Dermatological Conditions

16


Dermatological Conditions


Patrick Sexton, Todd L. Kanzenbach and Mary H. Lien



Objectives


At the completion of this chapter the reader should be able to do the following:


1. Describe the anatomy of the integumentary system


2. Recognize signs and symptoms of common skin conditions


3. Contrast the differences among viral, fungal, and bacterial skin disorders


4. Refer an athlete with a problematic skin disorder to the appropriate health care provider


5. Recognize environmentally induced conditions: skin cancers, cold injuries


6. Differentiate which acute skin conditions are contraindicated for certain athletic participation



Introduction


Dermatological conditions in athletes are common in a variety of settings and are a major reason that many athletes miss practice or competition. The National Collegiate Athletic Association (NCAA) Injury Surveillance System indicates that dermatological conditions account for 17.2% of practice time–loss injuries in intercollegiate wrestling and that of those, 45.3% are viral infections (herpes simplex and herpes zoster), 24.9% are bacterial infections (including staphylococcal, streptococcal, and impetigo), 22.1% are fungal infections (tinea), and the remaining 7.7% of time-loss skin infections come from a variety of other conditions.1 Although most dermatological conditions are the result of skin-to-skin contact and resultant transmission, some may involve respiratory or airborne transmission. Others may result from allergic reactions, cancer, or insect bites. The five main types of dermatological conditions are as follows: general, bacterial, viral, fungal, and parasitic. This chapter reviews pertinent anatomy and discusses clinical presentation, diagnosis, treatment, and the criteria for return to participation related to simple dermatological conditions.



Overview of Anatomy and Physiology


The skin, or integument, is the largest organ of the body and can be divided into three layers: the epidermis, the dermis, and the subcutaneous tissue or hypodermis (Figure 16-1). The epidermis itself is composed of up to five layers from deep to superficial: stratum basale; stratum spinosum; stratum granulosum; stratum lucidum, found only in the soles of the feet and palms of the hands; and stratum corneum.2


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FIGURE 16-1 Anatomy of the skin. (From Gartner LP, Hiatt JL: Color textbook of histology, ed 3, Philadelphia, 2007, Saunders.)

Each layer of the epidermis except for the stratum basale is composed of dead cells (Box 16-1). The epidermis provides the primary protective shield for the body through the constant formation of new cells and the sloughing of old cells and through the production of pigment known as melanin. The dermis, which is composed of a papillary layer and a reticular layer, contains a variety of vascular and sensory structures, hair follicles, sebaceous or sweat glands, and nails. Finally, the hypodermis, or subcutaneous layer, is made up of connective tissue, which binds the dermis to the deeper structures, and adipose, which provides insulation and cushioning. Together the epidermis, the dermis, and the hypodermis make up the integumentary system.2



BOX 16-1   LAYERS OF THE EPIDERMIS




From Van De Graaff K, Fox S: Concepts of human anatomy and physiology, ed 3, Dubuque, IA, 1992, William C. Brown, p 149.


The integumentary system serves as the interface between the body and the external environment. It is a dynamic system that serves as a protective barrier against invading organisms and outside influences such as ultraviolet radiation, toxic chemicals, thermal changes, and penetrating forces. However, at the same time, the integumentary system allows people to sense and to adapt to the environment in terms of thermoregulation; fluid loss; proprioception and kinesthesis; force dissipation; cutaneous absorption of gases, ultraviolet light, and toxins; and synthesis of vitamin D. Finally, the skin plays an important role in human communication by helping people to convey emotions through changes in skin color and texture as well as through facial expression.2


Nails are made up largely of keratin and are found on the dorsal surfaces of all fingers and toes (Figure 16-2). The nail is a hard, clear surface that presents a pink color from the underlying highly vascular epithelial cell layer. The lunula lies at the proximal end of all nails. It is a moon-shaped, white opaque layer that protects the nail matrix, which in turn produces new keratinized cells. The nail fold surrounds the lateral and proximal nail and hooks onto the nail bed. It is in this area that certain bacterial conditions arise.


