Dermatoses Resulting from Physical Factors

1. Dermatoses Resulting from Physical Factors Chapter 3 Andrew’s Diseases of the Skin JoAnne M. LaRow, D.O.

2. Heat Injuries • Thermal Burns • Electrical Burns • Hot Tar Burns • Miliaria • Miliaria Crystalline (Sudamina) • Miliaria Rubra (Prickly Heat, Heat Rash) • Miliaria Pustulosa • Miliaria Profunda • Postmiliarial Hypohidrosis • Tropical Anhidrotic Asthenia • Occlusion Miliaria

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

4. Deep –is pale and anesthetic Injury to reticular dermis compromises blood flow and destroys appendages Healing takes > 1 month Scarring occurs Two types-superficial and deep Superficial-transudation of serum from capillaries, causing edema of superficial tissues Vesicles and blebs form from serum gathering beneath the outer layers of the dermis Complete recovery without scar or blemish is usual Second-degree burns

5. 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

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

7. Second-Degree Burn • Curling iron burn

8. Third-degree burns • Full-thickness tissue loss • Often loss of subcutaneous tissue occurs • Since skin appendages are destroyed there is no epithelium for regeneration • An ulcerating wound occurs • Healing leaves a scar • Followed by constitutional symptoms

9. Fourth-degree burns • Destruction of entire skin and subcutaneous fat with any underlying tendons • Requires grafting for closure • Constitutional symptoms occurs • Constitutional symptoms depend on size of area involved, depth, and especially location • The more vascular the involved area, the more severe the symptoms

10. Symptoms of shock may appear within 24-hrs Next, symptoms of toxemia from the absorption of destroyed tissue on wound surface Symptoms of wound infection may then occur as a result of contamination with pyogenic organisms Symptoms of all three may merge making differentiation difficult Prognosis is poor when large surfaces are involved Particularly when > two thirds of body surface is burned Infection of the wound Cellulitis, sepsis, with seeding of internal organs (ie meninges, lungs, kidneys) Irregularities in electrolytes and fluid balance, loss or serum proteins Thermal Burns

11. Excessive scarring with keloidlike scars or flat scars with contractures of joints Chronic ulcerations because of local impaired circulation Burn scars may be the site of carcinoma or sarcoma Complications of thermal burns

12. For minor thermal burns-prompt cold applications until pain has resolved Do not open vesicles or blebs, they provide a natural barrier If tense and painful evacuate fluid under strict aseptic conditions via puncture of the wallto allow blister to collapse Apply topical antibiotic Severe deep wounds silver sulfadiazine ointment is indicated Antibiotics, fluid, and electrolyte support, supplemental vitamins Collagen-synthetic bilaminate membranes may be used In many centers, cultured epidermal grafts, both autologous and allogeneic, are being utilized Morbidtiy and mortality following severe burns is often due to bacterial and fungal infection Definitive tx consists of antishock measures, debridement of loose skin and dirt, and application of silver sulfadiazine ointment Treatment

13. Expedient primary excision of deep dermal and full-thickness burn wounds with subsequent grafting is standard of care Severe second- and third degree burns require specialized teams of physicians working together to provide most effective tx Treatment

14. Electrical Burns • Two varieties: • Contact and flash • 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 may cause burns after direct strike, where an exist and an entrance wound are visible • Lightening is the most lethal type of strike, cardiac arrest or other internal injuries may occur

15. Electrical Burns • Other types of strikes are indirect and result in linear burns that are either linear in areas at which sweat was present; are feathery or aborescent pattern, which is believed to be pathognomonic

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

17. Electrical Burn-pathology • Blistering and elongated keratinocytes

18. Hot Tar Burns • Demling has reported that the polyoxyethylene sorbitan in Neosporin ointment is an excellent dispersing agent that facilitates the removal of hot tar from burns

19. Miliaria • Retention of sweat as a result of occlusion of eccrine sweat ducts and pores • Produces an eruption that is common in hot, humid climates such as the tropics and during the hot summer months in temperate 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

