Skin Conditions and Skin Growths
Because of the compromised condition of a lymphovenous limb, we are often susceptible to a large number of skin complications. These may include various skin growths such as skin tags, warts, dermatofibromas, lymphangiomas,and rashes, fungal infections. This is in addition to the many infections associated with lymphedema superficial bacterial infections which include as impetigo, folliculitis, carbuncles, furuncles and boils and weeping wounds or sores.
With lymphedema, some types untreated skin conditions can lead to serious consequences including systemic infections (sepsis), gangrene, amputation and even death. Good skin care and health is critical to our overall good health.
Skin growths are accumulations of various types of cells that look different than the surrounding skin. They may be raised or flat and range in color from dark brown or black to flesh-colored to red. Skin growths may be present at birth or develop later.
When the growth is controlled and the cells do not spread to other parts of the body, the skin growth (tumor) is noncancerous (benign). When the growth is uncontrolled, the tumor is cancerous (malignant), and the cells invade normal tissue and even spread (metastasize) to other parts of the body. Noncancerous skin growths are often more of a cosmetic problem than anything else.
Doctors do not know what causes most noncancerous skin growths. Some growths, however, are known to be caused by viruses (for example, warts), systemic (bodywide) disease (for example, xanthelasmas or xanthomas caused by excess fats in the blood), and environmental factors (for example, moles and epidermal cysts stimulated by sunlight).
Dermatofibromas are small red-to-brown bumps (nodules) that result from an accumulation of collagen, which is a protein made by the cells (fibroblasts) that populate the soft tissue under the skin.
Dermatofibromas are common and usually appear as single firm bumps, often on the legs, particularly in women. Some people develop many dermatofibromas. Causes include trauma, insect bites, and cuts caused by shaving. Dermatofibromas are harmless and usually do not cause any symptoms, except for occasional itching. Usually, dermatofibromas are not treated unless they become bothersome or enlarge. A doctor can remove them with a scalpel.
An epidermal cyst is a common slow-growing bump consisting of a thin sac of skinlike material containing a cheesy substance composed of skin secretions.
Epidermal cysts, often incorrectly referred to as sebaceous cysts, are flesh-colored and range from ½ to 2 inches across. They can appear anywhere but are most common on the scalp, back, and face. They tend to be firm and easy to move within the skin. Epidermal cysts are not painful unless they become infected or inflamed.
Large epidermal cysts are removed surgically after an anesthetic is injected to numb the area. The thin sac wall must be removed completely or the cyst will grow back. Small cysts may be injected with corticosteroids if they become inflamed. Infected cysts are treated with an antibiotic and cut open to drain. Tiny cysts that are bothersome can be burned out with an electric needle.
Because sunlight may stimulate growth of epidermal cysts, fair-skinned people are advised to stay out of the sun and to use protective clothing and sunscreen.
A benign tumor which is made up of hairs, sweat glands, and sebaceous glands. Some internal dermoid tumors may even contain cartilage, bone fragments, and teeth. Dermoid cysts may be removed surgically for cosmetic reasons.
Smooth, firm, raised, fibrous growths on the skin that form in wound sites. Keloids are more common in African-Americans.
Keloids respond poorly to most treatment approaches. Injections of corticosteroid drugs may help to flatten the keloids. Other treatment approaches may include surgery or silicone patches to further flatten the keloids.
Round, flesh-colored growths that have a crater that contains a pasty material. These growths tend to appear on the face, forearm, or back of the hand. They usually disappear after a couple of months, but may leave scars.
Treatment usually includes a skin biopsy to rule out skin cancer. Other treatment may include surgical removal and/or injections of corticosteroids or fluorouracil.
Round or oval lumps under the skin caused by fatty deposits. Lipomas are more common in women and tend to appear on the forearms, torso, and back of the neck.
Lipomas are generally harmless, but if the lipoma changes shape, your physician may perform a biopsy. Treatment may include removal by surgery, if the lipoma bothers the child.
Small skin marks caused by pigment-producing cells in the skin. Moles can be flat or raised, smooth or rough, and some contain hair. Most moles are dark brown or black, but some are skin-colored or yellowish. Moles can change over time and often respond to hormonal changes.
