dermatology skin care

PRINCIPLES OF THERAPY

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Victoria P. Werth

The goal of therapy is to improve a skin condition with the least toxic and most specific approach. Because many treatments or medications can be applied directly to the skin, the option for topical therapy is attractive for treating many dermatologic diseases. However, many diseases require systemic therapies, particularly when patients have widespread involvement of the skin or a disease that cannot be improved with topical therapy. Therapies work by improving barrier function, removing scale, altering inflammation in the skin, altering blood flow, providing antimicrobial effects, or affecting proliferating cells. Recent advances in the understanding of cutaneous biology have not been routinely accompanied by evidence-based documentation of the benefits of many specific therapies.

EXAMINATION OF THE SKIN

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The examination of the skin is a critical component of the comprehensive medical approach to the patient. By learning how to examine the skin and approach the diagnosis of skin diseases, the physician can focus on the lesions that warrant therapy or provide important information about the systemic health of the patient. Other lesions may be of cosmetic concern to the patient even though they have little or no medical significance.

As the organ system that is an interface with the environment, the skin has an extensive array of mechanical, biochemical, immunologic, and neurologic properties that both inform and protect each individual. The skin also has a vast ability to alter its cellular and acellular components in response to internal or external insults, a process that leads to changes that are subsequently defined as disorders or diseases. The physical examination of the skin can provide information about both cutaneous and systemic diseases, and the examination can sometimes diagnose serious medical conditions at an otherwise asymptomatic stage.

Skin disorders can usually be visualized directly by both the patient and the physician. For example, the patient not only feels the itch and discomfort of an allergic contact dermatitis reaction to poison ivy but also sees the vesicular and crusted skin lesions. The appearance of new lesions or a sudden change in existing lesions can elicit emotional reactions in patients or their family members. The physician must learn to see the same eruptions using a careful and systematic approach that leads to a specific and treatable diagnosis.

ACNE ROSACEA

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ACNE ROSACEA - LarryMillikan, MD
BASICS
DESCRIPTION
Chronic skin eruption with flushing and dilatation of small blood vessels in the face, especially nose and cheeks. Sometimes associated with ocular symptoms (ocular rosacea)
• System(s) Affected: Skin/Exocrine
• Synonym(s): Rosacea
ALERT
Geriatric Considerations
• Uncommon after age 60
• Unlikely in this age group
• Use of oral isotretinoin contraindicated
GENERAL PREVENTION
No preventive measure known
EPIDEMIOLOGY
• Predominant age: 30-50 years
• Predominant sex: Female > Male
Prevalence
Common
RISK FACTORS
Genetics
People of Northern European and Celtic background commonly afflicted
ETIOLOGY
• No proven cause
• Possibilities include
- Thyroid and gonadal disturbance
- Alcohol, coffee, tea, spiced food overindulgence (unproven)
- Demodex follicular parasite (suspected)
- Exposure to cold, heat, hot drinks
- Emotional stress
- Dysfunction of the gastrointestinal tract
- Environmental trigger factors: Sun, wind, cold
ASSOCIATED CONDITIONS
• Seborrheic dermatitis of scalp and eyelids
• Keratitis with photophobia, lacrimation, visual disturbance
• Corneal lesions
• Blepharitis
• Uveitis

Actinic Keratosis

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Actinic keratosis (AK) (solar keratosis) is a squamous cell carcinoma confined to the epidermis. The lesions are common, sun-induced, and increase in number with age. Most lesions remain superficial. Lesions that extend more deeply to involve the papillary and/or reticular dermis are termed squamous cell carcinoma (SCC).

The potential for change cannot be predicted by clinical signs or histologic characteristics. Thick lesions are worrisome. Patients with AKs need periodic evaluation and usually repetitive treatments to prevent the development of aggressive cancers. Individuals with light complexions are more susceptible than those with dark complexions. Years of sun exposure are required to induce sufficient damage to cause lesions. Actinic keratoses may undergo spontaneous remission if sunlight exposure is reduced, but new lesions may appear.^[55] Patients often present with lesions that were first noticed during the summer, suggesting that the lesions may become more active after sunlight exposure. Immunosuppression is a risk factor. SCC is up to 65 times as likely to develop in transplant patients as controls. Lesions appear 2 to 4 years after transplantation and increase in frequency.

Epidermal Nevus

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The term epidermal nevus is commonly used to describe a group of cutaneous hamartomas linked by common clinical and histologic features. Linear epidermal nevus or nevus unius lateris (a linear, unilateral, wartlike nevus), nevus verrucosus (a localized, wartlike nevus), and ichthyosis hystrix (an irregular, bilateral, truncal nevus) are some of the names given to variants of epidermal nevus. Inflammatory linear verrucous epidermal nevus (ILVEN) is characterized by intensely erythematous, pruritic, inflammatory papules that occur as linear bands along the lines of Blaschko. The term nevus means a congenital defect of the skin characterized by the localized excess of one or more types of cells. Histologically the cells are identical to or closely resemble normal cells. Epidermal nevus should be used as a general term to designate an excess of one type of epidermally derived cells (e.g., squamous cell or sebocyte). However, the term is commonly reserved for congenital growths in which the predominant cell is the keratinocyte. These nevi arise from the pluripotential germinative cells in the basal layer of the embryonic epidermis. These cells give rise to keratinocytes and skin appendages (hair follicles, sweat glands).

Nevus Sebaceous

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Nevus sebaceous is a distinctive growth most commonly found on the scalp, followed by the forehead and retroauricular region.^[69]^[70] Involvement of the neck and trunk is exceptional. A nevus of epithelial and nonepithelial skin components, nevus sebaceous sustains age-related modifications in morphology. The nevus occurs singly and is asymptomatic. Two thirds of cases are present at birth; the others develop in infancy or early childhood. Males and females are equally affected. The very rare nevus sebaceous of Jadassohn syndrome consists of the triad of a linear sebaceous nevus, convulsions, and mental retardation. A variety of congenital malformations of the ocular, skeletal, vascular, and urogenital systems have been described in association with nevus sebaceous.^[71]^[72] Neurological abnormalities have been reported in patients with sebaceous nevi, but the incidence is low. It is recommended that patients with sebaceous nevi have a neurological assessment and that imaging be performed on all those in whom clinical abnormalities are demonstrated, as well as on those patients with large nevi involving the centrofacial area.

