March 30, 2007

Seborrheic keratoses, Skin tags

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Seborrheic keratoses

Seborrheic keratoses (seborrheic warts) are flesh-colored, brown, or black growths that can appear anywhere on the skin.

These harmless growths are very common in middle-aged and older people. Some people have a hundred or more. Although these growths can appear anywhere, they most often appear on the torso and the temples.

Seborrheic keratoses are round or oval and vary in size from less than ¼ inch to several inches. They appear to be stuck on the skin and often have a waxy or scaly surface. These growths develop slowly. They are not cancerous and do not become so. Dark brown keratoses may sometimes be mistaken for atypical moles or melanomas.

Treatment is not needed unless the keratoses become irritated or itchy or are cosmetically undesirable. They are best removed by freezing them with liquid nitrogen. Laser removal is also effective (see Using Lasers to Treat Skin Problems). Alternatively, a doctor can cut them out with a scissors, scalpel, or other sharp instrument.

Skin tags


Skin tags are soft, small, flesh-colored or slightly darker skin growths that develop mostly on the neck, in the armpits, or in the genital area.

Usually, skin tags cause no trouble, but they may be unattractive, and clothing or nearby skin may rub and irritate them so that they bleed or hurt. A doctor can easily remove a skin tag by burning it off with an electric needle or by cutting it off with a scalpel or scissors.


Adapted from: Merck & Co. Inc

Keloids, Keratoacanthomas, Lipomas, Moles

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Keloids
Keloids are smooth, shiny, flesh-colored, raised growths of fibrous tissue that form over areas of injury or surgical wounds.

Keloids are an extreme overgrowth of scar tissue over healed wounds. They may form in the months after an injury. They may be raised as much as ¼ inch above the surface of the skin. Keloids may form in any scar, even those resulting from severe acne. They are much more common in blacks than in whites and typically develop on the chest, shoulders, back, and, sometimes, face and earlobes. Keloids do not hurt, but they may itch or be sensitive to touch.

Keloids respond poorly to therapy, but monthly injections of corticosteroids may flatten them somewhat. A doctor may try surgical or laser removal followed by corticosteroid injections, but new keloids often form in the scar resulting from the treatment. Some doctors have applied silicone patches to keloids and have had some success in flattening them.

Keratoacanthomas
Keratoacanthomas are round, firm, usually flesh-colored growths that have a central crater that is scaly or crusted.

Keratoacanthomas appear most commonly on the face, forearm, and back of the hand and grow quickly. In 1 or 2 months, they can grow into lumps up to 1 inch wide, after which they begin to shrink. They usually disappear within 6 months, often leaving a scar. They may be caused by a virus, but doctors are not sure.

Keratoacanthomas closely resemble squamous cell carcinoma, a type of skin cancer, and some doctors believe that they may actually be an unusual form of squamous cell carcinoma. Therefore, doctors often perform a biopsy, in which a piece of skin is removed and examined under a microscope. Keratoacanthomas can be cut out or scraped (curetted). Alternatively, they can be treated with injections of corticosteroids or fluorouracil
.

Lipomas
Lipomas are soft deposits of fatty material that grow under the skin, causing round or oval lumps.

A lipoma appears as a smooth, soft bump under the skin. Lipomas range in firmness, some feeling rather hard. The skin over the lipoma has a normal appearance. Lipomas rarely grow more than 2 or 3 inches across. They can develop anywhere on the body but are particularly common on the forearms, torso, and back of the neck. Some people have only one, whereas others develop many lipomas. Lipomas rarely cause problems, although they may occasionally be painful if they grow against a nerve. Lipomas are more common in women than in men.

Usually, a doctor can easily recognize lipomas, and no tests are required for diagnosis. Lipomas are not a form of cancer, and they rarely become cancerous. If a lipoma begins to change in any way, a doctor may perform a biopsy (removal of a tissue sample for examination under a microscope). Treatment usually is not required, but bothersome lipomas may be removed by surgery or by liposuction (removal of fat with a suction device).