Most moles are benign and no treatment is necessary. Some benign moles may develop into skin cancer (melanoma). See below for signs.
Moles - atypical (dysplastic nevi)
Larger than normal moles (more than a half inch across), atypical moles are not always round. Atypical moles can be tan to dark brown, on a pink background. These types of moles may occur anywhere on the body.
Treatment may include removal of any atypical mole that changes in color, shape and/or diameter. In addition, people with atypical moles should avoid sun exposure, since sunlight may accelerate changes in atypical moles. Persons with atypical moles should consult a physician with any changes that may indicate skin cancer.
Red, brown, or bluish-black, raised marks caused by excessive growth of capillaries (small blood vessels) and swelling. Pyogenic granulomas usually form after an injury to the skin.
Some pyogenic granulomas disappear without treatment. Sometimes a biopsy is necessary to rule out cancer. Treatment may include surgical removal.
Flesh-colored, brown, or black wart-like spots. More common in middle-aged and older people, seborrheic keratoses may be round or oval and look like they are "stuck" on the skin.
Usually, no treatment is necessary. If the spots are irritated, or the patient wants them removed for cosmetic reasons, treatment may include freezing the area with liquid nitrogen or surgery.
Skin Tags (Acrochordons), Wart-like growths, Cutaneous skin tags
A small tag of skin that may have a stalk (a peduncle). Skin tags may appear on the skin almost anywhere although the favorite locales are the eyelids, neck, armpits (axillae), upper chest, and groin.
Skin tags are very common soft harmless lesions that appear to hang off the skin. They are also described as:
Treatment generally consists of removing with scissors, freezing (using liquid nitrogen), and burning (using medical electric cautery at the physician's office).
While skin tags can occur anywhere, with lymphedema the more common place for them is around or in the skin "folds" that many patients get from the swelling.
Venous stasis dermatitis
Signs and Symptoms
Stasis dermatitis can begin so slowly that it is barely noticeable or so rapidly that it seems to develop overnight. Signs and symptoms include:
Swelling in one or both lower legs. In severe cases, the swelling can include the foot and extend to just beneath the knee.
Thin and inflamed skin
Itching (can be severe)
Open sores that can be painful and heal slowly
Patches of skin can be dry and scaly or ooze
Reddish brown discoloration of the skin
Honey-colored crusting when the skin becomes infected
Skin thickens and darkens with repeated scratching and rubbing
Violet-colored lesions may appear on lower legs and tops of the feet
The risk of developing stasis dermatitis increases with advancing age and the following:
High blood pressure (hypertension)
Heart condition, such as congestive heart failure (a weakened heart cannot pump blood effectively)
People who develop stasis dermatitis have an increased risk of developing other medical conditions, including contact dermatitis (a common type of eczema) and cellulitis (a skin infection that extends deeper than the surface of the skin).
Stasis dermatitis often is a long-term condition that requires care even when the skin clears.
Diagnosis begins with a complete medical history and visual examination of the skin. The following tests may be ordered because another skin condition can be present and effective treatment includes improving the circulation in the lower legs:
Doppler testing to evaluate blood flow to the legs
Patch testing to determine if the patient has developed an allergy(ies) that causes the skin to react
Biopsy of the affected skin
Getting signs and symptoms under control requires that the patient follow a comprehensive treatment plan that may involve:
Elevating the legs above the heart. When sitting and sleeping, this can improve circulation in the legs and decrease swelling.
Wearing a compression stocking while awake. Sometimes compression boots are prescribed. Both the stockings and the boots can improve circulation.
Treating congestive heart failure. Treatment may involve taking a low-dose diuretic to treat congestive heart failure or high blood pressure.
Applying a low-dose topical steroid. This can reduce inflammation.
Applying a topical antibiotic. This is necessary if the skin becomes infected.
Avoiding scratching. This is necessary to clear the skin.
Following wound-care instructions.
Getting the recommended bedrest. Sometimes strict bedrest is necessary.
