A COLOR GUIDE TO DIAGNOSIS AND THERAPY

CLINICAL DERMATOLOGY

THOMAS P. HABIF FOURTH EDITION

Mosby

Disorders Index Cat-scratch disease, 528 Cavernous hemangiomas, 818

Cellulitis, 273

Cement dermatitis and burns, 95 Chancroid, 327 Chapped fissured feet, 62 Cherry angioma, 824 389 Cholinergic urticaria, 145 Chondrodermatitis nodularis chronica hellicis, 716 Churg-Strauss syndrome, 640, 649 Cicatricial pemphigoid, 548 Cold urticaria, 146 Compound nevi, 774 Condyloma acuminata, 358 Congenital nevi, 777 Congenital syphilis, 320 Contact dermatitis, 81 Contact urticaria syndrome, 152 Coral poisoning, 543 Corns 374 Cowden's disease, 912 Crab lice, 506 Cradle cap, 242 Creeping eruptions, 537 CREST syndrome, 617, 832 Cutaneous horn, 706 Cutaneous larva migrans, 537 Cutaneous lymphoma, 754 Cystic acne, 174 Delusions of parasitosis, 70 Dermal nevi, 775 Dermatitis herpetiformis, 548, 554 Dermatofibroma, 708 607 Dermatophytid reaction, 414 Dermographism, 142 Digital mucous cyst, 888 Discoid lupus erythematosus, 596, Dissecting cellulitis, 861 Distal nail splitting, 883

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Abscesses, 284 Acanthosis nigricans, 900 Acne keloidalis, 283, 861 Acne rosacea, 198 Acne, 162 lentiginous melanoma, 796 Acrochordon, 706

Actinic cheilitis, 738

Actinic comedones, 664 Actinic keratosis, 736 Adenoma sebaceum, 909 Allergic contact dermatitis, 84 Alopecia areata, 855 Androgenetic alopecia female 844 Androgenetic alopecia men, 842 147 Angiokeratoma, 824 Angular cheilitis, 450 Animal bites, 529 Ants, 538 pruritus, 147 Aquagenic urticaria, 142 Arsenical keratoses, 753 Arterial leg ulcers, 74 Arthritis-dermatitis syndrome, 333 Asteatotic eczema (xerosis), 60 Atopic dermatitis, 105 Atypical mole syndrome, 782 Baboon syndrome, 94 Bacillary angiomatosis, 827 Basal cell carcinoma, 724 Bathing trunk nevus, 778 Beau's lines, 463, 865, 884 Becker's nevus, 780 Bee stings, 531 Benign familial chronic pemphigus, 575 Benign juvenile melanoma, 781 Berlock dermatitis, 682 Bite wounds, 530 Black heel, 374 Black widow spider bites, 512 Blepharitis, 242 Blistering distal dactylitis, 287 Blue nevus, 782 Bowenoid papulosis, 343 Bowen's disease, 748 Brown recluse spider bites, 514 Bullous impetigo, 268 Bullous pemphigoid, 567-570, 568, 569 Buschke-Lowenstein, giant condylomata of, 752 spots, 694, 905 Candidiasis, 440 Capillary hemangioma, lobular, 826 Carbuncles, 284 Cat bites, 529 Caterpillar dermatitis, 510

Dog bites, 529

Drug eruptions, 490 Dyshidrosis (pompholyx), 58 Dysplastic nevi, 782 Dystrophic epidermolysis bullosa, 576 Ecthyma gangrenosum, 298 Ecthyma, 272 Eczema craquele, 60 Eczema 388 dermatitis, 107 En coup de sabre, 622 Eosinophilic folliculitis 358 Ephelides, 691 Epidermal cyst, 717 Epidermal nevus, 713

Disorders Index Labial melanocytic macule, 782 Lentigo (liver spots), 691 Lentigo maligna, 794 Leukocytoclastic vasculitis, 642 Leukonychia, 882 Leukoplakia, 751 Lichen planopilaris, 861 Lichen planus, 250 Lichen sclerosis et atrophicus, 257 Lichen simplex chronicus, 54, 63, 66 Linear bullous dermatosis, 556 Lupus erythematosus, 592 Lyme disease, Lymphangioma circumscriptum, 825 Male-pattern baldness, 842 Malignant melanoma, 786 Mastocytosis, 156 Measles, 460 299 Methotrexate 229 194 Miliaria rubra, 205 Morphea, 620 disease, 261 Muir-Torre syndrome, 914 Mycosis fungoides, 754 Myiasis, 534 Necrobiosis lipoidica, 897 Neurotic excoriations, 68 Nevoid basal cell carcinoma syndrome, 731 Nevus flammeus (port-wine stains), 819 Nevus sebaceous, 715 Nummular eczema, 54 Onycholysis, 880 Onychomycosis 875 Otitis externa, 294 Paronychia, 867 Parvovirus B-19 infection, 468 Pearly penile papules, 339 Pediculosis, 506 Pemphigoid, 567 Pemphigus, 559 Perioral dermatitis, 30, 195 Perleche, 450 Pilar cyst, 719 Pilar cysts, 719 Pitted keratolysis, 416 Pityriasis alba, 689 Pityriasis lichenoides chronica, 261 Pityriasis rosea, 246 Pityriasis rubra pilaris, 240 Plantar warts, 374 PLEVA 261 Poikiloderma vasculare atrophicans, 756 Poikiloderma, 609 Poison ivy, 85