20. Miliaria Crystalline • Characterized by small, clear, superficial vesicles without inflammation • Appears in bedridden pts in whom fever produces increased perspiration or when clothing prevents dissipation of heat and moisture, as in bundled children • Lesions are asymptomatic and rupture at the slightest trauma • Self-limited; no tx is required

21. Miliaria Crystallina • Minute, descrete vesicles resulting from profuse sweating secondary to a high fever

22. Miliaria Crystallina

23. Miliaria Rubra • Lesions are descrete, extremely pruritic, erythematous papulovesicles with sensation of prickling, burning, or tingling • Tingling may become confluent on a bed of erythema • Most frequently affected sites: antecubital and popliteal fossae, trunk, inframammary areas, abdomen • Site of injury is prickle cell layer where spongiosis is produced

24. Miliaria Rubra

25. Miliaria Pustulosa • Always preceded by some other dermatitis that has produced injury, destruction, or blocking of sweat duct • Pustules are distinct, superficial, and independent of hair follicle • Pruritic pustules occur most frequently on intertriginous areas, flexure surfaces of extrmities, sctrotum, and back of bedridden pts • Usually pustules contain sterile material, but may contain nonpathogenic cocci

26. Nonpruritic, flesh-colored, deep-seated, whitish papules Asymptomatic, usually lasting only 1 hr after overheating has ended Concentrated on the trunk and extremities Except for face, axillae, hands, and feet(where there may be a compensatory hyperhydrosis), all sweat glands are nonfunctional Occlusion is in upper dermis Only seen in tropics usually following a severe bout of miliaria rubra Miliaria Profunda

27. Postmiliarial Hypohidrosis • Results from occlusion of sweat ducts and pores and may be severe enough to impair one’s ability to perform sustained work in a hot environment • Affected pts may show decreasing efficiency, irritability, anorexia, drowsiness, vertigo, and headache; they may wander in a daze • Hypohidrosis invariably follows miliaria • The duration and severity of hypohidrosis are related to severity and duration of miliaria • Sweating may be depressed to half the normal amount for as long as 3 weeks

28. Tropical Anhidrotic Asthenia • Rare form of miliaria with long-lasting pore occlusion, producing anhidrosis and heat retention

29. Occlusion Miliaria • May be produced with accompanying anhidrosis and increased heat stress susceptibility after application of extensive polyethylene film occlusion for > 48 hrs • Tx-place pt in a cool environment • Even a night in an air-conditioned room helps alleviate the discomfort • Anhydrous lanolin resolves occlusion of pores and may help restore normal sweat secretions • Hydrophilic ointment helps dissolve keratinous plugs facilitating sweat flow • Soothing, cooling baths containing Aveeno colloidal oatmeal or cornstarch in moderation

30. 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 955 alcohol is effective • This should be dabbed on affected areas several times daily until desquamation sets in • An oily “shake” lotion such as calamine lotion, with 1% or 2% phenol may be effective

31. 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

32. All the various phases usually are present simultaneously in a patch, the color varying from pale pink to old rose or dark purplish brown After cause is removed the color tends to disappear gradually, but sometimes pigment is permanent Most common on the legs of women as a result of warming in open fireplaces, radiators, or heaters Similar changes may be produced with a hot water bag or electric heating pad Also occurs in cooks, stokers, invalids, and others exposed to long periods of moderate heat Epithelial atypia and Bowen’s disease has been reported Erythema Ab Igne

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

34. Steam radiators Car heaters Heated reclining chairs Heating blankets Hot bricks Infrared lamps Heating pads Hot water bottles Electric stove/heater Open fires Coal stoves Peat fires Wood stoves Heat sources causing EAI

35. Localized areas of reticulated erythema and hyperpigmentation Due to chronic exposure to a nonburning heat source Common locations: lumbosacral region and shins Key pathologic finding is squamous atypia There is a risk of cutaneous malignancy, in particular squamous cell carcinoma Also Merkel cell carcinoma risk Latent period of 30 years or more with carcinoma Key Features

36. Use of bland emollients is helpful No effective treatment Kligman’s combination of 5% hydroquinone in hydrophilic ointmant 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 Treatment