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FIGURE 16-2 Anatomy of the nail. (From Jarvis C: Physical examination & health assessment, ed 5, Philadelphia, 2008, Saunders.)


Evaluation of the Skin


The goal of a skin examination by the health care provider is to identify, or attempt to identify, unknown skin lesions in order to determine the need for referral, treatment, or activity status (i.e., to allow participation or to withhold from participation), and to prevent transmission among athletes. New or previously undiagnosed lesions must be diagnosed and treated. A history and a visual inspection can be very revealing, exactly how revealing depends on the patient’s history, the quality of the visual inspection, and the patient’s willingness to be truthful in either reporting or attempting to hide a skin lesion. The athletic trainer should be suspicious of an athlete-patient wearing a wrap or a bandage that the athletic trainer did not apply. When asking the patient to disrobe for the skin infection all tape, wraps, and bandages should be removed for inspection. In addition, wrestlers have been anecdotally known to self-abrade (e.g., using sandpaper) or apply caustic chemicals (e.g., bleach) to skin lesions in an attempt to hide or remove the infection.


A skin examination should be performed frequently enough to detect newly forming and potentially contagious lesions early enough to initiate treatment and to prevent transmission to others. Weekly skin examinations are considered the norm; however, when the possibility of an active outbreak exists they should be performed frequently enough to detect new lesions, thereby shortening the course of the outbreak among team or family members. For athletes, specific league rules may require that full body skin examinations be performed at specified intervals; however, compliance with league rules should be viewed by the athletic trainer only as the minimal standard, especially when more frequent inspections are warranted.


A skin inspection should be conducted in a well-lit room that provides a private, respectful environment. For full-body examination males should be wearing only shorts while females should be wearing shorts and a sports bra or swimsuit top. Whenever possible a health care provider of the same gender should be conducting the examination. Begin the examination with a history by asking the patient if he or she has any skin problems to report, if they have felt ill, nausea, fever, body aches, or fatigue. These symptoms may be especially indicative of viral or bacterial infections. The visual inspection is conducted with the patient standing erect, feet shoulder width apart, arms abducted to 90 degrees, palms forward with hands open. Avoid touching the patient whenever possible; however, this may be unavoidable when examining specific body parts, especially the scalp. If contact is necessary the athletic trainer should wear gloves whenever touching the patient and change gloves and disinfect hands between patients in order to avoid cross-contamination. Begin a systematic inspection of the patient including all aspects of the upper and lower extremities and the torso, including the axilla, the neck, the face, and the scalp. The scalp is especially important because hair may conceal active infections. Patients should be able to adjust their neck and move their hair to facilitate the inspection, but the athletic trainer may have to physically part the hair in order to visualize the scalp.3


The athletic trainer should look for any abnormalities and should note specifically any lesion’s pattern, color, and location3:



The athletic trainer is usually the first clinician to evaluate a dermatological lesion on an athlete. A lesion is synonymous for abnormal tissue. Lesions are typically in the very early stages of development and can be quite difficult to differentiate without microscopic or laboratory testing. Because these types of diagnostic procedures are beyond the scope of many health care providers, the athletic trainer must use sound clinical judgment when determining the appropriate course of action for athletes with dermatological conditions.


When referral to a medical doctor for evaluation and treatment is necessary, the health care provider must understand the patient’s signs and symptoms and be able to effectively describe findings to the physician, using dermatographical nomenclature. The terminology used to describe the appearance of a skin lesion or condition is very specific. The athletic trainer must have the knowledge and resources necessary to make these distinctions. It is much easier and more efficient to describe the lesion as a “fissure” rather than as a “linear loss of epidermis and dermis with sharp defined borders.” In addition, the clinician must understand that these terms are important to the description and are not a specific diagnosis (Table 16-1).



