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Diagnosis is based on clinical criteria after a thorough physical examination and exclusion of the differential diagnoses discussed earlier [5]. Obesity exposes people not only to wellknown metabolic and cardiovascular consequences including type 2 diabetes but also has significant effects on other body systems including the skin [2]. Vascular proliferations of the skin after radiation therapy for breast cancer: clinicopathologic analysis of a series in favor of a benign process: a study from the French Sarcoma Group. There are no explicit recommendations for the assessment of haematological parameters but the American Academy of Dermatology advises full blood counts alongside triglycerides, cholesterol and transaminases. It is more common in females, linked with higher mean platelet volume and higher fibrinogen levels, and is partly genetically determined. When responsible for disease, reversible acrocyanosis secondary to coldinduced acral agglutination is most common. Papules in the auricular concha: lichen amyloidosus in a case of biphasic amyloidosis. Manifestation of skin disease and systemic disease in the ear the external ear is often the site for the manifestation of skin disease and systemic disease presenting in the skin. Furthermore, silver particles may be seen lying free within the cell cytoplasm of epithelial cells of the secretory segment of eccrine sweat glands and in mast cells [9,10]. Aside from circumferential limb constrictions, pseudosyndactyly, intrauterine amputation and umbilical cord constrictions have been reported. The identification of associated genetic mutations can help to confirm this diagnosis. Many other organisms have been demonstrated, including Staphylococcus aureus, Klebsiella spp. Differential diagnosis this condition was recently distinguished from other eosinophilic vasculitides that affect mediumsized vessels (eosinophilic granulomatosis with polyangiitis; see separate section this chapter) and from eosinophilic disorders in which pruritic papules and/ or angiooedema may occur, such as hypereosinophilic syndrome, episodic angiooedema with eosinophilia, dermatitis herpetiformis, Wells syndrome, polymorphic eruption of pregnancy or drug eruptions. However, spironolactone cannot be relied on as a contraceptive and care must be taken to avoid conception while taking the drug. Recurrent symptoms can usually be attributed to small synchronous satellite lesions [34]. The most common symptom is recurrent oozing, usually of clear fluid (lymph), known as lymphorrhoea. The physical and psychological severity of acne will play a role in the decision whether to prescribe isotretinoin. A common finding is the histological evidence of chronic actinic damage, which is present in most biopsies, as might be expected in a predominantly sunsensitive middleaged population. The pustular element is often not as prominent and clustering into plaques is not a characteristic feature [1]. Second line Patients with contraindications to cyclophosphamide can be treated with rituximab 375 mg/m2 per week for 4 weeks instead [43,44]. At 5 years, there is a 16% incidence of cardiovascular events (myocardial infarctions, cerebrovascular accidents or coronary revascularization procedures) [21]. Serological tests for Borrelia burgdorferi are typically negative [13] although there are case reports of an association. Perhaps the most important part of the treatment, but the one most difficult to achieve, is keeping the hands dry. The middle and lower dermal collagen is separated by bluish grey fine fibrillar material, which is composed of thin wavy elastic fibres and fragmented elastic fibre bundles. Friction, sweating and maceration within body folds frequently lead to a painful erosive intertriginous dermatitis with secondary candidosis. Corticosteroidinduced rosacea-like facial dermatosis may take several weeks or even months to subside but eventually complete resolution occurs if topical corticosteroids are avoided. Mouse studies suggest the lymphoedema occurs as a result of abnormal lymphatic valve development [50].

