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Thursday, September 23, 2010

5.1 Physician's Notebooks 5/Skin & Surface Appearance

Physician's Notebooks 5  - http://physiciansnotebook.blogspot.com - See Homepage

Updated 30 Dec. 2017. Includes in scroll down, Chapter 1, on Acne, Itching, Dermatitis, Athlete's Foot, Warts, Cancers of Skin including my own and Basal Cell Cancer and advice on keeping skin healthy and preventing stains and diagnosing sweat condition. The below table of contents for all of Notebooks 5 is hyperlinked to reading text. Just click to read the chapters.
Physician’s Notebooks
An Old Doc Recommends to a New Generation
Skin to Bones


5.1 Skin & Surface Appearance
The descending column has the main headings of the chapter in order of each one's appearance in text. Use search & find or scroll to your interest.
Acne
Eczema
Athlete’s Foot
Scaly Skin Disease
Skin Rash 
Warts Virus
Skin Cancer
My Basal Cell Carcinoma 
Squamous Cell Cancer 
Melanoma 
Keeping Skin Healthy 
 Itching - a Summing Up
Surface Appearance   
 
Acne is common in teen and young adult: it starts with pimple at onset of puberty and progresses to pustule and scarring by age 20 before burning out in permanent disfigurement by age 30. Sweat glands get over-stimulated by androgen sex hormone that produces excess sebum (oil from the gland). It gets trapped in the swollen gland just beneath skin and infected by bacteria, causing pustule and scarring.
   Because androgen effect starts at puberty, everyone will notice a few pimples by age 11. In acne it progresses perhaps due to reaction to stress. Acne is a final-common pathway of many causes: abnormal androgen of adrenal or sex gland from birth control pill or a steroid to enhance sports or individual abnormal sensitivity to androgen. Severe acne victim should have screening test for androgen and its receptors at outset of treatment. Also ask: Am I taking sex hormones or steroids for anything?
   Where hormones are not the problem, acne is from genetic susceptibility and inciting behavior such as picking at and touching face too frequently, using irritating cosmetic or facial or washing-machine soap, sensitivity to medication, or poor facial hygiene. Bad eating plays a role; some victims note acne is worse with greasy food or chocolate. Or it may be weak immune system that allows normally harmless skin bacteria to become infectious.
   Prevention includes minimizing medication, cosmetic, cologne, perfume, soaps and deodorant; face washing using only tap water. Use soap sparingly, neutral and minimally perfumed, and do not use routinely but only as needed to remove dirt or stain or grease. Avoid picking at face, and avoid an unhealthy eating pattern of excess sweet and greasy, spicy ethnic food or chocolate. Increase your food sources of vitamin A (carrot, yellow fruit & vegetable).
   Treatments: Dermatologists often advise a course of tetracycline antibiotic. I question tetracycline use because of bad effect staining bones and teeth and also as cause of later eye cataracts. If you wish to try antibiotic, do Augmentin a 1-week course max dose.
   For many with mild case, acne is a self-image problem. My advice is to make your own observation to find out event or drug or food or weather or contact that provokes your acne and avoid whatever may be making it bad. It may mean re-arranging your life. (Going to live in acne-free climate like Pacific Northwest, getting rid of beloved pet, stopping favorite food, discontinuing birth control pill or sports steroid)
Eczema
is a disorder of skin function. ‘Itch’, ‘scratch’, ‘patch’, and ‘red’ describe eczema’s symptom and sign. Wet eczema is weepy blister on inner side of finger, caused by contact hypersensitivity. Most eczema presents in dry itchy form you scratch. Repeat cycle of itch, scratch and redness results in red patch changing color to buff and becoming dry and scaly. When in a flex crease of joint, it is atopic dermatitis. A patch of eczema I noticed on my right front lower leg was due to my frequent bathing and that spot on my leg front was constantly being hit by hot water from the tap filling the tub and causing repeat wet heat trauma. Moisture in body creases may cause itchy, scaly eczema in susceptible persons. Good hygiene against it is careful drying in creases, with rubbing alcohol - like in cleft of buttocks, behind knee - and with dry towel after shower or bath.
   Eczema gets better with corticosteroid ointment (Synalar ointment in U.S. or 0.12% beta methasone) rubbed sparingly onto warm and moistened skin once for a day or two. Also remove source of chronic irritation.
Athlete’s Foot