TABLE 16-1


Common Skin Lesions




















































































Type of Lesion Description
Primary Lesions
Nonpalpable  
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Palpable, solid  
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image
image
image
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Palpable, fluid-filled  
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image
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Secondary Lesions
Damaged or diminished skin surface  
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image
image
image
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Augmented or increased skin surface  
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image
image
image
image


image


image


From Copstead LEC, Banasik JL: Pathophysiology: biological and behavioral perspectives, ed 2, Philadelphia, 2000, Saunders, pp 1184–1185.


Dermatitis, for example, is an inflammation of the skin or dermal layers and can be the result of a variety of dermatological conditions with various causes. Whereas the term dermatitis merely indicates a general inflammation of the skin, contact dermatitis indicates an inflammation of the skin caused by direct contact with a specific allergen and actinic dermatitis indicates inflammation of the skin from exposure to sunlight or another irritating light source. Thus the term dermatitis is a general descriptor whereas contact dermatitis and actinic dermatitis indicate specific conditions and constitute a particular diagnosis.


Another way to describe dermatological conditions is by referencing the area of skin affected. Most physicians use millimeters (mm) to describe the width or breadth of a particular condition, but centimeters (cm) are used for larger surface areas. As a point of reference, 1 inch is equal to 25.40 mm or 2.54 cm (Figure 16-3).


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FIGURE 16-3 Comparison of size of lesions.


Pathological Conditions


Urticaria


Urticaria is a group of distinct skin conditions characterized by itchy, wheal-and-flare skin reactions, commonly known as hives.4 Urticaria is a common skin pathology that is often seen in athletes. When histamine is released from mast cells, it produces a characteristic triple response: vasodilation causing local erythema, erythematous flare beyond the local erythema, and leakage of fluid causing local tissue edema (Figure 16-4). The majority of cases are acute and can last up to a few weeks. The causes of urticaria are wide ranging and include allergies to foods such as shellfish, nuts, and eggs; food additives such as salicylates, dyes, and sulfites; drugs such as penicillin, aspirin, and sulfonamides; bacterial, viral, and fungal infections; and allergens such as pollens, mold, and animal dander. Internal disease; physical stimuli such as dermatographism, exercise, cholinergic agents, cold, and sun; skin diseases; hormones such as occur during pregnancy; and genetic predisposition can also trigger urticaria. The underlying cause of acute urticaria cannot be determined in about 50% of cases.4 A more rare variety of the condition is chronic urticaria, which arises from chronic infection, intolerance to food additives, or autoreactivity.4 A typical hive is an intensely itchy erythematous or white edematous area. A discussion of general urticaria and specific conditions follows.


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FIGURE 16-4 Urticaria, seen here in various stages of formation, is a local erythemic reaction to exercise, temperature changes, drugs, or allergies. (From Goldman L, Ausiello D: Cecill medicine, ed 23, Philadelphia, Saunders, 2008.)



Referral and Diagnostic Tests


Referral to a physician is appropriate if symptoms persist for an extended period and if they are interfering with daily activities. Immediate referral to a medical facility is necessary if an athlete shows signs or symptoms of anaphylactic shock, which may include facial edema, swollen tongue, difficulty breathing, difficulty talking, hoarseness, or having near-syncopal or syncopal episodes. Diagnostic testing to determine the exact cause of urticaria can be highly expensive and endless, commonly with no resolution.



image RED FLAGS FOR ANAPHYLACTIC SHOCK


General urticaria may also indicate anaphylactic shock. Any athlete with the following signs




Treatment


The most effective treatment is to determine and eliminate the cause, but this is often extremely difficult. Most athletes will need an oral nonsedating antihistamine, such as loratadine (Claritin) or fexofenadine (Allegra), because the sedating antihistamines may impair performance. Another popular antihistamine commonly used for urticaria is cetirizine (Zyrtec), but it also has mild sedative properties although not as severe as the sedating antihistamines listed in Box 16-2. If the aforementioned antihistamines are unsuccessful, the use of glucocorticoids (steroids) has been effective. In emergent situations, in which the athlete’s airway is compromised, use of epinephrine (EpiPen) injection prescribed for that athlete may be warranted. Chapter 4 describes the correct use of an EpiPen.



