The rash that becomes purpuric, petechial, hemorrhagic, or ecchymotic.

Hemorrhagic rashes are observed in a wide variety of conditions, ranging from harmless to life-threatening. This review offers a stepwise approach, which helps limit the possible differential diagnoses based on the clinical manifestations and the clinical picture. The most common and most important conditions, including infectious, coagulation and embolic disorders, vasculitides, and vasculopathies, are briefly reviewed focusing on morphology. Dermatologists often need to distinguish among infectious, reactive, or autoimmune etiologies of the rash and determine if the condition is dangerous or even life-threatening in order to make the right decision. Dermatologic expertise provides vital input in the diagnosis and care of complex interdisciplinary patients, such as those with sepsis, purpura fulminans, and thrombotic thrombocytopenic purpura.

Acrally distributed dermatoses: Vascular dermatoses (purpura and vasculitis).

Purpuric lesions appear in acral distribution in a variety of conditions and often provide clues to the clinical diagnosis. Purpuric means "hemorrhagic"-that is, the lesions do not blanch from pressure. This review focuses on dermatoses that produce hemorrhagic lesions in acral distribution from the large groups of the vasculitic diseases and their mimics. Cutaneous small vessel vasculitis is confined to the skin, involves mainly postcapillary venules, and has the hallmark manifestation of palpable purpura. Henoch-Schönlein purpura is an immune complex-mediated systemic vasculitis of the small vessels with manifestations from the skin, joints, kidneys, and gastrointestinal system. Only cases where the immune complexes contain immunoglobulin A type are classified as Henoch-Schönlein purpura. Cryoglobulinemic vasculitis is induced by the deposition of cold-precipitated immune complexes in the small vessels. Urticarial vasculitis comprises a spectrum of conditions with the characteristic course of chronic urticaria, with wheals that persist longer than 24 hours, leave hyperpigmentation, and have leukocytoclastic vasculitis on histologic examination. Polyarteritis nodosa is a rare multisystem, segmental necrotizing vasculitis of mainly the medium-sized vessels. Pigmented purpuric dermatoses are chronic benign dermatoses characterized by petechiae, purpura, and increased skin pigmentation. The hallmark of pigmented purpuric dermatoses is their orange-brown, speckled, cayenne pepper-like discoloration.

Methods for the Assessment of Barrier Function.

Due to the ease of skin accessibility, a large variety of invasive and noninvasive in vitro and in vivo methods have been developed to study barrier function. The measurement of the transepidermal water loss (TEWL) is most widely used in clinical studies. The different methods of determining TEWL, as well as skin hydration, skin pH, tape stripping and other modern less widely used methods to assess skin barrier function, are reviewed, including Raman spectroscopy and imaging methods such as optical coherence tomography and laser scanning microscopy. The modern imaging methods are important developments in the last decades which, however, determine the structure and, hence, cannot replace the measurement of TEWL in questions related to function.

Ultraviolet Exposure and Protection Behavior in the General Population: A Structured Interview Survey.

BACKGROUND: Exposure to solar ultraviolet (UV) radiation is a known and controllable risk factor for skin cancer. OBJECTIVE: To study the UV exposure and protection behavior of the general population. METHODS: Structured interview survey. RESULTS: A random sample of 865 volunteers from the EDEN (European Dermato-Epidemiology Network) Fragrance Study cohort was recruited. The individual skin type did not influence the occupation or leisure. The proportion of people who regularly used sunscreens was lower in the oldest age groups, where the risk of skin cancer is highest. Women used sunscreens significantly more frequently than men did and were more likely to have their moles checked by a specialist. CONCLUSIONS: A demand for public information on the risk factors for skin cancer and the role of protection was demonstrated by our study. The subpopulation of aged men represents a relevant target group for educational public campaigns on skin cancer risk avoidance.

Hand dermatitis: a review of clinical features, prevention and treatment.

Hand dermatitis is a socially significant health problem. This review provides a discussion on the clinical features and patterns as well as the differential diagnosis of hand dermatitis, because these are essential for proper diagnosis in clinical practice. The morphology, however, is poorly related to the etiology in chronic cases. In all cases of chronic hand dermatitis, a full diagnostic examination should be undertaken and the etiology should be clarified and addressed in the treatment concept, instead of just moving directly from a morphological diagnosis to therapy. Preventive measures should be included in the treatment concept according to etiology. A stepwise approach for escalating therapy is advised, including basic topical therapy, topical corticosteroids, calcineurin inhibitors, as well as phototherapy and systemic therapy with corticosteroids, alitretinoin, cyclosporine, methotrexate, azathioprine, and others.