itches intensely between 3rd and 4th and/or 4th and 5th toes. Pulling toes apart you see red skin in the web. It is caused by fungus that infects feet of person who walks barefoot in swimming pool or common shower area or uses cross-worn slipper. Treat the itch as it occurs using single application of the corticosteroid ointment. Ventilate feet often and keep ‘em cool (fungi love warmth) by as much as possible going without socks (but on safe clean floors only; or else very thin, white socks). A 21-day course of Lamisil 250 mgm daily (preceded by dermatologist microscope check for local fungus) should cure.
   But athlete’s feet can complicate. I know. It almost ruined me. I considered my athlete’s feet a minor bother. Then in the 1990s I developed severe callus on both feet and by 2001 it formed fissures and they caused sore heels. Unaware that this could be worsened by the athlete's feet fungus I did nothing and it was not until 2008 that a fungus infection of the callus was finally diagnosed. Treatment with anti-fungal Terbinafine Hydrochloride (Lamisil) 250 mg daily for 40 days cured it. (For more on fissured callus feet click 4.7 The Remedies
Scaly Skin Disease
is patch of skin that is thickened and looks white and scaly. It is sign of excess cell growth in skin, most often due to chronic irritation from scratching, but also external irritant like fungus infection or internal as in psoriasis. Also seen on sole of feet in oldster.
   Fungus is almost certain when you see coin-size oblong scaly patch with thin darker rim and pale core. “Ringworm” is the common name. Most often the patch is on arm or leg from fungus of finger or toe web. 
   In young man, on trip, such scaly patch only on upper body trunk is pityriasis rosea, unknown-cause, benign and self-limited. Self-diagnosing it, you may relax and not worry about rushing to Doctor. Lasts weeks, has no symptoms and disappears.
   Scaly patch without rim is psoriasis, a hyperkeratosis or callusing (Severity varies). Many cases respond to corticosteroid ointments as just mentioned. If not, get an experienced dermatologist at HMO.
   Flaky Skin is an extreme of scaly skin: the scales fall off and produce flake on shoulder. Also called “dandruff”, I leave it to magazine remedy. But if flaky skin spreads to face and ear, and skin creases get red and irritated patch, you have seborrheic dermatitis, a condition of over age 65, which never kills.
Skin Rash
Picture is worth many words so go to library and look for Fitzpatrick’s Textbook of Dermatology with photos of rashes from measles to molluscum or Google each by name. The measles-like rash, from virus, and also from allergy, is red with tiny elevation that is easier felt than seen, and all over body. Chickenpox and the assorted herpes rashes are small flat white pimples with a red surround at first and the pimples break leaving raw weepy areas. Its later occurrence as herpes zoster (shingles) occurs in zone of body; and herpes simplex is famous for breaking out on genitals or around mouth
Warts Virus
is found on sole of foot and on hand and finger because one carelessly walks unclean floors barefoot or touches source of virus with finger, and minor traumas rub it into broken skin. Different wart is molluscum contagiosum, which starts out as few tiny whiteheads that on close-up viewing are small plum-like bodies, and spread, usually at hairline from barber infection but also in child or sexual partner around genital. Third type is on penis or in vagina and called condyloma acuminatum due to human papilloma virus that also causes cervical cancer in women and now has a preventive vaccine. All are best treated by experienced GP or dermatologist usually by freezing or electro-cauterizing or chemical burning. Prevention: wear your own clean footwear, wash and dress a cut quickly, avoid barbershop or beauty parlor in favor of do-it-yourself, and choose monogamous sex partner.
Skin Cancer
Worry about skin cancer ought to be focused on ‘to biopsy or not?’ Skin biopsy is to cut out or pinch off skin lesion and test specimen to see if cancer or not? It is the best way to diagnose skin cancer in curable stage.
   To treat skin cancer surgically, the surgeon should cut it out and include sufficient border and depth to be sure nothing left behind. Surgery for melanoma and squamous cell carcinoma should be preceded by careful check to exclude spread of the cancer. Basal cell carcinoma, since it does not spread, can be treated more leisurely. It is slow-grow, warty hornlike; but it differs from wart in that it is scab and the scab easily brushed off by light trauma and regrows. Also appears where wart almost never is – body trunk, head, face. Best result is get a good plastic surgeon.