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Epidermolysis bullosa acquisita, 574 Epidermolysis bullosa simplex, 576 Erysipelas, 273 Erysipeloid, 287 Erythema ab 694 Erythema elevatum 653 Erythema Erythema multiforme, Erythema nodosum, 635 Erythema toxicum neonatorum, 582 419 psoriasis, 213 Erythroplasia of Queyrat, 749 Erythropoietic protoporphyria 680 subitum, 471 Exercise-induced anaphylaxis, 145 Exfoliative erythroderma, 491 External otitis, 294 Extramammary Paget's disease, 764 Fifth disease, 468 Fire ant stings, 538 Folliculitis decalvans, 860 Folliculitis, 279 Furuncles (boils), 284 Gardner's syndrome, 913 Genital warts, 336 German measles, 467 Gonorrhea, 330 Granuloma annulare, 898 Granuloma inguinale, 329 Guttate psoriasis, 212 Hairy leukoplakia, 363 Halo nevi, Hand eczema, 50 Hand, foot, and mouth disease, 462 Henoch-Schonlein purpura, 645 Herpes simplex, 381 Herpes zoster, 394 Herpetic whitlow, 873 Hidradenitis suppurativa, 202 Hirsutism, 846 Hypersensitivity vasculitis, 642 Ichthyosis vulgaris, 115 Idiopathic guttate hypomelanosis, 689 Intertrigo, 418 Irritant contact dermatitis, 82 Isotretinoin, 186 Junction nevus, 774 Kaposi's sarcoma, 827 Kawasaki syndrome, 474 Keloids, 709 Keratoacanthoma, Keratoderma blennorhagicum, 216 Keratolysis exfoliativa, 55 Keratolysis, pitted, 416 Keratosis pilaris,

Continued

Disorders Index Sweet's syndrome, 650 Swimmer's itch, 539 Sycosis barbae, 282 Syphilis, 315 Syringoma, 721 Systemic lupus erythematosus, 600 lyphoma, cutaneous, 754 Telangiectasia macularis eruptiva perstans, 157 Telangiectasia, 830 Telogen effluvium, 841 Tendinous xanthoma, 904 Terry's nails, 885 Tick bite paralysis, 526 Tinea 243 Tinea barbae, 434 Tinea capitis, 427 Tinea corporis, 420 Tinea cruris, 417 Tinea gladiatorum, 422 Tinea incognito, 38, 417, 426 Tinea pedis, 413 Tinea unguium, 874 Tinea versicolor, 451 Toxic epidermal necrolysis, 491, 627 Toxic shock syndrome, 479 Transient neonatal pustular melanosis, 582 Trichomonas vaginalis, 440 Trichomycosis axillaris, 862 Trichotillomania, 858 Tuberous sclerosis, 909 Tuberous xanthoma, 904 Tufted folliculitis, 860 Unilateral nevoid telangiectasia syndrome, 832 Urethritis, 309 Urticaria pigmentosa, 156 Urticaria, 129 Urticarial vasculitis, Vaginal lichen planus, erosive, 255 Vaginosis, bacterial, 313t Varicella, 389 Venous lake, 825 Venous ulcers, 73 Verrucous carcinoma, 752 Verrucous epidermal nevus, 714 Viral exanthems, 473

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Polyarteritis nodosa, 640 Polymorphous light eruptions, 671 Pompholyx 58 Porphyria cutanea tarda, 675 Port-wine stains, 819 Postherpetic neuralgia, 400 Pressure urticaria, 144 Prurigo nodularis, 68,

Pseudofolliculitis barbae, 280 folliculitis, 290 Pseudopelade, 860 Pseudoporphyria, 679 Pseudoxanthoma elasticum, 916 Psoriasis, 209 Pustular psoriasis Pyoderma gangrenosum, 653 Pyogenic granuloma, 826, 889 Rocky Mountain spotted fever, 524 Rosacea, 198 Roseola infantum, 471 Rubella, 467 Scabies, 497 Scarlet fever, 464 disease, 656 Scleroderma, 613 Seabather's eruption, 540 Sebaceous hyperplasia, 720 Seborrheic dermatitis, 242 Seborrheic keratosis, 698 Senile comedones, 194 Serum sickness, Sezary syndrome, 760 Shingles, 394 Skin tags, 706 Small-vessel vasculitis, Speckled lentiginous nevus, 778 Spider angioma, 830 Spider bites, Spitz nevus, 781 Squamous cell carcinoma, 744 Staphylococcal scalded skin syndrome, 288 Stasis dermatitis, 72 Stasis ulcers, 14 Steroid acne, 33, 191 Steroid atrophy, 34 Steroid rosacea, 30 Stevens-Johnson syndrome, 630 Stinging insects, 531 Strawberry hemangiomas, Striae, 15 Stucco keratosis, 705 Sturge-Weber syndrome, 822 Sunburn, 233 Superficial basal cell carcinoma, 726 Superficial spreading melanoma, 788

