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Papular urticaria | Parapsoriasis | Paronychia | Pediculosis | Peels (see chemical peels) | Pemphigoid (go to pemphigus and bullous pemphigoid) | Pemphigus and bullous pemphigoid | Perioral dermatitis | Peutz Jeghers syndrome | Photosensitivity | Pigmentation (go to melasma) | Pigmented purpuric dermatosis | Pimples (go to acne vulgaris) | Pitted keratolysis | Pityriasis alba | Pityriasis lichenoides | Pityriasis rosea | Pityriasis rubra pilaris | Pityriasis versicolor or tinea versicolor | Poikiloderma of Civatte | Polymorphic light eruption | Pompholyx | Porokeratosis | Porphyria cutanea tarda | Portwine stain | Pregnancy rashes | Prickly heat (go to milaria) | Prurigo nodularis | Pruritus | Pruritus ani | Pruritus vulvae | Pseudofolliculitis barbae (razor bumps) | Psoriasis | Purpura | Pyoderma gangrenosum | Pyogenic granuloma

Papular urticaria is a condition that usually affects the legs and other exposed parts such as the arms and face. It may affect any age group but is more common in children.

Cause

• Insect bites eg., fleas and mites from infested cats, dogs and birds.
• Reaction to insects or their products such as eggs and faeces.

  Symptoms

• Crops of itchy papules (bumps) and sometimes, blisters.
• Scratching leads to crusting and open sores.
• New spots may reactivate old ones.

  Complications

• Infection due to scratching.

  What you can do

• You should a doctor.
• Keep the house clean and insect free.
• Keep pets outside.
• Keep pet houses clean and pest free.
• Use insect repellents.
• Try to be as fully clothed as possible.
• Take antihistamines for itching.

  What the doctor may do

• Try to determine the cause (which may not always be possible).
• Treat with topical steroids or intralesional steroids.
• Treat infection with antibiotics.
• Prescribe antihistamines for itching.

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This consists of a group of disorders that produce a persistent red scaly rash that look a little like psoriasis (hence, the name, "parapsoriasis". Some forms are harmless but parapsoriasis en plaques is serious because it may progress to mycosis fungoides, a cutaneous (skin) lymphoma.

Symptoms

• Yellow-red to brown slightly raised patches with a fine scale.
• Usually occurs on the trunk, thighs and buttocks.
• May itch.

  Complications

• Many develop into mycosis fungoides.

  What you can do

• You should consult a doctor.

  What the doctor may do

• Perform a skin biopsy to confirm the diagnosis.
• Treat with topical steroids, UV-B phototherapy or PUVA.
• Follow up closely for development of mycosis fungoides.

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Paronychia is an inflammation of the nailfolds. It may be acute or chronic.

Causes

• Acute paronychia is caused by a bacteria, usually the staphylococcal or streptococcal bacteria and occasionally, the pseudomonas and proteus bacteria.
• Chronic paronychia may be caused by:

   

  • Infection with fungi and yeasts (Candida albicans and other candida species) and bacteria (pseudomonas).
  • Skin diseases such as psoriasis, eczema and lichen planus.

   

  Aggravating factors

• Frequent immersion in water eg., in fishmongers, housewives, bartenders, and domestic maids.
• Trauma such as pushing and clipping the cuticles.
• Hangnails.
• Poor circulation.

  Symptoms

• Acute paronychia - severe throbbing pain, collection of pus or pus discharging from under the nailfolds.
• Chronic paronychia - red, tender swelling around the nails with discoloured, roughened nails.

  Acute paronychia. Click on image for larger view

  What you can do

• You should consult a doctor.
• Paronychia cannot be cured until a new cuticle forms to seal off the gap between the nailfold and the nailplate. Careful nailcare and long-term measures are necessary.
• Keep the hands clean and dry. Avoid frequent handwashing and wear protective gloves for wet chores (see hand eczema).
• Keep the nailfolds clean. Apply spirit lotion or some other antiseptic to prevent acute infections.

  What the doctor may do

• Incise and drain the collection of pus in acute paronychia.
• Prescribe oral antibiotics for acute paronychia.
• Prescribe oral antifungals in cases of candidal paronychia.
• Counsel about proper hand care.

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Pediculosis is the medical term for louse infestation of the skin. The louse (singular for lice) lives by biting and feeding on the blood it extracts and can infest any part of the body that has hair. Three types of lice infestation may be seen:

• Pediculosis capitis (head lice) which affects the scalp and occasionally, the eyebrows and eyelashes.
• Pediculosis corporis (body lice) which affects the body.
• Pediculosis pubis (pubic lice) which affects the pubic region primarily and the lower abdomen, eyebrows, eyelashes and armpits occasionally.

   

  Causes

• Pediculosis capitis, caused by the head louse can be transmitted by:
  • Sharing combs, brushes (especially by schoolgirls), hats and towels.
  • Head-to-head contact.

   

• Pediculosis corporis, caused by the body louse can be transmitted by:
  • Sharing clothing or other personal items.

   

• Pediculosis pubis, caused by the pubic louse (crab louse) can be transmitted by:
  • Sharing beds, clothing or towels.
  • Close physical contact, eg., during sexual intercourse.

