Color Atlas of Dermatology

421 Pages·2012·170.16 MB·English

by  Martin Rocken, Martin Schaller, Elke Sattler, Walter Burgdorf, Martin Röcken

Martin Rocken
Martin Schaller
Elke Sattler
Walter Burgdorf
' Thieme
I
Thieme

Color Atlas of Dermatology
Martin Rocken, MD
Professor and Chairman
Department of Dermatology
Tiibingen University
Tiibingen. Germany
Martin Schaller, MD
Professor
Department of Dermatology
Tiibingen University
Tiibingen, Germany
Elke Sattler, MD
Staff Physician
Department of Dermatology and Allergology
Ludwig Maximilian University
Munich, Germany
Walter Burgdorf, MD
Thtzing, Germany
Former Professor and Chairman
Department of Dermatology
University of New Mexico
Albuquerque
New Mexico, USA
With 189 color plates by Professor juergen Wirth
Thieme
Stuttgart · New York
Ubrary of Congress Catuloging-in-PIIblicalion lmportaDt note: Medicine is an ever-changing
Data science undergoing continual development. Re
search and clinical experience are continually
lllschenatlas Dennatologie. English. expanding our knowledge, in particular our
Color atlas of dennatology I Martin Roclcen _ [e t knowledge of proper treatment and drug ther
a.l.] ; with color plalrs by jue~n Wirth; [trans apy. Insofar as this book mentions any dosage or
lator, Walter Burgdorf]. application, readers may rest assured that the
p.;an. authors, editors, and publishers have made f!tl
ISBN 978-3-13-132341-5 (pbk.) ery effort to ensure that such referen[Es are in
L Rocken, Martin. II. Title. accordance with the state of knowledge at the
[DNLM: 1. Skin Diseases--diagnosis-Atlases. time ofpruductlon of the book.
2. Skin Diseases--therapy--Atlases. WB 17] Nevertheless, this does not involve, imply, or ex
press any g\lill'antee or responsibility on the part
616.50022'3--dc23 of the publishers in respect to any do~ in
2011036883 structions and forms of applications stated in
the book. Every user is~ 10 eJWDine
This book is an authorized translation of the c:arefalJ,y the manufacturers' leaflets accompa
German edition published and copyrighted nying each drug and to check, if necessary in
2010 by Georg Thieme Verlag, Stuttgart Title of consultation with a physician or specialist,
the Gennan edition: Taschenatlas Dennatologie. whether the do~ schedules mentioned
Grundl~n - Diagnostik -Klinik. therein or the c:ontraindications stated by the
manufacturers differ from the statements made
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ticularly important with drugs that are either
lfanslator: Walter Burgdorf; Tutzing, Gennany rarely used or have been newly released on the
marla!t. Every do~ schedule or every form of
mustrator: Professor juergen Wirth, Dreieich application used is entirely at the user's own
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Prefaa many of the common disorders-such as pso
riasis and atopic dermatitis-so that one can
No organ is as exposed III the environment as not ignore both their medical and economic
the skin. It is the interface between individuals impact. Our abilities to treat autoimmune dis
and their surroundings. The skin protects us eases, such as lupus erythemaiiisus, have also
against a variety of potentially harmful greatly increased, once again challenging der
agents-ultraviolet irradiation, thermal dam matologists to work effectively with other spe
age, mechanical stress, pathogenic microbes, cialties to provide maximum care for this
and a variety of small and large molecules in group of patients.
cluding allergens. The skin also plays an im A decade ago no one expected an increase in
portant role in maintaining a stable internal severe infectious diseases of the skin. The anti
environment, regulating body temperature biotic armamentarium was strong and all were
and water content. optimistic. Instead we have been confronted
Disturbances in the function of the skin can with increasing antibiotic resistance, dramatic
produce a broad spectrum of diseases, which infections, and even diseases where we are
often extend beyond the skin III have systemic threatened with running out of possible thera
effects. No other organ presents such a large peutic choices. Sexually transmitted diseases
variety of diseases, including a number which have made a modest resurgence, and patients
are potentially life-threatening. Skin diseases with either HIV/AIDS or iatrogenic immuno
have the potential III interfere with body lan suppression present with a bewildering array
guage-with how we see ourselves and haw of unusual and generally severe viral, bacterial,
others react III us. Thus a number of common and fungal infections.