Virilization, 846 Vitiligo, 684

Von Recklinghausen's neurofibromatosis, 905 Warts, 368 Wegener's granulomatosis, 640, 648 White superficial onychomycosis, 876 Xanthelasma, 903 Xanthoma, 902 Xerosis, 60 Yellow nails syndrome, 884 Zoster sine herpete, 402

A brand new edition ...in a brand new way! A COLOR GUIDE TO DIAGNOS

CLINICAL DERMATOLOGY

Accessing unparalleled clinical guidance on the identification, diagnosis, and treatment of virtually every common skin disorder is now easier than ever! A variety of formats delivers unprecedented reference power! Clinical Dermatology: A Color Guide to Diagnosis and Therapy (Edition

THOMAS P. HABlF

Clinical Dermatology: A Color Guide to Diagnosis and Therapy, 4th edition By Thomas R Habif, MD

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Clinical Dermatology A COLOR GUIDE TO DIAGNOSIS AND THERAPY

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Clinical Dermatology A COLOR GUIDE TO DIAGNOSIS AND THERAPY Thomas Ρ Habif MD

Adjunct Professor of Medicine (Dermatology) Dartmouth Medical School Hanover, NH, USA

Commissioning Editor: Sue Hodgson Project Development Editor: Louise Cook Publishing Services Manager: Melissa Lastarria Layout Design: Jeanne Genz Design Coordinator: Jayne Jones Illustration Coordinator: Michael Ruddy

Project Organization: Laura A. McCann Medical Photography: Alan N. Binnick, MD, and Thomas P. Habif, MD

Photographs: Barry M. Austin, MD, Richard D. Baughman, MD, Daniel W. Collison, MD, Warren M. Pringle, MD, Cameron L. Smith, MD, and Steven K. Spencer, MD

Technical Advice: David V. Habif, Jr, MD Moral Support: Dorothy, Tommy, and David

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Edinburgh

London New York Oxford Philadelphia St Louis Sydney Toronto 2004

Mosby An Affiliate of Elsevier

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The Curtis Center Independence Square West Philadelphia, Pennsylvania 19106

CLINICAL DERMATOLOGY: A COLOR GUIDE TO DIAGNOSIS AND THERAPY

©

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All rights reserved.

No part of this publication may be reproduced or transmitted form or by any means, electronic or mechanical, including photocopying, recording, or any information storage and retrieval system, without permission in writing from the publisher. Permissions may be sought directly from Elsevier's Rights Department in Philadelphia, PA, USA: phone: (11) 215 238 7869, fax: (11) 238 2239, e-mail: You may also complete your request on-line via the Elsevier homepage by selecting 'Customer Support' and then Permissions'.

ronicor Dermatology is an ever-changing field. Standard safety precautions must be followed, but as new research and clinical experience broaden our knowledge, changes in treatment and therapy may become necessary or apReaders are advised to check the most current product information provided by the manufacturer of each to be administered to verify the recommended dose, the method and duration of administration, and contraindications. It is the responsibility of the licensed prescriber, relying on experience and knowledge of the patient, to determine dosages and the best treatment each individual patient. Neither the publisher nor the author assumes any liability for any injury damage to persons or property arising from this publication.

Previous editions copyrighted

International Standard Book Number 0-323-01319-8 Printed in Chile

Last digit i s t h e print n u m b e r :

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Preface

Clinical Dermatology is intended to be a practical resource for the busy clinician. Over 1000 illustrations are combined with disease descriptions and current and comprehensive therapeutic information. Bold headings are used to facilitate rapid access to information. Diseases can be accessed in many ways. The classic method of organizing skin diseases is used. Common diseases are covered in depth. Illustrations of classic examples of these disorders and photographs of variations seen at different stages are included. Basic dermatologic surgical techniques are covered in detail. Specialized techniques such as Mohs' surgery are described so that the physician can be better prepared to suggest referral. Theoretical information, disease mechanisms, and rare disease are found in comprehensive textbooks.

Rapid Access to the Text

1. List of disorders with page front cover. 2. List of common topical disorders pages. 3. List of diseases by region with page back cover. 4. List of diseases by lesion type with page 3. 5. Formulary is located on pages 945 to 973.

How to Use This Book

Students in the classroom

Students should learn the primary and secondary lesions and the distribution of diseases in Chapter 1 and study the differential diagnosis of each lesion. Select a few familiar diseases from each list and read about them. Study the close-up pictures carefully. Obtain an overview of the text. Turn the pages, look at the pictures, and read the captions.

Students in the clinic

You see skin abnormalities every day in the clinic. Try to identify these diseases, or ask for assistance. Study all eases, especially tumors, with a magnifying glass or ocular lens. Read about what you see and you will rapidly gain a broad fund of knowledge.

Study Chapters 20 (Benign Skin Tumors), 21 (Premalignant and Malignant Nonmelanoma Skin Tumors), and 22 (Nevi and Malignant Melanoma). Skin growths are common, and it is important to recognize their features. House officers are responsible for patient management. Read Chapter 2 and study all aspects of the use of topical steroids. These valuable agents are used to treat a great variety of inflammatory skin conditions. It is tempting to use these agents as a therapeutic trial and ask for a consultation only if therapy fails. Topical steroids mask some diseases, make some diseases worse, and create other diseases. Do not develop bad habits; if you do not know what a disease is, do not treat it. The diagnosis of skin disease is deceptively easy. Do not make hasty diagnoses. Take a history, study primary lesions and the distribution, and be deliberate and methodical. Ask for help. With time and experience you will feel comfortable managing many common skin diseases.