Development of a standardized testing procedure for assessing the irritation potential of occupational skin cleansers.

BACKGROUND: Frequent skin cleaning fulfils the definition of occupational 'wet work'. Standardized methods are required to assess the irritation potential of workplace cleansers. OBJECTIVES: To develop a standardized procedure for testing the irritation potential of occupational skin cleansers. METHODS: In this single-blind, single-centre trial in 25 healthy volunteers, the irritation potential of five generic reference cleansers was tested by three-times-daily washing with an automated skin cleaning device for 4 days, and quantification of cumulative skin barrier damage was performed by visual scoring, chromametry, transepidermal water loss TEWL, and corneometry. For two cleansers, reproducibility of the irritancy assessment was assessed. Furthermore, the irritation induced by four commercial workplace skin cleansers was studied. RESULTS: Whereas no significant changes were observed for any of the tested cleansers by either visual scoring or chromametry, significant increases in TEWL and significant decreases in stratum corneum hydration were found for all cleansers. Cleansers differed significantly in their irritation potential. On retesting of two cleansers, the first results were confirmed. Among the four commercial cleansers, one that was claimed to be mild was found to be disproportionally irritant. CONCLUSIONS: The presented model for testing cleansing preparations allows a highly controlled, practically relevant and reproducible irritancy assessment of occupational skin cleansers.

Impact of glove occlusion on cumulative skin irritation with or without hand cleanser-comparison in an experimental repeated irritation model.

BACKGROUND: Irritant contact dermatitis remains a substantial problem in the food processing industries. Irritants that are weak by themselves, such as glove occlusion and mild detergents, could interact to produce contact dermatitis. OBJECTIVES: To model the irritant action of an antibacterial hand cleanser and glove occlusion, with sodium lauryl sulfate (SLS) as a positive control. The effects of a pre-exposure cream and a post-exposure cream were also investigated. METHODS: A modified repeated short-time occlusive irritation test with 20 healthy volunteers, and application of irritants over 4 days, with pre-exposure and post-exposure creams and overnight glove occlusion, was performed. The changes in transepidermal water loss (TEWL) served as a measure of the irritant damage to the epidermal barrier. RESULTS: The antibacterial cleanser and the glove occlusion separately induced only minor increases in TEWL. When combined, the two showed a tandem effect, as the TEWL increase was significantly higher, and was similar to that seen with the positive control, SLS. The pre-exposure and post-exposure creams alone significantly mitigated the cumulative irritation, and this effect was strongest when the two creams were combined. CONCLUSIONS: Irritant contact dermatitis may develop through the tandem effects of long-term glove occlusion and the accumulation of barrier damage from hand washing, even when mild hand cleansers are employed.

Sensory irritation caused by two organic solvents-short-time single application and repeated occlusive test in stingers and non-stingers.

BACKGROUND: Neurosensory irritation is a subjective phenomenon induced by a number of chemicals. Objectives. To investigate the sensory irritation induced by two organic solvents - n-octane and cumene - between two groups of volunteers, stingers and non-stingers, identified as such according to the results of a lactic acid stinging test (LAST). METHODS: The immediate effects of the solvents were directly compared in a single simultaneous application test. The reaction intensities over time were studied in a repetitive irritation test over 4 days. The volunteers graded the reaction intensities by the use of a labelled magnitude scale. RESULTS: Cumene induced significantly stronger sensory irritation than octane in both the single and the repeated applications. Both substances induced less subjective irritation the more times the volunteers were exposed. The decline with time for cumene was statistically significant for the non-stingers but not for the stingers. However, no significant differences regarding the reaction intensities were detected in the direct comparisons of stingers and non-stingers. CONCLUSIONS. Further studies with larger sample sizes are needed to investigate a potential connection between the responsiveness to the sensory irritation caused by lipophilic irritants and lactic acid.

Teaching interventions in contact dermatitis.

Prevention of occupational contact dermatitis is of utmost significance for both insurers and legislators because it can preserve the individual's ability to work and result in decreased costs for public health. In the last 20 years, many concepts for educational interventions and a multitude of teaching aids have been developed by insurance associations and public institutions from different countries (eg, the United States, Sweden, Denmark, Switzerland, and Germany). For didactic purposes, terms of different levels of prevention have been inaugurated in northern Europe in the context of occupational dermatology. This review presents different educational interventions in the fields of primary, secondary, and tertiary prevention as well as evaluation studies of these measures, especially among health care workers, hairdressers, metalworkers, and bakers' apprentices. Special emphasis is put on the prevention of allergic contact dermatitis.

Dry skin, barrier function, and irritant contact dermatitis in the elderly.

