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Subungual Melanoma

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161. Glomus Tumor (Overview)

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 tumor in the floor of the mouth: a case report and review of the literature. World J Surg Oncol . 2018 Oct 10. 16 (...) , with most cases involving subungual sites. These tumors are characteristically painful, often causing paroxysmal pain in response to temperature changes (especially cold) or pressure. Note the images below. Glomus tumor. Multiple glomus tumors. Glomus tumors are thought to arise from the glomus body or Sucquet-Hoyer canal, a thermoregulatory arteriovenous shunt composed of modified smooth muscle cells. [ , ] Glomus tumors most frequently occur in areas with high concentrations of glomus bodies

2014 eMedicine.com

162. Dermoscopy (Overview)

) contains the primary clinical criteria for diagnosing suspected cutaneous . The early phase of malignant melanoma is difficult to identify because cutaneous malignant melanoma can share many clinical features with an atypical nevus. Several studies have described diagnostic accuracy rates ranging from 50-75%, indicating a need for additional diagnostic tools. The introduction of dermoscopy, also termed epiluminescence microscopy (ELM), has opened a new dimension in the examination of pigmented skin (...) 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% for the examination by naked

2014 eMedicine.com

163. Dermatologic Manifestations of Hematologic Disease (Overview)

, 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

164. Dermatologic Manifestations of Cardiac Disease (Overview)

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

165. Drug Eruptions (Overview)

the images below. Paronychia. Papules and annular plaques. Superficial and mid-dermal perivascular infiltrate of lymphocytes and eosinophils. Foci of extravasation of erythrocytes. Sorafenib [ ] (a novel multikinase inhibitor) - Hand-foot skin reaction, facial and scalp eruption, scalp dysesthesia, subungual splinter hemorrhages, alopecia, body hair loss, stomatitis, nipple hyperkeratosis or pain, and eruptive facial cysts Vemurafenib is a systemic medication recently approved by the Food and Drug (...) after drug withdrawal and any reaction with readministration Physical examination should address clinical features that may indicate a severe, potentially life-threatening drug reaction, including the following: Mucous membrane erosions Blisters Nikolsky sign Confluent erythema Angioedema and tongue swelling Palpable purpura Skin necrosis Lymphadenopathy High fever, dyspnea, or hypotension It is important to appreciate the morphology and physical features of drug eruptions, as follows: Acneiform

2014 eMedicine.com

166. Paraneoplastic Diseases (Follow-up)

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

167. Onychomatricoma (Follow-up)

. 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

168. Paronychia (Follow-up)

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

169. Psoriatic Arthritis (Follow-up)

). [ ] 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

170. Psoriatic Arthritis (Follow-up)

). [ ] 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

171. Psoriatic Arthritis (Follow-up)

). [ ] 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

172. Psoriasis, Plaque (Follow-up)

, 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

173. Incontinentia Pigmenti (Follow-up)

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

174. Keratosis Palmaris et Plantaris (Follow-up)

). 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

175. Leukemia Cutis (Follow-up)

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

176. Pyogenic Granuloma (Lobular Capillary Hemangioma) (Follow-up)

. 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

177. Acquired Digital Fibrokeratoma (Overview)

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

178. Neurilemoma (Follow-up)

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

179. Nail Surgery (Follow-up)

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

180. Melanonychia (Follow-up)

, 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

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