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Dermatology - Nail Findings of Lichen Planus
Approximately 10% of persons with disseminated lichen planus experience nail involvement, which can result in the destruction of the nails. In other cases, nail lesions may be the sole indication of the condition. The condition known as "twenty-nail syndrome" refers to the involvement of one, few, or all 20 nails, resulting in the loss of all nails without any other signs of lichen planus elsewhere on the body.
Onychorrhexis, characterized by longitudinal ridging and fissuring of the nail plate resulting in brittleness and breakage, is observed. However, it should be noted that this is not a distinctive feature and can also occur as a result of aging. Similar alterations occur in lichenoid graft-versus-host disease. Swelling and blue/red staining of the proximal nail fold are observed on the skin's dorsum.
A minor concentration may be observed in the matrix, manifesting as a protrusion beneath the proximal nail fold and a following vertical red line: The nail plate becomes thinner and develops a split at the distal end, a condition known as onychorrhexis. Matrix involvement refers to the scattered and specific degeneration of the nail plate, characterized by onychorrhexis (nail splitting) and/or transverse splitting. A red lunula can be either localized or widespread, and temporary longitudinal melanonychia may occur. There is a possibility of a total nail fracture. Pterygium development refers to the partial loss of the central nail plate, resulting in the destruction of the underlying matrix. This condition is characterized by a V-shaped extension of skin from the proximal nail fold that is firmly attached to the nail bed. The rapid and ongoing destruction of the nails, resulting in widespread nail shrinkage with or without the formation of a fold of skin over the nail (pterygium), ultimately leads to the total absence of nails (anonychia). Ulcerative lichen planus is characterized by the presence of bullae, erosions, bleeding, and scarring. In this variant, skin lesions typically occur on the palms and soles.
The disease has different forms, such as 20-nail dystrophy of childhood, which goes away on its own; lichen planus-like eruptions that occur after a bone marrow transplant in graft-versus-host disease; drug-induced reactions that resemble lichen planus, and permanent anonychia as the sole manifestation of lichen planus.
Observation of the physical manifestation and presence of LP lesions in other areas of the body. The differential diagnosis include all nail illnesses characterized by destruction, such as psoriasis, Darier disease, and onychomycosis.
Manage nail lesions by using intralesional triamcinolone and systemic glucocorticoids.
Approximately 10% of persons with disseminated lichen planus experience nail involvement, which can result in the destruction of the nails. In other cases, nail lesions may be the sole indication of the condition. The condition known as "twenty-nail syndrome" refers to the involvement of one, few, or all 20 nails, resulting in the loss of all nails without any other signs of lichen planus elsewhere on the body.
Onychorrhexis, characterized by longitudinal ridging and fissuring of the nail plate resulting in brittleness and breakage, is observed. However, it should be noted that this is not a distinctive feature and can also occur as a result of aging. Similar alterations occur in lichenoid graft-versus-host disease. Swelling and blue/red staining of the proximal nail fold are observed on the skin's dorsum.
A minor concentration may be observed in the matrix, manifesting as a protrusion beneath the proximal nail fold and a following vertical red line: The nail plate becomes thinner and develops a split at the distal end, a condition known as onychorrhexis. Matrix involvement refers to the scattered and specific degeneration of the nail plate, characterized by onychorrhexis (nail splitting) and/or transverse splitting. A red lunula can be either localized or widespread, and temporary longitudinal melanonychia may occur. There is a possibility of a total nail fracture. Pterygium development refers to the partial loss of the central nail plate, resulting in the destruction of the underlying matrix. This condition is characterized by a V-shaped extension of skin from the proximal nail fold that is firmly attached to the nail bed. The rapid and ongoing destruction of the nails, resulting in widespread nail shrinkage with or without the formation of a fold of skin over the nail (pterygium), ultimately leads to the total absence of nails (anonychia). Ulcerative lichen planus is characterized by the presence of bullae, erosions, bleeding, and scarring. In this variant, skin lesions typically occur on the palms and soles.
The disease has different forms, such as 20-nail dystrophy of childhood, which goes away on its own; lichen planus-like eruptions that occur after a bone marrow transplant in graft-versus-host disease; drug-induced reactions that resemble lichen planus, and permanent anonychia as the sole manifestation of lichen planus.
Observation of the physical manifestation and presence of LP lesions in other areas of the body. The differential diagnosis include all nail illnesses characterized by destruction, such as psoriasis, Darier disease, and onychomycosis.
Manage nail lesions by using intralesional triamcinolone and systemic glucocorticoids.
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Dermatology - Meningococcemia
Neisseria meningitides establishes itself in the human nasopharynx and is transmitted from one person to another through respiratory droplets.
The symptoms of meningococcal meningitis are characteristic of bacterial meningitis, including fever, headache, neck stiffness, and the presence of polymorphonuclear leukocytes (PMNs) in the cerebrospinal fluid.
