Dermatology THIRD EDITION AN ILLUSTRATED COLOUR TEXT Commissioning Editor. Timothy Home Project Development Manager: Jim Killgore, Lynn Watt Project Manager: Nancy Arnott Designer: Sarah Russell Illustrators: Peter Cox, Graeme Chambers Dermatology AN ILLUSTRATED COLOURTEXT David J. Gawkrodger MDFRCPFRCPE Consultant Dermatologist and Honorary Senior Clinical Lecturer, University of Sheffield, Royal Hallamshire Hospital, Sheffield, UK CHURCHILL LIVINGSTONE EDINBURGH LONDON NEW YORK OXFORD PHILADELPHIA ST LOUIS SYDNEY TORONTO 2002 IV CHURCHILL LIVINGSTONE An imprint of Elsevier Limited © Longman Group UK 1992 © Pearson Professional 1997 © Elsevier Science Limited 2002. All rights reserved. © Elsevier Limited 2003. All rights reserved. The right of David J. Gawkrodger to be identified as author of this work has been asserted by him in accordance with the Copyright, Designs and Patents Act 1988 No part of this publication may be reproduced, stored in a retrieval system, or transmitted in any form or by any means, electronic, mechanical, photocopying, recording or otherwise, without either the prior permission of the publishers or a licence permitting restricted copying in the United Kingdom issued by the Copyright Licensing Agency, 90 Tottenham Court Road, London WIT 4LP. Permissions may be sought directly from Elsevier's Health Sciences Rights Department in Philadelphia, USA: phone: (+1) 215 238 7869, fax: (+1) 215 238 2239, e-mail: healthpermissions@elsevier.com. You may also complete your request on-line via the Elsevier Science homepage (http://www.elsevier.com), by selecting 'Customer Support' and then 'Obtaining Permissions'. First edition 1992 Second edition 1998 Third edition 2002 Reprinted 2003 (twice) ISBN 0-443-07140-3 British Library Cataloguing in Publication Data A catalogue record for this book is available from the British Library Library of Congress Cataloging in Publication Data A catalog record for this book is available from the Library of Congress Note Medical knowledge is constantly changing. As new information becomes available, changes in treatment, procedures, equipment and the use of drugs become necessary. The author and the publishers have, as far as it is possible, taken care to ensure that the information given in this text is accurate and up to date. However, readers are strongly advised to confirm that the information, especially with regard to drug usage, complies with current legislation and standards of practice. your source for books, journals and multimedia in the health sciences www.elsevierhealth.com The publisher's policy is to use paper manufactured „, from sustainable forests Printed in China N/03 V Preface to the third edition Change in medicine occurs all the time. Medicine has become more a new section has been written on This often imperceptible progress is at international, aided by political 'Dermatology and the Internet' and a much more rapid pace than we changes, notably European integration, websites that give extra information imagine. With these thoughts in mind I and through the multinational nature and further reading have been tackled the third edition of this book, of most major pharmaceutical incorporated on each page. asking myself, for every sentence and companies, which take a world-wide I hope that the revisions and each page, 'how has the practice and view on the marketing of many drugs. additions made for the third edition approach to the topic been advanced?' The third edition has been written with will provide medical students, family Many changes, both subtle and more a more global flavour than its practitioners, residents or specialist blatant, were needed. Advances in predecessors. This is also reflected in registrars in dermatology or general genetics, molecular biology and the updated Bibliography and list of internal medicine, and dermatological immunology have been incorporated, Self-help groups. nurses with an account of dermatology alterations in treatment regimens The widespread availability of most in its theory and practice that is inserted and the cultural change of'the medical scientific knowledge via the concise, comprehensive and up-to-date. holistic team approach' has been Internet has led many physicians and integrated in the appropriate places. nearly all medical students to use the Figures have been brought up to date 'web' as a prominent source of and replaced if necessary. reference material. With this in mind, Sheffield 2 002 David J. Gawkrodger Preface to the first edition Recent advances in publishing bulleted items and 'key point' three sections. The first presents a technology and book presentation summaries. This unique approach, scientific basis for the understanding of demand that a modern text be which deals with each topic as an and clinical approach to skin disease. attractively and concisely presented, in educational unit, allows the reader better The second details the major colour and at an affordable price. This is accessibility to the facts and greater ease dermatological conditions, and the third essential for success in a very in revision than is possible with