  Symptoms

• Pediculosis capitis

   

  • Itchy scalp.
  • Presence of the lice themselves.
  • Nits (eggs) attached to the hair. Although nits can resemble dandruff, they cannot be flicked off or moved along the hair with the fingers. They may sometimes be found on the eyebrows, eyelashes and beard, as well.
  • Groups of red itchy papules (pimply bumps) on the neck.

   

• Pediculosis corporis
  • Generalised itching.
  • Red papules (pimply bumps) and bloody crusts at the points where the clothes comes into closest contact with the skin, eg., beneath collars, under the belt, under underwear and in the armpits.
  • Scratch marks, particularly in between the shoulder blades.
  • Pigmentation of the skin may be seen in longstanding cases.
  • Lice and nits are usually found in the clothes, only rarely are they found on the body hairs.

   

• Pediculosis pubis
  • Affects the lower abdomen, upper inner thighs and occasionally also the armpits, eyebrows, eyelashes and hairline.
  • Pubic itch.
  • Red itchy papules (pimply bumps).
  • Scratch marks.
  • Lice themselves.
  • Dried specks of blood on the underwear.
  • Nits attached to the pubic hair and occasionally, the eyebrows, eyelashes, armpit hair and hairline of the scalp.
  • Blue pigmentation may be present over the lower part of the abdomen, upper inner thigh and the armpits in chronic cases.

  Complications

• Secondary bacterial infection.

  What you can do

• You should consult a doctor to confirm the diagnosis.
• Follow the doctor's instructions on treatment. Do not overuse anti-lice medicines as some of them are irritating to the skin and can be toxic.
• Take antihistamines to relieve itching.

  What the doctor may do

• Look for nits or the lice themselves. In pediculosis corporis, the nits and lice are found in the seams of clothings rather than on the skin.
• Prescribe anti-lice applications such as permethrin, benzyl benzoate, gamma benzene hexachloride, pyrethrin with piperonyl butoxide and crotamiton.
• Prescribe antibiotics for secondary infection.
  
  Keypoints
• Family members require treatment, as well. Sex partners of individuals with pediculosis pubis (pubic lice) also need treatment. Classmates of those with pediculosis capitis (head lice) need to be examined.
• In pediculosis corporis (body lice), the nits and lice are found in the seams of clothings. Clothing must washed in hot water or dry cleaned and the seams must be ironed.
• Nits can remain on the hair after successful treatment. These can be removed by soaking the hair with 1:1 vinegar:water solution for 30 minutes under a shower cap or towel and then combing through with a fine toothed comb.

  Prevention

• Avoid close contact with infested persons.
• Avoid sharing hats, combs, towels and other personal items.
• Bathe and change clothes frequently.
• Avoid casual sex.

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These are skin diseases that cause the skin to blister.

Cause

• Autoimmune (self-allergy) disease in which antibodies are produced against the intercellular cement which hold the epidermal cells together (pemphigus) or the basement membrane which anchors the epidermis to the dermis beneath (bullous pemphigoid).
• Inherited as in Hailey-Hailey disease (familial benign chronic pemphigus).

  Symptoms

• Pemphigus

   

  • Multiple flaccid blisters that rupture easily, leaving raw painful areas.
  • Ulcers in the mouth.
  • Usually affects the middle-aged and elderly.

   

  There are several types of pemphigus for example pemphigus foliaceus, pemphigus vegetans, pemphigus vulgaris, pemphigus erythematosus and Hailey-Hailey disease (familial benign chronic pemphigus).

   

• Bullous pemphigoid

   

  • Itchy red patches which later develop into tense, fluid-filled blisters.
  • The blisters may also develop on normal skin.
  • The mouth is usually not affected.
  • Bullous pemphgoid usually affects the elderly.

  Bullous pemphigoid. Click on image for larger view

  Complications

• More common with pemphigus.
• Secondary bacterial infection which may lead to septicaemia (blood poisoning) and fatality.
• Fluid and electrolyte imbalance due to loss through the exposed raw skin.

  What you can do

• You should consult a doctor.

  What the doctor may do

• Admit for management.
• Prescribe oral steroids with or without immunosuppressive drugs.
• Prescribe antibiotics for secondary infection.

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This condition more commonly affects in women in the 20s and 30s and may be mistaken for acne vulgaris.

Causes

The most common cause is the inappropriate use of strong topical steroids on the face. Other factors that may play a role include:

 

• Atopic tendency.
• Inadequate cleansing.
• Overuse of moisturisers, foundation and sunscreens.
• Acne rosacea.
• Candidiasis.
• Fluoride toothpastes.
• Sun-exposure.

   

  Symptoms

• Small red papules (bumps) on a red scaly base.
• Occurs around the mouth sparing a strip of skin near the lips.
• Occasionally, the skin around the nose and eyes are also affected.
• Itching or occasionally, a burning sensation can be felt.

  Perioral dermatitis. Click on image for larger view

  What you can do

• You should consult a doctor.
• Cleanse with mild soaps.

  What the doctor may do

• Wean off or stop strong topical steroids (this is often followed by a temporary flare-up).
• Prescribe oral antibiotics for 2 - 3 months.

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This is an inherited disorder that causes freckles on the lips and gums and polyps in the gastrointestinal tract.

Cause

• Inherited in an autosomal dominant fashion which means the offspring has a 1 in 2 chance of inheriting the disease from an affected parent.