BOX 16-2   SEDATING ANTIHISTAMINES


The following antihistamines have a sedating effect that may be counterproductive to athletic participation:





Dermatographism


Dermatographism is hives induced by rubbing or stroking the skin or by rubbing of the skin with clothing. As many as 2% to 15% of the population may be dermatographical.5 The exact cause is unknown, but recent infections or medications appear to be the most common cause. The hives develop within 1 to 3 minutes of stroking the skin and resolve in 30 to 60 minutes. The patients affected will go through periods of reactivity during their lifetimes, but dermatographism is more common in younger patients.



Signs and Symptoms


Dermatographism presents with blanching and associated linear edema and erythema (Figure 16-5). It can occur on any part of the body because it does not matter if the skin is covered by clothing or equipment. Indeed, the friction caused by clothing or equipment may induce a dermatographical reaction.


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FIGURE 16-5 Drawing on the skin provided this reaction in a patient with dermatographism. (From Kanski J: Clinical diagnosis in ophthalmology, Philadelphia, 2006, Mosby.)




Cholinergic Urticaria


Cholinergic urticaria usually develops in younger patients between the ages of 10 and 30 years and resolves spontaneously in only a small percentage of these patients. This reaction consists of 2- to 4-mm hives with surrounding erythema that occur during or shortly after the patient experiences exposure to heat or overheating of the body during exercise, or stress. (Figure 16-6). This reaction typically occurs within 2 to 20 minutes of exposure but may be delayed for up to 1 hour. Signs and symptoms are induced by the parasympathetic nervous system’s release of acetylcholine and may last up to 3 hours.5


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FIGURE 16-6 Cholinergic urticaria consists of red, round papular wheals. (From Habif TP: Clinical dermatology, ed 5, St. Louis, 2010, Mosby.)






Cold Urticaria


Cold urticaria occurs often in athletes because ice baths and ice therapy are a common treatment modality. Hives occur with exposure to cold objects such as ice or cold temperatures. The initial episode may occur after infections, medications, or emotional stress and is most commonly seen in 18- to 25-year-old patients. The recurrences will spontaneously resolve, typically within 1 to 2 years, but some patients will have recurrences for 10 years or more.




Referral, Diagnostic Tests, and Differential Diagnosis


The athletic trainer refers any athlete with extreme reactions to cold to a physician for definitive diagnosis and evaluation for other systemic symptoms. Diagnosis is made in the physician’s office by applying ice to the skin for 1 to 5 minutes or by exposing the forearm to cold water (0° to 8° C; 32° to 46° F) for 5 to 15 minutes and monitoring for hives (Figure 16-7). This is recommended only under the supervision of a physician in a medical facility because systemic symptoms and anaphylaxis may develop. Urticarial vasculitis, cholinergic urticaria, Raynaud’s phenomenon, and dermatographism are all differential diagnoses for cold urticaria.


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FIGURE 16-7 Cold urticaria hive reaction produced by holding an ice cube on the ankle. (From Habif TP: Clinical dermatology, ed 5, St. Louis, 2010, Mosby.)




Solar Urticaria


Solar urticaria is a condition manifested by hives that occur within minutes of exposure to ultraviolet (UV) light and resolving within 1 to 3 hours. The range of the electromagnetic spectrum, or UV light, that causes the hives is between 290 and 500 nm.5 Systemic reactions such as syncope have occurred but are rare. Syncope typically occurs in young adults and more commonly in females shortly after sun exposure.






Sebaceous Cysts


Sebaceous cysts, also known as epidermal or keratinous cysts, are very common in young people to middle-aged adults. These cysts have a thin wall filled with a white keratin material produced by the skin epithelium. They are slow growing, movable, and nontender (Figure 16-8).