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Complications and comorbidities the main risks are complications of the arteriovenous fistula such as tissue ischaemia and high output cardiac failure. Part 10: SiteS, Sex, age Classification of severity the presence of cellulitis of the surrounding soft tissues without bacterial infection represents more severe infection, and is more likely in the immunocompromised. Associated diseases Constricting bands are often associated with other congenital abnormalities [6]. A bluegrey pigmentation of the sunexposed areas of the skin has also been reported with trifluoperazine and imipramine [7,8]. It most typically develops in trauma or lichen planus and its variants, including idiopathic atrophy of the nail [2] and graftversushost disease [3]. Eosinophils are not usually prominent in lesions of lupus panniculitis [25,30] but, in contrast with other forms of cutaneous lupus erythematosus in which eosinophils are characteristically absent, the infiltrate of lupus panniculitis may contain some eosinophils [35]. However, there is a difference in the cytokine production curve over time after treatment between P. This is rare autosomal dominant inherited condition characterized by the development of benign tumours on the face and upper body including fibrofilloculomas, trichodiscomas and acrochordon. Pathology the chief findings in varicose veins are intimal hypertrophy, subendothelial fibrosis, luminal dilation and wall thickening. Epidemiology Incidence and prevalence the lifetime incidence of leg ulcers is around 1%, with a point prevalence of 0. Encephalocraniocutaneous lipomatosis is associated with ophthalmological and neurological abnormalities. A distinctive condition known as tin ear syndrome has been considered pathognomonic of child abuse: a triad of isolated ear bruising, haemorrhagic retinopathy and a small, ipsilateral subdural haematoma [3]. The possible role of Helicobacter pylori infection of the stomach causing vasoactive neuropeptide release was raised but subsequent studies suggest that such an association is unlikely. Proteus syndrome is a disease characterized by progressive, segmental overgrowth of the bones, skin and connective tissue. Lesions that resolve typically heal without scarring but may leave persistent postinflammatory erythema. Differential diagnosis Clinical presentation is characteristic but onychomycosis and Bowen disease [77] should be ruled out. The gap between treatments allows those hairs initially in telogen to move into anagen. Differential diagnosis Clinical differential diagnoses include kerion, pyoderma gangrenosum and erosive pustular dermatosis of the scalp. Clinical variants Rarely, gastrointestinal involvement and arthritis can occur in the absence of skin disease. In Addison disease, the diffuse brown hyperpigmentation results from the melanogenic action of melanocortins derived from the pituitary. Histology shows that the affected papillae are distended by a large single ectatic capillary, lined by flattened endothelial cells of normal appearance. Age the median age at diagnosis of cryoglobulinaemia is the early to middle sixth decade. Use has increased enormously during the past 50 years and now men are using hair dyes. Disease course and prognosis Hyperhidrosis may persist for some years, but there is a tendency to spontaneous improvement of axillary and palmar hyperhidro sis after the age of 25 years. Investigations With black heel, the patient and physician can usually be reassured by carefully paring the affected area, thereby completely removing the abnormality. Increased pigmentation is almost invariable in pregnancy and is most marked in brunettes. A vasculitis screen may be used by inexperienced clinicians as a substitute for taking a history and examination and then applying logic. Another theory is that genetically determined changes in neutrophil activity/hyperreactivity to chemoattractants may result in reduced phagocytosis of P.

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This is most common in the toes and may give rise to clinical uncertainty as to whether it represents early subungual melanoma. According to Brauer and Baran [1], it is not advisable to cut or clip the nail plate, as this produces a shearing action that weakens the natural layered structure and promotes fracturing and splitting. Prevention is clearly the best approach, including the use of steroidsparing systemic drugs and topical agents such as calcineurin inhibitors to treat skin disease. If artefact is suspected, the affected area may be occluded for a week with a bandage: improvement would support a suspicion of self induced factitious panniculitis, for which appropriate social and psychiatric care should be offered. Baldness occurs only when all the hairs within the follicular units are miniaturized and is a relatively early event in men and a late event in women. These are not true tattoos but represent application of a black dye to produce a tattoolike appearance that lasts for a few days. Most melanin pigments in skin are mixtures or copolymers of eumelanins and phaeomelanins. The classic assumption that lesions from patients with Sweet syndrome lack histopathological fibrinoid necrosis of the vessel walls has been challenged. There is wide individual variation in the rate of progression of hair loss in male