Dermatofibroma

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Dermatofibromas are common, benign, asymptomatic-to-slightly itchy lesions occurring more frequently in females. They vary in number from 1 to 10 and can be found anywhere on the extremities and trunk, but they are most likely to occur on the anterior surface of the lower legs. Dermatofibromas may not be tumors; rather, they may represent a fibrous reaction to trauma, a viral infection, or an insect bite. They appear as 3- to 10-mm, slightly raised, pink-brown, sometimes scaly, hard growths that retract beneath the skin surface during attempts to compress and elevate them with the thumb and index finger (Figures 20-22 to 20-25 [22] [23] [24] [25]). Multiple dermatofibromas (i.e., more than 15) are very rare but have been reported with systemic lupus erythematosus,^[20]^[21] with and without immunosuppressive therapy. Dermatoscopic examination shows a central white scarlike patch and a delicate pigment network at the periphery (see Figure 20-40 ).

Etiologic Classification of Urticaria

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Foods
Fish, shellfish, nuts, eggs, chocolate, strawberries, tomatoes, pork, cow's milk, cheese, wheat, yeast
Food additives
Salicylates, dyes such as tartrazine, benzoates, penicillin
Aspartame (NutraSweet) probably does not cause hives *
Sulfites
Drugs
Penicillin, aspirin, sulfonamides, and drugs that cause a non-immunologic release of histamine (e.g., morphine, codeine, polymyxin, dextran, curare, quinine)
Infections
Chronic bacterial infections (e.g., sinus, dental, chest, gallbladder, urinary tract), Campylobacter enteritis, fungal infections (dermatophytosis, candidiasis), viral infections (hepatitis B prodromal reaction, infectious mononucleosis, coxsackie), protozoal and helminth infections (intestinal worms, malaria)
Inhalants
Pollens, mold spores, animal dander, house dust, aerosols, volatile chemicals
Internal disease
Serum sickness, systemic lupus erythematosus, hyperthyroidism, autoimmune thyroid disease, carcinomas, lymphomas, juvenile rheumatoid arthritis (Still's disease), leukocytoclastic vasculitis, polycythemia vera (acne urticaria–urticarial papule surmounted by a vesicle), rheumatic fever, some blood transfusion reactions
Physical stimuli (physical urticarias)
Dermographism, pressure urticaria, cholinergic urticaria, exercise-induced anaphylactic syndrome, solar urticaria, cold urticaria, heat, vibratory, water (aquagenic)
Nonimmunologic contact urticaria
Plants (nettles), animals (caterpillars, jellyfish), medications (cinnamic aldehyde, compound 48/80, dimethyl sulfoxide)
Immunologic or uncertain mechanism contact urticaria
Ammonium persulfate used in hair bleaches, chemicals, foods, textiles, wood, saliva, cosmetics, perfumes, bacitracin
Skin diseases
Urticaria pigmentosa (mastocytosis), dermatitis herpetiformis, pemphigoid, amyloidosis
Hormones
Pregnancy, premenstrual flare-ups (progesterone)
Genetic, autosomal dominant (all rare)
Hereditary angioedema, cholinergic urticaria with progressive nerve deafness, amyloidosis of the kidney, familial cold urticaria, vibratory urticaria

* Geha, R, Buckley CE, et al: J Allergy Clin Immunol 1993; 92:513.

Pathophysiology of urticaria

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Pathophysiology

Histamine

Histamine is the most important mediator of urticaria. Histamine is produced and stored in mast cells. There are several mechanisms for histamine release via mast cell surface receptors. A variety of immunologic, nonimmunologic, physical, and chemical stimuli may be responsible for the degranulation of mast cell granules and the release of histamine into the surrounding tissue and circulation. About one third of patients with chronic urticaria have circulating functional histamine-releasing IgG autoantibodies that bind to the high-affinity IgE receptor (Fc epsilon RI). Release of mast cell mediators can cause inflammation and accumulation and activation of other cells, including eosinophils, neutrophils, and possibly basophils. Histamine causes endothelial cell contraction, which allows vascular fluid to leak between the cells through the vessel wall, contributing to tissue edema and wheal formation.

When injected into skin, histamine produces the “triple response” of Lewis, the features of which are local erythema (vasodilation), the flare characterized by erythema beyond the border of the local erythema, and a wheal produced from leakage of fluid from the postcapillary venule. Histamine induces vascular changes by a number of mechanisms ( Figure 6-8 ). Blood vessels contain two (and possibly more) receptors for histamine. The two most studied are designated H1 and H2.

H1 RECEPTORS.

H1 receptors, when stimulated by histamine, cause an axon reflex, vasodilation, and pruritus. Acting through H1 receptors, histamine causes smooth-muscle contraction in the respiratory and gastrointestinal tracts and pruritus and sneezing by sensory-nerve stimulation. They are blocked by the vast majority of clinically available antihistamines called H1 antagonists (e.g., chlorpheniramine), which occupy the receptor site and prevent attachment of histamine.

H2 RECEPTORS.

When H2 receptors are stimulated, vasodilation occurs. H2 receptors are also present on the mast cell membrane surface and, when stimulated, further inhibit the production of histamine. Activation of H2 receptors alone increases gastric acid secretion. Cimetidine (Tagamet), ranitidine (Zantac), and famotidine (Pepcid) are H2 blocking agents (antihistamines). H2 receptors are present at other sites. Activation of both H1 and H2 receptors causes hypotension, tachycardia, flushing, and headache. The H2 blocking agents are used most often to suppress gastric acid secretion. They are used occasionally, usually in combination with an H1 blocking agent, to treat urticaria.

Urticaria and Angioedema

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Urticaria, also referred to as hives or wheals, is a common and distinctive reaction pattern. Hives may occur at any age; up to 20% of the population will have at least one episode. Hives may be more common in atopic patients. Urticaria is classified as acute or chronic. The majority of cases are acute, lasting from hours to a few weeks. Angioedema frequently occurs with acute urticaria, which is more common in children and young adults. Chronic urticaria (arbitrarily defined as episodes of urticaria lasting more than 6 weeks) is more common in middle-aged women.

Because most individuals can diagnose urticaria and realize that it is a self-limited condition, they do not seek medical attention.

