Clinical Dermatology

Aphthous ulcers (aphthous stomatitis) and herpes simplex infections (herpes labialis) account for approximately 95% of all oral ulcers. Both are often termed “cold sores” by the public, but separation is desirable and important.

Aphthous ulcers occur entirely within the mouth. Often, only a single ulcer is present, but even when there are multiple ulcers present, there is little tendency for the clustering that occurs with herpes. The individual lesions are true ulcers. That is, they are approximately as deep as they are wide. The smallest ulcers are only 1 or 2 mm in diameter, but lesions up to 1 cm in size are occasionally found.

The central crater is often filled with a white coagulum, and a thin rim of violaceous erythema usually encircles each ulcer. The lesions are usually quite painful. Aphthous ulcers may be located anywhere within the mouth, but they are most commonly seen on the buccal surfaces, the gingival margins, the gingival sulci, and the floor of the mouth, particularly around the frenulum of the tongue. Tender lymphadenopathy is often present.

Individual aphthous ulcers appear suddenly and then remain stable in size and symptoms for 7 to 10 days before resolving spontaneously. Multiple lesions may develop either simultaneously or sequentially.

Aphthous ulcers are intermittently recurrent over many years, but there is no particular tendency for reappearance in exactly the same sites as is so characteristic in herpes simplex infection. In most instances, aphthous ulcers are not associated with disease elsewhere in the body. They are, however, occasionally seen in association with chronic inflammatory bowel disease and Behcet’s syndrome.

An infectious etiology is suspected, but no single causative organism has been repeatedly or convincingly demonstrated. Immune mechanisms are important in pathogenesis. Mucosal cells from patients stimulate blast transformation of their own lymphocytes, and patients’ lymphocytes may be cytotoxic for their own mucosal cells.

The discomfort associated with aphthous ulcers may be treated with oral analgesic solutions (elixir of Benadryl, Xylocaine Viscous, or Dyclone), which are swirled in the mouth for several minutes. Alternatively, if easily reachable, each ulcer can be touched with a cotton-tipped applicator soaked in the analgesic solution. Unfortunately, the duration of analgesia obtained is rather short. Longer anesthesia occurs when the tip of a silver nitrate stick is applied to the base of each ulcer to necrotize the exposed nerve endings.

Tetracycline and other antibiotic suspensions reduce the duration and discomfort of the disease. They are swirled in the mouth for several minutes before being spit out or swallowed. Effectiveness is presumably related to their anti-inflammatory properties rather than to their antibiotic effect. Sometimes, topically applied steroids (Kenalog in Orabase, Temovate ointment, and steroid aerosols), intralesionally injected steroids, or even systemically administered steroids will be required.

Herpes simplex viral infectians, on the other hand, generally occur on the exposed lip rather than within the mouth. They appear as shallow erosions rather than as ulcers. Actually, the lesions begin as vesicles, but trauma quickly leads to breakdown of the vesicle roofs. Individual vesicles and erosions are 1 to 3 mm in diameter, but they are usually clustered so tightly that three to eight individual erosions coalesce, forming a single large erosion with a distinctly irregular configuration. The erosions are surprisingly uncomfortable considering how shallow they are. The base of the erosion is red, but there is little perilesional inflammation. Tender lymphadenopathy is sometimes present.

Individual herpetic erosions heal spontaneously in 5 to 10 days without scarring. Most patients with herpes labialis experience recurrent episodes intermittently throughout their lives. Recurrent episodes are triggered by psychologic stress and by physiologic stress such as sunburn, coryza, and fever.

Herpes labialis is caused by Herpesvirus hominis. Approximately 80% of oral lesions are due to type 1 virus; the remainder are due to type II virus. These two types of infection cannot be distinguished clinically.

Miscellaneous causes of oral erosion include erythema multiforme bullosum (Stevens-johnson syndrome), pemphigus, and cicatricial pemphigoid. Finally, painless, single ulcers occur in primary syphilis and squamous cell carcinoma of the mucous membranes.

More than 90% of all cutaneous bacterial infections arc caused by the two gram-positive organisms, Staphylococcus aureus and group A streptococci. Orally administered phenoxymethylpenicillin (Pen-Vee K) in a dosage of 1.0 g/day is the treatment of choice for streptococcal infection. Orally administered oxacillin (Prostaphlin), dicloxacillin (Dynapen, Veracillin), or nafcillin (Unipen) in a dosage of 1.0 gl day is preferred for the treatment of staphylococcal infections. Orally administered erythromycin (E.E.S., Erythrocin, E-Mycin) in a dosage of 1.0 g/day is usually quite effective against both staphylococcal and streptococcal infections. Erythromycin is usually the treatment of choice when the identity of the infecting organism is not known and when patients are allergic to penicillin products. Second-line antibiotics for skin infections include tetracycline derivatives such as minocycline (Minocin), and doxycycline (Vibramycin), and cephalosporins such as cephalexin (Keflex), cephradine (Anspor, Velosef), and cefadroxil.

