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Subungual Melanoma

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101. Psoriasis, Plaque (Diagnosis)

, and patients with a positive family history for psoriasis also tend to have an earlier age of onset. Mortality and morbidity Disease-related mortality is exceedingly rare in psoriasis. Even then, mortality is related primarily to therapy: systemic corticosteroid therapy may provoke pustular flares of disease, which can be fatal; methotrexate therapy may result in hepatic fibrosis; and phototherapy (eg, psoralen plus UVA [PUVA]) may induce skin cancers, with subsequent metastasis. Morbidity is a much (...) to a localized immunosuppression. More than 85% of patients report relief of disease symptoms with 20-30 treatments. Therapy is usually administered 2-3 times per week in an outpatient setting, with maintenance treatments every 2-4 weeks until remission. Adverse effects of PUVA therapy include nausea, pruritus, and a burning sensation. Long-term complications include increased risks of photo damage to the skin and (more importantly) skin cancer. PUVA has been combined with oral retinoid derivatives

2014 eMedicine.com

102. Nail Surgery (Diagnosis)

changes in the nail plate; and senile nail diseases (eg, onychauxis, subungual hyperkeratosis). [ , , ] In onychocryptosis, the primary direction of nail growth is lateral instead of the normal, forward orientation of nail growth in the longitudinal plane. A more pronounced transverse curvature of their toenails increases the likelihood of developing ingrown toenails. [ ] The laterally curved edge of the nail plate, or the nail spicule, penetrates the adjacent LNF, perforating the fold skin (...) exert pressure on the matrix, resulting in a deformed nail plate. If left alone, periungual and subungual warts tend to linger and persist as they continue to grow and invade the skin of the other neighboring digits. Nail trauma Traumatic injuries of the nail unit include simple or complex lacerations, crush injuries, avulsions, terminal phalanx fractures, and partial or complete hematomas. Preservation of nail structure and function is the most important consideration when managing injuries

2014 eMedicine.com

103. Leukemia Cutis (Diagnosis)

associated with non-melanoma skin cancer in patients with chronic lymphocytic leukemia. Dermatol Online J . 2010 Mar 15. 16(3):4. . Kaplan AL, Cook JL. Cutaneous squamous cell carcinoma in patients with chronic lymphocytic leukemia. Skinmed . 2005 Sep-Oct. 4 (5):300-4. . Fadilah SA, Alawiyah AA, Amir MA, Cheong SK. Leukaemia cutis presenting as leonine facies. Med J Malaysia . 2003 Mar. 58(1):102-4. . Heskel NS, White CR, Fryberger S, Neerhout RC, Spraker M, Hanifin JM. Aleukemic leukemia cutis: juvenile (...) and disease progression. Therapy-related leukemia cutis preceding a diagnosis of systemic acute leukemia has been reported among patients treated with chemotherapy for breast cancer. [ , , , , ] The pathophysiology underlying the specific migration of leukemic cells to the skin is not clear. While some associations can be made, no definitive phenotype has been demonstrated to consistently lead to leukemia cutis. A number of mechanisms have been proposed. It has been speculated that the chemokine, integrin

2014 eMedicine.com

104. Paraneoplastic Diseases (Diagnosis)

diagnosis of EMPD includes Bowen disease, amelanotic superficial spreading malignant melanoma, and eczematous dermatitis. Clinical course and prognosis Skin lesions slowly increase in size. Over time, the lesions may progress from pruritic to painful, and they may become ulcerated. Regional lymph nodes may become involved. The general course of the disease depends on the presence of an underlying internal cancer. EMPD patients have a 5-year survival rate of 72-85%. Patients with EMPD without an internal (...) adenocarcinomas of the rectum, mucin-secreting endocervical carcinomas, or transitional cell carcinomas of the bladder. In men, extragenital skin cancers (squamous cell carcinoma and melanoma) and prostate cancer are also associated with EMPD. In women, breast cancer is associated with the disease. The most common sites of metastasis are the lungs and para-aortic lymph nodes. Patients who present with EMPD should undergo investigation for an internal malignancy, in which the anatomic relationship described