  Symptoms

• Appears in early childhood.
• Blue-brown or brown freckles on the lips and mouth.
• Multiple polyps in the gastrointestinal tract, especially in the small intestine where they may cause abdominal pain, vomiting and haemorrhage.

  Complications

• There is a 2% risk of cancer developing in the polyp.

  What you can do

• You should consult a doctor.

  What the doctor may do

• Perform tests to exclude intestinal polyps.
• Follow up closely for the development of cancer.
• Us a pigment laser to remove the freckles for cosmetic reasons.
  

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Photosensitivity refers to an abnormal sensitivity to sunlight. Sensitivity may occur to ultraviolet B (short wave ultraviolet light that causes sunburn), ultraviolet A (long wave ultraviolet light that causes tanning) or even to visible light. Sometimes the sensitivity is so severe that even artificial light sources such as fluorescent lamps can cause it. Photocontact dermatitis is a type of allergic contact dermatitis which only occurs in the presence of light.

Causes

• Drugs (see table below).
• Photoallergic contact dermatitis) may be caused by some male after-shave lotions containing musk-ambrette , some antibacterial soaps and sunscreens.
• Phototoxic contact dermatitis which is caused by certain perfumes, tar products, plant psoralens (psoralens are light sensitising chemicals).
• Metabolic disorders such as porphyria (see porphyria cutanea tarda).
• Skin disorders that are aggravated by sunlight (see below).
• Idiopathic (true sun allergy) - see polymorphic light eruption (PMLE).

Drugs causing photosensitivity	Action
Amiodarone	Heart medicine
Chlorpropamide	Antidiabetic medicine
Frusemide, thiazides	Diuretics (used to remove excess water from the body)
Griseofulvin	Antifungal medicine
Tetracycline, sulphonamides, nalidixic acid	Antibiotics
Phenothiazines	Antihistamine, tranquilliser
Psoralens	Photosensitising medicine used in PUVA
Tretinoin and isotretinoin	Vitamin A acids (retinoids) used in the treatment of acne

Skin conditions aggravated by sunlight

• Lupus erythematosus
• Acne rosacea
• Herpes simplex virus infections
• Darier's disease. (a rare inherited skin disorder)
• Porphyria (rare metabolic disorder)

  Symptoms

• Rash on the sun-exposed areas sparing the shaded areas around the eyes, behind the ears and under the chin.
• Streaky pigmentation on the sides of the neck from perfumes and on the forearms from phytophotodermatitis (plant induced contact dermatitis).

  What you can do

• You should consult a doctor.
• Protect yourself against the sun (see sun protection).

  Sun-protection

• Limit exposure to sunlight especially between 11am to 3pm.
• Wear protective clothing (densely woven fabric is best) and brimmed hats, and use umbrellas.
• Use sunscreens.
• Remember that the sun can penetrate through water and wet white clothing and UV-A can pass through window glass. You may need to use special solar films on windows in the car and at home. Enquire from your doctor.

  What the doctor may do

• Determine the cause with the help of photo- and photo-patch tests (special light tests).
• Eliminate or treat the underlying cause.
• Counsel about sun protection.

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This refers to a group of disorders characterised by reddish-brown spots or patches. They are caused by the leakage of blood through the tiny capillaries the skin. Hence, it is also called capillaritis. The red colour is due to the blood pigment, haemosiderin. Exactly why the capillaries should become leaky is not known for certain but a hypersensitivity reaction to viral infection, food additives and medications have been cited. Types of pigmented purpuric dermatosis include:

• Gougerot-Blum syndrome (pigmented purpuric lichenoid dermatosis)
  • Itchy red brown spots and bumps that join together to form a thickened patch.

   

• Schamberg's disease (progressive pigmented purpura)
  • Flat red brown patches with rust coloured spots that look like cayenne pepper on the ouside.
  • Not itchy.

   

• Majocchi's disease (purpura annularis telangiectoides)
  • Like Schamberg's disease but with telangiectasias (dilated capillaries) and arranged in rings.

   

• Itching Purpura
  • Like Schamberg's but is more widespread and itchy.

   

• Lichen aureus
  • Patch has a yellowish hue (hence the term aureus means golden).
  • Usually occurs over varicose veins.

  Key point

• A similar rash has been reported due to an allergy to some dyes used in khaki uniforms.

  What you can do

• You should consult a doctor.
• Wearing compression stockings can help.

  Treatment

• Reassure the patient that it is mainly a cosmetic problem.
• Identify and remove the cause, if any.
• Prescribe topical steroids which may occasionally help.

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This is a relatively common bacterial skin infection affecting the feet in people with sweaty feet or who wear heavy shoes a lot. It usually affects adolescents and young adults.

Causes

• Infection by a bacteria such as Corynebacterium minutissimum and Dermophilus congolensis.
• Infection is encouraged by moisture and warmth so pitted keratolysis usually affects the feet of people who wear heavy shoes and people with hyperhidrosis (sweaty feet).

  Symptoms

• Irregular white patches with pits. The appearance is most dramatic when the feet is wet.
• Pitted keratolysis usually affects the pressure areas of the feet such as the forefeet, heels and toe pads.
• Hyperhidrosis (sweaty feet) may be present.
• The feet may smell.