diseases such as eczema and psoriasis. which The skin also serves as a window on many
do not cause permanent damage and are not systemic diseases. One can often recognize un
often fatal, still disrupt the lives of millions of derlying malignancies, metabolic diseases, and
affected people. inflammatory disorders with obvious systemic
Skin diseases are very common and thus significance based purely on the skin examina
place considerable demands on health care tion. Dermatology thus interacts with almost
systems. The problem is exacerbated by the every other discipline, both at a diagnostic and
fact that the incidence of several common skin therapeutic level.
diseases and tumors is on the increase. Both In our view, dermatology is marked by three
the aging population and environmental fac important characteristics. Firstly, one must be
tors play a role in these increases, but in many able to accurately describe skin findings; this
instances. we do not know what is responsible. coupled with a good visual memory and hard
The most deadly skin tumor is the mela study makes it possible for the dermatologist
noma. Its incidence has doubled every decade to generally make a rapid diagnosis-often to
for the past half-century; exposure III ultravio the amazement of colleagues or patients. Sec
let irradiation seems III be the most important ondly, a profound appreciation of cutaneous
faciiir. Melanoma is about III become the biology and haw it relates to disease is re
fourth most common metastatic tumor among quired to plan appropriate topical and sys
fair-skinned individuals. Basal cell carcinoma temic therapy; in addition, considerable tech
is already the most common human malig nical skill is also required as dermatology is
nancy, with an incidence of> 1 :140. The prob both a medical and a surgical specialty. Thirdly,
lems with skin cancers are made worse by the the dermatologist must be a caring physician, a
widespread use of immunosuppressive agents true friend to the patient. In addition to ensur
to treat autoimmune diseases and make organ ing that the best possible therapy is offered. he
transplantation possible. In addition, patients or she must be aware oft he many psydlosocial
with HIV/AIDS and immunodeficiency are also problems that accompany common skin dis
at greater risk for many tumors. eases, lila: acne, atopic dermatitis, and psoria
Dermatologists have at their disposal a sis, and help the patients and their families
much wider spectrum of systemic medications address these issues. The rewarding feature is
than they did a generation ago. They must be that although in some instances one must be
come skilled in using all the new medications. satisfied with supportive or even palliative ap
In addition, other specialties are also benefit proaches. in many instances therapeutic mea
ting from advancements in the pharmaceutical sures can be dramatically successful or even
industry, so that physicians and patients are curative.
increasingly confronted with skin reactions to The dassic position of dermatology in medi
new and unusual drugs. The new and expen cine, coupled with the many advances of the
sive medications are particularly relevant for last 20 years in understanding pathogenesis,
PrefiiDI!
facilitating diagnosis, and improving therapy, prepare texts in both languages. Walter Burg
have encouraged us to use the classic Thieme dorf. a native English speaker, was responsible
"flexibook" format to present our specialty. for the final English texts. Ms. Angelika-Marie
The concept of brief texts facing informative Findgntt and Ms. Annie Hollins from Thieme
and detailed color plates is an effective way to Publishers managed the English edition of the
give the reader a dear and relevant introduc book.
tion to dermatology. This book is in no way The photographers in our Tiibingen clinic,
designed to rompete with established large Mr. Oliver Hallmaier and Ms. Marianne Kelch
textbooks designed for the specialists. Instead were extremely helpful and provided almost
our goal is to give students an almost painless all the photographs; other sources are listed on
introduction to dermatology over a short pe page 392. Professor juergen Wirth provided all
riod of time, making not only the study of the the diagrams, helping convert our medical
skin, but all medical studies, more rewarding knowledgl! into instructive visual material.
and pleasurable. We also hope that young der Dr. Gisela Metzler provided all the photomi
matology residents and physicians in training crographs while Professor Helmut Breuninger
in other specialties will find this book useful as helped with the pages on operative dermatol
a quick refresher, hopefully helpful in common ogy.
clinical situations. The specialist may appreci We hope that every reader enjoys this book
ate our work as a reminder of the intricate re and learns from it In addition, if it helps our
lationship between scientific advances and colleagues to make the correct dermatologic
clinical dermatology. diagnoses and provide helpful therapy, then in
Every book reflects the efforts of many indi the end our patients will benefit Without
viduals. We would like to thank the many them, this book would not have been possible.
friends and colleagues who have helped us so
generously in preparing this book.
