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However, patients with systemic sarcoidosis may also develop sarcoidal granulomas involving the subcutaneous tissue as a specific cutaneous lesion and which is referred to as subcutaneous sarcoidosis. Chemical depigmentation A number of chemicals can produce cutaneous depigmentation when applied to the skin [1,2]. There are three isoforms of 5reductase, which are encoded by different genes [55,56]. Evidence for cold induction of brown fat as an adaptive response in humans is at present equivocal [9]. In most countries, it is rare to find families of any racial background with no acne. It is discussed here as it can present as a pigmented purpuric dermatosis related to exercise, where there is no evidence of venous disease. Typically, a polyvalent IgM rheumatoid factor binds to antigen (although other monovalent immunoglobulins can also be responsible) to produce immune complexes that activate complement resulting in endothelial activation and tissue damage. The full extent of the lesion is explored systematically with the probe, and the roof of the lesion surgically removed using the probe as a guide, leaving the partly epithelialized/granulating floor of the lesion exposed. Treatments are usually administered as part of a course of at least three visits separated by intervals of several weeks. Clinical features In trichorrhexis nodosa complicating a congenital defect of the hair shaft, the hair breaks so easily that large or small portions of the scalp show only broken stumps and alopecia may be gross. However, about 40% of those whose lesions cleared had a recurrence, in the majority of cases at the same sites as the original lesions. Transverse grooves scored proximally in the nail plate will confirm that the nail is growing by moving distally with time. The shallow atrophic lesions have sharp margins and may be linear, rectangular or varioliform. Statins, iloprost (prostacyclin analogue), pentoxifylline (oxpentifylline) and steroids have been reported as having limited success in therapeutic interventions to minimize organ damage [2,8]. Loss of dermal ground substance leads to a reorganization of the dermal architecture. The pain generally subsides within a few months, but the fibrous plaque may resolve, remain unchanged or progress [5]. Therefore, in a vertical medial thigh lift, choosing a dissection plane superficial to traumainduced lymphoedema introduction and general description Lymphoedema and other lymphatic complications, such as lymphocele or lymph fistula, can develop after therapeutic interventions or accidental damage to lymph drainage pathways. Cancer relapse may be in the pelvis or with infiltration of the abdominal wall skin. Recently, electron microscopy analysis has provided additional evidence for exocytosis and endocytosis as the predominant mechanism of melanin transfer. Cutaneous vasculitis should prompt a search for a wide array of differential diagnoses, including systemic vasculitides, cancer, infections, allergies, chemical exposures, etc. The acne is graded according to a scale of 0 to 10 on the face, back and chest [429]. This is usually palliative for bleeding, pain or the control of heart failure or prior to surgery. Topical retinoids have been shown to be superior to placebo for comedones and when used as monotherapy reduce the formation of microcomedones. A thorough clinical review, especially for respiratory symptoms, should be carried out at each visit to check for signs of compression or for the rare occurrence of malignant transformation. It is characterized by marked facial erythema with nodular abscesses and indurated haemorrhagic plaques that can result in significant scarring. Many macrophages contain greyblue foamy material in their cytoplasm, which is positive for Congo red and chlorazolfast pink [39].

