Acquired

Acquired

Campbell de Morgan spots These are arteriovenous fistulae at the dermal capillary level in - sun-exposed skin of older patients ( Figure 45.45 ). Spider naevi These are angiomata that appear (and may disappear) sponta neously at puberty or in two-thirds of pregnant women, usually disappearing in the puerperium ( Figure 45.46 ). Spider naevi are also associated with c hronic liver disease. They can be treated with intense pulsed light or pulsed-dye laser. Pyogenic granuloma These share many histological characteristics of haemangio mata and are probably a subtype thereof ( Figure 45.47 are small (0.5–1.5 /uni00A0 cm), raised, pedunculated, soft, red nodular lesions showing superficial ulceration and a tendency to bleed after trivial trauma. They should be excised with a minimal margin. Glomus tumour This arises from a subcutaneous arteriovenous shunt (Sucquet– Hoyer canals), especially in the corium of the nail bed. Typically , JP Sucquet , 1840–1870, anatomist, Paris, France. Heinrich Hoyer , 1834–1907, Professor of Histology , Embryology and Anatomy , Central Medical School, The Polish University , Warsaw , Poland. - it is a small, purple nodule measuring a few millimetres in size, which is disproportionately painful in response to insignificant stimuli, including cold exposure ( Figure 45.48 ). Subungual - varieties may be invisible causes of paroxysmal digital pain. ). Most Angiosarcoma (‘malignant angioendothelioma’) A rare, highly malignant tumour arising from the endothelial cells ( Figure 45.49 ). The lymphangiosarcoma variant arises from lymphatic endothelium and can develop in lymphoedem - atous tissue, particularly an extremity . Proliferation is rapid with early systemic spread.

Figure 45.44 ‘Port-wine’ stain (courtesy of St John’s Institute for Dermatology, London, UK). Figure 45.45 Campbell de Morgan spot (courtesy of Mr AR Green baum). Figure 45.46 Spider naevus (courtesy of St John’s Institute for Dermatology, London, UK).

Figure 45.47 Pyogenic granuloma (courtesy of St John’s Institute for Dermatology, London, UK).

Kaposi’s sarcoma Kaposi’s sarcoma is a malignant, proliferative tumour of vascular endothelial cells, which was first described in elderly Jewish men but is now most commonly associated with immune compromise after transplantation or HIV infection ( Figure 45.50 ). There appears to be a causal link with infection by human herpesvirus 8. Kaposi’s sarcoma usually starts as a red-brown, indurated, plaque-like skin lesion that becomes nodular and then ulcerates. Treatment is with radiotherapy .

Figure 45.48 Glomus tumour (courtesy of St John’s Institute for Dermatology, London, UK).

Acquired

Pressure sores These begin with tissue necrosis at a pressure point and develop into a cone-shaped volume of necrotic loss. As many as 10% of acute hospital inpatients will have some degree of pressure sore. The majority a ff ect the elderly and patients with spinal injury or decreased sensibility; 80% of paraplegics will get a pressure sore and 8% die as a result. The pathogenesis of pressure sores revolves around unre lieved pressure: an increase in local tissue pressure above that of perfusion pressure produces ischaemic necrosis that is directly proportional to the duration and degree of pressure and inver sely proportional to the area over which it is applied. Muscle and fat are more susceptible to pressure than skin. In a patient who has no predisposing factors management is aimed at debridement and repair of the defect, on the assump tion that recurrence will not occur once normal function and sensibility returns. In the paraplegic patient, recurrence is likely so management should involve a multidisciplinary approach. Primary treatment involves relieving pressure (special mattress, nursing care, relief of muscle spasm and contractures), opti mising nutrition, correcting anaemia and preventing infection. Surgery involves thorough debridement to promote healing and plastic surgery to reconstruct the defect. Ulcers An ulcer is a discontinuity of an epithelial surface. It is characterised by destruction of the surface epithelium and a granulating base. Ulcers can be classified as non-specific, specific and malignant ( Figure 45.51 ). Sinus A sinus is a blind-ending tract connecting a cavity lined with granulation tissue (often an abscess cavity) to an epithelial (a) (b) (c) (d ) ( e) Burrill Bernard Crohn , 1884–1983, gastroenterologist, Mount Sinai Hospital, New Y ork, NY , USA, described regional ileitis in 1932. - - surface ( Figure 45.52a ). Sinuses may be congenital or acquired. Congenital sinuses arise from the remnants of persistent embryonic ducts. Acquired sinuses can result from: a retained foreign body (ingrown hair or suture material); chronic infection (tuberculosis, osteomyelitis or actinomycosis); chronic - inflammation (Crohn’s disease); malignancy; or inadequate surgical drainage of a cavity . , Treatment of a sinus is directed at removing the underlying cause. Biopsies should always be taken from the wall of a sinus to exclude malignancy or specific infection. For specific man - - agement of the disease conditions, please refer to the appro - priate chapter. Fistula A fistula is an abnormal communication between two epithelium-lined surfaces ( Figure 45.52b ). This commu - nication or tract is usually lined by granulation tissue, but may become epithelialised in chronic cases. Fistulae may be congenital (e.g. tracheo-oesophageal and branchial fistulae) or acquired (e.g. enterocutaneous complicating Crohn’ s disease or surgery , or arteriovenous). Management of a fistula is directed at the underlying aetiology (see the appropriate chapters).

