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Dermatoses Resulting from Physical Factors

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Dermatoses Resulting from Physical Factors Chapter 3 Andrew s Diseases of the Skin Adam Wray, D.O. November 15, 2005 Heat Injuries Thermal Burns Electrical Burns ... – PowerPoint PPT presentation

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Title: Dermatoses Resulting from Physical Factors


1
Dermatoses Resulting from Physical Factors
  • Chapter 3
  • Andrews Diseases of the Skin
  • Adam Wray, D.O.
  • November 15, 2005

2
Heat Injuries
  • Thermal Burns
  • Electrical Burns
  • Miliaria
  • Miliaria Crystalline (Sudamina)
  • Miliaria Rubra (Prickly Heat, Heat Rash)
  • Miliaria Pustulosa
  • Miliaria Profunda
  • Occlusion Miliaria

3
Thermal Burns
  • First-degree burn- active congestion of
    superficial blood vessels
  • This causes erythema sometimes followed by
    epidermal desquamation
  • Constitutional reactions occur if area is large
  • Pain and increased surface heat may be severe

4
Second-degree burns
  • Deep
  • Pale and anesthetic
  • Injury to reticular dermis compromises blood flow
    and destroys appendages
  • Healing takes gt 1 month
  • Scarring occurs
  • Superficial
  • Transudation of serum causing edema of
    superficial tissues
  • Vesicles and blebs
  • Complete recovery without scar or blemish is usual

5
Second-degree burns
  • Thermal burn This superficial second degree burn
    is characterized by bullae that contain serous
    fluid

6
Second-Degree Burns
  • Inflicted scalds severe second degree burns
    after dipping
  • B two days after incident-to lower extremities
    and perineum
  • C foot and lower leg

7
Second-Degree Burn
  • Accidental scald
  • Splash-and-droplet pattern of an accidental scald
    from hot cup of tea

8
Second-Degree Burn
  • Curling iron burn

9
Third-degree burns
  • Full-thickness tissue loss
  • Skin appendages are destroyed
  • There is no epithelium for regeneration
  • Healing leaves a scar

10
Fourth-degree burns
  • Destruction of entire skin and subcutaneous fat
    with any underlying tendons

11
  • Rule of nines
  • In adults, an estimate of burn extent based upon
    this surface area distribution chart. Infants
    children have a relatively increased head trunk
    surface area ratio

12
Electrical Burns
  • Contact- small but deep, causing some necrosis of
    underlying tissues
  • Flash-burns usually cover a large area and are
    similar to a surface burn and should be tx as
    such
  • Lightening is the most lethal type of strike,
    cardiac arrest or other internal injuries may
    occur

13
Electrical Burns
  • Indirect- burns that are either linear in areas
    at which sweat was present are feathery or
    aborescent pattern, which is believed to be
    pathognomonic

14
Electrical Burn
  • It is characterized by erythema, edema, bulla
    formation and sloughing of the necrotic epidermis

15
Electrical Burn-pathology
  • Blistering and elongated keratinocytes

16
Miliaria
  • Retention of sweat as a result of occlusion
  • Common in hot, humid climates
  • Occlusion of eccrine sweat gland obstructs
    delivery of sweat to the skin surface
  • Eventually backed-up pressure causes rupture of
    sweat gland or duct at different levels
  • Escape of sweat into adjacent tissue produces
    miliaria
  • Different forms of miliaria occur depending on
    the level of injury to the sweat gland

17
Miliaria Crystalline
  • Small, clear, superficial vesicles without
    inflammation
  • Appears in bedridden pts and bundled children
  • Lesions are asymptomatic and rupture at the
    slightest trauma
  • Self-limited no tx is required

18
Miliaria Crystallina
  • Minute, discrete vesicles resulting from profuse
    sweating secondary to a high fever

19
Miliaria Crystallina
20
Miliaria Rubra
  • Discrete, extremely pruritic, erythematous
    papulovesicles with sensation of prickling,
    burning, or tingling
  • Site of injury is prickle cell layer where
    spongiosis is produced

21
Miliaria Rubra
22
Miliaria Pustulosa
  • Always preceded by some injury, destruction, or
    blocking of sweat duct
  • Pustules independent of hair follicle
  • Seen in intertriginous areas, flexure surfaces of
    extrmities, sctrotum, and back of bedridden pts
  • Sterile pustules

