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Subungual Melanoma

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201. Cutaneous Manifestations of HIV Disease (Diagnosis)

–AIDS-defining cutaneous cancers—in particular, basal cell carcinoma—among HIV-infected persons has exceeded that of AIDS-defining cutaneous cancers such as KS. In a prospective study, Crum-Cianflone et al found that 6% of HIV-infected persons developed a cutaneous malignancy over a mean follow-up period of 7.5 years. [ ] The development of cutaneous non–AIDS-defining cancers in this cohort proved to be associated with the traditional risk factors of increasing age and lighter skin color, rather (...) . Malignant melanoma appears to be more aggressive in patients with HIV. One study reported shorter disease-free and overall survival rates in patients with melanoma who had HIV disease, compared with those who did not have HIV. [ ] Children with AIDS have a higher risk of developing leiomyosarcoma, although the incidence is still low in this population. Kaposi sarcoma KS is an abnormally vascularized tumorlike lesion affecting skin, lymph nodes, and viscera. It is believed to be a proliferation

2014 eMedicine.com

202. Cutaneous Melanoacanthoma (Diagnosis)

as 10 cm in diameter and can therefore be unappealing to the patient. [ ] Previous Next: Patient Education Patients should be informed that cutaneous melanoacanthoma is benign and has no potential for malignant transformation. Cutaneous melanoacanthoma is not associated with any skin or visceral cancer; it is not an indicator of cancer, and its presence is not a risk factor for cancer. Previous References Mishima Y, Pinkus H. Benign mixed tumor of melanocytes and malpighian cells. Melanoacanthoma (...) . . Schlappner OL, Rowden G, Philips TM, Rahim Z. Melanoacanthoma. Ultrastructural and immunological studies. J Cutan Pathol . 1978 Jun. 5(3):127-41. . Lambert MW, Lambert WC, Schwartz RA, et al. Colonization of nonmelanocytic cutaneous lesions by dendritic melanocytic cells: a simulant of acral-lentiginous (palmar-plantar-subungual-mucosal) melanoma. J Surg Oncol . 1985 Jan. 28(1):12-8. . Lambert WC, Lambert MW, Mesa ML, et al. Melanoacanthoma and related disorders. Simulants of acral-lentiginous (P-P-S-M

2014 eMedicine.com

203. Blue Nevi (Diagnosis)

Next: Etiology See . Although blue nevi are most frequently seen on the skin, they have also been reported in the oral cavity, subungually, [ ] in lymph nodes, and in organs such as the brain, pulmonary tract, and prostate. Previous Next: Epidemiology Frequency United States Blue nevi are most frequently noted in Asian populations, where the prevalence is estimated to be 3-5% in adults. They are found in 1-2% of white adults and are rarely found in blacks. Blue nevi are uncommon at birth (...) somatic mutations of GNAQ in uveal melanoma and blue naevi. Nature . 2009 Jan 29. 457 (7229):599-602. . Emley A, Nguyen LP, Yang S, Mahalingam M. Somatic mutations in GNAQ in amelanotic/hypomelanotic blue nevi. Hum Pathol . 2011 Jan. 42(1):136-40. . Lambert WC, Brodkin RH. Nodal and subcutaneous cellular blue nevi. A pseudometastasizing pseudomelanoma. Arch Dermatol . 1984 Mar. 120(3):367-70. . Causeret AS, Skowron F, Viallard AM, Balme B, Thomas L. Subungual blue nevus. J Am Acad Dermatol . 2003 Aug

2014 eMedicine.com

204. Black Heel (Calcaneal Petechiae) (Diagnosis)

. Benzidine stain for the histochemical detection of hemoglobin in splinter hemorrhage (subungual hematoma) and black heel. Am J Dermatopathol . 1995 Aug. 17(4):362-7. . Weedon D. Skin Pathology . 2nd ed. Elsevier Limited; 2002. 595. Media Gallery Linear petechiae on the heel, characteristic of black heel. of 1 Tables Contributor Information and Disclosures Author Christine Malcolm, MD, FRCPC Resident Physician in Dermatology, Department of Internal Medicine, University of Toronto Faculty of Medicine (...) . [ ] Although clinically insignificant, black heel is important because of its close clinical resemblance to melanoma. A similar lesion termed black palm (tache noir) has been described on the thenar eminence in weightlifters, gymnasts, golfers, tennis players, mountain climbers, and baseball players. [ ] Superficial cutaneous hemorrhages of other areas of the feet have been published in the literature. [ , ] Next: Pathophysiology Black heel (calcaneal petechiae) is caused by a repeated lateral shearing