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FIGURE 16-8 Sebaceous cyst. (From Habif TP: Clinical dermatology, ed 5, St. Louis, 2010, Mosby.)






Dermatitis


The term dermatitis is used loosely. Dermatitis means inflammation of the skin, and the large variety of causes is beyond the scope of this chapter. This chapter discusses two conditions: eczema and psoriasis.



Eczema


Eczema is often used synonymously with dermatitis and is the most common inflammatory skin disease. Whereas eczema itself often indicates vesicular dermatitis, some refer to it as chronic dermatitis.10 It consists of three components: erythema, scales, and vesicles. The many causes of eczema include a contact allergic reaction such as to poison ivy, topical medicines including neomycin, atopic dermatitis, fungal infections, dyshidrosis, and habitual scratching. If left alone, most eczematous lesions will resolve, but patients are rarely able to avoid scratching.






Treatment, Prognosis, and Return to Participation

The most important treatment for eczema is removal from the allergen if possible. The acute stage is treated with cool compresses changed every 30 minutes, with or without Burow’s (aluminum sulfate) solution. Oral steroids may be needed to control the inflammation. Antihistamines may be used to reduce itching, and antibiotics should be started if there are signs of infection.


The subacute stage is treated by eliminating wet dressings and using topical steroids, ointments, creams, or lotions. Oral antibiotics may be necessary when signs of infection are present. The chronic stage is similar to the subacute stage, but stronger topical steroids are necessary and steroid injections may also be required. Prognosis of eczema depends on the severity of the reaction. Unless the reaction is severe or a significant infection has developed, the athlete may return to play without restriction.



Psoriasis


Psoriasis is a genetic, chronic, and recurring disorder that usually begins during childhood. It is a scaling, papular infection similar to eczema but without the epithelial eruptions, wet areas, and crusts. In some cases, a streptococcal infection may precipitate the onset of the disorder. Psoriasis affects an estimated 4% of the population worldwide.10 Psoriasis has a gradual onset and usually has chronic remission and recurrence rates that vary in frequency and duration, but permanent remissions are rare.10


A small percentage of patients with psoriasis also experience psoriatic arthritis.8 The exacerbation-remission cycle common to the skin disorder may coincide with the arthritic component. Most often, the distal interphalangeal joints of the fingers and toes are affected. Unlike rheumatoid arthritis (RA), psoriatic arthritis tends to enter remission more frequently and rapidly than RA, and it lacks the typical joint nodules associated with RA. The patient with psoriatic arthritis may progress to chronic, disabling arthritis, so complaints of joint pain in the psoriatic person must not be overlooked.10



Signs and Symptoms

The distinctive lesion of psoriasis is a silvery white plaque with surrounding erythema with distinct borders (Figure 16-10). The lesions usually begin as small, red, scaly papules that coalesce into round or oval plaques except in the skin folds, where they appear as deep red, macerated plaques. These lesions are most common on the extensor surfaces, such as the elbows and knees, but are also very common on the scalp, fingernails, toenails, gluteal clefts, and previous sites of trauma (Figure 16-11).


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FIGURE 16-10 Psoriasis is characterized by scaly erythematous patches with silvery scales on the top. (From Jarvis C: Physical examination & health assessment, ed 5, Philadelphia, 2008, Saunders.)

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FIGURE 16-11 Psoriasis is common on the elbows, knees, neck, and low back. (From Arnold HL, Odom RB, James WD: Andrew’s diseases of the skin: clinical dermatology, ed 8, Philadelphia, 1990, WB Saunders.)

Forms of psoriasis may develop other than the general chronic plaque type just described. Another common form is scalp psoriasis. The scalp, which may be the only site affected, has a thick erythematous silvery scale in multiple areas. This lesion may extend onto the forehead. Psoriasis of the nails is another type and is demonstrated by pitting of the nails.