Moles
Moles (nevi) are small, usually dark, skin growths that develop from pigment-producing cells in the skin (melanocytes).

Moles vary in size from small dots to more than 1 inch in diameter. They may be flat or raised, smooth or rough (wartlike), and may have hairs growing from them. Although they are usually dark brown or black, some moles are flesh-colored or yellow-brown. They may be red at first but often darken. Almost everyone has a few moles, and many people have large numbers of moles. Moles commonly develop in childhood or adolescence, although in some people they continue to develop throughout life. Moles respond to changes in hormone levels in women and may appear, enlarge, or darken during pregnancy. Once formed, moles remain for a lifetime. In fair-skinned people, moles occur more commonly on sun-exposed areas of the skin.

Moles usually are easily recognized by their typical appearance. They do not itch or hurt, and they are not a form of cancer. However, moles sometimes develop into or resemble malignant melanoma, a cancerous growth of melanocytes. In fact, many malignant melanomas begin in moles, so a mole that looks suspicious should be removed and examined under a microscope. Changes in a mole—such as enlargement (especially with an irregular border), darkening, inflammation, spotty color changes, bleeding, broken skin, itching, or pain—are warnings of malignant melanoma. People with more than 10 or 20 moles have a somewhat increased risk of melanoma and should be checked every year by a doctor. If a mole proves to be cancerous, additional surgery may be needed to remove the skin surrounding it.

Most moles, however, are harmless and do not require removal. Depending on their appearance and location, some moles may even be considered beauty marks. Normal moles that are unattractive or located where clothing can irritate them can be removed by a doctor using a scalpel and a local anesthetic.

Atypical moles (dysplastic nevi) tend to be larger than normal moles. Like cancerous skin growths, they tend to be multicolored and have irregular shapes and borders. People with even a few atypical moles have a slightly increased risk of developing malignant melanoma. This risk increases greatly if the person has close family members with malignant melanoma. The tendency to grow atypical moles is hereditary.

People with atypical moles—particularly those with a family history of melanoma—must look for any changes that might indicate malignant melanoma. They should have their skin checked at least yearly by a dermatologist to look for changes in the color or size of a mole. To help monitor such changes, dermatologists often use full-body color photographs. Atypical moles that change should be removed.

Sunlight accelerates the development of and changes in atypical moles. Even moderate sun exposure during childhood may be harmful and increase the risk of developing melanoma decades later. Therefore, fair-skinned people or those with atypical moles should avoid sun exposure. When in the sun, they should always use a sunblock with a high sun protection factor (SPF) rating to help shield against cancer-producing ultraviolet (UV) rays.

Adapted from: Merck & Co. Inc

Noncancerous Skin Growths

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Skin growths are accumulations of various types of cells that look different than the surrounding skin. They may be raised or flat and range in color from dark brown or black to flesh-colored to red. Skin growths may be present at birth or develop later.

When the growth is controlled and the cells do not spread to other parts of the body, the skin growth (tumor) is noncancerous (benign). When the growth is uncontrolled, the tumor is cancerous (malignant), and the cells invade normal tissue and even spread (metastasize) to other parts of the body. Noncancerous skin growths are often more of a cosmetic problem than anything else.

Doctors do not know what causes most noncancerous skin growths. Some growths, however, are known to be caused by viruses (for example, warts), systemic (bodywide) disease (for example, xanthelasmas or xanthomas caused by excess fats in the blood), and environmental factors (for example, moles and epidermal cysts stimulated by sunlight).

Dermatofibromas

Dermatofibromas are small red-to-brown bumps (nodules) that result from an accumulation of collagen, which is a protein made by the cells (fibroblasts) that populate the soft tissue under the skin.

Dermatofibromas are common and usually appear as single firm bumps, often on the legs, particularly in women. Some people develop many dermatofibromas. Causes include trauma, insect bites, and cuts caused by shaving. Dermatofibromas are harmless and usually do not cause any symptoms, except for occasional itching. Usually, dermatofibromas are not treated unless they become bothersome or enlarge. A doctor can remove them with a scalpel.