2014 eMedicine.com

205. Acquired Digital Fibrokeratoma (Diagnosis)

on cyclosporine, which the authors suggested may represent a causal association. [ ] Previous Next: Epidemiology Frequency Currently, no means of tracking nonmelanoma skin cancer, much less various benign dermatological conditions, are available in the United States; therefore, the actual incidence of acquired acral fibrokeratoma is unknown. Most cases of acquired digital fibrokeratoma reported in the literature involve individual case reports presented because of the lesions' unusual size, location (...) fibrokeratoma (ADFK). Subsequently, Pinkus [ ] reported 28 more cases; however, these lesions occurred not only on the fingers, but also on the proximal hand, toes, [ ] sole, and one in the prepatellar region. For this reason, Verallo et al suggested the entity might more appropriately be called an acral fibrokeratoma. [ ] Similar growths have been reported to occur in the subungual or periungual region of patients with tuberous sclerosis, and they are referred to as Koenen tumors or garlic clove fibromas

2014 eMedicine.com

206. Hand, Paronychia Drainage

: Bacterial, mycobacterial, or viral infection Metastatic cancer Subungual melanoma Squamous cell carcinoma Therefore, benign and malignant neoplasms should always be excluded when chronic paronychia does not respond to conventional treatment. Chronic paronychia most often occurs in persons whose hands are repeatedly exposed to moist environments or in those who have prolonged and repeated contact with irritants such as mild acids, mild alkalis, or other chemicals. People who are most susceptible include (...) paronychia. Classic presentation of paronychia, with erythema and pus surrounding the nail bed. In this case, the paronychia was due to infection after a hangnail was removed. Signs and symptoms Physical findings in acute paronychia include the following: The affected area often appears erythematous and swollen In more advanced cases, pus may collect under the skin of the lateral fold If untreated, the infection can extend into the eponychium, in which case it is called eponychia Further extension

2014 eMedicine.com

207. Epidermodysplasia Verruciformis (Diagnosis)

, the upper and lower extremities, and the face are typical. Malignant skin tumors (carcinomas), especially squamous cell carcinoma (in situ or invasive), develop frequently in these patients (30–70%), most commonly in sun-exposed areas starting between the ages of 20 and 40 years, which reflects the high-risk nature of the HPV infection. Skin cancers initially appear on sun-exposed areas, such as the face, neck, chest, and arms, reflecting the role of ultraviolet light and HPV infection in the promotion (...) of skin cancer development. Patients with epidermodysplasia verruciformis are usually infected with multiple types of HPV, including common types that affect individuals without epidermodysplasia verruciformis (eg, HPV types 3 and 10) and those unique to epidermodysplasia verruciformis, the so called epidermodysplasia verruciformis–associated HPVs (EV-HPVs). More than 30 EV-HPVs, such as types 4, 5a, 5b, 8,9, 12, 14, 15, 17, 19-25, 36-38, 47, and 50, have been identified in epidermodysplasia

2014 eMedicine.com

208. Wegener Granulomatosis (Overview)

vasculitis of small to medium–sized vessels of the brain or spinal cord and granulomatous masses that involve the orbit, optic nerve, meninges, or brain.4 Cutaneous manifestations Cutaneous findings are variable and nonspecific and usually affect the lower extremities Palpable purpura or skin ulcers (45%) [ ] ; ulcerations may resemble pyoderma gangrenosum Petechiae, vesicles, pustules, hemorrhagic bullae, livedo reticularis, digital necrosis, subungual splinter hemorrhages, and genital ulcers resembling (...) is a concern, as it is for patients with other inflammatory rheumatologic and nonrheumatologic diseases and for patients who have undergone organ transplantation. Increased rates of leukemia, lymphoma, and nonmelanoma skin cancers have been reported in a number of studies of treated patients with AAV. The observed overall incidence of cancers in this population is 1.6-2.4 times higher than in the general population. [ ] Clinicians caring for these patients should keep this increased risk in mind and refer

