Jonathan Tze-Wei Ho, M.A., M.D.
https://www.hopkinsmedicine.org/profiles/results/directory/profile/10003132/jonathan-ho
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Cannabisinduced dermatoses Chronic cannabis use can cause cannabis arteritis bipolar depression 7 months prozac 40 mg buy overnight delivery, a subtype of thromboangiitis obliterans, which may lead to peripheral necrosis, most often of the lower limbs [6] (see Chapter 103). It is thought to be caused by the vasoconstrictive effects of 9tetrahydrocannabinol and other unidentified contaminants. Cannabis arteritis presents with Raynaud phenomenon and, if neglected, digital necrosis. Duplex ultrasound can differentiate between cannabis arteritis and atherosclerosis [6]. Revascularization and reperfusion of an affected extremity should occur with discontinuation of cannabis along with antiplatelet and vasodilator therapies [7]. Ecstasy has unique psychoactive properties, producing a controllable emotional state of relaxation and happiness. The peak effects tend to occur during the next hour, and then diminish over the following 2 h. Among the more common side effects of ecstasy are tension in the jaw and grinding of the teeth (bruxism). Acute hepatotoxicity is recognized, while the exertion that follows fast dancing may compound the pharmacological effects of ecstasy resulting in collapse, convulsions and acute kidney injury [12]. Hyperthermia is another potentially lifethreatening side effect that may be mediated by increased dopamine release acting on D1 receptors [13]. The dermatosis consists of inflammatory papules and pustules, but no comedones, similar to perioral dermatitis [14]. Prolonged, heavy use of meth may be accompanied by persecutory symptoms resembling those of paranoid schizophrenia [15]. Methamphetamineinduced dermatoses the commoner cutaneous side effects of crystal meth abuse are xerosis and pruritus. It is caused by poor oral hygiene, bruxism, xerostomia and, perhaps, a reduction in saliva pH. Resorption of gingival bone from tooth decay and gum disease contributes to a loss of volume of the lower face, which exaggerates the premature ageing characteristic of crystal meth abuse [18]. The abuse of aerosolized cleaning fluid has been associated with cutaneous and mucosal blistering, and also with angiooedema [10]. Chemical burns around the nose and mouth caused by solvent irritancy have been also reported [11].
Pigmentation due to minocycline can occur in the skin and has also been reported in the sclera depression symptoms recovery cheap prozac 20mg with visa. As would be expected of such complex tissue, the eyelid gives rise to a large number of skin tumours. Tumours can arise from the epidermis and dermis in addition to the adnexal structures, which include the meibomian and Zeis sebaceous glands, eccrine and Moll apocrine sweat glands, and the specialized hair follicles of the eyelashes. They may also originate from lymphoid neural and vascular tissue found in the preseptal tissues of the eyelid. Although optimal treatment of the tumours begins with accurate diagnosis, many are rather nonspecific in their appearance and are only diagnosed with certainty by histology. They have similar clinical features to those elsewhere on the skin and are treated in the same way with local destructive measures, using carefully applied cryotherapy, curettage and cautery or laser ablation under local anaesthetic. Recurrent actinic keratosis should be biopsied and sent for histological examination to make sure it is not a deceptive manifestation of an early skin cancer. The cornea shows arcus senilis, which is also associated with hypercholesterolaemia. About 60% of patients have an associated hypercholesterolaemia and lipid levels should be measured. Although 90% trichloroacetic acid applied with a cotton wool bud is used there is a significant risk of spillage into the eye. More effective treatment is by surgical excision or ablation with carbon dioxide laser. Necrobiotic xanthogranuloma may look similar to xanthelasma but they are thicker and more nodular. Adnexal tumours [4] Syringomas, milia, trichoepitheliomas and tricholemmomas present as small papules around the eyelids. Syringomas are the most common, but histology from a biopsy is the only way to make a definite diagnosis. Eccrine hidrocystomas can present in an eruptive fashion on the face and eyelids; they may respond to topical atropine. Benign cysts of the eyelid Retention cysts may arise from either the glands of Moll or Zeis. An eccrine gland hidrocystoma is similar in appearance to a cyst of Moll but is not confined to the lid margin. Part 10: SiteS, Sex, age Juvenile xanthogranuloma [3] these lesions occasionally involve the eyelid, conjunctiva or uveal tract. Chalazion [5] this lesion represents a chronic granulomatous inflammatory reaction around a blocked sebaceous gland. Patients with seborrhoeic dermatitis and rosacea are at increased risk of chalazion formation. Chalazia will usually resolve spontaneously but large and troublesome lesions can be treated by everting the lid with a special clamp, incising the cyst and curetting the contents through the tarsal plate. Patients who develop recurrent chalazion associated with seborrhoeic dermatitis and rosacea benefit from longterm antibiotic treatment using tetracyclines.
