Ординатура / Офтальмология / Английские материалы / Clinical Medicine in Optometric Practice_Muchnick_2007

214 CLINICAL MEDICINE IN OPTOMETRIC PRACTICE

AD are the neck, hands, and eyes. Patients with ocular atopic dermatitis complain of itching and foreign body sensations of the eyes. Ocular involvement occurs caused by mast cell degranulation and results in blepharitis, bulbar conjunctival injection, papillae formation on the palpebral conjunctiva, atopic keratoconjunctivitis (AKC), and superficial punctuate keratitis. An infraorbital crease of skin forms in this condition known as the Dennie-Morgan fold. Interestingly, a greater frequency of cataract formation occurs in patients with atopic dermatitis. Patients with atopic dermatitis require a dilated fundus examination, because they are at greater risk of retinal detachment. Treatment of the dermatitis requires fluorinated corticosteroids to reduce cutaneous inflammation. Patients should be advised to avoid rubbing the eyelids, because this trauma will facilitate mast cell degranulation. Ice packs on the eyes will reduce the pruritic response. Typically, a cream-based hydrocortisone is applied with dressings to facilitate the action of the steroid. Topical NSAIDs, such as ketorolac tromethamine (Acular), will reduce the ocular itching associated with AD. Oral corticosteroids may be necessary to quell the systemic inflammation associated with AD. Oral antihistamines are effective in reducing bodywide pruritus.

Contact Dermatitis

Contact dermatitis (CD) is a cutaneous response to direct contact with an allergen that elicits an allergic reaction. The reaction typically occurs from 1 to 24 hours after contact with the offending agent. In some cases the response is immediate, with erythema forming within an hour. In other cases, a delay is caused by sensitization. In delayed sensitivity, a reexposure causes an inflammatory response, usually within 2 to 3 days. Thus, two types of CD exist: irritant CD and allergic CD. Irritant CD is typified by an onset within hours of contact and does not require a sensitizing exposure, whereas allergic CD is a delayedtype sensitivity that requires sensitization with the allergen. CD is a hypersensitivity reaction from exposure to airborne antigens, or direct contact with the skin of drugs, chemicals, or any environmental substance (Box 16-10). A partial list of offending substances includes any drugs, contact lens preservatives, concentrated acids or bases, chemicals, minerals, dyes, and cosmetics. The most common cause of allergic contact dermatitis is contact with plants such as poison ivy, poison oak, and poison sumac. Whether the response is immediate or delayed, the first reaction is typically erythema of the skin with associated burning and stinging. The immediate response is wet and edematous skin. In chronic conditions the skin is typically thick, dry, and scaly (Figure 16-12). The skin begins to itch, particularly if the allergic response is delayed. Papules and vesicles may eventually develop.

BOX 16-10

CAUSES OF ALLERGIC CONTACT DERMATITIS

■Nickel-jewelry, scissors, door handles, watch bands, belt buckles

■Chromium compounds-cement, leather gloves, leather shoes, metals, dyes, photographic processes

■Balsam of Peru: perfumes, shampoos, hair products

■Formaldehyde: cosmetics, wash and wear clothing, paper, glue

■Topical anesthetics: sunburn and antiitch preparations

■Paraben mix: cosmetics, topical creams and ointments, topical corticosteroid preparations

■Paraphenylenediamine: hair dyes, PABA sunscreens, sulfonamides

■Rubber: shoes, elastic, adhesive bandages, condoms, surgical gloves

■Acrylic fabrics

■Other chemicals in personal care products: Imidazolidinyl urea (preservative), wool alcohols, formaldehyde, quaternium-15

FIGURE 16-12 ■ Contact dermatitis of lower lid caused by dipivefrin ophthalmic solution (Propine): chronic, with dry scaling.

Ocular involvement includes papillary conjunctivitis and serous discharge. Blepharitis with an associated superficial punctate keratitis (SPK) may occur. Treatment of CD includes avoidance of known allergens and application of topical steroid cream to the affected areas. The patient should be encouraged not to scratch the affected areas, because this will worsen the skin condition.

Eczema

Eczema is a chronic dermatitis that is characterized by itching and skin eruptions. For example, chronic hand eczema is a dermatitis produced by exposure to water and detergents. The skin of the hands becomes dry, cracked, and erythematous. The use of rubber gloves

when exposed to water and detergents helps to eliminate this painful form of eczema. Latex allergy may produce an immediate type hypersensitivity reaction, however, that can cause a fatal anaphylactic reaction. Another common eczema condition is asteatotic eczema, or winter itch. During dry, cold, periods of the year, the elderly may complain of superficial itching of the legs. Examination reveals fine cracks, with erythema on the anterior surfaces of the legs. Topical emollients will help alleviate the associated pruritus.