The cause of acute urticaria is determined in many cases, but the cause of chronic urticaria is determined in only 5% to 20% of cases. Patients with chronic urticaria present a frustrating problem in diagnosis and management. History taking is crucial but tedious, and treatment is usually supportive rather than curative.

These patients are often subjected to detailed and expensive medical evaluations that usually prove unrewarding. Studies demonstrate the value of a complete history and physical examination followed by the judicious use of laboratory studies in evaluating the results of the history and physical examination.

Criteria for Diagnoses of Atopic Dermatitis

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Major Features (Must Have Three or More)
Pruritus
Typical morphology and distribution
Flexural lichenification in adults
Facial and extensor involvement in infants and children
Dermatitis—chronically or chronically relapsing
Personal or family history or atopy—asthma, allergic rhinitis, atopic dermatitis
Minor Features (Must Have Three or More)
Cataracts (anterior-subcapsular)
Cheilitis
Conjunctivitis—recurrent
Eczema—perifollicular accentuation
Facial pallor/facial erythema
Food intolerance
Hand dermatitis—nonallergic, irritant
Ichthyosis
IgE—elevated
Immediate (Type 1) skin test reactivity
Infections (cutaneous)—Staphylococcus aureus, herpes simplex
Infraorbital fold (Dennie-Morgan lines)
Itching when sweating
Keratoconus
Keratosis pilaris
Nipple dermatitis
Orbital darkening
Palmar hyperlinearity
Pityriasis alba
White dermographism
Wool intolerance
Xerosis

Data from Roth HL: Int J Dermatol 1987; 26:139; Hanifin JM, Rajka G: Acta Derm Venereol (Stockh) 1980; 92(suppl):44; and Hanifin JM, Lobitz WC Jr: Arch Dermatol 1977; 113:663.

Atopic Dermatitis

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The term atopy was introduced years ago to designate a group of patients who had a personal or family history of one or more of the following diseases: hay fever, asthma, very dry skin, and eczema.

Atopic dermatitis (AD) is a chronic, pruritic eczematous disease that nearly always begins in childhood and follows a remitting/flaring course that may continue throughout life. It develops as a result of a complex interrelationship of environmental, immunologic, genetic, and pharmacologic factors. It may be exacerbated by infection, psychologic stress, seasonal/climate changes, irritants, and allergens. The disease often moderates with age, but patients carry a life-long skin sensitivity to irritants, and this atopy predisposes them to occupational skin disease.

The disease characteristics vary with age. Infants have facial and patchy or generalized body eczema. Adolescents and adults have eczema in flexural areas and on the hands. The pattern of inheritance is unknown, but available data suggest that it is polygenic.

Allergic contact dermatitis phases

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SENSITIZATION PHASE.

Antigen is applied to the skin surface, penetrates the epidermal barrier (stratum corneum) and is taken up by Langerhans' cells in the epidermal basal layer. The antigen is “processed” and displayed on the surface of the Langerhans' cell. This cell migrates to the regional lymph nodes and presents the antigen to T lymphocytes. Cytokine-induced proliferation and clonal expansion within the lymph nodes results in T lymphocytes bearing receptors that recognize the specific antigen. These antigen-specific T lymphocytes enter the bloodstream and circulate back to the epidermis.

ELICITATION PHASE.

The elicitation phase occurs in sensitized patients with reexposure to the antigen. Langerhans' cells bearing the antigen interact with antigen-specific T lymphocytes that are circulating in the skin. This interaction results in cytokine-induced activation and proliferation of the antigen-specific T lymphocytes and the release of inflammatory mediators. Allergic contact dermatitis develops within 12 to 48 hours of antigen exposure and persists for 3 or 4 weeks.

Cross-sensitization

An allergen, the chemical structure of which is similar to the original sensitizing antigen, may cause inflammation because the immune system is unable to differentiate between the original and the chemically related antigen. For example, the skin of patients who are allergic to balsam of Peru, which is present in numerous topical preparations, may become inflamed when exposed to the chemically related benzoin in tincture of benzoin.

Systemically induced allergic contact dermatitis

Systemic contact dermatitis results from the exposure to an allergen by ingestion, inhalation, injection, or percutaneous penetration in a person previously sensitized to the allergen by cutaneous contact. Patients allergic to poison ivy develop diffuse inflammation following the ingestion of raw cashew nuts . Cashew nut oil is chemically related to the oleoresin of the poison ivy plant. Persons allergic to balsam of Peru and/or fragrance mix benefit from dietary avoidance of balsams

Allergic Contact Dermatitis

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Allergic contact dermatitis is an inflammatory reaction that follows absorption of antigen applied to the skin and recruitment of previously sensitized, antigen-specific T lymphocytes into the skin. It affects a limited number of individuals. The antigens are usually low-molecular-weight substances that readily penetrate the stratum corneum. Most contact allergens are weak and require repeated exposure before sensitization occurs. Strong antigens, such as poison ivy, require only two exposures for sensitization.

Interaction between antigen and T lymphocytes is mediated by antigen-presenting epidermal cells (Langerhans' cells) and is divided into two sequential phases: an initial sensitization phase and an elicitation phase. Langerhan's cells are abundant in skin and sparse at mucosal sites

THREE STAGES OF ECZEMA.

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THREE STAGES OF ECZEMA.

There are three stages of eczema: acute, subacute, and chronic. Each represents a stage in the evolution of a dynamic inflammatory process ( Table 3-1 ). Clinically, an eczematous disease may start at any stage and evolve into another. Most eczematous diseases, if left alone (i.e., neither irritated, scratched, nor medicated), resolve in time without complication. This ideal situation is almost never realized; scratching, irritation, or attempts at topical treatment are almost inevitable. Some degree of itching is a cardinal feature of eczematous inflammation.

Eczema and Hand Dermatitis

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Eczema (eczematous inflammation) is the most common inflammatory skin disease. Although the term dermatitis is often used to refer to an eczematous eruption, the word means inflammation of the skin and is not synonymous with eczematous processes. Recognizing a rash as eczematous rather than psoriasiform or lichenoid, for example, is of fundamental importance if one is to effectively diagnose skin disease. Here, as with other skin diseases, it is important to look carefully at the rash and to determine the primary lesion.