Epidermal Cysts
An epidermal cyst is a common slow-growing bump consisting of a thin sac of skinlike material containing a cheesy substance composed of skin secretions.

Epidermal cysts, often incorrectly referred to as sebaceous cysts, are flesh-colored and range from ½ to 2 inches across. They can appear anywhere but are most common on the scalp, back, and face. They tend to be firm and easy to move within the skin. Epidermal cysts are not painful unless they become infected or inflamed.

Large epidermal cysts are removed surgically after an anesthetic is injected to numb the area. The thin sac wall must be removed completely or the cyst will grow back. Small cysts may be injected with corticosteroids if they become inflamed. Infected cysts are treated with an antibiotic and cut open to drain. Tiny cysts that are bothersome can be burned out with an electric needle.

Because sunlight may stimulate growth of epidermal cysts, fair-skinned people are advised to stay out of the sun and to use protective clothing and sunscreen

Growths and Malformations of the Vessels

Growths and malformations of the vessels (angiomas) are collections of abnormally dense blood or lymph vessels, usually located in and below the skin, that cause red or purple discolorations.

Growths and malformations of the vessels often appear at birth or soon afterward, and some may be referred to as birthmarks. Examples include hemangiomas, port-wine stains, lymphangiomas, pyogenic granulomas, and spider angiomas. These different growths and malformations are usually recognized by their appearances, thus biopsies are rarely necessary. About one third of all newborns have some type of growth or malformation of the vessels, many of which disappear by themselves.

Hemangiomas

Hemangiomas are abnormal overgrowths of blood vessels that can appear as red or purple lumps in the skin and on other parts of the body.

Hemangiomas develop soon after birth and tend to enlarge rapidly during the first 6 to 18 months of life. After this, they begin to shrink. About three quarters of hemangiomas disappear by age 7, although the skin that remains is often slightly discolored or scarred.

Superficial hemangiomas (strawberry hemangiomas, cherry angiomas), the most common type of blood vessel growth, occur on or near the surface of the skin. They appear as raised, red, irregular growths or patches that range from tiny bumps to large, deforming swellings 3 or 4 inches across. They usually occur on the torso and can number from a few to dozens. Superficial hemangiomas are harmless; if they are bothersome, a doctor can remove them with an electric needle or laser.


Deep hemangiomas (cavernous hemangiomas) grow within the skin and deep beneath it. They cause the skin to bulge and may be purple or, if they are very deep, flesh-colored. Most deep hemangiomas grow between ¼ inch and 2 inches across, although sometimes they grow much larger. More than half occur on the head and neck. Sometimes, hemangiomas develop in organs, such as the liver.

Superficial and deep hemangiomas do not cause pain but occasionally break open (ulcerate) and bleed, which can be difficult to stop. Hemangiomas around the eye may grow large enough to block vision, which can lead to permanent vision loss if uncorrected. Hemangiomas may also block the nose or throat, which can obstruct breathing.

Because hemangiomas often go away on their own, doctors do not treat them when they first appear unless they grow rapidly, obstruct vision or breathing, ulcerate, or are cosmetically distressing. Doctors usually treat any facial hemangiomas that have not gone away by age 5 or 6.

When treatment is required, doctors inject small superficial hemangiomas with corticosteroids or surgically remove them if the injections do not work. People with rapidly growing or large, ulcerating hemangiomas take corticosteroids by mouth. For older children in whom the hemangioma has shrunken, laser therapy or surgery may improve the appearance of the skin.

Port-wine Stains

Port-wine stains (capillary malformations, nevi flammeus) are flat pink, red, or purplish discolorations present at birth due to malformed blood vessels.

Port-wine stains are harmless, permanent discolorations. However, their cosmetic appearance may be psychologically bothersome or even devastating. The stains appear as smooth, flat pink, red, or purple patches of skin. Port-wine stains may be small or may cover large areas of the body. Stains that appear on the nape of the neck of newborns have been referred to as stork bites. Very rarely, port-wine stains appear in conjunction with Sturge-Weber syndrome, a rare hereditary disorder that leads to mental retardation and growth deformities.