Seborrheic Dermatitis

This form of cutaneous reaction results in dry skin that produces dandruff. The chronic condition is characterized by pinkish-red, greasy scales overlying erythematous plaques. Seborrhea represents a disorder of the sebaceous glands. Although the etiology is unknown, it is believed that Pityrosporum ovale, a yeast found around the skin of the glands, has a causative role. Elimination of the yeast tends to improve the condition. Seborrheic dermatitis affects primarily the scalp, where the classic sign is dandruff. The ears, eyebrows, eyelashes, and central face may be involved, however. This condition is characterized by exacerbations and remission, is worsened by stress, and is often found in HIV/AIDS patients and those with Parkinson’s disease. The ocular condition associated with seborrheic dermatitis is known as seborrheic blepharitis. Patients complain of an ocular foreign body sensation and burning. Greasy scales, or scurfs, are noted on the skin of the lids. The lids may be erythematous. The hallmark characteristic of seborrheic blepharitis is the production of dandruff flakes of the eyelashes. Treatment of seborrheic blepharitis makes use of lid scrubs with dandruff shampoo and, if resolution is not forthcoming, the application of a topical antibiotic medication. In recalcitrant cases, topical glucocorticoids may be necessary to manage the underlying inflammation.

Psoriasis

This chronic skin condition, which affects as much as 4% of the world’s population, causes dry, elevated, and rounded erythematous plaques found most often on the knees or elbows. Characteristically, the plaque is covered in papules and silvery mica-like scales. The most common presenting symptom is pruritus. Psoriasis is worsened by stress, infections, lithium, betablockers and antimalarial drugs. It may occur on the eyelids resulting in conjunctivitis and keratitis. An increased frequency of corneal ulcers and iritis is associated with psoriasis of the eyelids. Psoriasis occurs in greater frequency among patients with HLA-B27 related syndromes, and a definite relationship exists between psoriasis and rheumatoid arthritis. Specific agents for the amelioration of psoriasis include reti-

DERMATOLOGY 215

noid gels (such as tazarotene [Tazorac], a vitamin A analog) used in combination with steroids and ultraviolet light therapy. In addition, methotrexate has been approved for the systemic treatment of psoriatic arthritis. A very effective treatment modality for psoriasis is psoralen ultraviolet A irradiation (PUVA). Topical glucocorticoids may aid in the amelioration of localized plaque-type psoriasis.

Acne Vulgaris

Considered the scourge of the teenage years, acne vulgaris is characterized by small cysts, or comedones, several of which will occur on a patch of erythematous skin. Associated with the comedo are any number of papules, pustules, and nodules. The comedo can be a whitehead or a blackhead. Whiteheads are closed and difficult to express. The content of this papule is typically pus filled with lymphocytes, thus imparting the white color that is accentuated on stretching of the skin. Blackheads have a large follicular opening and are easily expressed. The orifice is filled with dark, oxidized skin oil that imparts the black color. Acne vulgaris is associated with the increase in sebum production from the sebaceous glands that occurs after puberty. The sebum blocks the hair follicle and a comedo forms. Within the comedo, bacteria and yeast act on the sebum to release fatty acids, resulting in inflammation of the cyst wall. Eventually the comedo ruptures, spilling its contents of oil and keratin and leading to an intensified inflammatory response. Early in the evolution of the skin response, acne begins on the forehead. It then tends to travel down the cheeks to the central face. Acne is worsened by physical trauma to the skin and exposure to foreign materials such as chin straps on helmets. This condition may be aggravated by cosmetics and oral steroids. In addition, acne has been associated with use of lithium, isoniazid, and phenobarbital. The goals of acne treatment are the elimination of the comedones, a decrease in sebum production, the reduction of bacteria and yeast populations, and a decrease in overall skin inflammation. Topical retinoic acid prevents formation of comedones and aids in resolution of existing cysts. Topical antibiotics reduce the bacterial population within the comedones. Oral antibiotics reduce bacterial colonization. The synthetic retinoid isotretinoin causes dry skin and cannot be used in pregnancy, but is useful in the treatment of severe nodulocystic acne.

