Torn Earlobe Surgery
Torn earlobe and enlarged pierced earlobe canals are a common consequence of wearing heavy earrings for a prolonged period of time as well as other factors such as trauma, heavy earrings, infection, low placement of piercing, pressure necrosis, etc. It occurs most easily in thin ear lobules. Drooping or easily torn earlobes may also be secondary to a congenital defect or trauma. Here, a torn earlobe is reconstructed by primary repair.
Torn earlobe and enlarged pierced earlobe canals are a common consequence of wearing heavy earrings for a prolonged period of time as well as other factors such as trauma, heavy earrings, infection, low placement of piercing, pressure necrosis, etc. It occurs most easily in thin ear lobules. Drooping or easily torn earlobes may also be secondary to a congenital defect or trauma. Shown here is a female with a large tear defect of earlobe at the site of heavy earring.
Hypertrophic scars and keloids are both characterized by excess fibrous tissue at a site of injury in the skin. Hypertrophic scars are confined to the original wound site, whereas keloids, by contrast, extend beyond the original wound site. Both are common and frequently disturb patients greatly, both as an unsightly scar as well as a reminder of previous trauma or surgery. Acne scars result from the loss of underlying collagen and elastic tissue from dermal inflammation associated with acne, particularly cystic acne. Acne scars are also very common and a source of distress to the patient, both for their obvious appearance on the face as well as a reminder of previous acne. Shown here is a dermal injection of a hypertrophic scar that resulted from a shave biopsy.
Stretch Marks: Striae Rubra and Alba
Striae distensae, more commonly known as “stretch marks,” are atrophic linear bands of skin that appear after certain precipitating factors such as pregnancy, steroid use, and dramatic changes in weight or muscle mass. At presentation, they feature a purple or pink color (striae rubra) that fades to a paler white (striae alba) over time. They are most common in adult women. Numerous striae rubra and alba on the abdomen of a young woman.
Stretch Marks: White Striae, Axilla
Striae distensae, more commonly known as “stretch marks,” are atrophic linear bands of skin that appear after certain precipitating factors such as pregnancy, steroid use, and dramatic changes in weight or muscle mass. At presentation, they feature a purple or pink color (striae rubra) that fades to a paler white (striae alba) over time. They are most common in adult women. White striae, axilla. Prominent atrophy, textural changes, and depigmentation are observed.
HIV Lipodystrophy Treatment
HIV lipodystrophy describes a constellation of changes in subcutaneous and visceral fat distribution in patients on antiretroviral therapy. In distinction to “lipoatrophy” (which describes local fat loss), lipodystrophy refers to both the accumulation of fat as well as the loss of fat in other areas. In HIV lipostrophy, the findings include subcutaneous fat loss in the malar and buccal fat pads, ie, facial lipoatrophy, as well as on the extremities. It also features fat accumulation on the dorsocervical fat pad, ie, buffalo hump (shown here), breast, and intra-abdominal cavity. Its characteristic appearance is significant, in that it reduces patient compliance with antiretroviral therapy and deprives patients of HIV status privacy, particularly in communities where HIV rates are high. This disorder is also associated with a host of metabolic disorders with long-term impact on health including hyperglycemia, hyperlipidemia, and hypertriglyceridemia. Treatments vary according to the clinical findings. This is substantial reduction in the size of a buffalo hump after liposuction procedure.
HIV lipodystrophy describes a constellation of changes in subcutaneous and visceral fat distribution in patients on antiretroviral therapy. In distinction to “lipoatrophy” (which describes local fat loss), lipodystrophy refers to both the accumulation of fat as well as the loss of fat in other areas. In HIV lipostrophy, the findings include subcutaneous fat loss in the malar and buccal fat pads, ie, facial lipoatrophy, as well as on the extremities. It also features fat accumulation on the dorsocervical fat pad, ie, buffalo hump (shown here), breast, and intra-abdominal cavity. Its characteristic appearance is significant, in that it reduces patient compliance with antiretroviral therapy and deprives patients of HIV status privacy, particularly in communities where HIV rates are high. This disorder is also associated with a host of metabolic disorders with long-term impact on health including hyperglycemia, hyperlipidemia, and hypertriglyceridemia. Treatments vary according to the clinical findings. Shown here is a "buffalo hump” in dorsocervical back of HIV-infected male.