It is essential to recognize the quality and characteristics of the components of eczematous inflammation (erythema, scale, and vesicles) and to determine how these differ from other rashes with similar features. Once familiar with these features, the experienced clinician can recognize a process as eczematous even in the presence of secondary changes produced by scratching, infection, or irritation. With the diagnosis of eczematous inflammation established, a major part of the diagnostic puzzle has been solved.

Skin Anatomy

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Skin Anatomy

The skin is divided into three layers: the epidermis, the dermis, and the subcutaneous tissue. The skin is thicker on the dorsal and extensor surfaces than on the ventral and flexor surfaces.

Epidermis

The epidermis is the outermost part of the skin; it is stratified squamous epithelium. The thickness of the epidermis ranges from 0.05 mm on the eyelids to 1.5 mm on the palms and soles. The microscopic anatomy of the epidermal-dermal junction is complex; it is discussed in detail in Chapter 16 . The innermost layer of the epidermis consists of a single row of columnar cells called basal cells. Basal cells divide to form keratinocytes (prickle cells), which comprise the spinous layer. The cells of the spinous layer are connected to each other by intercellular bridges or spines, which appear histologically as lines between cells. The keratinocytes synthesize insoluble protein, which remains in the cell and eventually becomes a major component of the outer layer (the stratum corneum). The cells continue to flatten, and their cytoplasm appears granular (stratum granulosum); they finally die as they reach the surface to form the stratum corneum. There are three types of branched cells in the epidermis: the melanocyte, which synthesizes pigment (melanin); Langerhans' cell, which serves as a frontline element in immune reactions of the skin; and Merkel's cell, the function of which is not clearly defined.

Dermis

The dermis varies in thickness from 0.3 mm on the eyelid to 3.0 mm on the back; it is composed of three types of connective tissue: collagen, elastic tissue, and reticular fibers. The dermis is divided into two layers: the thin upper layer, called the papillary layer, is composed of thin, haphazardly arranged collagen fibers; the thicker lower layer, called the reticular layer, extends from the base of the papillary layer to the subcutaneous tissue and is composed of thick collagen fibers that are arranged parallel to the surface of the skin. Histiocytes are wandering macrophages that accumulate hemosiderin, melanin, and debris created by inflammation. Mast cells, located primarily about blood vessels, manufacture and release histamine and heparin.

Dermal nerves and vasculature

The sensations of touch and pressure are received by Meissner's and the Vater-Pacini corpuscles. The sensations of pain, itch, and temperature are received by unmyelinated nerve endings in the papillary dermis. A low intensity of stimulation created by inflammation causes itching, whereas a high intensity of stimulation created by inflammation causes pain. Therefore scratching converts the intolerable sensation of itching to the more tolerable sensation of pain and eliminates pruritus.

The autonomic system supplies the motor innervation of the skin. Adrenergic fibers innervate the blood vessels (vasoconstriction), hair erector muscles, and apocrine glands. Autonomic fibers to eccrine sweat glands are cholinergic. The sebaceous gland is regulated by the endocrine system and is not innervated by autonomic fibers.

Illustrated Skin Anatomy

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dermatology

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Encephalocele

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Encephalocele
Major points
• Cystic structure on the midline face
• Presents in the neonatal period with nasal
broadening (67%) or as a soft, blue pulsatile mass
that transilluminates on the nasal bridge
• Increases in size with crying, Valsalva maneuver, or
external compression of the jugular veins
• Associated with facial clefting and other midline
defects
Pathogenesis
• Herniation of brain tissue through the skull with
connection to the underlying brain
Diagnosis
• Image with MRI
• Biopsy of the skin lesion not recommended,
owing to the connection with the subarachnoid
space which could lead to CSF rhinorrhea and
infection
• Histology: similar to nasal glioma
Differential diagnosis
• Hemangioma
• Nasal glioma
• Dermoid cyst
• Hypertelorism
Treatment
• Evaluation with MRI or CT scan is essential
• Surgical excision is recommended by a skilled
pediatric neurosurgeon and otolaryngologist
Prognosis
• Lesions persist if not surgically corrected and may
become infected
References
Brown MS, Sheridan-Pereira M. Outlook for the child with
a cephalocele. Pediatrics 1992; 90: 914–19
Davis DA, Cohen PR, George RE. Cutaneous stigmata of
occult spinal dysraphism. J Am Acad Dermatol 1994; 31:
892–6
El Shabrawi-Caelen L, White WL, Soyer HP, et al.
Rudimentary meningocele: remnant of a neural tube defect?
Arch Dermatol 2001; 137: 45–50
Hoving EW. Nasal encephaloceles. Childs Nerv Syst 2000;
16: 702–6
Hunt JA, Hobar PC. Common craniofacial anomalies: facial
clefts and encephaloceles. Plast Reconstruct Surg 2003; 112:
606–15
Paller AS, Pensler JM, Tomita T. Nasal midline masses in
infants and children. Arch Dermatol 1991; 127: 362–6

Neonatal scars

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Neonatal scars
Major points
• The number of neonatal scars is related to gestational
age and length of time spent in an intensive care unit
• Scarring can occur with amniocentesis, chorionic
villus sampling, fetal monitoring, arterial or venous
punctures, catheter insertions, heel sticks, chest
tubes, adhesives and extravasated intravenous fluids
(Figure 2.14)
• Amniocentesis scars occur in <1% of neonates
whose mothers underwent amniocentesis; risk
decreases during second trimester; scars are usually
not apparent for weeks to months after birth
• If less than 29 weeks’ gestational age at birth,
anetoderma can develop at sites of monitors and
adhesives; presents as atrophic scars on the anterior
trunk and proximal extremities
Pathogenesis
• Caused by multiple procedures performed in utero
or in the neonatal intensive care unit
Diagnosis
• Consistent clinical history
• Clinical findings
Differential diagnosis
• Congenital dimples
• Congenital sinus tracts
• Aplasia cutis congenita
• Focal dermal hypoplasia (Goltz syndrome)
Treatment
• None effective
• Red lesions (vascular component) can be treated
with vascular laser with variable results
Prognosis
• Most commonly small and inconspicuous, but can
be large with underlying fibrosis
• Can develop secondary calcified papules and
hypertrophic scars
• Puncture sites can rarely become secondarily
infected with abscess or gangrene