Abnormalities
Shortly after the condition begins, there are small, pink spots and raised areas on the skin that can turn white when pressed. Petechiae and ecchymoses are observed on the ankles, wrists, axillae, mucosal surfaces, and conjunctivae due to vascular fragility and bleeding. Petechiae may form in clusters at areas of pressure, whereas ecchymoses and purpura might develop into hemorrhagic bullae, experience necrosis, and eventually ulcerate. Purpura fulminans, in extreme instances, manifests as irregularly shaped, merging necrotic hemorrhagic lesions that appear grayish to black. Fulminant disease may exhibit disseminated intravascular coagulation. Patients may develop sepsis, a potentially life-threatening condition characterized by a systemic infection. Additionally, they may experience peripheral gangrene, a condition where tissue in the extremities dies due to reduced blood flow. Waterhouse-Friderichsen syndrome is an acute and severe form of meningococcal septicemia. It is marked by symptoms such as high fever, shock, extensive purpura (purple discoloration of the skin), disseminated intravascular coagulation (abnormal blood clotting throughout the body), thrombocytopenia (low platelet count), and adrenal insufficiency (inadequate functioning of the adrenal glands).
A conclusive diagnosis necessitates the isolation of meningococci from either the bloodstream or the specific location of illness. The differential diagnosis encompasses adverse cutaneous drug eruptions, vasculitis, Rocky Mountain spotted fever, and infective endocarditis.
Administer third-generation cephalosporins (ceftriaxone or cefotaxime) as the initial treatment.
If the strain is susceptible, possible alternatives include penicillin G, ampicillin, fluoroquinolone, or aztreonam. The typical period of therapy is 7 days. For people with a strong allergy to penicillin, it is recommended to administer chloramphenicol (1 g IV every 6 hours) instead of taking the risk of experiencing cross-reactions with a third-generation cephalosporin. Administer supportive care measures to safeguard the functionality of affected organs.
Neisseria meningitides establishes itself in the human nasopharynx and is transmitted from one person to another through respiratory droplets.
The symptoms of meningococcal meningitis are characteristic of bacterial meningitis, including fever, headache, neck stiffness, and the presence of polymorphonuclear leukocytes (PMNs) in the cerebrospinal fluid.
Abnormalities
Shortly after the condition begins, there are small, pink spots and raised areas on the skin that can turn white when pressed. Petechiae and ecchymoses are observed on the ankles, wrists, axillae, mucosal surfaces, and conjunctivae due to vascular fragility and bleeding. Petechiae may form in clusters at areas of pressure, whereas ecchymoses and purpura might develop into hemorrhagic bullae, experience necrosis, and eventually ulcerate. Purpura fulminans, in extreme instances, manifests as irregularly shaped, merging necrotic hemorrhagic lesions that appear grayish to black. Fulminant disease may exhibit disseminated intravascular coagulation. Patients may develop sepsis, a potentially life-threatening condition characterized by a systemic infection. Additionally, they may experience peripheral gangrene, a condition where tissue in the extremities dies due to reduced blood flow. Waterhouse-Friderichsen syndrome is an acute and severe form of meningococcal septicemia. It is marked by symptoms such as high fever, shock, extensive purpura (purple discoloration of the skin), disseminated intravascular coagulation (abnormal blood clotting throughout the body), thrombocytopenia (low platelet count), and adrenal insufficiency (inadequate functioning of the adrenal glands).
A conclusive diagnosis necessitates the isolation of meningococci from either the bloodstream or the specific location of illness. The differential diagnosis encompasses adverse cutaneous drug eruptions, vasculitis, Rocky Mountain spotted fever, and infective endocarditis.
Administer third-generation cephalosporins (ceftriaxone or cefotaxime) as the initial treatment.
If the strain is susceptible, possible alternatives include penicillin G, ampicillin, fluoroquinolone, or aztreonam. The typical period of therapy is 7 days. For people with a strong allergy to penicillin, it is recommended to administer chloramphenicol (1 g IV every 6 hours) instead of taking the risk of experiencing cross-reactions with a third-generation cephalosporin. Administer supportive care measures to safeguard the functionality of affected organs.
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Dermatology - Stevens-Johnson Syndrome (SJS) and Toxic Epidermal Necrolysis (TEN)
SJS and toxic TEN are both severe and potentially fatal mucocutaneous reactions marked by widespread necrosis and separation of the epidermis. SJS and TEN are different forms of the same disease, which might be caused by unknown factors or drugs. The main difference between them is the extent to which the body surface is affected.
The interval between initial drug exposure and the appearance of symptoms typically ranges from 1 to 3 weeks, but this is more frequently observed with subsequent exposure. Prior to the eruption, there is commonly a prodrome characterized by fever, malaise, and arthralgia that typically lasts for 1-3 days. Malnutrition, sensitivity to light, uncomfortable urination, and anxiety may manifest.
Abnormalities
The individual experiences a mild to moderate sensation of tenderness in the skin, along with a burning or itchy feeling in the conjunctiva. This is followed by skin pain, a burning sensation, tenderness, and paresthesia. Oral ulcers cause significant discomfort and sensitivity. The initial rash is characterized by a morbilliform appearance and may exhibit target-like patterns, with or without the presence of purplish discoloration. The lesions quickly merge together; alternatively, there may be no distinct lesions, but instead a widespread redness and absence of a rash. As the rash advances, the outer layer of the skin undergoes necrosis, resulting in wrinkled patches that grow in size and merge together. Subsequently, there is a detachment of the outer layer of the skin, known as the epidermis, in a sheet-like manner. This is accompanied by the formation of soft and raised blisters that can spread when pressure is applied sideways (known as the Nikolsky sign) on reddened parts of the skin. Following trauma, the skin experiences a complete separation of the outermost layer, resulting in the exposure of the underlying dermis. This exposed dermis appears red and is accompanied by leaking, similar to a second-degree burn caused by heat. The lips, buccal mucosa, conjunctiva, and vaginal and anal skin are consistently affected. The eyes exhibit conjunctival diseases characterized by hyperemia, pseudomembrane development, keratitis, corneal erosions, and subsequent adhesions between the eyelids and bulbar conjunctiva.