balding. Serious chronic venous insufficiency leading to venous ulcers has an estimated prevalence of approximately 0. We recommend the removal of the proximal third of the nail plate cut transversally with nailsplitting scissors without initial incisional drainage. There may be an association with the follicular degeneration syndrome where there is a central scarring alopecia in the absence of an overt inflammatory process [22]. The development of imaging techniques could provide a tool to answer the question of its place in lymphatic treatment strategies. Approximately onequarter of the nail is covered by the proximal nail fold, and a narrow margin of the sides of the nail plate is often occluded by the lateral nail folds. Minor systemic side effects due to absorption of anticho linergic agents, such as dry mouth and eye symptoms, are not uncommon, and can be avoided if tap water alone is used. Psoriatic onycholysis can be considered the reference point for other forms of onycholysis and is typically distal, with variable lateral involvement. Epidermoid cysts are seen in some patients on external genitalia, the face and the thorax. Human hair greying is linked to a specific depletion of hair follicle melanocytes affecting both the bulb and the outer root sheath. Biopsy shows a focal loss of elastic tissue, and a perivascular infiltrate with prominent plasma cells [1,2]. This process may begin at any age after the onset of adrenarche and may precede pubarche. The stigma associated with facial lipodystrophy in particular may have a profound psychosocial impact and psychological support may be required. In a more gross form, this may present as congenital hypertrophic lip of the hallux, where soft tissue overgrowth may resemble fibrous tumours of the digit before spontaneously disappearing [3]. Histologically, particles of coal dust up to 100 m in diameter are seen at all levels in the dermis. Bacterial cultures from the skin are generally sterile but in some cases lesions are secondarily infected with Grampositive bacteria. These organisms replace the Grampositive flora of the facial skin and mucous membranes. Mild pitting may also occur in association with different patterns of eczema, but is usually more subtle or localized than psoriatic pitting. Hair transplantation and scalp reduction surgery for primary cicatricial alopecia is more complicated due to the often progressive nature of the condition, lack of adequate donor population and the potential for graft rejection due to persisting inflammation in the recipient skin.

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Some believe that the antiinflammatory effects of diet are important protective factors in acne mediated via the effects of dietary components on the gut microbiota [201]. Follicular miniaturization has been traditionally thought to occur in a stepwise fashion although there have been suggestions that it occurs rapidly, possibly in the space of a single hair cycle [7]. Generalized discoloration of skin resembling argyria following prolonged oral use of bismuth. Sarcoidosis with livedo is characterized by a high frequency of ophthalmological and central nervous system involvement [269,270]. It may spread from the region of the ear to the vertex, temporal or occipital areas, and there may be temporomandibular joint pain. The rupture results in the formation of adhesions between the amnion and fetal skin. Compression of leg lymphoedema, through bandages or pneumatic compression pumps, can push fluid up to the trunk. Nail bed biopsy Indications for nail bed biopsies are diseases of the nail bed presenting as onycholysis, subungual hyperkeratosis or tumour. Topical and intralesional steroids provide some benefit, but their use is limited by atrophy. Cutaneous small vessel vasculitis associated with solid organ malignancies: the Mayo Clinic experience, 1996 to 2009. Clinical variants Plantar and penile fibromatosis are closely related conditions (see later). Investigations None are necessary but biopsy can be confirmatory if the diagnosis is in doubt. Fibromas, lipomas and fibrolipomas present typically as ipsilateral skin taglike cutaneous polyps on the eyelid or following a line from the outer canthus to the tragus. It is clear that many individuals who blush frequently become very selfconscious of this tendency, and feel that the blush is more severe than in fact it is. Local antiseptics and antimicrobial ointments may help settle the infection secondary to nail unit damage. It has been observed in 8% of patients with cutaneous sarcoidosis in an Indian series [235] and is especially frequent in Taiwan, where it is often associated with eye involvement [236]. However, the common situation is where trauma plays a major part and predisposition has a relatively minor role. History In the published cases, diagnosis was delayed by an average of about 10 years. Volume reduction may be achieved through tissue reduction, but not through lymphatic drainage improvement. In others, it appears to develop from seborrhoeic dermatitis that has become secondarily infected. These mildly microcephalic, intel lectually impaired children have a low hairline and profuse over growth of the eyebrows. Resistin and leptin have been shown to be potential markers of extrapancreatic fat necrosis [18]. Poliosis Poliosis is defined as the presence of a localized patch