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TABLE OF CONTENT
DERMATOLOGICAL DISEASES
Introduction of Skin Diseases Dr. K.K. LO
Pruritus Dr. C.S. LEUNG
Eczema Dr. Y.M. TANG, Dr. H.F. HO & Dr. K.H. YEUNG
Psoriasis Dr. K.K. LO & Dr. L.Y. HO
Acne Vulgaris and Other Acneiform Eruptions Dr. C.Y. LEUNG
Urticaria Dr. C.Y. LEUNG
Vitiligo Dr. R. SU
Cutaneous Vasculitis Dr. R. SU
Collagen-vascular Diseases Dr. R. SU & Dr. Y.M. TANG
Blistering Diseases Dr. C.N. LOOK
Alopecia Dr. C.N. LOOK
Nail Diseases Dr. H.F. HO
Cutaneous Malignancies Dr. H.F. HO
Infection: Bacterial, Viral, Fungal Dr. W.K. FUNG
Infestations Dr. T.S. AU
Cutaneous Tuberculosis and Atypical Mycobacterial Infection Dr. L.Y.
CHONG
Leprosy (Hansen's Disease) Dr. N.R. HONEY & Dr. K.K. LO
Practical Guidelines for Phototherapy Dr. L.Y. CHONG
Health Nursing in Skin Clinics Ms. M. WONG, Mr. W. LEUNG, Mr. E. WAN
& Subordinates
Health Nursing in Special Skin Clinics Ms. M. WONG, Mr. W. LEUNG &
Subordinates
Cutaneous Laser Therapy Dr. L.Y. CHONG & Dr. H.H.L. CHAN
Cutaneous Manifestation of Internal Disease Dr. H.H.L. CHAN & Dr. W.K.
FUNG
Cutaneous Drug Eruptions Dr. L.Y. CHONG
SEXUALLY TRANSMITTED DISEASES
Introduction of STD Dr. L.Y. CHONG
Syphilis Dr. L.Y. CHONG
Gonorrhoea Dr. K.H. LAU & Dr. H.F. HO
Non-Gonococcal Urethritis and Non-Specific Genital Infection Dr. K.T.
CHAN
Chancroid Dr. Y.M. TANG
Lymphogranuloma Venereum Dr. N.M. LUK
Genital Warts Dr. C.Y. LEUNG
Genital Herpes Dr. C.N. LOOK
HIV Infection Dr. L.Y. CHONG
Molluscum Contagiosum Dr. S.Y. CHENG
Candidiasis Dr. L.Y. CHAN
Trichomoniasis Dr. C.S. LEUNG
Pediculosis Pubis Dr. W.M. CHEUNG
Balanitis, Bacterial Vaginosis and Other Genital Conditions Dr. T.S. AU &
Dr. K.H. YEUNG
STD in Pregnancy Dr. K.M. HO & Dr. W.S. LAM
Health Nursing in Social Hygiene Clinics Mr. W. LEUNG, Mr. S. LEUNG,
Mr. T. LAM & Subordinates
TOPICAL PREPARATIONS FOR
DERMATOLOGICAL & SEXUALLY TRANSMITTED DISEASES
Basic Pharmacology and Terminology of Topical Preparations
Dr. Y.M. TANG & Dr. R. SU
Principles of Prescribing Topical Preparations and Topical Steriods
Dr. Y.M. TANG & Dr. R. SU
Government Formulary
Dr. Y.M. TANG & Dr. R. SU
Commercial Dermatological Preparations and Sunscreens
Dr. K.M. HO, Dr. R. SU & Dr. Y.M. TANG
APPENDIX
Dermatology, Social Hygiene and Special Skin Clinics in Hong Kong
Medical staff of Social Hygiene Service
Publications from/Contributed by Social Hygiene Service
Annual Incidence and Trends of Disease
Suggested Books for Reading
Normal Laboratory Values
3. PHYSICAL EXAMINATION
3.1. General Examination
Good lighting, adequate privacy, light torch, spatula, magnifying glass and
transparent glass slide for diascopy. General impression on the patient is
very important especially for the general health, pallor, intellectual
assessment, queer personality etc. will be picked up by an observant doctor
when patient enters the consultation room.
3.2. Examination of Skin
Distribution of the rash, arrangement and morphology of individual rash.
Distribution of the lesion: symmetrical, asymmetrical, exposed area, sun
exposed area, scalp region, hand, extensor aspect, flexor aspect.
Arrangement and configuration of the lesion: grouped (as in insect bites,
dermatitis herpetiformis, herpes simplex, common warts), annular or
arciform (as in granuloma annulare, mycosis fungoides, tinea circinata,
erythema annulare centrifugum), linear pattern (as in Koebner phenomenon,
Psoriasis, lichen planus, plane wart, molluscum contagiosum; epidermal
naevus, sporotrichosis, lichen striatus, lichen simplex, morphoea, lichen
sclerosis, phytophotodermatitis).
Morphology of lesion: Individual lesion described with the help of
magnifying glass. To find out the early primary lesion and to inspect it
closely. Note the shape(geometric shape, oval), colour(salmon-pink,
erythematous, skin colour, yellow), size, margin (sharpness of edge, well-
defined, ill-defined), the surface characteristics (dome-shaped, umbilicated,
spike like), temperature and smell.
It is a good practice if affordable to have thorough examination of the whole
body especially for new consultation and for the elderly. Sometimes,
examination of the back and buttock of the elderly may pick up unexpected
lesions, even the patient himself or herself may not notice them e.g.
persistent chronic annular erythematous rash in the buttock found in a case
of tuberculoid leprosy. Do not skip examination of the nail, scalp and oral
mucous membrane because there may be valuable clues. Making it a habit to
examine these sites routinely is important.
3.3. Terminology Used in Dermatology
Macule: flat area of altered colour or texture (less than 0.5 cm)
Patch: large macule (more than 2 cm)
Papule: elevated solid lesion (less than 0.5 cm)
Nodule: elevated solid lesion (more than 0.5 cm)
Plaque: elevated area of skin of more than 2 cm in diameter, a disc shaped
lesion, formed by extension or coalescence of papules or nodules.
Vesicle: fluid filled blister (less than 0.5 cm)
Bulla: larger blister (more than 0.5 cm)
Pustule: collection of free pus
Abscess: localized collection of pus in a cavity (more than 1 cm)
Petechia: pinhead size extravasation of blood into skin
Ecchymosis: larger extravasation of blood into skin
Purpura: blood in skin up to 2 mm in diameter, may be palpable
Haematoma: large purpura
Wheal or weal: accumulation of dermal oedema
Angioedema: diffuse oedema of deep dermis extending to subcutaneous
tissue
Comedo (comedones): a plug of keratin and sebum wedged in a dilated
pilosebaceous orifice
Burrow: a small tunnel in the skin that houses scabies acarus
Telangiectasia: visible dilatation of small cutaneous blood vessels
Poikiloderma: combination of atrophy, reticulate hyperpigmentation and
telangiectasia
Sclerosis: induration of the subcutaneous tissues
Gangrene: death of tissue, usually due to loss of blood supply
Scale: flake from the horny layer
Crust: dried serum, exudate or tissue fluid
Ulcer: whole of the epidermis and part of dermis lost
Excoriation: linear erosion or ulcer produced by scratching
Erosion: partial loss of the epidermis
Fissure: slit in the skin
Sinus: channel that permits escape of pus or fluid
Scar: result of healing, normal structure replaced by fibrous tissue
Atrophy: thinning of skin due to diminution of the epidermis, dermis or
subcutaneous fat
Stria: linear, atrophic, pink or white lesions due to changes in connective
tissue
3.4. Special Techniques Used in Clinical Examination
Magnification with hand lens is important to note the fine details of skin
lesions: Magnification is essential to examine follicular plugging in lupus
erythematosus, Wickham's striae in lichen planus, telangiectasia and
translucence in basal cell carcinoma, changes in colour in malignant
melanoma.
Tangential shining of examination torch to the skin lesions will enhance and
detect elevated skin lesions with ease.
Diascopy consists of pressing a transparent slide or plastic spatula over a
skin lesion. Examiner will find this of special value to distinguish erythema
or purpura. It is useful to detect the glassy yellow-brown appearance of
papules in sarcoidosis, tuberculosis and other granuloma.
Darier's sign is positive when a brown macular or papular lesion of urticaria
pigmentosa becomes palpable wheal after being rubbed with the blunt end of
an instrument. Auspitz's sign is positive when slight scratching or curetting
of a scaly lesion reveals punctate bleeding points within the lesion which
suggests of psoriasis. Nikolsky's sign is positive when a new blister is
generated with ease by applying shearing force to skin.
4. DERMATOLOGY INVESTIGATIONS
4.1. Skin Biopsy
Specimen is sent for Histopathology, direct Immunofluorescence study or
culture and smear for AFB, fungus. Try to sample a representative lesion,
avoiding sites where scar would be conspicuous, avoid keloid prone area i.e.
upper anterior chest, avoid legs where healing is slow and histology
modified, avoid over bony prominence, place in proper fixative or fresh (as
in immunofluorescence staining or culture) and make sure the correct
labeling with name, site, history, diagnosis. Discussion with the pathologist
is often helpful.
Punch biopsy: 3 to 4 mm tissue punch, specimen not to be crushed with
tooth forceps, skin hook may be good in handling the tissue.
Scalpel biopsy: elliptical excisional, incisional or shave biopsy. 3/0 non-
absorbable sutures for legs, 5/0 for face and 4/0 else-where. In general,
stitches are planned to be removed from the wound in face 4-5 days, from
the neck and the scalp in 7 days, from the anterior trunk and arms in 12 to 14
days, from back and legs in 14 to 28 days. Skin splints in the form of Steri-
Strips can be applied after stitches are removed. They can be kept for two to
six weeks after suture removal.
4.2. Wood's Lamp Examination
Ultraviolet light of 365 nm wavelength is obtained by passing the beam
through a Wood's filter composed of nickel oxide containing glass. The
examination has to be done in a dark room. Infected hair in tinea capitis
caused by Microsporum canis will fluoresce bright green, skin lesion of
active pityriasis versicolor will fluoresce yellow, fresh urine in porphyria
cutanea tarda fluoresces a reddish colour, erythrasma will fluoresce coral
red, vitiligo lesion appears more white and ashleaf macule in Tuberous
sclerosis is more apparent, coral red fluorescence of teeth in congenital
erythropoietic porphyria. Make sure that there are no artificial cream or
cosmetic are left in the area of skin examined by Wood's light because many
creams or dyes will fluoresce under Wood's light.
4.3. Patch Test
This tests the type IV hypersensitivity reaction and it is a confirmatory test
for allergic contact dermatitis.
Trolab standard patch test is used to screen and confirm allergic contact
dermatitis. Further breakdown of the test may require patch test with
different series e.g. fragrance series. The test materials are applied to the
back under aluminium discs with occlusion. The sites are inspected at 48
hours and test materials removed. The sites are re-inspected at 96 hours for
delayed reaction. The grading of the reaction will be as follows:
No reaction: 0
Doubtful: +/-
Weak (erythema, non-vesicular): +
Strong (vesicular or edematous): ++
Extreme (with ulceration): +++
Irritant reaction: IR
Not tested: NT
4.4. Mycology Examination
Superficial fungi can be identified by examination of the skin scraping, nail
or hair. The scales, nail or hair should be collected onto a slide and a drop of
10 to 20 percent KOH to dissolve the keratin. It can be hastened by gently
warming the preparation but never over warm to cause bubbles with
artefacts affecting microscopic examination. It takes 10 to 15 minutes to
prepare for scales, but it takes longer for nail clipping from 30 to 45 minutes
for best preparation. Then it can be examined under low power objective and
then the high power objective for detail. The tissue can also be sent for
mycology culture. The result may not be available for 3 weeks.
4.5. Mite Examination
To identify the burrow in common area e.g. finger webs. With the help of
magnifying glass, the acarus may be seen as a tiny grey dot at the end of
burrow. It can be removed by a sterile needle. If mites not seen, burrow will
be moistened with liquid paraffin or mineral oil and scraping with the
scalpel blade and transferred to slide for examination.
4.6. Blood & Urine Tests
Just like that in general internal medicine, appropriate tests e.g. muscle
enzymes to exclude dermatomyositis, urine sugar test to exclude diabetes
mellitus.
4.7. Radiology Examination
The commonest tests done are X-ray chest to exclude pulmonary
tuberculosis and X-ray joints for psoriatic arthropathy. CT scan is important
for exclusion of internal enlarged lymph nodes in cutaneous lymphoma and
to exclude brain lesions in a case of neurofibromatosis.
4.8. Other Tests
Prick testing is much less helpful in dermatology. It is not done or available
in Social Hygiene Clinics. Multiple positive skin tests to commercially
prepared diluted antigens may only imply the atopic tendency of the tested
subject. Dark-ground examination for suspected genital ulcer to look for
Treponema Pallidum can be easily done when equipped with a dark-ground
microscope. It is the interpretation of the wet smear which may require some
experience. Acetic acid test on genital or cervical papules facilitates
detection of subclinical condylomata acuminata. Gauze saturated with 5%
acetic acid is wrapped around area for 5 to 10 minutes and the use of
colposcope or magnifying hand lens to detect the lesional white papules.
Cell cytology (Tzank smear) is not available in the clinic because it requires
a good and well trained cytologist for the smear.
4.9. Clinical Photography
Clinical photo is the best to document any lesion. One picture worths
thousand words of description. Usually all medico-legal cases, biopsy cases,
complicated cases and skin cancer cases require the clinical photo as an
additional documentation. It is a useful investigation tool for follow-up of
lesions e.g. naevus sebaceous, pigmented naevus. Standard macro lens with
fixed magnification in good focus, appropriate flash-lamp (with good
battery) or good lighting, with good backgrounds (pure blue or green cloth
as background) will make the photo not a waste. Date, site of photo taken
and a good filing system are needed to make it a useful and interesting tools
for investigation in dermatology.
5. PATTERN OF COMMON SKIN DISEASES IN SOCIAL HYGIENE
CLINICS
1) The commonest 20 skin diseases in the statistical return in 1996 in
dermatology clinic of Social Hygiene Service.
Rank Condition Incidence (new cases)
1 Eczema 4,931
2 Tinea (all types) 1,577
3 Verruca 1,263
4 Acne 764
5 Contact Dermatitis 642
6 Psoriasis 560
7 Urticaria 421
8 Herpes infections 381
9 Pigmentary disorders 329
10 Alopecia 322
11 Naevi (all types) 310
12 Neurodermatitis 292
13 Pityriasis versicolor 210
14 Rosacea 195
15 Skin tags 162
16 Scabies 157
17 Seborrhoeic wart 154
18 Nail dystrophy 86
19 Keratosis (all types) 81
20 Cysts 55
21 Others 2,628
¡@ Total 15,520
2) Skin malignancies (biopsy confirmed cases) in 1992 to 1996.
Diagnosis 1992 1993 1994 1995 1996
Basal cell carcinoma 53 59 79 72 84
Squamous cell carcinoma 10 12 9 10 22
Malignant melanoma 3 4 0 9 3
Bowen's disease 22 18 16 23 23
Extramammary Paget's Disease 5 1 7 1 1
Adenocarcinoma 2 0 0 1 0
Lymphoma/Mycosis Fungoides 3 9 5 16 9
Kaposi's sarcoma 0 3 4 3 1
Baso-squamous carcinoma 0 0 0 0 0
Angiosarcoma & Metastatic carcinoma 0 0 1 2 3
Sebaceous carcinoma & Trichilemmal
0 0 0 0 0
carcinoma
Other carcinoma of skin 0 0 0 2 4
Solar keratosis 18 15 21 32 54
Total 116 121 142 171 204
PRURITUS
Dr. C.S. LEUNG
CHAPTER 2
1. PATHOPHYSIOLOGY
Itch receptors are unmyelinated, unspecialized free nerve endings, found
near to the dermal- epidermal junction. It was widely believed in the past
that pain and itch are transmitted by the same nerve pathway, and also low
intensity stimulation of unmyelinated polymodal C fibre results in itch
sensation whereas high intensity stimulation causes pain. However, in recent
experiments, when single unmyelinated C fibres are stimulated two sets of
fibres have been identified. Stimulation of most these fibres produce pain
sensation, whereas a small number of fibres produce the sensation of
itchiness upon stimulation. (Greaves)
2. PERIPHERAL MEDIATORS
1) Histamine
2) Neuropeptides, including substance P
- Substance P, together with neuropeptides, is localised in cutaneous sensory
nerve endings. They could be depleted by capsacin cream.
3) Other relevant periperhal mediators
Arachidonic acid transformation products
- Prostaglandin E potentiates itchiness caused by other mediators
Platelet activating factor
Other vasoactive peptides and proteases
Others
Finally, it is found that enkephalins, which are opioid pentapeptides, exert a
modulatory action on transmission of pain and itchiness.
3. Causes of itchiness
Understanding the various causes of pruritus is fundamental to its
management.
3.1. Localized Causes
Certain skin disease may select to affect a particular site of a body causing
localized pruritus. Some of the important examples of localized pruritus are
as follows:
Scalp: Seborreic eczema and neurodermatitis, psoriasis
Eyelid: Airborne irritants or allergens; allergic reactions to cosmetics and
nail vanish
Fingers: Eczema, scabies, fowl mite infestation
Legs: Gravitational and discoid eczema, asteatosis
4. Evaluation
4.1. A, B, C
The patient must be evaluated for the A (external causes), B (skin diseases),
C causes (systemic causes: which in turn include the BLINKED causes) as
mentioned. The evaluation consists of taking a detailed history, physical
examination and laboratory investigations.
4.2. History: Detailed History of the Present Illness
Besides, the following questions concerning the features of pruritus is
relevant:
1) Is the pruritus localized (external cause) or generalized (internal cause)?
2) Is only the exposed skin affected? If yes, this implies an exogenous cause.
3) Are any other family members affected?
4) Is there relationship with occupation? e.g. exposure to fibre glass.
5) Is there any recent history of travel? (tropical infestations?)
6) Is there exposure to plants, animals or chemical?
Characteristics of pruritus:
1) Site, whether localized or generalized.
2) Precipitating and relieving factors: e.g. any relation to hot bath such as
found in aquaenic pruritus?
3) Severity: the influence on daily activities/sleep.
4) Time relationship: most itchiness are worse at night, esp. scabies.
5) Seasonal variation: asteatotic eczema is usually worse in winter.
The history should include assessment of personality, current emotional
stress.
Past medical history
Family medical history
4.3. Physical Examination
A complete physical examination is performed with the various possible
differential diagnosis (the A, B, C causes) in mind. During the physical
examination, particular attention should be paid to vital signs,
lymphadenopathy and enlargement of organs etc., with special alertness to
any possible connection between cutaneous sign and disease of other organ
system. In the absence of obvious localizing signs or symptoms indicating
systemic disease, rectal and pelvic examination should be included in the
full physical examination.
Patient with P.U.O. (pruritus of unknown origin) must be considered for any
underlying disorder, e.g. "occult carcinoma" may need to be ruled out in
elderly patient presenting with persistent pruritus.
4.4. Laboratory Investigation
1) Haematological: CBP, ESR
2) LFT, RFT, acid phosphatase, serum iron, serum protein electrophoresis,
immunoelectrophoresis
3) Thyroid function test/glucose
4) CXR
5) Stool for occult blood, ova/cyst
6) Urine for R/M
7) Skin biopsy
8) Others: e.g. test for HIV antibody, Pap smear, further radiological
examination if indicated
Further investigations may be necessary depending on the situation.
5. Treatment
1) Treat the underlying cause.
2) General symptomatic treatment
a) To reduce or avoid any provocative factors, e.g. dryness of the
environment, wearing irritating fabric, overheating, stress, vasodilatation
from hot food.
b) Topical applications: Emollient, menthol in calamine lotion can be used.
3) Commonly used oral medication: Antihistamine are most useful in
conditions in which antihistamine clearly plays a role, e.g. urticaria.
Histamine is the most consistent itch mediator known, but it is not always
useful as other mediators may also be involved.
* Tricyclic antidepressants may be of help in some patients with intractable
itching.
4) For treatment of the pruritus of some of the specific disorders, the
following measures have been reported to be useful. (Some of these
treatments may need further studies and trial for evaluation.):
a) Aquagenic pruritus +/- polycythaemia vera (PV)
Topical capsacin treatment
PUVA (maintenance therapy may be necessary), UVB
regional sponging at bathing may be helpful in aquagenic pruritus with PV.
Interferon alpha: not only controls the pruritus, also helps to contain the
increased haemopoiesis in PV, and lead to better haemopoietic control. Yet
some patients may not be able to stand the side effect.
Phlebotomy reported to be useful in a case of PV.
N.B.: The pruritus usually responds poorly to antihistamine
b) Obstructive jaundice
cholestyramine is helpful, but is associated with a high incidence of side
effects.
new anion resin, BR 350
rifampicin
antihistamine
naloxone infusion, opiate antagonist
Ondansetron, a specific serotonin type 3 (5-HT3) receptor antagonist
Flumecinol used in pruritic patients with primary biliary cirrhosis
propofol (an intravenous anesthetic induction agent) employed in a
subhynotic dose, for short term use.
c) Chronic renal disease: Some patients with hyperparathyroidism
secondarily to renal failure improve dramatically after subtotal
parathyroidectomy. However, only a minority of patients respond and the
improvement may only last a few months.