a outlines special topics, such as competitive market. In writing this book, conventional textbook. photoageing and dermatological I have attempted to present an The book is aimed at medical students surgery, that are of current importance introductory dermatology text for the but contains sufficient detail to be of use or that are poorly dealt with in other 1990s, using a format of individually to family practitioners, physicians in textbooks. designed double-page spreads, internal medicine, registrars or residents generously illustrated with colour in dermatology, and dermatological photographs, line drawings, tables, nurses. The contents are divided into Sheffield 1992 David J. Gawkrodger VI Acknowledgements In the production of the third edition of I thank colleagues who generously editor of the British Journal of this book it is a pleasure to acknowledge have provided figures for this and Dermatology and Dr E.E Bernstein of the contribution of the publishing staff previous editions, including Dr E.G. Jefferson Medical College, Philadelphia, at Elsevier Science, particularly Jim Benton of Edinburgh, Dr J.E. Bothwell of USA. Figures 2 and 4 (p. 114) are Killgore, project development manager, Barnsley, Dr J.S.C. English of reproduced courtesy of Blackwell Timothy Home, publishing manager, Nottingham, Dr EM. Lewis of Worcester, Science (having originally appeared in and Sarah Russell, senior designer. I am Dr S.M. Morley of Dundee, Dr M. Shah the Textbook of Dermatology, fifth grateful to colleagues who have advised of Dewsbury, and Professor S.S. Bleehen, edition, edited by R.H. Champion, J.L me on various aspects of the book, Mr D. Dobbs, Dr C.I. Harrington, Dr Burton, F.J.G. Ebling, 1982). including Dr M.D. Talbot, director of A.J.G. McDonagh, Dr A.G. Messenger I am grateful to the following for undergraduate education, Royal and Dr C. Yeoman of Sheffield. Figure 2 advice or for the provision of Hallamshire Hospital, and Dr S.M. Cp. 26) is reproduced by permission of illustrations; Professor R. StC. Barnetson, Morley of the University of Dundee. Dr the British Medical Association Dr G.W. Beveridge, Dr P.K. Buxton, Dr M. Liovic and colleagues of the (originally used in ABC of Dermatology G.B. Colver, the late Professor F.J.G. Universities of Ljubljana, Wales, Uppsala by P.K. Buxton, 1988) and Figure 2 (p. 16) Ebling, Dr M.E. Kesseler, Dr C. and Dundee kindly permitted the use of is reproduced by permission of McGibbon, Dr A. McMillan, Mrs E. the diagram of the keratin molecule Blackwell Science (originally used in McVittie, Dr C. StJ. O'Doherty, Miss M.J. (p. 8: published in J Invest Dermatol Clinical Dermatology by J.A.A. Hunter, Spencer and Dr A.E. Walker. I also thank 2001:116; 964-969, and reproduced J.A. Savin and M.V. Dahl, 1989). Figure 4 those patients who gave permission for with permission of Blackwell Science). (p. 101) is reproduced courtesy of the their faces to be shown without eye bars. VII Contents Microanatomy of the skin 2 Immunology of the skin 10 Examining the skin is Derivatives of the skin 4 Molecular genetics and the skin 12 Basics of medical therapy 20 Physiology of the skin 6 Terminology of skin lesions 14 Epidemiology of skin disease 22 Biochemistry of the skin 8 Taking a history 16 Body image, the psyche and the skin 24 Eruptions 26 Psoriasis — epidemiology, Eczema - basic principles/contact Lichenoid eruptions 36 pathophysiology dermatitis 30 Papulosquamous eruptions 38 and presentation 26 Eczema - atopic eczema 32 Erythroderma 40 Psoriasis - complications and Eczema - other forms 34 Photodermatology 42 management 28 Infections 44 Bacterial infection - staphylococcal Viral infections - herpes simplex Fungal infections 54 and streptococcal 44 and herpes zoster 50 Tropical infections and infestations 56 Other bacterial infections 46 HIV disease and immunodeficiency Infestations 58 syndromes 52 Viral infections — warts and other viral infections 48 Disorders of specific skin structures 60 Sebaceous and sweat glands - acne, Disorders of nails 64 Leg ulcers 68 rosacea and other disorders 60 Vascular and lymphatic diseases 66 Pigmentation 70 Disorders of hair 62 Allergy and autoimmunity 72 Urticaria and angioedema 72 Blistering disorders 74 Vasculitis and the reactive erythemas 78 Connective tissue diseases 76 Internal medicine 80 Skin changes in internal conditions 80 Drug eruptions 82 Associations with malignancy 84 Inherited disorders 86 Keratinization and blistering Neurocutaneous disorders and syndromes 86 other syndromes 88 Skin tumours 90 Benign tumours 90 Malignant melanoma 94 Premalignant epidermal disorders and malignant dermal tumours 98 Naevi 92 Malignant epidermal tumours 96 Special topics in dermatology m Ultraviolet radiation and the skin 100 Paediatric dermatology 108 Immunological tests 118 Cosmetics 102 The skin in old age 110 Dermatology and the internet 120 Basic dermatological surgery 1 04 Genitourinary medicine 1 1 2 Bibliography 122 Racially pigmented skin 114 Self-help groups 124 New trends in dermatological treatment 106 Occupation and the skin 116 Index 126 This page intentionally left blank Basic Principles