen clinically as erythematous brown or purple papules, nodules or plaques. If a non-sedating antihistamine is required, then the second generation antihistamines loratadine and cetirizine can be administered in the second and third trimester [2,3].
The evidence suggests that Zoon balanitis is a chronic, reactive, principally irritant dermatosis brought about by a dysfunctional prepuce. Age and sex Toxic erythema of chemotherapy affects both sexes equally, and all ages. Survivors of oesophageal squamous cell carcinoma have an almost sevenfold increase in risk of mouth and pharynx cancers. The substitution of one allergen by an alternative component may lead to the introduction of perhaps an even more sensitizing substance [4]. Most recall reactions occur when radiotherapy and chemotherapy are separated by less than 2 months [6]; the median interval is 40 days [3]. The high rate of metastasis and mortality in reported cases indicates that pilonidal sinusrelated squamous cell carcinoma tends to be aggressive [20,21]. Prevalence of mixed cryoglobulinaemia syndrome and circulating cryoglobulins in a populationbased survey: the Origgio study. There is a risk of unpleasant side effects, including extensive skin eruptions and perianal dermatitis [37]. Lingual thyroid Ectopic thyroid tissue may rarely present clinically in the mouth, though some 10% of cadaver tongues contain thyroid tissue. Penile oedema induced by continuous condom catheter use and mim icking keloid scar. Lipolytic mechanisms are poorly developed in the newborn, particularly in those born preterm [5]. They are occasionally associated with cystic the lingual tonsil is a mass of lymphoid tissue in the posterior third of the tongue, between the epiglottis posteriorly and the circumvallate papillae anteriorly [1,2]. By the time the patient has been sensitized, many body regions may have been in contact with the allergen, some indirectly by contamination from the fingertips. The allergen is the (2hydroxyethyl)dimethylsulphoxonium ion, a metabolite produced by the bryozoan [7,8]. Appropriate parenterally administered combination antibiotic therapy will be required. The natural presence of various metals in the skin means that quantification for toxicity purposes is meaningless unless compared with control levels. The eruption may be papular, nummular, diffuse or consist only of excoriated papules on almost normallooking skin. Clinical features the oral mucosa is almost invariably involved in white sponge naevus. Clinical examination reveals lymphadenopathy in at least two sites in the majority of patients. In reality, it is likely that there are a number of mechanisms at play, acting synergistically to produce the clinical phenotype. The risk of nail changes with epidermal growth factor receptor inhibitors: a systematic review of the literature and metaanalysis. Clinical features Epidemiology History There is usually a history of painful recurring lumps with a discharge that is often malodourous and blood stained. If the patient is not using a mostly or wholly hydrocolloid barrier it is worth changing to one as psoriasis may clear under occlusion with a hydrocolloid but not a thin fabric dressing [2,13]. If so, provocation testing might provide valuable prognostic information for newly diagnosed patients. Melanin pigmentation is often absent and there is little or no abnormality of melanocytes in the epidermis.
When clinical assessment points strongly towards an occupational allergic contact dermatitis, the occurrence of negative patch test results should always raise the possibility of the responsible allergen having been inadvertently omitted from testing [22,23]. Regardless, aggressive resuscitation and administration of 100% oxygen remains a mainstay of treatment. In hot climates, petrolatum may not be ideal, as it melts too quickly between preparation and application of the patch test. Bilateral cases of naevus of Ota are sometimes associated with extensive Mongolian spots. The diagnosis is now restricted to those few patients whose lesions cannot be attributed to other causes, such as contact sensitization or light (see Actinic cheilitis, p. Pressure the most important of the extrinsic factors is pressure, which is defined as a perpendicularly applied force. Investigations Investigations are the same as for autoimmune bullous disease on extragenital skin. The intact skin should be cleansed each day by gentle irrigation with warmed sterile water or sprayed with a weak solution of chlorhexidine (1/5000). It releases only small amounts of formaldehyde, and may therefore possibly be less of a problem than other formaldehyde releasers for formaldehyde sensitive subjects [12]. Eosinophilic, partially coalescent, Kamino bodies are present in the junctional area and upper papillary dermis. A review in 2009 looked at 38 reports of pregnancies from 49 women with pemphigus vulgaris. Retrospective analysis of the relationship between infantile seborrhoeic dermatitis and atopic dermatitis. Prognosis is also excellent for larger haemangiomas if there is no functional impairment, and if it is not at an aesthetically important site. Management Laser treatment has been reported to be useful in those who are unresponsive to topical steroids or retinoids [8]. Flares of dermatitis and perianal pruritus may occur in patients undergoing desensitization to Toxicodendron species, and systemic contact dermatitis may be induced