2014 eMedicine Pediatrics

209. Paronychia (Diagnosis)

: Bacterial, mycobacterial, or viral infection Metastatic cancer Subungual melanoma Squamous cell carcinoma Therefore, benign and malignant neoplasms should always be excluded when chronic paronychia does not respond to conventional treatment. Chronic paronychia most often occurs in persons whose hands are repeatedly exposed to moist environments or in those who have prolonged and repeated contact with irritants such as mild acids, mild alkalis, or other chemicals. People who are most susceptible include (...) paronychia. Classic presentation of paronychia, with erythema and pus surrounding the nail bed. In this case, the paronychia was due to infection after a hangnail was removed. Signs and symptoms Physical findings in acute paronychia include the following: The affected area often appears erythematous and swollen In more advanced cases, pus may collect under the skin of the lateral fold If untreated, the infection can extend into the eponychium, in which case it is called eponychia Further extension

2014 eMedicine Emergency Medicine

210. Paronychia (Follow-up)

: Bacterial, mycobacterial, or viral infection Metastatic cancer Subungual melanoma Squamous cell carcinoma Therefore, benign and malignant neoplasms should always be excluded when chronic paronychia does not respond to conventional treatment. Chronic paronychia most often occurs in persons whose hands are repeatedly exposed to moist environments or in those who have prolonged and repeated contact with irritants such as mild acids, mild alkalis, or other chemicals. People who are most susceptible include (...) paronychia. Classic presentation of paronychia, with erythema and pus surrounding the nail bed. In this case, the paronychia was due to infection after a hangnail was removed. Signs and symptoms Physical findings in acute paronychia include the following: The affected area often appears erythematous and swollen In more advanced cases, pus may collect under the skin of the lateral fold If untreated, the infection can extend into the eponychium, in which case it is called eponychia Further extension

2014 eMedicine Emergency Medicine

211. Endocarditis (Diagnosis)

of IE are found in as many as 50% of patients. They include the following: Petechiae: Common, but nonspecific, finding Subungual (splinter) hemorrhages: Dark-red, linear lesions in the nail beds Osler nodes: Tender subcutaneous nodules usually found on the distal pads of the digits Janeway lesions: Nontender maculae on the palms and soles Roth spots: Retinal hemorrhages with small, clear centers; rare Signs of neurologic disease, which occur in as many as 40% of patients, include the following (...) gingivitis, 10% have recurrent transient bacteremias (usually streptococcal species). Most cases of subacute disease are secondary to the bacteremias that develop from the activities of daily living (eg, brushing teeth, bowel movements). The skin is quite resistant to S aureus infection due in great part to its production of antimicrobial peptides. Soong et al discovered that, in vitro, the secretion of alpha toxin by S aureus allows the organism to successfully penetrate the keratinocyte layer

2014 eMedicine Emergency Medicine

212. Hand Infections (Diagnosis)

at risk include those repeatedly exposed to water and/or irritants as well as those who are immunocompromised. Metastatic cancer, subungual melanoma, and may rarely present as chronic paronychia. Felon The distal palmar phalanx is compartmentalized by tangentially oriented fibrous septa. These septa result in a closed compartment at the distal phalanx, which helps prevent the proximal spread of infection. Infection is typically due to direct inoculation of bacteria by penetrating trauma but may (...) to superficial trauma (eg, hangnails, nail biting, manicuring, finger sucking). Artificial nails have also been associated with acute paronychia. Although paronychia typically starts as a cellulitis, its progression to abscess formation is not uncommon. Infection that spreads to the proximal nail edge is termed an eponychia. Occasionally, infection can spread under the nail plate itself, resulting in a subungual abscess. Chronic paronychia resembles acute paronychia but is usually nonsuppurative. People