2014 eMedicine.com

105. Melanonychia (Diagnosis)

are wider than 3 mm in greater than 50% of cases. Below are the causes of melanonychia. [ , , , ] Melanocytic activation/hyperplasia–related causes are as follows: Nevi Melanotic macule of the nail unit Melanocytic activation Subungual melanoma Physiologic causes of melanonychia are as follows: Racial melanonychia (African American, Hispanic, Indian, Japanese, other dark-skinned races) (multiple bands) Pregnancy (multiple bands) Local and regional causes of melanonychia are as follows: Trauma (acute (...) syndrome in endocrine clinical practice. Endocrinol Diabetes Metab Case Rep . 2018. 2018: . Baran R, Kechijian P. Hutchinson's sign: a reappraisal. J Am Acad Dermatol . 1996 Jan. 34(1):87-90. . Takematsu H, Obata M, Tomita Y, Kato T, Takahashi M, Abe R. Subungual melanoma. A clinicopathologic study of 16 Japanese cases. Cancer . 1985 Jun 1. 55(11):2725-31. . Daniel CR 3rd, Jellinek NJ. Subungual blood is not always a reassuring sign. J Am Acad Dermatol . 2007 Jul. 57 (1):176. . Levit EK, Kagen MH

2014 eMedicine.com

106. Psoriatic Arthritis (Diagnosis)

). [ ] Swelling and deformity of the metacarpophalangeal and distal interphalangeal joints in a patient with psoriatic arthritis. See , a Critical Images slideshow, to help recognize the major psoriasis subtypes and distinguish them from other skin lesions. Signs and symptoms Onset of psoriasis and arthritis are as follows: Psoriasis appears to precede the onset of psoriatic arthritis in 60-80% of patients (occasionally by as many as 20 years, but usually by less than 10 years) In as many as 15-20 (...) at the attachment of the Achilles tendon and the plantar fascia to the calcaneus with the development of insertional spurs Dactylitis with sausage digits is seen in as many as 35% of patients Skin lesions include scaly, erythematous plaques; guttate lesions; lakes of pus; and erythroderma Psoriasis may occur in hidden sites, such as the scalp (where psoriasis frequently is mistaken for dandruff), perineum, intergluteal cleft, and umbilicus Psoriatic nail changes, which may be a solitary finding in patients

2014 eMedicine.com

107. Psoriatic Arthritis (Diagnosis)

). [ ] Swelling and deformity of the metacarpophalangeal and distal interphalangeal joints in a patient with psoriatic arthritis. See , a Critical Images slideshow, to help recognize the major psoriasis subtypes and distinguish them from other skin lesions. Signs and symptoms Onset of psoriasis and arthritis are as follows: Psoriasis appears to precede the onset of psoriatic arthritis in 60-80% of patients (occasionally by as many as 20 years, but usually by less than 10 years) In as many as 15-20 (...) at the attachment of the Achilles tendon and the plantar fascia to the calcaneus with the development of insertional spurs Dactylitis with sausage digits is seen in as many as 35% of patients Skin lesions include scaly, erythematous plaques; guttate lesions; lakes of pus; and erythroderma Psoriasis may occur in hidden sites, such as the scalp (where psoriasis frequently is mistaken for dandruff), perineum, intergluteal cleft, and umbilicus Psoriatic nail changes, which may be a solitary finding in patients