of white hair resulting from the absence or deficiency of melanin in a group of neighbouring follicles. Management A number of treatments are used empirically; however, rand omized controlled trial data are not available. As it has a much greater capillary network surrounding it compared to white fat (which is partly responsible for the brown colour), heat can be rapidly transferred into the circulation. The lesion is a nonpalpable haemorrhage with retiform margins, minimal erythema and central retiformintense haemorrhage, early necrosis and bullae formation. Because the inflammation is predominantly perifollicular, a surprising amount of regrowth may occur. Disease course and prognosis the postal questionnaire survey carried out by Wells and Smith [1] revealed that in about 50% of patients the lesions resolved within 2 years. The longterm outcome analysis showed complete or partial resolution of tissue swelling and oral ulceration in 78. Causative organisms Introduction and general description Although this relatively common chronic follicular inflammatory dermatosis characteristically involves the nape of the neck (Latin: nucha), it may extend into the scalp; for this reason, the term folliculitis keloidalis is preferred to folliculitis keloidalis nuchae; in order to avoid confusion with keloid formation in association with acne vulgaris, the term folliculitis keloidalis is preferred to acne keloidalis. Causative organisms Clinical observation points to Staphylococcus aureus as a potential trigger in some patients.

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Indications for use include the following: 1 Failed standard antibiotic/combination regimens. The histology of linear morphoea reveals thickened bundles of collagen, which appear to be intact on Bscan ultrasound imaging [5]. Investigations If the diagnosis is in doubt, skin biopsy and imaging can be performed. Differential diagnosis this includes chronic inflammatory disease of the ear canal and other tumours. Spillage of phenol onto the periungual tissues should be avoided as this causes unnecessary burns. Erosive pustular dermatosis of the scalp Introduction and general description this clinical entity particularly affects the elderly [1,2]. Gravimetric assessments of sebum can also quantify the sebum output but these are labour intensive and not viable for use in the clinic. Most penetrate the hair cuti cle and so are potentially permanent, but in recent years less per manent types have been introduced. Biotinidase deficiency and the trichohepatoenteric syndrome can both present with trichor rhexis nodosa. When available, gallium scintigraphy may be the most useful for assessing response to treatment [16,17]. The ring initially measures a few millimetres across but gradually expands, often attaining a diameter of several centimetres. Postinflammatory hyperpigmentation may also occur following trauma to the skin, including procedures such as dermabrasion, particularly in darker skin types. Occlusion, the recurrent nature of the disease and frequent use of antibiotics on an already damaged skin probably account for the high incidence of contact dermatitis at this site. Lymph node transfer surgery Autologous transplantation of normal lymphatic tissue within a local or free flap to a site deficient of lymph nodes and vessels has been performed. Cutaneous and mucosal mucormycosis mimicking pancreatic panniculitis and gouty panniculitis. In some cases, subcutaneous Sweet syndrome was followed by classical dermal Sweet syndrome [4], whereas another patient presented simultaneously with classical Sweet syndrome and Sweet panniculitis [17]. Those cases in which erythema is present share many features with lichen planus including lichenoid inflammation histopathologically with basement membrane zone damage and infiltration of T lymphocytes [6,7]. The arylamine and amino nitrophenol components give rise to this worry, but systematic reviews have suggested that it is not a hazard to those using it on their hair [16], although it might be a risk for hairdressers [17]. While pustules are strongly suggestive of folliculitis decalvans, they can also occur in lichen planopilaris and chronic cutaneous lupus. Measures to prevent complications [59] Many of the complications of ear piercing are avoidable. The term should not be applied to reactive fibrous proliferation, or to keloid, which is usually secondary to injury. Granulomatous acne the precise mechanism producing localized granulomatous acne is not known. It was originally described by Rackemann and Greene in 1939 as an allergic disease and not classified as periarteritis nodosa; Churg and Strauss later described the syndrome and its histopathological characteristics in 1951 [2]. Underlying systemic causes such as acromegaly or parkinsonism should be considered. Some reported associations may be coincidental, but it is probable that many inflammatory diseases may occasionally be complicated by anetoderma. Predisposing factors It has been reported to follow granuloma annulare [6] and other inflammatory conditions. It can occur in males or in children, and has been reported in females with Turner syndrome and in identical twins. In general medical treatment is disappointing and, in troublesome cases, the affected area may be excised and grafted or excised and allowed to heal by secondary intention.