Phototherapy by UVB for moderate to severe cases.
Emollients may relieve those with a dry skin.
Activated charcoal or cholestyramine orally may be helpful.
Capsacin cream topically.
Ketotifen.
Azelastine hydrochloride (an anti-allergic drug/antihistamine) orally.
Talidomide for difficult cases.
Other treatments including heparin, mexiletine, ion-exchange resin and
intravenous lignocaine have been advocated but are of uncertain
effectiveness and usually impractical to use.
Low protein diet was reported to be useful.
Antihistamine and topical steroids are usually not helpful.
d) Psychological/psychiatric diseases: psychiatric advice should be sought.
After careful consideration, antidepressant and anxiolytic drugs including
doxepin and hydroxyzine can be tried.
Pimozide has been advocated for delusions of parasitosis.
e) Atopic eczema:
Doxepin cream.
f) Myeloproliferative disorders and other disease:
Danazol has been tried in the treatment of refactory pruritus associated with
myeloproliferative disorders and other disease e.g. autoimmune disease etc.
5) Other medication/measures that has been employed to treat generalised
pruritus:
Odansetron (5 HT3 antagonist)
transcutaneous nerve stimulation
ECZEMA
Dr. Y.M. TANG, Dr. H.F. HO & Dr. K.H. YEUNG
CHAPTER 3
1. INTRODUCTION
1.1. Terminology
ECZEMA: Use as a clinical descriptive term, it describe a process that is
clearly superficial in form and that, early, is erythematous, papulo-vesicular,
oozing and crusting and, later, red-purple, scaly, lichenified and possibly
pigmented. Epithelial disruption and non-sharp margination are its
characteristics.
ECZEMA can be defined histologically by the presence of a predominantly
lymphohistiocytic infiltrate around the upper dermal blood vessels,
associated with varying degrees of spongiosis and acanthosis.
The terms 'ECZEMA' and 'DERMATITIS' are regarded as synonymous.
1.2. Table 1: Stages of Eczematous Inflammation
Exogenous Endogenous
Irritant Dermatitis Atopic
Photoallergic Contact
Asteatotic Dermatitis
Dermatitis
Eczematous Polymorphous
Discoid Eczema
Light Eruption
¡@ Gravitational Eczema
2. ATOPIC ECZEMA
Atopic eczema (AD) is a characteristic type of chronic dermatitis frequently
associated with atopy and an elevated IgE level. There are no single
distinguishing features of AD; however, the diagnosis can be made on a
combination of history, and morphological findings.
2.1 Epidemiology
AD has a world-wide distribution and affects all races. About 3% of children
under age 5 years had AD with a male to female ratio of 1.2 : 1. Majority of
patients presents within the first 5 years. AD runs in family. About 75% of
patients have a personal or family history of other atopic diseases, e.g.,
allergic rhinitis, asthma, hay fever.
2.2. Aetiology and Pathogenesis
The aetiology is unknown and the pathogenetic mechanisms are speculative.
However, a number of clinical, pathological and immunological
abnormalities are frequently observed in these patients and are briefly
discussed below:
1) Elevated IgE
Occur in about 80 percent of AD patients and are directed against a wide
variety of antigen like pollens, molds, foods, house dust mites (HDM) and
bacterial antigens etc. A high IgE level is not a unique feature of AD but
appears to correlate with the clinical severity and falls with remission.
2) Skin Prick Test and RAST
Patients with AD often show positive Prick test and RAST to common
household allergens like egg, milk, wheat, fish, soy, peanut, pollens, HDM
and animal danders etc. However, avoidance of such allergens does not
necessarily bring about a clinical response.
3) Bacterial Antigens
Staph. aureus colonization occurs in over 50% of AD patients and compared
to less than 5% in normal individuals, and is frequently isolated (> 90%)
from acute exudative lesions and lichenified plaques. The density of the
organism correlates with the severity of eczema and antibiotics that clear
Staph. aureus improve eczema.
4) Impaired Cellular Immunity
This includes a reduced CD8+ suppressor T cells, a reduced natural killer
cell function, a reduced IFN-g production, a reduced response to mitogens;
peripheral eosinophilia in some and abnormal neutrophil chemotaxis.
5) Inflammatory Cells and Mediators
A very characteristic feature of AD is intense pruritus. It has been shown that
an increased population of mast cells occurs in the skin of AD patients
which releases histamine, leukotrienes and cytokines much more readily
compared with normal subjects.
6) Abnormal Vascular Responses
Disturbed vascular reactivity like white dermographism, nicotine blanching,
and delayed blanch with methacholine are well documented.
7) Sweat and Sebum Production
AD patients tend to produce more sweating than nonatopic controls. It has
been suggested that an increase in transepidermal water loss, and a possible
deficiency of lipids in the epidermis account for the skin dryness.
2.3. Clinical Features
1) Pruritus
Is the hallmark of AD. It is more severe at night and is attributed to the
absence of distraction, capillary dilatation, and increased skin temperature. A
natural response to itch would be scratching, and scratching results in
erosions, weeping, crusts, secondary infections, prurigo papules and
lichenification.
2) Dry Skin (Xerosis)
Manifests as scaling, chapping and a feeling of skin roughness. It is worse in
winter times due to reduced ambient humidity and coldness. Dry skin is
enhanced by frequent use of detergents or defatting substances.
3) Eczematous Lesions
The most typical skin sign of infantile AD. They are polymorphic, with an
erythematous, papulovesicular, erosive and crusted appearance.
4) Prurigo
Is a dome-shaped papule, sometimes with a tiny vesicle on top. Excoriation
is frequent. Prurigo papules vary in number and distribution.
5) Lichenification
A lichenified plaque is a poorly demarcated, slightly tan to red plaque with
grossly accentuated skin markings. Lichenified plaques take long time to
resolve. The antecubital and popliteal fossae and the neck are predilected
sites.
6) Dennie Morgan Fold
Is an extra infraorbital eyelid fold. About 80% is bilateral. Some consider
this is a consequence of scratching of the eyelids.
7) Hand and Feet Ivolvement
Dry, nonpruritic plaques and recurrent hyperkeratosis and fissuring of the
finger pulps (and soles) are common. Linear furrows running across thenar
and/or hypothenar eminences referred to as hyperlinearity of palms occurs in
about 1/3 to 1/2 of AD patients. Coarse pitting and ridging of nails may
occur.
2.4. Four Phases of AD
1) Infantile Phase
Lesions first appear on the cheeks, forehead, and scalp, but may occur on the
trunk, neck, hands and feet. Eczema with oozing and crusts are more typical.
Nocturnal restless, irritability and crying are prominent. When the child
begins to crawl, the exposed areas especially the extensor aspects of knees
are affected.
2) Childhood Phase
At about 18 months, the eczematous lesions tend to be replaced by
lichenification. Prurigo papules occur and are very itchy. Elbow and knee
flexures, wrists and ankles and neck are commonly involved. The neck may
show striking reticulate repigmentation (dirty neck). Hands may be dry and
lichenified; sole involvement may mimic juvenile plantar dermatosis. The
face is less frequently affected. Problems with schooling may occur.
3) Adolescent/Young Adult Phase
Predominant features are pruritus, lichenification, prurigo papules, scratch
marks, and crusting. Lesions occur mostly on the face, neck, flexures, and
upper trunk. Localized patches of eczema around the nipple or vermillion of
the lips can occur. Psychological difficulties occur in some.
4) Adult Phase
AD resolves spontaneously in most patients after age of 20. Majorities of the
patients, however, still have sensitive, unstable skin and a higher tendency to
develop dermatitis. Full blown AD occurs in only a small percentage of
patients throughout adulthood.
2.5. Associations
The association of AD with allergic rhinitis, asthma and conjunctivitis is
well documented. Eczematous conditions like contact dermatitis, discoid
eczema, pityriasis alba, lip-stick eczema and follicular eczema are more
frequently seen in atopic subjects. Others like ichthyosis vulgaris, keratosis
pilaris, Netherton's syndrome, alopecia areata and vitiligo etc. also have
linkage.
2.6. Complications
1) Infection
Bacterial especially Staph. aureus, viral, and fungal infections are common,
and so as scabies. Eczema herpeticum, which is herpes simplex infection in
eczematous skin is characterized by multiple, painful, vesiculopustular
lesions; and often become haemorrhagic, eroded and crusted. Affected areas
may be very edematous; regional lymphadenopathy occurs and secondary
bacterial infection is common. Diagnosis can be established by Tzanck
smears or electronmicroscopy from scarping of the skin lesions.
2) Exfoliative Dermatitis
This is severe and requires hospitalization.
3) Eye
An increased incidence of anterior subcapsular cataract may be due to
extensive use of systemic steroid, and to topical steroid applying around the
eyes. Keratoconus is corneal degeneration characterized by increasing
conicity of the cornea resulting from a raised intraocular pressure. Visual
disturbance occurs.
4) Retarded Growth
May be attributed to a combination of reduced exercises, infections, and
malnutrition secondary to inappropriate dietary restriction; however,
frequent use of systemic/topical steroid is perhaps a more important
contributing factor.
¡@
2.7. Criteria for Diagnosis of Atopic Eczema
Major criteria Minor criteria
Pruritus Dryness
Typical morphology and distribution Hyperlinearity of palms/Keratosis
. pilaris
of skin lesions. Increased IgE
Chronic and relapsing course Early age of onset
Personal or family history of atopy Tendency to cutaneous infection
Cheilitis
Dennie-Morgan infraorbital folds
Pityriasis alba
Keratoconus/anterior subcapsular cataracts
White dermographism etc.
There is no single diagnostic feature for AD. However, it has been suggested
that a diagnosis of AD can be established with 3 or more major criteria plus
3 or more minor criteria.
2.8. Differential Diagnosis
Infantile seborrhoeic dermatitis has an earlier onset than AD. The presence
of family history, scratching, possible food intolerance, and high IgE level in
AD is absent in seborrhoeic eczema. Allergic contact dermatitis with
autosensitisation, psoriasis, candidiasis, dermatophytosis, pityriasis rosea,
scabies, nutritional deficiency may at times cause confusion.
2.9. Treatment
1) General Measures
a) Explanation
Explanation on the nature and management of AD improves compliance and
efficacy of treatment. AD runs a long course that can be controlled but not
cured. AD improves with increasing age, but patients often have a dry,
sensitive skin and avoidance of irritants and trigger factors is always
necessary. Good medical compliance is important. Scratching of skin should
be discouraged in order to disrupt the itch-scratch cycle; keep nails short.
Immunization is given as non-atopic subjects but should be cautious for
vaccines derived from eggs if patient is egg-sensitive. Defer vaccination if
the child has an acute flare of eczema. Career advice emphasizes the
selection of a 'clean' job. Occupations like barber, chef, laboratory
technician, car mechanic, nurse and jobs that require contact with chemicals
are not suitable.
b) Environmental Modification and Avoidance of Trigger Factors
Woolly underclothes irritate skin and should be avoided Woolly toys tend to
house allergens so as carpets. Pets have the similar problem; their hair and
excreta can be allergenic and pets are a source of infestation. Avoid
excessive heating in the bedroom as this increases dryness and itchiness.
Regular once daily bathing is not strictly required. Over-bathing or over-use
of soaps is detrimental to the sensitive skin. Avoid bathe with hot water, use
soap substitutes, avoid vigorous rubbing at the skin and keep the bathing
time short. The skin should be mopped dry immediately after bathing and
emollients applied. Swimming is permitted but chlorinated water irritates
skin and hence immediate showering is required afterwards. Many cosmetic
products have the potential to trigger a flare. Foods implicated as allergenic
include eggs, milk, wheat, legumes, seafood and peanuts. Few young
patients do have a clear relationship between food and eczema flares. In such
case, they can try a 3-4 week's period of suspected food elimination. One
should aware that unsupervised food restriction in the young may lead to
malnutrition. Avoid unnecessary physical and emotional stress.
2) Management of Dry Skin - Emollients and Soap Substitutes
Dry skin is more prone to itch and chapping and hence risk of infection and
subsequent perpetuation of eczema. A good dry skin care can be achieved
by:
a) Keep bathing time short and to a minimum necessary
b) Use lukewarm water not too hot
c) Use soap substitute e.g. emulsifying ointment
d) Avoid vigorous rubbing and cleaning at the skin
e) Pat dry, and
f) Apply emollients e.g., aqueous cream, as soon as after getting out of the
bath.
Emollients minimize dryness and is the mainstay in treating mild AD. Some
emollients are also humectants, e.g. urea cream. Humectants attract water
into the skin, and are useful on unbroken skin but can cause stinging.
Emollients should be applied as frequently as possible according to patient's
need. It is believed that regular and frequent use of emollients can reduce
10-20% of the amount of topical steroids used in the maintenance treatment
of AD. Some emollients contain lanolin that may sensitize skin e.g., Alpha
keri, oilatum etc. Chapters 35 and 37 give further description on the property
and use of emollients.
3) Ichthammol and Tar Preparations (0.5-1%)
Ichthammol impregnated bandages are old remedy but are still used for
treating childhood eczema in UK. Tar can reduce itch. Tar/steroid-
impregnated bandages are useful for chronic lichenified eczema. Tar bath is
a useful bath additive in reducing itchiness. Tar compounds can induce
folliculitis and photosensitisation; and because of its smell and colour,
patient compliance is a poor.
4) Topical Steroids
Is the mainstay of treatment for inflammatory aspect of atopic eczema. The
strength and the base used will depend on the stage and location of the
eczema. Acute weeping eczema should first be treated with potassium
permanganate (KMnO4) compresses followed by a steroid lotion or cream.
In chronic eczema, creams and ointments are both suitable. Twice daily
application is usually sufficient. Prolonged use of a potent corticosteroid
e.g., clobetasol propionate 0.05% over 50 g per week may result in systemic
and local side effects. Fear of side effects, however, should not limit the use
to a weaker but ineffective corticosteroid. Potent corticosteroids can be used
as a short-term measure aiming to obtain initial control, this is then changed
over to a weaker steroid suitable for the situation. Chapter 41 gives an
overview on topical corticosteroids.
"Wet-Wrap"is a newly developed way of using topical steroid under the
occlusion of wet tube gauze. It has the combined advantages of applying
steroid under occlusion, maintaining moisture and prevent scratching. It is
indicated in the chronic, dry, thickened and lichenified type to atopic
dermatitis especially in young children. Exudative lesions in acute and
subacute eczema is not suitable.
5) Control of Infections
Staph. aureus infection is a frequent cause of eczema flare requiring
systemic antibiotics, e.g., erythromycin or cloxacillin. Sometimes, a
prolonged course of antibiotics may be required. Topical mupirocin twice
daily to nasal vestibules and chlorhexidine massaging onto body during
bathing can reduce the number of Staph. aureus in a carrier. Systemic
antibiotics for treating large area of infected eczema are superior than using
large amount of topical antibiotics that carry risk of hypersensitivity and
inducing bacterial resistance. Eczema herpeticum needs systemic acyclovir.
Molluscum contagiosum, warts and fungal infections should be treated
accordingly.
6) Systemic Corticosteroid
It is not a routine management of atopic eczema and it should be avoided at
times of puberty. Sometimes, a short course of systemic corticosteroid is
effective in gaining control of a severe eczema flare. Whenever systemic
steroid is used, any infection must be looked for and treated promptly.
7) Systemic Antihistamines
Recommended doses can be given during periods of excessive scratching.
Avoid excessive doses as hyperexcitability may be quite marked in young
children.
8) PUVA
It is useful in chronic lichenified eczema where pruritus is intractable and a
useful adjunct to leaving off topical steroids at the time of pubertal growth
spurt. Patient selection is important. No PUVA should be given to children
under the age of 12 because of risk of cataract in the immature lens and
difficulty in co-operation and understanding with the PUVA regime. The
same precautions and procedures as PUVA for other conditions should be
undertaken. The response of AD to PUVA is not as good as compared with
that for treating psoriasis and the total dose required is often larger. The
experience in UK showed that approximately one-third showed remission or
significant response, one-third remit and relapse, and one-third no response.
9) Immunosuppressives
Azathioprine or cyclosporin are helpful in severe cases. Nevertheless, drug
toxicity and long-term hazards are a definite risk. They should only be
considered for chronic severe AD with poor response to the usual treatment.
10) Hospitalization
In severe cases, it can be very helpful. Remove the patient from his
environment and potential trigger factors, institute regular and intensive
treatments can lead to resolution of the eczema.
2.10. Alternative Treatments
1) Evening primrose oil
Which contains linoleic acid and gamma linolenic acid, was found to be
effective in some cases in reducing erythema and pruritus; but it may take 2-
3 months to see effect. It is also costly. The precise indications are not clear
and it cannot be predicted which patients will respond. It may be tried for
patients who failed with conventional therapy.
2) Chinese herbs
Recent studies in UK using a certain formulary of Chinese herbs for patients
with long-standing, widespread, and non-exudative AD have shown a
statistical significant improvement in symptoms and skin signs. At this stage,
Chinese herbs do seem to have a therapeutic potential in the treatment of AD
but its palatability, efficacy and its safety need further evaluation.
3) Sodium cromoglycate
It is given as 100-200 mg qid orally. In general, it is not effective.
4) Behavioral therapy
May be a useful adjunct for patients who cause excessive self-mutilation in
their families.
2.11. Prevention
There is no definite evidence that breast feeding is protective against
development of AD. It has been suggested that the early introduction of solid
foods (before age 4 months) does have a deleterious effect, and that a greater
variety of foods correlated with an increased probability of developing AD.
2.12. Prognosis
Studies investigating the long-term outcome of AD have been unsatisfactory.
In general, patients with a family history of AD, associated asthma, hay
fever, later-onset disease and the presence of severe dermatitis have higher
rates of persistent disease. Many quote 40-50 percent of recovery by age 15
years.
3. OTHER TYPES OF ECZEMA
3.1. Irritant Contact Dermatitis
1) Diagnostic features
The affected sites characteristically conform to history of specific contact to
a susceptible contactants. Some non-exposed areas are also susceptible to
irritant contact dermatitis, e.g., body folds and flexural areas, due to a
combination of friction and direct contact with sweat or urine. Once
exposure to the irritant ceases, improvement start to occur.
2) Clinical presentation
Strong irritant contact dermatitis can occur after a single brief exposure. The
latent period is short. Examples are acid and alkaline burns, thermal burns
and frost bites. The offending irritant is usually obvious. Weak irritant
contact dermatitis develops after multiple exposures, latent period is long.
3) Management
The offending irritant should be identified and removed. Soap and detergents
should appropriately be minimized. Cool water is less detrimental than hot
water. Advice on the use of protective barriers whilst at work, e.g., gloves,
protective clothes etc. should be strictly followed by the patient. Restoration
of the lipid layer can be accomplished by frequent application of emollients.
In case of maceration, wet clothing should be changed frequently, non-
porous clothing to be avoided. Inflammatory element can be controlled with
topical steroid.
3.2. Allergic Contact Dermatitis
1) Diagnostic features
The characteristic distribution of the lesions can often gives a clue to a
particular allergen (Table 3). Removal of the suspected allergen leads to
resolution of the dermatitis. A positive patch test to a suspected offending
contactant support the clinical diagnosis.
2) Clinical presentation
a) Both allergic contact dermatitis and irritant contact dermatitis bear similar
clinical signs. In acute cases weeping and crusting will be present, while in
chronic cases scaling and fissuring are the dominant findings. Sometimes,
allergic contact dermatitis differs from irritant contact dermatitis in that
erythema and edema may be more prominent and pruritus more troublesome
in the former.
b) Systemically induced allergic contact dermatitis: Patients who have been
sensitized to topical allergens may develop generalized eczematous
inflammation if these allergens or chemically related substances are
ingested. e.g. Patient with a history of nickel allergy may get a widespread
flare when he takes food rich in nickel; patient sensitized to topical
ethylenediamine may develop generalized inflammation following treatment
with aminophylline.
c) Airborne allergic contact dermatitis and photodermatitis have a similar
distribution. Look for sparing in the upper eyelids, areas below the chin, and
the Wilkinson's triangles behind the ear.
Table 3: Distribution of Allergens
Location Material
Scalp and
Shampoo, hair dyes, topical medicaments
ears
Anal
Haemorrhoid preparations, antifungal preparations
region
Lower
Topical medicaments, dye in socks
legs
antiseptics in topical
¡@ Quinoline mix
therapeutics
Ethylenediamine
¡@ medicaments
Dihydrochloride
¡@ Quaternium 15 cosmetics
¡@ Mercaptonbenzothiazole plant
Sesquiterpene lactone
¡@ ¡@
mix
PSO RI ASI S
Dr. K.K LO & Dr. L.Y. HO
CH APTE R 4
1. INT RO DU CTI ON
Psoriasis is a chronic inflammatory disease of unknown cause. It is now
considered to be due to T-lymphocytes mediated disease of abnormal
keratinocyte proliferation in genetic predisposed subject. In 1995, Psoriasis is the
sixth commonest skin condition found in all new cases attending dermatology
clinics of Social Hygiene Service (4.18% of all new cases) and it is one of the
common skin diseases worldwide. Although there is no study in the
documentation of the exact number of psoriatic patients or prevalence of the
disease in Hong Kong, the disease is commonly presented even in the primary
care setting. There had been analysis in the figure of some local dermatology
clinics of Social Hygiene Service in 1974 to 1976 and comparison with some of
the larger cities in China, Taiwan and Japan claiming the number of psoriasis in
the Mongoloid race to be around 0.3% or well below 1%.