Environmentally Induced Dermatological Conditions


Skin Cancer


The inclusion of skin cancer in this chapter is not intended to provide definitive diagnosis but to encourage an appreciation of suspicious lesions so that timely recognition and referral are made and so that prevention of skin cancer is brought to the forefront of the athletic trainer’s awareness. Two types of skin cancer are discussed: nonmelanoma and melanoma skin cancers. Each has subcategories based on the tissue invaded.



image RED FLAGS FOR MELANOMA




Moles: A mole is a benign skin tumor. Certain types of moles increase a person’s chance of getting melanoma. People with many moles and those who have some large moles have an increased risk for melanoma.


Fair skin: People with fair skin, freckling, light hair, or blue eyes have a higher risk of melanoma, but anyone can get melanoma.


Family history: About 10% of people with melanoma have a close relative (e.g., mother, father, brother, sister, child) with the disease. A strong family history of breast and ovarian cancer could mean that certain gene changes or mutations are present. Men with this gene change have a higher risk of melanoma.


Immune suppression: People who have been treated with medicines that suppress the immune system, such as transplant patients, have an increased risk of developing melanoma.


Ultraviolet (UV) radiation: Too much exposure to UV radiation is a risk factor for melanoma. The main source of such radiation is sunlight. Tanning lamps and booths are another source.


Age: About one half of melanomas occur in people over the age of 50 years, but younger people are also susceptible.


Gender: Men have a higher rate of melanoma than women.


Xeroderma pigmentosum (XP): XP is a rare, inherited condition. People with XP are less able to repair damage caused by sunlight and are thus at greater risk of melanoma.


Past history of melanoma: A person who has already had melanoma has a higher risk of getting another melanoma.


From the American Cancer Society website: http://www.cancer.org/Cancer/CancerCauses/SunandUVExposure/skin–cancer–facts



Nonmelanoma Skin Cancers


Nonmelanoma skin cancer (NMSC) is the most common cancer in humans worldwide. NMSC can be classified into two categories, basal cell carcinoma or squamous cell carcinoma, depending on which type of cell is affected. Both arise from skin cells termed keratinocytes, and rarely spread elsewhere. Basal cell carcinomas (BCCs) comprise 75% to 80% of NMSCs whereas squamous cell carcinomas (SCCs) comprise up to 25%.11 Whereas BCCs rarely metastasize and are infrequently fatal, SCCs, if left untreated, may lead to significant mortality. Actinic keratoses are considered to be precursors to SCC and are the most frequently treated lesions in humans. Actinic keratoses (AKs) are typically characterized as being “precancers” or premalignant because of the presence of atypical keratinocytes confined to the epidermis. The likelihood of invasive SCC evolving from any given AK has been estimated to occur at a rate of less than 0.1% per lesion per year. AKs characteristically appear on the sun-exposed regions of the body.


An estimated 2 million cases of NMSC were diagnosed in the United States in 2004.12 The number of skin cancer cases in the United States surpassed the number of cases of all other cancers combined. Approximately one in five Americans will develop skin cancer during their lifetime—more than 95% of which will be NMSC.11




Basal Cell Carcinoma


Basal cell carcinoma is the most common skin malignancy and occurs more frequently in males than females (an almost 2:1 ratio).13 The incidence of BCC increases with age, and most occur between the ages of 40 and 79 years.4 The incidence of BCC has risen between 20% and 80% in the past 30 years and is still increasing.14


There are many types of BCC. The most commonly occurring types of BCC are as follows:



The first two are discussed below.


Nodular basal cell carcinoma is considered to be the classic and most common type, comprising 50% to 54% of all BCCs. It typically presents as a pearly translucent pink papule with central telangiectasias on the head and neck regions, with a predilection for the nose (25% to 30%). A central ulceration with bleeding, crusting, and rolled borders may develop in this tumor, and it usually remains asymptomatic and rarely metastasizes. The nodular BCC may be mistaken for a benign nevus (plural, nevi) or an acneiform lesion.