Acne Rosacea

This cutaneous inflammation of the central face, now referred to as rosacea, occurs primarily in adults older than 30 years. Although this condition is seen mostly in women, men are more severely affected. The inflamed skin is characterized by a flushing of the skin across the bridge of the nose and symmetrically involving both

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cheeks. The skin is erythematous and contains small telangiectasias and pustules. No comedones are present as in acne vulgaris. Rosacea is caused by a disorder of the sebaceous glands of the skin initiated by bacteria that cause the release of inflammatory stimulating fatty acids. In chronic cases the skin of the nose thickens, enlarging the entire nose. The patients at greatest risk for acne rosacea are those who tend towards easy facial flushing. Patients who report that their faces flush in response to heat, spicy foods, emotions, and alcohol are all at greater risk for acne rosacea. The flush eventually becomes a permanent cutaneous fixture, and the sebaceous glands of the eyelids become involved. The presence of bacteria in the glands causes a release of irritating fatty acids, and these compounds appear to modify the meibomian gland release of lipids into the tears. This alteration in meibomian gland secretory compounds seems to increase surface evaporation from the tear layer, producing dry eye. Rosacea is associated with a litany of ocular complications, including blepharitis, keratitis, and iritis. Chronic rosacea may result in dry eye caused by heightened tear evaporation. The ocular manifestations of chronic dry eye then may yield recurrent hordeola and corneal damage. The treatment of rosacea is best achieved with oral tetracycline in doses of 250 to 1000 mg/d. The antibiotic reduces the free fatty acids released by the surface sebum, and this reduces inflammation and irritation. It is important to note that tetracycline reduces the lipase activity of the bacteria without reducing the bacterial population. Topical low-dose steroids may also be effective in alleviating the erythema, however, fluorinated topical glucocorticoids may actually worsen the condition. Chronic flushing is treated by clonidine, the only drug approved for this purpose.

Stevens-Johnson Syndrome

Also referred to as erythema multiforme major, SJS is characterized by a diffuse erythematous eruption of papules, most often on the soles of the feet and palms of the hand. Small blisters form on deep purple macules. The classic skin lesion of SJS is a bull’s-eye or target rash typified by an erythematous ring that surrounds a ring of normal tissue, all encompassing an erythematous center. The skin outbreak coincides with a fever, sore throat, malaise, and myalgias in approximately one third of cases. SJS is a systemic and potentially fatal condition that ultimately involves the mucus membranes of the nose, mouth, and eyes. SJS is a deranged and exaggerated response, usually to medication, and erythema multiforme is typically a reaction to infection. Ocular involvement begins with a pseudomembranous conjunctivitis with bullae formation. Rupture of the bulla leads to conjunctival scarring and symblepharon. The lids may undergo entropion with resultant trichiasis and corneal scarring. Treatment involves removal of

the causal agent. In addition, the use of systemic steroids and immunosuppressive agents, while controversial, has been shown to be effective. Topical aminoglycosides reduce the risk of ocular infection, and topical steroids will reduce the ocular inflammation. The fornices should be swept with a glass rod to prevent symblepharon formation between conjunctival surfaces.

Warts

These cutaneous neoplasms are caused by human papillomavirus (HPV) 6 or 12. Also known as verruca vulgaris, or papillomata, these skin lesions are pedunculated, grape-like, and dome-shaped and measure approximately 1 cm in diameter (Table 16-3). The wart has a central core of keratinized debris surrounded by a thick layer of keratin (Figure 16-13). Flat warts, or verruca plana, appear commonly on the face, are fleshcolored or pink, and 1 to 3 mm in size (Figure 16-14). The lesions may affect the genital tract and begin as small papillomas that grow into large, fungus-like lesions. They affect the labia in women and the shaft of the penis in men. Warts can occur on the eyelid margin, and may pour viral particles into the eye, initiating a viral conjunctivitis (Figure 16-15). HPV has been shown to be responsible for uterine cervical cancer. In the spring of 2006, the first HPV vaccination was approved to prevent cervical cancer. Several treatment modalities exist to remove warts depending on location. Cryotherapy with liquid nitrogen is convenient and effective in many cases. Genital warts are treated with podophyllin preparations or topical imiquimod. Trichloracetic acid or cantharidin are topical agents that are also used for wart removal.

