In Westernized societies, the proportion of people aged over 65 is high and continues to rise. Poor nutrition, lack of self-care and general illness contribute to skin disease in the elderly. Few people die from old skin, but many suffer from it. Intrinsic ageing of the skin The changes in aged, sun-protected skin are more subtle than those of photoageing (p. 130) and consist of laxity,…

The classification of vascular tumours can seem complicated, but it is important since prognoses differ, and some types are systemic, with internal organ involvement ( Box 67.1 ). Box 67.1 A classification of vascular birthmarks Vascular tumours Infantile haemangioma Congenital haemangioma – Rapidly involuting – Non-involuting Rare forms, e.g. tufted angioma Vascular malformations Capillary (slow flow) Venous (slow flow) Lymphatic (slow flow) Arteriovenous (fast flow) Combined:…

Some conditions are almost exclusive to childhood (e.g. napkin dermatitis and juvenile plantar dermatosis), and others are more common in children (e.g. atopic eczema or viral exanthems). The common childhood dermatoses not mentioned elsewhere are detailed here along with some rare but important disorders. Childhood eczemas and related disorders Forms of eczema found in childhood include: ● napkin (diaper) dermatitis ● infantile seborrhoeic dermatitis ● napkin…

A cosmetic is any substance applied to the body for cleansing, beautifying, promoting attractiveness or altering the appearance. The fields of cosmetology and dermatology have now converged so that patients often present having had a reaction to a cosmetic or asking for advice about cosmetic usage. Cosmetic procedures, i.e. minor surgical techniques designed to enhance the physical appearance of the skin, are now part of a…

Some dermatologists specialize in the field of skin surgery. All registrars and residents in dermatology are trained in these techniques. An outline of the subject is given here, including the use of flaps, grafts and Mohs’ surgery, along with mention of lasers and photodynamic therapy, and of some basic cosmetic procedures. Simple plastic repairs Simple plastic repairs are carried out by the following: ● Dog-ear excision…

The demand for the removal of benign and malignant skin lesions has increased considerably, such that skin surgery is now practised by many general practitioners as well as by dermatologists. Knowledge of basic surgical techniques is mandatory for all those who treat skin disease. Instruments and methods No one should attempt a procedure if unsure about it. Those with limited experience should remove only benign lesions.…

An interaction between natural sunlight and the skin is inescapable. The potential for harm depends on the type and length of exposure. Sunlight can help in certain skin diseases (p. 61). Both ultraviolet (UV)B and UVA are extensively used therapeutically. UVA is usually used combined with photosensitizing psoralens given systemically or topically, although by itself it has some therapeutic effects. Photoageing is a growing problem (p.…

The introduction of the biological response modifiers has revolutionized the management of a number of previously difficult-to-treat conditions such as Crohn’s disease, rheumatoid arthritis and severe psoriasis. Biologics are based on recombinant cytokines, fusion proteins and mouse or human monoclonal antibodies that interfere with the immunological mechanisms, such as tumour necrosis factor-α (TNF-α), cytokines and T cells (and their receptors), involved in the pathogenesis of several…

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Cutaneous T-cell lymphoma (CTCL) is the most common type of skin lymphoma, with an incidence of 0.6 per 100 000 (in the USA). B-cell lymphoma of the skin is rare. Malignant tumours of the dermis are infrequent. The commonest are secondary deposits (p. 109), Kaposi’s sarcoma (p. 71) and a malignancy of dermal fibroblasts (dermatofibrosarcoma). Cutaneous T-cell lymphoma (mycosis fungoides) CTCL describes a lymphoma that evolves…

Malignant melanoma is a malignant tumour of melanocytes, usually arising in the epidermis. It is the most lethal of the main skin tumours and has increased almost sevenfold in incidence since the 1970s, but overall there is 90% survival at 5 years. The important pathogenic role of excessive ultraviolet (UV) radiation exposure is estimated to contribute to 86% of cases and has been the subject of…

Squamous cell carcinoma (SCC) is a heterogeneous disease comprising clinically distinct but histologically similar entities with differing risk factors implicated in their aetiopathogenesis. Aetiopathogenesis SCC is derived from moderately well-differentiated keratinocytes. Ultraviolet (UV) radiation is clearly the strongest predisposing risk factor for this condition. The evidence for this is extensive and includes a direct correlation between average annual UV radiation and risk of SCC; increased incidence…

Malignant skin tumours are among the most common of all cancers. They are more frequent in light-skinned races, and ultraviolet (UV) radiation seems to be involved in their aetiology. The incidence of non-melanoma skin cancer in caucasoids in the USA was previously estimated at 230 per 100 000 per year, compared with 3 per 100 000 for African Americans. The majority of malignant skin tumours (…

Premalignant disorders in the skin are those which, if left untreated, may become skin cancers. The most important cancers with pre-cancerous states include squamous cell carcinoma (actinic keratosis; syn. solar keratosis) and melanoma (dysplastic naevus), although it is important to note that the risk of either of the lesions progressing to cancer is low. Actinic keratoses Aetiopathogenesis Actinic keratoses are induced by chronic exposure to ultraviolet…

A naevus is a benign proliferation of one or more of the normal constituent cells of the skin. Naevi may be present at birth or may develop later. The commonest naevi are those containing benign collections of melanocytic naevus cells, but other types of naevus are found ( Table 54.1 ). Vascular haemangiomas and malformations are dealt with on page 146. Table 54.1 A classification of…

Any connective tissue or appendageal element of the skin may undergo benign (and malignant) proliferation. Common non-malignant dermal growths such as dermatofibroma, lipoma and keloid are discussed in Chapter 52 (p. 114). Benign tumours of vascular and connective tissue Benign dermal proliferations can be categorized according to the tissue involved. Occasionally variants can be malignant. The classification includes: ● Collagen and elastin : dermatofibroma (p. 114),…

Skin tumours are common, and their incidence is rising in Western countries (p. 32). The treatment of skin tumours makes up a large part of current dermatological practice (p. 33). Many skin tumours of the epidermis and dermis are benign, and these are described in this section. Benign tumours of dermal structures and appendages are described in Chapter 53 (p. 116). Viral warts, actinic keratoses and…

Certain inherited skin disorders also have significant involvement of internal organs. The neurocutaneous disorders, the inherited diseases of connective tissue and the premature ageing syndromes are included. Neurofibromatosis von Recklinghausen’s neurofibromatosis 1 (NF1) is relatively common, affecting about 1 in 3000 births. Café-au-lait spots, cutaneous neurofibromas and other bony or neurological abnormalities characterize NF1. The disease shows autosomal dominant inheritance, although 50% of cases are new…

Common skin disorders, e.g. atopic eczema or psoriasis, have a genetic component that is often subject to environmental influences. The genodermatoses differ in being single gene defects and include keratinization, blistering and neurocutaneous syndromes. The ichthyoses The ichthyoses are inherited disorders of keratinization and epidermal differentiation. They are characterized by dry scaly skin and vary from mild and asymptomatic to severe and incompatible with life (…

Internal malignancy causes a variety of skin changes ( Table 49.1 ). Apart from direct infiltration, the mechanisms of these effects are often poorly understood. Some genetic conditions associated with malignancy include characteristic skin lesions that may arise before or after the cancer (e.g. mucosal lentigines in Peutz–Jeghers syndrome associated with bowel malignancy). Table 49.1 Cutaneous manifestations of malignancy Condition associated Commonest malignancies Almost always Acanthosis…