Gynecomastia is enlargement of the gland tissue of the male breast. During infancy, puberty, and in middle-aged to older men, gynecomastia can be common. Gynecomastia must be distinguished from pseudogynecomastia or lipomastia, which refers to the presence of fat deposits in the breast area of obese men. True gynecomastia results from growth of the glandular, or breast tissue, which is present in very small amounts in men. Gynecomastia is the most common reason for medical evaluation of the male breast. Characteristic appearance of gynecomastia in a middle-aged male after treatment.
Gynecomastia is enlargement of the gland tissue of the male breast. During infancy, puberty, and in middle-aged to older men, gynecomastia can be common. Gynecomastia must be distinguished from pseudogynecomastia or lipomastia, which refers to the presence of fat deposits in the breast area of obese men. True gynecomastia results from growth of the glandular, or breast tissue, which is present in very small amounts in men. Gynecomastia is the most common reason for medical evaluation of the male breast. Characteristic appearance of gynecomastia in a middle-aged male.
Low Blood Pressure (Hypotension)
Low blood pressure (hypotension) is pressure so low it causes symptoms or signs due to the low flow of blood through the arteries and veins. When the flow of blood is too low to deliver enough oxygen and nutrients to vital organs such as the brain, heart, and kidney, the organs do not function normally and may be temporarily or permanently damaged. An individual's blood pressure is expressed as systolic/diastolic blood pressure, for example, 120/80.The systolic blood pressure (the top number) represents the pressure in the arteries as the muscle of the heart contracts and pumps blood into them. The diastolic blood pressure (the bottom number) represents the pressure in the arteries as the muscle of the heart relaxes following its contraction. The range of systolic blood pressure for most healthy adults falls between 90 and 120 millimeters of mercury (mm Hg). Normal diastolic blood pressure ranges between 60 and 80 mm Hg. Current guidelines define normal blood pressure range as lower than 120/80.
Pancreatic Cancer Tumor
This is a gross section of a malignant tumor of the pancreas resected from the pancreatic body and tail.
An abdominal CT scan shows a small, vaguely seen 2-cm pancreatic adenocarcinoma (mass) causing obstruction of both the common bile duct (cbd) and pancreatic duct (pd).
A commonly injured area of the body is the foot, more specifically, the toes (phalanxes). This often causes one or more of the toe bones to break (fracture). Trauma or injury such as stubbing the toe (jammed toe) or dropping a heavy object on the toe may cause a broken toe. The location of the toes (in the front part of the feet) make them the most likely part of the foot to be injured. Prolonged repetitive movements, as in certain sports activities, can cause a type of broken type of broken toe called a stress or hairline fracture. Pain, swelling, or stiffness will occur in a broken toe following injury. It may be difficult to walk due to the pain, especially with a broken big toe. This is because the big toe bears much of the weight of the body when walking or pivoting. A broken little toe may be painful but usually does not limit the ability to walk. Other symptoms include bruising of the skin around the toe and a bent or deformed appearance of the toe if the broken bone is out of place.
Hip fractures typically occur as a result of a fall. With osteoporosis, hip fractures can occur as a result of trivial accidents. Hip fractures may also be difficult to heal after surgical repair because of poor bone quality.
A fracture that occurs during the course of normal activity is called a minimal trauma fracture or stress fracture. For example, some patients with osteoporosis develop stress fractures of the feet while walking or stepping off a curb.
For kidney stones that do not pass on their own, a procedure called lithotripsy is often used. In this procedure, shock waves are used to break up a large stone into smaller pieces that can then pass through the urinary system. Surgical techniques have also been developed to remove kidney stones. This may be done through a small incision in the skin (percutaneous nephrolithotomy) or through an instrument known as a ureteroscope that is passed through the urethra and bladder up into the ureter.
Kidney Stone Diagnosis
The diagnosis of kidney stones is suspected by the typical pattern of symptoms when other possible causes of the abdominal or flank pain are excluded. Imaging tests are usually done to confirm the diagnosis. A helical CT scan without contrast material is the most common test to detect stones or obstruction within the urinary tract. In pregnant women or those who should avoid radiation exposure, an ultrasound examination may be done to help establish the diagnosis.