The differential diagnosis comprises drug eruptions, erythema multiforme, scarlet fever, phototoxic eruptions, toxic shock syndrome, graft-versus-host disease, thermal burns, staphylococcal scalded-skin syndrome (rare in adults but present in young children), fixed drug eruption, and exfoliative dermatitis.
Prompt identification and cessation of potentially implicated medication(s) are of utmost significance. Patients receive optimal care in an intermediate or intensive care unit. Administer IV fluids and electrolytes in a manner consistent with patients suffering from a severe third-degree heat burn. However, a smaller amount of fluid is typically needed for a thermal burn of same size. Administering systemic glucocorticoids during the onset of the disease can be beneficial in minimizing the occurrence of illness or death, particularly when given in large quantities. In the advanced stages of the condition, they are not recommended. Administering a large amount of immunoglobulin through an intravenous route during the initial phases.
It is not advisable to have surgical debridement.
Early treatment of ocular lesions with erythromycin ointment is recommended.
SJS and toxic TEN are both severe and potentially fatal mucocutaneous reactions marked by widespread necrosis and separation of the epidermis. SJS and TEN are different forms of the same disease, which might be caused by unknown factors or drugs. The main difference between them is the extent to which the body surface is affected.
The interval between initial drug exposure and the appearance of symptoms typically ranges from 1 to 3 weeks, but this is more frequently observed with subsequent exposure. Prior to the eruption, there is commonly a prodrome characterized by fever, malaise, and arthralgia that typically lasts for 1-3 days. Malnutrition, sensitivity to light, uncomfortable urination, and anxiety may manifest.
Abnormalities
The individual experiences a mild to moderate sensation of tenderness in the skin, along with a burning or itchy feeling in the conjunctiva. This is followed by skin pain, a burning sensation, tenderness, and paresthesia. Oral ulcers cause significant discomfort and sensitivity. The initial rash is characterized by a morbilliform appearance and may exhibit target-like patterns, with or without the presence of purplish discoloration. The lesions quickly merge together; alternatively, there may be no distinct lesions, but instead a widespread redness and absence of a rash. As the rash advances, the outer layer of the skin undergoes necrosis, resulting in wrinkled patches that grow in size and merge together. Subsequently, there is a detachment of the outer layer of the skin, known as the epidermis, in a sheet-like manner. This is accompanied by the formation of soft and raised blisters that can spread when pressure is applied sideways (known as the Nikolsky sign) on reddened parts of the skin. Following trauma, the skin experiences a complete separation of the outermost layer, resulting in the exposure of the underlying dermis. This exposed dermis appears red and is accompanied by leaking, similar to a second-degree burn caused by heat. The lips, buccal mucosa, conjunctiva, and vaginal and anal skin are consistently affected. The eyes exhibit conjunctival diseases characterized by hyperemia, pseudomembrane development, keratitis, corneal erosions, and subsequent adhesions between the eyelids and bulbar conjunctiva.
The differential diagnosis comprises drug eruptions, erythema multiforme, scarlet fever, phototoxic eruptions, toxic shock syndrome, graft-versus-host disease, thermal burns, staphylococcal scalded-skin syndrome (rare in adults but present in young children), fixed drug eruption, and exfoliative dermatitis.
Prompt identification and cessation of potentially implicated medication(s) are of utmost significance. Patients receive optimal care in an intermediate or intensive care unit. Administer IV fluids and electrolytes in a manner consistent with patients suffering from a severe third-degree heat burn. However, a smaller amount of fluid is typically needed for a thermal burn of same size. Administering systemic glucocorticoids during the onset of the disease can be beneficial in minimizing the occurrence of illness or death, particularly when given in large quantities. In the advanced stages of the condition, they are not recommended. Administering a large amount of immunoglobulin through an intravenous route during the initial phases.
It is not advisable to have surgical debridement.
Early treatment of ocular lesions with erythromycin ointment is recommended.
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Dermatology - Nodular Melanoma
Nodular melanoma (NM) is the second most prevalent type of melanoma in individuals with light skin. It primarily affects middle-aged individuals and tends to develop on parts of the body that receive less sun exposure. Initially, this tumor undergoes vertical development, specifically affecting the dermis. For unexplained reasons, NM is significantly more prevalent among individuals of Japanese heritage, occurring eight times more frequently than superficial spreading melanoma.
Nodular melanoma (NM) can originate from a preexisting nevus, but it is more frequently developed from normal skin without any prior conditions. It typically progresses over a few months and is often identified by the patient as a new growth resembling a mole.
Abnormalities
The lesion is a consistently raised, thick plaque or a protruding, polypoid, or dome-shaped growth, typically exhibiting smooth and regular boundaries. The color pattern typically lacks variation, with the lesion appearing consistently blue or blue-black. In rare cases, it may be mildly pigmented or completely nonpigmented (amelanotic melanoma). Nodular melanoma (NM) is a kind of primary melanoma that develops quickly (between a few months to 2 years) from normal skin or a melanocytic nevus. It grows vertically without an adjacent epidermal component, which is always seen in lentigo maligna melanoma and superficial spreading melanoma. Initial lesions have a size ranging from 1 to 3 cm, however they can significantly increase in size if not discovered.