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Using the Rotterdam criteria, between 5 and 10% of adult women are classified as having the syndrome. Healing results in a porcelainwhite scar, frequently surrounded by telangiectasia. Three studies from the same group consistently found that milk intake increased the risk of acne (see Table 90. Eventually, the function of the hand is impaired due to fixed flexion of one or more digits. Granulomatous acne the precise mechanism producing localized granulomatous acne is not known. It may then be appropriate to take a swab and, while awaiting results, use a nonantibiotic treatment such as aluminium acetate solution. Complications and comorbidities Constricting bands may be associated with other congenital defects. Fifty per cent of pregnancies spontaneously abort, and of the remainder about half of the infants are born with cardiovascular or skeletal deformities. Given that the use of isotretinoin is an off license indication in this context, clinicians should ensure parents are well informed if using oral isotretinoin for acne in this age group. Administration of the somatostatin analogue octreotide, a synthetic polypeptide which inhibits pancreatic enzyme production, has been reported to result in a significant improvement in pancreatic panniculitis in some [13,38,78] but not all [17,30,37,48] patients with pancreatic carcinoma. One reported case was remarkable for the relative abundance of lymphocytes, some of them mildly atypical [19]. In patients allergic to penicillin, or in whom penicillin prophylaxis fails, alternative antibiotics such as erythromycin should be considered although there are no data on safety or efficacy [13]. First line mild to moderate disease Cutaneous lesions may respond to potent topical corticosteroids with few adverse effects [364,365]. Topical antibiotics Topical clindamycin has been shown to be superior to placebo when compared to vehicle for comedones but inferior to tretinoin. It may occur in particular patterns which have become associated with certain conditions. One case report indicates an association 2 weeks after a measles infection implying that the virus may trigger a transient release of inflammatory cytokines, resulting in acne fulminans in a predisposed individual [644]. Furthermore, in vivo high resolution timelapse digital images of this process have identified long dynamic filopedia arising from the melanocyte dendrite tips packed with melanosomes [4]. With time, pathological changes within the failing, but hitherto normal, lymphatics occur. Biopsy reveals both sarcoid granulomas and compact orthokeratosis with a diminished granular layer, mimicking ichthyosis vulgaris [260,261,262]. Healing of venous ulcers in an ambulatory care program: the roles of chronic venous insufficiency and patient compliance. Posttraumatic panniculitis may present as a solitary or as multiple subcutaneous nodules caused by traumatic separation and consequent devascularization of pieces of subcutaneous fat from (a) (b) figure 99. Increased oestrogen and progesterone receptors have been found by one group in the affected skin [3]. Excess adipose tissue will not respond to decongestive lymphoedema treatments, anastomosis surgery or lymph node transfer procedures. Gastrointestinal lesions are the most important as perforation of the gut is a cause of death [19]. Two populations have been shown to have excessive production and/or impaction of cerumen: individuals with learning difficulties and the elderly [7]. The exception is diet for which the best advice currently would be to eat healthily with everything in moderation and nothing in excess. They con gregate in the upper part of the anagen hair bulb amongst cells destined to form the hair cortex.

Diseases

• Colobomatous microphthalmia heart disease hearing
• Spondylo camptodactyly syndrome
• Retinoblastoma
• Camptodactyly vertebral fusion
• Cerebral calcifications opalescent teeth phosphaturia
• Otosclerosis
• Sex chromosome disorders

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Associated diseases Up to 40% of patients with scalp lichen planus and 30% of patients with discoid lupus of the scalp will have cutaneous disease elsewhere either at presentation or during followup. Canadian Inuit only began to develop acne and other diseases of Western civilization following the urbanization of their communities [167,168]. Presentation Occlusion syndromes triggered by cold exposure are suggested by an acral distribution of lesions of necrosis or purpura, often with retiform features, and sometimes associated with acral livedo reticularis. History, physical examination and laboratory studies, including C3, C4 and antinuclear antibody, should help to establish the extent of disease and to exclude underlying disease. Nevertheless, some early reports, and even some more recent ones, confuse monilethrix with other shaft defects. However, if a light shade has been produced and the subject wants a darker shade, then temporary rinses may safely be used as these only coat the hair surface and have no propen sity to cause structural damage. Age the disease is seen in younger people, typically below the age of 50, and is found also in children. It has also been used in combination with topical steroid on an alternating basis (a. Systemic corticosteroids have been reported to improve pain in some [15,23,53], while worsening it in other patients [54]. In many cases, perinatal complications are recorded, such as Rh factor incompatibility, meconium aspiration, umbilical cord prolapse, placenta praevia, birth asphyxia, seizures, congenital heart disease, intestinal perforation, hypothermia, sepsis, anaemia, obstetric trauma, figure 99. Anatomy and physiology of subcutaneous adipose tissue by in vivo magnetic resonance imaging and spectroscopy: relationships with sex and presence of cellulite. Iodides may be found in nonprescription preparations for asthma, expectorants, kelp and teas. It is lined by a single layer of columnar or cuboidal cells resting on a basement membrane. A periocular distribution is sometimes seen that can be more difficult to distinguish from rosacea. Although the condition has been recognized since the seventeenth century, it was not until the early twentieth century that it was recognized by Goldberger to be due to a nutritional deficiency [6], which was subsequently shown by Elvehjem to be niacin [7]. The validation and use of a radioimmunoassay for 5 alphaandrost16en3one in human axillary collections. Genome-wide association analysis implicates elastin microfibrils in the development of nonsyndromic striae distensae. Of all the persistent local reactions due to corticosteroids, atrophy is the most common [3]. As a result, wound pain improves dramatically, although the wounds do not necessarily start to heal. Infants with unsuspected immunodeficiency and individuals with valvular heart disease may be at particular risk [13]. The lesions appear as small painful nodules on the cheeks and posterior neck, the areas in which corticosteroid therapy has induced fat deposition. There is no associated pain or discomfort with these progressive nasal skin changes but the patient may note an unpleasant oiliness of the skin surface of the nose and malodorous greasy material may be discharged on squeezing the skin of the nose. Epidemiology Incidence and prevalence It is rare; a review in 1995 suggested that about 120 cases had been reported [3]. Early lesions show intense haemorrhage and an inflammatory infiltrate, mostly composed of lymphocytes and macrophages arranged around septal vessels. These cells have a high mitotic rate, with a rate of cell turnover similar to that in the bone marrow. Where cellulitis, in particular recurrent cellulitis, occurs then prophylactic antibiotics may be indicated [10].