The practicing clinician

Most skin diseases are treated by practitioners other than dermatologists. This includes primary care physicians, nurse practitioners and physician assistants. Clinicians involved in direct patient care should read the above guidelines for using this book. Learn a few topical steroids in each potency group. There are a great number of agents in the Formulary. Many in each table contain similar ingredients and have the same therapeutic effect. Develop an armamentarium of agents and gain experience in their use. Inflammatory conditions are often confusing, and sometimes biopsies are of limited value in their diagnosis. Eczema is common, read Chapters 2 and 3. Acne is seen everyday, read Chapter 7. Managing acne effectively will provide a great service to many young patients who are very uncomfortable with their appearance. The clinical diagnosis of pigmented lesions is complicated. A dermatologist can often make a specific diagnosis without the need for a biopsy.

The dermatologist

Many dermatologists use the pictures as an aid to reassure patients. Examine the patient, make a diagnosis, and then

Clinical Dermatology show them an illustration of their disease. Many patients see the similarity and are reassured. This book is designed to be a practical resource. All of the most current descriptive and therapeutic information that is practical and relevant has been included. All topics are researched on Medline. Details about basic science and complex mechanisms of disease can be found elsewhere. Rare diseases are found in larger textbooks.

Production The author writes the manuscript. The publishing company makes the book. Manufacturing a book is a complicated process. The key people involved in this effort are listed on the title page. As my first editor said 20 years ago, "if people ever realized what was involved in making a book, they would not believe that it could ever get done." The layout and design of each page in this book is done the "old fashion way," by cutting and pasting images and strips of text by the layout artist. Page layout design is a science and an art. Jeanne Genz has designed all four editions of this book. This older, slower, noncomputerized technique created by an expert produces pages that are balanced and of maximum clarity. Computer layout programs are not capable of this art. The final "pasted" book is then converted to a digital file and printed on high-grade glossy paper on a sheetfed press. Glossy paper retains ink at the surface to enhance definition. Sheetfed presses print slowly and allow ink to be laid down precisely so that exceptional sharpness and color balance are achieved.

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viii

Photography

The photographs were taken with medium format cameras, 35-mm macro cameras, and digital macro cameras. The digital images for this edition were taken by me with a Nikon digital camera fitted with a 60 mm macro lens and a Canfield TwinFlash. The macro camera takes pictures that simulate the view through a hand lens. Therefore the distribution of the disease and the primary lesion can be accurately illustrated. Over 4000 new digital images were acquired in preparation for this edition. Alan N. Adjunct Assistant Professor of Medicine (Dermatology), Dartmouth Medical School, provided all of the new images taken with transparency film. He has 25 years of experience as a clinician, teacher, and expert photographer. His entire collection was available for this edition.

Thomas P. Habif 2003

RH n I y zTºH ºHjn ¼º 1 Principles of Diagnosis and Anatomy 1 Skin anatomy 1 Epidermis 1 Dermis 1 Dermal nerves and vasculature 1 Diagnosis of skin disease 2 A methodical approach 2 Examination technique 2 Approach to treatment 2 Primary lesions 2 Secondary lesions 2 Special skin lesions 16 Regional differential diagnoses 18

2 Topical Therapy and Topical Corticosteroids 23 Topical therapy 23 Emollient creams and lotions 23 Severe dry skin (xerosis) 23 Wet dressings 24 Topical corticosteroids 25 Strength 25 Vehicle 26 Steroid-antibiotic mixtures 27 Amount of cream to dispense 27 Application 28 Adverse reactions 30

3 Eczema and Hand Dermatitis

41

Stages of eczematous inflammation 43 Acute eczematous inflammation 43 Subacute eczematous inflammation 44 Chronic eczematous inflammation 48 Hand eczema 50 Irritant contact dermatitis 51 Atopic hand dermatitis 53 Allergic contact dermatitis 54 Nummular eczema 54 Lichen simplex chronicus 54 Recurrent focal palmar peeling 55 Hyperkeratotic eczema 55 Fingertip eczema 57 Pompholyx 59 Id reaction 59

Eczema: various presentations 60 Asteatotic eczema 60 Nummular eczema 61 Chapped fissured feet 62 Self-inflicted dermatoses 63 Lichen simplex chronicus 63 Prurigo nodularis 68 Neurotic excoriations 68 Psychogenic parasitosis 70 Stasis dermatitis and venous ulceration: postphlebitic syndromes 72 Stasis dermatitis 72 Types of eczematous inflammation 72 Venous leg ulcers 74

4 Contact Dermatitis and Patch Testing Irritant contact dermatitis 82 Allergic contact dermatitis 84

81

Systemically induced allergic contact dermatitis 84 Clinical presentation 84 Rhus dermatitis 88 Natural rubber latex allergy 90 Shoe allergy 92 Metal dermatitis 93 Cement dermatitis and burns 95 Further examples of allergic contact dermatitis 95 Patients with leg ulcers 97 Cosmetic and fragrance allergy 97 Diagnosis of contact dermatitis 98 Patch testing 98