Kidney Stone Crystal
Kidney stones are made of salts and minerals in the urine that stick together, creating small "pebbles" formed within the kidney or urinary tract. They can be as small as grains of sand or as large as golf balls. Kidney stones are a common cause of blood in the urine and often severe pain in the abdomen, flank, or groin. One in every 20 people develops a kidney stone at some point in their life.
Diverticula can be seen via barium x-ray (barium enema). The diverticula are seen as barium filled pouches protruding from the colon wall. Direct visualization of the colon can be achieved through flexible sigmoidoscopy or colonoscopy. In patients suspected of having a diverticular abscess causing persistent pain and fever, ultrasound and CT scan of the abdomen and pelvis can be done to detect collections of pus.
Lamellar Ichthyosis Arms
Lamellar ichthyosis (LI) often presents at birth with the infant encased in a collodion–like membrane (collodion baby) that is soon shed, with subsequent formation of large, coarse scales involving the entire body, including all flexural areas as well as the palms and soles. During childhood and adulthood, the skin is encased in this platelike scale, which causes significant cosmetic disfigurement.Tesselated (tile-like) hyperkeratosis gives the appearance of reptilian scales on the arms around the elbows. The entire body was involved and there was ectropium.
Pre-Op Norwood IV–V
Pre-op Norwood IV–V.
Jessner Facial Peel
Solid white color immediately following a Jessner/35% TCA peel.
Erythema Following Fraxel Laser Treatment
Mild sunburn-like erythema immediately following Fraxel laser treatment with 6–8 mJ, 250 MTZ/cm2, eight passes. This erythema may persist for 3–7 days.
Tuberous Sclerosis (Periungual Fibroma)
Tuberous sclerosis, periungual fibroma. Flesh-colored periungual papule appearing in adolescence in an individual with tuberous sclerosis.
Tuberous Sclerosis (Fibrous Plaque)
Tuberous sclerosis, fibrous plaque. Raised skin-colored plaque on the forehead of a child representing a connective tissue nevus.
Tuberous Sclerosis (Adenoma Sebaceum)
Tuberous sclerosis, adenoma sebaceum. Small erythematous papules on the nose and cheeks of a child representing angiofibromata.
Tattoo with Q-Switched Laser Treatment
Tissue whitening after treatment with the 532 nm frequency doubled Q-switched Nd:YAG. Tissue whitening is the appropriate endpoint when treating tattoos with Q-switched lasers.
Hyperhidrosis: Starch-Iodine Test
Hyperhidrosis, or excessive sweating, is a common disorder that produces a lot of unhappiness. An estimated 2%-3% of Americans suffer from excessive sweating of the underarms (axillary hyperhidrosis) or of the palms and soles of the feet (palmoplantar hyperhidrosis). Underarm problems tend to start around puberty, while palm and sole sweating may begin earlier, often during childhood. Untreated, these problems may continue throughout life. Pictured is an example of the starch-iodine test in the left axilla. Mote the prominent dark blue-black discoloration at sites of hyperhidrosis.
Tattoo with Laser Treatment
Improvement after six treatments with 1064 nm Q-switched Nd:YAG laser. While improvement is not complete, the cosmetic result is far superior to that of dermabrasion.
Tattoo with Dermabrasion
Left shoulder tattoo with inferior scar resulting from prior treatment with dermabrasion.
Tattoo Allergic Reaction
Exuberant blistering reaction in red tattoo pigment. The reaction occurred with each treatment and predictably resolved completely within a few days with routine topical skin care.
Henna Tattoo Reactions
The Food and Drug Administration has received complaints from people who have received products marketed as henna temporary tattoos, especially so-called "black henna," at places such as salons and kiosks at beaches and fairs. There have been reports of allergic reactions, skin irritations, infections, and even scarring. "Black henna" may contain the added "coal tar" color, p-phenylenediamine, also known as PPD, which can cause allergic reactions in some people. Henna itself is made from a plant and typically produces a brown, orange-brown, or reddish-brown tint. Other ingredients must be added to produce other colors. Even brown shades of products marketed as henna may contain other ingredients intended to make them darker or make the stain last longer. While the FDA has approved henna for coloring hair, and PPD is used in cosmetics as a hair dye, neither of these color additives is approved for direct application to the skin.