Cholinergic urticaria bipolar depression quiz online cheap prozac 60mg with visa, precipitated by Infantile acne Infantile acne is rare, but should be easily distinguished from the transient sebaceous gland hyperplasia/milk spots seen in the neonate (see also Chapter 90). No underlying endocrinopathy was found in infants [1,3], in contrast to older children presenting with preadolescent acne in whom more detailed investigation may be merited. Treatment may be topical (benzoyl peroxide, erythromycin or retinoids) in mild cases [1]. In more extensive disease, the majority of children will clear with oral erythromycin, but trimethoprim can also be used if there is erythromycin resistance [1]. In severe disease, oral isotretinoin has been shown to be safe and effective in infants [2]. Scarring is estimated to occur in 17% of infants with acne [1], reflecting the proportion with more severe disease. Urticaria in infancy may be a feature of systemic disease including systemic lupus erythematosus, juvenile rheumatoid arthritis, mastocytosis and Kawasaki disease [7], but is rarely the only presenting feature. Often this is nonspecific and harmless [1], but some viral infections have very characteristic features that allow a diagnosis to be made. A detailed account of viral infections appears in Chapter 25, but the most frequent or important infections seen in children are highlighted here. Viral exanthems account for the most common presentation to a paediatric emergency department [3]. However, differentiation from exanthems due to other causes (drugs, bacterial toxins, autoimmune disease) must be made [1,2]. Overall, petechial changes are much more likely to occur in exanthems associated with infections, particularly of viral origin (although meningococcal septicaemia should always be considered) [2]. A more reticulate rash then appears on the limbs and body, and palmoplantar erythema is common. The eruption fades over 7 days, but recrudescences are not infrequent, particularly if the child gets hot. Older individuals may develop a papulopruritic eruption in a glove and stocking distribution with parvovirus B19 infection [3], but this pattern is rarely seen in infants. Hand, foot and mouth disease this is a common infection in young children, affecting the oral cavity and extremities. A high fever develops that lasts for 3 days and may rarely be associated with febrile convulsions [4]. As the pyrexia subsides a fine, lacy, macular erythema appears, which may be accompanied by occipital lymphadenopathy.
Scrotal angiosarcoma complicating oedema following sur gery and radiotherapy for carcinoma of the rectum has been described [11] mood disorder dsm 4 buy prozac 20 mg with mastercard. Melanoma is even rarer on the scrotum, with only four cases appearing in the literature [4,5]. Genital melanoma presents as a pigmented macule or as a pig mented or amelanotic papule or nodule, possibly developing from Part 10: sites, sex, age 111. Localized perianal involvement [14], a solitary plaque on the penis [15] and response to treatment with imiqui mod have been described [15,16]. Although lymphoma is the most frequent secondary tumour of the testis, it is rare in other parts of the male urogenital tract [4]. Ulcerating scrotal lymphoma has been reported [23], as have scrotal and penile ulceration resulting from leukaemic infiltra tion [24,25]. Metastases to the penis are rare, but several hundred cases have been reported [26,27]. They are usually secondary to cancer of the urogenital tract [28] or gastrointestinal system, or other common cancers such as of the lung [29], and present with pain, swelling, priapism, urinary symptoms or haematuria. A very rare cause is secondary melanoma [26,30] and primary cholangiocarcinoma [31]. They are benign but, because they may be large or enlarging, with irregular edges and multifocal and variegated pigmentary patterns, they arouse concern about atypical melano cytic proliferation and acral lentiginous melanoma. Such clinical concerns should lead to biopsy [3]; it is important to decolorize slides from deeply pigmented lesions because large quantities of melanin can obscure cytological detail [2]. The eruptive appearance of melanotic macules and papules in the anogenital region may be associated with advanced meta static adenocarcinoma [6]. On histological examination there may be increased basal epidermal pigmentation, with or without benign lentiginous melanocytic hyperplasia, or an increase in basal melanocyte number. Patients ask for treatment of penile melanosis as it is unsightly and embarrassing, but options are limited [2]. Part 10: sites, sex, age hypopigmentation Striae as a consequence of growth or weight surges are common around the pelvic girdle, or represent a complication of topical corticosteroid application [14]. Vitiligo is a commonly observed affliction of the male genitalia, although patients may be unaware of it and clinicians might not always observe it [15]. Penile vitiligo attributed to the use of topical imiquimod for the treatment of genital warts has been described [16]. A common factor in many but not all causes of swelling may be oedema or lymphoedema. Causes of anogenital lymphoedema and penoscrotal swelling are listed in Boxes 111.