2014 eMedicine.com

108. Psoriatic Arthritis (Diagnosis)

). [ ] Swelling and deformity of the metacarpophalangeal and distal interphalangeal joints in a patient with psoriatic arthritis. See , a Critical Images slideshow, to help recognize the major psoriasis subtypes and distinguish them from other skin lesions. Signs and symptoms Onset of psoriasis and arthritis are as follows: Psoriasis appears to precede the onset of psoriatic arthritis in 60-80% of patients (occasionally by as many as 20 years, but usually by less than 10 years) In as many as 15-20 (...) at the attachment of the Achilles tendon and the plantar fascia to the calcaneus with the development of insertional spurs Dactylitis with sausage digits is seen in as many as 35% of patients Skin lesions include scaly, erythematous plaques; guttate lesions; lakes of pus; and erythroderma Psoriasis may occur in hidden sites, such as the scalp (where psoriasis frequently is mistaken for dandruff), perineum, intergluteal cleft, and umbilicus Psoriatic nail changes, which may be a solitary finding in patients

2014 eMedicine.com

109. Keratosis Palmaris et Plantaris (Diagnosis)

). The keratodermas can then be further subdivided based on whether only an isolated keratoderma is present or whether other skin findings are present and/or other organs are involved. The first subclassification is simple keratoderma, which is isolated PPK. The second is keratodermas with associated features such as lesions of nonvolar skin, hair, teeth, nails, or sweat glands and/or with abnormalities of other organs. Acquired forms are divided into keratoderma climactericum, keratoderma associated (...) psoriasislike plaques or lichenoid patches may be present on the knees and the elbows. Patients may have severe hyperhidrosis, possibly accompanied by malodor. Secondary bacterial and fungal infections are common. Perioral erythema; periorbital erythema and hyperkeratosis; nail changes (eg, koilonychia, subungual hyperkeratosis); and lingua plicata, syndactyly, hair on the palms and the soles, high-arched palate, and left-handedness are other clinical features. Histologic findings include orthokeratosis

2014 eMedicine.com

110. Onychomatricoma (Diagnosis)

Author: Annie Wester, MD, MS; Chief Editor: William D James, MD Share Email Print Feedback Close Sections Sections Onychomatricoma Overview Background An onychomatricoma is a subungual tumor of the fingers and toes, described in 1992. [ ] The terminology describing onychomatricomas has slowly been adjusted over time. In 1992, the original description termed this tumor an onychomatrixoma, based on the description of a filamentous, tufted tumor in the matrix. Subsequently, the term onychomatricoma (...) with fibrokeratoma of the nailbed. Am J Dermatopathol . 2001 Feb. 23(1):36-40. . DiMaio DJ, Cohen PR. Trichilemmal horn: case presentation and literature review. J Am Acad Dermatol . 1998 Aug. 39(2 Pt 2):368-71. . Yasuki Y. Acquired periungual fibrokeratoma--a proposal for classification of periungual fibrous lesions. J Dermatol . 1985 Aug. 12(4):349-56. . Baran R, Perrin C. Bowen's disease clinically simulating an onychomatricoma. J Am Acad Dermatol . 2002 Dec. 47(6):947-9. . Patel MR, Desai S. Subungual

2014 eMedicine.com

111. 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.com

112. Neurilemoma (Diagnosis)

in paravertebral locations and the flexor regions of the extremities (especially near the elbow, wrist, and knee) and occasionally involve the skin. The presence of a noninvasive tumor next to a peripheral nerve suggests the diagnosis of neurilemmoma. The major forms of neurilemmoma recognized are conventional (common, solitary), cellular, plexiform, ancient forms, and melanotic schwannoma. [ , , ] Specific variants such as plexiform and giant sacral neurilemmoma have been associated with an increased risk (...) by a capsule formed from the perineurium and epineurium. Occasional axons are present. Most neurilemmomas are of the conventional (common) type, arise as solitary tumors smaller than 10 cm, and are not associated with a genetic syndrome. They display the classic gross and microscopic features described in Histologic Findings. The cellular variant is rare in the skin, developing more commonly as a tumor of the mediastinum, retroperitoneum, and deep soft tissue. It is composed of a hypercellular mass