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In granular external otitis, the lining of the meatus and canal is replaced in part or whole by granulation tissue, which can project inwards as pedunculated masses. The prevalence rises with age: oral or labial lesions were observed in 8% of a large cohort of preschool Brazilian children [2] and in 95% of a large cohort of adult Israeli Jews [3]. Other vegetable dyes include extracts from logwood and walnut shell, and these can be used by patients who are paraphenylenediamine sensitive. These findings demonstrate that the mononuclear cells that make up Miescher radial granuloma, and those seen in the socalled histiocytoid Sweet syndrome, are actually immature myeloid cells, providing a link between erythema nodosum and Sweet syndrome, two conditions in which neutrophils participate. Drugs known to be secreted include sulfaguani dine, sulfadiazine, amphetamines, arsenicals, iodides, phenytoin, phenobarbitone, carbamazepine, griseofulvin, ketoconazole, flu conazole, ciprofloxacin, diamorphine, cocaine and nicotine [1]. Disease course and prognosis these lesions are benign and increase in number with age. The nail bed dermal collagen is mainly orientated vertically, being directly attached to the phalangeal periosteum and the epidermal basal lamina. Camptodactyly is associated with numerous inherited disorders, the most important of which are described below. Investigations Diagnostic techniques the hair pull test, handheld epiluminescent microscopy and global photography are valuable in the diagnosis and manage ment of this condition. At birth, there is often a degree of distal ingrowing, particularly in the great toe, as the nail has not surmounted the tip of the digit in its development [2]. Epidemiology Incidence and prevalence Necrotizing external otitis is a rare disease. Distinctive pupuric lesions are characterized by petechial haemorrhage (or extravasation or erythrocytes in the skin with marked hemosiderin deposition). Orf affecting the ear has been described, presenting as an inflammatory nodule on the tragus. Some crosssectional studies appear to support this [156,160,172,175,176] whereas others found no link between diet and acne [15]. Later, with prolonged treatment, a violaceous brown colour develops that is most noticeable in lesional skin [1]. It is closely associated with heritable disorders of connective tissue and Down syndrome. There are also regional differences in both the hormonal responsiveness and metabolic activity of human adipose tissue. The symptoms and signs, however, are normally mild unless complicated by secondary factors and usually consist of no more than superficial scaling and a little discomfort or itching. It is the commonest type of annular elastolytic giant cell granuloma, in which abnormal elastic fibres are progressively destroyed by an expanding ring of elastolysis and granulomatous inflammation. In individuals deficient of the enzyme alcohol dehydrogenase an area of erythema develops in the tested skin. Apocrine secretions are largely odourless, but biotransformation by bacteria, particularly corynebacteria, results in the liberation of short and medium chain volatile fatty acids (C2 to C10 branch length), 16andros tene steroids and thioalcohols, each of which may produce its own odour signature [1]. After acute and chronic pancreatitis, pancreatic carcinoma is the next most common cause of pancreatic panniculitis. Deep venous reflux/obstruction and/or postthrombotic findings can only be examined with duplex ultrasound. Third line Other treatments which have all been reported to be successful in small series include aspiration followed by intralesional triamcinolone [12], fibrin [13,14], minocycline or trichloracetic acid. Within a few cen timetres of the scalp, the free margin of these cells lifts up and breaks irregularly. A short course of oral pred nisolone is used to stabilize rapidly progressive disease. A historical review [13] identified a number of studies showing that males have more severe acne in late adolescence than girls. Pathophysiology Predisposing factors Inflammation results either from the hair being cut too short, so that it may retract into the follicle and then directly penetrate the follicle wall, or from hair left to grow for a few days after being cut or shaved, such that the hairs curve backwards and penetrate adjacent skin [1,2]. Trichoepitheliomas are firm, red nodules that commonly occur on the scalp (see Chapter 138). Diagnosis, treatment, and long term management of Kawasaki disease: a statement for health professionals from the Committee on Rheumatic Fever, Endocarditis, and Kawasaki Disease, Council on Cardiovascular Disease in the Young, American Heart Association. This can be described as acute or chronic; the latter is defined as pruritus lasting 6 or more weeks.