Environmental factors Halo naevi sometimes appear after intense sun exposure [146] anxiety 8 months pregnant discount prozac 10 mg fast delivery. This white halo is particularly visible during the summer months when the unaffected adjacent skin acquires a tan. During the following months the naevus may gradually shrink or even disappear completely, leaving a white macule. Approximately half of halo naevi undergo total clinical and histological regression. Differential diagnosis In older patients presenting a single lesion, the possibility of a melanoma in regression should be excluded. In a case of melanoma, both the central pigmented area and the surrounding halo appear irregular, while the centre of the lesion presents dermoscopic features that are suggestive of melanoma. A subgroup may progress through stages of involution with a return to normal colour, but even these lesions usually persist for several years (average of 7. A halo naevus presenting in an older patient should raise concern, especially in the absence of vitiligo and no history of halo naevi in the past. In such cases, a thorough skin and lymph node examination is recommended to exclude melanoma elsewhere. Epidemiology Incidence and prevalence A Meyerson naevus is an unusual type of naevus. Differential diagnosis Single lesions could occasionally be confused with melanoma or halo naevus. In multiple Meyerson naevi, the differential diagnosis includes pityriasis rosea and roseola of secondary syphilis [132]. Predisposing factors Treatment with interferon has been reported prior to the development of Meyerson naevi [153,154]. Pathology Histology reveals a common, usually compound, melanocytic naevus with associated spongiotic dermatitis of the overlying epidermis. Disease course and prognosis the eczematoid changes usually resolve spontaneously after a few months, leaving the involved naevus intact, although some degree of hypopigmentation or even complete resolution of the naevus has been described [157]. Meyerson naevus is a similar lesion to halo naevus and may coexist with this entity in the same patient. Occasionally, a Meyerson naevus can progress to a halo naevus or vice versa [158,159]. The lesion resembles a naevus with superimposed discoid eczema and it may be slightly pruritic. Clinical re evaluation and dermoscopic examination will confirm that the underlying naevus is benign.