  What you can do

• You can consult a doctor.
• Wear full leather shoes (ie., leather uppers and soles) which allow the skin to "breathe" or wear open footwear, whenever possible.
• Wear heavy shoes for short periods at a time.
• Switch to cotton socks.
• Change socks frequently and alternate between two pairs of shoes, allowing one to dry completely before wearing.
• Replace old smelly shoes.
• Wash with soap or antiseptic cleanser twice a day.
• Use antiperspirants to reduce sweating.
• Sprinkle dusting powder or corn starch to absorb the sweat.

  What the doctor may do

• Prescribe oral antibiotics, topical antibiotics or Castellani paint.
• Treat associated hyperhidrosis.

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Pityriasis alba causes pink slightly scaly patches which clear, leaving patches of paler looking skin. The pink stage is mild and often go unnoticed. Most patients are alerted by the pale patches. Pityriasis alba usually affects young children and occasionally, young adults, as well. It is more noticeable in darker skinned individuals, especially after a spell in the sun. Pityriasis alba may affect the face, neck, upper trunk and upper portions of the limbs.

Causes

• May be a mild form of atopic dermatitis or xerosis (skin dryness).
• The affected areas are less able to tan compared to the surrounding skin.

  Symptoms

• Pink, slightly scaly patches initially. This stage often passes unnoticed.
• Pale patches appear after the pink patches clear. This is the stage that most patients notice and seek medical attention because of concerns about pityriasis versicolor, a fungal infection that causes pale patches.
• The pale patches become more obvious after exposure to the sun because the affected areas tan poorly compared to the surrounding skin.
• Non-itchy.
• Pityriasis alba usually clears after several months to years even without treatment.

  Pityriasis alba. Click on image for larger view

  What you can do

• You should consult a doctor to confirm the diagnosis.
• Use mild soaps.
• Apply moisturisers.
• Use sunscreens to prevent the surrounding skin from darkening and accentuating the pale patches.

  What the doctor may do

• Exclude other conditions that cause pale patches such as leprosy, pityriasis versicolor and vitiligo.
• Prescribe mild topical steroids.

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Pityriasis lichenoides is an uncommon skin disorder that affects adolescents and young adults. It occurs in two forms:-

• Pityriasis lichenoides acuta et varioliformis (PLEVA) or Mucha Haberman disease.
• Pityriasis lichenoides chronica (PLC).

  Cause

• The cause is unknown but it is generally believed to be a hypersensitivity reaction to an as yet unidentified microorganism.

  Symptoms

• Pityriasis lichenoides acuta et varioliformis (PLEVA) or Mucha Haberman disease

   

  • Crops of red papules (bumps) which blister and crust over and heal, leaving depressed scars rather like chickenpox.
  • New crops appear as old ones heal.
  • PLEVA usually affects the trunk and the insides of the forearms and back of the legs.
  • The person usually feels well, although occasionally, there may be a slight fever or headache.
  • PLEVA tends to be very persistent.

   

• Pityriasis lichenoides chronica (PLC)

   

  • PLC causes small red brown spots with an adherent scale that can be scraped off to reveal a shiny brown surface. These scales are often referred to as mica scales.
  • PLC usually affects the trunk and the insides of the thighs and forearms.
  • The rashes take a long time to clear, hence the name "chronica" and often leaves a brown stain that may take months to fade.

  What you can do

• You should consult a doctor.
• Moderate exposure to the sun without getting burnt may help to clear pityriasis lichenoides chronica.

  What the doctor may do

• Perform a skin biopsy to confirm the diagnosis.
• The doctor may prescribe topical steroids, antibiotics for 2 - 3 months or use phototherapy. Pityriasis lichenoides is not, generally, very responsive to treatment.
• If PLEVA is very persistent, he may even prescribe methotrexate, an immunosuppressive drug.

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This is a relatively common, self-limiting skin disorder that affects mainly children and young adults.

Causes

• May be due an to infective agent such as a virus.
• Secondary syphilis and drugs such as barbiturates (a tranquilliser), metronidazole (an antibiotic), gold (sometimes used for treating rheumatoid arthritis), captopril (used for treating severe high blood pressure), clonidine (used for treating high blood pressure) and penicillamine (sometimes used for treating rheumatoid arthritis) have been reported to cause a pityriasis rosea-like rash.

  Symptoms

• Starts as a single 2 - 5 cm pink or brown patch with a fine scaly border on the trunk, upper arms, neck and thigh. This patch is called the herald patch because it is followed by a more generalised rash.
• The generalised rash appears 5 - 10 days later on the trunk and upper portions of the limbs. It is comprised of multiple pink, oval shaped patches measuring 0.2 - 2 cm in diameter. The surface has a wrinkled appearance and a fine "cigarette-paper" white scale (known as a colarette) can be seen around the border. On the trunk, the long axes of the rash run parallel to the ribs, resulting in a "Christmas tree" pattern.
• Itching is usually absent, although in a few individuals, it can be unusually severe.

  What you can do

• You should consult a doctor.
• Although a viral cause is suspected, isolation is not necessary.
• Mild exposure to sunlight may help the problem clear faster.
• Take antihistamines if itching is severe.

  What the doctor may do

• Exclude other causes.
• Prescribe topical steroids.
• Use UV-B phototherapy using to clear persistent cases.