The diagnosis is made through a clinical assessment, which is then confirmed with dermoscopy and/or biopsy. Performing a complete excisional biopsy with minimal margins is the most effective approach. If the biopsy results are positive, it is necessary to perform a reexcision. Incisional or punch biopsy is a suitable alternative when it is not possible to do a complete excisional biopsy or when the lesion is large and would require considerable surgery to remove it entirely. The differential diagnosis for blue/black lesions includes hemangioma (with a long history), pyogenic granuloma, and pigmented basal cell cancer. Any newly formed nodule like a blueberry should be surgically removed or, if it is of significant size, subjected to a biopsy.
The treatment involves surgically removing tissue down to the fascia. To guarantee proper treatment for lesions that are less than 1 mm thick, it is important to have a margin of 1 cm from the edges of the lesion. Biopsy of lymph nodes should only be performed if the nodes can be felt or detected through touch. For lesions that are larger than 1 mm in thickness, it is important to have a 2-cm margin and do a biopsy of the sentinel lymph nodes. Proceed with excision followed by immediate closure or repair using skin grafts. Perform lymphadenectomy exclusively for nodal basins that contain hidden tumor cells or if the nodes are clinically detectable and show signs of potential tumor presence. Adjuvant therapy should be considered in cases where there is a danger of recurrence, such as when there are positive regional lymph nodes or the cancer is in an advanced stage.
Nodular melanoma (NM) is the second most prevalent type of melanoma in individuals with light skin. It primarily affects middle-aged individuals and tends to develop on parts of the body that receive less sun exposure. Initially, this tumor undergoes vertical development, specifically affecting the dermis. For unexplained reasons, NM is significantly more prevalent among individuals of Japanese heritage, occurring eight times more frequently than superficial spreading melanoma.
Nodular melanoma (NM) can originate from a preexisting nevus, but it is more frequently developed from normal skin without any prior conditions. It typically progresses over a few months and is often identified by the patient as a new growth resembling a mole.
Abnormalities
The lesion is a consistently raised, thick plaque or a protruding, polypoid, or dome-shaped growth, typically exhibiting smooth and regular boundaries. The color pattern typically lacks variation, with the lesion appearing consistently blue or blue-black. In rare cases, it may be mildly pigmented or completely nonpigmented (amelanotic melanoma). Nodular melanoma (NM) is a kind of primary melanoma that develops quickly (between a few months to 2 years) from normal skin or a melanocytic nevus. It grows vertically without an adjacent epidermal component, which is always seen in lentigo maligna melanoma and superficial spreading melanoma. Initial lesions have a size ranging from 1 to 3 cm, however they can significantly increase in size if not discovered.
The diagnosis is made through a clinical assessment, which is then confirmed with dermoscopy and/or biopsy. Performing a complete excisional biopsy with minimal margins is the most effective approach. If the biopsy results are positive, it is necessary to perform a reexcision. Incisional or punch biopsy is a suitable alternative when it is not possible to do a complete excisional biopsy or when the lesion is large and would require considerable surgery to remove it entirely. The differential diagnosis for blue/black lesions includes hemangioma (with a long history), pyogenic granuloma, and pigmented basal cell cancer. Any newly formed nodule like a blueberry should be surgically removed or, if it is of significant size, subjected to a biopsy.
The treatment involves surgically removing tissue down to the fascia. To guarantee proper treatment for lesions that are less than 1 mm thick, it is important to have a margin of 1 cm from the edges of the lesion. Biopsy of lymph nodes should only be performed if the nodes can be felt or detected through touch. For lesions that are larger than 1 mm in thickness, it is important to have a 2-cm margin and do a biopsy of the sentinel lymph nodes. Proceed with excision followed by immediate closure or repair using skin grafts. Perform lymphadenectomy exclusively for nodal basins that contain hidden tumor cells or if the nodes are clinically detectable and show signs of potential tumor presence. Adjuvant therapy should be considered in cases where there is a danger of recurrence, such as when there are positive regional lymph nodes or the cancer is in an advanced stage.
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Dermatology - Genital Human Papilloma Virus (HPV) Infection
The majority of sexually active individuals have subclinical HPV infections, and approximately 1% of sexually active adults between the ages of 15 and 19 acquire lesions. The infection has the ability to remain inactive for extended periods of time and can become contagious periodically. An emerging vaccination targeting certain strains of HPV has the potential to reduce the occurrence of HPV-induced cancer.
The dysplasia of the anogenital and oral skin and mucosa varies in severity from minor to severe.
Warts have the potential to progress into squamous cell cancer. Recurrences typically arise from reactivation rather than reinfection. During pregnancy, warts may have an augmentation in both size and quantity, exhibit heightened vaginal involvement, and demonstrate an elevated incidence of secondary bacterial infection.
Children born through the vaginal canal to moms with genital HPV infection are susceptible to developing recurrent respiratory papillomatosis.
Abnormalities
The lesions, known as condylomata acuminata, vary in appearance from little papules to larger nodules or even merging masses. They can be found on the skin or mucous membranes of the anogenital area, as well as the oral mucosa, including the external genitalia, perineum, cervix, and oropharynx. The lesions can appear in various colors such as skin-colored, pink, red, tan, or brown. They can be either solitary, dispersed, or isolated, or they might form large, merging clusters.