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Hair microscopy can be a useful part of clini cal assessment in some situations [1], including a range of hereditary or acquired metabolic disorders, where the hair shaft can sometimes provide clues to the diagnosis (Table 89. There is a dose effect with a tendency to a greater number of lentigines in those who have Addison disease Hyperpigmentation may be a cutaneous manifestation of Addison disease. The prevalence of superficial skin infections such as candidosis, dermatophytosis and erythrasma is raised in the obese [2]. These broader metabolic effects can make it a useful therapy where hirsutism is not the only problem; it is not a drug likely to be prescribed by a dermatologist. A mild perivascular and interstitial lymphocytic infiltrate with frequent plasma cells is commonly seen in this subtype. Histologically, there was a neutrophilic folliculitis without necrosis; bacteriologically only the usual resident microflora of the scalp were detected, with P. Only tumours that have a particular predilection for the scalp are mentioned here. Whilst hypertri chosis may be evident at birth, it may not become apparent until later in childhood or adolescence. The outer third of the canal is cartilaginous and is lined by a thicker layer of skin than the inner portion within the temporal bone. Trauma this can occur from pressure on the lobe and postauricular skin, or from inaccurate insertion of the post of the earring. Lymphocytoma cutis (see Chapter 140) is another rare condition that may present with papules or nodules on the face and ears. Age As it occurs secondary to atheromatous plaques, it is no surprise that cholesterol embolus is a syndrome reported primarily in men aged 50 years or older. A small study in university students during exams found changes in stress scores significantly and highly correlated with changes in acne severity when confounding variables had been adjusted for [245]. Facial fillers such as injectable polyllactic acid as well as autologous fat transfers have both been used to correct severe facial lipoatrophy [35,36]. Patients present with acne conglobata at an older average age and the condition has a protracted and more chronic course than acne fulminans with fewer systemic symptoms (see section on Acne fulminans; see Table 90. Bismuth the administration of bismuth at regular intervals over a period of years has often been practised, yet generalized pigmentation is extremely rare. Exposure to high concentrates of copper in industry or from inad vertently high concentrations in tap water [39] or in swimming pools may cause green hair, particularly visible in blondhaired subjects [40]. If histopathology shows that the lesion is malignant, further surgery is required. There may be a dermal perivascular infiltrate consisting of macrophages and T lymphocytes. Over time the extent of hair loss can vary, and hair growth may recover temporarily. Presentation It is characterized by recurrent crops of itchy sterile pustules, which recur over several months or years. Platelet activation causes the release of serotonin and thromboxane A2, both of which cause vasoconstriction, and increase platelet adhesiveness and aggregation leading to the formation of a platelet plug. Similar histological changes are seen in patients undergoing chemotherapy, presumably forming part of a spectrum of cytotoxic eccrine damage, which includes neutro philic eccrine hidradenitis [5]. The first descriptions were by Hutchinson and Bury in the 1880s, and the condition was later named in 1894 by Radcliffe Crocker and Williams. A seroma is a pocket of clear serous fluid that also collects in a tissue space usually after surgery. Other co morbidities are mostly related to the associated obesity or the psychiatric morbidity. Constitutional symptoms such as fever, rigors, headache or vomiting can be profound and sudden in onset. When the limbs are involved, infantile hemiplegia and lipodystrophy must also be considered. The extent of the alopecia appears to be dose related, but there is no clear threshold over which all patients treated with busulphan will develop permanent alopecia. There is a change in the ratio of terminal to vellus hairs from greater than 8: 1 to less than 4: 1.