2. CL INI CAL FE ATU RE
Psoriasis is a chronic erythemato-squamous condition characterized by sharply
circumscribed salmon pink patches, plaques covered with silvery scales. The
onset of the disease is usually gradual and becomes noticeable by the patient
from 30 years onwards. However, in patient with family history positive for
psoriasis, there may be earlier onset at teenager or even below ten. In these
cases, the prognosis is worse. From a study in China, the majority (97.98%) of
the types of psoriases is the psoriasis vulgaris or chronic plague type. We have
similar experience in Social Hygiene Service with over 91% of the psoriasis are
chronic plaque type (see Table 1).
The classification of psoriasis may vary with different author's preference but for
simplicity and practicability, we take the following classification for psoriasis: I)
Non-pustular psoriasis II) Pustular psoriasis III) Psoriasis with arthropathy. They
can be subclassified further into:
2. 1. No n- pu st ula r Pso ri asi s
Chronic Plague type
Acute Guttate
Inverse, flexural
Erythrodermic
Regional: Scalp, palms & soles, nails
Unstable nummular
Sebo-psoriasis
2. 2. Pu st ul ar P so rias is
Generalized Pustular psoriasis (von Zumbusch)
Localized pustular psoriasis of palms & soles
2. 3. Ps or iasi s w ith Ar th ro pa th y
5 Types of arthropathy found: oligoarticular asymmetrical arthritis, symmetrical
involving small joints of fingers likes rheumatoid arthritis, classical distal
arthropathy involving distal interphalangeal joints, destructive arthritis mutilans
and psoriatic spondyloarthropathy which is similar to ankylosing spondylitis.
Two interesting phenomena occur in Psoriasis. They are mutually exclusive:
Koebner and reverse Koebner responses. Any form of trauma may result in
psoriasis appearing in the traumatized areas which is known as Koebner
phenomenon or isomorphic response. A degree of healing may occur when a
psoriatic plague is traumatized which is the reverse Koebner phenomenon. It also
explains why some patient found cryotherapy is useful to suppress psoriasis.
The commonest form of psoriasis is the chronic plague type which usually
presents as brightly erythematous scaly plagues at the predisposed areas i.e. the
extensor aspect, the tip of elbows, knees, sacral area, the scalp. They may be
associated with no symptoms to moderate pruritus. Excessive dandruff and
scaling from the lesional area may be an early complaint. Family history is not
very commonly found in this group because the other family members may not
have the disease at all or if possess, usually in a very mild degree. Patient may
have history of acute guttate psoriasis before but it either never clears or
reappears as plague form. The most useful form to confirm the diagnosis is to
use the wooden spatula to scrape the surface of the suspected lesion, profuse
Guttate 45 7.39
Flexural 0 0
Erythrodermic 1 0.16
2. AETIOLOGY
The release of histamine, and possibly other vasoactive mediators from mast
cells leads to a sudden increase in vascular capillary permeability allowing
the escape of fluid from the circulation into the tissues. Mast cells may
degranulate in response to a number of stimuli including physical, chemical,
pharmacological and immunological.
Different mechanisms may be operating in different types of urticaria. The
type I hypersensitivity is mediated through the IgE attached to the mast cell
which will degranulate on exposure to the specific antigen. Patients suffering
from this type of allergic urticaria frequently have a personal or family
history of atopy. Mast cells can also degranulate by other non-
immunological stimuli. Certain drugs, for example morphine, codeine,
ethanol, polymyxin B, and bacterial, plant or invertebrate toxins can
stimulate mast cells to degranulate directly. Other drugs like salicylates and
NSAIDs on the other hand act on the mast cell through its action on the
cyclo-oxygenase pathway. It has been postulated that food additives such as
tartrazine, azo dyes, benzoates and sulphites can provoke urticaria through a
similar mechanism. Recently some research workers have demonstrated the
presence of IgG auto-antibodies directed against IgE receptor Fc epsilon RI
of mast cells and basophils in some patients with chronic idiopathic
urticaria, which can activate the mast cells to degranulate. This autoimmune
hypothesis of idiopathic chronic urticaria has led to the use of various
immune therapies for treatment of the condition (see below).
Vasodilatation, dermal oedema and a mild perivascular infiltration of
lymphocytes and eosinophils are seen in a typical lesion of urticaria.
However in a small number of patients repeated biopsies may show a
predominance of neutrophils and eosinophils infiltrate and absence of
endothelial damage, representing a late phase reaction. This picture would
suggest that other cellular elements and mediators may operate in the
pathogenesis of urticaria in some cases.
3. CLASSIFICATION OF URTICARIA
Various types of classifications exist, the following classification adopts a
more practical approach.
3.1. Acute Urticaria and Urticaria with an Identifiable Cause
In acute urticaria, a self evident precipitating factor is usually present (table
1). Some patients with chronic urticaria may also have a well defined cause
although this is uncommon.
3.2. Chronic Idiopathic Urticaria
Defined arbitrarily as urticaria that persisted for six weeks or more without
any identifiable cause.
3.3. Physical Urticaria
cholinergic urticaria
symptomatic dermographism
delayed pressure urticaria
solar urticaria
cold urticaria
aquagenic urticaria
vibratory urticaria
3.4. Angio-Oedema
May accompany any types of urticaria. Hereditary angioedema is due to C1
esterase inhibitor deficiency. An acquired form of this enzyme deficiency is
also known. ACE inhibitors can provoke angio-oedema through inhibition of
the kinin system.
3.5. Others: hereditary urticaria, contact urticaria, papular urticaria,
urticarial vasculitis, and urticaria pigmentosa.
Table 1: Common Causes of Urticaria
salicylates, penicillin, ACE inhibitors, NSAID,
Drugs
allopurinol and many others.
Food
azo dyes, benzoates, sulphites and yeast.
additives
4. CLINICAL FEATURES
The lesions in urticaria are usually not difficult to recognize. They are
intensely itchy, with a white palpable centre of oedema and a variable halo
5. INVESTIGATION
In most patients suffering from urticaria, the correct diagnosis can be made
after history taking and physical examination. A complete blood count
together with ESR is adequate for the majority who has no other abnormal
physical finding. Other investigations should be done when necessary.
1) complete blood count and ESR: look for eosinophilia
2) Liver function test
3) complement C3 and C4
4) C1 esterase inhibitor level
5) Investigating underlying infections: chest radiograph, urine for culture,
stool for ova, throat swab, HbsAg, viral study etc.
6) ANF, RF etc. in suspected connective tissue disease
7) Skin biopsy: urticarial vasculitis, urticaria pigmentosa
8) RAST: controversial as to its usefulness
9) Skin prick test: useful for contact urticaria. Difficult to interpret for
chronic idiopathic urticaria
6. ACUTE URTICARIA
Patients with acute urticaria are usually seen by their family doctors or by
doctors in the A&E department. The cause of the acute attack is often
obvious and there may be a history of similar attack. Initial investigations
should include the differential white cell count and ESR measurement. The
presence of eosinophilia points to parasitic infestation. Other possible
causative factors listed above should be sought for.
Since the causal factor can usually be withdrawn, subsequent attack can be
avoided and long-termed treatment is usually not required. Challenge test is
not advisable since acute urticaria is frequently IgE mediated and there is a
definite risk of anaphylaxis during the test. Though the prognosis is good in
most cases, those with persistent symptoms for weeks may actually be
suffering from chronic idiopathic urticaria with an acute onset.
Most of these acute episodes can be successfully controlled with
antihistamine. In acute urticaria of serum sickness type hypersensitivity, a
short course of systemic steroid may be necessary. Parenteral adrenaline is
life saving in case of anaphylaxis and bronchial constriction. Resuscitation
procedures should be carried out as indicated.
7. CHRONIC IDIOPATHIC URTICARIA
Chronic idiopathic urticaria is defined as urticaria lasting longer than 6
weeks, for which no obvious cause can be found. This is the commonest
type of urticaria in a dermatology clinic and a study by Champion reported
that 80% of urticaria is chronic idiopathic urticaria. Although symptomatic
relief can be achieved with drug therapy, a certain percentage of patients
may suffer from continuous symptoms for years without true remission.
Numerous factors have been suggested for causing this disease including sea
food, azo dyes, food preservatives, candida in the gut and trace of penicillin
in dairy products. Some patients may benefit from elimination of one of
these factors, but for most others the cause of the disease remains obscure.
Recently an autoimmune aetiology has also been proposed.
By definition, no obvious aetiological factor is apparent and special
investigations are nearly always unhelpful. For most patients with chronic
idiopathic urticaria, a complete blood count, ESR for screening may be
adequate. Stool for ova is indicated if there is eosinophilia. Other tests
detailed above should be performed for individual patient as directed by the
history and examination. Prick test and intradermal skin test are often
positive but are difficult to interpret. Challenge tests with food coloring
agents and preservatives if available, are helpful in the management.
Although no underlying cause can be found, for the majority of patients their
symptoms can be well controlled by drug with minimal disturbance to their
daily life. Depending on the patient's tolerance, a sedating or non sedating
antihistamine can be prescribed during daytime. Because most patients have
more severe attack at night time, an additional nocte dose of more sedating
drug like promethazine is helpful. The patient should be encouraged to keep
a food diary. Food containing tartrazine dye and preservatives as well as
drugs that known to aggravate urticaria should be avoided. In suitable cases,
elimination diet can be carried out with the help of a dietitian.
Tolerance to antihistamine therapy may develop in a patient whose
symptoms are previously under control. This tolerance cannot be overcome
by increasing the dosage or by changing to another antihistamine. The cause
of tolerance is thought to be due to the down regulation of the H1 receptors.
Ketotifen and sodium cromoglycate can be tried and responsiveness to
antihistamine may return. Hospital admission may be required for alternative
therapy in difficult cases.
8. CHOLINERGIC URTICARIA
A common condition in young adults with intensely itchy and short-lived
eruption developing in response to sweating, exercise, emotion and hot
foods. It is postulated that an increase in blood temperature triggers a neural
reflex which releases acetylcholine from sympathetic nerve endings, in turn
activate the mast cell to degranulate. Characteristic small wheals, less than 2
mm in diameter with surrounding red halo are more profuse on the upper
trunk and proximal parts of the upper limbs. Thus it is also called
micropapular urticaria. Associated systemic symptoms include faintness,
headache, wheezing and palpitation.
Diagnosis is established from the history and the finding of characteristic
rash during an attack. The rash can also be brought up on exercise or whole
body warming. These lesions can often be reproduced by intradermal
injection of cholinergic drugs, e.g., metholyl or acetylcholine.
Treatment is unsatisfactory. Patients, especially those with associated
systemic symptoms, should be told to avoid situations that can precipitate an
attack. Some patients improve with antihistamine therapy. This can be taken
regularly or at times when they anticipate attacks. Fortunately for most
patients the condition tends to improve spontaneously.
9. PRESSURE URTICARIA
This rather rare condition is not a true urticaria. Delayed cutaneous erythema
and oedema and subcutaneous oedema occur in response to the sustained
application of pressure to the skin. The lesions itch and burn. They appear
between 30 min to 9 hours after the stimulus. A large proportion of these
patients have associated chronic idiopathic urticaria.
The lesions characteristically occur after certain activities: sitting on hard
chairs, carrying bags, leaning against furniture, wearing seat belts and lying
on hard mattresses. Swelling of the feet and hands, often indistinguishable
from angio-oedema, occurs after walking, jogging, running, climbing ladder
and using a screwdriver. During severe attacks, arthralgia and a flu-like
illness may accompany the rash.
The pathogenesis of pressure urticaria is not known. Histamine is probably
not an important mediator of this disease and treatment with antihistamine is
useless. Other forms of treatment including the use of NSAIDs and
colchicine have been tried with varying results. Systemic steroid is an
effective agent but is limited by its side effects.
15. ANGIOEDEMA
This is a variant of urticaria where massive oedema involves subcutaneous
tissues rather than the dermis. It may involve any part of the body surface
like the lips, eyelids, tongue and larynx. This condition can be associated
with urticaria of any cause. The hereditary form is caused by a quantitative
or functional deficiency of C1 esterase inhibitor and is inherited as an
autosomal dominant trait. An acquired form of C1 esterase inhibitor may
develop in patients with lymphoproliferative disorders and systemic lupus
erythematosus.
Hereditary Angioedema
In hereditary angioedema attacks are infrequent in childhood, common in
adolescence and early adult life and may subside later. It is precipitated by
trauma and the lesions may affect the skin, mucosal surface and intestine.
Subcutaneous swelling is not itchy and typically persisted for a few days.
Intestinal oedema may causes symptoms simulating acute abdomen.
Laryngeal oedema may lead to upper airway obstruction and death. The C2
and C4 level are low in between attacks and C3 is normal. There is a low C1
esterase inhibitor level. In acute airway obstruction, subcutaneous adrenaline
may be life saving. Fresh frozen plasma should be administered by
intravenous infusion or, alternatively a purified C1 esterase inhibitor
concentrate can be given. For long term management attenuated androgens
stanozolol or danazol can be used for prophylaxis. They act by stimulating
hepatic synthesis of C1 inhibitor. Antifibrinolytic agents like tranexamin
acid and epsilon aminocaproic acid are less effective as prophylaxis but can
be tried in patient who cannot tolerate androgenic steroids.
Dimenhydrinate
50-100 mg qid
Ethanolamines Diphenhydramine
25-50 mg qid
(Benadryl)
Chlorpheniramine
(Piriton) *1 4 mg tid
Alkylamines Dexrochlorpheniramine 2-4 mg tid
(Polaramine) *2 75 mg bid
Pheniramine (Avil)
Promethazine
(Phenergan) 10-25 mg bid
Phenothiazines Trimeprazine 10-30 mg qid
(Vallergan) 5 mg bd
Mequitazine (Primalan)
Cyproheptadine
4 mg tid
Piperidines (Periactin)
1-2 mg tid
Azatadine (Zadine)
Vitiligo
Dr. R. SU
CHAPTER 7
1. Definition
An area of acquired cutaneous depigmentation characterized by well-
circumscribed milky white macules devoid of identifiable melanocytes.
2. Aetiological Hypothesis
Various theories are suggested as the aetiology of vitiligo; the same
mechanism may not apply to all cases.
2.1. Autoimmune Hypothesis
Autoimmune destruction of cutaneous melanocytes with total loss of
melanocytes and melanin pigment in the skin of the affected area.
Lymphocytic infiltration on skin biopsy indicate lymphocytes are involved
in the destruction process. Frequently associated with other autoimmune
diseases; such as alopecia areata, autoimmune thyroid disorders, Addison¡¦s
adrenal disease, atrophic gastritis and pernicious anaemia, diabetes. Serum
autoimmune antibodies against melanocyte, thyroid, adrenal, islet-cell,
gastric parietal cell, and intrinsic factor have been demonstrated.
2.2. Neurogenic Hypothesis
A compound is released at peripheral nerve endings in the skin which is
toxic to melanocytes and inhibits melanogenesis. It is postulated that in the
dermatomal variant, the affected area shows sympathetic nerve dysfunction.
Catechol neurotransmitters probably destroy the melanocytes instead. There
is little support for this hypothesis.
2.3. Self-destruct Theory of Lerner
Defect of a natural protective mechanism in melanin synthesis within
melanocytes, leading to accumulation of toxic precursors (phenolic
compounds) which destroy melanocytes. This hypothesis is based on the
lethal effects produced by chemical compounds (phenols) on functional
melanocytes; the resulting leukoderma is indistinguishable from idiopathic
vitiligo.
3. Clinical Presentation
Affects around 1% of the population in all races, but more troublesome in
dark skin where there¡¦s marked contrast between normal and depigmented
areas. Hence the incidence may be apparently higher in pigmented races
where the social impact is also greater. Family history of the condition is
found in one third of the affected patients. Sex ratio is equal. Half the
patients first present before 20 years old. It may be precipitated by injury or
sunburn. In light skin individuals, vitiligo may only be discernible in
summer, when the vitiliginous area becomes sunburnt.
The main symptom being cosmetic and presents when the patient notices
that the affected area fails to tan after sun exposure, unlike the surrounding
normal skin. It is an essentially clinical diagnosis, based on the morphology
and distribution of the lesions as well as the exclusion of other
hypopigmented skin lesions.
Vitiligo may rarely be associated with premature greying of hair, retinal
pigmentary loss, uveitis, deafness, CNS involvement (Vogt-Koyanagi
syndrome). Other associations include: halo naevus, malignant melanoma,
alopecia areata, autoimmune thyroid disorders, Addison's adrenal disease,
chronic atrophic gastritis, Pernicious anaemia and diabetes mellitus.
4. Diagnostic Hallmarks
4.1. Distribution
Localized: Sun exposed areas such as dorsal surface of hands and
the face, including peri-orificial and peri-orbital areas.
Hyperpigmented areas such as axilla, groin, genitalia,
flexures, and nipple.
Sites of friction and bony prominences like elbows
and knees.
Generalized: Widespread
Unilateral variant: unilateral segmental pattern seen in children occurs
(linear/dermatomal) occasionally.
4.2. Individual Lesions
Sharp margin
No scale
Normal texture and intact sensation
Typical: milk white colour
Atypical:
Trichome vitiligo
- an intermediate uniform tan colour
- naturally evolves to a typical vitiligo macule
Quadrichrome vitiligo
- macular peri-follicular or marginal hyperpigmentation seen in
repigmenting vitiligo
Inflammatory vitiligo
- erythematous, raised border similar to that seen in tinea versicolor.
5. Differential Diagnosis of vitiligo and other Hypopigmented lesions
Generalized hypomelanosis albinism
hypopituitarism
Patchy hypomelanosis vitiligo
piebaldism
tubero-sclerosis
chemical leukoderma
Patchy hypomelanosis tinea versicolor
with inflammation and scaling leprosy
pityriasis alba
Patchy hypomelanosis with morphea
atrophy or induration lichen sclerosis
post-inflammatory
hypopigmentation
6. Investigation
Skin biopsy will show absence of melanocyte and melanin in the affected
area, but this is often not necessary as the diagnosis is clinically obvious.
Other investigations are considered to exclude associated autoimmune
disorders. The extent of the investigations may depend on the history and
physical findings.
7. Treatment
Educate and encourage relatives, friends and society to overcome the
stigma that this is infectious.
Acceptance of patient by physicians setting an example (e.g. shaking
hands) should be supportive to patient and help to overcome stigma.
Reassurance that this is a cosmetic problem and does not affect the patient's
health directly.
Educate the patient about the nature of the disease, that treatment may be
difficult and prolonged, and the results may not be predictable. While the
patient should not have unrealistic expectation they need not be discouraged.
More important is to take good care of their own skin, concentrate on what
can be done even if the condition can not be cured at present.
1) Sunscreen (SPF 15-30)
These are recommended for three reasons: 1) Vitiliginous areas are more
susceptible to sunburn, 2) Sunburn injury can further extend area of
depigmentation (Kobner response). 3) Sun-induced darkening of the
surrounding normal skin causes accentuation of the cosmetic disfigurement.
Sunscreens which shield both UVB and UVA light should be used.
For the same reason, avoiding outdoor activities under the strong mid-day
sun, together with protective clothing, will reduce ultraviolet damage to
depigmented skin which is devoid of protective melanin.
2) Camouflage Cosmetics (Covermark, Dermablend etc.)
Covermark and Dermablend are cosmetic that can be used to match most
skin hues.
Quick-tanning preparations containing dihydroxy-acetone may be used to
tan the vitiligo a more acceptable colour. It can produce different shades.
Instructions and guidance from a cosmetic instructor are required to give the
best cosmetic results and safety. These preparations are especially useful on
the eyelids where potent topical corticosteroids and ultraviolet-light should
not be used.
3) Repigmentation therapies
Moderately potent to potent topical corticosteroids
e.g. Sicorten Cream (0.5% halometasone)
This may be applied to affected area twice daily as a trial. Therapy should be
discontinued if repigmentation has not begun after six to twelve months. The
patient needs to be seen every 1-2 months to check for signs of cutaneous
atrophy from treatment. Caution is needed when applying it to the face and
flexures (once daily/alternate day). It should not be applied to eyelids and
periorbital areas to avoid the risk of steroid-induced glaucoma and cataract.
PUVA Therapy: Topical or systemic (Refer to chapter 17)
Topical PUVA involves ultra-violet A irradiation 30 minutes after application
of meladinine (topical methoxasalen) to the localized vitiliginous area.
Systemic PUVA involves ingestion of methoxasalen (0.6 mg/kg) two hours
before irradiation.
Treatment should be attempted under the supervision of a dermatologist or
those experienced in its use. In inexperienced hands PUVA may carry the
risk of phototoxic reaction, ocular damage etc.