23
Miliaria Profunda
  • Nonpruritic, flesh-colored, deep-seated, whitish
    papules
  • Asymptomatic, usually lasting only 1 hr after
    overheating has ended
  • Concentrated on the trunk and extremities
  • Occlusion is in upper dermis
  • Only seen in tropics usually following a severe
    bout of miliaria rubra

24
Occlusion Miliaria
  • May be produced with accompanying anhidrosis and
    increased heat stress susceptibility after
    application of extensive polyethylene film
    occlusion for gt 48 hrs
  • Tx-place pt in a cool environment
  • Even a night in an air-conditioned room helps
    alleviate the discomfort

25
Occlusion Miliaria
  • Mild cases may respond to dusting powders, such
    as cornstarch or baby talcum powder
  • A lotion containing 1 menthol and glycerin and
    4 salicylic acid in 95 alcohol is effective
  • An oily shake lotion such as calamine lotion,
    with 1 or 2 phenol may be effective

26
Erythema (pigmentatio) Ab Igne
  • Aka toasted skin syndrome
  • Persistent erythema or coarsely reticulated
    residual pigmentation resulting from it
  • Produced by long-continued exposure to excessive
    heat without production of a burn
  • It begins as a mottling caused by local
    hemostasis and becomes a reticulated erythema,
    leaving pigmentation

27
Erythema Ab Igne
  • Reticulated hyperpigmentation with some epidermal
    atrophy and scaling secondary to use of a heating
    pad

28
Erythema ag igne
  • Use of bland emollients is helpful
  • No effective treatment
  • Kligmans combination of 5 hydroquinone in
    hydrophilic ointment containing 0.1 retinoic
    acid and 0.1 dexamethasone may reduce unsightly
    pigmentation
  • Histologically, an increased amount of elastic
    tissue in the dermis is seen
  • Changes are similar to actinic elastosis, and has
    been suggested to call these changes thermal
    elastosis

29
Cold Injuries
  • Chilblain
  • Frostbite
  • Immersion injury

30
Chilblains
  • Acute chilblains is the mildest form of cold
    injury
  • Pts are usually unaware of injury until they
    develop burning, itching, and redness

31
Chilblains (pernio)
32
Treatment
  • Nifedipine 20mg TID
  • Vasodilators (nicotina
  • amide 100 mg TID or dipyridamole 25 mg TID)
  • Systemic corticoid tx is helpful in chilblain
    lupus erythematosus
  • Pentoxifylline may be useful
  • Smoking strongly discouraged

33
Frostbite
  • When soft tissue is frozen and locally deprived
    of blood supply
  • Frozen part is painless and becomes pale and
    waxy
  • Four stages
  • I- Frost-nip erythema, edema,cutaneous anesthesia
    transient pain
  • II- second degree hyperemia, edema blistering,
    with clear fluid in bullae
  • III- third-degree full-thickness dermal loss
    with hemorrhagic bullae formation or waxy, dry,
    mummified skin
  • IV- full-thickness loss of entire part

34
First-Degree Frostbite
35
Immersion Foot Syndromes
  • Trench Foot
  • Warm Water Immersion Foot

36
Trench Foot
  • Results from prolonged exposure to cold, wet
    conditions without immersion or actual freezing
  • Term derived from trench warfare in World War 1,
    when soldiers stood, sometimes for hours, in
    trenches with a few inches of cold water in them
  • Tx-removal from causal environment

37
Tropical immersion Foot
  • Seen after continuous immersion of the feet in
    water or mud of temperatures above 71.6 degrees F
    (22 degrees C) for 2-10 days
  • AKA paddy foot in Vietnam
  • Erythema, edema, and pain of the dorsal feet
  • Also fever and adenopathy
  • Resolution occurs 3 to 7 days after the feet have
    been dried

38
Dermatoses with Cold Hypersensitivity
  • Erythrocyanosis Crurum
  • Acrocyanosis
  • Cold Panniculitis

39
Erythrocyanosis Crurum
  • Slight swelling and a bluish pink tint of the
    skin of the legs and thighs of young girls and
    women
  • May be unilateral
  • May have cramps in the legs at night
  • Small tender nodules may be found on palpation
  • Nodules may break down and form small, multiple
    ulcers
  • Seen in northern countries and probably due to an
    abnormal reaction of blood vessels to prolonged
    cold