Superficial basal cell carcinoma comprises 9% to 11% of all BCCs and usually is found in patients younger than those who have nodular basal cell carcinoma (mean age, 57 years). This type presents as an asymptomatic, erythematous scaly plaque that enlarges very slowly and typically occurs on the trunk or extremities (Figure 16-12). Superficial BCC may grow to be as large as 15 cm in diameter without ulceration or bleeding. It may be mistaken for psoriasis or a squamous cell carcinoma in situ.


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FIGURE 16-12 Basal cell carcinoma.



Classic Invasive Squamous Cell Carcinoma


Squamous cell carcinoma occurs on the mucous membranes as well as on sun-exposed skin. SCCs generally arise from actinic keratoses (AKs), which are considered premalignant precursors, at a rate of 0.075% to 0.096% per lesion per year.15 Actinic keratosis presents as an erythematous crusted papule on sun-damaged skin. It is often recognized more easily by touch rather than sight (Figure 16-13). The presence of an AK indicates that skin has been sun-damaged and skin cancer may develop. The most common sites of predilection include the head and neck, dorsal hands, lower lip, and genitalia. SCC commonly develops as a hyperkeratotic erythematous nodule or plaque on sun-damaged skin. Sites with a higher associated risk of metastases include the lip and ear, as well as sites with scarring or inflammation.


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FIGURE 16-13 Actinic keratoses (AKs) are often precursors of cancer. Because they are recurring rough patches of skin they are discovered more often by feel than by sight.


Signs, Symptoms and Referral

A thorough medical history must be obtained, focusing on the genetic and environmental risk factors such as a personal or family history of melanoma or atypical moles, fair skin type, a large number of moles, childhood history of sunburns, immunosuppression, and genetic syndromes with skin cancer predisposition. A detailed history about a suspicious lesion should be obtained regarding whether it was present at birth; any changes in appearance; symptoms such as itching, bleeding, burning, or pain; and any other systemic symptoms such as weight loss, fatigue, cough, or headache.


A complete total body skin examination should be performed to rule out any suspicious lesions. Both the American Academy of Dermatology and the American Cancer Society use the ABCD mnemonic as a guide to better recognize suspicious pigmented lesions.16 The ABCD mnemonic is as follows (Table 16-2):




A mole or lesion should have clear, definitive borders. If it does not, the lesion is suspicious and needs to be evaluated by a physician. The athletic trainer needs to refer to a physician any athletes with changes in shape, border, or size of a mole or lesion or the development of ulceration or bleeding, all of which are suggestive of melanoma (see Figure 16-14). Typically a biopsy is performed on a suspicious pigmented lesion. The preferred procedure is an excisional biopsy, as this will allow accurate staging of the tumor. An excisional biopsy, or excision in toto, is a procedure by which the physician cuts away the suspect lesion and its border and evaluates it under a microscope via histopathological examination. The pathologist can then clearly identify the types of cells attributed to the lesion.


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FIGURE 16-14 Melanoma is characterized by asymmetry, border irregularity, and color differences within its borders. (From Kumar V, Abbas AK, Fausto N, et al: Robbins and Cotran pathologic basis of disease, ed 8, Philadelphia, 2010, Saunders.)

Because the degree of atypia and depth of invasion may not be uniform in a pigmented lesion, this type of excision decreases the risk of sampling error by allowing the pathologist to examine the entire lesion. Although ocular (eye) melanoma is rare, comprising only 5% of all melanomas, patients with dysplastic nevi have a higher risk of ocular nevi. Dysplastic nevi are atypical moles that look different from other, more common forms of mole.