Sclerema neonatorum

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Sclerema neonatorum
Major points
• Characteristic widespread thickening and
induration of the skin in critically ill newborns
(e.g. sepsis, hypoglycemia and metabolic acidosis)
• May occur up to 4 months of age
• Presents with sudden onset of rapid hardening of
the skin that starts distally and progresses to
involve the skin diffusely but with sparing of the
palms, soles and genitalia
• No pitting of the skin is noted with pressure
• Skin becomes bound-down with mask-like facies
and immobile joints
Pathogenesis
• Etiology unknown; hypothesis of cold injury and
secondary solidification of the tissue due to
enzymatic dysfunction
Diagnosis
• Clinical findings in typical setting
• Histology: identical to subcutaneous fat necrosis
Differential diagnosis
• Subcutaneous fat necrosis of newborn
• Restrictive dermopathy
• Systemic sclerosis
• Stiff skin syndrome
Treatment
• Supportive measures to reverse the underlying
disorder: temperature control, hydration, electrolyte
balance and aggressive antibiotic therapy
• Systemic corticosteroid use is controversial
• Exchange transfusions
Prognosis
• High infant mortality related to the underlying
condition
• Skin changes can resolve with treatment of the
underlying disorder
• Worse prognosis with thrombocytopenia,
neutropenia, and progressive acidosis
References
Battin M, Harding J, Gunn A. Sclerema neonatorum following
hypothermia. J Paediatr Child Health. 2002; 38: 533–4
Burden AD, Krafchik BR. Subcutaneous fat necrosis of the
newborn: a review of 11 cases. Pediatr Dermatol 1999; 16:
384–7
Requena L, Sanchez Yus E, Panniculitis. Part II. Mostly
lobular panniculitis. J Am Acad Dermatol 2001; 45: 325–61,
quiz 362–4

Umbilical granuloma

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Major points
• Pink papule or nodule within the umbilical stump
that bleeds easily (Figure 2.8)
• Develops at the site of the umbilical cord remnant
after it falls off
• Clinically resembles a pyogenic granuloma
Pathogenesis
• Inadequate healing at umbilical stump with
subsequent endothelial cell proliferation and
inflammation (granulation tissue)
• Not true granuloma
Diagnosis
• Clinical findings
• Histology: endothelial cell proliferation without
atypia
Illustrated Manual of Pediatric Dermatology 14
Differential diagnosis
• Omphalomesenteric duct cyst/umbilical polyp
• Patent urachus
Treatment
• Silver nitrate application
• Cryocautery, ligature and excision have been
reported to be successful
Prognosis
• Can resolve spontaneously but usually requires
treatment
• Persistence indicates the presence of an umbilical
remnant
References
Campbell J, Beasley SW, McMullin N, Hutson JM. Clinical
diagnosis of umbilical swellings and discharges in children.
Med J Aust 1986; 145: 450–3
Donlon CR, Furdon SA. Assessment of the umbilical cord
outside of the delivery room. Part 2. Adv Neonatal Care
2002; 2: 187–97

Milia

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Major points
• Occurs in up to 40% of infants, most commonly
on the face
• Known as Epstein’s pearls when they occur in the
oral cavity; affect up to 85% of newborns
• 1–2mm white, firm papules on the face, but can
also occur on the trunk, extremities, genitalia and
oral mucosa (Figure 2.4)
• Can occur at sites of scars
Pathogenesis
• Keratinous cyst originating from vellus hair follicle
• Results from retention of keratin within the lowest
portion of the infundibulum of the pilosebaceous
unit at the level of the sebaceous duct
Diagnosis
• Clinical findings
• Histology: identical to epidermal cysts except for
smaller size; lined by stratified epithelium; contains
laminated keratin
Differential diagnosis
• Neonatal acne
• Sebaceous hyperplasia
• Molluscum contagiosum
Treatment
• No intervention required
• Incision and expression rarely required
Neonatal dermatology 11
Figure 2.4 Milia – multiple white papules on the face
Prognosis
• Typically resolves within weeks to months
• Can be associated with syndromes: type I
oral–facial–digital syndrome, hereditary
trichodysplasia, pachyonychia congenita
References
Akinduro OM, Burge SM. Congenital milia in the nasal
groove. Br J Dermatol 1994; 130: 800
Bridges AG, Lucky AW, Haney G, Mutasim DF. Milia en
plaque of the eyelids in childhood: case report and review of
the literature. Pediatr Dermatol 1998; 15: 282–4
Langley RG, Walsh NM, Ross JB. Multiple eruptive milia:
report of a case, review of the literature, and a classification.
J Am Acad Dermatol 1997; 37: 353–6
Larralde de Luna M, Paspa ML, Ibargoyen J.
Oral–facial–digital type I syndrome of Papillon-Leage and
Psaume. Pediatr Dermatol 1992; 9: 52–6
Stefanidou MP, Panayotides JG, Tosca AD. Milia en plaque:
a case report and review of the literature. Dermatol Surg
2002; 28: 291–5

Vernix caseosa

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Major points
• Common finding in the neonatal period
• Characteristic white to gray, greasy covering on the
skin surface of the newborn (Figure 2.1)
• Thickness increases with gestational age
• Considered a protective covering and mechanical
barrier to bacteria
• Lipid composition is variable depending on
gestational age
• Discoloration and odor can indicate fetal distress
and/or intrauterine infection
Pathogenesis
• Composed of shed epidermal cells, sebum and
lanugo hairs
• Variable lipid composition of cholesterol, free fatty
acids and ceramide
Diagnosis
• Clinical diagnosis
Differential diagnosis
• Ichthyoses (disorders of keratinization) if atypical
Treatment
• None needed
Prognosis
• Sheds without therapy during the first week of life
References
Hoeger PH, Schreiner V, Klaassen IA, et al. Epidermal
barrier lipids in human vernix caseosa: corresponding
ceramide pattern in vernix and fetal skin. Br J Dermatol
2002; 146: 194–201
Joglekar VM. Barrier properties of vernix caseosa. Arch Dis
Child 1980; 55: 817

PRINCIPLES OF CLINICAL DIAGNOSIS

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GENERAL
• Diagnosis of cutaneous disorders in infants and
children requires careful inspection of skin, hair
and nails
• Skin disorders of infants are different from skin
disorders in adults
1. For example, erythema toxicum neonatorum is
only seen in newborns
2. Skin of a young child tends to form blisters
more easily (e.g. insect bites or mastocytomas)
• Determining morphology of skin lesions, their
color and distribution will help generate a
differential diagnosis