following the ingestion of cashew nuts, whose shells contain an oleoresin closely related to that found in poison ivy [16]. Dermoid cysts usually become clinically obvious in the second decade of life and cause elevation of the tongue. The patient must also be assessed for other sites of disease with cervical cytology, colposcopy and anoscopy if appropriate. Respiration may be impaired as a result of intrapartum aspiration of squamous debris shed into the amniotic fluid. In cyclic neutropenia, ulcers appear episodically at 21day intervals in association with the neutropenic episodes. It is presumed that penetration of the irritant is primarily via sweat ducts and hair follicles, is not related to pH and that the reaction involves stimulation of sensory nerve endings. The treatment should be a short course and it should not be used long term as the safety of these immunosuppressants is still unknown, particularly as the condition carries a risk of neoplastic change. Vascular changes the vascular changes of pregnancy are similar to those in hyperthyroidism or cirrhosis. Desquamative gingivitis; retrospective analysis of disease associations of a large cohort. For patients with large naevi covering extensive body surface areas that are difficult for the patient to selfexamine, clinical surveillance and sequential dermoscopic examination should be offered. Patients with dysplastic naevus syndrome should be referred to an ophthalmologist for ocular assessment (see Chapter 132). These toxins reach the skin via the circulation from a distant focus of infection, usually in the umbilicus, breast, conjunctiva or site of circumcision or herniorrhaphy. It may cause pain and bleeding; however, this method can encourage a stalled wound to begin healing as a reaction to the now acute wound. In our experience a relevance for a gold sodium thiosulphate positive patch test is found infrequently, and generally these patients can wear jewellery and have gold dental fillings without problems [2,3].
This variation in the reported incidence of photoallergy may result from differences in patient selection, photopatch testing methodology, the test battery that is used and interpretation of test results. Otherwise the aetiology may be obscure, though sun, wind, cold weather and smoking are thought to predispose. A small firm pink macule changes to a papule which ulcerates to form a painless round ulcer with a raised margin and indurated base [4,10]. The coating in most cases consists of epithelial, food and microbial debris; indeed, the tongue is the main oral reservoir of some microorganisms, such as Candida albicans and viridans streptococci. In up to onethird of patients, the jaw lesions are the first manifestation of the tumour. Angiolipomas, spindle cell lipomas and liposarcomas are in the differential diagnosis. In some cases where polypharmacy has been in place, this may not be straightforward, but all efforts must be made to ascribe causality to a likely culprit, based on latency and notoriety data. A softtissue mass in the penis associated with systemic amyloid has been reported [25]. Paracoccidioidomycosis can be the cause of scrotal swelling and genital nodules and erosions [29]. Acute attacks require admission to hospital and treatment with systemic broad spectrum antibiotics; a short course of prednisolone may also be helpful. Unless the choice of substances kept for patch testing is constantly supplemented, rubber dermatitis will be missed. A range of longterm oral complications may occur resulting in functional impairments. With prolonged exposure, a form of hardening can occur, with the pruritus, but not the visible signs of dermatitis, reducing in intensity [3]. Clinical features Injuries commonly occur on the feet or legs as a result of the victim stepping on the fish. Investigations Monochromator phototesting should be undertaken whilst on the drug and repeated after a period off the drug, the interval depending on the kinetics of the drug and its metabolites. Herbal teas, medicines and cosmetics may all contain Compositae plants or extracts. Also in plentiful number are holocrine sebaceous glands, usually in association with hair follicles but also occurring as free glands at some sites such as the anal rim or around the coronal sulcus (Tyson glands). They are similar to the striae seen in patients with Cushing syndrome, corticosteroid therapy and rapid changes in body weight. They may contain adnexal structures such as hair or eccrine glands, and very rarely bone and teeth. Because of late diagnosis, sebaceous gland carcinoma carries a significant mortality. Randomised controlled study of early pulsed dye laser treatment of uncomplicated childhood haemangiomas: results of a 1year analysis. Any underlying renal dysfunction may be exacerbated by the syndrome, and prerenal causes of kidney impairment such as dehydration from fever in the prodromal phase may contribute. Stainless steel saucepans release negligible nickel, but cooking acid fruit in them, particularly when new, has the potential to contribute to dietary intake [32]. The anus is principally for the evacuation of faeces, but may also be an organ of sexual utility. Nevertheless, anecdotal observations of a similar nature had been made prior to this, usually by applying the suspected causative agent to intact skin [12]. The allergen has been identified as the (2hydroxyethyl) dimethylsulfoxonium ion [2].
