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Subungual Melanoma

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141. Epidermodysplasia Verruciformis (Treatment)

for the management of skin cancers include topical imiquimod and 5-fluorouracil, systemic retinoids, interferon, and 5-aminolevulinic acid . [ , ] In 2016, Kim et al described the first case of a patient with imiquimod-resistant epidermodysplasia verruciformis, which was successfully treated with topical ingenol mebutate. [ ] In advanced human papillomavirus (HPV)–related carcinomas, an experimental therapy involves treatment with a combination of 13- cis retinoic acid and interferon-alfa or cholecalciferol (...) analogues. [ ] For localized multiple malignant lesions, autotransplantation of skin from uninvolved areas has been reported with success in preventing further development of cancers. UV-B exposure, UV-A exposure, and x-ray irradiation should be avoided because radiation therapy often promotes the recurrence of more aggressive skin cancers. Next: Surgical Care Surgical and electrosurgical removal and cryotherapy are used in the treatment of benign and premalignant skin lesions. Surgery is also indicated

2014 eMedicine.com

142. Keratosis Palmaris et Plantaris (Treatment)

). 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

143. Paronychia (Treatment)

instead of Augmentin in patients who are allergic to penicillin. If the paronychia does not resolve or if it progresses to an abscess, it should be drained promptly. Chronic paronychia The initial treatment of chronic paronychia consists of the avoidance of inciting factors such as exposure to moist environments or skin irritants. Keeping the affected lesion dry is essential for proper recovery. Choice of footgear may also be considered. Any manipulation of the nail, such as manicuring, finger sucking (...) it meets the nail itself, at the point of maximum fluctuance The skin of the nail fold is lifted, releasing pus from the paronychia cavity A gentle side-to-side motion may then be used to increase the size of the incision made by the needle, improving drainage; since the area incised is made up mostly of necrotic tissue, this is often painless Gentle pressure can be placed on the external skin to express any remaining pus from the paronychia The cavity can then be irrigated with saline A small piece

2014 eMedicine.com

144. Paraneoplastic Diseases (Treatment)

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

145. Psoriatic Arthritis (Treatment)

). [ ] 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

146. Psoriatic Arthritis (Treatment)

). [ ] 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

147. Psoriatic Arthritis (Treatment)

). [ ] 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

148. Psoriasis, Plaque (Treatment)

, 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

149. Pyogenic Granuloma (Lobular Capillary Hemangioma) (Treatment)

. Case reports: mitozantrone-induced onycholysis associated with subungual abscesses, paronychia, and pyogenic granuloma. J Drugs Dermatol . 2005 Jul-Aug. 4(4):490-2. . Devillers C, Vanhooteghem O, 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 (...) cytogenetic abnormality in a lobular capillary hemangioma of the nasal cavity. Cancer Genet Cytogenet . 2006 Oct 1. 170(1):69-70. . Patrice SJ, Wiss K, Mulliken JB. Pyogenic granuloma (lobular capillary hemangioma): a clinicopathologic study of 178 cases. Pediatr Dermatol . 1991 Dec. 8(4):267-76. . Sills ES, Zegarelli DJ, Hoschander MM, Strider WE. Clinical diagnosis and management of hormonally responsive oral pregnancy tumor (pyogenic granuloma). J Reprod Med . 1996 Jul. 41(7):467-70. . Harris MN, Desai

2014 eMedicine.com

150. Verrucous Carcinoma (Treatment) Full Text available with Trip Pro

. . Sheen MC, Sheen YS, Sheu HM, Wong TW, Lee YY, Wu CF, et al. Subungual verrucous carcinoma of the thumb treated by intra-arterial infusion with methotrexate. Dermatol Surg . 2005 Jul. 31(7 Pt 1):787-9. . Bernadas SR, Evgenios E, Dimitriadis PA, Hamal P, Uppal R. Verrucous carcinoma of the upper arm. ANZ J Surg . 2014 Dec. 84(12):983-4. . Warner CL, Cockerell CJ. The new seventh edition American Joint Committee on Cancer staging of cutaneous non-melanoma skin cancer: a critical review. Am J Clin (...) RR, Chaukar DA, Deshpande MS, et al. Verrucous carcinoma of the oral cavity: A clinical and pathological study of 101 cases. Oral Oncol . 2009 Jan. 45(1):47-51. . Terada T. Verrucous carcinoma of the skin: a report on 5 Japanese cases. Ann Diagn Pathol . 2011 Jun. 15(3):175-80. . Hagiwara H, Kanazawa T, Ishikawa K, et al. Invasive verrucous carcinoma: a temporal bone histopathology report. Auris Nasus Larynx . 2000 Apr. 27(2):179-83. . Desai A, Ugorji R, Khachemoune A. Acral melanoma foot lesions

