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Subungual Melanoma

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121. Infective Endocarditis (Overview)

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

122. Keratosis Palmaris et Plantaris (Overview)

). 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

123. Cutaneous Manifestations of HIV Disease (Overview)

–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

124. Cutaneous Melanoacanthoma (Overview)

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

125. 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.com

126. Warts, Nongenital (Overview)

children, and peak at 12-16 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 (...) on the plantar surfaces. Although 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

2014 eMedicine.com

127. Cutaneous Melanoacanthoma (Treatment)

reflectance confocal microscopy features of a melanoacanthoma. Dermatol Pract Concept . 2016 Oct. 6 (4):27-30. . 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 (...) . Verrucous melanoma simulating melanoacanthoma: Dermoscopic, reflectance confocal microscopic and high-definition optical coherence tomography presentation of a rare melanoma variant. Australas J Dermatol . 2016 Feb. 57 (1):72-3. . Papageorgiou V, Apalla Z, Sotiriou E, Papageorgiou C, Lazaridou E, Vakirlis S, et al. The limitations of dermoscopy: false-positive and false-negative tumours. J Eur Acad Dermatol Venereol . 2018 Jan 5. . Shahriari N, Grant-Kels JM, Rabinovitz HS, Oliviero M, Scope A. In vivo

2014 eMedicine.com

128. Cutaneous Manifestations of HIV Disease (Treatment)

–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

129. Neurilemoma (Treatment)

lip: case report with distinct histologic features and review of the literature. J Oral Maxillofac Surg . 2011 Jun. 69(6):e118-22. . Kara M, Akyüz M, Yilmaz A, Hatipoglu C, Ozçakar L. Peripheral nerve involvement in a neurofibromatosis type 2 patient with plexiform neurofibroma of the cauda equina: a sonographic vignette. Arch Phys Med Rehabil . 2011 Sep. 92(9):1511-4. . Yeh I, Argenyi Z, Vemula SS, Furmanczyk PS, Bouffard D, McCalmont TH. Plexiform melanocytic schwannoma: a mimic of melanoma. J (...) invasive sacral schwannoma. Its clinical features and surgical management without stability. Neurosciences (Riyadh) . 2014 Jul. 19(3):224-8. . Rodríguez-Peralto JL, Riveiro-Falkenbach E, Carrillo R. Benign cutaneous neural tumors. Semin Diagn Pathol . 2013 Feb. 30(1):45-57. . Huntley JS, Davie RM, Hooper G. A subungual schwannoma. Plast Reconstr Surg . 2006 Feb. 117(2):712-3. . Ritter SE, Elston DM. Cutaneous schwannoma of the foot. Cutis . 2001 Feb. 67(2):127-9. . Sitenga JL, Aird GA, Nguyen

2014 eMedicine.com

130. Nail Surgery (Treatment)

is frequently used as a therapeutic adjunct in long-standing fungal infections of the nail, such as chronic onychomycosis, and in acute bacterial infections. [ , ] In traumatic nail injuries, avulsion may be used to evaluate the stability of the nail bed or to release a subungual hematoma after failed puncture aspiration. Paring the nail plate is the process of taking off pieces of the nail in a transverse or longitudinal fashion to fully observe an involved area on the nail bed. [ ] In the case of verrucae (...) of the blade must be oriented to lie directly against the undersurface of the plate and the PNF. Proximal nail avulsion is attempted when creating a cleavage plane between the nail plate and the nail bed distally is impossible because of the presence of distal nail dystrophy, which prevents access to the distal free edge of the nail plate. This presentation may be seen in distal subungual onychomycosis. [ , , ] First, the Freer elevator is inserted beneath the cuticle in the proximal groove to separate

2014 eMedicine.com

131. Hypertrophic Osteoarthropathy (Overview)

, 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

132. Epidermodysplasia Verruciformis (Overview)

, 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

133. Blue Nevi (Overview)

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

134. Black Heel (Calcaneal Petechiae) (Overview)

. 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

135. Candidiasis (Overview)

, nausea, vomiting, fever, chills and hematuria Fungal balls - Intermittent urinary tract obstruction with subsequent anuria and ensuing renal insufficiency See for more detail. Diagnosis Diagnostic tests for candidiasis include the following: Mucocutaneous candidiasis - For a wet mount, scrapings or smears obtained from skin, nails, or oral or vaginal mucosa are examined under the microscope; a potassium hydroxide smear, Gram stain, or methylene blue is useful for direct demonstration of fungal cells (...) Cutaneous candidiasis - Using a wet mount, scrapings or smears obtained from skin or nails can be examined under the microscope; potassium hydroxide smears are also useful Genitourinary candidiasis - A urinalysis should be performed; evidence of white blood cells (WBCs), red blood cells (RBCs), protein, and yeast cells is common; urine fungal cultures are useful Gastrointestinal candidiasis - Endoscopy with or without biopsy See for more detail. Management See the list below: Cutaneous candidiasis