Contact dermatitis history

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1. Determine the onset – exact time and location of
appearance of lesions
2. Course of dermatitis – progression, recurrence,
remission
3. Topical medicines used
4. Previous therapy and response
5. Work exposure – relation to work, days off,
vacation, duties
6. Other persons having similar dermatitis
7. Hobbies – chemical exposure
8. Topical cosmetics – perfumes, soaps,
sunscreens, toothpaste, nail polish, hair dyes,
etc.
9. Plant exposure – poison ivy, chrysanthemums,
weeds, etc.
10. Chemical exposure – work and home
11. Water exposure – hand washing, job-related
12. Clothing history – underwear, jewelry, watches,
earrings, belts, snaps
13. Atopic history – asthma, eczema, personal
and/or family history
14. Immune status

Criteria for the diagnosis of atopic dermatitis in children

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Major features
1. Pruritus
2. Typical morphology and distribution
Facial and extensor involvement during
infancy and early childhood
Flexural lichenification in childhood or
adolescence
3. Chronic or chronically relapsing dermatitis
4. Personal or family history of atopy
Minor or less specific features
1. Xerosis
2. Periauricular fissures
3. Ichthyosis
4. Hyperlinear palms
5. Keratosis pilaris
6. IgE reactivity (increased serum IgE, RAST, or
prick test positivity)
7. Hand or foot dermatitis
8. Cheilitis
9. Scalp dermatitis
10. Susceptibility to cutaneous infections (especially
Staphylococcus aureus and herpes simplex)
11. Perifollicular accentuation (especially in darkly
pigmented races)
12. Dennie’s lines (Figure 4.12)
13. Pityriasis alba (Figure 4.13)

Interviewing and treating pediatric dermatology patients

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1. Children are different from adults. Learn the differences.
2. Approach patients cautiously. Sit across the room and talk to the parents before examining the child. This gives
them time to ‘size you up’.
3. Speak directly to the child as if he/she understands what you are saying. Make eye contact with the child.
4. Keep the parent in the room for procedures as much as possible unless it interferes with the procedure or the
parent wishes to step out of the room.
5. Conservative management is best. Try to use the lowest effective dose of medication for the shortest time.
6. Avoid new therapies which do not have a proven track record in pediatrics until adequate clinical trials are performed.
7. Do not use treatments which may decrease growth or mental development.
8. Anticipatory guidance and emotional support are helpful especially in chronic disorders (e.g. alopecia areata, atopic
dermatitis).
Adapted from Honig PJ. Potential clinical management risks in pediatric dermatology. Risk Management in
Dermatology, Part II. AM Medica Communications LTS: New York, 1988: 6

SKIN CARE TREATMENTS

2008-12-10T19:00:00.000-08:00

Because your skin is the hallmark of your beauty
The skin of the human body is more than an outer protective coating. It has always been regarded the mark of a persons beauty and capability. If the skin is soft and fine, the person is regarded as delicate and beautiful. If the skin is coarse and hard yet smooth, the person is known to be diligent and hard working. A healthy skin is the mark of a healthy body and personality.
At www.advancedlaserskin.com, we bring to you the best in skin treatment. We have
a number of skin care treatments available but there are four major treatments that are available with us. These are Laser Hair Removal, Intense Pulsed Light (IPL)
Photofacials, Microdemabrasion and Chemical Peel Treatments. Let us discuss each of
these in detail.
We have developed the new FDA approved Light Sheer Diode to provide to you the best
possible Laser hair removal. Being FDA approved, the technology is extremely safe and yes, it works very effectively. Unlike the more painful and costly, electrolysis process, the Light Sheer Laser Hair removal system is a much better technology and in case you face any problems then we also have a topical anesthetic facility available just for you.
We use patented ChillTip technology to ensure that treatment does not make you feel
uncomfortable. We also offer the unique ability to treat any type of skin including those with a tan. We have a proven reliability of our equipment and we promise that your laser skin treatment will not be hampered because of equipment downtime.
Another one of famous skin treatment service that we offer includes the new chemical
peel treatment. These chemical peels are clinically proven to be totally safe for human skin. We offer many types of affordable skin peels, including the Vitalize Peel which improves skin texture, lessens fine lines and provides a healthier looking skin. Our Basic Salicylic Acid Peel is a deep cleansing treatment which removes the dead skin cells and stimulates skin regeneration. The Glycolic Acid Peel uses alpha hydroxyl acids and is used to allow fresher skin to surface by stimulating collagen production. Our Ultra peel exfoliating treatment specially treats dehydrated, maturing skin, skin damaged by smoking & pigmentation disordered skin.
Other chemical peels include the oxygenating chemical peel, Sensi chemical peel,
Pumpkin chemical peel treatment, Esthetique chemical peel, Smoothing chemical body
peel and Oxygen-trio treatment. If you want more information about Laser hair removal treatment, Chemical peels, Microdermabrasion or IPL Photofacial, just visit us at www.advancedlaserskin.com.

SKIN TREATMENTS HELP AT ADVANCE LASER CLINIC

2008-12-10T18:59:00.000-08:00

Imagine you are browsing through various skin care aisles and finding the perfect product boasting all-natural ingredients. You go further and read the label stating benzoic acid, butyl stearate, along with some unpronounceable names. And you think that this is the prefect product containing no preservatives and chemicals. Problem is majority of these products can actually irritate sensitive skin. This is when Advanced Laser Clinics’ skin renewal treatment comes into picture.
Advanced Laser Clinics is Chicago’s best skin care centre. It is a one-stop-shop for all your skin and unwanted hair removal needs. It offers not just permanent hair removal by laser but also skin renewal treatment. Advanced Laser Clinics’ performs skin renewal treatment via Intense Pulsed Light (IPL) Photofacials.
Intense Pulsed Light (IPL) Photofacials is not a new technique as Advanced Laser Clinics has been using this technique effectively and successfully for quite some time. This treatment can effectively treat sun tan or sun damage, age spots such as sun-induced freckles, broken capillaries, telangiectasias, and most benign brown pigments. If you are experiencing any one of these, they can be effectively treated at Advanced Laser Clinics and that too within your budget. Anyone residing in Chicago simply contacts Advanced Laser Clinics for skin renewal treatment and permanent hair removal. All these treatments are not just safe and effective but also affordable.
Advanced Laser Clinics is one place where you can get rid of all the skin and unwanted hair related problems, that too within few treatment sittings. All of its provided treatments are cost-effective with no side effects. FDA approved, this IPL Photofacial is the most exciting technology used by Advanced Laser Clinics for skin renewal. It usually corrects or actually reverses various skin conditions and facial imperfections, specially the signs of aging.
This skin renewal treatment is slightly different from laser procedures. It is thoroughly tested and perfected therapy providing long-term improvement. All the other treatments at Advanced Laser Clinics are cost effective and are customized. Customization means each and every treatment program is based on your particular wants, needs and desired results.
Before beginning with your treatment, Advanced Laser Clinics’ highly-trained,
professional technicians will analyze your skin. By that they will suggest you the
treatment and the number of sittings required. And all these steps are available in a pocket friendly budget. Thus, what are you waiting for, if you wish to revitalize your skin or want to know more about skin renewal and luxury skin care products simply contact Advanced Laser Clinics at www.advancedlaserskin.com.