TABLE 16-3 CLINICAL CHARACTERISTICS OF VERRUCAE

FIGURE 16-13 ■ Common wart (verruca vulgaris), with heavily keratinized, lobulated surface.

FIGURE 16-14 ■ Two flat warts (verruca plana) that are slightly elevated, papular, and flesh-colored.

Benign Elevated Ocular Skin Tumors

Papilloma

The squamous papilloma is also known as an acrochordon, or skin tag, and appears as a projection of the skin in a frond-like configuration (Table 16-4). This papilloma is the most common of all benign eyelid lesions. Viewed histiologically, this tumor has an increased thickness caused by redundant epithelium (Figure 16-16). These lesions may be excised for cosmetic reasons.

Inclusion Cyst

These slow-growing epidermal lesions are the second most common benign lid lesion, and they can occur spontaneously or from trauma. The inclusion cyst arises from the infundibulum of hair follicle, appearing as a firm nodule on the skin surface (Table 16-5). As a cyst, it is filled with keratin, and several forms of inclusion cyst exist (Figures 16-17 and 16-18). Removal is best achieved through excision or curettage.

Sudoriferous Cyst

Caused by occlusion of the gland of Moll duct, these cysts are associated with the eyelash follicle. The cyst appears filled with translucent fluid (Table 16-6). The syringoma are a common and benign variation of the

TABLE 16-4 CLINICAL CHARACTERISTICS OF PAPILLOMAS

218 CLINICAL MEDICINE IN OPTOMETRIC PRACTICE

TABLE 16-5 CLINICAL CHARACTERISTICS OF INCLUSION CYSTS

FIGURE 16-17 ■ Epidermal cyst on upper eyelid, with fine texture and small, central drainage channel.

FIGURE 16-18 ■ Senile sebaceous hyperplasia, with multiple, lobulated papules.

TABLE 16-6 CLINICAL CHARACTERISTICS OF SUDORIFEROUS CYSTS

sudoriferous cyst, that appear as waxy, pale, and yellowish papules near the eyelid margin (Figure 16-19). These cysts are common in pregnant women.

Seborrheic Keratosis

This benign skin condition of the elderly is a growth of the basal epithelial cells and contains pseudocysts. The classic appearance is that of a greasy, oily, pigmented lesion that is “stuck on” to the underlying epidermis (Box 16-11). The surface of the lesion is crust-like (Figure 16-20), and can be removed by excision for cosmetic considerations. Constant irritation of the seborrheic keratosis may result in a cutaneous horn.

FIGURE 16-19 ■ Sudoriferous cyst at inner canthus; fluidfilled, translucent, with level of cellular debris.

BOX 16-11

CLINICAL CHARACTERISTICS OF SEBORRHEIC KERATOSIS

Variable tan to black color Multiple confluent papules

Granular, keratinized, crumbling surface Possibly multilobed or wart-like Variable elevation (flat to pedunculated) “Stuck on”

Sharp borders

Cutaneous Horn

Also known as inverted follicular keratosis, the appearance of the cutaneous horn is similar to a wart (Box 16-12). Histiologically, lobules of proliferating basal and squamous cells are present (Figure 16-21). Complete excision is used for cosmetic reasons.

Molluscum Contagiosum

These are waxy, nodular lesions similar to warts with umbilicated central ulcers (Figure 16-22). If located on the eyelid, an associated follicular conjunctivitis may

BOX 16-12

CLINICAL CHARACTERISTICS OF CUTANEOUS HORN

Keratin build-up

Possibly conical shape

Associated with a primary lesion

FIGURE 16-21 ■ Cutaneous horn developing on verruca vulgaris.

be present. Many of these lesions spontaneously resolve in less than a year, thus a period of observation and photography is recommended. Removal is by excision, curettage, or cryotherapy.

Premalignant Epithelial Lesions

Keratoacanthoma

This premalignant epithelial lesion grows quickly and has an ulcerated center filled with keratin (Box 16-13). Keratoacanthoma appear most often on sun-exposed areas of the body (Figure 16-23). Complete excision of the lesion is recommended, because these are considered low-grade squamous cell carcinomas.

Actinic Keratosis

Actinic keratosis is a premalignant epithelial lesion that appears as a flat, erythematous, scaly lesion (Box 16-14). These lesions occur most often on sunexposed areas of the body (Figure 16-24). More than one tenth of these lesions transform into squamous cell carcinoma, thus rapid identification and excision is necessary in all cases.