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This is a rare disorder of keratinisation, the process by which cells accumulate keratin as they reach the surface of the skin.

Cause

• Inherited - Inherited PRP occurs in infancy and tends to persist.
• Acquired - Acquired PRP occurs in adults and usually clears by 3 years.

  Symptoms

• Firm red or orange papules (pimply bumps) centred around hair follicles (follicular papules).
• Usually occur on the elbows and back of the fingers.
• There may be a yellowish thickening of the palms and soles (keratoderma).

  Complications

• May spread to the entire body causing an erythroderma (generalised reddening of the skin) with small areas of normal skin ("skip areas" or "islands of sparing"). This complication is more common in adults.

  What you can do

• You should consult the doctor.

  What the doctor may do

• Prescribe topical steroids (unfortunately response is often quite poor).
• Treat with oral retinoids with or without UV-B phototherapy.

TOP

Pityriasis versicolor or tinea versicolor is a superficial fungal infection of the skin, seen more commonly in the tropics and subtropics and during the summer in temperate countries. It occurs most commonly in adolescents and young adults.

Cause

• Pityrosporon orbiculare, a yeast found on the majority of adult skins. Infection occurs when the skin environment changes and it is conducive for the fungus to overgrow.
  
  Predisposing factors
• Humidity.
• Hot tropical climate, summers in temperate climate.
• Excessive sweating.
• Pregnancy.
• Cushing's syndrome (excessive production of steroids) or excessive use of systemic steroids.

  Symptoms

• Pinkish, light brown or off-white patches with fine ash-like scaling.
• The patches may join together to form irregular geographical patterns on the skin.
• The affected areas fail to tan properly and may cause pale patches on the dark-skinned.
• Itching is absent or may be induced by sweating.
• Pityriasis versicolor tends to recur.

  Pityriasis versicolor. Click on image for larger view

  What you can do

• You can consult a doctor.
• Apply antidandruff shampoos containing selenium sulphide or zinc pyrithione to the body and limbs and rinse off after 30 minutes. Repeat daily for about 2 weeks. If irritation occurs (especially with selenium sulphide), wash it off immediately.

   

  What the doctor may do

• Confirm the diagnosis using Wood's light (the fungus fluoresce a golden colour) or by examining skin scrapings for the fungus.
• Prescribe antifungal shampoos or lotions.
• Prescribe oral antifungals for resistant or extensive cases.

  Key points

• More than half the cases recur within 12 - 24 months after successful treatment.
• Pale patches may remain for several months following successful treatment.
• Pityriasis versicolor is not contagious since the fungus comes from the persons own skin.

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This is a relatively common skin condition seen in people who have had significant sun-exposure.

Cause

• Cumulative effect of sun exposure.
• Perfumes containing photosensitising chemicals may aggravate the condition.

  Symptoms

• Red brown colour due to increased pigmentation and the presence of telangiectasias (broken capillaries).
• The hair follicles are often more prominent.
• Usually affects the sides of the neck, sparing the area under the skin which is usually shaded from the sun. Sometimes, the neck and face are also affected.

  What you can do

• Protect the skin against the sun by using appropriate clothing and sunscreens (see sun-protection).
• Avoid using perfumes on the area.

  What the doctor may do

• Counsel you about sun-protection
• Treat with hydroquinone lightening creams or vascular lasers.

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Polymorphic light eruption (PMLE) is the most common type of true photosensitivity. It usually affects young and middle-aged women. PMLE is more common in temperate climates and usually occurs during spring. The skin hardens (becomes more resistant) as the summer approaches. It is less commonly seen in tropical countries which are sunny throughout the year, presumably because the skin has hardened.

Cause

• Sensitivity to ultraviolet B and occasionally ultraviolet A.
• An inherited form of PMLE has been observed in American Indians.

  Symptoms

• Pink or red papules (bumps ) on the arms, chest or legs. The face is usually spared.
• Sometimes PMLE is more severe and blisters may develop.

  What you can do

• You should consult a doctor.
• Reduce exposure to the sun (see sun protection).

  What the doctor may do

• Prescribe beta carotene, antimalarial drugs or oral steroids.
• Use PUVA to help the skin harden and become tolerant of the sun.

TOP

Pompholyx or dyshidrotic eczema is a type of eczema characterised by small deep-seated blisters on the palms and/or soles.

Cause

• A type of endogenous eczema characterised by small vesicles (blisters).

  Predisposing factors

• Hyperhidrosis (sweaty palms or soles).
• Heat, whether due to the environment or the climate.
• Allergy to chromates and nickel in the diet.
• Stress.

  Symptoms

• Small deep-seated blisters looking like sago grains or frog spawn.
• Affects the sides of the fingers, palms and the soles.
• Itching and burning
• As blisters dry up, the skin becomes dry and cracked.

  Complications

• Deep cracks may cause bleeding and pain.
• Secondary bacterial infection.

  What you can do

• You should consult a doctor.
• Soak in potassium permanganate solution for 15 minutes twice a day until the blisters dry up.
• Do not break blisters as this encourages bacterial infection.
• Take antihistamines to relieve itching.
• Adopt the same measures as for hand eczema.

