I have a rash in my axillae

 The commonest conditions the Pharmacist would see in the axillae would be intertrigo, contact irritant or allergic dermatitis, psoriasis and candida infection. Erythrasma would be more common than tinea. Rarely a patient with hidradenitis suppurativa could present fo advice.

 

In obese individuals skin tags are found. There also may be features of intertrigo from sweating or mild irritant or seborrhoeic dermatitis. The axilla is also a common site for contact dermatitis from a deodorant, and also for flexural psoriasis and occasionally rarer diseases such as Darier’s or Hailey-Hailey disease which will show a characteristic splitting of the skin, but these aren’t things you are going to commonly see in a skin cancer practice though clinically they are quite distinctive.

We are also seeing recently a lot of superficial peeling of the skin in the axillae and groin in patients with axillary granular parakeratosis, a contact irritant reaction to Canesten washes. (Dermnet)

Hailey Hailey but Dariers would look similar Rx Strong topical steroid, mupirocin and antifungal cream such as Lamasil

Mild axillary granular parakeratosis  Stop any additives to washing clothes.

The axilla can also be a common area to get a condition called erythrasma. (GSA) It is a Corynebacterial infection and it will give rise to a spreading annular lesion coming out of the axilla that is red or  brown in colour.  There is no real clearing behind it and there is no real scale at the advancing edge that you would see in a tinea infection.

Rx  It is best treated just with 1% topical Clindamycin Lotion twice daily.  You can do some scrapings to show the Corynebacteria there.  It will also fluoresce pink with a Woods light. 

Groin rather than axilla but same appearance

Trichomycosis axillaris is another corynebacterial infection presenting with small orange concretions attached to the axillary hairs. See the description in the image details below.

The other condition that you should know about is hidradenitis suppurativa.  (GSA) This commonly presents in the axilla as a series of sinuses or abscesses.  They may look like tumours when you are examining the patient.  Unfortunately this disorder is difficult to manage.  In an early stage surgical therapy is often best to just cut out the damaged areas, but later on three monthly courses of antibiotics are required, or some of the new TNF alpha inhibitors such as Humira are used. They are given as 2 weekly injections of 80mgs per injection and will reduce the level of inflammation and abscess formation if continued for some months. Antiandrogens such as Aldactone 100 mgs daily are also of value in perimenopausal women. Hidradenitis is particularly common in people who are overweight, and it can come on suddenly.

Well established HS Needs biologic to settle 

Long standing HS with sinuses and scarring

I have a rash on my legs

 The Pharmacist is most likely to be consulted about stasis eczema, lichen simplex chronicus and psoriasis if it is a red scaly rash. Pigment changes around the ankles from leaky varicose veins might also be presented. An acute cellulitis in a diabetic would be the most worrying presentation to correctly diagnose and refer for treatment 

 

The main solar lesions you will see on the lower legs are solar keratoses, SCC in situ, and occasionally melanoma particularly in women, but there are a variety of medical conditions that can affect the lower legs and present as lumps as well.  

Examples of this include hypertrophic lichen planus      (GSA)  particularly on the anterior shins.  It will have a purple colour with surrounding pigmentation but the nodules can be quite significant and can simulate a squamous cell carcinoma. 

Hypertrophic lichen planus Note color and Wickham's striae

 

Lichen simplex chronicus (GSA)    can affect the lower legs as well, and again give rise to nodules, but this time we call them prurigo nodules.  These can look very similar to keratoacanthomas but usually have a much longer duration and dont have a true keratin core.  KA’s  erupt quickly. 

Lichen simplex chronicus with prurigo nodule

 

The lower leg is a site of chronic lymphedema. (Dermnet)  It is also the site of stasis.  Chronic lymphedema can be congenital or it can be acquired.  The congenital version is known as Milroy’s disease, and these patients are very susceptible to infection but also they get overlying thickened changes in the epidermis with time that makes them susceptible to cellulitis.  

Stasis dermatitis is something you will see in a lot of lower legs.  It is due to venous hypertension.  There can be weeping and scarring, and if there is a lot of scarring it goes under the name of Lipodermatosclerosis or  atrophie blanche.  Generally the skin here is very thick.  It is difficult to do excisions, and most surgical procedures end up requiring skin grafts.  These patients will generally have to be in hospital with their legs elevated and some degree of negative pressure device applied to allow the skin graft to take. 

Stasis dermatitis

Atrophie Blanche

 

A curious phenomenon you may see just around the ankle beneath the medium malleolus are small hernia like protrusions known as piezogenic papules.  This is just a pressure phenomenon of mild herniation of the underlying fascia or fat, and it is of no significance.  The lesions certainly don’t need to be biopsied or removed.  