We would especially like to thank Ms. Tiibingen, Munich. and 1\Jtzing
Susanne Schimmer who skillfully coordinated
our efforts to produce the final texts and plates Marlin Rllcken
for the German edition. About one-third of the Marlin SChaller
book was originally written in English, the rest ElkeSatder
in German, and the authors worlced together to Walter Burgdorf
Contents
I Basic Principles
Introduction •••••••••••••••••• 2 5.1 Interaction between Innate and
1.1 Dermatology and the Skin •••••• z Spl!dfic Immunity ••••••••••••• 20
A. Mechanical Barriers •••..••...••.. 20
A. Dermatology .................... 2
B. Innate Immunity ................ 20
cB.. !F'Urenqcutieonncsy o off t Shkei nS kDinis. e.a.s.e.s. .............. 22 c. Specific Immunity ............... 20
5.2 Orgilns of the Immune System ••• 22
2 Embryology and Anatomy •••••• 4 A. Orgiins of the Immune System .... 22
2.1 Embryology and the Eplclennls •• 4 5.3 Cells of the Immune System:
A. Embryology ..................... 4 Overview .................... 24
B. The Epidermis ................... 4 A. Development of Immune Cells .... 24
c. The Basement Membrane Zone ... 4 B. Antigen-presenting Cells ......... 24
c. Granulocytes and Mast Cells ...... 24
2.2 Adnexal structures •••••••••••• 6
D. Natural Killer Cells ............... 24
A. The Adnexal Glands .••..••••..••• 6
B. Temperature Control. •..••••..••• 6 5.4 TCells ....................... 26
A. T-cell Development and Function . 26
2.3 TheDerml1 ................... I
B. Interaction between Antigen-
A. TheDermis. ..................... 8
presenting Cells and T Cells ...••.. 26
B. Extracellular Matrix Components . 8
5.5 T-ee!! Differentiation: T.,, and
ZA The Hair, Nalls.
Regulatory T Cells ............. 28
and Subad:aneous Fat •••••••••• 10
A. Tm, and Regulatory T Cells ••..•••. 28
A. Hair Development and Structure .. 10
B. Tm,Cells ........................ 28
cB.. TyYhpee Hs aoifr H cyacirl e. ...................................... 1100 c. RegulatoryT Cells ................ 28
D. Nail Development and Structure .. 12 5.6 BCells ....................... 30
E. Subcutaneous Fat ................ 12 A. Development and Function
ofBCells ........................ 30
3 Biochemistry ................. 14
5.7 Important Mediators of the
3.1 !Cet'atln ...................... 14 Immune System ............... 32
A. Keratinization ................... 14 A. Cytokines ....................... 32
B. Structural Correlates of the B. Chemokines ..................... 32
Epidermis ....................... 14 c. Surface Molecules ............... 32
c. Patterns of Keratinization ........ 14
5.8 lntolennce Reactions •••••••••• 34
3.2 Melanin ..................... 16 A. Immediate Reaction (yYpe I) ...... 34
A. Melanocytes. .................... 16 B. Cytotoxic Reaction ('IYpe D) ....... 34
B. Melanogenesis. .................. 16 c. Immune-complex Reaction
c. Defects in Melanocytes ..••••..••. 16 ('IYpeiii) ........................ 34
D. Skin Color and TYPe .............. 16 D. Delayed Reaction ('IYpe IV) ....... 34
E. Approach to Pigmented Lesions ••. 16
5.9 Type I Reaction:
Immediate Hypersensitivity ••••• 36
4 Physiology ................... 11
A. IgE Production ................... 36
4..1 cutaneous Sensation ••••••••••• 18 B. Elfector Mechanisms:
A. Cutaneous Innervation ..••....••. 18 Immediate Phase ................ 36
B. The Neuronal Basis of Pruritus .••. 18 c. Elfector Mechanisms: Late Phase,
c. Sympathetic Nerves .••..••....••. 18 Persistent Inflammation .......... 36
5.10 Type II and Type Ill Reactions •••• 31
5 Immunology ................. 20 A. TYPe II Reaction (Immunoglobulin-