Syndromes
Oxandrolone (10 mg depression symptoms not eating purchase 60mg prozac amex, twice daily) has also been shown to decrease hospital stay, morbidity and mortality [46]. Finally, long term treatment with oxandrolone decreases hypermetabolism and promotes weight gain, with lean body mass and bone mineral content increasing from 6 to 12 months postburn [128,129]. A recent longterm study in severely burned children found significant benefit for longterm oxandrolone administration over 5 years [130]. Propranolol Of the anticatabolic therapies for burns, the adrenergic blocker, propranolol, is perhaps the most effective [131]. When administered acutely, propranolol exerts antiinflammatory and antistress effects [132]. Longterm propranolol treatment significantly reduces predicted heart rate and resting energy expenditure, decreases accumulation of central mass and central fat, prevents bone loss and improves lean body mass accretion [136]. This finding has been confirmed by a blinded placebocontrolled trial, which also showed that fenofibrate increases mitochondrial glucose oxidation, ultimately reducing blood glucose concentrations [146]. The biguanide metformin (Glucophage) suppresses gluconeogenesis and increases peripheral insulin sensitivity, making it a candidate for the treatment of hyperglycaemia associated with severe burns [147,148]. To date, no large randomized controlled trials have been conducted in burn patients; however, two small studies have shown that metformin decreases glucose production, speeds glucose removal and improves muscle protein synthesis/net muscle protein balance [147,149]. Although metformin has clear advantages, it and other biguanides often produce lactic acidosis [150]. Metformin is an interesting agent that may or may not have a place in the treatment of postburn metabolism. Summary and conclusions Burn injury triggers pronounced metabolic changes accompanied by prolonged impairments in glucose metabolism, both of which lead to detrimental outcomes. Progress in diminishing the hypermetabolic response has led to a clinically significant improvement in patient outcomes; however, developing strategies to counteract longlasting hypermetabolism and associated hyperglycaemia still remain a challenge. Prompt wound excision and closure remains the most important development in burn care over the last 20 years, with this advance considerably reducing basal energy expenditure and increasing survival. Currently, the adrenergic blocker propranolol appears to be the most effective pharmacotherapy for countering catabolism in burn patients. Additional studies are needed to identify ideal glucose ranges and determine if the above-mentioned agents are safe for the critically ill. Insulin Burn patients with stressinduced hyperglycaemia have a greater incidence of bacteraemia/fungaemia, poorer wound healing, more pronounced protein catabolism and lower likelihood of survival than burn patients with adequate glucose control [81,82]. In a recent study patients receiving insulin exhibited better wound healing and organ function than controls [84].
Pruritus ani can be primary (idiopathic) or secondary and is not a diagnosis unless qualified as constitutional or idiopathic anxiety ed 10 mg prozac purchase fast delivery. Management requires detailed assessment to determine whether there is an underlying cause. Pruritus ani can be associated with most forms of anorectal disease or perianal skin disease. Pruritus ani is considered idiopathic when no dermatological or anorectal cause can be found. The pathogenesis of idiopathic pruritus ani is thought to be primarily the consequence of faecal contamination or possibly the intake of certain food or drinks. The common factor linking most cases of idiopathic pruritus ani is faecal contamination. These will cause faecal soiling and an increase in perianal trauma from frequent wiping of the skin. The role of food and drinks is uncertain but those implicated include coffee, tea, cola, beer, chocolate, tomatoes, spices and citrus fruits. The mechanisms proposed include effects on anal sphincter tone, production of loose stools and undigested food components irritating or sensitizing the perianal skin. Patients are often tense individuals in whom everyday problems induce a profound colonic reflex, resulting in defecation and soiling. Clinical features History the complaint is of itching, stinging or soreness that may be chronic and recurrent. Symptoms may be triggered by a bowel movement or wiping with toilet paper, but may occur at night. Differential diagnosis Fungal infection often causes intense pruritus, and diabetes must be excluded in all severe or persistent candidal infection. Complications and comorbidities Lichenification, excoriation and secondary infection can occur. Patients with idiopathic pruritus ani have a high incidence of loose stools and are rarely constipated. Any factor that increases faecal contamination exposes perianal skin to irritants. Exaggerated rectoanal inhibitory refex and anal sphincter dysfunction may result in faecal soiling. Common allergens include neomycin, fragrance mix, Balsum of Peru [3] and methylisothiazolinone [4].
Differential diagnosis includes eosinophilic pustulosis of the scalp depression symptoms severe discount prozac 10mg amex, transient pustular melanosis, scabies, neonatal acne and infections with Candida or Staphylococcus aureus [7]. It appears that Candida is, however, able to find its way into the amniotic fluid without prior rupture of membranes. Foreign bodies in the uterus or the cervix increase the risk, particularly intrauterine contraceptive devices [8]. There is no evidence that maternal antibiotic therapy or immunodeficiency in the infant play a role in predisposition [6,9]. An extensive eruption of scattered pinkish red macules and papules is present at birth or appears within a few hours. More or less any part of the skin surface may be affected, including the nails, palms and soles. In fact, palmar and plantar pustules are regarded as a hallmark of congenital cutaneous candidiasis. Paronychia may occur and isolated involvement of the nail plates has been described [10]. Oral involvement is usually absent, and the napkin area tends to be spared, at least initially. Skin function in the neonate Barrier function 5 Raone B, Raboni R, Rizzo N, et al. Transepidermal water loss in newborns within the first 24 hours of life: baseline values and comparison with adults. Sterile neonatal pustulosis associated with transient myeloproliferative disorder in twins. Ongoing blistering in a boy with congenital erosive and vesicular dermatosis healing with reticulated supple scarring. Congenital erosive and vesicular dermatosis: a new case and review of the literature. Spontaneous atrophic patches in extremely premature infants: anetoderma of pregnancy. Neonatal herpes simplex virus infection introduced by fetal monitor scalp electrodes. Neonatal bullous eruption as a result of transient porphyrinemia in a premature infant with hemolytic disease of the newborn.