Piezogenic papules foot

Pigment changes in the lower leg are quite common especially in stasis, but the pigment in this case is due to hemosiderin not melanin.  It is due to pinpoint haemorrhage from capillaries in the skin due to increased venous pressure and capillary pressure.  It is more prominent on people who are on blood thinners.  It goes under the name of pigmented purpuric dermatosis. (GSA) (Dermnet)  Some of these can take an annular pattern.  Some can look a golden orange colour and are called lichen aureus, but they are all basically due to hemosiderin from capillary leakage.  If the capillary leakage can be decreased by support stockings then the pigmentation will slowly fade over six months or more.

Pigmented purpuric dermatosis

Lichen aureus

Other medical conditions commonly occurring on the lower legs anteriorly include erythema nodosum.  (GSA)  This usually follows a streptococcal throat infection or a female coming off the contraceptive pill, but occasionally it can be a manifestation of sarcoidosis so a chest x-ray should be ordered if you diagnose this condition.  The lesions represent a septal paniculitis, in other words it is inflammation in the septae between the lobules of fat, so it is deep in the skin.  There may be slight leakage of red blood cells since a small degree of bruising can be seen around the lesions which are usually tender, and on the anterior shins.  

Rx with rest and non-steroidal anti-inflammatories and support bandaging. 

Erythema nodosum

 

 

Other medical conditions seen along the front of the shins include necrobiosis lipoidica,    (GSA) particularly in diabetics.  It has a very characteristic location over the underlying tibial plate.  It has a yellowish look to it because of the overlying epidermal atrophy, and often shows the prominent blue veins underlying it.  It is important not to biopsy the centre of this but to biopsy the edge if you are going to.   It is a difficult condition to treat.  If patients injure or ulcerate this area it can be slow to heal.  

Rx There aren’t any good treatments.  You try and just get their diabetes under better control.  You can try a little bit of diluted intralesional steroid into any new lesions that come up.  The earlier you are able to get them the more effective the intralesional steroid is in treatment.

Necrobiosis lipoidica

 

 A patient may have a linear lump under the skin in the lower legs and this usually a superficial thrombophlebitis with a recent injury.  Generally these will slowly resolve on their own.  There is usually no deep venous involvement.

 

Ulcers in the lower leg are the classic venous ulcer over the medium malleolus, the arterial ulcer that is punched out, and the neuropathic ulcer typically on the soles of the feet and more prominent in diabetics.  

Venous stasis ulcer

Arterial ulcer

Neuropathic ulcer

Radionecrotic ulcer

Ulcerated SCC

Early arterial ulcer

 

The lower leg is a common site for dermatitis.  Usually it is a stasis dermatitis.  Occasionally it can be an allergic contact dermatitis that people have been applying, so always take that into account when you are assessing reactions around ulcers.  Make sure you know what the patient has put on them. 

Discoid eczema is also common on the lower legs. It is a red scaly itchy patch with small surface erosions and slight crusts if infected. Psoriasis is a differential but it does not have the small ewrosions of eczema or the crusts. 

Rx Discoid eczema is treated with a strong topical steroid and topical Mupoirocin for any secondary infection. Psoriasis plaques are best treated with Enstilar foam applied daily until cleared then as required for flares.

Infected dermatitis legs Contact superimposed

Patch of weeping discoid eczema

Severe plaque psoriasis leg

Psoriasis or Eczema?

 

I have a rash on my hands

 Presentations to the Pharmacist would include irritant and allergic contact dermatitis, pompholyx eczema, palmar psoriasis, tinea infections and possibly granuloma annulare and vitiligo. 

Solar lentigo back of hand 

Granuloma annulare (GSA) is an annular condition that is often seen over joints on the back of the hands, particularly the MP joints. It looks like ringworm but of course there is no scale associated, just papules of granuloma under the skin mainly seen at the edge of the annular lesion. 

Rx  Treatment of these is best with some diluted intralesional Kenacort, 1ml of Kenacort A10 with 3ml of local anaesthetic just injected into the edge in the dermis. They will often melt away with just one injection. This treatment is particularly effective for early lesions. Topical steroids just wont penetrate adequately. A rarer variant of GA on the back of the hand can show percutaneous perforation expulsion of the damaged collagen. GSA

Spreading non scaly edge of granuloma annulare dorsum hand

 

GA over the MP joint - no scale

Examining the palm of the hand you may notice palmar fascia thickening with an early Dupytren's contracture. Ultimately this will require surgical release,

A couple of annular rashes on the palms are worth diagnosing.

 

The first is secondary syphilis (GSA) with salmon pink scaly macules on both palms. Check the mouth and genital areas for other features of secondary syphilis, do a VDRL and treat with penicillin IM. Look for other sexually acquired diseases as well.