40
Acrocyanosis
  • A persistent cyanosis with coldness and
    hyperhidrosis of hands and feet
  • Chiefly occurs in young women
  • At times, on cold exposure, a digit becomes stark
    white and insensitive (acroasphyxia)
  • Cyanosis increases as the temperature decreases
    and changes to erythema with elevation of
    dependent part
  • Cause is unknown
  • Smoking, coffee, and tea should be avoided

41
Acrocyanosis
42
Cold Panniculitis
  • After exposure to severe cold, well-demarcated
    erythematous warm plaques may develop,
    particularly on the cheeks of young children
  • Lesions usually develop within a few days after
    exposure, and resolve spontaneously in 2
    weeks(approx)
  • No tx is indicated
  • Popsicle dermatitis is a temporary redness and
    induration of the cheek in children resulting
    from sucking Popsicles

43
Sunburn and Solar Erythema
  • Below 400 nm is the ultraviolet spectrum, divided
    into three bands
  • UVA, 320 to 400 nm
  • UVB, 290 to 320 nm
  • UVC, 200 to 290 nm
  • Virtually no UVC reaches the earths surface,
    because it is absorbed by the ozone layer
  • Exception Australia, welders
  • Parts of solar spectrum important to
    photomedicine
  • Visible light 400 to 760 nm
  • Infrared radiation beyond 760 nm
  • Visible light has little biologic activity,
    except for stimulating the retina
  • Infrared radiation is experienced as radiant heat

44
Sunburn and Solar Erythema
  • UVB is 1000 times more erythemogenic than UVA
  • UVA is 100 times greater than UVB radiation
    during the midday hours
  • Most solar erythema is cause by UVB
  • Sunlight early and late in the day contains more
    UVA
  • UVA is reflected from sand, snow, or ice to a
    greater degree than UVB
  • Amount of ultraviolet exposure increases at
    higher altitudes, is greater in tropical regions,
    and temperate climates in summer

45
Clinical signs and symptoms
  • Sunburn is normal cutaneous reaction to sunlight
    in excess of an erythema dose (the amount that
    will induce reddening)
  • UVB erythema peaks at 12 to 24 hrs after exposure
  • Desquamation is common about a week after sunburn
    even in non-blistering areas

46
Sunburn treatment
  • Cool compresses
  • Topical steroids
  • Topical remedy
  • Indomethacin 100 mg
  • Absolute ethanol 57 ml
  • Propylene glycol 57 ml
  • spread widely over burned area with palms and
    let dry

47
Skin Types
48
Second-degree sunburn
49
Prophylaxis
  • Avoid sun exposure between 10 am and 2 pm
  • Barrier protection with hats and clothing
  • Suncreen agents include UV-absorbing chemicals
    and UV-scattering or blocking agents(physical
    sunscreens)

50
Sunscreens
  • Chemical suncreens-para-aminobenzoic acid(PABA),
    PABA esters, cinnamates,salicylates,
    anthranilates, benzophenoes)
  • Physical agents-titanium dioxide
  • Combinations of the two
  • Water resistant-maintaining their SPF after 40
    minutes of water immersion
  • Water proof-maintaining their SPF after 80 mins
    of water immersion
  • UVA protection- sunscreens containing
    benzophenones or dibenzoylmethanes
  • Apply sunscreen at least 20mins before sun
    exposure

51
Photoaging(Dermatohelioisis)
  • Characteristic changes induced by chronic sun
    exposure
  • Risk of developing these changes correlated with
    baseline pigmentation(constitutive pigmentation)
    and abilitiy to resist burning and tan following
    sun exposure(facultative pigmentation)

52
Dermatoheliosis
  • Poikiloderma of Civatte-refers to reticulate
    hyperpigmentation with telangiectasia, and slight
    atrophy of sides of the neck, lower anterior neck
    and V of neck, and V of chest
  • Submental area is spared
  • frequently presents in fair-skinned men and women
    in their middle to late thirties or early forties

53
Dermatoelastosis
  • Cutis rhomboidalis nuchae (sailors neck or
    farmers neck) is characteristic of long-term,
    chronic sun exposure
  • Skin on back of neck becomes thickened, tough,
    and leathery and normal skin marking become
    exaggerated

54
Dermatoheliosis
  • Favre-Racouchot syndrome
  • Thickened yellow plaques studded with comedomes
    and cystic lesions
  • Tx-removal , retinoic acid cream, surgical
    removal of cysts and redundant skin