The diagnosis is primarily based on clinical evaluation, and in some cases, it may be further validated with a biopsy. The differential diagnosis includes various conditions, such as normal anatomical variations (sebaceous glands, pearly penile papules, vestibular papillae), squamous cell carcinoma, benign tumors (moles, seborrheic keratoses, skin tags, pilar cyst, angiokeratoma), inflammatory skin diseases (lichen nitidus, lichen planus), molluscum contagiosum, condylomata lata, folliculitis, and scabietic nodules.
There is currently no therapy that has been proven to completely eliminate HPV or effectively prevent cervical or anogenital cancer.
Optimal treatment outcomes are more likely when warts are of diminutive size and have been present for less than one year. Treatment options are determined based on the specific requirements of the patient, with the aim of avoiding costly, harmful therapies, as well as procedures that may lead to scarring. The use of Imiquimod 5% cream or podophylox 0.5% solution by the patient is both efficacious and feasible. Cryosurgery, intralesional podophyllin (10-25%), trichloroacetic acid (80-90%), surgical removal, and electrodesiccation are all viable possibilities for treatment.
The majority of sexually active individuals have subclinical HPV infections, and approximately 1% of sexually active adults between the ages of 15 and 19 acquire lesions. The infection has the ability to remain inactive for extended periods of time and can become contagious periodically. An emerging vaccination targeting certain strains of HPV has the potential to reduce the occurrence of HPV-induced cancer.
The dysplasia of the anogenital and oral skin and mucosa varies in severity from minor to severe.
Warts have the potential to progress into squamous cell cancer. Recurrences typically arise from reactivation rather than reinfection. During pregnancy, warts may have an augmentation in both size and quantity, exhibit heightened vaginal involvement, and demonstrate an elevated incidence of secondary bacterial infection.
Children born through the vaginal canal to moms with genital HPV infection are susceptible to developing recurrent respiratory papillomatosis.
Abnormalities
The lesions, known as condylomata acuminata, vary in appearance from little papules to larger nodules or even merging masses. They can be found on the skin or mucous membranes of the anogenital area, as well as the oral mucosa, including the external genitalia, perineum, cervix, and oropharynx. The lesions can appear in various colors such as skin-colored, pink, red, tan, or brown. They can be either solitary, dispersed, or isolated, or they might form large, merging clusters.
The diagnosis is primarily based on clinical evaluation, and in some cases, it may be further validated with a biopsy. The differential diagnosis includes various conditions, such as normal anatomical variations (sebaceous glands, pearly penile papules, vestibular papillae), squamous cell carcinoma, benign tumors (moles, seborrheic keratoses, skin tags, pilar cyst, angiokeratoma), inflammatory skin diseases (lichen nitidus, lichen planus), molluscum contagiosum, condylomata lata, folliculitis, and scabietic nodules.
There is currently no therapy that has been proven to completely eliminate HPV or effectively prevent cervical or anogenital cancer.
Optimal treatment outcomes are more likely when warts are of diminutive size and have been present for less than one year. Treatment options are determined based on the specific requirements of the patient, with the aim of avoiding costly, harmful therapies, as well as procedures that may lead to scarring. The use of Imiquimod 5% cream or podophylox 0.5% solution by the patient is both efficacious and feasible. Cryosurgery, intralesional podophyllin (10-25%), trichloroacetic acid (80-90%), surgical removal, and electrodesiccation are all viable possibilities for treatment.
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Dermatology - Anogenital Region Malignant Melanoma
Although malignant melanoma of the anogenital region is uncommon, the prognosis is unfavorable due to early metastasis through lymphatic veins. Moreover, due to the lack of regular examination of the anogenital region for precancerous and cancerous abnormalities, the diagnosis is frequently delayed until the disease has progressed significantly.
The presence of macules or papules displaying a mixture of brown-black color, uneven boundaries, and frequently accompanied by raised papular elevation or ulceration. In males, lesions are predominantly found on the glans (67%), prepuce (13%), urethral meatus (10%), penile shaft (7%), and coronal sulcus (3%). In females, lesions are primarily seen on the labia minora and clitoris.
The diagnosis is established through clinical examination and further validated by doing a biopsy of the affected area. Complete excisional biopsy with limited margins is the most favorable approach, while incisional or punch biopsy is acceptable in cases where complete excisional biopsy is not feasible. Avoid utilizing shave biopsy since it does not accurately indicate the extent of invasion. The possible causes for the condition are genital lentiginosis, old fixed drug eruption, squamous cell carcinoma (SCC), hemangioma, and intraepithelial neoplasia (Bowenoid papulosis).
The treatment involves the complete removal of tissue down to the fascia. When dealing with lesions that are less than 1 mm thick, it is important to have margins of 1 cm from the edges of the lesion. Biopsy of lymph nodes should only be done if the nodes can be felt. For lesions that are larger than 1 mm in thickness, it is important to have a margin of 2 cm and do a biopsy of the sentinel lymph nodes. Proceed with excision followed by immediate closure or repair using skin grafts. Perform lymphadenectomy exclusively for nodal basins exhibiting occult tumor cells or in cases where nodes are clinically palpable and display suspicious characteristics indicative of tumor presence. Adjuvant therapy should be considered in cases where there is a danger of recurrence, such as when there are positive regional lymph nodes or the cancer is in an advanced stage.
Although malignant melanoma of the anogenital region is uncommon, the prognosis is unfavorable due to early metastasis through lymphatic veins. Moreover, due to the lack of regular examination of the anogenital region for precancerous and cancerous abnormalities, the diagnosis is frequently delayed until the disease has progressed significantly.