Recently, several new, oral antibiotics useful in the treatment of skin infections have become available. Ciprofloxacin (Cipro) is an extremely potent agent for the increasingly common methicillin-resistant staphylococcal infections. It is usually administered in a dosage of 500 mg b.i.d., but a dosage of 250 mg b.i.d. may be sufficient for less serious infections. Azithromycin (Zithromax) and clarithromycin (Biaxin) are macrolides somewhat similar in structure to erythromycin. Both are effective in the treatment of skin infections resulting from staphylococcal and streptococcal species, but organisms resistant to erythromycin will be resistant to these two agents also. Both agents require treatment for only 5 to 7 days and therefore increase the likelihood of patient compliance. They also appear to be effective in the treatment of atypical mycobacterial infections of the skin.

Most cutaneous infections such as impetigo, furunculosis, folliculitis, and cellulitis can be treated empirically without incurring the cost of cultures. Cultures should be obtained, however, in situations of recurrent infection, resistant infection, infection occurring in a hospital setting, and infection occurring in immunocompromised individuals. Antibiotics are used rather differently in the treatment of acne.

Getting the right body is not a cakewalk! Wait am not discouraging you! It is just a discussion to let you know that if you want a hard good looking body, you have to work hard and also take care of your diet and supplements. We cannot meet the exact amount of nutritional requirements of the body. In such case supplements come to great rescue. There are different types of supplements which are formulated for different purposes. Protein supplement is one of the important supplements which body builders require. A lot of people who hit the gym want to know if they should take protein supplements for their health. The answer is yes they should take protein supplements if they are into real ironing and pumping of muscles.

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If you look at the distal tip of your fingernail, you will notice that the free edge, where it grows outward beyond the nail bed, is white. This opacification occurs because of the second air-nail interface, which is present on the underside of the nail. In situations where the nail plate is separated more proximally from the nail bed, a similar white or yellow-white opacification occurs. This asymptomatic separation and whitening is known as onycholysis.

Onycholysis is most commonly caused by infection with Candida sp. especially Candida albicans. These candidal infections occur with particular frequency in dishwashers, bartenders, waitresses, health professionals, and others who are regularly involved in wet work. Onycholysis resulting from candidal infection is often, but not always, accompanied by paronychial swelling and inflammation . Onycholysis also occurs in psoriasis and is somewhat less often seen with trauma, hypcrthyroidism, and as a result of photochemical separation in patients taking tetracycline. Bacteria may colonize this blind pocket of onycholysis and add color: Pseudomonas sp. causes a green color, and Proteus sp. causes a brown or black color.

A diagnosis of onycholysis caused by candidiasis is generally made on a clinical basis. KOH preparations are not very helpful in confirming the diagnosis, but positive cultures can usually be obtained from pieces of loose nail that have been clipped away. Therapy requires that all free nail plate be removed so that topically applied preparations such as clotrimazole (Lotrimin) solution can be appropriately applicd. Bandaging of the fingertip following such clipping should be avoided, since the maceration that this induces favors further growth of the yeast.

Sunburn is inflammation of the skin and the tissues just beneath it caused by over­exposure to the ultraviolet rays of the sun. The affected area becomes red, hot, tender and swollen, and in severe cases blisters may form. You are much more likely to become sunburned if you have light skin. In addition, a few people are extra-sensitive to the sun because they have a disease or they are taking a drug that makes them particularly sensitive to the sun.

You can become sunburned without sitting under the blazing sun. Ultraviolet rays will penetrate a hazy atmosphere in which you may feel quite comfortable. Also, if you are on the water or on sand, sun rays may reflect off those surfaces and burn parts of your skin that you think are protected.

Sunburn is a special problem throughout the year in the intense sunlight of the south­eastern and southwestern United States. Vacationers are particularly susceptible, because they may unwisely try to acquire a tan too quickly.

Because cold temperatures do not block ultraviolet rays, and snow reflects them the same way that sand and water do, you can also get a sunburn on a skiing vacation.
What are the risks?

Repeated sunburn, or regular exposure to strong sun over many years, breaks down the elastic tissues in the skin and makes it look prematurely old and wrinkled. In addition, it can cause solar keratoses, which are roughened red patches of skin, to appear on exposed places, especially in fair-skinned people. Solar keratoses and/or long-term exposure to strong sun increase the risk of your getting skin cancer.
What should be done?