My Basal Cell Carcinoma
It is 1965 and I am 32 y/o doc in training. Over several months I become aware of pimple growing under hair on right scalp. My attention is pointed to it because I keep banging into it whenever I comb my hair. So I begin to feel it and get look at it in mirror. Looks like little thin wart, toothpick size, growing out of scalp several millimeters, but more fragile. It breaks off from base easily but quickly re-grows, and breaks again with little or no bleeding, and the piece looks like crust. Three months into this and getting worried. Consult plastic surgeon. He clips small area of scalp with biopsy pincer and one week later says, “basal cell carcinoma" (BCC). I go in hospital and, the day after, under local anesthesia, he cuts out a 1-inch diameter circle of full scalp centered on the BCC point and grafts skin.
From 2007 to 2010 I watched a basal cell cancer develop on the left side of nose of my then 86 to 89-year-old cousin Dan. In that time it grew from pimple size to about 1 1/2 inch diameter bleeding scab. Finally, Dan consulted a plastic surgeon who did a 2-hour total removal under local anesthesia and transplanted a flap of skin from the cheek and after 2 months you could not tell he'd had the surgery and by 6 years later the result is perfect. In future I would not advise waiting 3 years.
Today, in 2017 many dermatologists treat Basal Cell Ca with liquid nitrogen freezing, laser or topical cancer chemotherapy. 
I wondered why I got my skin cancer, Basal Cell Carcinoma is rare before age 40 so mine must have had potent and perhaps memorable cause. BCC is mostly caused from UV in sunlight but on scalp beneath full young head of hair the UV is unlikely cause. Also X-rays cause BCC. Here I recall in 1944, at age 11, a severe run of cavities involving right upper molars caused me to get dental X-rays. The films of right upper molars involved positioning so that x-rays were shot upwards into my mouth, on a line that hit my scalp just where I developed the BCC, 21 years later, which fits the latent period between X-ray DNA damage and clinical cancer.
   Limit x-ray to necessary minimum with modern safer machine and shielding of nearby structure in line of x-ray beam.
Squamous Cell Cancer
starts as ulcer and will metastasize and kill within 5 years from discovery if untreated. Sunlight's or tanning parlor's UV causes SCC. A reason not to get tanned!
   Because SCC is so malignant, it should be biopsied and treated quickly surgically plus follow-up chemotherapy as required, by plastic surgeon assisted by oncologist.
Melanoma
is the most deadly skin cancer. By name it means pigmented lesion, usually starting flat like freckle but growing, changing color, having irregular border and located on sun-exposed part. Treatment starts with biopsy and check for spread in hospital; then world-class plastic surgeon with oncologist consultation before expert-guided decision on initial treatment, and then continued expert oncologist follow-up.
Keeping Skin Healthy
Sunlight causes skin cancer, damages immune function, and results in aging spot and premature wrinkling because of UV rays that are now increasing because of loss of ozone layer. Also due to tanning lamp in the salon! So you stay healthier, younger and more beautiful by staying away from sun’s ray and the tanning lamps.
Skin is sensitive to getting contact dermatitis from wide range of irritant chemical (worst, poison ivy) so using neutral no-perfume soap and avoiding shampoo and shaving cream (simple soap can substitute for shaving cream; better yet use good Braun  electric shaver) and it will save you a lifetime of irritated skin woe. For women, stopping cosmetics and beauty parlor would assure healthier, more beautiful skin.
   Unrecognized source of dermatitis is washing machine detergent and dye chemical in clothing and bed sheet. These are culprits behind mysterious bouts of itching and skin reddening.
In lower leg or foot or waist belt-line or neck collar line, suspect the cause of the itching to be colored socks or elastic band (but do not forget bed- or sofa-bug bites); also around female breast because of brassieres and low back (loin) and in groin because of chemical in underpants, and on the shoulder, wrist, hand and finger because of glove, band and ring. Prevention is to stop commercial washing and when doing it yourself, put minimal detergent in machine and no bleach and follow with pure water washing machine-run to rinse out residual soap. Use only smooth white cotton touching skin. Also avoid jewelry and elastic or other constricting bands. And suspect old beds and old sofas or harboring biting bugs especially on the exposed legs.
                                                        Itching - a Summing Up 
Perhaps most irritatingly caused by insect bites. Bad recurrent itches of crotch and webs of fingers should have a check for scabies. a kind of mite that infests the pubic hair and is transmitted by careless sex body contact. Body itch mostly on the legs or exposed areas may be from bed or couch and sofa bugs. Just look at the itch area and you should see small red spots where the bugs have bit, mostly on exposed skin when you sleep or sit for long periods. A really malignant itch can occur after the shingles (herpes zoster) always in the shingles skin area on one side of body. And a person who uses opioids may note mild to moderate itching mostly around the head and usually not bothersome or serious and relieved by a pleasant rubbing. An immediate treatment of itching that is always at least temporarily successful is the corticosteroid ointment already mentioned. Just rub it in and best done over the warm moist skin itch area after shower or bath and on foot it is best kept in contact for an hour under a Saran wrap. Relief of itch is almost immediate and often for weeks. Of course, in cases of insect itch, get rid of the insects; and with bad Athlete's feet, use Lamisil 250 mg a day for a month, and with detergent itch, do as I wrote above.
Surface Appearance
Staining of skin, teeth and fingernail: Cigarettes are worst offender so it is one more reason to stop. If you drink wine, choose white over red because the pigment of red wine stains skin and teeth enough to have subtle effect on appearance. Coffee is a similar offender but if you must have coffee rinse mouth with water right after drinking). A worst case is to wrongly use betadine or other organic iodine antiseptic fluids as mouthwashes. Happily, a dentist can remove all the stains from teeth
   Sweating and soaking one’s clothes, in absence of fever, or of hot surroundings or of exercise, is a strong sign of the start of a hypoglycemic (low blood sugar) reaction – either to insulin, to oral hypoglycemic or simply to a hungry state. A cube of sugar or candy or sucrose drink can’t hurt and may help. Repeated attacks of sweating should have a checkup for blood glucose and for hyperthyroidism. 
End of Chapter. To read on next, now, click 5.(2-5) Bumps in skin/Allergy/Carotid Pulse/Face...










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