Once the signs and symptoms have cleared, the patient may require lifelong preventive maintenance that includes:
Taking regular walks
Not standing for long periods
Elevating the legs when sitting or sleeping
Wearing compression stockings while awake
Moisturizing the legs regularly, usually with petroleum
Skin Care Physicians
COMMON INFECTIONS AND
INFLAMMATORY DISEASES OF THE SKIN
Scott Norton, M.D., LTC, MC, USA
Subjects covered in this
include common cutaneous infections and inflammatory skin diseases. The
of this lecture will be to present a clinical image of the disease, a
the histopathology, and a brief discussion of diagnosis and
treatment. Try to integrate the clinical presentation with
histopathologic features – this is called a clinicopathologic
SUPERFICIAL BACTERIAL INFECTIONS (OR PYODERMAS)
pyodermas on the depth of invasion of the skin and by the
organism. Impetigo remains the most superficial running through
fasciitis as the deepest pyoderma. These bacterial skin infections are
most commonly by the pyogenic bacteria, Streptococcus
Group A Strep and Staph.
aureus. Some lesions, such as
folliculitis and furuncles, are most commonly
caused by Staph.
is an acute superficial
pyoderma which heals without scar formation.
It is the most common bacterial infection of the skin in
Adults are sometimes affected, particularly athletes,
and those in institutions. Minor
especially from insect bites, as well as poor hygiene and a warm, humid
climate, all predispose to this
There are two clinical forms of
impetigo: a common vesicuopustular type, and a bullous variant, which
studies have shown
aureus is now the
usual organism isolated from common impetigo, which in the past was
mostly by group a β-hemolytic Streptococcus
(sometimes with Staph aureus as a
secondary invader). The
form has always been related exclusively to Staph
aureus, usually of phage group II. Staph scalded skin
syndrome is also a
toxin-mediated condition, with separation of the superficial stratum
from the lower epidermis.
Clinically impetigo appears as grouped small
flaccid blisters and honey-colored crusting, usually on exposed areas
head, neck and extremities. Bullous impetigo characteristically
round (circinate) blisters, which, when ruptured, leave a weeping
with a collarette of scale. This is most common in infants and
Histologically impetigo appears as epidermal vesiculobullous lesions with a very superficial separation at or below the granular layer. Subcorneal collections of neutrophils (pus) are seen in bullous impetigo.
is a deeper
then impetigo and much less common.
has a predilection for the extremities of children, often at sites of
trauma or insect bites, which allow entry of the causative bacteria.
Group A Streptococci,
particularly Strep pyogenes, are
usually implicated although Staph aureus
is sometimes isolated as well. The
lesions, sometimes multiple, consist of a dark crust adherent to a
and surrounded by rim of erythema. Scarring
usually results when the lesions heal.
Clinically ecthyma appears as
thick, crusted lesion, most commonly on the anterior shins. Insect
scabies, or minor scratches that become bacterially infected may
become ecthyma. If the crust is removed (naturally or mechanically),
there is a
small, saucer-shaped ulceration. Ecthyma will scar because it disrupts
Histologically ecthyma appears
as an epidermal ulcer with deep dermal inflammation, neutrophils,
is the diffuse
inflammation of the
connective tissue of the skin and deeper soft tissues.
It is deeper than impetigo and some cases of ecthyma,
Clinically, cellulitis present as an expanding area of
erythema, which is
usually and edematous, warm, and tender.
sometimes supervenes. The
these infections were usually caused by b-hemolytic
streptococci or Staph aureus.
A wide range of organisms is now implicated in
is a distinctive type
of cellulitis that has an elevated border and spreads rapidly.
Vesiculation may develop, particularly at the edge of the
The condition occurs particularly on the lower
extremities, and less
commonly on the face. Underlying
lymphedema may be present.
The causative Group A b-streptococci
or other organisms gain entry through superficial abrasions.
Clinically erysipelas appears as a large warm red plaque
characteristic raised or indurated border. It occurs most frequently on
and is associated with fever, malaise, chills, headache, and
Erysipelas and cellulitis are fairly similar although erysipelas
more elevated due to involvement of superficial lymphatics.
fasciitis (AKA the
flesh-eating bacterial disease) is a deep form of cellulitis that
progresses to gangrene and necrosis of several layers of tissue,
overlying skin, and occasionally including muscle. It often starts at
minor trauma such as a laceration, surgical wound, or puncture wound.
