Prurigo nodularis
Prurigo nodularis is a chronic skin disease that causes hard, itchy lumps or nodules to form on the skin.
And, the itching can be so intense that it causes people to scratch themselves to a point of bleeding or
pain and the scratching can cause more lesions to appear. And,these.skin nodules or lumps usually appear in
a symmetrical pattern in easy to reach places such as the arms,legs or upper back.
Therefore, prurigo nodularis causes a scratch itch cycle since the more you itch,the more you scratch
and the more yopu scratch, the more you itch. Consequently,treatment includes topical(applied on the skin),
oral and intralesional(ie,injected) corticosteroids in an allemp to alleviate the inflammation and the sense
of itching.
In addition, antihistamines and anti-anxiety drugs are also given orally as well as a drug notorious for
causing birth defects called thalidomide-although this drug and its derivatives can only be given to women
of child bearing age if they are on strict birth control measures.
Also, there are small case studies showing the potential for the use of methotrexate,a folic acid
antagonist widely used for autoimmune inflammatory disorders such as psoriasis.
However,before treatment especially in recalcitrant cases,a thorough history and physical exam as well
as lab work should be done to rule out underlying medical conditions such as severe anemia or liver and
kidney disease or a type of malignancy called lymphoma as well as HIV(human immunodeficiency virus).
In my practice,I have even done skin biopsies on various skin nodules to rule out a type of skin
cancer called squamous cell carcinoma which can eventuate from chronic itching and skin irritation.
In conclusion,I would urge anyone with long term itchy, crusty skin lesions to contact their
healthcare provider to ascertain that they are not coming from an internal disease.
,
The basal cell carcinoma is the most common of all skin cancers,accounting for 80 percent of
non-melanoma skin cancers while the squamous cell carcinoma accounts for nearly 20 percent.
And,non-melanoma skin cancers are more common in men with squamous cell carcinoma affecting
2 to 3 times as many men as women while basal cell carcinoma occurs at a rate of 1 1/2 times of
men to women.
The American Cancer Society estimates that in 2019 an approximate 57,000 cases of
melanoma will be diagnosed in men and about 39,000 cases in women.And,the incidence of
melanoma is higher among men across most racial/ethnic populations.
Since most cases of skin cancer link to sun exposure ,it naturally follows that the
incidence increases with age.And,the incidence of melanoma increases after age 19 and peaks
for individuals older than 85. between 2011 and 2015 the median age for the diagnosis of melanoma
was 64.
In addition, the incidence of specific types of skin cancer varies according to race and
ethnicity.Consequently, the risk is more than 20 times higher for the white population than for people
with darker skin such as black,American Indian/Alaskan natives,Hispanic and Asian/pacific islander populations.
And,this is due to the photoprotection provided by increased melanin in the epidermis(outer skin layer)
of individuals with darker skin,which can filter twice as much UV radiation as the epidermis of white
individuals.
As is true for the white population,basal cell carcinoma is the most common skin cancer among
Hispanic and Asian populations . In contrast,squamous cell carcinoma is the most common skin cancer
in the black population and melanoma is the third most common skin cancer among all racial/ethnic
populations.
And, the highest rate of melanoma is found amiong white men and the lowest is among black
women. Although melanoma is predominate among white men compared to white women,the incidence
of melanoma in men and women is similar in black,Hispanic, and Asian/pacific islander population.
In addition to sun exposure and radiation exposure,the risk of skin cancer is also inluenced
by co-morbid or other conditions such as non-healing ulcers and tatoos as well as arsenic in the
well water . People whose immune systems are compromised either
by cancer or the drugs used to treat it are also at increased risk for skin cancer.
Also, skin cancer can develop in 30 to 70 % of organ transplant patients-with a 100 fold
increase for squamous cell carcinoma ,a 24 fold increase for a very dangerous type of skin cancer
called merkel cell carcinoma(please see my previous articles on merkel cell carcinoma),a six fold
increase for basal cell carcinoma and a two fold increased risk for melanoma.
Please see my previous article entitled: Skin Cancer-not just from the sun.
In addition, the prevalence of skin cancers is also high among individuals infected witrh
HIV (human immunodeficiency virus) and lesions in this population tend to be more aggressive.
Also, there is a high risk of squamous cell carcinoma associated with seropositivity for the
human papilloma virus (HPV) type 16 and 18 but a direct causal relationship has not been
established.
Individuals with a history of skin cancer are at increased risk for another skin cancer and
people living in areas where the sun's rays are most intense such as the equator have an
increased risk for melanoma skin cancer.
I saw a new patient in my office this week who came in for another problem but complied
with my request to take his shirt off when I promptly diagnosed a melanoma on his back.
A few years ago I diagnosedf 6 patients with melanomas in about 6 months.
In conclusion, if you see a change in the size,shape,color or behavior of spots on your
skin,get checked by your healthcare provider.
Dermatologists and other health care practitioners are often visited by a patient with a
hand rash-sometimes accompanied by a foot rash also.
And,specialists like dermatologists often immmediately think of eczema,psoriasis,contact
dermatitis and, perhaps,even a fungal infection.
As for myself,,in addition to taking a histoery of the rash which includes how long he or she
has been aware of it,I also list any treatments already tried and I always ask the patient what he or she thinks
may have caused it.
In addition,I would immediately look at the patient's fingernails and elbows,looking for signs
of psoriasis which can be manifested by a red scaley plaque like surface on the elbows and ragged fingernails.