  What the doctor may do

• Prescribe topical steroids and in severe cases, a short course of oral steroids.
• Exclude underlying tinea pedis which may produce an allergic reaction consisting of blisters on the hands.
• Perform patch tests to exclude allergy to nickel or chromate. Those found to be allergic may benefit from nickel- or chromate- free diets.

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Porokeratosis refers to a group of 3 rare skin disorders:

• Porokeratosis of Mibelli,
• Disseminated superficial actinic porokeratosis.
• Porokeratosis plantaris or palmaris.

  Cause

• Inherited by autosomal dominant transmission which means only one parent need to be affected and the offsprings have a 1 in 2 chance of inheriting the defect and developing the disorder.

  Symptoms

• Porokeratosis of Mibelli.

   

  • Thinned depressed area with a raised slowly enlarging ridged border.
  • My occur singly or in groups over a segment of the skin.
  • Usually appears in early childhood and may enlarge to several centimeters in size.

   

• Disseminated superficial actinic porokeratosis

   

  • Affects the sun-exposed skin.
  • Multiple small, slightly depressed red or brownish spots with a ridged border.
  • Often itchy.
  • Affects young adults.

   

• Porokeratosis palmaris or plantaris

   

  • Similar to disseminated superficial actinic porokeratosis except that they are confined to the palms and soles.
  • Usually occurs in the teens.

  Complications

• Squamous cell cancer may occasionally develop in porokeratosis of Mibelli.

  What you can do

• You should consult the doctor.
• Disseminated superficial actinic porokeratosis is induced by sunlight. Therefore, use physical protection and sunscreens (see sun-protection).

  What the doctor may do

• Follow-up, especially in cases of porokeratosis of Mibelli.
• Treat with 5 fluorouracil cream.
• Small lesions may be removed surgically or destroyed with the carbon dioxide laser or with electrosurgery.

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Porphyria cutanea tarda is a rare photosensitive (light-sensitive) skin disorder.

Cause

• A defect in a liver enzyme (uroporphyrinogen decarboxylase) that is involved in the synthesis of the haem (red pigment in haemoglobin). This results in abnormal levels of porphyrins in the skin, making it sensitive to light.

  Aggravating factors

• Alcohol.
• Oral contraceptives.
• Excessive intake of iron.
• Exposure to polychlorinated hydrocarbons (found in some pesticides), chlorinated phenols , tetra-chlorodibenzo-p-dioxin.

  Symptoms

• Blisters on the back of the hands and the forearms.
• The blisters break to form small ulcers which heal with scarring and milia formation (milia are small whitehead-like cysts).
• Occasionally the skin may become brown and hardened (scleroderma-like) on the face, neck and "v" of the chest.
• There may be increased facial hair.

  What you can do

• You should consult the doctor.
• Protect the skin against the sun (see sun protection).
• Avoid alcohol, oral contraceptives and iron supplements.

  What the doctor may do

• Perform a skin biopsy.
• Examine the urine and stools for porphyrins. Urine containing porphyrins give a coral red fluorescence when illuminated with a Wood's lamp.
• Perform blood tests to check on the haemoglobin level, iron stores and liver enzymes.
• Perform phlebotomy (blood-letting) to remove haemoglobin.
• Prescribe anti-malarial medication to promote urinary excretion or porphyrins.

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The portwine stain or naevus flammeus is a vascular birthmark. It may be found on any part of the body, especially on one side of the face where it can be cosmetically, very distressing. Portwine stains are present at birth and persist for life.

Cause

• Abnormal development of the blood vessels in the skin.

  Symptoms

• Pink or purple patch that looks like the stain left by rich red port wine.
• Usually unilateral (one-sided).
• The colour may be become deeper purple when the child cries.

  Complications

• The portwine stain on one side of the face may occasionally be associated with with underlying malformation of the blood vessels inside the skull, epilepsy (fits) and glaucoma. This condition is known as Sturge-Weber syndrome.
• Portwine stains affecting the extremity may occasionally be associated with an overgrowth of the underlying bone and soft tissue (a condition known as Klippel-Trenaunay-Weber syndrome).

  What you can do

• Leave alone or use cosmetic camouflage.
• You should consult a doctor.

  What the doctor may do

• Treat with vascular lasers.

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Pre-existing skin conditions such as acne, eczema or psoriasis may sometimes get worse during pregnancy. However, there are other disorders that are specifically caused by pregnancy and are described below:

• Spangler's dermatitis (papular dermatitis of pregnancy).

   

  • Groups of red papules (bumps) with scratched-off crusted tops.
  • Fade after pregnancy.
  • Heal with a dark stain.
  • Associated with 30% risk of stillbirth or spontaneous abortion.
  • Treatment is with oral steroids.
  • May recur with subsequent pregnancies.

   

• Pruritic urticarial papules and plaques of pregnancy (PUPPP)

   

  • Red papules (bumps) plaques (elevated patches) that look like urticaria (hives).
  • They usually start on the abdomen, especially along the stretch marks and spread to the thighs, buttocks and arms.
  • They usually appear during the last 3 months of pregnancy.
  • Itch is very severe and often disturbs sleep.
  • Not associated with any adverse effects on the baby.
  • Clears with delivery of the child.
  • Usually affects first time pregnant women.
  • Usually does not recur with subsequent pregnancies. If it does, it is usually less severe.
  • Treatment is with oral antihistamines and topical steroids. Oral steroids may be used in severe cases.