Serosanguinous blisters may develop, constitutional symptoms are
mortality may be high. It often occurs in somewhat debilitated patients
diabetics or alcoholics) although the majority of cases are in
fasciitis shows prominent inflammation in and around cutaneous arteries
fibrinoid necrosis and fibrin thrombi. There is dermal necrosis that
along fascial planes accompanied by infiltration with many inflammatory
(especially neutrophils), and large numbers of clumped
gram-positive bacteria in
Clinically a pustule is a
red papule at the opening of a hair follicle and often has a white head
(collection of pus).
Histologically it shows a necrotic hair follicle surrounded
by neutrophils, often accompanied by bacteria.
(AKA boil) is a painful, red perifollicular
nodule with formation of central pustule. When the pustule contains
heads (because it connects furuncles of several adjacent hair
follicles), it is
called a carbuncle.
Histologically a furuncle shows a deep follicular lesion
with perifollicular necrosis and many neutrophils and
Abscess is.a deep-seated inflammation with erythema, pain and possible fluctuance
an abscess shows inflammation and necrosis
with neutrophils and lymphocytes extending into the dermis and
1. Gram stain
3. Tissue gram stain (Brown
& Brenn; Brown & Hopp)
Topical, oral, parenteral
2. Anti-infective dyes (e.g., gentian violet)
Other Bacterial Infections:
albicans is the most frequent species of Candida
implicated in human infections. These
range relatively trivial superficial infections to fill disseminate
C. albicans is a normal
inhabitant of the gastrointestinal tract and is found in the mouths of
percent of normal individuals. It
is sometimes isolated from the skin surface, but it is not a usual
of the skin flora. There
factors that predispose to clinical infection.
These include pregnancy, the neonatal period,
immunological or endocrine
dysfunction, antibiotic therapy, and immunocompromised or debilitated
Local factors such as increased skin moisture and heat
also play a role.
Superficial candidiasis appears as red patches and
plaques surmounted by pustules, and crusting. Often there are red
pustules surrounding the primary area. Candidiasis is most commonly
mucocutaneous areas such as the mouth (thrush), perineal region
dermatitis), and intertriginous areas (candida intertrigo).
A number of clinical variants of candidiasis occur: acute
candidiasis, chronic mucocutaneous candidiasis, systemic or
candidiasis, and neonatal candidiasis.
periungual (paronychial), and genital candidiasis may also be
Histologically subcorneal pustule with neutrophils,
may be seen in the stratum corneum
1. KOH examination: pseudohyphae
1. Imidazole antifungals – topical or systemic
2. Amphotericin B (for systemic
The dermatophytes are a group
related filamentous fungi that have the ability to invade and colonize
keratinized tissues of man and animals.
caused by these fungi, which account for about five percent of
consultations, are known as dermatophytosis, ringworm, or tinea.
The clinical appearances are quite variable and depend on
a number of
factors, which include: species the fungus, site of infection,
status of the patient, and the prior treatment attempts (e.g. topical
antifungals, topical steroids. The
usual appearance on labor skin is a red, annular, centrifugally growing
with peripheral scale and exclamation and central clearing.
Broken hairs and second nails occur with infections
Tinea corporis, capitis, cruris, pedis, manuum and
erythematous, and scaly plaques. May also see non-inflammatory scaling,
erythematous papules or pustules. A type of inflammatory tinea capitis
kerion – boggy, inflamed, tender, crusted plaque with pustules. Another
variant is Majocchi’s granuloma: nodular perifolliculitis caused by
infection. Red, raised, crusted, boggy nodule, usually on the shins or
May be able to see the dermatophyte in the stratum
corneum, but best seen
with fungal stain (PAS). With tinea capitis, the fungal elements can
seen within (more common) or around the hair shafts.
1. Trichophyton spp. (e.g., T. tonsurans, T. rubrum, T. mentagrophytes)
2. Epidermophyton floccosum (does not cause tinea capitis)
spp. (e.g., M. canis)
1. KOH examination; calcifluor fluorescence microscopy
1. Topical and systemic imidazoles or triazoles
V. VIRAL INFECTIONS WITH HERPES SIMPLEX VIRUS
Infection/Recurrent disease: grouped vesicles on
usually localized, but may be generalized in immunocompromised persons.
primary infection may cover a larger surface area and is often
constitutional symptoms. Immunocompromised host may have variant
such as ulcerative, vegetative, or verrucous lesions.