55
Solar Elastosis
  • Homogenization and a faint blue color of
    connective tissue of the upper reticular dermis,
    so-called solar elastosis
  • Characteristically there is a zone of normal
    connective tissue below the epidermis

56
Photosensitivity
  • Photosensitizers may induce an abnormal reaction
    in skin exposed to sunlight or its equivalent
  • Substances may be delivered externally or
    internally
  • Increased sunburn response without prior allergic
    sensitization called phototoxicity
  • Phototoxicity may occur from both externally
    applied (phytophotodermatitis and berloque
    dermatitis) or internally administered chemicals
    (phototoxic drug reaction)
  • Or by external contact- (photoallergic contact
    dermatitis)

57
Phototoxicity vs photoallergy
  • In the case of external contactants
    phototoxicity occurs on initial exposure, has
    onset lt 48 hrs, occurs in most people exposed
    to the phototoxic substance and sunlight
  • Photoallergy, in contrast, occurs only in
    sensitized persons, may have delayed onset, up to
    14 days( a period of sensitization), and shows
    histologic features of contact dermatitis

58
Photosensitivity
  • Drug-induced photosensivity-photoallergic
    dermatitis on sun-exposed areas of an infant
    following topical use of hexachlorophene

59
Photoallergic dermatits
  • Papulovesicular lesions of photoallergic
    dermatitis due to hexachlorophene

60
Phytophotosensitivity
  • Plant-induced photosensitivity-linear
    hyperpigmentation on the face of a child
    following exposure to limes and sunlight

61
Phytophotosensitivity
  • Hyperpigmentation on the dorsal aspect of the
    hands following the use of limes and sunlight
    exposure

62
Photosensitivity in Tattoos
  • Yellow cadmium sulfide may be used as a yellow
    dye or may be incorporated into red mercuric
    sulfide pigment to produce a brighter red color
    for tattooing
  • When exposed to 380, 400, and 450 nm wavelengths
    of light, these areas in tattoos may swell,
    develop erythema, and become verrucose

63
Phototoxic Drug Reactions
  • In the case of amiodarone and chlorpromazine,
    hyperpigmentation is a well-recognized pattern of
    phototoxicity
  • It causes slate blue(amiodarone) or slate gray
    (chlorpromazine) coloration, resulting from drug
    deposition in the tissues
  • Most occur from tetracyclines, nonsteroidal
    antiinflammatory drugs, amiodarone, and
    phenothiazines
  • Action spectrum for all is in the UVA range

64
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65
Drug induced photosensitivity
  • The erythema is less apparent in black skin, but
    the involvement of the nose in this patient
    suggests phototoxicity, in this case caused by
    thiazide

66
Drug-induced photosensitivity
  • Not only the nose was but also the V of the
    neck which was highly suggestive of phototoxicity
  • Same pt

67
Drug-induced photosensitivity
  • There is erythema and edema on the exposed sites,
    the V of the neck .
  • This distribution would suggest the diagnosis

68
Drug induced photosensitivity
  • The backs of the hands are the classic sites to
    be involved in light induced eruption
  • Same pt

69
  • Phototoxic reaction to a nonsteroidal
    antiinflammatory drug

70
  • Photoallergic dermatitis on sun-exposed areas

71
Polymorphous Light Eruption
  • Most common form of sensitivity
  • All races and skin types affected
  • Typically in first three decades
  • Females outnumber males
  • Unknown pathogenesis
  • Positive family history in 10-50 of pts
  • Different morphologies seen, although in the
    individual the morphology is constant

72
PMLE
  • Exposed areas such as the backs of the hands and
    forearms are affected. Ultraviolet A is mainly
    responsible and may penetrate window glass

73
PMLE
  • The patchiness of the edematous papules and
    plaques is characteristic

74
PMLE
  • The eruption is less red and confluent than a
    sunburn (left)
  • Lesions are typically papular clustered (right)

75
PMLE-pathology
  • Characteristic perivascular mononuclear cell
    infiltration

76
PMLE
  • Very itchy, red,edematous papules, which may
    coalesce into plaques, occur 1 or 2 days after
    exposure to light

77
PMLE
  • This young women developed a widespread pruritic,
    papular eruption after using a sunbed, which
    emitted ultraviolet A

78
PMLE
  • Polymorphous light eruption erythematous
    papulovesicular and plaque-like lesions with
    characteristic distribution on the sun-exposed
    areas of the cheek