Careful patient selection is also required. Within the Social Hygiene Service,
predominantly facial lesions (except eyelids) of recent onset are considered
for PUVA, because they tend to give better results. Some degree of
repigmentation occurs in 50-75% of cases compared with 15-20% in
controls.
The patient undergoes treatment 2 times per week, and needs to avoid
sunlight for 2 days after each treatment, using sunscreens both indoor and
outdoor. It takes at least 2-3 months to begin having an effect and therapy
needs to be continued for at least one year (100-200 treatment sessions)
before maximum benefit is reached. Hence a long term commitment to
therapy is required, and this must be appreciated by the patient before
embarking on therapy. The physician also needs to take into consideration
the patients¡¦ age, sex and disease severity, medical, social, occupational and
psychological factors.
If perifollicular pigmentation has not appeared after three months of therapy,
it is unlikely to occur; treatment might as well be stopped. But once
repigmentation has begun, it tends to persist and spread with continuous
treatment. However complete repigmentation occurs in 15-20% only.
Systemic PUVA is less often used than topical PUVA in vitiligo.
Contra-indications for systemic PUVA include:
Pregnancy, children <12 year old, photosensitivity, cardiac, hepatic and renal
disease, aphakia, and cataracts, and history of skin cancers.
4) Depigmentation therapies using bleaching agents such as 20%
monobenzyl ether of hydroquinone (Benzoquin 20%) once or twice daily is
indicated when vitiligo is extensive (>50% involvement or near universal).
Benzoquin may cause a contact dermatitis, hence as a test before generalized
therapy, it should be applied to a single pigmented spot daily for 1 week.
Thereafter large pigmented areas are treated twice daily for up to 6 months.
The compound is cytotoxic to melanocytes and destroys them. This process
which removes pigment from the remaining normal skin is irreversible. The
skin becomes albinoid, but the cosmetic appearance is improved
substantially. The patient must remember they are sun-sensitive and need
protective sunscreen.
Experimental Repigmentation modalities:
These can be tried in stationary vitiligo which are not extending any further.
They have achieved variable success in different individuals.
Grafts from uninvolved skin containing viable melanocytes; punch mini-
grafting using autologous pigmented donor sites is the simplest least
invasive surgical approach. Alternatives include growing melanocytes in
vitro from the patients¡¦ normal skin, and injecting them into artificially
induced blister cavities in the depigmented areas. Repigmentation by
tattooing has also been tried with some success.
CUTANEOUS VASCULITIS
Dr. Pedro Sá Cabral
CHAPTER 8
1. Introduction
Vasculitides compromise heterogeneous entities with diverse aetiologies and
manifestations. Vasculitis is strictly defined as a process through which
inflammatory destruction of the blood vessel wall occurs. Nowadays, most
clinicians use the term vasculitis in a broad sense to mean any condition or
process in which the blood vessel wall is inflamed and destroyed. The
process may be confined to the skin or involve other organ systems, such as
kidney, gut, nerves and joints.
2. AETIOLOGY
A causative agent can sometimes be implicated in small and medium vessel
vasculitis. Examples include: 1) Drug e.g. Aspirin, NSAID, penicillin etc. 2)
Infection, e.g. Hepatitis B, Streptococcus etc. 3) Blood disorder, e.g.
essential mixed cryoglobulinaemia. 4) Neoplastic, e.g. multiple myeloma,
lymphoma. In large vessel vasculitis, a causative agent is not identified yet.
e.g. Temporal arteritis, Takayasu's disease. 5) Connective Tissue Disease e.g.
rheumatoid arthritis, Sjogrens, lupus erythematosis, dermatomyositis.
3. HISTOPATHOLOGY
3.1. Major Features
The main histopathological features are fibrinoid necrosis of the affected
vessel wall and inflammatory cells within the vessel wall. Accompanying
extravasation of red cells are frequent and responsible for palpable purpura
observed clinically.
3.2. Minor Features
The minor histopathological features that often but not invariably
accompany vasculitis include: 1) thrombosis occluding the vessel lumen; 2)
associated inflammation and damage to surrounding tissue (e.g. panniculitis,
ischaemia, necrosis); 3) direct immuno-flourescence staining showing
immunoglobulin IgG, IgM, IgA and C3 deposition within the vessel wall*.
3.3. Vessel Size
The small vessels (post-capillary venules) are involved in leukocytoclastic
or hypersensitivity (allergic) vasculitis. The medium size vessels are
involved in polyarteritis nodosa. The large arteries are involved in giant cell
arteritis.
PS: Pitfall - Perivascular lymphocytic infiltration without involving the
vessel wall itself is commonly seen in many conditions but should not be
regarded as vasculitis.
3.4. Type of Inflammatory Cells
The type/s of inflammatory cells present differ in different types of vasculitis
and differ at different age of the lesion. The different types of inflammatory
cells and the clinical conditions in which they are found are outlined below:
Leucocytoclastic vasculitis:
Neutrophils are predominant. Examples include Henoch-Scholein Purpura,
drug-induced vasculitis, erythema elevatum diutinum, granuloma faciale,
hypo-complementaemic vasculitis, polyarteritis nodosa.
Lymphocytic vasculitis:
Lymphocytes are predominant. Examples include: erythema nodosum, lupus
erythematosus, lymphoma, pityriasis lichenoides.
Eosinophilic vasculitis:
Churg-Strauss is an example. Eosinophils are predominant.
Granulomatous vasculitis:
Wegener¡¥s granulomatosis and Churg-Strauss Angiitis**. Cells include:
histiocytes, plasma cells, lymphocytes and occasional giant cells.
Giant cells arteritis:
This occurs cranial and temporal arteritis and polymyalgia rheumatica.
Multinucleated giant cells are predominant.
* The optimum specimen selected for biopsy should be a lesion between 18-
36 hours old.
** Churg-Strauss (Granulomatosis) Angiitis has features of a necrotising
granulomatous (with eosinophils) vasculitis.
4. PATHOGENESIS
4.1. Immune Complex Deposition
Following exposure to an antigenic stimulus, antibodies (usually IgG or IgM
class) are formed and complex with the antigen in the circulation. These
complexes circulate without any difficulty until reaching certain sites, where
local factors (e.g. antigen excess in gravitational dependent areas) cause
them to deposit and bind to the vessel wall.
4.2. Complement Activation and Consumption
The Fc portion of the immunoglobulin molecule binds complement and
initiates the complement cascade. Subsequent elaboration of the potent
chemotactic factor C5a attracts neutrophils into the vessel wall. Tissue injury
occurs as the activated neutrophils phagocytise the immune complexes and
thereby release destructive proteolytic enzymes. The resulting inflammation,
necrosis, and haemorrhage appear clinically as palpable purpura when they
occur on the skin.
4.3. Lymphocytic Infiltration
Following exposure to antigenic material, tissue lymphocytes and histiocytes
become activated to produce various cytokines and inflammatory mediators.
Their interaction with intercellular adhesion molecules on cell surfaces will
initiate and regulate cell mediated immunity, leading to further lymphocyte
proliferation and macrophage aggregation at the site of inflammation.
4.4. Granulomatous Inflammation and Giant Cell Formation
Failure to clear the antigen will perpetuate the inflammatory processes and
eventually lead to epitheloid giant cell and granuloma formation.
5. CLINICAL PRESENTATION
5.1. Cutaneous Features
Morphology of skin lesions:
Persistent urticated lesions, tender palpable purpura, papules, nodules,
haemorrhagic bulla, ulcers, atrophie blanche, livedo reticularis, nail fold-
telangiectasia, infarct, digital gangrene.
Distribution of Skin lesions:
Often start on dependent areas initially (e.g. lower legs, buttocks, back)
before becoming generalized. This is due to the effect of hydrostatic force on
the post-capillary venules, leading to the preferential deposition of immune
complexes in these sites.
Course of skin lesions:
Occur in successive crops, evolving from papules, nodules to palpable
purpura which resolve leaving pronounced post-inflammatory
hyperpigmentation. Depending on the aetiology, the course may be acute,
resolving within few days to few weeks; or it may be chronic and recurrent,
persisting from months to years.
5.2. Extra-cutaneous Features
General: fever, malaise, mucous membrane ulcers
Renal: glomerulonephritis - proteinuria, haematuria, hypertension
Pulmonary: pneumonitis and haemorrhage - haemoptysis, dyspnoea
GI tract: malaena, abdominal pain
Musculoskeletal: joint pain, myalgia
Neurological: mononeuritis multiplex, myelopathy, CVA
Eye: iritis, uveitis
Cardiac: pericarditis, endocarditis, myocarditis and infarct
6. INVESTIGATION
Investigations are performed to: 1) Confirm the diagnosis of vasculitis and
determine the predominant cell infiltrate by skin biopsy. 2) Screen for any
extra-cutaneous organ involvement and hence the systemic nature of
vasculitis. 3) Exclude an offending causative agent and remove it if possible
e.g. drug. 4) Screen for and treat any underlying disease processes that may
be responsible for the vasculitis e.g. infection, connective tissue disease or
malignancy.
1) Skin biopsy for histopathological studies, including immunoflourescent
staining.
2) Blood Tests for
Complete blood count & Erythrocyte sedimentation rate
Antinuclear Factor Screen
Rheumatoid Factor
Complements C3, C4
Liver and Renal biochemistry profile
C-Reactive Protein
Anti-streptolysin O titre
Cryoglobulins
Anticardiolipin Antibody (Quantitative VDRL)
Immunoglobulin pattern and Serum protein electrophoresis
Hepatitis B Antigen
Anti-Neutrophil Cytoplasmic Antibody
3) Throat swab for culture
4) Urinalysis for proteinuria, Red blood Cell, White cell, and Casts
5) Stool for Occult Blood
6) Chest X ray
7) Nerve Conduction Studies and/or Nerve Biopsy
N.B.: More invasive investigations like renal or lung biopsy may be relevant
but should not be taken lightly unless clearly indicated and in conjunction
with the physician.
7. TREATMENT
7.1. Cutaneous
1) Supportive:
Bed rest, elevation of dependent parts and avoidance of trauma and cold
2) Anti-inflammatory agents:
Include topical steroids, non-steroid anti-inflammatory drug e.g.
indomethacin, colchicine 0.5 mg bd or tds, dapsone 50-100 mg qd (esp
erythema elevatum diutinum), sulphapyridine, Minocin.
3) Antiplatelet agents:
Such as aspirin or dipyridamole are sometimes used.
4) Systemic corticosteroids given as a short course may be useful in an acute
severe episode to reduce morbidity and produce early resolution of lesions
7.2. Systemic
Systemic vasculitis with widespread involvement of internal organs (e.g.
renal, heart, lung) may result in life-threatening complications (e.g. acute
renal failure). Prompt treatment with high dose systemic steroids and
immunosuppressives, e.g. cyclophosphamide are required to reduce
morbidity and are often life-saving. Monitoring of electrolytes,
haematological picture, and hepato-renal function is necessary during
treatment.
7.3. Life-Threatening Systemic Vasculitis
IV Pulse Methylprednisolone, 1 g QD for 3-5 days
IV Cyclophosphamide 2 mg/kg/day, for 5-7 days
Plasmapheresis, plasma exchange
These agents are indicated in emergency situations where immediate control
of the disease activity is imperative to prevent mortality and preserve organ
(e.g. renal) function. IV Cyclophosphamide may cause haemorrhagic
cystitis. Careful monitoring of fluid and electrolyte balance is necessary
during administration. Any infection should be identified and treated
promptly.
COLLAGEN-VASCULAR DISEASES
Dr. R. SU & Dr. Y.M. TANG
CHAPTER 9
1. LUPUS ERYTHEMATOSUS
1.1. Epidemiology
In the nineteenth century, a group of diseases of erythematous and atrophic
nature was classified as lupus erythematosus (LE). It was thought the skin
appearance was due to the gnawing by a wolf (Latin: lupus). Today, the term
coins a group of autoimmune diseases that bears various characteristic
cutaneous and histological features, and protean systemic manifestations in
some. (q.v.) This group of diseases is divided into three major subsets;
namely, chronic cutaneous LE (CCLE), also called discoid LE, subacute
cutaneous LE (SCLE) and systemic LE (SLE).
CCLE affects female and male at a ratio of 2:1, from their second to eighth
decade with a mean age of 38 (37.8 in a local study). The incidence of
CCLE is not certain, it is probably under-reported as many cases are trivial
and may have escaped diagnosis. Generally speaking, females at a younger
age predominate in SLE, blacks and Chinese are more susceptible than
whites. An estimated incidence of 6.0-50.8 cases/100,000 population in the
western world is noted.
1.2. Essential Features of the Major LE Subsets
Discoid plaque is prototypic lesion in CCLE. The lesions frequently occur in
the head and neck and exposed areas with sizes varying from a few
millimetres to a few centimetres. It begins as erythematous, oedematous
scaling papules which spread centrifugally and coalesce into a plaque that
exhibits thick and adherent scales. Lifting of the scales produces a carpet-
tack appearance, revealing dilated pilosebaceous orifices occupied by horny
plugs (follicular plugging). Healing of lesion usually takes place in the
centre producing atrophy, scarring, telangiectasia and pigmentary changes
(hypopigmentation in the centre and hyperpigmentation in the active
margin). Histopathology of an established lesion shows typical histologic
changes. (q.v.) Systemic or serological abnormalities in these patients are
absent or minimal and the revised criteria of the American College of
Rheumatology (ACR) for SLE are not met.
In SCLE, skin lesions are annular or papulosquamous, and they share similar
morphology with discoid lesions but healing is not accompanied with
scarring and atrophy is minimal or absent. Photosensitivity and serological
abnormalities are more frequent than CCLE. The full gamut of LE-
associated problems can occur though mild.
SLE is a systemic disease characterised by the association of immunological
abnormalities and multiple organ involvement. The main clinical features
include fever, rashes (especially malar) and arthritis, as well as renal,
pulmonary, cardiac and neurological diseases. A diagnosis of SLE is
established if four or more of the ACR revised criteria for SLE are satisfied.
1.3. Pathogenesis of and Relationship Among Different Types of LE
The pathogenesis of LE is not definitively known. A T-cell mediated injury
is implicated in the discoid lesions. Anti-Ro (SSA) has strong implication in
the production of disease in photosensitive SCLE and neonatal LE (NLE).
Ultraviolet light induces Ro antigen expression on the keratinocytes,
targeting it for binding by anti-Ro antibody and/or sensitized T cells. In SLE,
many features are a consequence of antibody production and immune
complex formation.
It is debatable whether CCLE and SLE are distinct entities or represent
either end of a disease spectrum. They both share similar clinical,
haematological, biochemical and immunological abnormalities. Considering
that: 1) both have different age and sex distribution, 2) presence of
laboratory abnormalities in CCLE does not appear to predispose to the
development of SLE, 3) immunoglobulins and complements are present in
uninvolved skin of SLE but not in CCLE, 4) a patient with CCLE can
develop into overt SLE but is rare, and 5) evidence is available that both
have different genetics; it would appear that they share similarities but are
different diseases.
1.4. Mucocutaneous Features
Mucocutaneous lesions of LE are commonly divided into specific and non-
specific types. Table I shows the specific mucocutaneous lesions of LE.
They are characteristic of LE and help us infer which particular LE subset
the patient suffers; however, the three LE subsets are not mutually exclusive.
Table II tabulates the lesions that commonly occur during the course of LE
but are not sufficiently specific to be indicative of LE.
Table I: Specific LE Lesions
Chronic Subacute Acute
Palmar/plantar 3 ¡@ ¡@
LE panniculitis 4 ¡@ ¡@
Discoid lesion, though is representative in CCLE, also found in 15% of SLE
Maculopapular lesions
Mucinous infiltration
Nonscarring alopecia
Oral erosions 2
Photosensitivity 3
Arthritis/arthralgia 71
Renal 69
Haematological (thrombocytopenia,
pancytopenia, leucopenia, 38
haemolytic anaemia)
Serositis 20
Neurological 26
Others ¡@
Unexplained fever 28
Lymphadenopathy 18
Raynaud's phenomenon 15
1.6. Investigations
For every patient with skin lesions of LE irrespective of the morphology, an
initial work-up should be performed to exclude any systemic involvement. A
battery of blood tests include:
1.6.1. Blood Tests
Haematology: Haemoglobin, reticulocyte, white cell with differentials,
ESR
Biochemistry: Renal and liver functions
Urinalysis: Red cells and proteins
Serology/Immunology:
1) Anti-nuclear antibody (ANA)
2) Anti-double stranded DNA (Anti-dsDNA)
3) Anti-ENA (especially anti-Ro/La)
4) Anti-cardiolipin antibody (ACL)
5) Lupus anticoagulant
6) Immunoglobulins (Igs)
7) Complement levels
8) VDRL test for syphilis
In the absence of specific clinical symptoms and if initial investigations are
normal, a half to one yearly monitor of complete blood count, ANA, and
urinalysis is adequate. Patients with persistent abnormal test results should
be seen more frequently (e.g. 3-monthly) to identify evidence of SLE.
Compared with SLE, blood test results in cutaneous LE are usually normal
or only mildly deranged. Abnormal test results in cutaneous LE include a
low haemoglobin, thrombocytopenia, leukopenia, raised ESR, raised titres of
ANA, anti-Ro (SSA)/La (SSB), ACL and biological false positive VDRL
test for syphilis.
ANA is one of the most common tests requested. It is a group of antibodies
that react with one or several nuclear constituents. It is usually detected by
indirect immunofluorescence tests where antibodies in the patient's serum
react with a substrate (rat liver, monkey oesophagus or HEP-2 human cell
line), and after washing and incubation with fluorescein-labelled antihuman
Igs. It is then examined under the fluorescence microscope and a patterned
fluorescence in the substrate nuclei is revealed. The information on pattern
and titre can be obtained from this test. The different patterns of ANA
observed correlated with antibodies against specific nuclear antigens and
may infer different rheumatological disorders. However, pattern
differentiation needs experience, and in the case where antibodies to more
than one nuclear constituent are present, the interpretation is even more
difficult. Therefore, to identify ANAs by antigen instead of fluorescence
pattern is more rewarding. ANA titres are elevated in about 20 to 60% of
CCLE, whereas a higher incidence is noted in SLE. It should be noted that a
positive low ANA titre can occur in normal individuals and non-LE diseases
and hence its presence is not specific for LE. ANA titres fluctuate during the
course of a disease. They cannot accurately reflect disease activity and
therefore not recommended to gauge progress of LE.
Anti-Ro (SSA) antibody is present in 30-50% of SLE (this figure is higher in
Orientals b) and up to 95% of SCLE on repeated testing. Hence, absence of
these is evidence against the clinical diagnosis of SCLE. Anti-dsDNA and
anti-Sm occur in SLE, whereas anti-U1RNP suggests mixed connective
tissue diseases. The high titre of anti-Ro in SCLE is said to be related to
photosensitivity but the low titre that appears in some cases of CCLE does
not indicate the risk of photosensitivity. Lee et al b reported a 69% positive
rate for anti-dsDNA antibodies in SLE.
1.6.2. Histopathology
The early stage of acute LE rash shows non-specific features, papillary
dermal oedema and perivascular lymphocytic infiltrate can be found.
Adnexal involvement is lacking. In an established lesion, epidermal atrophy,
liquefaction degeneration, and papillary dermal fibrinoid deposition are
noted.
CCLE shows epidermal hyperkeratosis with follicular plugging, thinning
and flattening of the stratum malpighii, basal cell hydropic degeneration,
periappendageal lymphoid cell infiltration, and upper dermal oedema and
vasodilatation. SCLE shows similar histological features except that scarring
and follicular plugging are absent and epidermal atrophy is not prominent.
Lupus panniculitis is characterised by infiltration of fat cells by
lymphocytes, plasma cells, and histiocytes. Septal fibrosis, lobular
hyalinised sclerosis, and vessel wall hyalinization are evident. Lymphoid
follicles are often present.
Bullous SLE shows interface dermatitis, superficial ?/font> deep
perivascular infiltrate with neutrophil predominance. Mucin deposition in
dermis is evident. A subepidermal blister is evident in an established case.
Immunofluorescence (IMF) study is not essential for the diagnosis of LE but
is helpful when other features are not diagnostic (e.g. a biopsy from an acute
LE lesion or scalp with scarring alopecia). Direct IMF study often shows
IgG, IgM and complement deposition at the dermoepidermal junction. The
lupus band test is positive for nonlesional exposed and sometimes
unexposed skin in SLE but this is usually negative in CCLE.
2. Dermatomyositis
This is characterized by skin rash, muscle weakness and tenderness. In
addition to skin and skeletal muscle involvement, there may be involvement
of muscles of gastrointestinal system (dysphagia and aspiration), heart
(cardiomyopathy, arrhythmias), and lung (pulmonary fibrosis).
2.1. Epidemiology
Dermatomyositis (DM) is an uncommon condition. Female is twice as
commonly affected as male. In young female patients it is associated with
autoimmune connective tissue diseases. There may be underlying systemic
malignancy, particularly for patients over 40 years old. DM is more often
associated with malignancy than polymyositis. Common malignancies
include breast, lung, gastrointestinal, ovarian cancer, and in our locality
nasopharyngeal carcinoma. The cancer may precede, occur simultaneously,
or follow DM. Removal of underlying malignancy may be associated with
resolution of DM, and recurrence of malignancy may lead to relapse of DM.