Figure 45.51 Some characteristic shapes of the edges of ulcers. /uni00A0 (a) Non-speci /f_i c ulcer: note the shelving edge. (b) Tuberculous ulcer: note the undermined edge. (c) Basal cell carcinoma (rodent ulcer): note the rolled edge, which may exhibit small blood vessels. thelioma: note the heaped-up, everted edge and irregular thickened base. (e) Syphilis: note the punched-out edge and thin base, which may be covered with a ‘wash-leather’ slough. Figure 45.52 A sinus (a) and a /f_i stula (b) ; both usually arise from a preceding abscess. (a) This is a blind track, in this case a pilonidal abscess. (b) This is a track connecting two epithelium-lined surfaces, in this case a colocutaneous /f_i stula from colon to skin.

Acquired

Campbell de Morgan spots These are arteriovenous fistulae at the dermal capillary level in - sun-exposed skin of older patients ( Figure 45.45 ). Spider naevi These are angiomata that appear (and may disappear) sponta neously at puberty or in two-thirds of pregnant women, usually disappearing in the puerperium ( Figure 45.46 ). Spider naevi are also associated with c hronic liver disease. They can be treated with intense pulsed light or pulsed-dye laser. Pyogenic granuloma These share many histological characteristics of haemangio mata and are probably a subtype thereof ( Figure 45.47 are small (0.5–1.5 /uni00A0 cm), raised, pedunculated, soft, red nodular lesions showing superficial ulceration and a tendency to bleed after trivial trauma. They should be excised with a minimal margin. Glomus tumour This arises from a subcutaneous arteriovenous shunt (Sucquet– Hoyer canals), especially in the corium of the nail bed. Typically , JP Sucquet , 1840–1870, anatomist, Paris, France. Heinrich Hoyer , 1834–1907, Professor of Histology , Embryology and Anatomy , Central Medical School, The Polish University , Warsaw , Poland. - it is a small, purple nodule measuring a few millimetres in size, which is disproportionately painful in response to insignificant stimuli, including cold exposure ( Figure 45.48 ). Subungual - varieties may be invisible causes of paroxysmal digital pain. ). Most Angiosarcoma (‘malignant angioendothelioma’) A rare, highly malignant tumour arising from the endothelial cells ( Figure 45.49 ). The lymphangiosarcoma variant arises from lymphatic endothelium and can develop in lymphoedem - atous tissue, particularly an extremity . Proliferation is rapid with early systemic spread.

Figure 45.44 ‘Port-wine’ stain (courtesy of St John’s Institute for Dermatology, London, UK). Figure 45.45 Campbell de Morgan spot (courtesy of Mr AR Green baum). Figure 45.46 Spider naevus (courtesy of St John’s Institute for Dermatology, London, UK).

Figure 45.47 Pyogenic granuloma (courtesy of St John’s Institute for Dermatology, London, UK).

Kaposi’s sarcoma Kaposi’s sarcoma is a malignant, proliferative tumour of vascular endothelial cells, which was first described in elderly Jewish men but is now most commonly associated with immune compromise after transplantation or HIV infection ( Figure 45.50 ). There appears to be a causal link with infection by human herpesvirus 8. Kaposi’s sarcoma usually starts as a red-brown, indurated, plaque-like skin lesion that becomes nodular and then ulcerates. Treatment is with radiotherapy .

Figure 45.48 Glomus tumour (courtesy of St John’s Institute for Dermatology, London, UK).