79
Actinic Prurigo
  • The clinical features are somewhat suggestive of
    PML, but the lesions are persistent and the HLA
    type was DR4( occurs in 80-90 of AP pts)

80
AP
  • Severe actinic prurigo shows spread to buttocks
    (left)
  • Arms show crusted papules that are denser
    distally they are also worse in summer

81
Actinic prurigo
  • Actinic prurigo in Native American brothers

82
Actinic prurigo
  • Actinic prurigo in Native American boy

83
AP-pathology
  • Early lesions have variable acanthosis and
    spongiosis of the epidermis with an underlying
    perivascular mononuclear cell infiltrate with
    edema
  • Later lesions show crusts, increasing acanthosis
    and variable lichenification plus a heavy
    infiltrate of mononuclear cells, leading to a
    non-specific picture(as seen here)

84
Hydroa Vacciniforme
  • Photodermatosis with onset in childhood
  • Lesions appear in crops with disease free
    intervals
  • Attacks may be preceded by fever and malaise
  • Ears, nose, cheeks, and extensor arms and hands
    are affected
  • Within 6 hrs of exposure stinging may occur

85
Hydroa Vacciniforme
  • There is an early, PML-like eruption, but with
    vesicles around the mouth and umbilicated lesions
    on the nose

86
Hydroa Vacciniforme
  • A later, more severe example shows vesiculation
    with umbilication, but also marked hemorrhagic
    crusting

87
Hydroa Vacciniforme
  • A severe example of the typical vacciniform
    facial scarring that may develop following
    repeated acute attacks

88
Acute Radiodermatitis
  • With an erythema dose of ionizing radiation
    there is a latent period of up to 24 hrs before
    visible erythema develops
  • Initial erythema lasts 2-3 days but may be
    followed by a second phase beginning up to 1 week
    after the exposure and lasting up to 1 month

89
Acute Radiodermatitis(fluoroscopic induced)
90
Chronic Radiodermatitis
  • Chronic exposure to suberythema doses of
    ionizing radiation over a prolonged period will
    produce varying amounts of damage to skin and
    underlying skin after a variable latent period of
    several months to several decades
  • Telangiectasia, atrophy, and hypopigmentation
    with residual focal increased pigment (freckling)
    may appear

91
Radiation Cancer
  • After a latent period averaging 20 30 yrs,
    various malignancies may develop
  • Most frequent are basal cell carcinomas
  • Next frequent are squamous cell carcinomas
  • These may occur in sites of prior radiation even
    without evidence of chronic radiation damage
  • SCCs arising in sites of radiation therapy
    metastasize more frequently than purely
    sun-induced SCCs
  • Other cancers induced by radiation angiosarcoma,
    malignant fibrous histiocytoma, sarcomas, and
    thyroid carcinoma

92
Radiation Cancer
  • SCC developing in a chronic radiation ulcer on
    the chest

93
Callus
  • Nonpenetrating, circumscribed hyperkeratosis
    produced by pressure
  • Occurs on parts subject to intermittent
    pressure(palms, soles, bony prominences of the
    joints)
  • Callus differs from clavus in that a callus has
    no penetrating central core and is a more diffuse
    thickening
  • Calluses tend to disappear spontaneously when
    pressure is removed

94
Clavus(Corns)
  • Circumscribed, horny, conical thickenings with
    the base on the surface and the apex pointing
    inward and pressing on adjacent structures
  • Two typeshard and soft
  • Hardoccur on dorsa of toes or on soles
  • Softoccur between toes, softened by macerating
    action of sweat

95
Hard Corn
96
Corns
  • Plantar corns can be differentiated from plantar
    warts by paring off the surface keratin until
    either the pathognomonic elongated dermal
    papillae of the wart with its blood vessels, or
    the clear horny core of the corn can be
    visualized
  • Ddx also includes porokeratosis plantaris
    discreta- a sharply marginated, cone-shaped,
    rubbery lesion common beneath the metetarsal heads

97
Porokeratosis Plantaris Discreta
  • Multiple lesions can occur
  • Females are affected 3 times as frequently than
    men
  • It is painful
  • Frequently confused with a plantar wart or corn
  • Keratosis punctata of the palmar creases may be
    seen in the creases of the digits of the feet
    where it may be mistaken for a corn