mediated Cytotoxicity) ..•••..•••. 38
B. TYPe ID Reaction (Immune-complex
Reaction). ....................... 38
Contents
5.11 Type IV !miction (Delayed-type 6 Genetics ••••••••••••••••••••• 44
Hypersensitivity !miction) •••••• 40
6.1 Genetics ••••••••••••••••••••• 44
A. '!YPe IV Reaction. ................ 40
A. Genodermamses. ................ 44
B. CD4+ T-cell-mediated Immune
B. Patterns of Inheritance •..•••..••. 44
c. CRDeaSc+ti oImn m..u.n..e. R..e.a.c.t.io.n.. ................... 4420 c. Uses of Genetics ................. 44
7 Laboratory ••••••••••••••••••• 48 8 In-vtvo Allergy Diagnosis •••••••• 58
7.1 ln·vltro Diagnosis of Allergy ••••• 48 8.1 Overview of Allergy Telling ••••• 58
A. Definition and Indications .••..••• 48 A. Requirements for Allergy Testing. . 58
B. Test Procedures .................. 48 B. Exogenous Influences ............ 58
c. Cellular Allergen Stimulation Test • 48
8.2 Physial Testing ••••••••••••••• 60
D. Eosinophilic cationic Protein and
A. O!.oice oflest Methods ........... 60
Tryptase ........................ 48
B. Physical Urticaria ................ 60
7.2 Histopathology ••••••••••••••• 50
8.3 Skin Tests I ••••••••••••••••••• 62
A. Biopsy Techniques ............... 50
A. SkinTests ....................... 62
B. Staining Techniques .............. 50
c. Histological Features ............. 52 B. Thberculin Test .................. 62
D. Patterns oflnflammation ......... 52 8.4 Skin Tests II ................... 64
E. Approach to Slides ............... 52 A. Patch Testing .................... 64
B. Test Substances .................. 64
7.3 Immunofluorescence and Electron c. Special Situations
Microscopy• •••••••••••••••••• 54
and Test Modifications ........... 64
A. '!YPes of Examination ............ 54
B. Technical Tips ................... 54
c. Examples ofU ses ................ 54 9 Imaging Procedures ••••••••••• 66
D. Advanced Techniques ............ 54 9.1 DermatoKOpy •••••••••••••••• 66
E. Electron Microscopy ............. 54 A. Dermatoscopy ................... 66
B. Digital Dermamscopy ...••...••.. 68
1A Mycology and Bacteriology ••••• 56
A. Mycological Diagnosis• ..••••..••• 56 9.2 Sonography •••••••••••••••••• 70
B. Bal:teriologic Diagnosis. .••••..••• 56 A. Sonography ..................... 70
B. Other Imaging Procedures ........ 70
Ill Treatment of Dermatologlc Diseases
10 Medkallberapy •••••••••••••• 74 lOA Biologicals ••••••••••••••••••• 82
A. Definition ....................... 82
10.1 Principles of Topical Therapy •••• 74
B. Anti-TNFTherapy ................ 82
A. Interactions be~en Medications c. Anti-IL-12/IL-23p40 Therapy .•••. 82
and Skin ........................ 74
D. New Compounds ................ 82
B. Vehicles ......................... 74
c. Compounding ................... 74 10.5 Cytoldni!S, Toll-lib Receptor
D. Tricks for Topical Prescribing ..... 74 Agonlsts ••••••••••••••••••••• 84
A. lmmunostimulaiDrs .••..•••..•••. 84
10.2 Conlcosterolds ••••••••••••••• 76
B. lnterleukin 2 .................... 84
A. Structure and Potency• ..••••..••• 76 c. lnterleukin 12 ................... 84
B. Mechanisms of Action. ........... 76
c. Indications and Side Effects. ...... 78 D. Interferons ...................... 84
E. Toll-like RecepiDr Agonists ...••.. 84
10.3 taldneurln Inhibitors, Azathioprine, F. CTLA-4 Antagonists .••..•••..••.. 84
and Mycophenolate Mofetll ••••• 80
10.6 Thalidomide, Chloroquine,
A. Calcineurin Inhibitors ............ 80
and Fumaric Add Esters •••••••• 86
B. Azathioprine .................... 80
c. Mycophenolate Mofetil. .......... so A. Thalidomide. .................... 86
B. Chloroquine ..................... 86
c.