The presence of macules or papules displaying a mixture of brown-black color, uneven boundaries, and frequently accompanied by raised papular elevation or ulceration. In males, lesions are predominantly found on the glans (67%), prepuce (13%), urethral meatus (10%), penile shaft (7%), and coronal sulcus (3%). In females, lesions are primarily seen on the labia minora and clitoris.
The diagnosis is established through clinical examination and further validated by doing a biopsy of the affected area. Complete excisional biopsy with limited margins is the most favorable approach, while incisional or punch biopsy is acceptable in cases where complete excisional biopsy is not feasible. Avoid utilizing shave biopsy since it does not accurately indicate the extent of invasion. The possible causes for the condition are genital lentiginosis, old fixed drug eruption, squamous cell carcinoma (SCC), hemangioma, and intraepithelial neoplasia (Bowenoid papulosis).
The treatment involves the complete removal of tissue down to the fascia. When dealing with lesions that are less than 1 mm thick, it is important to have margins of 1 cm from the edges of the lesion. Biopsy of lymph nodes should only be done if the nodes can be felt. For lesions that are larger than 1 mm in thickness, it is important to have a margin of 2 cm and do a biopsy of the sentinel lymph nodes. Proceed with excision followed by immediate closure or repair using skin grafts. Perform lymphadenectomy exclusively for nodal basins exhibiting occult tumor cells or in cases where nodes are clinically palpable and display suspicious characteristics indicative of tumor presence. Adjuvant therapy should be considered in cases where there is a danger of recurrence, such as when there are positive regional lymph nodes or the cancer is in an advanced stage.
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Dermatology - Lichen Planus
Lichen planus is a rare skin condition that affects fewer than one percent of the global population and is characterized by acute or chronic inflammation of the skin. The age at which symptoms first appear is typically between 30 and 60 years, and the occurrence of the condition is more frequent in women. The cause of this condition is usually unknown, however cell-mediated immunity can have a significant impact.
The onset can be either abrupt (occurring within a few days) or gradual (taking place over several weeks), and the lesions persist for a duration of months to years.
Lesions can either be without symptoms or cause itching, and lesions on the mucous membranes are particularly unpleasant, especially if they are ulcerated. Postinflammatory hyperpigmentation is a frequent occurrence. Lesions may appear on the lips and in a linear pattern following trauma, known as the Koebner or isomorphic phenomena.
Abnormalities
Manifesting as papules ranging from 1 to 10 mm in diameter, this condition is distinguished by its shiny, pruritic, polygonal appearance, with colors ranging from pink to purple. Lesions in the flexural aspects of extremities sometimes have a generalized pattern, appearing as clustered, annular, or diffused scattered isolated lesions. Oral lesions are uncomfortable, characterized by milky-white reticulated papules that have the potential to develop erosions and ulcers.
Wickham striae can frequently be observed with a hand lens. The different variations include hypertrophic, atrophic, follicular, reticular, vesicular, pigmented, nail, and genital manifestations.
The diagnosis is determined through clinical examination and verified by doing a biopsy of the affected area. The differential diagnosis comprises lupus, psoriasis, pityriasis rosea, atopic dermatitis, basal cell carcinoma, squamous cell carcinoma in situ, lichen simplex chronicus, prurigo nodularis, stasis dermatitis, and Kaposi sarcoma.
Apply topical glucocorticoids with occlusion for skin lesions, provide intralesional triamcinolone (3 mg/mL) for lesions in the mouth and lips, and use cyclosporine and tacrolimus solutions as a mouthwash for very symptomatic oral lesions.
Systemic
For very resistant and widespread cases, a daily oral dose of 5 mg/kg of cyclosporine can effectively bring about a quick improvement in symptoms, with a minimal likelihood of the condition returning. Oral prednisone is beneficial for those experiencing symptomatic pruritus, painful erosions, dysphagia, or cosmetic deformity.
An abbreviated, gradually decreasing regimen is preferred: 70 mg initially, decreased by 5 mg per day. Retinoids, specifically Acitretin, at a dosage of 1 mg/kg per day, can be beneficial as a supplementary treatment in severe instances. However, additional topical treatment is necessary. Photochemotherapy can be beneficial for those who do not respond well to both topical and systemic treatments.
Lichen planus is a rare skin condition that affects fewer than one percent of the global population and is characterized by acute or chronic inflammation of the skin. The age at which symptoms first appear is typically between 30 and 60 years, and the occurrence of the condition is more frequent in women. The cause of this condition is usually unknown, however cell-mediated immunity can have a significant impact.
The onset can be either abrupt (occurring within a few days) or gradual (taking place over several weeks), and the lesions persist for a duration of months to years.
Lesions can either be without symptoms or cause itching, and lesions on the mucous membranes are particularly unpleasant, especially if they are ulcerated. Postinflammatory hyperpigmentation is a frequent occurrence. Lesions may appear on the lips and in a linear pattern following trauma, known as the Koebner or isomorphic phenomena.
Abnormalities
Manifesting as papules ranging from 1 to 10 mm in diameter, this condition is distinguished by its shiny, pruritic, polygonal appearance, with colors ranging from pink to purple. Lesions in the flexural aspects of extremities sometimes have a generalized pattern, appearing as clustered, annular, or diffused scattered isolated lesions. Oral lesions are uncomfortable, characterized by milky-white reticulated papules that have the potential to develop erosions and ulcers.