Histologically lesions of HSV
show ballooning degeneration of epidermal cells with epidermal necrosis
(ulcerations) or hyperkeratosis (vegetative, verrucous lesions).
Multinucleate giant cells, margination of nuclear
1. Tzanck smear (multinucleated giant cells)
2. Direct fluorescent antibody test (DFA)
4. Viral culture
1. Acyclovir, Valacyclovir
or chickenpox is an acute systemic viral illness, usually of children,
characterized by a pruritic generalized vesicular eruption and fever.
caused by the varicella-zoster virus (VZV) for which there is a
zoster is caused by the same virus as chickenpox, occuring in
partial or waning immunity from a prior varicella infection.
grouped blisters on
erythematous base, in a dermatomal/unilateral distribution. A few
lesions (up to
15-20) may fall outside of the dermatome, but if more than this, it may
represent disseminated zoster. Zoster represents reactivation of latent
sensory ganglia. The
through the sensory nerves to reach the skin, where it replicates in
epidermal keratinocytes. Clinically,
zoster is an acute disease that occurs almost exclusively in adults.
The condition begins with pain in the area innervated by
sensory ganglia. The
skin in this
area becomes red, and papules to develop.
quickly transformed to vesicles and then pustules.
Crusts then form and later healing takes place.
Chronic hyperkeratotic and verrucous lesions may occur in
immunocompromised patients. Sometimes
there is residual scarring, particularly if there has been secondary
infection of the vesicles. The
ganglia most usually involves are those of the lumbar and thoracic
Ocular damage may result when the ophthalmic division of a
nerve is involved.
infections appear the same as Herpes Simplex.
2. Tzanck smear (multinucleated giant cells)
3. Direct fluorescent antibody test (DFA)
1. No intervention
2. Acyclovir, Valacyclovir
3. supportive measures: pain relief, antipruritics,
4. infection control
VII. VIRAL INFECTIONS WITH MOLLUSCUM CONTAGIOUSM VIRUS
contagiosum occurs as a solitary or multiple dome-shaped,
umbilicated, waxy or
pearly papules with a predilection for flexural areas of children and
may occur and is often indicated by the appearance of molluscum on the
arch. Papules range
from 2 to 8 mm
in diameter, although solitary lesions may be slightly larger.
Spontaneous regression often occurs within a year,
persistent lesions are encountered.
lesions can occur in immunocompromised patients, particularly those
are synonymous but non-specific terms that encompass inflammatory
eruptions that are red, scaly, vesicular, and pruritic. There are many
eczema including allergic contact, atopic, nummular, seborrheic,
stasis, irritant contact, and associated with infections.
chronic disease of the skin. Most commonly one sees flexural
erythema, scaling, lichenification. With acute flares, there will be
redness, scaling, yellow crusts (impetiginization).
seen primarily in infants
and post-pubertal children and adults. Greasy, dull red or yellowish
the seborrheic areas.
eczema (pomphylox): itchy, vesicular eruption of
the palms, soles and
digits. Deep seated nature of the vesicles may give them the appearance
multiple round, coin-shaped
plaques with scaling and vesiculation. May be associated with atopic
very dry skin (xerosis), and irritants
impaired venous return from
the lower limb, with resultant irritation, dry skin, and pigmentary
Usually seen on the medial aspect of the leg and ankle.
Allergic contact dermatitis: erythematous plaques with micro- and macrovesicles and serous crusting. Caused by an immune-mediated reaction to environmental/topical allergens. Frequent offenders include plants (poison ivy), metals (nickel), fragrances.
Histologically for all the
conditions, the histologic appearance may vary, depending on the
Acute allergic contact dermatitis is a model for other eczemas. Histologically we see an epidermal intercellular edema (spongiosis) with micro- or macro-vesicles. There is a superficial dermal lymphocytic infiltrate with some migration of inflammatory cells into the epidermis (exocytosis).
testing (allergic contact dermatitis)
Other related Skin Conditions:
Elephantiasis nostras verrucosa - Skin Plaque and Nodules
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