5 Atopic Dermatitis

105

Pathogenesis and immunology 106 Clinical aspects 107 Infant phase (birth to 2 years) 108 Childhood phase (2 to 12 years) 111 Adult phase (12 years to adult) 114 Associated features 115 Dry skin and xerosis 115 Ichthyosis vulgaris 115 Keratosis pilaris 116 Hyperlinear palmar creases 118 Pityriasis alba 118

Overview of diagnosis and treatment 163 Etiology and pathogenesis 169 Approach to acne therapy 170 Acne treatment 171 Therapeutic agents for treatment of acne 178 Acne surgery 190 Other types of acne 190 Perioral dermatitis 195 Treatment 197 Rosacea (acne rosacea) 198 Skin manifestations 198 Ocular rosacea 200 Treatment 200 Hidradenitis suppurativa 202 Clinical presentation 202 Pathogenesis 202 Management 203 Miliaria 205 Miliaria crystalline 205 Miliaria rubra 205 Miliaria profunda 205

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Atopic pleats 118 Cataracts and keratoconus 118 Triggering factors 120 Temperature change and sweating 120 Decreased humidity 120 Excessive washing 120 Contact with irritating substances 120 Contact allergy 120 Aeroallergens 120 Microbic agents 120 Food 120 Aeroal lergens 120 Treatment 120 Dry skin 122 Inflammation and infection 122 Infants 123 Children and adults 123 Tar 124 Hospitalization for severely resistant cases 125 Lubrication 125 Sedation and antihistamines 125 Phototherapy 126 Diet restriction and breast-feeding 126

6 Urticaria and Angioedema 129

Clinical aspects 130 Pathophysiology 133 Initial evaluation of all patients with urticaria 134 Acute urticaria 134 Chronic urticaria 136 Treatment of urticaria 139 Antihistamines 140 Epinephrine 141 Oral corticosteroids 141 Immunotherapy 141 Physical urticarias 142 Dermographism 142 Pressure urticaria 144 Cholinergic urticaria 145 Exercise-induced anaphylaxis 145 Cold urticaria 146 Solar urticaria 147 Heat, water, and vibration urticarias 147 Aquagenic pruritus 147 Angioedema 147 Acquired forms of angioedema 148 Hereditary angioedema 151 Contact urticaria syndrome 152 Pruritic urticarial papules and plaques of pregnancy 152 Urticarial vasculitis 154 Serum sickness 155 Mastocytosis 156

7

Acne, Rosacea, and Related Disorders 162 Acne 162 Classification 163

8

Psoriasis and Other Papulosquamous Diseases 209 Psoriasis 209 Clinical manifestations 210 Histology 211 Clinical presentations 211 Chronic plaque psoriasis 212 Guttate psoriasis 212 Generalized pustular psoriasis 213 Erythrodermic psoriasis 213 Light-sensitive psoriasis 214 Psoriasis of the scalp 214 Psoriasis of the palms and soles 214 Pustular psoriasis of the palms and soles 214 Keratoderma blennorrhagicum (Reiter's syndrome) 216 Psoriasis of the penis and Reiter's syndrome 216 Pustular psoriasis of the digits 216 Psoriasis inversus (psoriasis of the flexural or intertriginous areas) 217 Human immunodeficiency virus (HlV)-induced psoriasis 217 Psoriasis of the nails 218 Psoriatic arthritis 220 Treatment of psoriasis 222 Topical therapy 224 Systemic therapy 228 Biologic therapy for psoriasis 238 Pityriasis rubra pilaris 240 Seborrheic dermatitis 242 Infants (cradle cap) 242 Young children (tinea amiantacea and blepharitis) 242 Adolescents and adults (classic seborrheic dermatitis) 245 Acquired immunodeficiency syndrome 245 Pityriasis rosea 246 Lichen planus 250 Localized papules 250