  Pruritic urticarial papules and plaques of pregnancy (PUPPP). Click on image for larger view

• Immune progesterone dermatitis of pregnancy
  • Papules (pimply bumps) and pustules (pusheads) that resemble acne on the buttocks and limbs.
  • Occurs during the first trimester of pregnancy.
  • May recur with subsequent pregnancies.
  • Treatment is with oestrogens (one of the female hormones).

   

• Pruritus gravidarum
  • Itching during the third trimester which clears after birth.
  • Recurs with subsequent pregnancies.

   

• Melasma (mask of pregnancy).
• Striae distensae (stretch marks).

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This is a nodular form of lichen simplex chronicus. It may affect adults of any age but is more common in the elderly.

Cause

• The cause is unknown but it may have something to do with the sensory nerves in the skin which appear to be hypertrophied (enlarged) and possibly oversensitive.
• Patients with a personal or family history of atopic dermatitis, asthma and hay fever are more prone to develop prurigo nodularis.

  Symptoms

• Intensely itchy nodules (swellings) which cause the person to scratch and dig at their skin.
• The tops are often scratched off and topped by a crust or dried blood.
• Prurigo nodularis usually affects the neck and limbs.

  Prurigo nodules. Click on mage fo larger view

  Complications

• Secondary bacterial infection.

  What you can do

• You should consult a doctor.
• Avoid scratching or picking the nodules as this usually cause the nodules to enlarge.

  What the doctor may do

• Treat with topical steroids or intralesional steroids injections or liquid nitrogen.
• Prescribe antihistamines and occasionally, antidepressants.
• Treat with PUVA phototherapy.
• A gluten free diet may help to protect the intestine and improve the skin.

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Pruritus is the medical term for itching. Pruritus may be localised to one area such as the vagina (pruritus vulvae) or around the anus (pruritus ani) or it may be generalised (generalised pruritus).

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Pruritus ani is the medical term for itching around the anus.

Causes

• Faecal soiling due to haemorrhoids, fissures (tears) and fistulae (tunnels connecting the rectum to the outside skin).
• Skin problems affecting the area such as atopic dermatitis, seborrhoeic dermatitis, psoriasis, lichen sclerosus et atrophicus and fungal infection (see tinea).
• Irritation or allergy to antiseptics, scented toilet paper or medicines for haemorrhoids (piles).
• Threadworm infestation (in children).
• Diabetes.
• Diet of highly seasoned foods.
• Idiopathic (of unknown cause).

  What you can do

• You should consult a doctor.
• Observe careful anal hygiene; clean thoroughly after each bowel movement. Wash the area with water after bowel movement or wipe the area with cotton moistened with water.
• Avoid strong antiseptics.
• Wear loose fitting cotton underwear.
• Avoid highly seasoned foods.
• Avoid constipation.
• Take antihistamines to relieve itching. Resist scratching.

  What the doctor may do

• Diagnose the underlying cause and treat accordingly.
• Prescribe mild topical steroids.

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Pruritus vulvae is the medical term for itching of the vaginal area.

Causes

• Candidiasis.
• Allergy or irritation caused by contraceptives, deodorants and douches.
• Threadworms infestations (in young girls).
• Skin diseases affecting the area such as atopic dermatitis, psoriasis, lichen simplex chronicus, seborrhoeic dermatitis, fungal infection (see tinea) and lichen sclerosus et atrophicus.
• Menopause which causes a degenerative condition of the vagina known as senile or atrophic vaginitis.

  What you can do

• You should consult a doctor.
• Use warm water or very mild soap to clean.
• Keep the area cool, avoid nylon underwear.
• Take antihistamines to relieve itching. Try not to scratch.

  What the doctor may do

• Determine the cause and treat accordingly.
• Prescribe mild topical steroids.

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Pseudofolliculitis barbae or razor bumps is commonly seen in men with stiff or curly hairs, especially black men.

Causes

• Ingrown hairs due to stiff hairs piercing the follicular canal or due to curly hairs re-entering the skin and causing inflammation.

  
  Symptoms

• Papules (pimply bumps) and pustules around the hair follicles.
• May be itchy or painful.
• Usually affects the scalp, pubic and beard areas.
  
  Complications
• Scarring.

  
  What you can do

• You should consult a doctor.
• Switch to electric razors if you have pseudofolliculitis barbae or grow a beard.
  

  What the doctor may do

• Treat with oral or topical antibiotics.
• Prescribe mild steroid creams to reduce the inflammation.
• Remove the in-grown hairs.

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Psoriasis is a chronic skin disorder affecting about 1 - 2% of the population. It usually begins between the ages of 15 and 30 years and tends to run in families. Psoriasis runs a very protracted course with periods of exacerbations and remissions and there is no permanent cure. However, treatment is available to control the disease and permit a productive life.

Causes

• The cause is unknown but in psoriasis the skin cells are dividing faster than normal, resulting in a scaly thickening of the skin. Fifty per cent of those affected give a family history of psoriasis, suggesting that genetic factors may play a role. If one parent is affected, the offspring has a 1 in 4 chance of developing psoriasis.

  Precipitating factors

• Stress.
• Streptococcal sorethroat.
• Drugs such as beta blockers (used to treat high blood pressure), lithium (used to treat manic-depressive states) and antimalarial medicines.
• Alcohol.
• Stopping systemic steroids.