Wickham striae can frequently be observed with a hand lens. The different variations include hypertrophic, atrophic, follicular, reticular, vesicular, pigmented, nail, and genital manifestations.
The diagnosis is determined through clinical examination and verified by doing a biopsy of the affected area. The differential diagnosis comprises lupus, psoriasis, pityriasis rosea, atopic dermatitis, basal cell carcinoma, squamous cell carcinoma in situ, lichen simplex chronicus, prurigo nodularis, stasis dermatitis, and Kaposi sarcoma.
Apply topical glucocorticoids with occlusion for skin lesions, provide intralesional triamcinolone (3 mg/mL) for lesions in the mouth and lips, and use cyclosporine and tacrolimus solutions as a mouthwash for very symptomatic oral lesions.
Systemic
For very resistant and widespread cases, a daily oral dose of 5 mg/kg of cyclosporine can effectively bring about a quick improvement in symptoms, with a minimal likelihood of the condition returning. Oral prednisone is beneficial for those experiencing symptomatic pruritus, painful erosions, dysphagia, or cosmetic deformity.
An abbreviated, gradually decreasing regimen is preferred: 70 mg initially, decreased by 5 mg per day. Retinoids, specifically Acitretin, at a dosage of 1 mg/kg per day, can be beneficial as a supplementary treatment in severe instances. However, additional topical treatment is necessary. Photochemotherapy can be beneficial for those who do not respond well to both topical and systemic treatments.
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Dermatology - Black or White Hairy Tongue
Black or white hairy tongue occurs due to an abnormal shedding process of filiform papillae, leading to the formation of hair-like projections on the upper surface of the tongue. It is linked to frequent tobacco consumption, breathing via the mouth, using antibiotics that affect the whole body, inadequate dental hygiene, overall weakness, undergoing radiation therapy, and long-term usage of antacids containing bismuth.
Patients experience a sensation of gagging, changes in taste, bad breath, and cosmetic deformity.
The dorsal tongue is covered with hairy patches, and the tongue can be discolored white, yellow, green, brown, or black due to the presence of chromogenic bacteria or external pigments. Secondary candidiasis may arise.
The diagnosis is based on clinical assessment, with the aim of excluding any underlying diseases.
Mitigate underlying issues and advise patients to maintain optimal dental hygiene.
Black or white hairy tongue occurs due to an abnormal shedding process of filiform papillae, leading to the formation of hair-like projections on the upper surface of the tongue. It is linked to frequent tobacco consumption, breathing via the mouth, using antibiotics that affect the whole body, inadequate dental hygiene, overall weakness, undergoing radiation therapy, and long-term usage of antacids containing bismuth.
Patients experience a sensation of gagging, changes in taste, bad breath, and cosmetic deformity.
The dorsal tongue is covered with hairy patches, and the tongue can be discolored white, yellow, green, brown, or black due to the presence of chromogenic bacteria or external pigments. Secondary candidiasis may arise.
The diagnosis is based on clinical assessment, with the aim of excluding any underlying diseases.
Mitigate underlying issues and advise patients to maintain optimal dental hygiene.
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Dermatology - Squamous Cell Carcinoma of the Perineum
The development of squamous cell carcinoma in the perineum is attributed to infection by the human papilloma virus, as well as chronic low-grade balanoposthitis and chronic dermatoses such as ulcerative lichen planus and lichen sclerosus.
Pruritus, ulceration, and precursor lesions may be observed.
The penis, vulva, and anogenital region have distinct, isolated, irregularly shaped patches, papules, or plaques that are either red or white. These patches have a smooth or velvety surface and are characterized by excessive keratinization. Penile lesions may exhibit slight hardening and can be accompanied by tissue death or a secondary infection in the tight foreskin. Vulvar lesions can manifest as either bulky and white growths or as pigmented areas of thickened or hardened skin. The individual may experience pain, discharge, difficulty urinating, bleeding, and the formation of ulcers in a specific area.
The diagnosis is established through clinical examination and subsequently confirmed by performing a biopsy of the affected area. The presence of a nodule or ulcer indicates the advancement of the disease into an invasive stage. In cases of HPV-associated disease, the likelihood of progressing to invasive disease is rather low, however it is higher for vulvar lesions.
The differential diagnosis encompasses various distinct pink-red plaques, such as nummular eczema, psoriasis, seborrheic keratosis, solar keratoses, verruca vulgaris, verruca plana, condyloma acuminatum, superficial basal cell carcinoma, amelanotic melanoma, and nonmammary Paget disease.
The treatment options include topical application of 5-fluorouracil, either with or without occlusion, as well as imiquimod, cryosurgery, CO2 laser evaporation, or excision, including Mohs micrographic surgery.
Topical chemotherapy requires a significant amount of time. Cryosurgery can result in the formation of scars.
Laser therapy can be arduous and agonizing. Surgical excision offers the most effective treatment with the highest likelihood of complete recovery. However, it also has the greatest risk of leaving scars. Nonetheless, it should be employed whenever the possibility of invasion has not been ruled out by a biopsy.
The development of squamous cell carcinoma in the perineum is attributed to infection by the human papilloma virus, as well as chronic low-grade balanoposthitis and chronic dermatoses such as ulcerative lichen planus and lichen sclerosus.
Pruritus, ulceration, and precursor lesions may be observed.