Prevent sunburn by not sunbathing, or if you must, sunbathe sensibly. On the first day spend only 20 to 30 minutes in the sun. Increase this by 30 minutes each day until you are beginning to tan, which usually takes four to five days. During this early period, use a remedy such as sunscreen, or sunblock, lotion with an SPF (Sun Protection Factor) rating of 10 to 15. The rating should appear on the label. Try not to sunbathe between 11 :00 am and 3:00 pm, when the sun is strongest. Once your tan is started, use plenty of suntan oil or lotion to soothe your skin.

If you do get a sunburn, adopt the following self-help measures. Protect sunburned skin, even while swimming, b

Malignant melanoma is the most serious of the three types of skin cancer , and Squamous cell carcinoma, previous article. This is because, unlike the other two, malignant melanoma often metastasizes, or spreads, throughout the body. Changes in the underlying skin cells that produce melanin, or skin-coloring pigment, cause a malignant, or life-threatening, tumor to develop. This cancerous lump sometimes develops from pigment cells in a mole present since birth, sometimes in a mole that developed later, and sometimes from pigment cells in what looks like ordinary skin. Many years of exposure to strong sunlight seem to playa part in the development of the disease.
What are The Symptoms of Malignant melanoma?

The most common symptom is that a mole you have had since childhood changes in one of several ways, It may begin to spread, to become patchy, lighter or darker, to develop a black margin that spreads into the surrounding skin, to bleed spontaneously, or to itch. Later it develops a lump and becomes thicker. Another common symptom is the development of a new mole at any time after adolescence. These moles also develop a lump and thicken if the disease is present. Less commonly, a pale patch may develop.
What are The Risks?

This form of skin cancer is not as common as the other two. Melanoma rarely occurs before adolescence. When it does it may occur in a mole present from birth. The tumors appear to be more prevalent among middle­aged or elderly people with light skin who have spent much of their lives in strong sunlight. Because the cancer may spread quickly, early recognition, diagnosis and treatment is essential. Otherwise the outlook is poor.
What Should be Done?

A change in a mole may not signal cancer, but may be due to some minor injury. In the same way, a change in the pigment of an area may be caused by a harmless skin condition. However, if you develop any of the symptoms described, you should take no chances and should see a physician immediately. Even if the physician thinks the mole or paler skin is harmless, he or she may still recommend that you have it removed and examined under a microscope for signs of cancerous cells. If the diagnosis of malignant melanoma is confirmed, you will probably be hospitalized immediately for treatment. The melanoma is cut out along with a wide margin of nearby tissue. In addition, any nearby lymph glands may be removed, because the cancer car: spread through them. A skin graft to cover the area is often done at the same time. In some cases, cytotoxic, or anticancer, drugs are also given .

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Two classes of serologic tests for syphilis (STS) are available: those that use a nonspecific antigen and those that use a specific, treponemal antigen. The two most widely used nonspecific tests are the rapid protein reagin (RPR) test and the Venereal Disease Research Laboratory (VDRL) test. Both are easy to perform and inexpensive. The sensitivity of these two tests for the presence of infectious syphilis is excellent. The specificity is also good, although occasional false-positive reactions are encountered.

The most widely available test using a specific treponemal antigen is the fluorescent treponemal antigen (FTA-Abs) test. This test is technically more difficult to perform, but because of its excellent specificity it is regularly used as a final arbiter in diagnosis of syphilis. The more recently developed, highly specific microhemagglutination assay for antibodies to Treponema pallidum has an advantage in that titers of antibodies are easily determined.

The VDRL and RPR tests generally become positive within 2 weeks after a syphilitic chancre (primary syphilis) has appeared. The ITA-Abs test may be positive slightly earlier. With the exception of the rarely encountered prozone phenomenon, all serologic tests in patients with secondary syphilis will be positive. Patients with signs and symptoms suggestive of infectious syphilis and a positive STS are assumed to have the disease, and treatment can be carried out on this basis. Once infectious syphilis has been treated, quantitative STS are periodically obtained. The titer gradually drops, and by the end of 2 years, assuming no reinfection, all the tests will become negative.

A positive RPR or VDRL is sometimes found in the absence of clinical evidence for syphilis. In such instances, the FTA-Abs test should be performed. If the FTA-Abs test is negative, the patient most likely has a false-positive serologic reaction. These false-positive reactions most commonly occur in the presence of collagen-vascular disease, but they may also be found in patients with malaria, leprosy, and various parasitic or viral diseases. A very few instances of false-positive FTA-Abs tests have been reported in the presence of lupus erythematosus, dysproteinemias, and malignancy, but for practical purposes the presence of a positive FTA-Abs test is tantamount to a diagnosis of present or past syphilis.

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