Sucking blister. The oval blister pictured here was present at birth and is a result of normal sucking behavior in utero. Sucking blisters are fairly common and are usually located on the forearm, wrist, or hand. They are most often solitary and involve only one upper extremity. However, lesions involving both hands, or even involving a foot, are sometimes seen. The sucking blister resolves spontaneously as soon as bottle or breast is offered as a dietary substitute.
Serum sickness. Urticarial, coalescing plaques on the lower legs of an adolescent with serum sickness.
Rothmund-Thomson syndrome. Erythema and poikloderma on the cheek of a child.
Panniculitis from Cold
Panniculitis from cold. Local exposure to cold leads to the formation of ice crystals within cells. Injury to cell contents occurs during both cooling and thawing.
Juvenile xanthogranuloma. This is a common and completely benign cutaneous nodule. Typically, a juvenile xanthogranuloma is firm and dome-shaped. At first, the lesion is reddish, but develops a fairly typical orangebrown hue over time. Most juvenile xanthogranulomas are located on the head or neck, as pictured in these two infants, but the lesions sometimes occur on the trunk or extremities. They may be present at birth, but most develop during the first year of life. Juvenile xanthogranuloma is not associated with abnormalities in serum cholesterol or triglycerides, and the individual lesions undergo spontaneous involution, usually over a period of 1–2 years. A diagnostic biopsy analysis is sometimes needed, but surgical intervention beyond this is certainly not required. Multiple juvenile xanthogranulomas on the skin may be accompanied by intraocular lesions. For this reason, the physician must pay careful attention to the examination of the eyes.
Fordyce's condition. The face abounds in sebaceous glands. Normally their distribution stops sharply at the junction of the skin and vermilion of the lips. Commonly, however, ectopic sebaceous glands are found within the lips under the vermilion and sometimes within the oral mucosa of the lips and even in the buccal mucosa. The condition is harmless and may have been present long before the patient or parents became aware of it. No treatment is required or available.
Erythema Ab Igne
Erythema ab igne. This disorder results from prolonged and repeated exposure to infrared radiation. Historically, and before the advent of central heating, erythema ab igne was seen on the legs of individuals who sat or stood in front of heating devices. In this era, more common causes are hot water bottles and heating pads. The patient used a heating pad for relief from menstrual cramps.
Auricular tags. Supernumerary vestiges of the external structures of ears are common. Accessory tragi and auricular tags with or without communication to deeper structures may be deceptively simple. Those in Fig. 27-13 are probably harmless nubs of tissue that could be sliced off and their bases delicately electrodesiccated. Should that be all there is, the cosmetic result would be fine. Sometimes, however, such structures bear cartilage within them and have communication to uncertain depths toward the more important structures in the external canal or middle ear.
Scurvy. Perifollicular hemorrhage on the leg. The follicles are often plugged by keratin (perifollicular hyperkeratosis). This eruption occurred in a 46-year-old alcoholic, homeless male, who also had bleeding gums and loose teeth.
A hammertoe is a toe that is bent because of a weakened muscle. The weakened muscle makes the tendons (tissues that connect muscles to bone) shorter, causing the toes to curl under the feet. Hammertoes can run in families. They can also be caused by shoes that are too short. Hammertoes can cause problems with walking and can lead to other foot problems, such as blisters, calluses, and sores. Splinting and corrective footwear can help in treating hammertoes. In severe cases, surgery to straighten the toe may be necessary.
Wearing shoes that do not fit properly or wearing shoes without socks can cause blisters, which can become infected. When treating blisters, it's important not to "pop" them. The skin covering the blister helps protect it from infection. Use an antibacterial cream and clean, soft bandages to help protect the skin and prevent infection.
A corn is a build-up of hard skin near a bony area of a toe or between toes. Corns may be the result of pressure from shoes that rub against the toes or cause friction between the toes. Proper care is necessary if you have a corn.
Corns and Calluses
Corns: Corns generally occur on the tops and sides of the toes. A hard corn is a small patch of thickened, dead skin with a packed center. A soft corn has a much thinner surface and usually occurs between the 4th and 5th toes. A seed corn is a tiny, discrete callous that can be very tender if it's on a weight-bearing part of the foot. Seed corns tend to occur on the bottom of the feet, and some doctors believe this condition is caused by plugged sweat ducts. Calluses: Calluses can develop on hands, feet, or anywhere there is repeated friction -- even on a violinist's chin. Like corns, calluses have several variants. The common callus usually occurs when there's been a lot of rubbing against the hands or feet. A plantar callus is found on the bottom of the foot.