AN ARTICLE ON ACNE TREATMENT

2008-12-10T18:57:00.000-08:00

From the intermittent pimple during times of stress to the regular breakouts before menses, acne affects almost all every women at some time in their lives. Acne is not just restricted to women, men also suffer the same. Acne is a common problem experienced during the preteen and early teen years. There is no fixed age bar as acne can also arise in young adulthood and persist for years. That’s why anyone suffering from acne these days simply selects for acne skin care treatment.
Recently concluded studies revealed that, women feel more frustrated by acne than
men. Moreover, dealing with some kind of chronic disorder that too associated with
puberty can lead to more frustration. But don’t feel disheartened if you have acne as effective acne skin care treatment is easily available. Before jumping onto the solution, it is wise to know how acne occurs. You skin carries thousands of oil glands producing sebum. This sebum is used to moisturize and enhance the skin’s ability to act as a protective barrier.
Each gland carries sebum to the surface through pores. However, the highest density of oil glands is deposited on your face particularly at the nose, forehead and mid-cheek areas. This is the reason why, acne mostly occurs on the face, chest and back. Many medical experts and doctors think that hormones play a major role in pore blockage and increased oil production. This increased production or piling up of oil within the pore results in the formation of blemishes such as blackheads and whiteheads.
There are various steps that can be taken to curb acne but among all acne skin care
treatment heads the list. In many situations acne can be aggravated by sleeping on
damp hair, thick, pore-blocking creams, long hair brushing the skin on your back, neck, and face, clothing, hats, helmets or pads that retain sweat or moisture in them, hair gels and sprays where they may touch your skin, and many more. If you are suffering from acne instead of panicking, simply contact Advanced Laser Clinics for acne skin care treatment.
Advanced Laser Clinics’ acne skin care treatment not just cures your acne but also minimizes the risk of scars by improving your skin’s appearance. At Advanced Laser Clinics, your treatment begins with your skin analysis and discovering what triggers your acne. After knowing this, your treatment is determined which will help you to control the condition. If you are tired of your acne problem and looking for a perfect solution, Advanced Laser Clinics' acne skin care treatment is the best solution available . Wish to know more about acne skin care treatment, microdermabrasion, chemical peels, IPL Photofacial, and acne treatment? If Yes, click www.advancedlaserskin.com.

LASER SKIN TREATMENT FOR A WIDE RANGE OF SKIN PROBLEMS

2008-12-10T18:56:00.001-08:00

Men have also started booking appointments at salons or spas these days. They also go for eyebrow waxing to boast the much hyped ‘metrosexual’ look. With celebrated men like David Beckham boasting nicely-shaped brows, it seems that men aren't settling for less. This has increased the popularity of laser hair removal treatment. In a latest survey it was revealed that, 86% of the male, nowadays, get their eyebrows waxed.
Getting eyebrows waxed isn’t a good option when you have easily available laser hair
removal treatment. You will be shocked to know that up to 22% of women in North America have excessive or unwanted facial hair. This unwanted facial hair usually affects the quality of life for many individuals and they are compelled to rid themselves of unwanted body hair. With the help of laser hair removal, you can easily get rid of unwanted body hair which is dictated by popular culture and appearance anxieties.
Having body hair is undesirable for various patients having cultural, social, cosmetic, or psychological reasons. Unwanted hair generally results in feelings of embarrassment or emotional burden, but why to worry when laser hair removal treatment is at your service. If you are in Chicago and looking for the reliable laser hair removal treatment, Advanced Laser Clinics is there for you.
Advanced Laser Clinics offers various treatments such as laser hair removal, light pulse skin renewal, microdermabrasion, and chemical peels. All these treatments are not just safe but also affordable. Advanced Laser Clinics makes sure that it uses adequate and safe methods for not just laser hair removal but also for all other treatments. It houses some of the highly trained medical technicians making laser hair removal an effective form of treatment for unwanted body hair.
Advanced Laser Clinics’ IPL Photofacial treatment is also FDA approved & ensuring 100% results with no or minimal side effects. There is a misconception that laser treatment involves certain side effects. This misconception has been disregarded by the technicians working at Advanced Laser Clinics. They say that this treatment is not just safe but also result oriented. In laser hair removal treatment, a laser beam basically killing the hair follicles is emitted. However, result of this treatment may vary from your skin pigmentation and the color of your hair.
For this Advanced Laser Clinics’ technicians analyze your skin and according to that design a program for you. This program determines how many sittings you will be undergoing. The biggest benefit of getting laser hair removal treatment at Advanced Laser Clinics is that this treatment is pocket friendly. This means you don’t have to spill thousands of dollars for undergoing this treatment. What you are waiting for, if you wish to know more about laser hair removal, chemical peels and microdermabarision, just click www.advancedlaserskin.com.