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Clinical manifestations 299 Hypertrophic lichen planus 252 Diagnosis 301 Generalized lichen planus and lichenoid drug eruptions 252 Differential diagnosis 301 Lichen planus of the palms and soles 252 Management 301 Follicular lichen planus 252 Nontuberculous mycobacteria 304 Oral mucous membrane lichen planus 254 Μ. ulcerans, Μ. fortuitum, Μ. chelonei, and M. avium Follic ular lichen planus 252 intracellulare 304 Nails 255 Diagnosis 255 10 Sexually Transmitted Bacterial Infections 307 Treatment 256 Sexually transmitted disease presentations 307 Lichen sclerosus et atrophicus 257 Genital ulcers 307 Lichen sclerosus et atrophicus of the penis 258 Syphilis 315 Pityriasis lichenoides 261 Incidence 315 Bacterial Infections 267 Stages 315 Skin infections 267 Risk of transmission 317 Impetigo 267 T. pallidum 317 Primary syphilis 317 Ecthyma 272 Secondary syphilis 318 Cellulitis and erysipelas 273 Cellulitis of specific areas 274 Latent syphilis 320 Necrotizing fasciitis 278 Tertiary syphilis 320 Syphilis and human immunodeficiency virus 320 Folliculitis 279 Staphylococcal folliculitis 279 Congenital syphilis 320 Syphilis serology 321 Keratosis pilaris 280 Pseudofolliculitis barbae (razor bumps) 280 Treatment of syphilis 323 Posttreatment evaluation of syphilis 324 Sycosis barbae 282 Acne keloidalis 283 Rare sexually transmitted diseases 325 Furuncles and carbuncles 284 Lymphogranuloma venereum 325 Location 284 Chancroid 327 Granuloma inguinale (donovanosis) 329 Bacteria 284 Predisposing conditions 284 Diseases characterized by urethritis and cervicitis 330 Clinical manifestations 284 Gonorrhea 330 Neisseria gonorrhoeae 330 Differential diagnosis 285 Treatment of furuncles 285 Nongonococcal urethritis 334 Recurrent furunculosis 286 11 Sexually Transmitted Viral Infections 336 Erysipeloid 287 Genital warts 336 Clinical manifestation 287 Human papillomavirus 336 Diagnosis 287 Incidence 336 Treatment 287 Transmission 336 Blistering distal dactylitis 287 Clinical presentation 337 Staphylococcal scalded skin syndrome 288 Diagnosis 340 Epidermolytic toxin 288 Treatment 340 Incidence 288 Bowenoid papulosis 343 Clinical manifestations 288 Molluscum contagiosum 344 Pathophysiology 289 Clinical manifestations 344 Diagnosis 289 Diagnosis 344 Treatment 289 Treatment 345 Pseudomonas aeruginosa infection 290 Genital herpes simplex 346 Pseudomonas folliculitis 290 Prevalence 346 Pseudomonas hotfoot syndrome 290 Risk factors 346 Pseudomonas cellulitis 292 Rate of transmission 348 External otitis 294 Primary and recurrent infections 348 Malignant external otitis 297 Prevention 350 Toe web infection 298 Laboratory diagnosis 350 Ecthyma gangrenosum 298 Serology 351 Meningococcemia 299 Psychosocial implications 352 Transmission 299 Treatment of genital herpes (Centers for Disease Control Incidence 299 Guidelines) 352 Pathophysiology 299

9

Chronic mucocutaneous candidiasis 450 Tinea versicolor 451 Pityrosporum folliculitis 454

Exanthems and Drug Eruptions 457

Exanthems 460 Measles 460 Hand, foot, and mouth disease 462 Scarlet fever 464 Rubella 467 Erythema infectiosum (parvovirus B19 infection) 468 Roseola infantum (human herpes virus 6 and 7 infection) 471 Enteroviruses: echovirus and coxsackievirus exanthems 473 Kawasaki syndrome 474 Superantigen toxin-mediated illnesses 478 Toxic shock syndrome 479 Cutaneous drug reactions 482 Drug eruptions: clinical patterns and most frequently causal drugs 485 Exanthems (maculopapular) 485 Urticaria 488 Pruritus 489 Drug eruptions 490 Acute generalized exanthemous pustulosis 490 Acneiform (pustular) eruptions 490 Eczema 490 Blistering drug eruptions 491 Erythema multiforme and toxic epidermal necrolysis 491 Exfoliative erythroderma 491 Fixed drug eruptions 492 Lichenoid (lichen planus-like drug eruptions) 493 Lupus erythematosus-like drug eruptions 493 Photosensitivity 493 Pigmentation 494 Vasculitis 494 Lymphomatoid drug eruptions 494 Chemotherapy-induced acral erythema 494 Skin eruptions associated with specific drugs 494

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Genital herpes simplex during pregnancy 354 Genital herpes simplex dur infection 355 Acquired immunodeficiency syndrome 356 Human immunodeficiency virus pathogenesis 356 14 Diagnosis 356 Viral burden 356 Assessment of immune status (CD4 + T-cell determinations) 357 Revised Centers for Disease Control and Prevention classification and management 357 Dermatologic diseases associated with human immunodeficiency virus infection 358

12 Warts, Herpes Simplex, and Other Viral Infections 368

Warts 368 Common warts 371 Filiform and digitate warts 372 Flat warts 373 Plantar warts 374 Subungual and periungual warts 378 Genital warts 378 Molluscum contagiosum 379 Herpes simplex 381 Oral-labial herpes simplex 384 Cutaneous herpes simplex 386 Eczema herpeticum 388 Varicella 389 Chickenpox in the immunocompromised patient 391 Chickenpox and HIV infection 391 Chickenpox during pregnancy 391 Congenital and neonatal chickenpox 392 Herpes zoster 394 Herpes zoster after varicella immunization 398 Herpes zoster and HIV infection 398 Herpes zoster during pregnancy 398 Syndromes 398 Prevention of postherpetic neuralgia: early combined antiviral drugs and antidepressants 404 15 Infestations and Bites 497 Treatment of postherpetic neuralgia 404 Scabies 497 Anatomic features, life cycle, and immunology 499 13 Superficial Fungal Infections 409 Clinical manifestations 500 Dermatophyte fungal infections 409 Diagnosis 503 Tinea 413 Treatment and management 504 Tinea of the foot 413 Scabies in long-term care facilities 505 Pitted keratolysis 416 Pediculosis 506 Tinea of the groin 417 Tinea of the body and face 420 Biology and life cycle 506 Clinical manifestations 507 Tinea of the hand 425 Diagnosis 508 Tinea incognito 426 Treatment 509 Treatment of the scalp 427 Caterpillar dermatitis 510 Tinea of the beard 434 Clinical manifestations 510 Treatment of Fungal Infections 434 Diagnosis 512 Candidiasis (Moniliasis) 440 Treatment 512 Candidiasis of normally moist areas 440 Spiders 512 Candidiasis of large skin folds 446 Black widow spider 512 Candidiasis of small skin folds 449