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Adverse prognostic factors include facial palsy, extensive bony involvement [10] and both nodal and distant metastasis. In humans, mutations in mi are associated with Waardenburg syndrome type 2A, an autosomal dominant condition characterized by deafness and patchy abnormal pigmentation [11]. They may occur in isolation as an area of increased hair density or in association with congenital melano cytic naevi, Becker naevi, spinal dysraphism or neurofibromas. Systemic oral antifungals agents such as ketoconazole, itraconazole and terbinafine should be reserved for severe unresponsive refractory cases. Recurrence is likely if there are background factors such as heat, humidity, frequent swimming, an abnormal ear canal, eczema, etc. The significance of these observations is, however, unclear and their contribution to disease pathogenesis remains to be elucidated. Children with hair loss Whilst conditions such as telogen effluvium and alopecia areata are relatively common in children, there are a number of other considerations in approaching the child presenting with hair loss, especially when hair loss is evident early in life. The back and sides of the neck are most commonly affected, but the lesions may also occur on the cheeks or on the arms or thighs, and are sometimes bilaterally symmetrical [1,16,18,19]. Furthermore, approximately 25% of patients will experience recurrence of lipohypertrophy after liposuction. In the differential diagnosis of panatrophy, the various forms of panniculitis must be excluded. Alternative therapies Clofazimine 200 mg three times a week has been shown to improve acne fulminans [665]. Its precise nosology is uncertain but it has been accepted by the National Rosacea Society Expert Committee as a variant of rosacea [1,35]. The striae in Cushing syndrome or those induced by steroid therapy may be larger and more widely distributed, and involve other regions, including sometimes the face. The hair fol licle also has a specialized dermal component, which includes the dermal or connective tissue sheath surrounding the follicle, and the dermal papilla, which invaginates the hair bulb. Presence and interpretation of vascular immune deposits in human skin: the value of direct immunofluorescence. However, there is not an a priori pharmacokinetic reason to support the concept of accumulation of drug or a cumulative dose effect and recent publications suggest that the dose should be tailored to the tolerability of the drug as well as the clinical response and have demonstrated that the cumulative doses previously recommended may not be necessary in all patients. Whether this condition ever truly burns out, or merely extends too slowly to be noticed, is uncertain. Clinical characteristics of generalized idiopathic pruritis in patients from a tertiary referral center in Singapore. Reddishblue pigmentation has been reported within scarred areas of lupus erythematosus in one patient [2]. There is a mild spongiotic dermatitis with perifollicular inflammation and pustules. However, this is not without hazard as wound dehiscence and overwhelming infection can present serious lifethreatening risks. The initial lymphatic vessels are present (confirmed on histological examination) but unable to absorb interstitial fluid [33]. On the trunk and limbs, the fine, dry scales are associated with a polycy clic and serpiginous eruption whose horny margin slowly changes its pattern. Presentation the patient, usually a middleaged to elderly man, seeks advice on account of pain. In patients with severe renal disease, plasmapheresis may have a role in saving the kidney [42]. Pathophysiology Pathology Early lesions are characterized by a dyskeratotic follicular epithelium with associated spongiosis.