2014 eMedicine.com

151. Melanonychia (Treatment)

, Mishra K, Jandial A, Khadwal A, Malhotra P. Melanonychia. QJM . 2018 Jul 6. . Miličević T, Žaja I, Tešanović D, Radman M. Laugier-Hunziker 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 (...) N, Balme B, Dalle S, Thomas L. Conservative surgical management of subungual (matrix derived) melanoma: report of seven cases and literature review. Br J Dermatol . 2011 Oct. 165(4):852-8. . Dawber RP, Colver GB. The spectrum of malignant melanoma of the nail apparatus. Semin Dermatol . 1991 Mar. 10(1):82-7. . Massi G, Leboit PE. Nevi on Acral Skin. Histological Diagnosis of Nevi and Melanoma . Berlin, Germany: Springer-Verlag; 2004. 289. Amin B, Nehal KS, Jungbluth AA, Zaidi B, Brady MS, Coit

2014 eMedicine.com

152. Leukemia Cutis (Treatment)

by leukaemic cells: a case report. Acta Derm Venereol . 2001 Jun-Jul. 81(3):215-6. . Smoller BR. Leukemic vasculitis: a newly described pattern of cutaneous involvement. Am J Clin Pathol . 1997 Jun. 107(6):627-9. . Wilson ML, Elston DM, Tyler WB, Marks VJ, Ferringer T. Dense lymphocytic infiltrates 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 (...) clinical outcome. Leukemia Research . 2004. 28:1007-1011. . Assaf C, Gellrich S, Whittaker S, Robson A, Cerroni L, Massone C, et al. CD56-positive haematological neoplasms of the skin: a multicentre study of the Cutaneous Lymphoma Project Group of the European Organisation for Research and Treatment of Cancer. J Clin Pathol . 2007 Sep. 60(9):981-9. . . Diaz-Cascajo C, Bloedern-Schlicht N. Cutaneous infiltrates of myelogenous leukemia in association with pre-existing skin diseases. J Cutan Pathol . 1998

2014 eMedicine.com

153. Incontinentia Pigmenti (Treatment)

for the cutaneous lesions, although use of topical tacrolimus and topical corticosteroids has been reported to hasten the resolution of the inflammatory stage. [ , ] The vesicles of the inflammatory stage should be left intact, and the skin should be monitored for the development of secondary bacterial infections. Emollients and topical antibiotics may be used as needed. As there is a risk for the development of cutaneous malignancy, in particular subungual keratinocytic tumors and tumors within areas (...) of hyperpigmentation and hypopigmentation, periodic skin examinations with attention to skin cancer screening are warranted. Oral hygiene and regular dental care is necessary, and dental restoration may be indicated. Seizures should be treated with anticonvulsants. Additionally, routine neurodevelopmental assessments should be made, with referral to occupational and physical therapists as warranted. The use of systemic corticosteroids has been reported to reduce neurologic symptoms, including seizure frequency

2014 eMedicine.com

154. Onychomatricoma (Treatment)

. Pigmented Onychomatricoma: A Rare Pigmented Nail Unit Tumor Presenting as Longitudinal Melanonychia That Has Potential for Misdiagnosis as Melanoma. J Foot Ankle Surg . 2015 Jul-Aug. 54 (4):723-5. . Spaccarelli N, Wanat KA, Miller CJ, Rubin AI. Hypopigmented onychocytic matricoma as a clinical mimic of onychomatricoma: clinical, intraoperative and histopathologic correlations. J Cutan Pathol . 2013 Jun. 40(6):591-4. . Kallis P, Tosti A. Onychomycosis and Onychomatricoma. Skin Appendage Disord . 2016 May (...) 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 keratoacanthoma in the hand. J Hand Surg [Am] . 1989 Jan. 14(1):139-42. . Bokszczanin A, Levinson AI. Coexistent yellow nail syndrome and selective antibody deficiency. Ann Allergy Asthma Immunol . 2003 Nov. 91(5):496-500. . Wynes J, Wanat KA, Huen A, Mlodzienski AJ, Rubin AI

2014 eMedicine.com

155. Paronychia (Overview)

: 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

156. Paraneoplastic Diseases (Overview)

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

157. Nail Surgery (Overview)

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

158. Neurilemoma (Overview)

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

159. Onychomatricoma (Overview)

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

160. Leukemia Cutis (Overview)

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

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