Localized pemphigoid 571 Benign chronic bullous dermatosis of childhood 572 Herpes gestationis (pemphigoid gestationis) 573 Pemphigoid-like disease 574 Epidermolysis bullosa acquisita 574 Benign familial chronic pemphigus 575 Epidermolysis bullosa 576 The newborn with blisters, pustules, erosions, and ulcerations 577

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Brown recluse spider 514 Ticks 516 Lyme disease and erythema migrans 517 Rocky mountain spotted and spotless fever 524 Tick bite paralysis 526 Removing ticks 527 Cat-scratch and related diseases 528 Clinical manifestations 528 Neurologic complications 528 Bacillary angiomatosis 528 Diagnosis of cat-scratch disease 529 Treatment 529 Animal and human bites 529 Management 529 Stinging insects 531 Toxic reactions 531 Allergic reactions 531 Diagnosis 532 Indications for venom skin testing and immunotherapy 532 Treatment 532 Biting insects 533 Papular urticaria 533 Fleas 533 Myiasis 534 Mosquitoes 536 Creeping eruption 537 Management 537 Ants 538 Fire ants 538 Dermatitis associated with swimming 539 Swimmer's itch (fresh water) 539 Nematocyst stings 539 Florida, Caribbean, Bahamas 541 Echinoderms (sea urchins and starfish) 543

16 Vesicular and Bullous Diseases 547 Blisters 547 Autoimmune blistering diseases 547 Major blistering diseases 547 Classification 550 Diagnosis of bullous disorders 551 Dermatitis herpetiformis and linear IgA bullous dermatosis 554 Gluten-sensitive enteropathy 556 Lymphoma 556 Diagnosis of dermatitis herpetiformis 556 Bullae in diabetic persons 559 Pemphigus 559 Pathophysiology 561 Pemphigus vulgaris 561 Pemphigus foliaceus, IgA pemphigus, and pemphigus erythematosus 562 Diagnosis of pemphigus 564 Treatment 565 Pemphigus in association with other diseases 566 The pemphigoid group of diseases 567 Bullous pemphigoid 567

17 Connective Tissue Diseases 587

Diagnosis 587 Antinuclear antibody testing 587 Lupus erythematosus 592 Clinical classification 592 Subsets of cutaneous lupus erythematosus 593 Chronic cutaneous lupus erythematosus 596 Subacute cutaneous lupus erythematosus 598 Systemic lupus erythematosus 600 Other cutaneous signs of lupus erythematosus 602 Drug-induced lupus erythematosus 603 Neonatal lupus erythematosus 604 Diagnosis and management of cutaneous lupus erythematosus 605 Treatment 605 Dermatomyositis and Polymyositis 607 Polymyositis 607 Dermatomyositis 607 Scleroderma 613 Systemic sclerosis 613 Chemically induced scleroderma 613 CREST syndrome 617 Localized scleroderma 620

18 Hypersensitivity Syndromes and Vasculitis 626

Hypersensitivity syndromes 626 Erythema multiforme 626 The Stevens-Johnson syndrome/toxic epidermal necrolysis spectrum of disease 630 Stevens-Johnson syndrome 630 Toxic epidermal necrolysis 632 Erythema nodosum 635 Vasculitis 637 Vasculitis of small vessels 642 Hypersensitivity vasculitis 642 Henoch-Schonlein purpura 645 Antinuclear cytoplasmic antibody-associated small-vessel vasculitis 648 Wegener's granulomatosis 648 Churg-Strauss syndrome 649 Microscopic polyangiitis 649 Antinuclear cytoplasmic antibody-negative small-vessel vasculitis 649 Neutrophilic dermatoses 650 Sweet's syndrome (acute febrile neutrophilic dermatosis) 650 Erythema elevatum diutinum 653 Pyoderma gangrenosum 653 Schamberg's disease 656

19 Light-Related Diseases and Disorders of Pigmentation 661

RH n I y zTºH ºHjn ¼º

Photobiology 661 Sun-damaged skin 662 Suntan and sunburn 668 Sun protection 668 Polymorphous light eruption 671 Hydroa aestivale and hydroa vacciniforme 674 Porphyrias 675 Porphyria cutanea tarda 675 Pseudoporphyria 679 Erythropoietic protoporphyria 680 Phototoxic reactions 681 Photoallergy 683 Disorders of hypopigmentation 684 Vitiligo 684 Idiopathic guttate hypomelanosis 689 Pityriasis alba 689 Nevus anemicus 690 Tuberous sclerosis 690 Disorders of hyperpigmentation 691 Freckles 691 Lentigo in children 691 Lentigo in adults 691 Melasma 692 Cafe-au-lait spots 694 Diabetic dermopathy 694 Erythema ab igne 694

Bowen's disease 748 Erythroplasia of Queyrat 750 Leukoplakia 751 Verrucous carcinoma 753 Arsenical keratoses and other arsenic-related skin diseases 753 Cutaneous T-cell lymphoma 754 Paget's disease of the breast 763 Extramammary Paget's disease 764 Cutaneous metastasis 765