The pathogenesis of the depression not eating purchase 40mg prozac, often severe, follicular and papillary conjunctivitis that accompanies this condition is assumed to be due to a combination of transient infection and hypersensitivity. Some researchers have hypothesized that toxins produced by the bacteria may cause irritation, but no specific toxin has been identified [18,19]. Demodex folliculorum are small parasitic mites that live in hair follicles, sebaceous glands and meibomian glands. They are found Part 10: SiteS, Sex, age Meibomian gland disease the meibomian lipids (meibum) are a complex mixture of cholesterol esters and esterified unsaturated fatty acids. These lipids are responsible for maintaining a stable tear film, reducing tear film evaporation (and, therefore, preventing drying of the ocular surface) [23], preventing tear spill over the lid margins by lowering surface tension and reducing ocular surface contamination by sebum from the cutaneous surface of the lids, which otherwise forms dry spots. Bacterial lipases are produced by all the bacteria that colonize the lid margin and have the potential to break down meibum into free fatty acids, which will destabilize the tear film [25]. These bacteria colonize the gland orifices and expression of lipid from deeper within the glands can stabilize the tear film. Neither the pathogenesis of the conjunctival inflammation that is common in meibomitis (and which is a feature of ocular rosacea), nor that of the keratitis in ocular rosacea, has been explained. Ocular rosacea the precise aetiology and pathophysiology of ocular rosacea remains unknown, although different theories have been proposed [27] (see also Chapter 91). Recent molecular studies propose that abnormal recognition of common environmental stimuli leads to activation of proinflammatory systems as well as innate immune responses. Factors that trigger the innate immune system lead to increased expression of certain cytokines and antimicrobial molecules such as cathelicidin, which is vasoactive and proinflammatory [28]. Overreaction to environmental stimuli is believed in part to be due to elevated expression of tolllike receptor 2 in the epidermis of rosacea patients, which leads to increased serine protease and cathelicidin production. Furthermore, tetracyclines, which improve the signs and Blepharitis, meibomian gland dysfunction, rosacea, seborrhoeic dermatitis 109. Blepharitis, meibomian gland dysfunction, rosacea, seborrhoeic dermatitis Table 109. Causative organisms Staphylococcal blepharitis is believed to be associated with staphylococcal bacteria on the ocular surface, but there are likely to be additional contibuting factors, given that in some studies there is no difference in positive culture levels between controls and blepharitis patients. Demodex mites have also been considered a causative factor in blepharitis and papulopustular rosacea. Another proposed mechanism is that Demodex mites may act as vectors for other organisms such as Bacillus olenorius, which may be responsible for initiating the inflammatory response via stimulation of tolllike receptor 2 and production of antigenic proteins [22]. In severe and longstanding staphylococcal blepharitis, trichiasis (misdirection of eyelashes towards the eye), poliosis (depigmentation of the eyelashes), madarosis (loss of eyelashes), eyelid ulceration, and eyelid and corneal scarring may occur [3].