2014 eMedicine.com

136. Dermoscopy (Treatment)

of pigmented skin lesions and, especially, in the identification of the early phase of cutaneous malignant melanoma. Dermoscopy is a noninvasive method that allows the in vivo evaluation of colors and microstructures of the epidermis, the dermoepidermal junction, and the papillary dermis not visible to the naked eye. These structures are specifically correlated to histologic features. The identification of specific diagnostic patterns related to the distribution of colors and dermoscopy structures can (...) better suggest a malignant or benign pigmented skin lesion. The use of this technique provides a valuable aid in diagnosing pigmented skin lesions. Because of the complexity involved, this methodology is reserved for experienced clinicians. Vestergaard et al have reported dermoscopy assessment is more accurate than clinical evaluation by naked eye for the diagnosis of cutaneous melanoma (odds ratio = 15.6, P = .016). In this study, the mean sensitivity in the diagnosis of melanoma was 74

2014 eMedicine.com

137. Dermatologic Manifestations of Hematologic Disease (Treatment)

, purpura, ecchymoses, painful skin nodules, and subungual splinter hemorrhages. Livedo reticularis is a presenting sign in up to 40% of patients with the diagnosis of SLE. [ ] Skin changes defined as livedo reticularis are violaceous, red or blue, reticular, or mottled pattern of the skin of the arms, legs, and the trunk. They are not reversible with rewarming. [ ] Noninflammatory vascular thrombosis is the most frequent finding in skin lesions of patients with antiphospholipid syndrome. Differential (...) patients), increased skin pigmentation (5 patients), and squamous cell cancer (2 patients). Other manifestations include alopecia (rare), facial and peripheral edema, gangrene, nail and/or skin atrophy, scaling, and violet papules. Previous Next: Leukemia Overview In leukemia, specific or nonspecific lesions of the skin may occur. Specific lesions ( ) contain leukemia cells, which directly infiltrate the epidermis, dermis, or subcutaneous fat. Nonspecific lesions, which are more common, are considered

2014 eMedicine.com

138. Dermatologic Manifestations of Cardiac Disease (Treatment)

be used in facilitating a diagnosis of the underlying cardiac disease. For example, the diagnosis of acute rheumatic fever in patients presenting with acute carditis includes 2 skin signs out of the 5 classic Jones criteria (ie, arthritis, carditis, erythema marginatum, subcutaneous nodules, and chorea). [ ] Certain congenital cardiac defects are associated with unique skin manifestations, such as coarctation of the aorta associated with external features of Turner syndrome or atrioventricular (AV (...) ) septal defects associated with skin features of Down syndrome. In some patients, the dermatologic manifestations represent a component of a full systemic or vascular disorder that also involves defects in the cardiovascular system as another accompanying component. Advanced medical and invasive therapies have led to recognition of many new dermatologic manifestations, for example, angioedema from ACE inhibitors, ankle swelling due to calcium channel blockers, or radiation skin burns following

2014 eMedicine.com

139. Glomus Tumor (Treatment)

glomus tumor recurrences. J Hand Surg Am . 2010 Jun. 35(6):986-9. . Lu H, Chen LF, Chen Q. Rupture of a subungual glomus tumor of the finger. BMC Cancer . 2018 May 2. 18 (1):505. . McEvoy BF, Waldman PM, Tye MJ. Multiple hamartomatous glomus tumors of the skin. Arch Dermatol . 1971 Aug. 104 (2):188-91. . Sbai MA, Benzarti S, Gharbi W, Maalla R. A Rare Case of Glomus Tumor of the Thigh with Literature Review. J Orthop Case Rep . 2018 Sep-Oct. 8 (5):22-24. . Zou H, Song L, Jia M, Wang L, Sun Y. Glomus (...) removal of the tumor capsule is recommended to relieve pain and minimize risk for recurrence. Most subungual lesions are treated with total nail avulsion followed by excision, although several additional techniques have been described to include a straightforward excision using a nail bed margin approach, [ ] a trap-door technique, [ ] and a technique described by Lee et al designed to conserve the nail plate itself. [ ] In the transungual approach, the nail plate is removed, the tumor excised

2014 eMedicine.com

140. Blue Nevi (Treatment)

, Celebi JT. B-RAF and melanocytic neoplasia. J Am Acad Dermatol . 2005 Jul. 53(1):108-14. . Van Raamsdonk CD, Bezrookove V, Green G, Bauer J, Gaugler L, O'Brien JM, et al. Frequent 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. 49(2):310-2. . Di Cesare A, Sera F, Gulia A, Coletti G, Micantonio T, Fargnoli MC, et al. The spectrum of dermatoscopic patterns in blue nevi. J Am Acad Dermatol . 2011 Oct 24. . Dailey VL, Hameed O. Blue nevus of the prostate. Arch Pathol Lab Med . 2011 Jun. 135(6):799-802. . Cooper PH. Deep penetrating (plexiform spindle cell

2014 eMedicine.com

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