2.2. Clinical Features
Presentation and clinical course may be: acute, subacute, chronic.
The severity of cutaneous involvement does not correlate particularly well
with severity of associated myositis. Muscle involvement without cutaneous
features is termed polymyositis. Cutaneous involvement may precede
muscle involvement, or occur without apparent muscle involvement.
Muscle involvement include:
Muscle pain and tenderness affecting trunk, limb girdles and proximal limbs.
Muscle weakness is symmetrical and bilateral.
Weakness is progressive, with difficulty rising from low chairs, climbing
stairs, and holding arms above shoulder during combing hair.
Facial and bulbar muscles are usually spared, but may be affected in cases
associated with malignancy or myasthenia. Dysphagia may occur due to
oesophageal involvement, arrhythmia and cardiac failure due to myocarditis.
Cutaneous features include:
Violaceus erythema and oedema of periorbital region, especially upper
eyelids. There may be diffuse redness and swelling of entire face, extending
to other sun-exposed areas.
Photosensitivity, poikiloderma (erythema, pigmentation, telangiectasia,
atrophy) of face and upper chest shoulders and arms.
Red to violaceous patches and plaques over extensor surface of elbows and
knees.
Gottron's sign refers to such patches and plaques over knuckles (dorsal
surfaces of interphalangeal joints). In LE, similar changes are
characteristically located on dorsal phalanges between the phalangeal joints
instead.
Raynauds phenomenon, periungal erythema and telangiectasia.
Lupus like and sclerodermatous skin involvement.
Calcinosis, chronic ulcers. Calcinosis universalis in juvenile DM.
Childhood form of DM is often slow and progressive, characterized by
calcinosis. The calcinosis often involve intermuscular fascial planes, but
may be subcutaneous and acral (elbow, knees, fingers) as in adults. Juvenile
DM are usually steroid responsive, but often associated with contractures
and deformity, leading to functional disability and morbidity. One variant is
characterized by vasculitis of muscles and gastrointestinal tract, rapid onset
of severe weakness, steroid unresponsiveness and death. Internal malignancy
is seldom seen in either type.
2.3. Diagnosis
This is essentially clinical, supported by investigations (q.v.).
Periorbital heliotrophic rash, especially upper eyelids.
Gottrons patches over knuckle.
Poikilodermatous rash over sun-exposed areas and extensor surfaces of
upper limbs.
Peri-ungal erythema and telangiectasia.
Proximal girdle muscle tenderness and muscle weakness.
Muscle enzymes are raised, and muscle biopsy shows typical inflammatory
changes.
Diagnosis is straightforward with classical cutaneous features and
documented muscle involvement. However diagnostic difficulty arises when
there is no apparent muscle involvement and the skin rash is relatively non-
specific. With time clinical features may become characteristic of DM, but
sometimes another diagnosis (e.g. LE) may become apparent instead. The
diagnostic implication of adult DM is to screen for underlying malignancy,
together with close monitoring and follow up.
2.4. Diagnostic Pitfalls
The following conditions may be confused with DM when the clinical
presentation is atypical. In such situations, DM needs to be considered and
differentiated from such conditions.
1) Cutaneous Features
Systemic LE, subacute lupus, mixed connective tissue disease.
Rosacea, facial eczema, photosensitive dermatitis, erythema multiforme.
Erysipelas, angioedema, lymphatic or SVC obstruction.
Radiodermatitis, mycosis fungoides, scleroderma
2) Muscle Weakness
trichinosis
myasthenia gravis
muscular dystrophy
toxoplasmosis
2.5. Investigations
1) Diagnosis
Diagnosis is essentially clinical, as cutaneous histopathological features are
non-specific. There is vacuolar interface dermatitis with sparse superficial
perivascular lympho-histiocytic infiltrate, which is consistent but not
diagnostic of DM. Immuno-flourescence studies do not show significant
immune deposits at dermo-epidermal junction. Skin biopsy may differentiate
LE from DM when clinical features are nonspecific, but this is also difficult
unless characteristic LE histopathological features are present. (q.v.)
2) Assess extent of involvement
a) Muscle enzymes CPK, AST, LDH are performed to document myositis
and assess progress during treatment. Muscle enzymes are not specific of
DM, it may be elevated in other situations or apparently normal in DM
without significant muscle involvement. Twenty four hour urine for creatine
may increase sensitivity, but is not readily available.
b) Muscle involvement is often focal, and electromyography EMG may help
to locate the affected muscles. Random muscle biopsy is subjected to
sampling errors. Magnetic resonance imaging (MRI) has recently been
investigated as a sensitive tool for locating subclinical myositis and guide
muscle biopsy, even if muscle enzymes and EMG were apparently normal.
c) ECG and echocardiography may be necessary as clinically indicated to
assess cardiac involvement. Lung function may be need to monitor
respiratory muscle involvement. Barium swallow to assess pharyngeal and
eosophageal motility, and aspiration.
3) Look for an aetiology
Routine and special investigation as directed by thorough history and careful
examination.
a) Screening for underlying malignancy
Stool for Occult Blood
CBP, ESR
Carcino-Embryonic Antigen, a -Feto Protein
IgA-EBV
Chest X Ray
Skull X Rays for NPC views
ENT examination and nasopharyngeal biopsy
Careful examinations of gastro-intestinal, breast, pelvic and gynaecological
systems, with endoscopy, mammography, and ultrasound pelvis, as
indicated.
b) Auto-immune screen
These investigations may help to differentiate DM from other auto-immune
connective tissue diseases and overlapping syndromes, in conjunction with
clinical features.
ANA is present in both LE and DM.
Anti-double stranded DNA, low C3 and C4 (systemic LE).
Anti-ENA, Anti-U1RNP (Mixed Connective Tissue Disease).
Anti-Ro, Anti-La (Subacute cutaneous lupus and Sjogrens syndrome).
Anti PM-Scl (Polymyositis scleroderma overlap syndrome).
Anti-Jo1 (histidyl tRNA synthetase) antibody, polymyositis with interstitial
lung disease, pulmonary fibrosis.
2.6. Treatment
1) Treatment of skin diseases:
Sunprotection: Avoid outdoor activity around mid-day, protective clothing,
broad spectrum UVA and UVB sunscreens with SPF>15
Topical steroids
Antimalarials: Hydroxychloroquine (below 6.5 mg/kg/day), same as for
cutaneous LE.
Systemic steroids are sometimes used but generally more effective in
controlling myositis than cutaneous manifestations Systemic steroids may
cause steroid myopathy with prolonged use, leading to paradoxical decrease
in muscle weakness following steroid dosage reduction. Twenty four hour
urine creatine levels are not elevated in steroid myopathy.
2) Treatment of muscle involvement:
This should preferably be managed in conjunction with physicians.
Bed rest during the acute phase. Physical therapy, physiotherapy especially
important in juvenile DM to prevent contractures and deformity.
Systemic steroids are the mainstay of therapy for myositis. Initial dose of
prednisolone is 1 mg/kg/day, with dose adjusted according to clinical
response and muscle enzymes.
Methotrexate, azathioprine, cyclophosphamide, cyclosporin as
immunosuppressives and steroid sparing agents.
Pulse intravenous methyl-prednisolone, plasmapheresis and intravenous
immunoglobulin infusion have been tried in acute life threatening stages for
rapid control and stabilization.
2.7. Prognosis
The prognosis of adult DM is that of the underlying malignancy. Childhood
DM usually has less mortality, but substantial morbidity including
calcification and contractures especially if not treated early. DM and
pregnancy may adversely affect each other. Facial lesions and muscle
weakness get worse, fetal loss occurs.
3. Scleroderma
Scleroderma describes the thickening and hardening of the skin due to
progressive accumulation of dermal collagen, leading to fibrosis and loss
mobility of skin. It can exist as cutaneous or systemic form. Cutaneous
forms are morphea, linear scleroderma, and generalised morphea, these are
confined to the skin as tight indurated plaques. Systemic sclerosis refers to a
similar process involving not only the skin but internal organs as well, and
may lead to organ failure or even death. Organs affected include lung, gut,
kidneys, heart and skeletal muscle. Common causes of death are aspiration
pneumonia, pulmonary fibrosis, and renal failure,
3.1. Diagnosis
Proximal diffuse (truncal) sclerosis, with skin tightness, thickening and
nonpitting induration.
Sclerodactyly, with sclerosis affecting only fingers or toes, leading to
sausage shaped digits.
Pitted scarring of finger tips due to loss of substance from digital pulp, with
tapering of fingertips.
Bilateral basal pulmonary fibrosis.
Other clinical features include: Raynauds phenomenon, telangiectasia of
posterior nail fold, calcinosis of finger tips and matted telangiectasia on face
and hands. Skin tightening may lead to mask face, beaked nose, and radial
furrows around mouth. There may be generalised hyperpigmentation with
hypopigmented patches on the skin.
3.2. Skin Biopsy
In the dermis there are thick bundles of collagen running parallel to the skin
surface, with entrapment of sweat glands and adenexal structures. The
overlying epidermis tends to be thin and atrophic.
3.3. Immunology
ANA
CREST: anti-centromere antibody positive
MCTD: associated with ENA, anti-U1RNP positivity
Systemic sclerosis: ANA, Scl 70 antibody positivity
3.4. Sclerodermatous Syndromes
Many conditions have widespread induration of the skin. It is beyond scope
here to discuss individual conditions, but they should be borne in mind in the
differential diagnosis of a sclerodermatous condition. Some conditions are
more responsive to treatment than systemic sclerosis.
Auto-immune or connective tissue diseases:
Generalised morphea
Progressive systemic sclerosis
CREST syndrome (calcinosis, Raynauds, oesophageal dysmotility,
sclerodactyly, telangiectasia)
Mixed Connective Tissue Disease (MCTD): DM, SLE, scleroderma
Eosinophilic fasciitis
Chronic graft versus host disease
Environmental agents or drugs:
Bleomycin cancer chemotherapy
Eosinophilic myalgic syndrome following L-tryptophan ingestion
Occupational vinyl chloride, epoxy resin
Metabolic or associated conditions:
Porphyrias: porphyria cutanea tarda, variegate porphyria, hereditary corpo-
porphyrias
Porphyria like conditions: pseudoporphyria, epidermolysis bullosa acquisita
Diabetic chrieopathy, scleredema
InfectiInfective, malignant, infiltrative conditions:
Papular mucinosis, scleromyxoedema
Primary systemic amyloidosis
Cutaneous T-cell lymphoma
Lepromatous leprosy
3.5. Treatment
Systemic sclerosis is an uncommon condition with a highly variable course.
Some progress relentlessly till death, others remain insidious or even
improve with time. Many agents have been tried, but to date no single agent
has predictably arrest or reverse the fibrosing process. Treatments that have
been tried include penicillammine, colchicine, ketotifen, cyclosprine, g
-interferon, plamapheresis, PUVA and extra-corporeal photochemotherapy.
Treatment is mainly symptomatic, or to prevent complications. Raynauds
phenomenon and digital ischaemia may be controlled with calcium channel
blockers such as nifedipine, supplemented with pentoxifylline,
dipyridamole, intravenous prostacyclin infusion. Cutaneous ulcers may be
managed by protective occlusive dressing. Physiotherapy with emphasis on
full range of motion of all large joints to prevent contractures and deformity,
thereby preserving function. Management of extra-cutaneous involvement
should be in conjunction with physicians. Renal hypertension is treated with
captopril. Steroids are not effective in systemic sclerosis, but useful for
myositis in MCTD and for eosinophilic fasciitis.
Palm and sole blisters usually remain intact because of the thick stratum
corneum.
Grouped vesicles along a dermatome is characteristic of herpes infection.
2) Site of blister:
Pompholyx occurs at palm and soles.
Blisters at sites of frequent trauma suggests Epidermolysis Bullosa.
3) Mucosal membrane involvement is frequently found in pemphigus, erythema
multiforme and fixed drug eruption.
2. BU LLOU S IM PETIG O
Bullous impetigo is usually caused by Staph. aureus while non-bullous type can
be caused by Staph. Aureus and occasionally by Strep. pyogenes. More common
in children and mainly affects face and hands. Bullae are flaccid and usually
contain pus. When the pustules are ruptured, they give rise to golden crusts.
Diagnosis: Swab from pustules for culture
Treatment:
1) Topical antibiotics (e.g. fusidic acid cream, mupirocin ointment,
chlortetracycline ointment) is good for localized infection.
2) Oral antibiotics (e.g. cloxacillin, erythromycin) for widespread lesions.
6. PO MPH OLYX
A distinct pattern of acute dermatitis as characterized by acute onset of multiple
itchy vesicles +/- bullae at palms and soles. Vesicles seldom rupture because of
the thick stratum corneum. Usually, the cause is unknown but occasionally may
be secondary to severe tinea infection or contact dermatitis occurring in other
part of the body.
Treatment: Requires potent topical steroid (e.g. 0.025% fluocinolone). Oral
antibiotics (e.g. erythromycin) is indicated if there is evidence of secondary
bacterial infection. In very severe case, a short course of oral steroid may be
required.
7. HE RPES IN FECT IO NS (HE RPES S IMPLE X/ HER PES ZOSTE R)
Pain is the most useful symptom to differentiate blisters caused by herpes
infections from other blistering disorders. Eczema or tinea infection gives rise to
itchy rather than painful vesicles. In contrast to pemphigus or pemphigoid which
may give rise to painful lesions, the vesicles of herpes infections are more
localized.
Refer to Chapter 14 for clinical features and management.
8. FR ICT IO N BL ISTERS
It occurs at hands and feet. Diagnosis can be easily made from history e.g.
wearing ill-fitting or new shoes.
11 .3 . C/F
It presents as blisters attacking the skin including mucosae (i.e. oral mucosa,
conjunctiva). Intact blister is seldom seen because the roof of the blister is thin
and is easily ruptured. Ruptured bullae lead to the formation of erosions.
Nikolsky's sign (i.e. rubbing normal skin causes new lesion to form) is
characteristic. Eruption tends to develop on the trunk and the face with sparing
of the extremities (centripetal distribution). Involvement of the oral mucosa gives
rise to painful ulcers.
11 .4 . Inv est iga ti on
1) Skin biopsy for histology
This is done to confirm the diagnosis. In order to see the diagnostic features,
new, rather than old lesion should be chosen for biopsy. Classically, one should
find suprabasal blister with acantholysis in histology.
2) Skin biopsy for Direct Immunofluorescence (IMF)
Perilesional skin shows the presence of intercellular IgG deposition within the
epidermis.
3) Indirect Immunofluorescence (Serology)
Serum from the patient allows the titre of the circulating anti-intercellular
antibody to be measured. The titre correlates with the disease activity and is a
good parameter for monitoring the disease progress. A more than twofold
increase in titre is an indication of relapse. This test is not casually available. It
can only be done in a few hospital-based centres with special arrangement.
4) Tzanck test
A cytology method revealing the characteristic acantholytic cells. It provides an
instant diagnosis. However, it is seldom done since it requires expert cytologist
and it also carries a significant false positive as well as false negative rates.
11 .5 . Mana gement
Potentially lethal disease. Hospitalization is often required for close monitoring
of disease progress. Hospitalization is particularly indicated if any one of the
following conditions which signifies severe involvement occurs:
1) Extensive cutaneous involvement
2) Systemic upset
3) Mucosal involvement other than oral cavity
4) High indirect immunofluorescence (IMF) titre.
11 .6 . Top ica l Trea tmen t
Potent topical steroids have to be used (e.g. clobetasol propionate). Usually
given as an adjuvant therapy. Rarely, when skin lesions are very localized, then
topical treatment can be given as a single therapy. For oral lesions, one can try
triamcinolone in orabase, intralesional steroids or steroid aerosol.
11 .7 . Sys temi c Treatme nt
1) Oral Steroid
Prednisolone is the drug of choice. To control the acute attack, usually it requires
a very high dose (i.e. 60-80 mg daily) to start with. Occasionally, > 100 mg of
prednisolone has to be prescribed for very severe cases. Steroid may be
increased by 50% every 4-7 days until the disease is controlled. The dose of
prednisolone is adjusted further to consolidate the remission and is maintained
for 2-4 weeks. It can then be gradually tailed down. The control of the disease
activity is indicated by no new eruption, low titre of anti-intercellular antibody.
Watch out for complications especially silent infection during high dose oral
steroid treatment.
2) Steroid-sparing Agents
Since a relatively high dose of prednisolone is usually required to control the
disease, in order to prevent the long term side effects of oral steroid (e.g.
opportunistic infections, osteoporosis), an immunosuppressant can be added for
its steroid sparing effect. Commonly used immunosuppressants are:
a) Azathioprine (2-3 mg/kg/day)
b) Cyclophosphamide
c) Methotrexate
The major side effects of azathioprine and methotrexate are marrow suppression
and hepatotoxicity. Cyclophosphamide may give rise to haemorrhagic cystitis,
infertility as well as marrow suppression. Regular monitoring of CBP and LFT is
needed when prescribing these steroid sparing agents. Because of the delayed
onset of action of the immunosuppressants at 4-8 weeks, they are often
commenced together with the oral steroids.
11 .8 . Treatme nt o f R ecal ci tr an t Ca ses
1) Plasmaphaeresis
This in-patient treatment is only available in major hospitals. The renal team in
the hospital can be consulted for providing the treatment if it is indicated.
2) Pulse Methylprednisolone Therapy
3) Cyclosporin A
4) Dapsone
5) Tetracycline/minocycline + niacinamide
6) Gold
7) Chlorambucil
11 .9 . Ind icat io ns o f T reatme nt Res po nse
1) No new lesion develops
2) Healing of old lesions
3) Dropping circulating antibody titre (indirect IMF)
ALOPECIA
Dr. C.N. LOOK
CHAPTER 11
1. DEFINITION
Alopecia is defined as excessive or abnormal loss of hairs.
2. PHYSIOLOGY
Natural hair loss is a physiological phenomenon. It is not a disease. Only
when the loss is excessive or when the pattern of loss is abnormal, then it is
pathological. Before one talks about the causes of alopecia, one has to
understand the physiology of hair growth (Diagram 1).
Diagram 1: Hair Cycle
2-6 years
Anagen ---------------------------------------» Catagen
| |
Hair shedding «---------------------------------Telogen
100 days
90% of our terminal hairs are at anagen phase which is the growing phase. It
lasts for 2-6 years. The scalp hair on average grows at the rate of 0.37 mm
per day.
Catagen is a transient period. Hair matrix cells stop dividing. As a result,
there is no hair growth.
Less than 10% of our hairs should be in telogen phase which lasts for 100
days (about 3 months). Since on average, each person has about 100,000
hairs. Therefore, less than 10,000 should be in telogen phase and on each
day less than 100 hairs fall off physiologically.
NA IL DI SEASES
1. DI SEASES O F NA IL PL ATE
Pits Psoriasis, alopecia areata, hand dermatitis, nail
biting, lichen planus
Horizontal ridges Beau's lines, any inflammation affecting soft
tissues around nails
Longitudinal
ridges: Pressure effect e.g. tumour in nail fold
Single Psoriasis, lichen planus, alopecia areata,
Multiple Darier's disease
Paronychia (inflammation of
nail fold):
Acute Trauma
Chronic Trauma, wet work, drugs e.g.
etretinate
3. DI SEASES O F NA IL B ED AN D M ATR IX
Subungual exostosis
Glomus tumour
Tumour
Naevus
Malignant melanoma
CUTANEOUS MALIGNANCIES
Dr. H.F. HO
CHAPTER 13
Duties of dermatologists in Social Hygiene Service in the management of
cutaneous malignancy:
1) To identify the high risk patients and the suspicious lesions.
2) To confirm the diagnosis.
3) Assess and decide whether the lesion can be adequately treated in our
clinic and give the most appropriate accordingly.
4) Refer those which cannot be adequately treated in our clinics and refer
them to a multi-disciplinary clinic for further management. Prepare to give
opinion regarding choice of treatment.
5) Follow-up of the patient.
The management of basal cell carcinoma, squamous cell carcinoma,
melanoma and mycosis fungoides will be discussed in chapter.
"rodent ulcer" .
3) Infiltrative form
- Infiltrative morphoea-form BCC
- Infiltrative non-morphea-form BCC
1.2. Diagnosis
Diagnosis of skin tumour should include a careful physical examination, not
only of the target lesion but also search for the presence of other skin
tumours. A general examination paying special attention to regional lymph
nodes and organomegaly is necessary, although distant metastasis in BCC is
rare.
Skin biopsy is indicated to confirm the diagnosis.
1.3. Treatment
The treatment goals are:
1) Cure.
2) Cosmesis, when the first goal is reached.
Treatment modalities:
Common treatments: Curettage and desiccation
Surgical excision
Mohs surgery
Cryosurgery
Radiotherapy
Evolving treatments: Interferon, photodynamic therapy, oral retinoids, 5-
fluorouracil.
Systemic chemotherapy. These will not be discussed in detail.