98
Surfers Nodules
  • Nodules 1 to 3 cm (rarely as much as 5 or 6 cm)
  • Sometimes eroded or ulcerated
  • Develop on tops of feet or over tibial tubercles
    of surfboard riders who paddle their boards in a
    kneeling position, as is customary in cold water
    off the California coast
  • Nodules seldom occur in surfers in warmer waters
    like Hawaii,because a prone position is used
  • Nodules involute over months when there is no
    surfing

99
Pressure Ulcers (Decubitus)
  • The bedsore is a pressure ulcer produced anywhere
    on the body by prolonged pressure
  • Caused by ischemia of underlying structures of
    skin, fat, and muscles resulting from sustained
    and constant pressure
  • Usually in chronically debilitated persons unable
    to change position
  • Bony prominences of body are most frequently
    involved

100
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101
Care-Tx
  • Ulcer care is critical
  • Debridement-except stable heel ulcers(do not need
    debridement if only a dry eschar is present)
  • Clean wounds initially and at each dressing
    change via nontraumatic technique
  • Normal saline is best
  • Dressing selection should maintain moist
    environment
  • Occlusive dressings like film and hydrocolloid
    are often utilized
  • Surgical debridement with reconstructive
    procedures may be needed
  • Electrical stimulation of refractory ulcers may
    be beneficial

102
Friction Blisters
  • Formation of vesicles or bullae occurring at
    sites of combined pressure and friction
  • Enhanced by heat and moisture
  • Examples feet of military recruits in
    training,palms of oarsmen not having developed
    protective calluses, beginning drummers
    (drummers digits)

103
Sclerosing Lymphangiitis
  • Cordlike structure encircling the coronal sulcus
    of the penis, or running the length of the shaft
  • Attributed to trauma
  • Produced by a sclerosing lymphangiitis
  • No tx is needed
  • Follows a benign, self-limiting course

104
Black Heel
  • Also called talon noir, calcaneal petechiae, and
    chromidrose plantaire
  • A sudden shower of minute macules occurs most
    often on the posterior edge of the plantar
    surface of one or both heels
  • Sometimes occurs distally on one or more toes
  • Black heel is seen in basketball, volleyball,
    tennis, or lacrosse players

105
Painful Fat Herniation
  • AKA painful piezogenic pedal papules
  • Rare cause of painful feet representing fat
    herniations through thin fascial layers of
    weight-bearing parts of the heel
  • These dermatoceles become apparent when wt is
    placed on the heel
  • These disappear when pressure is removed
  • Extrusion of fat tissue together with its blood
    vessels and nerves initiates pain on prolonged
    standing
  • Avoidance of prolonged standing is the only way
    to provide relief
  • Majority of people experience no symptoms

106
Painful Fat Herniation
107
Narcotic Dermopathy
  • Heroin(diacetylmorphine) is a narcotic prepared
    by dissolving the heroin powder in boiling water
    and then injecting it
  • Favored route is IV
  • Resulting in thrombosed, cordlike, thickened
    veins

108
Narcotic Dermopathy
  • Subcutaeous injection (skin popping) can result
    in multiple, scattered ulcerations, which heal
    with discrete atrophic scars

109
Narcotic Dermopathy
  • Ulcer from extravascular injection of speed
    (amphetamine)

110
Tatooing
  • Photosensitivity can occur from pigments used
    (cadmium sulfide-used for yellow color or to
    brighten up cinnabar red)
  • Unsanitary tattooing has resulted in inoculation
    of syphilis, infectious hepatitis, tuberculosis,
    HIV, and leprosy
  • Occasionally keloid formation occurs
  • Accidental tattoo marks may be induced by
    narcotic addicts who sterilize needles for
    injection by flaming needle with a lighted match

111
Tattooing
  • Discoid lupus has been reported to occur in
    red-pigmented portions of tattoos
  • Sarcoid nodules and granuloma annulare-like
    lesions have also been seen
  • Dermatitis in areas of re (mercury), green
    (chromium), or blue (cobalt) have been described
    in pts patch-test positive to these metals
  • TxQ-switched laser allows removal without
    scarring
  • One report of five pts who developed darkening
    after tx due to ferrous oxide formation

112
Paraffinoma
  • AKA-sclerosing lipogranuloma
  • Injection of paraffin into skin for cosmetic
    purposes
  • Smoothing of wrinkles and breast augmentation
  • Oils like paraffin, camphorated oil, cottonseed
    or sesame oil, beeswax were used
  • These can produce plaque-like indurations with
    ulcerations after time
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