The penis, vulva, and anogenital region have distinct, isolated, irregularly shaped patches, papules, or plaques that are either red or white. These patches have a smooth or velvety surface and are characterized by excessive keratinization. Penile lesions may exhibit slight hardening and can be accompanied by tissue death or a secondary infection in the tight foreskin. Vulvar lesions can manifest as either bulky and white growths or as pigmented areas of thickened or hardened skin. The individual may experience pain, discharge, difficulty urinating, bleeding, and the formation of ulcers in a specific area.
The diagnosis is established through clinical examination and subsequently confirmed by performing a biopsy of the affected area. The presence of a nodule or ulcer indicates the advancement of the disease into an invasive stage. In cases of HPV-associated disease, the likelihood of progressing to invasive disease is rather low, however it is higher for vulvar lesions.
The differential diagnosis encompasses various distinct pink-red plaques, such as nummular eczema, psoriasis, seborrheic keratosis, solar keratoses, verruca vulgaris, verruca plana, condyloma acuminatum, superficial basal cell carcinoma, amelanotic melanoma, and nonmammary Paget disease.
The treatment options include topical application of 5-fluorouracil, either with or without occlusion, as well as imiquimod, cryosurgery, CO2 laser evaporation, or excision, including Mohs micrographic surgery.
Topical chemotherapy requires a significant amount of time. Cryosurgery can result in the formation of scars.
Laser therapy can be arduous and agonizing. Surgical excision offers the most effective treatment with the highest likelihood of complete recovery. However, it also has the greatest risk of leaving scars. Nonetheless, it should be employed whenever the possibility of invasion has not been ruled out by a biopsy.
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Dermatology - Dysplastic Melanocytic Nevus
Dysplastic nevi (DN) are distinct acquired pigmented lesions characterized by the abnormal growth of melanocytes, which are cells responsible for producing pigment. These lesions have the potential to develop into superficial spreading melanoma, a kind of skin cancer. They can appear spontaneously or as a component of a compound melanocytic nevus. Clinically, they are easily distinguishable from common acquired nevi due to their bigger size, more varied coloration, asymmetrical form, and uneven borders. They also exhibit specific histologic characteristics.
Lesions typically develop in later infancy compared to common acquired nevomelanocytic nevi (NMN), which generally emerge in late childhood, shortly before puberty. Additional lesions persistently emerge over an extended period of time. While conventional nevomelanocytic nevi (moles) often follow a similar progression in a certain area of the body (such as junctional, compound, dermal), dysplastic nevi (DN) deviate from this pattern. DN may exhibit a combination of large and small, flat and elevated, tan and very dark lesions.
The diagnosis is established through the clinical identification of characteristic and unique skin lesions, and further validated with dermoscopy. Once a diagnosis of DN is confirmed in a family member, it is advisable to also evaluate siblings, children, and parents for the condition. The differential diagnosis include congenital nevomelanocytic nevi, common acquired nevomelanocytic nevi (moles), superficial spreading malignant melanoma, melanoma in situ, lentigo maligna, Spitz nevus, and pigmented basal cell carcinoma.
The excision of DN should be performed carefully with precise margins. The use of laser or other physical destruction methods should be avoided since they do not allow for histopathologic verification of diagnosis. It is crucial to closely monitor patients with DN in the familial melanoma context, and it is essential to conduct regular photographic follow-up. It is crucial to educate patients about the distinct characteristics of DN, malignant melanoma, and typical acquired NMN as digital dermoscopy provides the most dependable results. Advise patients to refrain from sunbathing or utilizing tanning salons, and to apply sunscreens while exposed to the outdoors.
Dysplastic nevi (DN) are distinct acquired pigmented lesions characterized by the abnormal growth of melanocytes, which are cells responsible for producing pigment. These lesions have the potential to develop into superficial spreading melanoma, a kind of skin cancer. They can appear spontaneously or as a component of a compound melanocytic nevus. Clinically, they are easily distinguishable from common acquired nevi due to their bigger size, more varied coloration, asymmetrical form, and uneven borders. They also exhibit specific histologic characteristics.
Lesions typically develop in later infancy compared to common acquired nevomelanocytic nevi (NMN), which generally emerge in late childhood, shortly before puberty. Additional lesions persistently emerge over an extended period of time. While conventional nevomelanocytic nevi (moles) often follow a similar progression in a certain area of the body (such as junctional, compound, dermal), dysplastic nevi (DN) deviate from this pattern. DN may exhibit a combination of large and small, flat and elevated, tan and very dark lesions.
The diagnosis is established through the clinical identification of characteristic and unique skin lesions, and further validated with dermoscopy. Once a diagnosis of DN is confirmed in a family member, it is advisable to also evaluate siblings, children, and parents for the condition. The differential diagnosis include congenital nevomelanocytic nevi, common acquired nevomelanocytic nevi (moles), superficial spreading malignant melanoma, melanoma in situ, lentigo maligna, Spitz nevus, and pigmented basal cell carcinoma.
The excision of DN should be performed carefully with precise margins. The use of laser or other physical destruction methods should be avoided since they do not allow for histopathologic verification of diagnosis. It is crucial to closely monitor patients with DN in the familial melanoma context, and it is essential to conduct regular photographic follow-up. It is crucial to educate patients about the distinct characteristics of DN, malignant melanoma, and typical acquired NMN as digital dermoscopy provides the most dependable results. Advise patients to refrain from sunbathing or utilizing tanning salons, and to apply sunscreens while exposed to the outdoors.