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Perivascular adipocytes have been also demonstrated to be powerful endocrine cells capable of responding to metabolic changes and transducing signals to adjacent blood vessels. Despite an identical libido, bald men are likely to have fewer lifetime sexual partners than nonbald men, reflecting reduced physical attrac tiveness to potential partners [21]. Numerous developmental defects can affect the palpebral fissure or size and shape of the eyelids. In Norway, the range of onset is from 7 to 76 years in the primary group and 18 to 81 years in the secondary group [2]. Clinical features Management History Squamous cell carcinoma of the auricle may become apparent as a change in a preexisting lesion. Eosinophils are more common in subcutaneous granuloma annulare than in the dermal superficial lesions [19]. Fourteen patients had been recommended a topical or oral gabapentin regimen and of the seven followed up, four noted an improvement in symptoms when taking gabapentin. Buffing creams, which contain waxes and finely ground pumice, and buffing powders are abrasive and should not be overused on thin nails. Prolonged periods of sitting or standing may impede normal blood flow and lead to stasis, which alters microcirculation and may increase the risk of cellulite. Causative organisms the disease is thought to be triggered by as yet unidentified infectious agents. Unsurprisingly, all samples from pigmented skin showed a higher melanin content than those from unpigmented skin. There appears to be anecdotal evidence of its occurrence, but little documentation. Contact immunotherapy has been in use for 30 years and no longterm side effects have been reported. This suggests that effective management of inflammation during the development and resolution stages of acne may help to control scarring. In Mondor disease involving other venous territories, the natural history is less well known and, as with other conditions with superficial venous thrombosis, can be associated with deeper thrombosis. In the vast majority of people who develop a bacterial pustular folliculitis of the scalp it is transient, resolves with antibiotics and heals with out scarring. The authors postulated that chronic muscle tension placed on the pericranial muscles or scalp aponeurosis secondary to the underlying cervical spine disease may lead to the symptoms of scalp dysaesthesia [3]. These invaginations surround optically empty cavities in a characteristic Vshaped configuration [28]. With the development of guidelines on the use of gadolinium based contrast agents [4], it is hoped that the condition will become a matter of historical importance only. Note the cyanotic hue more typical of sarcoid and the absence of patulous follicles. Most other causes of leukocytoclastic vasculitis cause a more superficial vasculitis on biopsy specimens, and if cryoglobulin deposits are seen histologically then the diagnosis is usually suspected (although this is much commoner in type I cryoglobulinaemia). Thinning and ultimately total loss of pubic and axillary hair has been noted in many cases. If treatment is stopped, clinical regression occurs within 6 months to the state of baldness that would have existed if treatment had not been applied [79]. Fully developed lesions show granulomatous infiltrates involving the fat lobule, whereas longstanding lesions are characterized by lipophagic granulomata and surrounding fibrosis. When it occurs in the younger patient [1] there is sometimes a structural abnormality and/or a pathological process in the cartilage, or use of an abnormally hard pillow. The hair may be lost in the frontoparietal region on the affected side but is often normal; occasionally, localized canities is an early change. Acne induction is partly due to androgen receptor binding leading to hypertrophy of the sebaceous glands with consequent increased sebum output and a concomitant increase in the population density of P. The skin changes typically develop after puberty and usually before 30 years of age.