Small port-wine stains can be covered with cosmetic cover-up cream. If a stain is bothersome, its appearance can be greatly improved with laser therapy (see Using Lasers to Treat Skin Problems).

Lymphangiomas

Lymphangiomas (lymphatic malformations) are skin bumps caused by a collection of enlarged lymph vessels—the channels that carry lymph (a clear fluid related to blood) throughout the body.

Lymphangiomas are uncommon, but usually appear between birth and age 2. They may be tiny bumps or large, deforming growths. Lymphangiomas do not itch or hurt and are not a form of cancer. Most lymphangiomas are yellowish tan, but a few are reddish. When injured or punctured, they release a colorless fluid. Although treatment is not usually needed, lymphangiomas can be removed surgically. However, such surgery requires the removal of many layers of skin and underlying tissue, because lymphangiomas grow deep beneath the surface.

Pyogenic Granulomas

Pyogenic granulomas are scarlet, brown, or blue-black slightly raised areas caused by increased growth of capillaries (the smallest blood vessels) and swelling of the surrounding tissue.

The condition develops rapidly, usually after injury to the skin. For unknown reasons, large pyogenic granulomas may develop during pregnancy, appearing even on the gums (pregnancy tumors). Pyogenic granulomas appear as ¼- to ½-inch growths that rise from the surface of the skin. They do not hurt, but they bleed easily when bumped or scratched because they consist almost entirely of capillaries.

Pyogenic granulomas sometimes disappear by themselves, but if they persist, a doctor usually removes them surgically, with laser therapy, or with an electric needle (electrocoagulation). A sample of tissue may be sent to a laboratory to ensure that the growth is not a type of melanoma or other skin cancer. Sometimes pyogenic granulomas recur after treatment.

Spider Angiomas

Spider angiomas are small, bright red spots consisting of a central dilated blood vessel surrounded by slender dilated capillaries that resemble spider legs.

Many people have a few spider angiomas, which are often referred to as "broken" blood vessels. Spider angiomas on the face are commonly seen in fair-skinned people and are thought to be due to sun exposure. In most people, there is no known cause, but people with cirrhosis often develop many spider angiomas, as do many women who are pregnant or who are using oral contraceptives. Spider angiomas are not present at birth.

Spider angiomas appear as tiny, hard-to-see red spots less than ¼ inch across. They are harmless and generally cause no symptoms; they are only of cosmetic significance. Spider angiomas that develop during pregnancy or oral contraceptive use usually disappear on their own 6 to 9 months after childbirth or after discontinuing oral contraceptive use. If treatment is desired for cosmetic reasons, a doctor can destroy the central blood vessel with laser therapy or with an electric needle.

Adapted from: Merck & Co. Inc

Stevens-Johnson Syndrome (SJS) and Toxic Epidermal Necrolysis

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Rosacea,
Rosacea (acne rosacea) is a persistent skin disorder that produces redness, tiny pimples, and noticeable blood vessels, usually on the central area of the face.

The cause of rosacea is not known. The disorder usually appears during or after middle age—age of onset helps distinguish it from acne. Rosacea is most common among people of Celtic or Northern European descent who have fair complexions but it does affect and is probably under-recognized in darker-skinned people. Although usually easy for doctors to recognize, rosacea sometimes looks like acne and certain other skin disorders. It is often called "adult acne."

The skin over the cheeks and nose becomes red, often with small pimples. The skin may appear thin and frail, with small blood vessels visible just below the surface. The skin around the nose may thicken, making it look red and bulbous (rhinophyma).

Treatment
People with rosacea should avoid foods that cause the blood vessels in the skin to dilate—for example, spicy foods, alcohol, coffee, and other caffeinated beverages. Other triggers include sunlight, emotional stress, cold or hot weather, exercise, wind, cosmetics, and hot baths or hot drinks.