One patient was diabetic and also had lesions on the legs [23]; the others had penile lesions only bipolar depression with psychosis generic prozac 60 mg visa, and were treated with oral pentoxifylline [24,25]. Pyoderma gangrenosum is a diagnosis made when other causes of purulent ulceration, such as infection (sexually acquired and exotic or rare, including Fournier gangrene), malignancy and arte fact have been excluded. Systemic treatment is usually required but one case has responded to topical tacrolimus [37]. Calciphylaxis is a rare and serious complication of chronic renal failure in which extending ischaemic gangrenous necrosis affects acral tissues and sometimes the thighs, buttocks and genitals [38,39,40,41,42,43]. Treatments include intralesional corticosteroid injection [10], including deliv ery by Dermojet [11]. Symptomatic relief has been claimed following iontophoresis of drugs such as dexamethasone, lido caine (lignocaine), paraaminobenzoic acid and verapamil [13,14]. The eruption is acute, with an ery thematous plaque, sometimes with central blister formation, ero sion and ulceration. Cases have occurred in men after congress with sexual partners who have taken the drug to which they were known to be sensitive: cotrimoxazole, diclofenac, isosorbide and aspirin are the drugs cited [1,2]. The differential diagnosis of penile fixed drug eruption includes herpes simplex and erythema multiforme. Ulceration has been reported following the inadvertent subcu taneous injection of papaverine for the treatment of erectile impo tence [3]. Dequalinium is a topical antibacterial that was used for the treatment of impetigo and moniliasis in the 1950s and 1960s, but it caused a necrotizing balanitis with ulceration when used for the treatment of balanitis in uncircumcised men [4]. Alltrans retinoic acid has been reported to induce scrotal ulceration in a patient with acute promyelocytic leukaemia [5]. Nicorandil is a newly recognized cause of anogenital and peristomal ulceration [10,11]. Penile argyria due to chronic application of silver sulfadiazine has been reported [12], as has necrosis follow ing warfarin administration [13,14]. Some of the reported cases have been complicated by actinomycosis [2,4], and one has been associated with a dermoid cyst [5]. Patients have comedones, papules, pustules and inflammatory nodules of the proximal shaft of the penis. It presents with pain and curvature on erection, a sensation of a cord within the penis, palpation of a lump or knot, decreased erection distal to the plaque, interference with intercourse and progressive impotence.
Hogar, 61 years: As a result of this affinity, the metabolites have a predilection for the skin, hair and nails. The LawrenceSeip syndrome, which is a congenital generalized lipodystrophy with the onset of insulinresistant diabetes around the time of puberty, may also result in clitoral hypertrophy. The biomechanics of the foot that lead to callosities have been investigated in detail [68].
Tamkosch, 65 years: The exact relationship between episodes of acute infection and chronic penile oedema, which often is complicated by cellulitis, is uncertain. A common scenario proposes that naevi originate from a single precursor melanocyte of unknown nature. Monochromator phototesting can only be undertaken if there is sufficient clear skin on the back.
Nefarius, 23 years: A 2010 Cochrane review found that adding chemotherapy to surgery or radiotherapy for oropharyngeal cancer can work better than one of these treatments alone [110]. Treatment may be topical (benzoyl peroxide, erythromycin or retinoids) in mild cases [1]. They comprise 13 mm diameter, white, globular papules, which occur at the same sites as sebaceous gland hyperplasia.
Giores, 58 years: Commercially available perfumes are mixtures of essential oils from these sources and synthetic compounds, with usually at least 10, and up to several hundred, ingredients [3]. Melanoma transmitted in this way may result in the appearance of nodular skin deposits in the neonate. They can spread onto the perineum and around the anus, and may develop into soft, warty, vegetating lesions.
Gorn, 31 years: Antihistamines may need to be used in combination and there may be a synergistic benefit with sunscreens [70,78,79]. Speech is not usually affected in patients with ankyloglossia but the ability to suckle [8] and to cleanse the buccal sulcus with the tongue may be, and there can be effects on jaw development [9]. Cleft palate is more prevalent in females, while cleft lip is more prevalent in males.
Reto, 52 years: Thus, in an individual case, the two reactions may be clinically indistinguishable. Melanotic macules can be excised to exclude melanoma or for cosmetic reasons, or removed by laser or hidden by lipstick [812]. There has been concern about aspirin and diazepam as possible causes but there is no real evidence.
Malir, 56 years: These topical agents are generally applied in the evening after cleaning the area first. Management the lesions need to be swabbed for bacteriology and appropriate oral and topical antibiotics given. Highermolecularweight resins may contain small amounts of the oligomers or monomer but rarely sufficient for the induction of sensitivity.
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