Syndromes

• Normal facial feature
• X-ray
• Vitamin B12 level 
• Heart disease
• Double vision when looking to one side
• Partial or complete vision loss in the affected eye
• Depression and other emotional problems if the nevi affect appearance
• X-ray

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The most frequent type of adipocyte necrosis is lipophagic necrosis, which consists of the replacement of necrotic adipocytes by foamy macrophages formed by the engulfing of lipid products released from dead adipocytes by macrophages. Proteinuria or haematuria may indicate glomerulonephritis, which may progress to endstage renal failure, particularly in those with childhood onset. Clinical variants Keloids on the beard area sometimes undergo central suppurative necrosis. Pseudofolliculitis has also been reported as an adverse drug reaction to oral minoxidil [7]. However, in contrast with a true lobular panniculitis, necrosis of the adipocytes at the centre of the fat lobule is never seen in erythema nodosum. They all give a rather dull (metallic) appearance and may cause brittle or damaged hair if used too often. Three lines of evidence suggest that the dermal papilla is the pri mary target of androgen action in the hair follicle. Finally, the degradation of melanosomes may vary in different disorders of pigmentation. Medical assessment Part 9: Vascular Medical assessment aims to identify and exclude other causes of peripheral oedema. However, the chronic oedema may already reflect a compromised lymph drainage, in which case surgery may further undermine lymph drainage and make swelling worse. One third said it improved, one third said it worsened and one third said it stayed the same. Because of the relatively benign safety profile of tetracycline, proposed therapeutic strategies include initiating treatment with minocycline for 3 months; if the response is unsatisfactory, hydroxychloroquine can be added, and if the desired improvement is not achieved, methotrexate may then be added to the regimen [363]. Although friction from the collar is often incriminated, the evidence is unconvincing [3]. Presentation Chronic, noninflammatory, asymmetrical lower limb oedema should always suggest a cause within the hindquarter. On the palms and soles, it has a welldeveloped coil structure that is not so apparent in other sites. Some neutralizers contain shellac, which may react with alcohol groups to cause hair discoloration. Age Initially reported in elderly males [1], although subsequently reported patients are chiefly adolescents [5,6,7]. The physical and psychological severity of acne will play a role in the decision whether to prescribe isotretinoin. Other adipokines Many other adipokines have been described [6,18] and most are still being evaluated for their relevance to human biology. Isotretinoin has been used to alter the follicu lar environment to make it less suitable for S. There are some cases, however, that defy precise classification, and others in which histological criteria may be a poor guide to prognosis. The lateral discoloured edges of the nail plate become crossridged when the disease mainly affects the lateral nail fold. These may be differentiated from rheumatoid nodules in that they ulcerate, whereas rheumatoid nodules do not. The condition is now much less frequent, although it is a continuing cosmetic problem [9]. Acanthosis nigricans has also been reported in association with dermatomyositis [2]. Naxos disease and Carvajal disease are characterized by woolly hair and other cutaneous and systemic features including cardiomyopathy (see Chapter 68). Children with circumferential or nearcircumferential amniotic bands may undergo surgical release with a Zplasty procedure [2]. Firstly, dermatologists usually evaluate different morphological aspects of the skin anomalies to reach a specific diagnosis, but subcutaneous tissue is too deep to be visible to the examining eye. This challenges the interpretation that nail thickens over the nail bed because of a contribution from underlying structures.