Secondary syphilis Scaly macules

The other condition presenting with annular "target" lesions on the palms and lower legs is Erythema multiforme. (GSA) This is usually secondary to recent herpes simplex elsewhere or a mycoplasma chest infection. The lesions are not scaly. They resolve without treatment. See this example in GSA

Erythema multiforme Target lesions

In colder areas, painful, itchy purplish  nodules on the back of the hands, particularly over the joints, may be a feature of perniosis, (GSA) but generally this is acute, and it is not a chronic thing that a skin cancer doctor is going to see much. Generally perniosis affects children or young women.

Rx Nicotinic acid or other vasodilators can help but protection from cold with appropriate clothing is best.

Perniosis

 

Hands that have been subject to rheumatoid arthritis or scleroderma over the years can show characteristic binding down of the skin of the fingers and tapering of the tips (sclerodactyly) giving a pencil shaped deformity, particularly in scleroderma, and ultimate atrophy of the tips of the fingers. Rheumatoid arthritis and gout can give rise to nodules. They are fairly soft with rheumatoid but can be quite firm under the skin in gout. Also with chronic scleroderma calcification under the skin is not uncommon, and this may present as firm lumps in this area.

Gouty nodules fingers

 

Changes in the colouration of the palm of the hand -  Red palms, can be a feature of underlying liver disease. Purple palms with papules can be a feature of lichen planus. Keratoderma of the palms of the hands can be a presentation of psoriasis particularly if it is over the  friction involved areas, but the association of malignancy occurs when you see palmar plantar keratoderma with oesophageal cancers. There are various congenital disorders that will give thickening of the palms but these are really too rare for us to discuss.

Violaceous colour of lichen planus of the palms

Plaque of palmar psoriasis on the thenar eminence

Rx A plaque of psoriasis like the one above would be best treated with Enstilar foam. This is a combination of calcipotriol and a strong steroid Betamethasone which penetrates the thick psoriatic scale and reduces the thickness preventing splitting of the keratin.

Presentation of scale just on one palm with the other palm being normal and similar scale on the soles of the feet, is one that is typically seen with a fungal infection called trichophyton rubrum. These patients invariably need oral Terbinafine 250 mgs daily for three months to try and clear this fungus. 

 Thickened psoriasis on the palms of the hands is best treated with some Enstilar Foam particularly at night. You can use some Glad Wrap occlusion to make it penetrate it better, but you then have to protect the hands with gloves from frictional factors that tend to keep the psoriasis going.

Tinea rubrum of the palm

Tinea nigra (GSA)     (Dermnet)    is an uncommon pigmented fungus that is seen on the palms and soles in tropical areas. It will scrape off with a blade and the scrapings can be sent for microscopy and culture. It is easily treated with an azole anti fungal cream or with terbinafine cream.

Brown spot of Tinea nigra

Dermatoscopy of Tinea nigra

Pompholyx (GSA) is an acute dermatitis involving the palms of the hands and the sides of the fingers with small vesicles of clear fluid trapped under a thick overlying stratum corneum. It is very itchy. The vesicles may join up to form blisters as in this case below. Pompholyx has a variety of causes but consider irritant or allergic contact dermatitis, occlusion causing hyperhidrosis or emotional stress. Some cases may be an ID reaction to a fungal infection between the toes. (Dermnet) 

Rx A strong topical steroid such as full strength betamethasone 0.1% cream or Diprosone OV cream or even a short course of oral steroids. Protect the hands from irritants after the skin overlying the blisters peels off. It takes two months for the normal skin barrier function to return so keep protecting plus gloves even after the skin looks normal at 3 weeks!

Blistering pompholyx

Pustular pompholyx Secondary Staph infection

Keratolysis exfoliativa

Keratolysis exfoliativa is a common superficial peeling disorder which is best regarded as a mild form of dermatitis but it does not respond to topical steroids and only needs a moisturiser and protection from irritants. It is not itchy. (Dermnet) It seems to just flare up with the change of the seasons in some people.

Crusted or Norwiegian scabies

Crusted scabies   (GSA)  is one hand you dont want to touch without gloves! It will probably be a Nursing home patient whom you are seeing for skin cancer  who has had a stroke or is immunosuppressed in some way, who has been itchy for some time. Look at all the usual places for scabies and confirm with a dermatoscope. (Dermnet)

Rx is with oral Ivermectin 12 mgs daily (4x 3 mgs tabs) on alternate days 3 times in a week with daily application of Permethrin (Lyclear cream 30 gms) all over for a week. Treat nearest and dearest as well with a couple of applications of Lyclear cream a week apart,  plus probably the rest of the nursing home and Nursing staff!