Acquired

Pressure sores These begin with tissue necrosis at a pressure point and develop into a cone-shaped volume of necrotic loss. As many as 10% of acute hospital inpatients will have some degree of pressure sore. The majority a ff ect the elderly and patients with spinal injury or decreased sensibility; 80% of paraplegics will get a pressure sore and 8% die as a result. The pathogenesis of pressure sores revolves around unre lieved pressure: an increase in local tissue pressure above that of perfusion pressure produces ischaemic necrosis that is directly proportional to the duration and degree of pressure and inver sely proportional to the area over which it is applied. Muscle and fat are more susceptible to pressure than skin. In a patient who has no predisposing factors management is aimed at debridement and repair of the defect, on the assump tion that recurrence will not occur once normal function and sensibility returns. In the paraplegic patient, recurrence is likely so management should involve a multidisciplinary approach. Primary treatment involves relieving pressure (special mattress, nursing care, relief of muscle spasm and contractures), opti mising nutrition, correcting anaemia and preventing infection. Surgery involves thorough debridement to promote healing and plastic surgery to reconstruct the defect. Ulcers An ulcer is a discontinuity of an epithelial surface. It is characterised by destruction of the surface epithelium and a granulating base. Ulcers can be classified as non-specific, specific and malignant ( Figure 45.51 ). Sinus A sinus is a blind-ending tract connecting a cavity lined with granulation tissue (often an abscess cavity) to an epithelial (a) (b) (c) (d ) ( e) Burrill Bernard Crohn , 1884–1983, gastroenterologist, Mount Sinai Hospital, New Y ork, NY , USA, described regional ileitis in 1932. - - surface ( Figure 45.52a ). Sinuses may be congenital or acquired. Congenital sinuses arise from the remnants of persistent embryonic ducts. Acquired sinuses can result from: a retained foreign body (ingrown hair or suture material); chronic infection (tuberculosis, osteomyelitis or actinomycosis); chronic - inflammation (Crohn’s disease); malignancy; or inadequate surgical drainage of a cavity . , Treatment of a sinus is directed at removing the underlying cause. Biopsies should always be taken from the wall of a sinus to exclude malignancy or specific infection. For specific man - - agement of the disease conditions, please refer to the appro - priate chapter. Fistula A fistula is an abnormal communication between two epithelium-lined surfaces ( Figure 45.52b ). This commu - nication or tract is usually lined by granulation tissue, but may become epithelialised in chronic cases. Fistulae may be congenital (e.g. tracheo-oesophageal and branchial fistulae) or acquired (e.g. enterocutaneous complicating Crohn’ s disease or surgery , or arteriovenous). Management of a fistula is directed at the underlying aetiology (see the appropriate chapters).

Figure 45.51 Some characteristic shapes of the edges of ulcers. /uni00A0 (a) Non-speci /f_i c ulcer: note the shelving edge. (b) Tuberculous ulcer: note the undermined edge. (c) Basal cell carcinoma (rodent ulcer): note the rolled edge, which may exhibit small blood vessels. thelioma: note the heaped-up, everted edge and irregular thickened base. (e) Syphilis: note the punched-out edge and thin base, which may be covered with a ‘wash-leather’ slough. Figure 45.52 A sinus (a) and a /f_i stula (b) ; both usually arise from a preceding abscess. (a) This is a blind track, in this case a pilonidal abscess. (b) This is a track connecting two epithelium-lined surfaces, in this case a colocutaneous /f_i stula from colon to skin.

Acquired

Campbell de Morgan spots These are arteriovenous fistulae at the dermal capillary level in - sun-exposed skin of older patients ( Figure 45.45 ). Spider naevi These are angiomata that appear (and may disappear) sponta neously at puberty or in two-thirds of pregnant women, usually disappearing in the puerperium ( Figure 45.46 ). Spider naevi are also associated with c hronic liver disease. They can be treated with intense pulsed light or pulsed-dye laser. Pyogenic granuloma These share many histological characteristics of haemangio mata and are probably a subtype thereof ( Figure 45.47 are small (0.5–1.5 /uni00A0 cm), raised, pedunculated, soft, red nodular lesions showing superficial ulceration and a tendency to bleed after trivial trauma. They should be excised with a minimal margin. Glomus tumour This arises from a subcutaneous arteriovenous shunt (Sucquet– Hoyer canals), especially in the corium of the nail bed. Typically , JP Sucquet , 1840–1870, anatomist, Paris, France. Heinrich Hoyer , 1834–1907, Professor of Histology , Embryology and Anatomy , Central Medical School, The Polish University , Warsaw , Poland. - it is a small, purple nodule measuring a few millimetres in size, which is disproportionately painful in response to insignificant stimuli, including cold exposure ( Figure 45.48 ). Subungual - varieties may be invisible causes of paroxysmal digital pain. ). Most Angiosarcoma (‘malignant angioendothelioma’) A rare, highly malignant tumour arising from the endothelial cells ( Figure 45.49 ). The lymphangiosarcoma variant arises from lymphatic endothelium and can develop in lymphoedem - atous tissue, particularly an extremity . Proliferation is rapid with early systemic spread.