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Secondary trimethylaminuria can occur when there is an increased burden of trimethylamine, and is seen when there is an increased production of it from its precursors by gut bacteria in conditions such as blind loop syndrome, uraemia and liver disease. Genetics No genetic factor has been reliably incriminated, although familial cases have been reported [14], and morphoea and atrophoderma of Pasini have occurred in siblings with phenylketonuria [15]. However, the pathway remains a work in progress as new subtypes and causal genes are discovered [10]. IgA deposition may be detected on fibres, implying an immunopathogenic mechanism may be relevant [4]. In the perifollicular variant histology shows a noninflammatory perifollicular loss of elastin fibres [8]. Head and neck oedema occurring in utero may regress by birth but can leave signs such as prominent medial epicanthic folds or neck webbing postnatally, as seen in Turner and Noonan syndromes. Current techniques for lymphatic imaging: state of the art and future perspectives. Scalp metastases the scalp is a common site for cutaneous metastases, accounting for 12% of all skin metastases (see Chapter 147). The clinical history with lesions localized only at the injection sites rules out lupus panniculitis [15,16]. Rhinophyma has also been reported to follow actinic damage and to occur in patients with acne vulgaris. Associated diseases Hepatitis C is responsible for about 80% of cryoglobulinaemic vasculitis. Investigations With black heel, the patient and physician can usually be reassured by carefully paring the affected area, thereby completely removing the abnormality. Males with extensive truncal acne, more severe acne and/or suffering from acne for less than 7 years, fail to respond as well as, and relapse more quickly than, female patients with predominantly facial acne of a less severe grade. A focused history and examination for signs of accelerated growth, precocious puberty and hirsutism or other signs of hyperandrogenism should be employed. It is unusual for hair to be lost completely within the affected area (in contrast with alopecia areata). In the initial evaluation of patients with suspected sarcoidosis the entire skin surface must be examined [177]. Another report describes itchy pustules and papules on the lower face resolving within 4 days [6]. Other symptoms include bleeding, otorrhoea and, with spread of the neoplasm, nerve palsies. Triple combination therapy, comprised of hydroquinone, a retinoid and a corticosteroid, is a highly effective and safe treatment for melasma. To some extent the selection of the biopsy site depends on what information is needed. Treat erythema with topical receptor agonists such as brimonidine or oxymetazoline [38]. Oral isotretinoin should be used with caution as paradoxically it has been reported to induce acne fulminans in some patients [664]. Facial hair in boys first appears at about the same time as the axillary hair, starting at the corners of the upper lip, and spreading medially to complete the moustache and then the cheeks and beard. Support stockings have been used, but have also been reported to exacerbate the condition.

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They often give a history of the ability to grow their hair very long in childhood, suggestive of a long anagen phase, and report a high hair density prior to the onset of hair loss [14,15]. The skin lesions are usually the first feature, and may be the only manifestation over many years. Soaking the fingertips several nights a week in vinegar or sodium hypochlorite solution (Milton) for 5 min can be useful to prevent recurrence. It presents with semitranslucent reddish brown papules and nodules that must be distinguished from tuberculosis, Crohn disease, syphilis, foreignbody reactions and lymphogranuloma venereum [309]. Age Vitiligo can begin at any age but in the majority of cases becomes apparent between the age of 20 and 30 years. When the aetiology is unclear, serological tests for those bacterial, viral, fungal or protozoal infections most prevalent in the area should be undertaken. These localized lesions usually occur in the periumbilical area in obese, multiparous black or Asian women, and it is possible that this represents a response to repeated cutaneous stretching. A corticosteroid was introduced to this treatment to reduce inflammation as it is a side effect of both hydroquinone and tretinoin. Subcutaneous fat necrosis of the newborn Pathophysiology Predisposing factors the pathogenesis of this disorder is unknown. Anophthalmia Astichiasis Blepharitis Blepharochalasis Bruch membrane Chemosis Coloboma Dermatochalasis Distichiasis Ectropion Entropion Epicanthal fold Epicanthus inversus Epiphora Episcleritis Follicular inflammation Absence of eye Absence of lashes Inflammation of the eyelid margin Elastic tissue atrophy causing loose eyelid skin the retinal layer sandwiched between the retinal pigment epithelium and the vascular choroid Swelling or oedema of the conjunctiva, due to exudation from capillaries Congenital cleft created by failure of development of a portion of the eye or adnexal structures Laxness of the skin of the eyelids Accessory row of eyelashes Eversion of the eyelid Inversion of the eyelid Accessory fold of skin at the inner canthal region of the eye Lower lid fold larger than upper lid fold Excess tearing Inflammation of the superficial scleral tissues Inflammatory response of the conjunctiva characterized by discrete, round elevated lesions of the conjunctiva with a vascular network around the follicle, diameter 0. It develops in an older age group than sclerema neonatorum and subcutaneous fat necrosis of the newborn, with reported ages ranging from 20 months to 14 years [3]. It is stated that if more than 50% of the visible nail is affected, the nail plate should be removed. Presentation Early lesions tend to present as painful purpuric plaques, often with a retiform or stellate pattern, and may show central necrosis. Factors that contribute to this include an inflammatory dermatosis, trauma, microbial