  Symptoms

• Well-defined pink patches with characteristic, silvery white scales.
• Affects any part of the body, especially on the elbows, knees, near the base of the spine and on the scalp.
• Usually symmetrically located, that is on more or less identical sites on each side of the body.
• Red glazed patches in the body fold areas such as the armpits and groins.
• Nail changes in the form of pitting, brown spots resembling oil stains on a paper bag, onycholysis and thickening or crumbling of the nail plate may be seen.
• Itching may or may not be present.
• Palmoplantar pustulosis - is a form of pustular psoriasis that affects the hands and feet. It may also cause the skin to crack and bleed.

  Psoriasis. Click on image for larger view

  Complications

• Psoriasis may spread to involve the whole body, causing an erythroderma. This type of psoriasis is called erythrodermic psoriasis.
• Psoriasis may become pustular (with pusheads) all over the body. This is called generalised pustular psoriasis. When this is accompanied by fever and malaise (feeling of illness), the term von Zumbusch's pustular psoriasis is used.
• Psoriatic arthritis occurs in 10% of cases.

  What you can do

• You should consult a doctor.
• Avoid scratching as psoriasis tends to develop at sites of skin injury.
• Apply moisturisers after baths to reduce flakiness and roughness.
• Avoid strong topical medicaments because they can make psoriasis worse and cause it to develop into an erythroderma or become pustular.
• Avoid obesity as this may cause psoriasis to develop in the body folds.
• Try to get some sunlight (not sunburn) on the skin as this helps to clear psoriasis.
• Confront and deal with stresses.
• Maintain a positive outlook on life.
• Maintain good physical health by avoiding drug abuse, alcohol and smoking.

  What the doctor may do

• Prescribe topical steroids, tar preparations, anthralin or dithranol (a tar derivative) and calcipotriol, a vitamin D-like compound.
• Prescribe oral methotrexate (an immunosuppressive drugs), acitretin (an oral retinoid) or cyclosporin (an immunosuppressive drugs used to prevent the rejection of transplanted organs) in resistant or extensive cases.
• Start phototherapy (light treatment) using tar and ultraviolet-B (Geokerman regimen) or anthralin and UVB (Ingram regime) or PUVA.

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Purpura is caused by the leakage of blood from the vessels into the skin.

Causes
Purpura is usually classified into two types:

• Thrombocytopaenic purpura caused by a deficiency in the number of platelets (a type of white blood cells that plug up any holes in blood vessels and stop bleeding). Causes include:

   

  • Autoimmune (self-allergy)
  • Drugs.
  • Infections, including dengue haemorrhagic fever.
  • Bone marrow abnormality.
  • Enlarged spleen.

  
  

• Non-thrombocytopaenic purpura in which the number of platelets are normal. This type of purpura may be due to:

   

  • Drugs.
  • Coagulation defects (deficiency of clotting factors in the blood)
  • Vasculitis.
  • Weakening of the blood vessel walls due to ageing and/or sun-damage (senile purpura) or overuse of topical and systemic steroids (steroid purpura).

  Symptoms

• Red or purplish haemorrhagic patches which do not disappear when pressed.

  Senile purpura. Click on image for larger view

  What you can do

• You should consult a doctor.

  What the doctor may do

• Determine the cause and treat accordingly.

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This is a rare ulcerative skin condition that may be associated with internal disorders.

Cause

• May be a hypersensitivity reaction to underlying disorders such as:-

   

  • Inflammatory bowel disease such as Crohn's disease and ulcerative colitis.
  • Rheumatoid arthritis.
  • Chronic active hepatitis.
  • Haematological abnormalities.

  Symptoms

• Begins as one or more red papules (bumps) or pustules (pusheads) that break down rapidly to form ulcers.
• The ulcers enlarge several centimeters a day and have a bluish or purple undermined edge.
• Pain is often severe.

  Complications

• Very rarely, pyoderma gangrenosum runs a very aggressive course, affecting nerves and resulting in fatalities. This aggressive form is sometimes called malignant pyoderma gangrenosum.

  What you can do

• You should consult a doctor.
• Clean the ulcer gently and cover with a dressing.

  What the doctor may do

• Treat with topical, intralesional or oral steroids, sulphapyridine, methotrexate (an immunosuppressive drug), minocycline (an antibiotic), antileprosy drugs such as dapsone and clofamazine. Cyclosporin (an immunosuppressive drug) may also be used.
• Pyoderma gangrenosum is generally very difficult to treat. The underlying cause should be identified and treated.

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Pyogenic granulomas or proud flesh are rapidly developing vascular growths appearing at the sites of injury.

Cause

• Non-cancerous proliferation of the blood vessels in reaction to injury.

  Symptoms

• Occurs anywhere especially on the lips, gums, digits, face and scalp.
• Soft raspberry-like growth.
• Fragile, bleeds with minor trauma.

  Pyogenic granuloma Click on image for larger view

  What you can do

• You should consult a doctor.
• If bleeding occurs, apply pressure for 5 minutes.

  What the doctor may do

• Destroy with liquid nitrogen, electrosurgery, curettage, carbon dioxide laser or a vascular laser.
• Recurrence after treatment is common, requiring retreatment.

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