PERMANENT LASER HAIR REMOVAL

2008-12-10T18:54:00.000-08:00

You must have heard the latest buzz surrounding permanent hair removal with the help
of lasers. Everyone wants to look beautiful and for that the best way is to get rid of all the unwanted hair. This is the reason why more and more people are going for permanent hair removal.
You will be surprised to know that in permanent hair removal process, actual lasers are not used. Instead laser replacements are used which emit the same strong pulses of light. However, they are much safer than a real laser.
According to the medical experts, if you are going for permanent hair removal it is advisable to contact highly trained professionals. Many trained professionals or websites use precision equipment to send light into the hair follicle. This emitted light penetrates the melanin surrounding the follicles. This penetration rapidly increases the temperature of the hair follicle, causing removal and finally complete destruction of the follicle. That’s why; permanent hair removal with laser is so successful in many candidates.
Being a permanent hair remover, it is less painful than some other methods and usually requires around four treatments. Isn’t it a convenient way to get rid of unwanted hair?
When this process is done by a properly trained medical professional, permanent hair removal with laser proves to be very effective. However, there are still no guarantees but its true, hundreds of thousands satisfied customers who have undergone this treatment, have thrown away their razors. The biggest advantage of permanent hair removal is that it can be used on all parts of your body, whether it is your hand, leg, buttock, chin, chest, face, and any other body part.
There are a few strict guidelines and parameters followed by a laser specialist for treating certain damaged skin areas. Moreover, if your skin is in good health, then hair covering can be removed easily. If you have a skin problem in a particular area, a doctor can refuse to treat that area. For instance, if you are having acne on your face, doctors may not treat your upper lip or eyebrows with the fear of making the acne condition worse. This is a precaution taken by most doctors. Also if you have dry and flaky skin, you will likely be passed over for permanent hair removal with the fear of exacerbating the condition.
If you are annoyed with your unwanted hair and want to get rid of them permanently,
permanent hair removal with laser is the best option. Wish to know more about
permanent hair removal, laser hair removal, laser hair removal prices, and laser hair removal Chicago? If yes, click www.advancedlaserskin.com.

SKIN RENEWAL WITH IPL PHOTOFACIAL

2008-12-10T18:53:00.001-08:00

Science and technology has come a long way in recent years. Now with various
techniques you can retain your beauty and can also get your skin renewed. Skin renewal isn’t a new technique but it got a massive boom with the emergence of IPL Photofacials.
Intense Pulsed Light (IPL) Photofacials has taken the medical world with a stride as now it has been used regularly by many people. Anyone who wishes to put full stop to the increasing age, simply go for skin renewal via IPL Photofacials.
IPL Photofacials can effectively treat various body parts and damages such as sun
damage, age spots or sun-induced freckles, broken capillaries, telangiectasias, and benign brown pigments. All these problems are effectively treated with no side effects.
IPL Photofacial has emerged as the most exciting technology in today’s aesthetic
environment. It not just corrects various skin conditions and facial imperfections but actually reverse them all.
This skin renewal treatment is different from laser procedure as it is a carefully tested and perfected therapy providing long-term improvement. This long-term improvement is not restricted to the complexion but also to texture of an entire area. FDA approved IPL Photofacials effectively treats the skin and eliminate all signs of aging. This skin renewal treatment is very easy to undergo as the emitted pulsed light eliminates all age spots,freckles, broken capillaries, and signs of rosacea. Apart from that it simultaneously stimulates collagen production.
The biggest advantage of IPL Photofacials is that you can experience the changes within a few treatments. You will see smoother and firmer skin, marking a significant decrease in fine lines and light wrinkles. Now you don’t have to suffer long periods of healing, prolonged redness and discomfort while renewing your skin. IPL Photofacials can be easily and effectively performed on any area you desire such as hands, chest and neck.
With the help of IPL Photofacials treatment you can curb the signs of aging by reducing fine lines and scars, thinning of enlarged pores, reducing sun damage and photo-aging, eliminating the redness, flushing and appearance of rosacea, and many more. If you wish to go for skin renewal, Advanced Laser Clinics is there at your service. Advanced Laser Clinics is the one stop shop for all your skin queries and problems.
To treat your skin effectively, Advanced Laser Clinics customize a treatment program for you. This treatment program is crafted as per your specific wants, needs and desired results. This will determine the number of treatment you’ll be undergoing. All the treatments offered at Advanced Laser Clinics are provided by highly-trained & professional technicians. Hence, if you wish to stop your age or want to know more about IPL Photofacials or light pulse skin renewal, skin renewal, and photo rejuvenation skin care, just click at www.advancedlaserskin.com.

AGE SPOTS REMOVAL TREATMENTS

2008-12-10T18:49:00.000-08:00

Age spots removal is the biggest concern for the people touching their 40s. Being a telltale sign of one’s age, majority people look for the ways to treat and reduce them.
Also known as liver spots, sun spots, or lentigines, they are usually flat, harmless brown skin discolorations occurring on hands, face and neck.
Age spots are mainly caused by over exposure to the sun for many years, and it can only be cut down by using sunscreen regularly. They are flat, harmless patches of increased pigment, like freckles that increase in number as we get older. The only question that pops up is - should we worry about it? The answer can be yes as well as no.
Though cosmetically worrisome, age spots aren’t that threatening and do not need to be treated. Moreover, it is not a coincidence that age spots normally appear on the backs of hands and necks, forearms and the face. In short, all those body parts that receive the maximum sun exposure. According to the experts, age spots are a reflection of considerable sun damage. They can be easily repaired by age spots removal treatment. Excessive sun damage which is not treated on time means there is an increased risk for skin cancer.
You will be amazed to know that skin cancer is the most common form of cancer. It has affected one in seven Americans. But if it is caught early and treated by age spot removal treatment, it has shown 90 percent cure rate. Age spots can be divided into three types of carcinomas. Those are basal cell (the most common), squamous cell and melanoma, the deadliest form. There is a misconception that melanoma is a raised bump. This is partially true as it can also be flat. ‘Prevention is better than cure’, this quote may be cliché but is the best step taken.
If you wish to avoid age spots removal treatment then the only option you have is
protection from sun. Try to cut down sun exposure by wearing protective clothing
accompanied with your sunscreen. But this does not mean you can stay out in the sun
twice as long. You need to apply sunscreen regularly and also after swimming. When we talk about protective clothing, you can find some of the new high-tech materials offering SPF protection. This type of clothes contains brighteners and resigns that easily absorb ultra violet, or UV, light.
Age spots removal is the most common treatment available at various skin care
centers but it’s Advanced Laser Clinics that heads the list. Advanced Laser Clinics is Chicago’s best skin care clinic offering various treatments. If you wish to revitalize your skin or want to know more about age spot removal, laser removal age spots, and skin renewal, just click www.advancedlaserskin.com.