20 Benign Skin Tumors 698

Seborrheic keratoses 698 Stucco keratoses 705 Dermatosis papulosa nigra 706 Cutaneous horn 706 Skin tags (acrochordon) and polyps 706 Dermatofibroma 708 Hypertrophic scars and keloids 709 Keratoacanthoma 711 Epidermal nevus 713 Nevus sebaceous 715 Chondrodermatitis nodularis chronica helicis 716 Epidermal cyst 717 Pilar cyst (wen) 719 Senile sebaceous hyperplasia 720 Syringoma 721

21

Premalignant and Malignant Nonmelanoma Skin Tumors 724

Basal cell carcinoma 724 Pathophysiology 725 Histologic characteristics 726 Clinical types 726 Management and risk of recurrence 732 Actinic keratosis 736 Squamous cell carcinoma 744 Squamous cell carcinoma of the extremities (Marjolin's ulcer) 747

22 Nevi and Malignant Melanoma 773

Melanocytic nevi 773 Common moles 774 Special forms 776 Atypical nevi 782 Malignant melanoma 786 Superficial spreading melanoma 789 Nodular melanoma 792 Lentigo maligna melanoma 794 Acral lentiginous melanoma 796 Benign lesions that resemble melanoma 797 Dermoscopy 798 Classification of atypical melanocytic nevi 799 Pregnancy, oral contraceptives, prognosis, and risk 806 Management 806 Biopsy 806 Initial diagnostic workup 808 Follow-up examinations 808 Staging and prognosis 810 Melanoma staging system 810 Medical treatment 810 Treatment of lentigo maligna 811

23 Vascular Tumors and Malformations 814

Congenital vascular lesions 814 Hemangiomas of infancy 815 Malformations 819 Acquired vascular lesions 824 Cherry angioma 824 Angiokeratomas 824 Venous lake 825 Lymphangioma circumscriptum 825 Pyogenic granuloma (lobular capillary hemangioma) 826 Kaposi's sarcoma 827 Telangiectasias 830 Spider angioma 830 Hereditary hemorrhagic telangiectasia 831 Unilateral nevoid telangiectasia syndrome 832 Scleroderma 832 Generalized essential telangiectasia 832

24 Hair Diseases 834

Anatomy 834 Physiology 836 Evaluation of hair loss 838 Generalized hair loss 841

Pseudoxanthoma elasticum 916 Guide to information for families with inherited skin disorders 917

27 Dermatologic Surgical Procedures 921

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Localized hair loss 842 Androgenic alopecia in men (male-pattern baldness) 842 Adrenal androgenic female-pattern alopecia 844 Hirsutism 846 Alopecia areata 855 Trichotillomania 858 Traction (cosmetic) alopecia 859 Scarring alopecia 860 Trichomycosis 862

25 Nail Diseases 864

Anatomy and physiology 864 Normal variations 868 Nail disorders associated with skin disease 869 Acquired disorders 871 Bacterial and viral infections 871 Fungal nail infections 874 Trauma 880 The nail and internal disease 884 Congenital anomalies 886 Color and drug-induced changes 886 Tumors 888

26 Cutaneous Manifestations of Internal Disease 893

Internal cancer and skin disease 893 Cutaneous paraneoplastic syndromes 893 Cutaneous manifestations of diabetes mellitus 896 Necrobiosis lipoidica 896 Granuloma annulare 898 Acanthosis nigricans 900 Xanthomas and dyslipoproteinemia 902 Neurofibromatosis 905 Tuberous sclerosis 909 Cancer-associated genodermatoses 912 Cowden's disease (multiple hamartoma syndrome) 912 Muir-Torre syndrome 914 Gardner's syndrome 915

Local anesthesia 922 Hemostasis 922 Wound healing 923 Postoperative wound care 925 Skin biopsy 926 Punch biopsy 926 Shave biopsy and shave excision 926 Simple scissor excision 928 Electrodesiccation and curettage 929 Techniques 929 Curettage 930 Techniques—curettage 930 Techniques—electrodesiccation and curettage of basal cell carcinoma 930 Blunt dissection 931 Technique 931 Cryosurgery 931 Technique 932 Extraction of cysts 933 Technique 933 Mohs' micrographic surgery 934 Technique 934 Chemical peels 936 Filling materials 936 Liposuction 936 Lasers 937 Botulinum toxin 938

Appendix 940

Dermatologic Formulary 945 Index 975

SKIN ANATOMY

RH n I y zTºH ºHjn ¼º

shaft

Melanocyte

Huxley's layer

Hair follicle

Sebaceous gland

layer

muscle

External sheath

corpuscle

Glassy membrane

Connective layer

Free nerve endings

Pore of sweat gland

—

Stratum

-Stratum

Stratum

Stratum spinosum Stratum basale

Sweat gland

Hair matrix

Papilla of follicle

Hair cuticle

Motor (autonomic) nerve

Sensory nerve

Elastic fibers

Vater-Pacini corpuscle

(Copyright 1967, CIBA Pharmaceutical Company, Division of CIBA-GEIGY Corporation. Reprinted with permission from Clinical Symposia. Illustrated by Frank H. Netter, All rights reserved.)

Vein