37. Cold Injuries • Local cold injuries are divided into chilblain, frostbite, and immersion injury • Immersion foot is encountered almost entirely in the armed forces • Intense vasoconstriction resulting from local action of cold and reflex vasoconstrictor stimulation is reinforced by the passage of cold blood through the vasomotor center • Vasoconstriction evokes tissue anoxia • Decreased muscular activity further diminishes blood supply • Ice crystal formation in blood vessels usually does not occur, but when it does necrosis occurs

38. Recurrent, localized erythema and swelling caused by exposure to cold Blistering and ulcerations may develop in severe cases In pts predisposed by poor circulation even moderate exposure to cold may produce chilblains Acute chilblains is the mildest form of cold injury Occurs chiefly on hands, feet,ears, and face, especially in children Onset is enhanced by dampness Pts are usually unaware of injury until they develop burning, tiching, and redness Areas are bluish red, the color partial or totally blanches with pressure, and are cool to touch Chronic chilblains occurs repeatedly during cold weather and disappears during warm weather Chilblains

39. Chilblains (pernio)

40. Nifedipine 20mg TID Vasodilators (nicotinaamide 100 mg TID or dipyridamole 25 mg TID) Systemic corticoid tx is helpful in chilblain lupus erythematosus Pentoxifylline may be useful Affected areas should be cleansed with water and massaged gently with warm oil each day and should be protected against further injury and exposure to cold or dampness If feet are affected, woolen socks should be worn at night during cold months Careful use of electric pads may be used Smoking strongly discouraged Treatment

41. When soft tissue is frozen and locally deprived of blood supply Ears, nose, cheeks,fingers,and toes most common sites Frozen part is painless and becomes pale and waxy Various degrees of tissue destruction similar to those of burns are seen Erythema and edema, vesicles and bullae, superficial gangrene, deep gangrene Injury to muscles, tendons, periosteum, and nerves Arolla index-formula linking duration of exposure (defined by temperature and wind chill index) with frostbite Frostbite (Congelation)

42. Frostbite

43. First-Degree Frostbite

44. Early- (before swelling develops) covering body with clothing or a warm hand or other body surface to maintain a warm temperature to maintain adequate blood circulation Rapid rewarming in bath water between 100 degrees and 110 F Analgesics(because rewarming is painful) Slow thawing results in more extensive tissue damage When the skin flushes and is pliable, thawing is complete Supportive measures: bed rest, high protein/high calorie diet, wound care, avoidance of trauma, avoid rubbing of affected parts After swelling and hyperemia have developed, bed rest with limb slightly flexed, elevated and at rest Room temperature relieves pain and helps prevent tissue damage Treatment

45. Treatment • Protection by a heat cradle may be helpful • Anticoagulants to prevent thrombosis and gangrene • Papaverine and nicotinic acid may reduce vasospasm • Antibiotics for prophylactic measures and an updated tetanus immunization is recommended • Recovery may take months

46. Immersion Foot Syndromes • Trench Foot • Warm Water Immersion Foot

47. 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 • Lack of circulation produces edema, paresthesias, and damage to blood vessels • Gangrene may occur in severe cases • Tx-removal from causal environment, bed rest, and circulatory restoration • Measures underlined on tx for frostbite should be performed

48. Exposure of feet to warm, wet conditions for 48 hrs or more may produce a syndrome of maceration, blanching, and skin wrinkling of soles and sides of feet Itching and burning with swelling may persist a few days after removal of the cause, but disability is temporary Commonly seen in military service members in Vietnam Also seen in persons wearing insulated boots, the so-called moon-boot syndrome Tx-by allowing feet to dry for a few hrs out of 24 hrs Or by greasing soles with a silicone grease once/day Recovery is usually rapid and complete if dried thoroughly for a few hrs Warm Water Immersion Foot

49. 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

50. Warm Water Immersion Foot • This was known as “paddy foot” in Vietnam • It involves erythema, edema, and pain of the dorsal feet, and fever and adenopathy • Resolution occurs 3-7 days after the feet have been dried • Can be prevented by allowing the feet to dry for a few hrs out of every 24 or by greasing the soles with a silicone grease once daily • Recovery is usually rapid if feet are thoroughly dried for a few hrs