2014 eMedicine Emergency Medicine

213. Candidiasis (Diagnosis)

: Pathophysiology Candida is a unicellular yeast whose cells reproduce by budding. This organism can flourish in most environments. It frequently colonizes the oropharynx, skin, mucous membranes, lower respiratory tract, gastrointestinal tract, and genitourinary tract. Pathogenesis occurs with increased fungal burden and colonization, such as in the setting of broad-spectrum antimicrobial therapy; breakdown of normal mucosal and skin barriers, which can occur with indwelling intravascular devices or with recent (...) : a systematic review. Int J Infect Dis . 2010 Nov. 14(11):e954-66. . Hachem R, Hanna H, Kontoyiannis D, Jiang Y, Raad I. The changing epidemiology of invasive candidiasis: Candida glabrata and Candida krusei as the leading causes of candidemia in hematologic malignancy. Cancer . 2008 Jun. 112(11):2493-9. . Trofa D, Gacser A, Nosanchuk JD. Candida parapsilosis, an emerging fungal pathogen. Clin Microbiol Rev . 2008 Oct. 21(4):606-25. . Wellinghausen N, Moericke A, Bundschuh S, Friedrich W, Schulz AS, Gatz SA

2014 eMedicine Emergency Medicine

214. Wegener Granulomatosis (Diagnosis)

palsies CNS manifestations include vasculitis of small to medium–sized vessels of the brain or spinal cord and granulomatous masses that involve the orbit, optic nerve, meninges, or brain.4 Cutaneous manifestations Cutaneous findings are variable and nonspecific and usually affect the lower extremities Palpable purpura or skin ulcers (45%) [ ] ; ulcerations may resemble pyoderma gangrenosum Petechiae, vesicles, pustules, hemorrhagic bullae, livedo reticularis, digital necrosis, subungual splinter (...) of other cancers associated with immunosuppression in patients with AAV is a concern, as it is for patients with other inflammatory rheumatologic and nonrheumatologic diseases and for patients who have undergone organ transplantation. Increased rates of leukemia, lymphoma, and nonmelanoma skin cancers have been reported in a number of studies of treated patients with AAV. The observed overall incidence of cancers in this population is 1.6-2.4 times higher than in the general population. [ ] Clinicians

2014 eMedicine Pediatrics

215. Candidiasis (Follow-up)

and the various non-albicans Candida spp among candidemia isolates from inpatients in various parts of the world: a systematic review. Int J Infect Dis . 2010 Nov. 14(11):e954-66. . Hachem R, Hanna H, Kontoyiannis D, Jiang Y, Raad I. The changing epidemiology of invasive candidiasis: Candida glabrata and Candida krusei as the leading causes of candidemia in hematologic malignancy. Cancer . 2008 Jun. 112(11):2493-9. . Trofa D, Gacser A, Nosanchuk JD. Candida parapsilosis, an emerging fungal pathogen. Clin (...) . Lett Appl Microbiol . 2009 Mar. 48(3):269-74. . [Guideline] Pappas PG, Kauffman CA, Andes DR, Clancy CJ, Marr KA, Ostrosky-Zeichner L, et al. Clinical Practice Guideline for the Management of Candidiasis: 2016 Update by the Infectious Diseases Society of America. Clin Infect Dis . 2016 Feb 15. 62 (4):e1-50. . Hidalgo J. Candidiasis. Medscape. Available at . Accessed: December 30th, 2014. Liu CY, Huang LJ, Wang WS, Chen TL, Yen CC, Yang MH, et al. Candidemia in cancer patients: impact of early

2014 eMedicine Emergency Medicine

216. Warts, Plantar (Overview)

years. [ ] Previous Next: Prognosis Approximately 65% of warts disappear spontaneously within 2 years. When warts resolve on their own, no scarring is seen. However, scarring can occur as a result of different treatment methods. Growth of periungual or subungual warts may result in permanent nail dystrophy. Treatment failures and wart recurrences are common, more so among immunocompromised patients. Normal appearing perilesional skin may harbor HPV, which helps explain recurrences. Common warts (...) this type of cancer rarely metastasizes, it can be locally destructive. Previous Next: Patient Education Alert patients to the risk factors for transmission of warts. These include trauma or maceration of the skin, frequent wet work involving hands, hyperhidrosis of feet, swimming pools, and nail biting. Butchers and slaughterhouse workers also are at increased risk for developing warts. Alert patients that some warts may require multiple treatments and may be resistant to several treatment modalities