flora, alterations in cerumen and anatomical variations. In another series the incidence of lymphatic complications from 5407 surgical procedures for varicose veins was 118 cases (2. In developed countries most patients with cellulitis are treated for the acute episode and discharged, yet the rate of recurrence is high, suggesting that underlying predisposing factors. The impact of the disorder on the patient (psychological/social/ occupational) should be included in the evaluation of severity [2]. Infection Increased pressure within vessels Physical Drugs Others Epidemiology Incidence and prevalence Either sex may be affected by black heel, but the condition is virtually confined to athletic adolescents. Healthy children and adults with single lesions or only a few typical lesions Multiple lesions: examine for clinical signs of pregnancy, liver disease or thyrotoxicosis No investigations needed Age They normally spontaneously appear in middle age and increase in number with age though they can first appear in the second decade of life. There are obvious sexual differences in the distribution of fat around the body surface, with an increase in thickness resulting in the rounded contours of the female trunk, breasts, hips, pubis and thighs. Individual lesions may be slightly tender but there are no associated symptoms such as pain, itch or discomfort. Surgery cannot completely reverse the constriction so the child is left with a degree of impaired lymphatic drainage within the affected limb. This lytic effect is attributed to the very rapid compression from the tumour rather than tumour invasion [61]. The mode of action of aluminium salts is uncertain, but they can be shown to affect both the duct and the secretory coil [8]. Cryofibrinogenaemia may be idiopathic or can be associated with malignant disorders (especially haematological), thromboembolic disease, IgA nephropathy or various inflammatory, connective tissue or infectious syndromes [8,9]. Two divisions of the trigeminal nerve supply sensation to the eyelids; the upper lid and medial canthus are supplied by the ophthalmic division, and the remainder of the lower lid by the maxillary division. Permanent obliteration of lymphatic collectors may follow severe or recurrent lymphangitis. Superficial venous thrombosis Definition and nomenclature this is common condition where there is the formation of a thrombus in the veins near the surface of the skin which is usually associated with inflammation of the walls of the vein.

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Exostoses are usually bilateral, symmetrical, multiple, diffuse, broadly based growths of bone. Leakage of sweat into the epidermis is responsible for the final production of the lesions, and for their further aggravation. Although most laboratory studies are normal, mild peripheral blood eosinophilia may be present [10]. The cause of the pigmentation is usually obvious, although the preceding lesions have sometimes not been noticed by the patient or have been transitory or clinically imperceptible. Conjunctival pigmentation has been noted particularly in Oriental races and may be striking, especially in the lower fornix and bulbar conjunctiva. Distal occlusion syndromes (cholesterol emboli, acral antiphospholipid antibody syndrome) may also present similarly, but lack a history of cold exposure and the presence of lesions on the nose and ears. Provision of made-tomeasure compression hosiery can improve lymphatic drainage if worn on a daily basis. On the trunk and limbs, the fine, dry scales are associated with a polycy clic and serpiginous eruption whose horny margin slowly changes its pattern. The risk of developing sarcoidosis in the cotwin of an affected monozygotic brother was increased 80fold while in dizygotic twins the risk was only sevenfold higher [118]. Nail biology Genes influencing the presence or absence or malformation of nails have been sought in connection with inherited abnormalities of the nail unit. Nail plate changes include thinning or thickening, onychorrhexis, brittleness, crumbling or fragmentation, and accentuation of surface longitudinal ridging. The largest published series identifies the right index and middle fingers as the most commonly affected. Supraventricular and ventricular arrhythmias and aberrations of atrioventricular or intraventricular conduction may result in complete heart block or sudden death; papillary muscle dysfunction and congestive heart failure may be present. Lesions typically present as annular, red or yellow plaques, with or without atrophy and telangiectasia, and often involve the forehead and frontal scalp [1]. For small minimally invasive lesions, simple excision, cryotherapy or curettage with electrodesiccation may be adequate. Introduction and general description Deepvein thrombosis is a common and important disease. In contrast to systemic polyarteritis nodosa, there is little or no evidence of systemic disease. Again, a lateral ablation may be adequate, but more complex procedures entail altering the alignment of the matrix [2,7,8], level of the nail bed [9] and addressing any midline hypertrophy of the distal phalanx. Oral azithromycin using intermittent dosing schedules (250 mg three times a week) due to the long halflife of 68 h has been reported to be effective for acne in four open and two investigator blinded trials [523,527]. It may be useful for the patient to keep a record of flushing episodes, detailing possible triggers and associated symptoms such as headache, abdominal pain, wheeze, diarrhoea or chest pain. They are irritant and require care in terms of strength of prepa ration and duration of exposure. Ultrastructural studies have shown that even in normal people the elastic fibres begin to deteriorate from the age of 30 years onwards, regardless of the amount of sun exposure, although sunlight undoubtedly increases the damage [5]. Lesional skin is thickened and indurated; as well as pallor there may be marginal hyperpigmentation. The lateral nail folds are in continuity with the skin on the sides of the digit laterally, and medially they are joined by the nail bed.