Bunion: A bunion is a localized painful swelling at the base of the big toe (the great toe). The joint is enlarged (due to new bone formation) and the toe is often misaligned. It is frequently associated with inflammation. It can be related to inflammation of the nearby bursa (bursitis) or degenerative joint disease (osteoarthritis). Bunions most commonly affect women. Ballet dancers are prime candidates for bunions. Tight-fitting shoes and high heels can contribute to bunions. The treatment of bunions includes rest, a change in shoes, foot supports, medications or surgery.
Graves disease: Generalized diffuse overactivity ("toxicity") of the entire thyroid gland which becomes enlarged into a goiter. Graves disease is the most common cause of hyperthyroidism. There are three components to Graves disease: Hyperthyroidism (the presence of too much thyroid hormone), Ophthalmopathy specifically involving exophthalmos (protrusion of the eyeballs), Dermopathy with skin lesions. The ophthalmopathy can cause sensitivity to light and a feeling of "sand in the eyes." With further protrusion of the eyes, double vision and vision loss may occur. The ophthalmopathy tends to worsen with smoking. The dermopathy of Graves disease is a rare, painless, reddish lumpy skin rash that of Graves disease is an autoimmune process. It is caused by thyroid-stimulating antibodies which bind to and activate the thyrotropin receptor on thyroid cells. Graves disease can run in families. The rate of concordance for Graves disease is about 20% among monozygotic (identical) twins, and the rate is much lower among dizygotic (nonidentical) twins, indicating that genes make only a moderate contribution to the susceptibility to Graves disease. No single gene is known to cause the disease or to be necessary for its development. There are well-established associations with certain HLA types. Linkage analysis has identified gene loci on chromosomes 14q31, 20q11.2, and Xq21 that are associated with susceptibility to Graves disease. Factors that can trigger the onset of Graves disease include stress, smoking, radiation to the neck, medications (such as interleukin-2 and interferon-alpha), and infectious organisms such as viruses. The diagnosis of Graves disease is made by a characteristic thyroid scan (showing diffusely increase uptake), the characteristic triad of ophthalmopathy, dermopathy, and hyperthyroidism, or blood testing for TSI (thyroid stimulating immunoglobulin) the level of which is abnormally high. Current treatments for the hyperthyroidism of Graves disease consist of antithyroid drugs, radioactive iodine, and surgery. There is regional variation in which of these measures tends to be used -- for example, radioactive iodine is favored in North America and antithyroid drugs nearly everywhere else. The surgery, subtotal thyroidectomy, is designed to remove the majority of the overactive thyroid gland. The disease is named for Robert Graves who in 1835 first identified the association of goiter, palpitations, and exophthalmos. Graves disease is also commonly known as diffuse toxic goiter.
Keloid: A scar that doesn't know when to stop. When the skin is injured, cells grow back to fill in the gap. Somehow, they normally "know" when the scar tissue is level with the skin, at which point the cells stop multiplying. When the cells keep on reproducing, the result is a what is called a overgrown (hypertrophic) scar or a keloid -- a tough heaped-up scar that rises quite abruptly above the rest of the skin. It is irregularly shaped and tends to enlarge progressively. In other words, keloids are due to an excessive response to trauma such as a cut to the skin. In creating a normal scar, connective tissue in the skin is repaired by the formation of collagen. This occurs in the dermis (the layer of skin just below the epidermis, the outer layer of skin). Keloids arise when there is too much collagen formed in the dermis during the repair of connective tissue. To develop keloids, a person must be susceptible to keloid formation. This susceptibility is clearly genetic. For instance, keloids are known to have occurred in 5 successive generations within a single family. People of African or Asian descent are more likely to get keloids than people with lighter skin. These peoples tend to have keloid susceptibility genes. This tendency to form keloids is important when someone of African or Asian descent is considering elective plastic surgery; the surgery can cause more trouble than it cures. The dense tumorlike scar was called a "keloid" ("cheloïde" in French) in 1835 by the dermatologist Jean-Louis Albert. However, the word "keloid" was already in use in France as early as 1817, according to the Nouveau Petit Robert Dictionaire. The origin of the term "keloid" is not entirely certain. The Petit Robert attributes it to the Greek word "chele" meaning in French "pince" and in English "a talon, claw, or hoof." Other authorities such as Dorland's Illustrated Medical Dictionary attribute "keloid" to the Greek " kelis", "blemish" or to the Greek "kele", "a rupture." To learn more, see Keloid.