Choosing the modality will depend on:
1) Tumour factor: BCC are considered to be high risk if:
Recurrent
Size greater than 1 to 2 cm
Long duration, fast growth
Indistinct margins
Aggressive histological pattern
High risk sites: nose eyelids, ears, medial canthus, nasolabial fold, scalp, lip,
fingers, toes, genitals.
2) Patient factors: age, medical status, psychological factors, concomitant
medications.
3) Availability of the expertise and facilities.
Surgical treatment
Excision
This is useful for both primary and recurrent lesions, and it enables
histological examination of surgical margins. In good hands, cure rates
approaches 95%. Cure rate >99% if margins histologically negative.
For lesion size more than 1.5 cm or in critical cosmetic sites, other
modalities e.g. Mohs surgery, radiotherapy, or excision by plastic surgeon
with frozen-section control are more preferrable.
Curettage and electrosurgery
Commonly used for tumour size less than 1.5 cm. Cure rate approaches 95%
in good hands. This is not the appropriate treatment for infiltrative lesion and
recurrent lesions in scar tissue.
Cryosurgery
Useful in primary tumour and sometimes in recurrent lesion, and especially
useful in patients with multiple small lesions. Curettage is done to debulk
the lesion before freezing. Local anaesthesia is not needed and there is no
bleeding and scarring may be less than it is with surgery. No tissue is
available for histological confirmation and healing takes several weeks.
Tissue needs to frozen 4-6 mm beyond the clinical border . Thermo-couples
are necessary for larger lesions and this method is not suitable for infiltrative
lesions.
Mohs surgery
The technique is recommended for recurrent, large, difficult tumour, if it is
available.
Laser surgery
Laser may used to vaporize the tumour or as a scalpel blade for excision and
for hemostasis.
Non-surgical treatment
Radiation therapy
This is useful for definitive treatment of primary and recurrent tumour and
for palliation of inoperable lesions. It is painless, without postoperative
scarring. Potentially carcinogenic, it should be reserved for the older
patients. It provides no margin control and radiation dermatitis may develop.
1.4. Follow-up
Long-term follow-up is indicated. Physical examination to search for
recurrence, new tumours (BCC, SCC, Melanomas etc.). Prevention and
education advices should be given. This will include sun avoidance,
sunscreen protection, self-examination, dietary modification to reduce
calories from fatty sources and addition of b -carotene or multivitamins.
2. CUTANEOUS SQUAMOUS CELL CARCINOMA
2.1. Introduction
Being the second most common malignant tumour of the skin, SCC
possesses a higher potential for metastasis than BCC (3%-30% in SCC and
0.3%-3% in BCC). Actinic damage is the most important factor but SCCs
may also develop in certain geno-dermatosis, immunologically
compromised chronic inflammation, UV radiation, ionizing radiation,
arsenic poisoning and other chemical agents.
2.2. Diagnosis
Histological examination is necessary to confirm the diagnosis. A detailed
history and careful examination should be done to search for regional and
distant metastasis. A CXR is basic, whereas further investigation should be
directed by clinical findings.
melanocytic naevus )
3.3. Identify the High Risk Lesions
Symptoms:
CHANGES in size, shape, height, colour of a lesion.
Bleeding, erosion, ulceration, crusting and itching.
Signs:
Stage I ?1.5 mm no no
< 0.75 mm 1 cm
0.76 mm - 1.49 mm 1 - 2 cm
1 - 2 cm +/-ELND +/-adjuvant
1.5 mm - 4 mm
therapy
4. MYCOSIS FUNGOIDES
Mycosis fungoides (MF) is the commonest cutaneous T cell lymphoma.
CUTANEOUS MALIGNANCIES
Dr. H.F. HO
CHAPTER 13
Duties of dermatologists in Social Hygiene Service in the management of
cutaneous malignancy:
1) To identify the high risk patients and the suspicious lesions.
2) To confirm the diagnosis.
3) Assess and decide whether the lesion can be adequately treated in our
clinic and give the most appropriate accordingly.
4) Refer those which cannot be adequately treated in our clinics and refer
them to a multi-disciplinary clinic for further management. Prepare to give
opinion regarding choice of treatment.
5) Follow-up of the patient.
The management of basal cell carcinoma, squamous cell carcinoma,
melanoma and mycosis fungoides will be discussed in chapter.
"rodent ulcer" .
3) Infiltrative form
- Infiltrative morphoea-form BCC
- Infiltrative non-morphea-form BCC
1.2. Diagnosis
Diagnosis of skin tumour should include a careful physical examination, not
only of the target lesion but also search for the presence of other skin
tumours. A general examination paying special attention to regional lymph
nodes and organomegaly is necessary, although distant metastasis in BCC is
rare.
Skin biopsy is indicated to confirm the diagnosis.
1.3. Treatment
The treatment goals are:
1) Cure.
2) Cosmesis, when the first goal is reached.
Treatment modalities:
Common treatments: Curettage and desiccation
Surgical excision
Mohs surgery
Cryosurgery
Radiotherapy
Evolving treatments: Interferon, photodynamic therapy, oral retinoids, 5-
fluorouracil.
Systemic chemotherapy. These will not be discussed in detail.
Choosing the modality will depend on:
1) Tumour factor: BCC are considered to be high risk if:
Recurrent
Size greater than 1 to 2 cm
Long duration, fast growth
Indistinct margins
Aggressive histological pattern
High risk sites: nose eyelids, ears, medial canthus, nasolabial fold, scalp, lip,
fingers, toes, genitals.
2) Patient factors: age, medical status, psychological factors, concomitant
medications.
3) Availability of the expertise and facilities.
Surgical treatment
Excision
This is useful for both primary and recurrent lesions, and it enables
histological examination of surgical margins. In good hands, cure rates
approaches 95%. Cure rate >99% if margins histologically negative.
For lesion size more than 1.5 cm or in critical cosmetic sites, other
modalities e.g. Mohs surgery, radiotherapy, or excision by plastic surgeon
with frozen-section control are more preferrable.
Curettage and electrosurgery
Commonly used for tumour size less than 1.5 cm. Cure rate approaches 95%
in good hands. This is not the appropriate treatment for infiltrative lesion and
recurrent lesions in scar tissue.
Cryosurgery
Useful in primary tumour and sometimes in recurrent lesion, and especially
useful in patients with multiple small lesions. Curettage is done to debulk
the lesion before freezing. Local anaesthesia is not needed and there is no
bleeding and scarring may be less than it is with surgery. No tissue is
available for histological confirmation and healing takes several weeks.
Tissue needs to frozen 4-6 mm beyond the clinical border . Thermo-couples
are necessary for larger lesions and this method is not suitable for infiltrative
lesions.
Mohs surgery
The technique is recommended for recurrent, large, difficult tumour, if it is
available.
Laser surgery
Laser may used to vaporize the tumour or as a scalpel blade for excision and
for hemostasis.
Non-surgical treatment
Radiation therapy
This is useful for definitive treatment of primary and recurrent tumour and
for palliation of inoperable lesions. It is painless, without postoperative
scarring. Potentially carcinogenic, it should be reserved for the older
patients. It provides no margin control and radiation dermatitis may develop.
1.4. Follow-up
Long-term follow-up is indicated. Physical examination to search for
recurrence, new tumours (BCC, SCC, Melanomas etc.). Prevention and
education advices should be given. This will include sun avoidance,
sunscreen protection, self-examination, dietary modification to reduce
calories from fatty sources and addition of b -carotene or multivitamins.
melanocytic naevus )
3.3. Identify the High Risk Lesions
Symptoms:
CHANGES in size, shape, height, colour of a lesion.
Bleeding, erosion, ulceration, crusting and itching.
Signs:
Stage I ?1.5 mm no no
< 0.75 mm 1 cm
0.76 mm - 1.49 mm 1 - 2 cm
1 - 2 cm +/-ELND +/-adjuvant
1.5 mm - 4 mm
therapy
4. MYCOSIS FUNGOIDES
Mycosis fungoides (MF) is the commonest cutaneous T cell lymphoma.
disease and recurrent disease. Oral and facial lesions are usually due
to Herpes Simplex type 1 while anogenital lesions are mostly due to Herpes
Simplex type 2.
2.1.1. Primary Infections
Primary infection with herpes simplex occurs primarily by direct exposure
through mucocutaneous contact with another infected individual. It is
defined as the first infection with the virus in a seronegative patient. The
infection can be subclinical but below are listed the symptomatic clinical
presentations.
1) Primary gingivo-stomatitis
Primary herpetic infection (usually type 1 herpes simplex) of the mouth and
pharynx is more common in the children. Vesicles inside the mouth on the
buccal mucosa and gums coalesce to form plaques covered with a grey-
membrane. The vesicles are very painful and the infection may accompany
with high fever, tender lymphadenopathy and generalized complaints.
2) Primary genital herpes
Primary genital herpes, generally by type 2 virus, is a common sexually
transmitted disease characterized by multiple grouped, umbilicated vesicles,
oedema, fever, pain and dysuria, with regional lymphadenopathy in men and
vulvovaginitis in woman. The incubation period is from 3 to 14 days.
3) Herpetic whitlow
Herpetic whitlow refers to painful vesicles with clear serous fluid on the
fingers or hands. It is a common occupational hazard for medical and dental
personnel. The inoculation usually occurs in areas of abraded or broken skin.
The vesicles will subsequently progress to form superficial ulcers.
4) Herpetic keratoconjunctivitis
Primary herpes can involve the conjunctive and cornea. The eyelids are
usually swollen and there are vesicles and ulcers on them.
5) Aseptic meningitis, encephalitis
6) Primary herpes hepatitis
2.1.2. Recurrent Infections
The virus remains in the dorsal root ganglion, from which secondary
infections are repeatedly seeded to the skin over a period of years. Recurrent
attacks then occur and presents as grouped umbilicated vesicles on an
erythematous and somewhat edematous background.
1) Recurrent facial-oral herpes simplex (cold sores)
The cold sore usually appears at the vermilion border of the lip. The
erythematous papule becomes vesicular and then ulcerates. The open sore
heals in 8 to 9 days. Recurrent genital herpes also recur easily and these are
mainly due to type 2 virus. The number of recurrences is about 3 or 4 per
year.
2) Keratitis
Reactivation less commonly affects the eye, recurrent lesions are usually
restricted to the cornea and the conjunctiva is not involved.
3) Recurrent lumbosacral herpes simplex
Recurrent herpetic lesions appearing on the lumbal area and buttocks may
cause "sciatic pain".
4) Herpes infection in the immunocompromised patient
Reactivation of herpes is very common in patients with defective cellular
immunity from hematological malignancies, Human Immunodeficiency
Virus (HIV) infection and those receiving immunosuppressive agents or
transplant patients. Herpes infection recurs more frequently, have a more
severe and prolonged course and may present atypically e.g. in the form of
granuloma.
Common causes of recurrent infection
1) Stress
2) Pneumonia
3) Onset of menstrual cycle
4) Sun exposure
5) Mechanical trauma
6) Sexual activity (in genital herpes)
Diagnosis
1) Viral culture from scrapped tissues or fluids.
2) Immunofluorescence in scrapings from lesions to detect viral antigens.
3) Electronmicroscopy to demonstrate the virus.
4) Serology which may be useful for diagnosing primary infections is very
difficult to interpret in recurrent infections because of high levels of existing
antibody and recurrences usually do not cause a rise in titre. So serology is
not routinely performed in the Social Hygiene Clinic. Also, commercially
available serological tests cannot reliably distinguish its types 1 and 2
infection.
Treatment
1) Facial-oral herpes, Genital herpes
a) Topical antibiotic cream. e.g. aureomycin cream
b) Topical acyclovir cream
c) KMnO4 wet compress
d) Oral acyclovir therapy is only used in very severe and extensive situation.
e.g. acyclovir 200 mg 5 x daily x 5/7 with 24 hours of active new lesion.
e) Oral Famciclovir 125 mg tds x 5/7 or oral valaciclovir is an alternative
2) Herpetic Keratitis
a) Idoxuridine 0.5% eye drops.
b) Acyclovir ophthalmic ointment.
3) Treatment of herpes infections in the Immunocompromised patient
- Intravenous (IV) acyclovir
4) Recurrent infections (>6 attacks per year)
- Prophylactic oral dose acyclovir for several months has been shown to
reduce severity and frequency of relapse e.g. Acyclovir 400 mg bd.
However, the whole course of treatment is quite expensive.
2.2. Herpes Zoster (HZ)
The varicella-zoster virus causes the characteristic herpetic lesion similar to
herpes simplex. Whereas varicella represents a primary lesion, herpes zoster
(shingles) represents reactivation of the virus from the dorsal root ganglion
and results in the classic dermatomic distribution. Herpes zoster is a
common condition. There is a correlation between age and incidence of the
condition. The disease usually affects the elderly and the
immunocompromised patients. Constitutional symptoms are followed by
tingling and pain, erythema, and vesicle formation in a dermatomic
distribution .
Major complications of herpes zoster
1) Acute phase
a) Ocular involvement-Herpes ophthalmitis
b) Secondary infection
c) Cutaneous or visceral dissemination
2) Chronic phase
a) Post-herpetic neuralgia
b) Scarring
c) Motor neuropathy, post-infection encephalomyelitis, paralysis
Treatment
1) Topical agents
a) Acyclovir cream
b) Topical antibiotic cream may be useful in lesions with secondary infection
2) Systemic agents
a) Oral acyclovir 800 mg 5 times daily for 1 week
b) Oral Famciclovir 250 mg 3 times daily for 1 week
c) Oral Valaciclovir 1 gram 3 times daily for 1 week
In immunocompromised patient, IV acyclovir treatment is indicated.
Indications of systemic anti-viral treatment.
a) Patients get skin rashes within 3 days of onset, especially for the elderly
group.
b) Patients suffer from ophthalmopathy within 3 days of onset.
c) Immunocompromised patient whenever vesicles present.
2.3. Molluscum Contagiosum
It is caused by a large DNA virus of the pox group. The umbilicated pearly
lesions, often multiple, are more common in childhood and resolve
spontaneously after becoming inflamed. The lesions occur anywhere on the
body. Lesions occurring on the genitalia or lower abdomen in adults are
almost sexually transmitted. In children, the lesions can be left behind as it is
harmless and involute spontaneously. In adults, either cryotherapy or
piercing with a cocktail stick dipped in iodine can be used as treatment. In
patients with genital lesions, both the patient and the sexual partner should
be screened for other sexually transmitted diseases.
2.4. Warts
Viral warts are caused by the Human Papilloma virus (HPV). More than 50
subtypes exist. Warts are contagious and spread easily if there is local breaks
on the skin. Their morphology varies with the viral subtype and anatomical
site. Spontaneous resolution may occur.
2.4.1. Common Warts
They are mostly due to HPV type 2. The lesions are discrete, firm papules
INFESTATIONS
Dr. T.S. AU
CHAPTER 15
1. SCABIES
1.1. Morphology and Biology of the Scabies Mite
The adult female mite is 0.4 mm long while the male mite is 0.2 mm long.
Copulation occurs in a small burrow excavated by the female mite. The
fertilized female enlarges the burrow and begins egg-laying. About 50 eggs
are laid by each female mite during its life span of 4 to 6 weeks. The mite
shows a preference for certain sites to burrow. They tend to avoid area with a
high density of pilosebaceous follicles. Infested patients harbour an average
of 11 mites.
1.2. Incidence and Epidemiology
The incidence of scabies in developed countries show cyclical fluctuation. It
affects all races and social classes world-wide. The interval between the end
of one epidemic to the beginning of another is about 10-15 years. Scabies
may occur in any age but it is most common in children and young adults.
The overall sex incidence is equal. Overcrowding associated with poverty
and poor hygiene in under-developed countries encourages the spread of
scabies. Transmission is by close physical contact like sharing of a bed.
Studies have demonstrated that indirect spread by clothing and bedding is
not important. Although scabies is common in school-age children,
transmission in schools is unlikely. Outbreaks occur in hospitals, old-age
homes and other institutions. Outside the host, free adult mite and eggs can
survive 36 hours and 10 days respectively.
1.3. Clinical Features
Symptom occurs 3 to 4 weeks after the acquire of the infection. This latency
period may not occur if an individual has had a previous infestation.
Itchiness is the most obvious symptom of scabies. It is worst at night time
when the patient is warm.
The pathognomonic sign of scabies is a burrow; it is a short, wavy, dirty-
appearing line crossing skin lines. They may occur on the wrists, the borders
of the hands, the sides of the fingers and the finger web-spaces , the
feet particularly the instep and in male the genitalia and nodules on
scrotum. Burrows are uncommon on the trunk in adult but they may be
found in elderly and infants. Pruritic papules which accompany
hypersensitivity reaction occur around axillae, peri-areolar regions, peri-
umbilical regions, buttock and thighs. The lesions do not occur above the
neck-line. Secondary change like eczematous change frequently give
confusion to the clinical picture. Inappropriate use of topical steroid may
change the clinical picture to mimic other dermatoses.
1.4. Diagnosis
Absolute confirmation can only be made by the discovery of the burrows
and microscopic examination. A burrow is gently scraped off the skin with a
blunt scalpel, and the material placed in a drop of mineral oil on a
microscopic slide. Oil mounting of the specimen sharpens the microscopic
image and does not kill the mites which may be present (as potassium
hydroxide would). Presence of mites, eggs or fragments of egg-shells
3. PEDICULOSIS CAPITIS
3.1. Epidemiology
The infection rate was higher in urban than in rural areas. In the early 1980s,
there was a resurgence of infection due to the emergence of the so-called
'super-louse' which was resistant to DDT powder.
Lice are more common on children than on adults, and female of all ages are
more frequently infected than males. There does not appear to be any direct
correlation between hair length and louse infection rates, and it has been
suggested that large masses of hair may, in fact, impede transmission of lice
from scalp to scalp. The vast majority of head louse infections are acquired
by direct head-to-head contact. Spread of lice is encouraged by poverty,
ignorance, poor hygiene and overcrowding. Overcrowding is perhaps the
most important factor. Transmission of head lice by sharing personal articles
such as hair brushes, combs and towels is possible.
3.2. Clinical Features
These occur in the long hair of the scalp, but may also invade eyebrows and
eyelashes. The characteristic manifestation of head louse infection is scalp
pruritus. Secondary bacterial infection may occur as a result of scratching,
and concomitant head louse infection must always be considered in cases of
scalp impetigo. Pruritic papular lesions may occur on the nape of the neck,
and occasionally a generalized non-specific pruritic eruption develops. In
severe, neglected cases pus and exudate may produce matting of the hair.
Nits are egg-cases. They occur in greatest density on the occipital and
parietal regions. Most of the unhatched nits are within 5 mm of the scalp
surface. The eggs can be distinguished from dandruff by the fact that they
are firmly attached to the hair. Moreover, if the affected hair is cut off and
observed under microscope, the oval egg capsule can be easily identified.
Adult lice and nymphs may be seen in heavy infestation.
3.3. Treatment
Treatment of pediculosis of the scalp aims at the destruction of the lice and
the ova. Other members of the family and the whole class of school children
should be examined, otherwise re-infestation will occur.
Malathion is effective and has good ovicidal activity. It is adsorbed onto
keratin, a process which takes approximately 6 hours, and has a residual
protective effect against re-infection for about 6 weeks. Malathion should be
left on the scalp for 12 hours before washed off. The insecticide is degraded
by heat, and a hot-air dryer should not be used. Treatment should be
repeated 2 weeks later when the larvae have hatched out. Lotions are
preferable to shampoos, as the latter expose the insects to relatively low
concentrations of insecticide which will favour the development of
resistance.
Empty egg-cases are difficult to dislodge, they persist for some time until
they are gradually worn away by repeated washing. They may be removed
with a fine-tooth comb or forceps. A cream rinse containing formic acid may
facilitate the removal.
4. PEDICULOSIS CORPORIS
4.1. Incidence and Epidemiology
Pediculosis corporis is now uncommon in developed countries. It mainly
affects the poor and neglect and flourishes in overcrowded, dirty situations
where individuals seldom change their clothes. There is great variation in the
number of eggs and lice on the clothing. In most cases the number of lice is
small but in some thousand of lice may be present. Transmission is mainly
by direct close body contact or by sharing infested clothing. Lice on a
cooling dead body will look for alternate lodgings, and doctors asked to
certify death in a vagrant should be aware of this.
4.2. Clinical Features
Intense pruritus is the chief complaint. It is due to sensitization to salivary
antigens of the lice. Excoriation with secondary bacterial infection and
hyperpigmented changes are common physical findings.
When the lice are not feeding, they stay in the clothing. Therefore, it is
important to examine the inner lining of clothing including the seams of
underpants.
Hands and feet are usually not involved and there is a predilection for the
upper back. The characteristic distribution helps to distinguish it from
scabies. The principal louse-borne diseases are epidemic typhus, trench fever
and louse borne relapsing fever.
4.3. Treatment
It is the clothing rather than the patients which require treatment.
Destruction of the lice is accomplished by laundering or boiling the clothing
and bedding. High temperature laundering of underpants and dry-cleaning of
outer clothing are also effective. Tumble-drying is the most effective means
of killing both lice and eggs.