And,often I can make the diagnosis by the simple history and physical exam described above,especially if the
feet are also involved.
Also, a simple test for fungus not only includes taking a skin scraping for examination under
the microscope and /or a culture to try to grow it. In addition,a fungal rash is more likely to involve 2 hands
and 1 foot or 2 feet and 1 hand-thus,adding up to 3 rather than 2 hands and/or 2 feet .
However, the main thrust of this narrative is to impress upon the reader that there are many
more serious causes of hand and foot rashes than the above.
To begin with, Woringer Kolopp disease which is a cutaneous form of an internal cancer
called lymphoma is manifested by psoriasis like thickened plaques on the hands and also the feet. It is
a type of mycoses fungoides lymphoma which can be treated by surgical excision and radiation therapy
and could easily be mistaken clinically for psoriasis.
Another serious disease that can appear as a rash on the hands and feet is palmoplantar
syphilis which could be misdiagnosed as palmoplantar psoriasis. In fact, secondary syphilis has often been
called one of the great masqueraders in dermatology since it can mimic many types of skin didease and
is often missed when it can frequently diagnosed with a simple blood test.
Basex syndrome is a paraneoplastic(a set of signs and symptoms that is a consequence of
cancer in the body but is not due to the local presence of cancer cells)syndrome characterized by thickened
skin on the hands or feet(ie,acral areas) as well as on the ears and nose . It is associated with malignancies
of the upper aero digestive tract such as cancer of the esophagus.
And, I would not want to leave this topic by not discussing the entity known as "mechanic's
hands." Mechanics hands refers to a non-itching, thickened skin eruption accompanied by scaling,fissuring and
hyperpigmentation giving one the appearance of the calloused hands of a manual laborer.
In my opinion,mechanics hands could be easily misdiagnosed as hand eczema. However,
over the years mechanics hands have become recognized as a clinical marker for pulmonary disease
as well as occurring in a condition called Dermatomyositis . People with the latter have not only skin
rashes but a 20 % incidence of internal cancer.
Dermatomyositis is also characterized by muscle weakness,various other skin findings as
well as a marked sensitivity to the sun.,
In summary, I would urge patients with dry thickened skin on their hands(and feet) that has
not responded to topical and (sometimes)internal steroids or antifungals to see their healthcare
provder for a detailed history and physical exam of the entire body looking for telltale signs of internal
malignancy.
Coming soon.
As a young hospital pharmacist I often dispensed nitroglycerin tablets to relieve angina
(chest pain) caused by coronary artery disease. Later,as a physician internist I prescribed it both
while working in the emergency room and on the hospital floors.
Now,as a physician dermatologist, I am amazed at the many uses of this valuable
medication even when used topically(ie,not taken internally but applied to various parts of the outside
of the body.)
Nitroglycerin can be applied as an ointment to the skin where it again -as in the heart-
dilates or widens small blood vessels which have been vasoconstricted by various factors including
cold temperatures,emotions,hormones and even certain medications.In addition, autoimmune
diseases such as systemic lupus erythematosus and systemic sclerosis can also cause this
condition.
This vasosparm or constriction of the blood supply to body parts such as the fingers
and toes is called Raynaud's phenomenon. And,if your fingers or toes have ever been exposed to
freezing cold temperatures even for a short time,you know how discomforting it is and how fast
you have tried to rewarm them.
Pernio,also called chilblains,is an inflammatory response to cold on the hands and
feet and is characterized by itching,red patches and swelling and blistering.
Also,topical nitroglycerin ointment has been used in dermatology to treat small
tender nodules usually found on the outer rim of the ears (ie,the helix of the ear) which are
exquisitely sensive to pressure-especially when the patient lays on them in bed at night.
This condition is called chondrodermatitis nodularis helicis (literally inflamation of the ear
cartilage)
In addition,topical nitroglycerin ointment is also used to relieve the severe
pain caused by long term tears in the lining of the anal cavity,called anal fissures, by
reducing the pressure on them.
Two of the most common side effects of topical nitroglycerin include headaches
and dizziness,although this is even less likely with the 1 % formulation than with the
2 % product.
In summary, topical nitroglycerin may be a safe,inexpensive and effective
therapy wherever increased cutaneous blood flow is needed.
Did you know that the new onset of dry skin-called ichthyosis or "fish scale skin" in adult life
and which does not respond to lubricating creams may be related to a type of internal cancer,especially a
type of malignancy called Hodgkins disease which is a type of lymphoma although the use of some
medications and some benign conditions such as hypothyroidism and sarcoidosis as well as malnutrition
may be the cause.
Acquired ichthyosis (or dry skin) has also been related to other internal cancers including
reticulolymphosarcoma,T-cell lymphoma,multiple myeloma, and lung,breast and cervical cancers.
In addition,this dry skin of adulthood not responding to lubricating creams can also occur in
people suffering from leprosy,AIDS,tuberculosis,and typhoid fever.
Also, carcinomas originating in many internal body areas have a very high frequency to
metastasize(ie,spread) to the skin. In one large reported study of internal cancers there was a 5 % spread
to the skin and in 0.8 % the skin metastasis was the first sign of the internal malignancy.
These skin metastases often present as erythematous( red) ,painless,and rapidly growing
solitary or multiple skin nodules(a small rouded lump) on the skin or under the skin .
Usually, the location correlates with the underlying carcinoma,ie,breast cancers most commonly
spread to the anterior(ie,front ) chest wall.
Again,the teaching point is to get an exam by your healthcare provider for any change in
color,shape,texture or size of your skin.
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