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Associated diseases Cases have been associated with a prothrombotic state [5], suggesting a similarity to anetoderma. They may be single or multiple, and may occur anywhere in a line from the tragus to the angle of the mouth. Human ears grow throughout the entire lifetime according to complicated and dimorphic patterns-conclusions from a cross-sectional analysis. Such changes are common in Turner syndrome, and there may be associated sensorineural deafness. This syndrome has been associated with lupus anticoagulant activity and with autoantibodies to protein S [2,3]. Both mutations result in a high tendency for the protein to polymerize, especially in the Z variant. In patients without hepatitis C, renal involvement is associated with greater morbidity. Pathology Genetics Wells described a family with eight cases in four sibships of two generations [6]. Fibrillar changes in the basal cells lead to the formation of colloid bodies and at an early stage these, and macrophages containing pigment, may be seen in the dermis. Alternative photosensitizers including khellin have been advocated but there are concerns over hepatotoxicity and it has not been widely adopted [39]. The subcutaneous lesions may form indurated linear bands from the elbow to the hand [36,229]. As lymph flow is responsible for the drainage of all tissue fluid, except for transient periods of venous reabsorption, a chronically swollen arm due to fluid indicates lymph drainage failure. Epidermal sheet of marginal depigmented area showing marked reduction in the number of melanocytes. These patients should be followed up because some of them will develop involvement of other organs and thus fulfil the diagnostic criteria for sarcoidosis. However, it is generally a more superficial process than progressive facial hemiatrophy. Differential diagnosis this includes other angiokeratomas, malignant melanoma and cherry angiomas. Second line Tetracycline antibiotics are frequently prescribed to reduce the inflammation but are notoriously ineffective. An unusual case of intense green colour in a patient with multiple organ failure was attributed to dyes in the liquid tube feeds [1]. It is clinically characterized by the sudden eruption of several erythematous, tender, nonulcerating nodules and plaques, typically located on the shins. The nail was longer at that place because the papilloma impaired nail clipping (pain). Fat loss typically progresses over a period of about 18 months, although it may continue for several years. Another study showed that the proportion of mono saturated fatty acids was significantly higher in Dercum disease patients than in healthy controls [7]. This may affect either sex but typically presents in young women with oily skin, often during or immediately following pregnancy [6]. The auricle is attached to the head by fibrous ligaments and three vestigial auricularis muscles. In some cases, involvement of the joint capsule or bone results in limitation of movement of the joints of the hands and feet, or of the shoulders. Cryotherapy and intralesional steroid injection [237] may be appropriate for symptomatic localized lesions although the risk of permanent scarring or atrophy is significant.

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Developing platelet plugs are reinforced by fibrin strands formed as a result of activation of the plasma clotting system by platelet factor 3, when this is exposed by alterations in the surface characteristics of the aggregated platelets. Localized lipoatrophy and/or lipodystrophy Localized lipoatrophy and/or lipodystrophy is a heterogeneous group of disorders presenting as one or multiple depressions of various sizes, ranging from a few centimetres to greater than 20 cm in diameter. Pathology [3] It is a two stage process: initially there is a dense inflammatory cell infiltrate and usually a thrombus occluding the lumen of the affected veins; thereafter, connective tissue proliferation occurs in the vessel leading to a hard cord which resolves when the vessel canalizes. High potency topical, or intralesional, corticosteroids may minimize the size of lesions in patients with limited disease; 5% topical dapsone gel has been described as effective [26]. Clinical features the clinical features of spider telangiectases are described in Table 103. The hair tends to be dry, brittle and lustreless and may show trichorrhexis nodosa, but it does not occur in all patients with this metabolic disorder. Management the establishment of a relationship between the physician and the patient, or with the parents of an affected child, is an important step in the management of trichotillomania. A diagnosis of subcutaneous Sweet syndrome should be made, however, only in those cases in which the neutrophilic infiltrate involves exclusively the subcutaneous tissue with few or no neutrophils in the dermis. The face, neck and upper chest may flush red to violaceous, with an associated mild burning sensation. Anetoderma: an altered balance between metalloproteinases and tissue inhibitors of metalloproteinases. Important considerations include the biopsy technique, selection of biopsy sites, processing of the biopsies and access to a dermatopathologist skilled in the inter pretation of hair pathology. It has been suggested that patients who develop very severe flares of acne after starting isotretinoin may have an exaggeration of this response [640]. Embedded earrings the springloaded gun method of ear piercing can result in the earring backing becoming embedded in the back of the ear [41]. The hair cycle in genetic hair loss has a shorter growth phase and proportionally more hair will be in telogen phase at any given moment, so an increase in hair shedding can be expected. Orf affecting the ear has been described, presenting as an inflammatory nodule on the tragus. Melanomas however tend to have more variation in colour density within the lesion than in lentigo. Additionally, it is thought to help regulate protease stimulated activation of lymphocytes and phagocytosis by macrophages and neutrophils. The smallest veins to contain valves lie at the dermal subcutaneous junctions [4] and the valves are extremely variable. Potent topical steroids such as clobetasol propionate ointment or shampoo once daily usually relieve associated symptoms such as itch or pain, and may slightly inhibit the process [14]. Suggested mechanisms include repeatedly standing or sitting in an unvarying position in which the affected area is constantly compressed by or knocked against various objects [1,12]. Vascular birthmarks in the skin that look like blood capillary malformations may be mistaken for lymphatic capillary dermal malformations as seen in Proteus syndrome. Trichostasis spinulosa is a rare condition that may present with redness of the nose and prominent follicular openings with plugging. A case apparently associated with Borrelia burgdorferi responded to doxycycline [16]. For severe cases with liver and lung involvement, the best option is replacement of 1antitrypsin using human pooled plasma from normal donors (Prolastin).