The exact relationship between episodes of acute infection and chronic penile oedema, which often is complicated by cellulitis, is uncertain. Patients typically describe a prodromal phase characterized by asthenia, malaise and fatigue. In a case of melanoma, both the central pigmented area and the surrounding halo appear irregular, while the centre of the lesion presents dermoscopic features that are suggestive of melanoma. More extensive series have been advocated as a screen, but even these may miss some shoe allergens, including biocides, vegetable tans, hydroquinone and polyurethane agents. They are transient, developing within minutes, and fade quickly (usually within hours). Systemic therapies, often with immunosuppressants or immunomodulatory agents, may be required in severe disease. Nevertheless, this is unlikely at doses below 15 mg prednisolone daily [9], and we have identified relevant positive patch tests in patients who could only be investigated while they were taking other immunomodulators. Continuous therapy is more likely to cause side effects than intermittent therapy. Lichen planus is often of the hypertrophic variety especially on the scalp, and severe and irreversible alopecia may follow [26]. First line Reduction in friction, with the use of emollients and a moderately potent topical steroid. Prolonged or severe postherpetic neuralgia is a painful and unpleasant sequel to herpes zoster infection. However, less common allergens may be included if they are potentially easily overlooked and are important. In the birchrich areas of northern and central Europe almost all birch pollenallergic patients are sensitized to Bet v1, the major allergen component of pollen from Betula verucosa. Management Surgical excision is tailored to the individual, and is determined by the size and site of the tumour. Papules and vesicles on the hands and fingers are a feature of scabies, and this disorder must always be excluded by a careful history and examination for diagnostic burrows. This type of inflammation in scars is typical and can be recurrent over many years in Crohn disease. Association of autoimmune diseases with lichen sclerosus in 532 male and female patients. Vaginal pH is normal Causative organisms Staphylococcus aureus is the most common bacteria to cause folliculitis and furunculosis. Segmental or plaquelike infantile haemangiomas of the head and neck and of the lumbosacral region may be associated with structural anomalies. Detergents at lower levels of exposure predominantly affect the horny layer, causing dryness and scaling by destroying lysosomal enzymes in the horny layer [19], whereas at higher concentrations they will dissolve cell membranes and damage lysosomes [20]. Incidence and prevalence Actinic prurigo ranges in prevalence from about 3 per 100 000 population in Scotland [3] to around 10% of the population amongst some isolated susceptible populations. The sport of mudwrestling has been associated with Gramnegative folliculitis [14]. There is no evidence that maternal antibiotic therapy or immunodeficiency in the infant play a role in predisposition [6,9]. Calcifications within the periodontal ligament space and pulp calcifications have been reported. There are many choices of support surfaces for the prevention and treatment of pressure ulcers; however, the challenge is to use the most costeffective surface given the available evidence. In order for this binding process to occur, the drug must first undergo enzymatic degradation. Components of kumkum, applied as a cosmetic to the forehead, commonly cause a pigmented dermatitis [13]. It is important not to miss this diagnosis as it is reversible if drug exposure is stopped. Skin thickness Although not extensively applied, highfrequency ultrasound has also proved valuable for the assessment of another aspect of the irritant response, namely changes in skin thickness [41].
Pathology the classic histology is a thinned epidermis with flattening of the rete pegs. The main cytokines involved in this reaction are tumour necrosis factor, interleukins 1 and 6 and transforming growth factor [7]. Lead has effects on multiple organs including peripheral neuropathy, problems with learning and memory function, erythrocyte fragility, Fanconilike syndrome, plumbism gout (saturnine gout), increased blood urate concentrations and urate crystals in the joints, hypertension, altered cardiac electrophysiology, infertility, hypothyroidism, hypopituitarism, lead lines in the bones, impaired bone growth, shortened stature and gastrointestinal toxicity resulting in lead colic and leadinduced constipation. There is an increased number of fibroblastlike cells in early lesions, whereas these are diminished or predominantly at the margin in advanced ones. It has been suggested that this mechanism could be mediated by continued lowlevel secretion of the inflammationmediating cytokines induced by radiation. The rash has features of erythema multiforme, in that single lesions appear targetlike, but the distribution is not necessarily acral as in classic erythema multiforme nor is the histology characteristic. In the absence of erythroderma, life expectancy is normal and there is no evidence of increased risk of lymphoreticular or other malignancies [58,66]. Anaphylactic reactions have been reported, for example following the topical use of bacitracin, cephalosporins, rifamycin and chlorhexidine. Complications and comorbidities Squamous cell carcinoma is a rare complication that may arise in chronic complex fistulae. The oldest and best studied dermal substitute is Integra which was developed by a team led by surgeon John Burke from the Massachusetts General Hospital and by scientist Ioannis V. Curiously, when they are multiple, all the lesions tend to develop on one side of the vulva. Eccrine carcinoma [25] these are rare cancers of the eye and may present as an indurated thickening of the lid or with a