2014 eMedicine Emergency Medicine

217. Candidiasis (Treatment)

, with fluconazole as the preferred first-line agent. Intertrigo and diaper rash respond to decreased moisture around the skin. Nystatin powder or cream is used with the addition of a topical steroid for diaper rash. Uncomplicated vulvovaginal candidiasis treatment includes many options of topical or oral therapy. Recurrent candidal vaginitis requires a prolonged course of oral medication; probiotic Lactobacillus may help in facilitating treatment of this disease. [ ] Invasive candidiasis typically requires (...) , Hanna H, Kontoyiannis D, Jiang Y, Raad I. The changing epidemiology of invasive candidiasis: Candida glabrata and Candida krusei as the leading causes of candidemia in hematologic malignancy. Cancer . 2008 Jun. 112(11):2493-9. . Trofa D, Gacser A, Nosanchuk JD. Candida parapsilosis, an emerging fungal pathogen. Clin Microbiol Rev . 2008 Oct. 21(4):606-25. . Wellinghausen N, Moericke A, Bundschuh S, Friedrich W, Schulz AS, Gatz SA. Multifocal osteomyelitis caused by Candida dubliniensis. J Med

2014 eMedicine Emergency Medicine

218. Hand Infections (Overview)

at risk include those repeatedly exposed to water and/or irritants as well as those who are immunocompromised. Metastatic cancer, subungual melanoma, and may rarely present as chronic paronychia. Felon The distal palmar phalanx is compartmentalized by tangentially oriented fibrous septa. These septa result in a closed compartment at the distal phalanx, which helps prevent the proximal spread of infection. Infection is typically due to direct inoculation of bacteria by penetrating trauma but may (...) to superficial trauma (eg, hangnails, nail biting, manicuring, finger sucking). Artificial nails have also been associated with acute paronychia. Although paronychia typically starts as a cellulitis, its progression to abscess formation is not uncommon. Infection that spreads to the proximal nail edge is termed an eponychia. Occasionally, infection can spread under the nail plate itself, resulting in a subungual abscess. Chronic paronychia resembles acute paronychia but is usually nonsuppurative. People

2014 eMedicine Emergency Medicine

219. Endocarditis (Overview)

are found in as many as 50% of patients. They include the following: Petechiae: Common, but nonspecific, finding Subungual (splinter) hemorrhages: Dark-red, linear lesions in the nail beds Osler nodes: Tender subcutaneous nodules usually found on the distal pads of the digits Janeway lesions: Nontender maculae on the palms and soles Roth spots: Retinal hemorrhages with small, clear centers; rare Signs of neurologic disease, which occur in as many as 40% of patients, include the following [ ] : Embolic (...) gingivitis, 10% have recurrent transient bacteremias (usually streptococcal species). Most cases of subacute disease are secondary to the bacteremias that develop from the activities of daily living (eg, brushing teeth, bowel movements). The skin is quite resistant to S aureus infection due in great part to its production of antimicrobial peptides. Soong et al discovered that, in vitro, the secretion of alpha toxin by S aureus allows the organism to successfully penetrate the keratinocyte layer

2014 eMedicine Emergency Medicine

220. Candidiasis (Overview)

: Pathophysiology Candida is a unicellular yeast whose cells reproduce by budding. This organism can flourish in most environments. It frequently colonizes the oropharynx, skin, mucous membranes, lower respiratory tract, gastrointestinal tract, and genitourinary tract. Pathogenesis occurs with increased fungal burden and colonization, such as in the setting of broad-spectrum antimicrobial therapy; breakdown of normal mucosal and skin barriers, which can occur with indwelling intravascular devices or with recent (...) : a systematic review. Int J Infect Dis . 2010 Nov. 14(11):e954-66. . Hachem R, Hanna H, Kontoyiannis D, Jiang Y, Raad I. The changing epidemiology of invasive candidiasis: Candida glabrata and Candida krusei as the leading causes of candidemia in hematologic malignancy. Cancer . 2008 Jun. 112(11):2493-9. . Trofa D, Gacser A, Nosanchuk JD. Candida parapsilosis, an emerging fungal pathogen. Clin Microbiol Rev . 2008 Oct. 21(4):606-25. . Wellinghausen N, Moericke A, Bundschuh S, Friedrich W, Schulz AS, Gatz SA

2014 eMedicine Emergency Medicine

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