2014 eMedicine.com

113. Hypertrophic Osteoarthropathy (Diagnosis)

, nasopharyngeal carcinoma and esophageal cancer) may also be involved. [ ] Clubbed digits Clubbing is elevation of the nail and widening of the distal phalanx caused by swelling of the subungual capillary bed resulting from increased collagen deposition, interstitial inflammation with edema, and proliferation of the capillaries themselves. Increased vascular supply to the nail bed and increased connective tissue growth, together producing the characteristic clubbing. [ ] Perivascular infiltrates (...) osteoarthropathy (HPOA). It is a syndrome characterized by excessive proliferation of skin and bone at the distal parts of extremities and by digital clubbing and periostosis of the tubular bones. [ ] Hippocrates first described digital clubbing 2500 years ago, hence the use of the term Hippocratic fingers. [ ] Observations made in modern times by Bamberger (1889), [ ] Pierre Marie (1890), [ ] and other investigators led to identification of various causes of this digital anomaly, which can be the first

2014 eMedicine.com

114. Infective Endocarditis (Diagnosis)

signs 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.com

115. Psoriatic Arthritis (Overview)

). [ ] Swelling and deformity of the metacarpophalangeal and distal interphalangeal joints in a patient with psoriatic arthritis. See , a Critical Images slideshow, to help recognize the major psoriasis subtypes and distinguish them from other skin lesions. Signs and symptoms Onset of psoriasis and arthritis are as follows: Psoriasis appears to precede the onset of psoriatic arthritis in 60-80% of patients (occasionally by as many as 20 years, but usually by less than 10 years) In as many as 15-20 (...) at the attachment of the Achilles tendon and the plantar fascia to the calcaneus with the development of insertional spurs Dactylitis with sausage digits is seen in as many as 35% of patients Skin lesions include scaly, erythematous plaques; guttate lesions; lakes of pus; and erythroderma Psoriasis may occur in hidden sites, such as the scalp (where psoriasis frequently is mistaken for dandruff), perineum, intergluteal cleft, and umbilicus Psoriatic nail changes, which may be a solitary finding in patients

2014 eMedicine.com

116. Psoriasis, Plaque (Overview)

, and patients with a positive family history for psoriasis also tend to have an earlier age of onset. Mortality and morbidity Disease-related mortality is exceedingly rare in psoriasis. Even then, mortality is related primarily to therapy: systemic corticosteroid therapy may provoke pustular flares of disease, which can be fatal; methotrexate therapy may result in hepatic fibrosis; and phototherapy (eg, psoralen plus UVA [PUVA]) may induce skin cancers, with subsequent metastasis. Morbidity is a much (...) to a localized immunosuppression. More than 85% of patients report relief of disease symptoms with 20-30 treatments. Therapy is usually administered 2-3 times per week in an outpatient setting, with maintenance treatments every 2-4 weeks until remission. Adverse effects of PUVA therapy include nausea, pruritus, and a burning sensation. Long-term complications include increased risks of photo damage to the skin and (more importantly) skin cancer. PUVA has been combined with oral retinoid derivatives

2014 eMedicine.com

117. Psoriatic Arthritis (Overview)

). [ ] Swelling and deformity of the metacarpophalangeal and distal interphalangeal joints in a patient with psoriatic arthritis. See , a Critical Images slideshow, to help recognize the major psoriasis subtypes and distinguish them from other skin lesions. Signs and symptoms Onset of psoriasis and arthritis are as follows: Psoriasis appears to precede the onset of psoriatic arthritis in 60-80% of patients (occasionally by as many as 20 years, but usually by less than 10 years) In as many as 15-20 (...) at the attachment of the Achilles tendon and the plantar fascia to the calcaneus with the development of insertional spurs Dactylitis with sausage digits is seen in as many as 35% of patients Skin lesions include scaly, erythematous plaques; guttate lesions; lakes of pus; and erythroderma Psoriasis may occur in hidden sites, such as the scalp (where psoriasis frequently is mistaken for dandruff), perineum, intergluteal cleft, and umbilicus Psoriatic nail changes, which may be a solitary finding in patients