Figure 45.44 ‘Port-wine’ stain (courtesy of St John’s Institute for Dermatology, London, UK). Figure 45.45 Campbell de Morgan spot (courtesy of Mr AR Green baum). Figure 45.46 Spider naevus (courtesy of St John’s Institute for Dermatology, London, UK).

Figure 45.47 Pyogenic granuloma (courtesy of St John’s Institute for Dermatology, London, UK).

Kaposi’s sarcoma Kaposi’s sarcoma is a malignant, proliferative tumour of vascular endothelial cells, which was first described in elderly Jewish men but is now most commonly associated with immune compromise after transplantation or HIV infection ( Figure 45.50 ). There appears to be a causal link with infection by human herpesvirus 8. Kaposi’s sarcoma usually starts as a red-brown, indurated, plaque-like skin lesion that becomes nodular and then ulcerates. Treatment is with radiotherapy .

Figure 45.48 Glomus tumour (courtesy of St John’s Institute for Dermatology, London, UK).

Acquired

Pressure sores These begin with tissue necrosis at a pressure point and develop into a cone-shaped volume of necrotic loss. As many as 10% of acute hospital inpatients will have some degree of pressure sore. The majority a ff ect the elderly and patients with spinal injury or decreased sensibility; 80% of paraplegics will get a pressure sore and 8% die as a result. The pathogenesis of pressure sores revolves around unre lieved pressure: an increase in local tissue pressure above that of perfusion pressure produces ischaemic necrosis that is directly proportional to the duration and degree of pressure and inver sely proportional to the area over which it is applied. Muscle and fat are more susceptible to pressure than skin. In a patient who has no predisposing factors management is aimed at debridement and repair of the defect, on the assump tion that recurrence will not occur once normal function and sensibility returns. In the paraplegic patient, recurrence is likely so management should involve a multidisciplinary approach. Primary treatment involves relieving pressure (special mattress, nursing care, relief of muscle spasm and contractures), opti mising nutrition, correcting anaemia and preventing infection. Surgery involves thorough debridement to promote healing and plastic surgery to reconstruct the defect. Ulcers An ulcer is a discontinuity of an epithelial surface. It is characterised by destruction of the surface epithelium and a granulating base. Ulcers can be classified as non-specific, specific and malignant ( Figure 45.51 ). Sinus A sinus is a blind-ending tract connecting a cavity lined with granulation tissue (often an abscess cavity) to an epithelial (a) (b) (c) (d ) ( e) Burrill Bernard Crohn , 1884–1983, gastroenterologist, Mount Sinai Hospital, New Y ork, NY , USA, described regional ileitis in 1932. - - surface ( Figure 45.52a ). Sinuses may be congenital or acquired. Congenital sinuses arise from the remnants of persistent embryonic ducts. Acquired sinuses can result from: a retained foreign body (ingrown hair or suture material); chronic infection (tuberculosis, osteomyelitis or actinomycosis); chronic - inflammation (Crohn’s disease); malignancy; or inadequate surgical drainage of a cavity . , Treatment of a sinus is directed at removing the underlying cause. Biopsies should always be taken from the wall of a sinus to exclude malignancy or specific infection. For specific man - - agement of the disease conditions, please refer to the appro - priate chapter. Fistula A fistula is an abnormal communication between two epithelium-lined surfaces ( Figure 45.52b ). This commu - nication or tract is usually lined by granulation tissue, but may become epithelialised in chronic cases. Fistulae may be congenital (e.g. tracheo-oesophageal and branchial fistulae) or acquired (e.g. enterocutaneous complicating Crohn’ s disease or surgery , or arteriovenous). Management of a fistula is directed at the underlying aetiology (see the appropriate chapters).

Figure 45.51 Some characteristic shapes of the edges of ulcers. /uni00A0 (a) Non-speci /f_i c ulcer: note the shelving edge. (b) Tuberculous ulcer: note the undermined edge. (c) Basal cell carcinoma (rodent ulcer): note the rolled edge, which may exhibit small blood vessels. thelioma: note the heaped-up, everted edge and irregular thickened base. (e) Syphilis: note the punched-out edge and thin base, which may be covered with a ‘wash-leather’ slough. Figure 45.52 A sinus (a) and a /f_i stula (b) ; both usually arise from a preceding abscess. (a) This is a blind track, in this case a pilonidal abscess. (b) This is a track connecting two epithelium-lined surfaces, in this case a colocutaneous /f_i stula from colon to skin.