signetring appearance. In hot regions, during summer months, dry dead plant material contributes to the airborne pattern of dermatitis. Management Antiviral drugs reduce the duration and severity of acute herpes zoster but must be given within the first 3 days of the onset of the rash to be effective. An overview of the most common or important dermatoses presenting in this age group is discussed, as well as infant and congenital haemangiomas, but the list is not exhaustive. If the changes are confined to irritation and scaling, the various forms of exfoliative cheilitis must be excluded. Penile thrombophlebitis as the initial pres entation of a paraneoplastic migratory thrombophlebitis resulting Other inflammatory dermatoses Bottomley and Cotterill [1] have described an acutely tender ery thematous scrotum associated with zinc deficiency in a patient with Crohn disease. In rural areas, sporadic cases of animal ringworm may occasionally occur, but are exceedingly rare in this age group. Many lowmolecularweight materials, including the monomers and oligomers used in resins, are allergenic, but a fully polymerized resin should not be sensitizing. Disease course and prognosis It usually spontaneously improves and may resolve by teenage years or early adulthood; the precise proportion amongst whom this occurs is unknown. Ultrastructural studies demonstrate reduplication of the basal lamina with branching structures within the upper dermis and cleavage between the lamina densa and the cell membrane of the keratinocytes. The nonspecificity of the clinical appearances makes for an important differential diagnosis, which includes psoriasis, lichen sclerosus, lichen planus, Zoon balanitis and extramammary Paget disease. Characterization and management of exfoliative cheilitis: a singlecenter experience. The concentration necessary to test an individual substance is often greater than its concentration in the product. The quality of the complex care that burn patients receive is directly related to patient outcome and survival. Contact allergy is normally detected by patch testing with wool alcohols, and enhanced identification of allergic subjects has been attempted by testing with a wider range of lanolin derivatives and lanolin itself.
Patch testing for Toxicodendron, if considered necessary, can be undertaken by diluting the oleoresin 1: 10 in acetone. Nicorandil ulcers are sometimes painful but rarely inflamed and tend to look rather bland. Peeling citrus fruit with the bare hands should be avoided by those with hand eczema and an allergy to balsam of Peru. Triggers are not necessarily chemical, and include environmental factors such as wind. Biopsy is usually indicated and reveals necrosis and pseudoepitheliomatous changes probably resulting from squamous metaplasia following infarction of minor salivary glands [16]. The additive effect of multiple weak sensitizers [32], or the additive effect of weak allergens and irritants, should be considered [33]. However, it is essential to establish whether the injury has been inflicted by an adult or another child by assessing the size of the dentition from the marks on the skin. Allergy in a child with chronic otitis externa treated with aluminium acetate ear drops has been seen [3]. Minocycline can, in a minority of patients, produce bluegrey gingival pigmentation caused by staining of the underlying bone, and some intrinsic faint bluishgrey staining, mainly near the anterior teeth. In this group, 26% of respondents reported that this slightly or moderately altered their music making, with only 2% reporting severe disease. Open testing on retroauricular skin, with a 2day reading, is thought to be an accurate method of identifying sensitized persons [32], but this is rarely done by the individual or the hairdressing salon. Auditory testing and renal ultrasound are Linear morphoea Morphoea develops less commonly in infancy than in earlyschool aged children [1], and most commonly presents in the linear form [1,2] (see also Chapter 57). A recent metaanalysis suggests that 1% of nickelallergic subjects will develop systemic allergic contact dermatitis from normal daily exposure to nickel in drinking water and the diet. Presentation the signs may be subtle, but scaling and erythema are seen on the inguinal folds, labia majora, perineum and perianal skin. Dietary manoeuvres have also been reported to be helpful for cheilitis and oral symptoms, particularly in those with positive patch tests to balsam of Peru, cinnamates, eugenol, colophony, flavours and antioxidants [14]. Patients with more than 100 naevi have a sevenfold increase in melanoma risk [89]. It has been proposed that this placental phenotype may be the result of embolization of placental endothelial cells to the fetal circulation [3]. A much higher return of relevant allergy, mainly inducing hand dermatitis, was seen in Israel, particularly in mechanics. Oral submucous fibrosis: an overview of the aetiology, pathogenesis, classification, and principles of management. It has been suggested that Mycobacterium marinum may play a pathogenic role in some cases of sea urchin granuloma [6,7]. Lyme disease Clinical features [16,17] Onchocerciasis or river blindness is caused by the filarial organism, Onchocerca volvulus (see Chapter 33). These laws only relate to metallic items in prolonged and direct skin contact, for example jewellery, clothing items and spectacle frames. Topical imiquimod 5% followed by a new biopsy at the end of treatment may be considered in cases where surgical excision is technically difficult [35], although some patients may suffer a severe topical irritation. However, more recently efforts have been made to improve the identification of allergic subjects following studies on a range of fragrances [44,45]. Part 10: SiteS, Sex, age Management Treatment involves removal of the lesions by curettage.
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