2014 eMedicine.com

118. Psoriatic Arthritis (Overview)

). [ ] Swelling and deformity of the metacarpophalangeal and distal interphalangeal joints in a patient with psoriatic arthritis. See , a Critical Images slideshow, to help recognize the major psoriasis subtypes and distinguish them from other skin lesions. Signs and symptoms Onset of psoriasis and arthritis are as follows: Psoriasis appears to precede the onset of psoriatic arthritis in 60-80% of patients (occasionally by as many as 20 years, but usually by less than 10 years) In as many as 15-20 (...) at the attachment of the Achilles tendon and the plantar fascia to the calcaneus with the development of insertional spurs Dactylitis with sausage digits is seen in as many as 35% of patients Skin lesions include scaly, erythematous plaques; guttate lesions; lakes of pus; and erythroderma Psoriasis may occur in hidden sites, such as the scalp (where psoriasis frequently is mistaken for dandruff), perineum, intergluteal cleft, and umbilicus Psoriatic nail changes, which may be a solitary finding in patients

2014 eMedicine.com

119. Pyogenic Granuloma (Lobular Capillary Hemangioma) (Overview)

, Henrijean A, Ramaut M, de la Brassinne M. Subungueal pyogenic granuloma secondary to docetaxel therapy. Clin Exp Dermatol . 2009 Mar. 34(2):251-2. . Paul LJ, Cohen PR. Paclitaxel-associated subungual pyogenic granuloma: report in a patient with breast cancer receiving paclitaxel and review of drug-induced pyogenic granulomas adjacent to and beneath the nail. J Drugs Dermatol . 2012 Feb. 11(2):262-8. . Sibaud V, Dalenc F, Mourey L, Chevreau C. Paronychia and pyogenic granuloma induced by new anticancer (...) =aHR0cHM6Ly9lbWVkaWNpbmUubWVkc2NhcGUuY29tL2FydGljbGUvMTA4NDcwMS1vdmVydmlldw== processing > Pyogenic Granuloma (Lobular Capillary Hemangioma) Updated: Jun 04, 2018 Author: Joseph C Pierson, MD; Chief Editor: William D James, MD Share Email Print Feedback Close Sections Sections Pyogenic Granuloma (Lobular Capillary Hemangioma) Overview Background Pyogenic granuloma (lobular capillary hemangioma [ ] ) is a relatively common benign vascular lesion of the skin and mucosa whose exact cause is unknown. Also see the Medscape Drugs & Diseases article . Pyogenic granulomas

2014 eMedicine.com

120. Melanonychia (Overview)

are wider than 3 mm in greater than 50% of cases. Below are the causes of melanonychia. [ , , , ] Melanocytic activation/hyperplasia–related causes are as follows: Nevi Melanotic macule of the nail unit Melanocytic activation Subungual melanoma Physiologic causes of melanonychia are as follows: Racial melanonychia (African American, Hispanic, Indian, Japanese, other dark-skinned races) (multiple bands) Pregnancy (multiple bands) Local and regional causes of melanonychia are as follows: Trauma (acute (...) syndrome in endocrine clinical practice. Endocrinol Diabetes Metab Case Rep . 2018. 2018: . Baran R, Kechijian P. Hutchinson's sign: a reappraisal. J Am Acad Dermatol . 1996 Jan. 34(1):87-90. . Takematsu H, Obata M, Tomita Y, Kato T, Takahashi M, Abe R. Subungual melanoma. A clinicopathologic study of 16 Japanese cases. Cancer . 1985 Jun 1. 55(11):2725-31. . Daniel CR 3rd, Jellinek NJ. Subungual blood is not always a reassuring sign. J Am Acad Dermatol . 2007 Jul. 57 (1):176. . Levit EK, Kagen MH

2014 eMedicine.com

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