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Cryofibrinogen deposits consist of a complex of fibrinogen, fibrin and fibronectin that forms on cold exposure [5]. Many authors have suggested that striae develop as a result of stress rupture of the connective tissue framework [1], but others disagree. Natu ral fibre wigs look better, are easier to style and last longer, but are considerably more expensive. Occasionally, similar plaques may form elsewhere than on facial skin, such as the forearm [7]. Moult waves are regulated within the skin and are accompanied by changes in other skin structures, such as epidermal and dermal thickness. It is not uncommon during the years of reproductive activity and has been attributed, without acceptable proof, to a variety of ovarian disorders. A sight transient reduction of thenar and hypoth enar muscle power is a minor problem after palmar injections [18]. In many patients there is no clinical evidence of preceding or concomitant rosacea or of other inflammatory dermatosis. Ethnicity Giant cell arteritis is considered a disease that particularly targets white people of northern European origin, being less common in African Americans, native Americans and Asians. Phleboedema and mixed lymphovenous disease 1 Kaipainen A, Korhonen J, Mustonen T, et al. Focal elastolysis can also occur in association with lupus erythematosus [7], severe rheumatoid arthritis [8] and coeliac disease [9]. Thrombocytopenia usually causes petechiae but more extensive bleeding may occur at lower levels of platelet count. However, a detailed phototrichogram study found no change in hair growth parameters in patients taking tamoxifen [1] and it is not yet clear whether hair loss is a genuine side effect of antioestrogen drugs or just reflects the relatively high frequency of diffuse hair loss that occurs naturally in the relevant age group. Contact dermatitis (irritant or allergic) is a possible consequence of using this agent so caution is advised. It has been reported at many body sites including the face, ears, nipples, palms, soles, lower limbs and abdomen [2]. The crease can be graded in terms of length and depth, and deeper, longer creases have the strongest association. The age of onset and the distribution of the lesions tend to be more or less constant in each family, but show interfamily variation. Open surgery, lipectomy and liposuction, with or without ultrasound assistance, have been tried with varying success rates. Etanercept then tapered to once a week for 1 month then alternate weeks for 2 months and isotretinoin reduced to 10 mg daily Marked decrease in size and degree of inflammation of nodular lesions by 4 weeks at 12 weeks full resolution of nodular lesions. The finding of Borrelia organisms in six of seven cases of necrobiotic xanthogranuloma using focusfloating microscopy has led some authors to propose an infectious aetiology for this process [8]. Rarely, dermatitis herpetiformis may present as a vesicular pustular facial eruption, but it is usually very itchy unlike acne. Other treatment modalities that can be adopted are hyfrecation for superficial and small lesions and curettage and cautery and cryotherapy. Type 2 diabetes is a common complication of obesity and is associated with a variety of specific skin disorders (see Chapter 64). The reasons why the hair follicle should become the target of inflammation are poorly understood. Delayed trauma the most common kind of chronic deformity following an acute injury is a split nail or reduction in the length of the nail bed with consequent overcurvature of the tip of the nail. In atruncular lymphatic malformations compression may prove fruitless, as the lymph fluid is trapped within the closed vessel system of the malformation [17]. A number of autoinflammatory syndromes cite acne conglobata as a possible clinical presentation within the context of the syndrome; these are described in more detail in Chapter 49. One survey, which determined the problem of chronic oedema (as a surrogate for lymphoedema) in the community, ascertained 823 patients in a catchment area of 619 000 in southwest London.

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