The patient should bath thoroughly with soap and water. Theoretically, this
is sufficient. However, many dermatologists would prescribe gamma
benzene hexachloride to treat the body as well. Mass delousing of large
number of persons can be carried out successfully by simply blowing DDT
powder under the clothing with a hand dust gun.
2. AETIOLOGY
Cutaneous mycobacterial infections are chronic granulomatous lesions
affecting skin at various regions of the body. Micro-biologically they are
classified as follows:
2.1. Tuberculous, Pathogenic
M tuberculosis M bovis
M lepra M africanum
2.2. Non-tuberculous, potentially pathogenic
1) Slow growing
M marinum M ulcerans
M kansasii M avium-intracellulare
M scrofulaceum
2) Rapid growing
M fortuitum M chelonei
3. CLINICAL FEATURES
There are different clinical presentations in cutaneous tuberculous infections,
depending on the virulence and number of bacilli infected, immunological
status of the host and the route of infection. Traditionally the clinical types
are divided into two groups:
1) True cutaneous tuberculosis
Lupus vulgaris
Tuberculous verrucosa cutis
Scrofuloderma
Tuberculous chancre, gumma, cold abscess
Miliary tuberculosis
2) Tuberculids
Papulonecrotic tuberculid
Lichen scrofulosorum
Erythema induratum
3.1. True Cutaneous Tuberculosis
This group of cutaneous tuberculosis is infected through direct inoculation
from an exogenous source, contiguous or haematogenous spread from an
endogenous focus.
3.1.1. Lupus Vulgaris
This is a chronic, progressive and tissue-destructive form of cutaneous
tuberculosis in patient with moderate or high degree of immunity. It occurs
more common in females than in males. The classical lesions consist of
reddish-brown plaque with "apple-jelly" colour on diascopy. The lesions
progress by peripheral extension and central healing, atrophy and scarring.
The areas of predilection are head and neck (80%), followed by arms and
legs, then trunk. It can be associated with tuberculosis of lymph node, lung,
bone and joint. In long-standing cases, patients may have scarring,
deformity, squamous cell carcinoma, basal cell carcinoma or sarcoma. The
main differential diagnosis includes discoid lupus erythematosus,
sarcoidosis, leprosy, lupoid leishmaniasis, tertiary syphilis, deep fungal or
atypical mycobacterial infection, granulomatous rosacea and Wegener's
granulomatosis.
3.1.2. Tuberculosis Verrucosa Cutis
In the past, this condition was common in Chinese boys over the buttocks
and knees. This is mainly due to their habit of playing and squatting in the
streets with open-bottom trousers. It usually presents as an indolent, purplish
or brownish red, warty and hyperkeratotic plaque lesion. It affects patients
with moderate or high immunity through direct inoculation of the tubercle
bacilli at sites of trauma. The areas of predilection are therefore over the
buttock, knee, elbow, hand and finger. Its progression is usually very slow
and spontaneous resolution may occur. This condition must be differentiated
from lupus vulgaris, viral wart, mycobacteria marinum infection,
chromomycosis, tertiary syphilis and hypertrophic lichen planus.
3.1.3. Scrofuloderma
This results from direct extension of an underlying tuberculous focus such as
lymph node, bone or joint to the overlying skin, often associated with
pulmonary tuberculosis. It is characterized by undermined ulcers, nodules,
fistulae, sinuses and scar. The areas of predilection are neck, supraclavicular
fossae, axillae and groin. The differential diagnosis mainly includes
hydradenitis suppurativa, actinomycosis, sporotrichosis and atypical
mycobacterial infection.
3.2. Tuberculids
It has been postulated that tuberculids are the result of hypersensitivity
reaction to haematogenous dissemination of tubercle bacilli or their toxin in
patients with moderate or high degree of immunity. Usually no identifiable
focus of active tuberculosis can be detected and the tissue culture for acid-
fast bacilli is often negative. There is still much controversy about these
conditions.
3.2.1. Papulonecrotic Tuberculid
This condition usually presents with symmetrical crops of papular eruption
that proceed to central necrosis, ulceration and depressed scar. It occurs
predominantly in young adult, most commonly affecting the limbs. There
may be history or distant foci of tuberculous infection. The main differential
diagnosis includes prurigo simplex, papular eczema, folliculitis,
leukocytoclastic vasculitis, pityriasis lichenoides et varioliformis acuta and
secondary syphilis.
3.2.2. Lichen Scrofulosorum
This is a rare form of tuberculid, presenting with grouped lichenoid papules
with perifollicular pattern over the trunk. It is frequently found in children or
young adults and may be associated with tuberculosis of lymph node, bone
or joint. The lesions often involute slowly in months without scar and then
recur. This condition must be differentiated from lichenoid drug eruption,
lichen nitidus, keratosis spinulosa, sarcoidosis, lichenoid syphilis and
eruptive syringoma.
3.2.3. Erythema Induratum (Bazin)
This is a nodular tuberculid presenting with indolent inflamed deep-seated
nodule and plaque, occurring bilaterally over the calves or feet. In severe
case there may be necrosis, ulceration, depressed scar and pigmentation. It is
more common in females than males. Usually there is no evidence of other
distant tuberculous foci. The main differential diagnosis is erythema
nodosum and other forms of nodular vasculitis.
3.3. Mycobacteria Marinum Infection
(Swimming pool or fish tank granuloma)
This is a chronic granulomatous infection of the skin caused by M marinum,
acquired by inoculation through abrasions. It is more vulnerable in children
and adolescents who frequently go to swimming pools, and among
fishermen and fishmongers. The lesion commonly occurs on fingers,
knuckles, elbows, knees and feet. Clinically it presents as an inflamed
nodule, pustule, ulcer or abscess. Sporotrichoid spread may occur. The main
differential diagnosis includes lupus vulgaris, sporotrichosis and
leishmaniasis.
4. INVESTIGATIONS
4.1. Skin biopsy x histopathology (AFB stain)
x tissue culture for M tuberculosis
+ tissue culture for atypical mycobacterial and deep fungi
The histopathological diagnosis and clinical correlation are important
because there is only a small percentage of cases with positive smear or
culture. When the skin biopsy is performed, one must make sure that
adequate tissue has been taken for both histological sections and tissue
culture. Repeated skin biopsy may sometimes be necessary to make a final
diagnosis. It is also important to specify on the laboratory form if one wants
to do a culture for atypical mycobacteria. They require different temperature
for growth in culture medium, for example, M marinum requires a
temperature of 30-32 degree centigrade within 2-3 weeks.
4.2. Tuberculin Test
In Hong Kong, Mantoux test is usually done by starting with 1 unit of PPD
intradermally over the forearm. If the result is negative, then the test is
repeated with 10 units. The results are interpreted as follows:
Diameter of induration Conclusion
5-10 mm suspicious
> 10 mm positive
> 15 mm strongly positive
However this test is of limited diagnostic value locally because of the high
incidence of exposure to mycobacteria and early vaccination of BCG. A
negative result nevertheless excludes active tuberculosis, except the miliary
form and diseases in immunocompromised patients.
4.3. Screening for Extracutaneous Tuberculosis
The presence of tuberculosis elsewhere provides supportive evidence in the
diagnosis of cutaneous tuberculosis, especially in the tuberculids. Chest X-
ray is mandatory. Other tests such as sputum, pus or early morning urine for
acid-fast bacilli, lymph node biopsy or bronchoscopy should be done if
indicated.
5. TREATMENT
Combination drugs therapy should be given to all true cutaneous
tuberculosis such as lupus vulgaris, tuberculosis verrucosa cutis and
scrofuloderma. Controversy exists about whether tuberculids should receive
multiple drugs treatment. Papulonecrotic tuberculide is commonly treated
with combination therapy, whereas erythema induratum and lichen
scrofulosorum can be treated by suppressive therapy with isoniazid alone.
The regimens of antituberculous therapy used in Hong Kong are
summarized as follows:
5.1. Standard Drug Regimens (totally 6 months)
1) Initial phase (3-4 drugs daily for 2 months)
Adult Child
a) Isoniazid 300 mg 5-8 mg/kg
+
b) Rifampicin > 50 kg 600 mg 10-12 mg/kg
< 50 kg 450 mg
+
c) Pyrazinamide > 50 kg 2.0 gm 20-35 mg/kg
< 50 kg 1.5 gm
or
Ethambutol < 60 days 25 mg/kg Not recommend
> 60 days 15 mg/kg
or
Streptomycin 3/4 gm IMI 15-20 mg/kg
2. PUVA (Psoralen-ultraviolet A)
2.1. Indications
1) Psoriasis
PUVA is used mainly in plaque type psoriasis. It is relatively contraindicated
for unstable, generalized pustular and erythrodermic psoriasis. Special
cautions should be exercised if PUVA is used in these situations as it may
further aggravate the disease. It is also difficult to monitor the dosage of the
ultraviolet light in erythroderma.
2) Mycosis fungoides (CTCL)
PUVA is a relatively safe and effective treatment in the patch stage and
plaque stage of mycosis fungoides.
3) Vitiligo
The response to PUVA in vitiligo is better for face than the limbs and trunk.
However, in practice only a small proportion of patients has satisfactory
response.
4) Others:
Severe atopic dermatitis, pityriasis lichenoides et varioliformis acuta
(PLEVA), pityriasis lichenoides chronica, prurigo nodularis, polymorphic
light eruption, etc.
2.2. Contraindications
PUVA is contraindicated or relatively contraindicated in the following
conditions:
1) Pregnancy
2) Children < 12-year old
3) Photosensitivity
4) Severe cardiac, hepatic or renal diseases
5) History of skin cancers
6) Aphakia or cataracts
7) Immunosuppressed patients (probably)
2.3. Factors for Consideration in Psoriasis
Age & sex
Severity (>30% involvement - arbitrary)
Previous treatment for psoriasis
Concomitant medical illness
Social & economic factors
2.4. Before Starting PUVA
Consider indications & contraindications
Thoroughly inform the patient about the nature of therapy and give the
instruction sheet of PUVA to patient
Written consent
Blood screening if indicated (LFT, RFT, ANF)
Body weight
2.5. Initiation of Treatment
Starting dose of psoralen should be calculated according to the body weight.
(0.6 mg/kg body weight)
Body Weight (Kg) Meladinine (Methoxsalen)
(10 mg/tablet)
<50 20 mg
50-65 30 mg
65-80 40 mg
80-90 50 mg
>90 60 mg
(Phototesting: determine the Minimal phototoxic dose and use 80% of MPD
as the starting dose)
Frequency of therapy: twice per week during clearing phase
Increment of dosage at each subsequent visit:
Initial: 0.5-1.0 J/cm2 (depends on skin type and starting dose)
If no response after 10 treatments: 1.0-1.5 J/cm2
If still no response after 15 treatments: Increase dosage of methoxsalen
Defaulter
a) Miss one regularly scheduled treatment: dosage should not be increased,
use the last dosage
b) Miss more than one session: dosage should be reduced by 0.5 J/cm2per
session missed (Minimum: starting dose)
c) Default for more than two sessions: see doctor before restart the treatment
Reaction (inform doctor)
a) If trace of erythema occurs, dosage should not be increased but the patient
may be treated with previous exposure time.
b) If more than trace of erythema occur, or patient complains of hotness and
tightness, the areas affected should not be retreated until these subside.
When more than 95% clearance (flexible), the last dosage should be
maintained, and a maintenance schedule should begin.
If no significant response or still not ready for maintenance treatment after
30 treatments, patient may be designated as treatment failure.
2.6. Frequency of Assessment by Doctor
The patient should be seen by doctor two weeks after initiation of treatment,
and then every four weeks during active phase. However, patient should be
seen by doctor as soon as possible if any reaction occurs.
Doctor should specify the starting dosage, subsequent increment and
frequency of therapy on the treatment sheet.
2.7. Maintenance Therapy
1) The last clearance dose is maintained at once-weekly interval.
2) If clearing persists for 4 weeks, reduce the frequency to one exposure
every 2 weeks (most patients need this frequency for maintenance).
3) If clearing persists for another 8 weeks, reduce to one exposure every
month. If it persist for another 4 months, the treatment may be stopped.
4) If there is relapse during maintenance, treatment is increased to twice a
week and UVA dose is increased by 0.5-1.5 J/cm2 for each successive
treatment. Maintenance is then given at a higher frequency than the one
which did not work.
5) During maintenance therapy, if erythema occurs as a result of decreasing
pigmentation, the UVA dose should be decreased by 0.25 J/cm2 per
treatment until erythema is no longer present.
2.8. Sites for Special Consideration
1) Extremities, especially legs, do not respond as well as the other areas.
Additional exposure time up to one fourth of the total may be given with
shielding of the other sites.
2) Intertriginous areas, scrotum, perineum, pendulous breasts and abdomen
are more sensitive to UV light. If necessary, they may be shielded with
folded cloth for one third of the total exposure time until tanning occurs.
3) Hairy scalp does not benefit from PUVA therapy.
4) Face may be shielded with cloth after the first few exposures if it is not
affected by psoriasis.
5) Normal skin is more sensitive to UVA than psoriatic skin.
2.9. Precautions that must be taken by Nursing Staff
1) Before treatment
a) Ask whether the patient has taken psoralen
b) Check whether the patient has erythema
c) Check the correct exposure time
2) During treatment
a) Make sure that the patient is wearing the protective goggles
b) Make sure that accurate exposure time is given
c) Withhold treatment if patient complains of discomfort
3) After treatment
a) Remind the patient to wear the sunglasses (Polarised grey - or green-
tinted) for 8 hours after therapy (both indoor and outdoor), and shield from
direct sunlight with sunscreen, suitable clothing, hat or umbrella.
b) Check the next follow-up time
c) Calculate the cumulative dose given
4) Maintenance of the PUVA machine
Check the irradiance of the machine with the UVA photometer every month.
Inform the technician to change the fluorescent tubes at the recommended
interval (For Waldmann UV3001 & 8001K PUVA machine: after 1500-2000
hours; Daavlin spectra 305/350: 850 hours) or when the irradiance drops.
(new lamps of 3001: 10.5 mW/cm2 at a distance of 21 cm; change lamps if
output falls below 6 mW/cm2 or when warning message appears in control
panel of Daavlin spectra 305/350)
2.10. Complications
1) Excessive erythema
If more than E1 occurs, PUVA therapy should be withheld. Patient should
be treated as having burns.
2) Pruritus
Bland emollients and antihistamines should be given. If the pruritus is
severe and persistent, withhold the phototherapy.
3) Nausea
The following measures may help to minimize the nausea due to taking of
methoxsalen:
a) Always take methoxsalen with some food
b) Mild nausea: take half the total dose of methoxsalen two and half hours
and the remainder two hours before phototherapy
c) Severe nausea: take antiemetic half hour prior to ingestion of methoxsalen
or decrease the dose of methoxsalen by 10 mg
4) Pigmentation
Reassure the patient that it will fade as exposures become less frequent
after the clearing phase.
5) Cataract
Annual ophthalmological examination is preferred.
6) Premature ageing and potential carcinogenesis in skin
Cautions should be taken about these potential risks when the cumulative
dose of the UVA over 1500 J/cm2
3. PUVA IN VITILIGO
The treatment is essentially the same as that in psoriasis. Start the dose of
UVA as that in type I skin with 0.5 J/cm2, with each increment of 0.25 J/cm2
and a frequency of two to three treatments per week. Try PUVA for 3
months. If there is response, may continue up to one year. However if there
is no response, stop it. Patient should be fully informed about the limitation
and risk of this treatment modality to avoid overexpectation or false hope.
In Social Hygiene Service, because of the shortage of manpower and PUVA
machine, a modified regimen using Wood's lamp and topical psoralen has
been used for years in vitiligo clinic. However, it is difficult to standardize
the exposure time as different models of UV lamps are used and these lamps
wear with time. It therefore depends much on the experience of individual
therapist with that particular lamp.
3.1. Machine and Specifications
Model B-100A Blak-ray Ultraviolet Lamp:
Peak wavelength: 366 nm
Minimal intensity: 1.020 mW/cm2 at 15 inches
Radiation (measured with UVA photometer):
at 6 inches is approx 6 mw/cm2
3.2. Patient Selection
Those patients with vitiligo on the face of relatively short duration may be
offered a trial. The eyelids should be avoided from irradiation. Those with
vitiligo of long duration and with involvement on trunk and limbs usually do
not respond to the treatment.
3.3. Before starting Topical PUVA for vitiligo
1) Explanation about the procedures and possible complications
2) Written consent
3.4. Dosimetry
1) Start with 30 seconds at a distance of 6 inches
2) Frequency: twice per week
3) Increase 10 seconds each session until E1 occurs
4) Try three months' duration. Continue if there is response; stop if there is
no response.
3.5. Procedures
1) Apply topical meladinine 30 minutes before radiation. Apply a thin layer
to the site of vitiligo only. Avoid the junction between the normal skin and
vitiligo. Avoid application to eyelids. Never dispense the topical meladinine
to patient for home application.
2) Warm up the machine for 5 minutes before use.
3) Fix the required distance.
4) Treat with the required exposure time.
5) Wash away the topical meladinine after treatment.
6) Leave the lamp on until all patients are treated, do not shift on and off
frequently.
7) If the lamp is shifted off, wait for 5 minutes or more before restart.
3.6. Defaulter
1) Miss one regularly scheduled treatment: dosage should not be increased,
use the last dosage
2) Miss more than one session: dosage should be reduced by 10 seconds per
session missed (Minimum: starting dose)
3) Default for more than two sessions: see doctor before restart the treatment
3.7. Precautions that must be taken by Nursing Staff
1) Before treatment
a) check whether the patient has erythema
b) check the correct exposure time
2) During treatment
a) make sure that the patient is wearing the protective goggles
b) make sure that accurate exposure time is given
3) After treatment
a) Advise the patient to avoid sunlight for 2 days
Use broad-spectrum sunscreen (Coppertone 45, Sunsense, etc.) both indoor
and outdoor
b) Check the next follow-up time
4) Maintenance of the machine
Check the irradiance of the machine with the UVA photometer every month.
Inform the technician to change the bulb at the recommended interval or
when the irradiance drops (minimal: 1.020 mW/cm2 at 15 inches distance)
3.8. Frequency of Assessment by Doctor
(same as PUVA)
3.9. Complications of Topical PUVA
1) Erythema
Local reaction with intense erythema with pain and blistering may occur
(either due to over-exposure or photoallergic contact dermatitis). For large
area of vitiligo on face, it is better to try the treatment on a small area first.
2) Photosensitivity
Photosensitivity of the skin can persist for 48-72 hours after application of
topical psoralen.
3) Hyperpigmentation
Marked hyperpigmentation may occur at the site of treatment.
4. UVB PHOTOTHERAPY
4.1. Indications
1) Psoriasis
2) PLEVA, Pityriasis lichenoides chronica, Pityriasis rosea
3) Uraemic pruritus
4.2. Regimens for Psoriasis (Chronic Plaque Type)
1) Goeckerman regimen (Tar + UVB)
2) Ingram regimen (Dithranol + UVB)
3) UVB alone
4.3. Goeckerman Regimen
- Mainly for inpatient treatment
- Average duration of treatment: 28 days
- Monitor parameters: thickness, scaling and erythema
Procedures:
1) Apply 3-10% Coal tar paste topically to the plaques (or whole body) bd.
2) Daily LPC (Liquor Pica Carbonis) bath. The coal tar paste should be
washed away with liquid paraffin one hour before the UVB irradiation.
3) After the UVB therapy in Physiotherapy Department (QMH, QEH),
reapply the coal tar.
Side-effects of coal tar:
1) Messiness and staining of the clothes
2) Irritation of uninvolved skin
3) Folliculitis especially over flexures
4.4. Ingram Regimen
- Mainly for inpatient treatment (Not used in Hong Kong now because the
dithranol in lassar paste is no longer available)
- Average duration of treatment: 21 days
Procedures:
1) Apply dithranol in Lassar paste (start with lowest concentration available:
0.25%) once daily to the plaques ONLY (Avoid the normal skin). The
applied paste is then powdered (e.g. using Talcum powder) to harden the
surface and prevent spreading to uninvolved skin. The treated areas are then
enveloped in Tubegauze and left for 24 hours. Increase the concentration of
dithranol if tolerated.
2) Daily LPC bath. The paste is removed with liquid paraffin one hour
before the UVB irradiation.
3) After the UVB therapy in Physiotherapy Department, reapply the
dithranol again.
Side-effects of dithranol:
1) Brown staining of the skin (reversible)
2) Burning, which can be severe
3) Irritation (avoid applying to flexures, face and eyes)
4.5. UVB Therapy
1) UVB machine: fluorescent bulbs with peak emission around 300 nm are
commonly used
2) Dosimetry
Unlike the relatively standardised regimen in PUVA, the empirical starting
dose and subsequent increment of UVB usually has to depend on the
recommendations of the manufacturers of different UVB machine, and on
the individual therapist's experience, taking account of the skin type of the
patient.
Another more precise approach is to determine the patient's sensitivity by
the phototesting. The aim is to achieve an erythema of E1. During the course
of therapy, patient will develop various degree of tanning, which may
require an increase of exposure dosage.