Fumaric Acid Esters .............. 86
Contents
10.7 Nonsteroidal Anti-Inflammatory 10.16 Miscellaneous Topical Agents •••• 116
Agents and Dapsone ••••••••••• 88 A. Antiperspirants• ...••...••...••.. 116
A. Nonsteroidal Anti-inflammatory B. Medications for Disturbances of
Agents .......................... 88 Pigmentation .................... 116
B. Dapsone ........................ 88 c. Skin Oeansers and Protective
Agents .......................... 116
10.8 Cytostatic Agents• ••••••••••••• 90
A. Indirect Inhibition of DNA
11 Physkill Modes of Therapy •••••• 118
Function ........................ 90
B. Direct DNA Interactions .••••..••• 92 11.1 Phototherapy• •••••••••••••••• 118
c. Molecular Therapy ............... 92 A. Ultraviolet Radiation •...••...••.. 118
D. Topical Use ...................... 92 a Principles of Phototherapy• ...••.. 118
c. UVB Phototherapy ............... 118
10.9 Antibacterial Agents ••••••••••• 94
D. UVA and UVA Phototherapy ..•••. 120
A. Patient-Bacteria Interactions ..... 94 1
E. Photochemotherapy •••.•••..•••. 120
B. Site of Action .................... 94
c. Mechanisms ofA ction and 11.2 Photodynamic Therapy, Radiation
Resistance ....................... 94 Therapy, and cryotherapy• •••••• 122
D. Oasses ofA ntibiotics. ............ 94 A. Photodynamic Therapy• .•••..•••. 122
E. Topical Antibiotics ............... 100 B. Radiation Therapy ............... 122
F. Disinfectants .................... 100 c. Cryotherapy ..................... 122
10.10 Antimycotic Agents •••••••••••• 102 11.3 user Therapy. ................ 124
A. Inhibitors of Ergosterol Synthesis . 102 A. Principles ofLaser Therapy ....... 124
B. Pyridones ....................... 102 B. Nonspecific Coagulation .......... 124
c. Inhibitors of Cell Wall or c. Semi-selective Lasers ............ 124
DNA Synthesis ................... 102 D. Selective Photothennolysis ....... 124
D. Polyene Antibiotics .............. 102 E. Vaporization and Ablation ........ 124
F. Intense Pulsed Light ............. 124
10.11 Antiviral Agents ••••••••••••••• 104
A. Mechanisms ofA ction •..••••..••• 104
12 Operative Dermatology• •••••••• 126
B. Antiviral Agents in HIV/AIDS ..••. 106
12.1 General Aspects and Ted!nlques • 126
10.12 Antiparasitic Agents ........... 108
A. General Aspects ................. 126
A. AcaricidesJinsecticides ........... 108
B. Operative Techniques •..•••..•••. 126
B. Repellents ....................... 108
c. Antihelmintic Agents ............ 108 12.2 Aestlletlc Dermatology ••••••••• 130
A. Botulinum 1bxin A ............... 130
10.13 Retlnolds .................... 110
B. Fillers ........................... 130
10.14 Antihistamines and Antipruritic c. Peeling. ......................... 130
Agents ...................... 112 D. Laser Skin Resurfacing ........... 130
A. Antihistamines .................. 112 E. Dermabrasion ................... 132
B. Antipruritic Agents .............. 112 F. Lip Augmentation. ............... 132
G. Lifting .......................... 132
10.15 Keratolytlcs and Antlpron~rattve H. Thermal Lifting .................. 132
Agents ...................... 114
I. Liposuction ..................... 132
A. Kel'iltolytics ..................... 114
J. Cosmetic Vein Surgery ..•••..••.. 132
B. Antip roliferative Agents .••....••. 114
K. Plastic-reconstructive Surgery ••.. 132
lc: Diseases
13 Dermatologic Examination •••••• 136 13.2 Types of Lesions ............... 138
A. Primary Lesions ................. 138
13.1 History and symptoms ••••••••• 136
B. Secondary Lesions ............... 138
A. History. ......................... 136 c.
Features of Lesions ............... 138
B. Symptoms ....................... 136
c. Signs (Physical Findings) ••••.•••• 136