It is known that individuals who burn easily typically possess fair skin, blond/red hair, and blue eyes, and therefore, have a higher risk of developing cutaneous (skin) melanoma. However, it is currently not established whether there is any link between ultraviolet radiation exposure and the development of ocular (eye) melanoma.17



Treatment of Nonmelanoma Skin Cancer

Although benign moles, freckles, and age spots may provoke suspicion, it is wise to refer any questionable lesion to a medical doctor for inspection and likely a biopsy. If caught early, surgically removed melanoma has a high cure rate, but once it metastasizes to the lymph nodes, the 5-year survival rate drops to 30% to 40%.18,19 If organ involvement has occurred through this spread, the survival rate drops again to 12%.9 Excision includes removing at least 1 cm lateral to the tumor.20 Large surgical areas may require skin grafts or loss of underlying tissue that could result in deformity of the area involved.


Although the standard treatment of NMSC is surgical excision, electrodesiccation and curettage or cryosurgery are acceptable treatment options for appropriately selected tumors. Mohs micrographic surgery offers the highest cure rate for those high-risk NMSCs that are recurrent, exhibit an aggressive histology, are larger than usual (>2 cm), or are located at sites that require tissue conservation. Mohs surgery is an office procedure in which the physician cuts around the tumor with a small scalpel, using local anesthesia, and evaluates the margins of the tumor. Other treatment modalities include radiation therapy, photodynamic therapy, laser ablation, topical chemotherapy (typically 5-fluorouracil or imiquimod), and systemic retinoid therapy.


Suspect but not confirmed lesions are often treated by a regimen of topical chemotherapy, followed by photodynamic therapy. The purpose of this treatment is to remove the most superficial layers of the skin, most likely taking with it the damaged, possible precancerous aspects of it. The topical cream is applied to lesions and reacts to nontypical cells. During the time of treatment (typically 1 to 2 weeks) patients are cautioned to remain out of the sun, as the chemotherapy reacts to sunlight. Patients will report a gradual reddening of the skin, followed by possible open sores resembling fever blisters. The subsequent photodynamic therapy reacts to the topical cream, and although this treatment lasts only up to 30 minutes, the burn effect of the light continues for 24 to 48 hours. During this time, the patient will report deepening reddening of the skin, tightness, and eventually peeling. It is imperative to refrain from sunlight, even from windows, for the first several days after photodynamic therapy. A biopsy may be performed after the chemotherapy and/or photodynamic care, if lesions are still present or suspected.



Melanoma


Melanoma is a skin cancer arising from melanocytes; the lifetime risk for Caucasian Americans is more than 1 in 79.9 Melanocytes are found in the stratum basale (deepest layer of the epidermis), eye, inner ear, meninges, heart, and bone. They produce the pigmentation in skin, also known as melanin. The risk of melanoma will surely grow with the increasing number of people exposed to UV light from either the sun or tanning booths.21 The rate of malignant melanoma has increased by an alarming 190% since the 1930s, has tripled since 1980, and is growing at more than 9% per year.22 The American Cancer Society listed 68,720 diagnosed cases of melanoma in the United States in 2009, and 8,650 deaths.23 The most susceptible individuals have fair skin and blue eyes, sunburn easily, had multiple sunburns at an early age, and have a personal or family history of skin cancer.21,23 Because 40% to 50% of malignant melanomas arise from pigmented moles, people with moles or freckles should be especially cautious.10


Melanoma is a malignancy originating from the pigment-producing skin cell, or melanocyte, and is one of the most common types of skin cancer in young adults. Because of its recent rising incidence and overall mortality rate, melanoma is recognized as a public health issue. The incidence of melanoma in the United States has increased 15-fold over the past 40 years. Approximately one American dies every hour from melanoma.19 Notably, melanoma kills young adults more frequently than most other cancers.24 Significant attempts have been made to increase public awareness through public sun protection campaigns for the past 25 years. In fact, the health campaigns may be a factor in the decreasing incidence and mortality in young adults in Australia noted in 2002.20

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Sep 3, 2016 | Posted by in MUSCULOSKELETAL MEDICINE | Comments Off on Dermatological Conditions

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