Certain antibiotics taken by mouth relieve rosacea. Tetracyclines are usually most effective and produce the fewest side effects. Antibiotics that are applied to the skin, such as metronidazole, clindamycin, and erythromycin, are also effective. In rare cases, antifungal creams, such as ketoconazole or terbinafine cream, are used. Topical azelaic acid gel also can be an effective treatment for rosacea.

Isotretinoin is effective when taken by mouth or when applied to the skin. Corticosteroids applied to the skin tend to make rosacea worse. Severe rhinophyma is unlikely to improve completely with drugs. Therefore, a person with this disorder may need surgery or laser treatment


Stevens-Johnson Syndrome (SJS) and Toxic Epidermal Necrolysis

Stevens-Johnson syndrome and toxic epidermal necrolysis are two forms of the same life-threatening skin disease that cause rash, skin peeling, and sores on the mucous membranes.

In Stevens-Johnson syndrome, a person has blistering of mucous membranes, typically in the mouth, eyes, and vagina, and patchy areas of rash. In toxic epidermal necrolysis, there is a similar blistering of mucous membranes, but in addition the entire top layer of the skin (the epidermis) peels off in sheets from large areas of the body. Both disorders can be life threatening.

Nearly all cases are caused by a reaction to a drug, most often sulfa antibiotics; barbiturates; anticonvulsants, such as phenytoin and carbamazepine; certain nonsteroidal anti-inflammatory drugs (NSAIDs); or allopurinol. Some cases are caused by a bacterial infection. Occasionally, a cause cannot be identified. The disorder occurs in all age groups but is more common among older people, probably because older people tend to use more drugs. The disorder is also more likely to occur in people with AIDS.

Symptoms

Stevens-Johnson syndrome and toxic epidermal necrolysis usually begin with fever, headache, cough, and body aches. Then a flat red rash breaks out on the face and trunk, often spreading later to the rest of the body in an irregular pattern. The areas of rash enlarge and spread, often forming blisters in their center. The skin of the blisters is very loose and easy to rub off. In Stevens-Johnson syndrome, less than 10% of the body surface is affected. In toxic epidermal necrolysis, large areas of skin peel off, often with just a gentle touch or pull. In many people with toxic epidermal necrolysis, 30% or more of the body surface peels away. The affected areas of skin are painful, and the person feels very ill with chills and fever. In some people, the hair and nails fall out. The active stage of rash and skin loss can last between 1 day and 14 days.

In both disorders, blisters break out on the mucous membranes lining the mouth, throat, anus, genitals, and eyes. The damage to the lining of the mouth makes eating difficult, and closing the mouth may be painful, so the person may drool. The eyes may become very painful, swell, and become so filled with pus that they seal shut. The corneas can become scarred. The opening through which urine passes (urethra) may also be affected, making urination difficult and painful. Sometimes the mucous membranes of the digestive and respiratory tracts are involved, resulting in diarrhea and difficulty breathing.

The skin loss in toxic epidermal necrolysis is similar to a severe burn and is equally life threatening. Huge amounts of fluids and salts can seep from the large, raw, damaged areas. A person who has this disorder is very susceptible to organ failure and infection at the sites of damaged, exposed tissues. Such infections are the most common cause of death in people with this disorder.

Treatment

People with Stevens-Johnson syndrome or toxic epidermal necrolysis are hospitalized. Any drugs suspected of causing the disorder are immediately discontinued. When possible, people are treated in a burn unit and given scrupulous care to avoid infection. If the person survives, the skin grows back on its own, and unlike burns, skin grafts are not needed. Fluids and salts, which are lost through the damaged skin, are replaced intravenously.

Use of corticosteroids to treat the disorder is controversial. Some doctors believe that giving large doses within the first few days is beneficial, whereas others believe that corticosteroids should not be used. These drugs suppress the immune system, which increases the potential for serious infection. If infection develops, doctors give antibiotics immediately.

In many cases, doctors give intravenous human immunoglobulin (IVIg) to treat toxic epidermal necrolysis. This substance helps to prevent further immune damage to the skin and further progression of blistering.

Adapted from: Merck & Co. Inc.