Dry skin is characterized by a decreased lipid content and a delayed reconstitution of the epidermal barrier after skin irritation. These are problems of high relevance in the aged population, especially in the development of irritant contact dermatitis. Asteatotic and perineal irritant dermatitis are the most important subtypes of irritant contact dermatitis in the elderly. This contribution presents a compressed survey on these subtypes and elucidates their relation to an impaired barrier function. Typical irritants affecting aged individuals are explained and compared with irritants that seem to be more significant in younger people. Results of biophysical investigations, such as measurement of transepidermal water loss, are discussed regarding their age-dependence. Transepidermal water loss decreases with age, which was formerly interpreted as an indication of a decreased sensitivity. Today, we know that reconstitution of the epidermal barrier after irritation is delayed once it has been impaired. Reasons are decreased activities of enzymes involved in lipid synthesis and processing, a changed cytokine profile, a reduced acidification of aged skin, and alterations in the function of epidermal stem cells. Owing to these new insights, a reevaluation of the sensitivity of aged skin has to be initiated, especially with regard to occupational dermatology.

The lactic acid stinging test predicts susceptibility to cumulative irritation caused by two lipophilic irritants.

BACKGROUND: Skin exposure to lipophilic irritants at workplaces is a risk factor for the development of occupational irritant hand dermatitis. Suitable lipophilic model irritants to be used in repeated irritation studies in volunteers are needed to gain a better understanding of the chemical-dependent mechanisms of skin irritation. OBJECTIVES: To investigate acute and cumulative irritation elicited by two new lipophilic model irritants, octane (CAS No. 111-65-9) and cumene (CAS No. 98-82-8), in stingers as compared with non-stingers. METHODS: Short-time occlusive and repetitive occlusive irritation patch tests were performed over 5 days with octane and cumene in two groups of healthy volunteers (n = 15 each) who were classified as stingers and non-stingers according to a preceding lactic acid stinging test. Acute and cumulative irritation was quantified using clinical assessments and bioengineering methods (laser Doppler flowmetry, transepidermal water loss, capacitance measurements, and skin colour reflectance). RESULTS: Significantly stronger cumulative irritation was observed in stingers than in non-stingers for both irritants (visual scoring, stratum corneum hydration, and skin colour reflectance). CONCLUSIONS: The preliminary results suggest the existence of a distinct sub-population with increased susceptibility to cumulative irritation induced by lipophilic irritants that can be identified by the lactic acid stinging test.

Psoriatic erythroderma associated with enalapril.

A 59-year-old man with a 35-year personal and positive family history of psoriasis was admitted to our department for treatment of psoriatic erythroderma. The patient had commenced therapy with enalapril 10 mg b.i.d. for the treatment of hypertension approximately 6 weeks before hospitalization. Five weeks after the initiation of enalapril, his psoriasis began to flare, and for a period of about 1 week it reached the extent of erythroderma. The patient did not associate the psoriatic flare with other factors such as infections, trauma, or stress. The patient presented with diffuse erythema and pronounced desquamation covering his entire trunk, scalp, and extremities (Figure). Nearly 100% of the body surface area was involved. The palms and soles were also affected, displaying erythema, hyperkeratosis, and painful fissures. The nails showed pits, oil spots, and subungual hyperkeratosis. The patient also had psoriatic arthritis affecting the interphalangeal joints of his fingers. Laboratory tests revealed an elevated erythrocyte sedimentation rate, an elevated creatinine level of 180 mmol/L, a blood urea nitrogen level of 10.8 mmol/L, and a uric acid level of 716 mmol/L. Urinalysis showed proteinuria of 1.5 g/24 h. The patient's renal condition was diagnosed as chronic tubulointerstitial nephritis, most probably related to his dermatologic disease. Allopurinol and dietary measures were recommended. Following treatment with methotrexate and replacement of enalapril therapy, the erythema and scaling gradually subsided and became confined to his pre-eruptive chronic plaques (approximately 5% of body surface area). Rechallenge with enalapril was not performed.

Drug-induced lupus erythematosus.

Among the numerous idiopathic immune-mediated diseases that can be drug-induced, such as pemphigus, psoriasis, lichen, etc, drug-induced lupus is the most widely commented upon and investigated. The terms drug-induced lupus (DIL) and drug-induced lupus erythematosus (DILE) are preferred, but other ones are also used--drug-related lupus, lupus-like syndrome, and lupus erythematosus medicamentosus. This review discusses the general issues in DILE, such as pathogenic mechanisms, clinical forms, and diagnostic criteria, and provides more detailed information for some of the implicated drugs: minocycline, statins, terbinafine, etc.