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A urine microscopy demonstrates active urinary sediment in patients with glomerulonephritis. In exogenous ochronosis, it may be caused by inhibition of homogentisic oxidase and accumulation of homogentisic acid (an intermediate in lphenylalanine and ltyrosine catabolism) which polymerizes to form ochre (brownishyellow) pigment in the papillary dermis [2]. Age Actinic folliculitis has been described in young to middleaged adults of both sexes. Age Keloids are rare in infancy and old age, occurring chiefly between puberty and age 30 years. Depending on the relative balance between the coagulation and thrombolytic pathways, thrombus propagation occurs. Complications and comorbidities In patients with hepatitis Cinduced disease, the complications are those of liver involvement. Plaques gradually spread outwards Punctuate telangiectases and petechiae inside border Location Usually lower legs; also involves trunk, arms, thighs and buttocks Irregularly distributed on both sides with few or many patches Usually lower extremities Usually on lower extremities Itching purpura Pigmented purpuric lichenoid dermatosis of Gougerot and Blum Lichen aureus Purpura annularis telangiectodes (Majocchi disease) Contact allergy Exerciseinduced Usually lower extremities Commonly overlies a varicose vein Trunk, lower extremities (proximal) Only affects skin in contact with material responsible. It may be difficult to differentiate from rosacea and is believed by some to be a variant of rosacea (lymphoedematous rosacea) in which lymphatic drainage from the face is defective. Pulsed intravenous corticosteroids administered alongside isotretinoin have been used to control the disease in a 16yearold male with good effect [666]. They can extend into the ipsilateral arm, and even the forearm, creating linear grooves. Hydroxychloroquine has been reported as a successful treatment inducing rapid remission and hair regrowth in idiopathic follicular mucinosis [2]. Transepidermal elimination of liquefied dermis may occur as a secondary phenomenon [27]. Pathology In the early stages, there may be a mild dermal lymphocytic infiltrate, and in the later stages the elastic fibres in the lids fragment and decrease [2]. Although this illustrates that the pathol ogy can result in structural weakness, it only rarely leads to a clinical complaint of fragility. Major surgery Experimental therapies Radiotherapy metronidazole and moxifloxacin [56]. Benign and malignant tumours can arise from the epidermis, the pilosebaceous unit or adnexal structures. It typically presents in women as a single raised plaque on the bridge of the nose, central face, ears or scalp [202,234]. Conversely, if the hair is loose, the main differ ential diagnoses are telogen effluvium and alopecia areata. Chronic lymphatic obstruction as a result of filarial worms leads to the development of hydroceles, lymphoedema/elephantiasis skin changes (severe hyperkeratosis, papillomatosis and skin fissuring) and rarely chyluria. Necrotizing lymphocytic folliculitis of the scalp margin 1 Kossard S, Collins A, McCrossin I. A randomized, placebocontrolled trial of 5% and 2% topical minoxidil solutions in the treatment of female pattern hair loss. Many authors have suggested that striae develop as a result of stress rupture of the connective tissue framework [1], but others disagree. Cryotherapy and intralesional steroid injection [237] may be appropriate for symptomatic localized lesions although the risk of permanent scarring or atrophy is significant. An understanding of this pathway is important in diagnosing and treating these syndromes. In chronic cases, normocytic normochromic anaemia and hypoalbuminaemia are frequently found [20]. In the absence of any bony involvement, this was diagnosed as an eosinophilic granuloma [1]. The frequency and severity of pattern hair loss is lower in women than in men but it still affects a sizeable proportion of the popu lation. Unilateral or bilateral subcutaneous fatty masses are often seen in the frontotemporal or zygomatic region, and they are rarely seen outside the craniofacial region. The predominant androgen secreted by the ovaries is androstenedione during the reproduc tive years, and testosterone after the menopause. The pattern of pitting may be disorganized or occur in transverse/longitudinal rows as seen in alopecia areata [2].