Malignant Cutaneous Lesions

Basal Cell Carcinoma

This nonmelanoma skin malignancy arises from the epidermal basal cells, and there are several types of basal cell carcinomas each with their own inherent characteristics (Table 16-7). The classic appearance of the BCC is an elevated, pearly nodule with an umbilicated bleeding center (Figure 16-25). These lesions can present with a variable amount of pigment, and each type of BCC can be confused with a wide variety of other skin conditions (Box 16-15). BCC grows fairly slowly, and the tumor rarely

BOX 16-13

CLINICAL CHARACTERISTICS

OF KERATOACANTHOMA

Single lesion

Dome-shaped

Pink or red papule

Central crater or umbilication

Keratin cap

Less common: elevated, warty, ulcerated

FIGURE 16-23 ■ Keratoacanthoma, typically presenting as a dome-shaped papule with a central keratin core.

BOX 16-14

CLINICAL CHARACTERISTICS OF ACTINIC KERATOSIS

Initially flat

Pink, increased vascularity

Increasing erythema over time

Increasing surface keratin over time

TABLE 16-7 CLINICAL CHARACTERISTICS OF BASAL CELL CARCINOMA

BOX 16-15

CONDITIONS FREQUENTLY CONFUSED WITH SEBACEOUS GLAND CARCINOMA

Chalazion

Basal cell carcinoma Squamous cell carcinoma Unilateral blepharitis

Unilateral blepharoconjunctivitis

Granulomatous lid lesions (from tuberculosis, sarcoid, syphilis)

Meibomitis

Superior limbic keratoconjunctivitis Leukoplakia

Ocular pemphigoid Carcinoma in situ Cutaneous horn Lacrimal gland tumor

FIGURE 16-26 ■ Sclerosing basal cell carcinoma, with appearance of scar tissue, lacking erosion or crusting.

FIGURE 16-27 ■ Early squamous cell carcinoma, with erythema and elevated scale.

DERMATOLOGY 221

bridge of the nose (Figure 16-26). Biopsy of these small red lesions usually confirms the presence of basal cell carcinoma even before the classic signs of bleeding or the presence of a pearly-white margin appears (Figure 16-27). Treatment of BCC is usually directed at full-thickness dissection. Most often, dermatologists use electrodissection and curettage for low-risk tumors, and more aggressive tumors are excised. Mohs micrographic surgery is used for BCC of the eyelids, because it permits maximal histiological control with minimal tissue disruption.

Squamous Cell Carcinoma

Much less common than BCC but much more deadly, squamous cell carcinoma (SCC) appears as a greasy, reddened, ulcerated nodule or superficial erosional lesion (Figure 16-28) that disrupts the normal anatomy

FIGURE 16-28 ■ Nodular basal cell carcinoma on lower lid, flesh-colored, with slight central umbilication but no erosion.

BOX 16-16

CLINICAL CHARACTERISTICS OF SQUAMOUS CELL CARCINOMA

Firm nodule Flat patch Erythematous

Variable surface scale

Heavy, thick when derived from actinic keratosis Mild when derived from actinically damaged skin

Fissured surface Ulceration Bleeding, crusting

Purulent discharge, infection Wartlike

Cystic Cutaneous horn

No telangiectasias No pearly borders

222 CLINICAL MEDICINE IN OPTOMETRIC PRACTICE

BOX 16-17

CONDITIONS CONFUSED WITH SQUAMOUS CELL CARCINOMA

Actinic keratosis Adenoacanthoma Adnexal carcinoma

Basal cell carcinoma (nodular)

Basal cell carcinoma (noduloulcerative) Basal cell carcinoma (morpheaform)

Basal cell carcinoma with pseudoepitheliomatous hyperplasia

“Benign keratosis” (seborrheic keratosis) Bowen’s disease

Cutaneous horn

Inverted follicular keratosis Keratoacanthoma Papilloma

Pseudoepitheliomatous hyperplasia Sebaceous gland carcinoma

Seborrheic keratosis with surface irritation Wart (verruca)

of the skin, lower lip, or eyelid margin (Box 16-16). SCC arises from keratinized epidermal cells and can be confused with a host of other cutaneous lesions (Box 16-17). Overlying telangiectasias are an uncommon feature of SCC. SCC is very aggressive, and disseminates quickly throughout the body through the nerve endings, lymph channels, and bloodstream. Surgical excision and radiation treatments are the standard treatment modalities. Metastases are treated with lymph node dissection and radiation.

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