Starting dosage: 80% of the MED as determined by the phototesting or the
starting dose as recommended by the manufacturer (e.g. in Daavlin spectra
726-SP: start with 15 seconds)
Subsequent increment: 1/8 (12.5%) of the last dosage
3) Frequency
Inpatient: 5 times per week (except Saturday & Sunday)
Outpatient: 3 times per week
4) Distance
Depend on different machine used. If the distance is changed during the
treatment, the correct exposure time should be calculated accordingly.
(Waldmann UV100 and Daavlin spectra 726-SP: about 20 cm from the
lamps)
5) Maintenance
UVB phototherapy is mainly used as clearance schedules on intermittent
basis. Effect from long term maintenance is unclear, if being given, most
psoriatic patients require one to three exposures each week to maintain a
clear state.
4.6. Complications
(similar to those of PUVA)
4.7. Machines and Specifications
Clinic Model
YMT Dermatology Clinic Waldmann UV100
irradiance: approx. 1 mW/cm2
at 20 cm distance
Daavlin spectra 726-SP
irradiance: approx. 3 mW/cm2
at 20 cm distance
YFS Dermatology Clinic Hohensonne 3030
4.8. Before Starting UVB Phototherapy
1) Explanation about the procedures and possible complications
2) Written consent
3) Phototesting
4.9. Phototesting
1) A template with holes of different size (approx 2 x 2 cm2 is covered to the
back
2) Irradiate with different doses of UVB at a fixed distance
3) Read the result 24 hours later and determine the MED
4.10. Dosimetry
1) Start with 80% of MED or as recommended by the manufacturer (usually
15-30 seconds) (if phototesting has not been done) at a fixed distance
2) Frequency: three times per week
3) Increase 1/8 (12.5%) of previous dosage each session, stop the increment
if more than faint erythema (E1) occur.
4.11. Defaulter
1) Miss one regularly scheduled treatment: dosage should not be increased,
use the last dosage
2) Miss more than one session: dosage should be reduced by 1/8 (12.5%) per
session missed. (Minimum: starting dose)
3) Default for more than two sessions: see doctor before restart the treatment
4.12. Precautions that must be taken by Nursing Staff
1) Before treatment
a) Check whether the patient has erythema
b) Check the correct exposure time
2) During treatment
Make sure that the patient is wearing the protective goggles all the time.
Patient must be warned beforehand that the goggles should not be taken off
at any time during the treatment.
3) After treatment
Check the next follow-up time
4) Maintenance of the machine
Inform the technician to change the bulb at the recommended interval
(Waldmann UV100: should be renewed after approx. 1000 hours; Daavlin
spectra 726-SP: 450 hours).
4.13. Frequency of Assessment by Doctor
(same as PUVA)
5. PHOTO-PATCH TEST
Photo-patch test is performed for those with photo-allergic contact
dermatitis. Most reaction can be elicited by irradiating with UVA.
5.1. Procedures
1) Patch two symmetrical strips of photoallergans on the back of patient: one
as control and the other as test strip.
2) Read the result as usual 48 hours later to see whether there is contact
dermatitis and then remove the strips.
3) Irradiate one side with 5-10 J/cm2 UVA (PUVA machine or Wood's lamp).
The control side must be covered during the irradiation. If the Wood's lamp
is used, make sure to measure the irradiance with the photometer and
calculate the correct time of irradiation.
4) Read the result again after another 48 hours.
2. INVESTIGATIVE PROCEDURES
2.1. Venepuncture
This issue has been discussed in Section 2A of this chapter but the following
points are worth mentioning:
1) As skin diseases often co-exist with internal medical conditions, a variety
of serological tests may be needed. Nurses should ensure that the correct
specimen bottles and laboratory request forms are used for the tests
prescribed.
2) The amount of blood, request form and specimen bottle required may
differ from individual investigation and nurses must comply with these
different requests to prevent rejection of any incompatible specimen from
diverse institutions.
2.2. Skin Patch-Test
2.2.1. Indication
To find out patient's allergen(s).
2.2.2. Application of the Test Substances
Mark identification on the top of each tape to show the order of the test
agents through out the testing procedure.
Place the tape on the desk with the chambers facing up and remove the
protective paper.
Semi-solid test agents are applied directly into the chamber, filling slightly
more than a half of the chamber volume.
For liquid test agents, place a filter paper disc in the chamber. Moisten the
disc thoroughly without surplus and place the test tape onto the skin within a
few minutes (dry paper disc may result in weak or false negative reactions).
Patient should stand or sit in a relaxed 'normal' position.
The tests are applied to healthy skin of the back, (sometimes on the lateral
aspects of the upper arms), which is free of ointment and excessive sebum
(if present, remove by non-irritant lotion before the application).
Apply the tape starting with the lower part and press the chamber from
below upwards to let air escape.
Press each chamber gently with the finger to ensure an even distribution of
the test agents.
A blue marker may be used to locate the test sites.
Additional non-irritant tape may be applied to take margin for better
adherence.
Left Right
Patient's Back
2.2.3. Instruction to Patients
Skin Patch Test is so designed to find out the patient's allergen(s).
The patient is required to come for follow-up on the third and fifth day after
the first visit for Skin Patch Test.
Rash or itchiness at a particular test site denotes he is allergic to that kind of
substance.
Do not wet or remove the plastic adhesives until removal by nursing staff or
doctor on the third day.
Avoid heavy exercise to prevent sweating.
Avoid rubbing and scratching the back.
Protect his back from direct sunlight.
Add ordinary plaster-adhesive to the original ones if it comes off
accidentally. Report this to nursing Staff or doctor on the next visit.
Come back for follow-up if any reaction occurs on his skin within three
weeks of the Test.
2.2.4. Record and Report
Patient's details are written down on a "Patch Test Form" and attached to the
case record file.
He has to come back on the third and fifth day for reading of the test.
When the patient comes back for follow-up on the third day, the tape is
removed and the Test is read after 30 minutes by nursing staff or attending
dermatologist.
2.3. Skin Scraping and Nail Clipping
The diagnosis of a superficial fungal infection is made by the observation of
fungal elements in infected keratin. This can be achieved by direct
inspection of fungal elements by means of bright field microscopy or
mycology culture.
2.3.1. Explanation to Patient
Explain the nature and procedures of the investigation to the patient,
emphasizing that the skin will be scraped and not cut.
No pain will be encountered during the whole process.
2.3.2. Procedure
Clean the desired area thoroughly and remove all local application at the
scraping site (ether solvent is best).
A blunt scalpel is used for skin scraping.
Sterilization of the scalpel by heat before and after each procedure is
essential.
Cool down the scalpel before scraping (avoid burning the patient).
Adequate specimen should be obtained from the expanding edges of a lesion
as these are the sites of most active infection.
Separate scalpels should be used to obtain specimens from different sites for
an individual patient to avoid misinterpretation.
For nail clippings, nail fragments should be taken from any discoloured,
dystrophic or brittle parts of the suspected nail. These should be cut as far
back as possible from the free edge of nail and include its full thickness.
For hair, specimen from the scalp is best obtained by scraping with a blunt
scalpel. The sample should include hair stubs, the contents of plugged
follicles and skin scales. Hair may also be plucked from the scalp with
epilation forceps.
4. PHOTOTHERAPIES
Phototherapy alone or together with ingested Psoralen (Photochemotherapy)
has been proven to be effective in the management of many difficult skin
disorders. Nurses' role in this issue includes the input of detail information
on the treatment regime and advice on the outcome, to the patients.
Supervision during the whole course of therapy and patients' compliance
with the regime must also be keenly observed.
4.1. PUVA
4.1.1. Pre-treatment Preparation
A clear verbal explanation on the nature of the therapy and the procedures in
detail together with an instruction sheet on PUVA treatment must be given to
the patient prior to commencement.
Obtain written consent.
Blood screening for LFT, RFT, ANF.
Measure patient's body weight for doctor to assess the Meladinine dosage.
Clinical photographs are taken for future assessment.
Ensure the patient has taken Psoralen (Meladinine) 2 hours before
phototherapy (Psoralen enhances absorption of solar irradiation).
Wear ultraviolet-proof sunglasses, suitable clothing, hat or umbrella to
protect exposed areas of the body after ingestion of Psoralen. This will
prevent excessive exposure to sunlight especially in summer seasons.
Observe patient's skin condition before and after each treatment for progress
or changes especially any onset of erythema.
Check the correct exposure time.
4.1.2. Procedures
Tell the patient to remove all clothing and cover the genitalia. The face may
be shielded with a towel if it is not affected. For female patients, cover the
breasts if not involved.
Ensure the patient is wearing the protective goggles.
The patient is instructed to stand or lie at a designated distance away from
the light source.
To give accurate exposure time as prescribed.
A nurse is assigned to observe the entire procedure in a special designed
observation room through an observation window. Verbal communication
during the process is essential as a reassurance to the client.
Withhold treatment if patient complains of discomfort and inform the doctor
immediately.
The lower legs frequently take longer to respond to phototherapy and may
need additional exposures. All other areas should be draped during the added
treatment.
Remind the patient not to move about during the treatment.
4.1.3. After Treatment and Advice
Remind the patient to wear sunglasses (which should be prechecked to
ensure UVA opaque) for 8 hours after therapy (both indoor and outdoor), and
shield from direct sunlight with sunscreens, suitable clothing, hat or
umbrella to avoid over absorption of solar irradiation.
Apply sufficient emollient onto skin surface to minimize irritation because
skin is usually dry after treatment.
Reassure that pigmentation that may occur will fade as exposures become
less frequent after the clearing phase.
Observe and report any pricking, painful or itching skin sensation
occurrence immediately after treatment. Inform the doctor if erythema or
discomfort arises.
For female patients, advise contraception. If query of pregnancy, inform the
doctor immediately to stop the treatment.
Check and arrange the next appointment.
Calculate the cumulative dose given.
4.1.4. Defaulters
Miss one regularly scheduled treatment: dosage should not be increased, use
the last dosage.
Miss more than one session: dosage should be reduced by 0.5 J/cm per
session missed (Minimum: starting dose).
Defaulted for more than two sessions: see doctor again before restarting the
treatment.
4.1.5. Maintenance of the Machine
Check the irradiance of the machine with the photometer every month.
Inform the technician to change the fluorescent tubes at the recommended
interval or any deviations of intensity from normal range.
4.2. UVB
4.2.1. Pre-treatment Preparations
Thoroughly inform the patient on the nature of the therapy. Give the
instruction sheet on UVB treatment to him.
Obtain written consent.
Perform phototesting as stated by Doctor.
Check whether the patient has erythema.
Check the correct exposure time.
4.2.2. Phototesting
A test kit consisting of panels and mittens is affixed to the body or limbs
according to the site being chosen for the test.
Irradiate with different doses of UVB (10, 20, 30, 40 seconds). (NB
delivered dose of UVB will vary with different model.)
Read the result 24 hours later and determine the minimal erythemogenic
dose (MED).
4.2.3. Procedures
Fix the required distance according to different models.
Select the UV switch and reflector units.
Set the required exposure time with timer switch.
Tell the patient to remove all clothing and cover the genitalia. The face may
also be shielded if it is not affected. For female patients, cover the breasts if
not involved.
Ensure that the patient is wearing the protective goggles.
Remind the patient not to move about during treatment.
A nurse is assigned to observe the entire procedure in a special designed
observation room through an observation window. Verbal communication
during the process is essential as a reassurance to the client.
After being switched off, the system must be allowed to cool down at least
for the set period before restarted.
The field size of irradiation should be considered (e.g. if the whole body is
treated, the upper and lower parts have to be treated separately).
4.2.4. After Treatment and Advice
Reassure the patient that it takes 2-3 months to notice the outcome of the
treatment.
Apply sufficient emollient onto skin surface to minimize irritation because
skin is usually dry after treatment.
Avoid direct sunlight and protect himself by sunscreen, clothing, hat and
sunglasses.
Inform the doctor if erythema or discomfort occurs.
Check and arrange the next appointment.
4.2.5. Defaulters
Miss one regularly scheduled treatment: dosage should not be increased, use
the last dosage.
Miss more than one session: dosage should be reduced by 1/8 (12.5%) per
session missed. (Minimum: starting dose.)
Defaulted for more than two sessions: see doctor again before restarting the
treatment.
4.2.6. Maintenance of the Machine
Check the irradiance of the machine with the photometer every month.
Inform the technician to change the fluorescent tubes at the recommended
interval or any deviation of intensity from normal range.
4.3. Topical PUVA for Vitiligo
4.3.1. Pre-treatment Preparations
Explain on the procedure and possible complications.
Obtain written consent.
Check whether the patient has erythema.
Check the correct exposure time.
Put the date, dose and nurse's signature on the referral and return the referral
to the patient before he leaves.
4.3.2. Procedures
Thoroughly clean and assist patient to remove all dirt, make-up, sweat or
other local applications on the sites to be irradiated. Advice on the untoward
out-comes of such treatment, e.g. redness, blistering.
A thin layer of Meladinine paint should be applied to the leukodermic patch
or bald area by means of a dressed applicator.
The paint should be applied at least 30 minutes before Ultraviolet
illumination.
Warm up the machine for 5 minutes before use.
Refrain from applying paint to delicate areas, e.g. eyelid. Make sure no paint
gets into the eyes.
Both patient and nurse should put on goggles.
Give the correct exposure.
Wash off the topical Meladinine after treatment and application of sunscreen
agent onto the sites is advisable.
The treatment can be given twice weekly with an initial dose of 30 seconds
at a distance of 15 cm. An increase of 10 seconds per subsequent treatment
is recommended until E1 occurs.
4.3.3. Frequency of Assessment
The doctor is responsible to prescribe the starting dosage, subsequent
increment and frequency of therapy for each case. He will reassess the case
two weeks after commencement of treatment, then every four week during
active phase, but, patients should be seen by the doctor if any reaction
occurs.
4.3.4. Advice to Patients
Inform patient of the possible response and complication e.g. redness,
blistering, rash and pain.
Avoid exposure to sunlight especially on the day and the next of UV
treatment. Advise on the use of sunscreens both indoor and outdoor.
4.3.5. Reactions and Defaulters
If reaction is mild, maintain the dose of the last treatment. This also applies
to those who has defaulted treatment once.
If defaulted for more than one session, dosage should be reduced by 10
seconds per session missed. (Minimum: starting dose.)
Defaulted for more than two sessions, or if reaction is severe, e.g. severe
blistering, excoriation or burning sensation, withhold treatment and the
patient should be reassessed by the doctor.
4.3.6. Maintenance of the Machine
Check the irradiance of the machine with the UV photometer every month.
Inform the technician to change the bulb at the recommended interval or
when the irradiance drops.
5. LASER THERAPY
Laser Safety Officer (LSO): one of the nurses in the clinic will be appointed
as LSO. His/her duty is to ensure all safety measures are followed in
operating with a laser machine.
5.1. The information of Laser Therapy in our Skin Clinic is as follow:
At present, there are two types of Laser systems being used in our Service.
1) The VisErase is a free-standing mobile unit which uses a copper vapour as
lasing medium for treating a variety of vascular and benign pigmented
cutaneous lesions. The copper vapour laser emits green (511 nm) and yellow
(578 nm) Lights.
2) HGM Surgica K1 is another type of Laser unit which uses Krypton ion as
a convenient source of light for treating cutaneous and vascular pigmented
skin lesions. This Laser system emits lights of predominately two
wavelengths: 520-530 (green) and 568 (yellow) nanometers.
5.2. Indications
1) Recommended Laser Treatment: Yellow light
a) Capillary cavernous haemangioma
b) Cherry angioma
c) Hereditary haemorrhagic telangiectasia
d) Kaposi's sarcoma
e) Lymphangioma
f) Port wine haemangioma
g) Post rhinoplasty red nose
h) Rosacea
i) Spider telangiectasia
j) Telangiectasias
2) Recommended Laser Treatment: Green light
a) Naevus of Ota
b) Freckle
c) Keratosis (Actinic/Congenital/Seborrhoeic/Solar)
d) Lentigo
f) Neurofibroma
g) Naevus
h) Viral wart
5.3. Operation of Laser Machine
5.3.1. Manual Turn On of VisErase
Check that the AC power lamp is lit.
Turn the key switch to start (fully clockwise).
Wait 5 seconds - press the HIGH button - the button should flash.
After 10 minutes check that Laser Emission Lamp is lit and that no
malfunction is indicated.
Laser emission should begin approximately 30-35 minutes after the HIGH
button has been pressed and should stabilize after 40-50 minutes.
5.3.2. Manual Turn On of Surgica K1
Check that the main circuit breaker on the back of the unit must be in the
ON position.
Turn the key switch to the ON position.
After approximately 45 seconds, the Laser system can now be switched
either to the TREAT or STANDBY modes of operation by depressing the
appropriate button on the front panel.
When the laser is first turn on, it will go into the STANDBY mode
automatically after warming up. One may change to the TREAT mode
simply by depressing the green treat button.
When in the TREAT mode, the treat button lights up and generates a red
aiming beam. Pressing onto the foot switch will light up the Laser head
which will then release laser energy to the delivery device.
Note * Safety goggles must be worn by all personnel when the laser is in
use.
* Treatment should not be commenced until the Laser power has stabilized.
5.4. Preparation of Patient
Record all the particulars: name, clinic no., laser therapy no., site of
treatment and especially contact telephone no. on the treatment progress
sheet.
Obtain consent form after explaining the procedure and aftercare to the
patient by the MO i/c.
Take Clinical photo before treatment and every follow up.
5.5. Preparation for Laser Therapy
Safety goggles must be worn by all personnel when the laser is used.
Protect patient's eyes with safety goggles or eye shield.
Provide local anaesthesia (2% Lignocaine without adrenaline) as prescribed.
Sometimes a thick layer of EMLA cream (a kind of local anaesthetic agent)
with an occlusive dressing is applied to the area to be treated 1 hour before
therapy (this allows better absorption).
For lesions near to the eyes, Novesin eyedrop is instilled if eye shields are to
be used.
A technique for reducing thermal damage to surrounding tissues during laser
surgery is to precool the surgical site prior to laser energy exposure if
possible. Constant irrigation with saline solution will also carries excessive
heat away from the surgical site.
Mark the treatment time.
Assist the doctor in certain procedures, e.g. light adjustment, vacuum suction
of excessive smoke, installation of different lens pieces.
A good functioning Smoke Evacuation system should be installed. It is
especially useful to provide a germ free environment when performing
operations with pathological conditions suspected to be of viral origin.
Make sure all windows are shut. No reflection of light is allowed. The door
should be locked while the laser is being used. Turn on the warning light
whenever therapy is proceeding.
5.6. Manual Turn Off of Laser Machine
After treatment for all patients, turn the key switch of VisErase to finish. The
Laser will shut down but the cooling fan will continue to operate for about a
further 15-30 minutes. The fan will automatically turn itself off at the end of
this period. As for Surgica K1, wait 5 minutes for cool down and then turn
off the machine.
5.7. Aftercare Following Laser Treatment
Inform patient a sunburn like reaction with possible blistering with the first
24-48 hours is expected.
A crust or scab may occur after 2-3 days. Advise the patient not to remove it
and let it fall off itself.
Keep the area clean and dry until the scab/crust falls off. Wash gently with
soap and water and apply a thin layer of antibiotic ointment.
Avoid direct sunlight or sun exposure to the treated area for 3-6 months. Use
at least an SPF of 15 or greater sunscreen, or wear a hat or other protective
clothing (preferably both).
Reassure the patient that the treatment may take up to three months to
adequately judge the true response of the skin condition to the laser
treatment.
Check and arrange next follow-up time.
5.8. Maintenance of Laser Machine
Make sure the AC power lamp is always lit. Do not turn off the main switch
for Laser.
Do not move the laser while it is operating or within 30 minutes of turning it
off.
Make sure the castor brakes are locked.
The laser unit should be protected from standing in pooled liquid.
Avoid liquid to enter the laser through apertures such as air vent holes. If
liquid does enter, terminate use immediately, disconnect power and call for
service.
Do not place the fibreoptic fibre on the floor, avoid pressing across it with
hard objects.
Never press the utility mode when controlling the panel.
5.9. Precautions
Never look directly at the Laser bean emerging from the aperture on the
main assembly or from the fibre, handpiece or scanner if one is fitted.
Never operate the laser unless all personnel in the area are wearing approved
laser safety goggles.
All laser personnel should consider the laser plume to be potentially
hazardous, both in terms of particulate matter and infectivity. Operating staff
should wear masks and latex surgical gloves.
If the laser light is being used near a patient's eyes, additional eye protection
must be provided for the patient, i.e. using the eyeshield and anaesthetic eye
drops.
Always lock the door of the room during treatment.
Never look at the laser light reflected, diffused or scattered from reflective
surfaces such as glass, mirrors, metal, glossy paint, polished floors, plastic
mouldings, window frames or paper.
Do not use the laser in the presence of flammable substances, e.g. ether.
Never point the laser handpiece at any person except at the treated area.
Electric
Power source Flashlamp Electric current
current
Wavelength
488, 514 577, 585 511, 578
(nm)
400-500
Pulse duration 0.2-20 s 20 ns
us
Depth of
penetration at 200-300 400, 600 300-400
50% (um)