Wrinkles: Wrinkles are a by-product of the aging process. With age, skin cells divide more slowly, and the inner layer, called the dermis, begins to thin. The network of elastin (the protein which causes skin to stretch) and collagen fibers (the major structural proteins in the skin), which support the outer layer, loosen and unravel, causing depressions on the surface. With aging, skin also loses its elasticity, is less able to retain moisture, oil-secreting glands are less efficient and the skin is slower to heal. All of these contribute to the development of wrinkles.
A milium is a white papule, 1–2 mm in size, composed of laminated, keratinous material and situated as a solid cyst in a pilosebaceous follicle. Milia are fairly common on the brow, glabella, and nose in newborn infants and in such infants tend to disappear quickly and spontaneously. There may be few or many, and they may develop later in infancy, in childhood, and in adolescence. In older children and adolescents, they tend to 6 Color Atlas of Pediatric Dermatology persist, may precede acne or be associated with incipient acne and commonly develop on or around the eyelids. Milia may be ablated, if desirable, by delicate incision and expression of the keratinous content. Lesions so treated do not recur, but if new lesions appear, they have to be treated in the same way. The operation is trivial and uncomplicated. There are no preventive measures.
White Bumps (Milia)
Tiny white spots very often appear on a newborn's face and gums during the first week. The spots are called milia (say "MIL-ee-uh"). Sometimes they also appear on the roof of the mouth (palate), where they are called Epstein pearls. Milia go away by themselves in a few weeks and aren't harmful. In the first few months of a baby's life, any rash associated with other symptoms (such as fever, poor feeding, lethargy, cough) needs to be evaluated by a pediatrician as soon as possible.
Acanthosis nigricans: A skin condition characterized by dark thickened velvety patches, especially in the folds of skin in the axilla (armpit), groin and back of the neck. The condition is complex. It can occur with endocrine diseases such as Cushing disease, tumors of the pituitary, and diabetes mellitus. It is common in people who have insulin resistance -- whose body is not responding correctly to the insulin that they make in their pancreas. Acanthosis nigricans also occurs with underlying malignancies (especially carcinomas of the vicera), administration of certain drugs, and as a genetic disorder inherited in an autosomal dominant manner.
Granuloma annulare:The definition of granuloma annulare in one of the standard print medical dictionaries begins: "a benign, usually self-limited granulomatous disease of unknown etiology, chiefly involving the dermis." Translation: This condition usually clears up by itself (it is "usually self-limited); it is not malignant (it is "benign"); we don't have a clue as to what causes it (it is "of unknown etiology"); it affects the layer (the "dermis") of the skin just below the outside layer (the epidermis). A granuloma is a localized nodular inflammation which has a typical pattern when the involved tissue examined under a microscope. Annulare comes from the Latin word "anus" meaning ring. Granuloma annulare is thus a ring-like granuloma in the skin. Granuloma annulare tends to occur in children, predominantly girls. We recently heard from a viewer who wrote: "I was told my daughter has granuloma alanarra. She has a raised spiral inflammation on her ankle with a clear center. It has increased in size by 3 inches (7-8 cm) in the past year. My doctor told us that it would clear on its own. Is this true? Is there another name I should look under?" There is only one name for this condition to the best of our knowledge -- granuloma annulare -- and that is the name to look under. Granuloma annulare looks very much as this viewer has described it in his/her daughter.
Spider Veins After Sclerotherapy Treatment
Spider veins. Marked resolution of the spider veins after sclerotherapy treatment.
Spider veins: A group of widened veins that can be seen through the surface of the skin. Their wheel-and- spoke shape resembles a spider. Also known as spider telangiectasia.
X-linked ichthyosis. More pronounced fish-scale pattern on the legs of a child with X-linked ichthyosis. The diffuse brown scale gives the child a "dirty" appearance.
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