Pathology: General Notes


Highly contagious bacterial infection of epidermis

Infectious agent: Staph aureus and Group A Strep

Common in children

Signs and symptoms:

Itchy, fluid filled blisters

Erosions with honey-colored crusts (Fig. 1.12)

Usually forms around mouth, nose or ears; can be elsewhere

Treatment: antibiotics


Keep open lesions clean and covered when possible


Systemically contraindicated until the infection has been eradicated

Folliculitis and Furuncles

Bacterial infection of a hair follicle and perifollicular dermis

Infectious agent: Staphylococcus aureus

Common locations: shaved regions (beard, neck, legs, axilla) or occlusion (axilla, below breasts, buttocks)

If follicular infection extends into dermis, an acute local inflammatory process with tissue destruction results:

Furuncle (boil): 1-2cm

Carbuncle: coalescing furuncles that may develop subQ abscess

Pilonidal cysts: chronic abscess of follicle near sacrum

Hidradenitis suppurativa: infection/inflammation of apocrine glands in axilla, anogenital region, breasts

related to cystic acne; forms double open comedomes

Signs and symptoms:

Folliculitis: follicular red bump or pustule

Furuncle: red, hot, fluctuant, painful nodule

May develop central necrotic plug or pustule

Central pustule may rupture and drain pus


Hot compresses

Incision and drainage



At least locally contraindicated

Isolate sheets

Watch for signs of systemic infection


Cellulitis and Erysipelas

Acute, rapidly spreading bacterial infection of the dermis and subcutaneous tissue (Fig. 1.4)

Infectious agent:
Erysipelas: Group A Streptococcus (GAS), H. influenza B in peds (facial)
Cellulitis: Staph aureus, GAS

Requires a portal of entry: interdigital tinea pedis, bee sting!

Signs and symptoms:

Erysipelas: red, raised, hard, hot, painful area with distinct margin

esp face (rhinitis, conjunctivitis, OM) and lower legs

Cellulitis: red, flat, hard, hot, painful area with indistinct margin

Lymphatic spread (lymphangitis): red streaks proximal to site

Systemic symptoms: fever, chills, malaise

Complications: septicemia (potentially fatal)

Treatment: Antibiotics

Massage? Systemically contraindicated until infection resolves

Fungal Infections (Not discussing candidiasis or “yeast infections”)

Other names:




Lesions are called tinea

Causative agents are fungi:

Tricophyton, Epidermophyton, Microsporum

Fungi like warm, moist, dark places

Infection is spread by direct contact (skin to skin or fomite to skin)

Signs and symptoms:

Several days’ gestation before symptoms develop; communicable during this time

Tinea corporis (body ringworm) (Fig. 1.6)

Itchy, scaled, raised, reddish ring

Central clearing (heals from center out)

Spreads with scratching

Tinea capitis (head ringworm) (Fig. 1.7)

Itchy, flaking skin; looks like dandruff

Can cause permanent hair loss

Tinea pedis (athlete’s foot) (Fig. 1.8)

Often starts between 3rd and 4th toes

Weepy blisters; cracked and peeling skin; itching and burning

Moccasin type: heels, soles, lateral borders of feet; like T. corporis – red with distinct, raised, scaly margin

Risk of secondary infection

Difficult to get rid of (treat shoes too)

Tinea cruris (jock itch) (Fig. 1.9)

Groin, buttocks, thighs; NOT penis or scrotum

Itchy, red lesion with distinct margin

Less contagious than other forms

T. manus: hands; may be connected to athlete’s foot

T. barbae: beard; looks like folliculitis

T. unguium: nails; also known as onychomycosis

T. versicolor = Pityriasis versicolor:

Pityrosporum ovale inhibits melanin synthesis

Typically pales when surrounding skin tans

Neck, trunk, upper arms


Topical or oral anti-fungals

Sodium selenite shampoo


Recognize it; avoid it. Be careful about athlete’s foot

Local contraindication or caution, if well-contained and covered

Herpes Simplex

Viral infection leading to painful blisters on the skin

Oral, genital, other

HSV-1 v. HSV-2: no longer a significant issue

Primary Outbreak: days – 3 weeks after exposure

May be unnoticeable; may be extremely severe with systemic symptoms

Recurrent herpes: virus is never expelled;

Virus goes dormant in dorsal root ganglia

Reactivation of virus triggers another outbreak

Incidence: Who knows?

Oral herpes: 80%?

Genital herpes: 60%?


Virus is shed in mucus and respiratory secretions

Lesion not required for shedding

Can spread between outbreaks and during prodromic stage

Virus is stable on surfaces outside a host for hours

Can spread from one part of the body to another (eye!)

Vertical spread: mother to vaginally-delivered infant

Types of herpes:

Oral: “cold sore” or “fever blister” (Fig. 1.10)


Whitlow: paronychial (Fig. 1.11)

Gladiatorum: wrestlers


Physical or emotional stress

Hormonal changes


High arginine foods (chocolate, nuts)

Signs and symptoms:

Tingling, itching, burning during prodromic stage

Painful blisters on a red base

Scabbing after acute phase (less contagious)

Genital herpes: maybe systemic sx and urethritis


Secondary infection

Increased risk of spreading HIV

Increased risk of cervical cancer (HPV)



Antivirals to shorten episode (prevention in frequent cases)


Systemic Contraindication for systemic symptoms

Local contraindication during outbreaks, prodromic stage

Isolate linens and treat accordingly

Be careful of spreading from therapist to client!


Viral infection of keratinocytes

Causative agent: human papilloma virus (HPV)

Spread by skin-to-skin contact

Virus grows slowly, usually self-limiting

Causes epidermal hyperplasia – a benign neoplasm

Types of warts:

Verruca vulgaris: cauliflower type

On sites of trauma: fingers, hands, knees

Verruca plana: flat warts (flat, light brown)

On dorsum of hand, face, shins

Verruca plantaris: plantar wart

On sole of foot or palm of hand

Genital warts: tag-like growths on penis, vulva, anust, etc.

NOT associated with cervical cancer

Different strains of HPV are are spread with sexual contact and linked with cervical dysplasia and cervical cancer

Signs and symptoms:

Hard, crusty pile-up of keratin (Fig. 1.19)

Can resemble callus on the feet; important to distinguish between them (Fig. 1.20)


Abrade and apply salicylic acid (compound W), duct tape, raw potato…

Liquid nitrogen, lasers

Immune support

Warts are suggestible–many folk remedies


Local contraindication (virus is in shedding skin)


Molluscum Contagiosum

NOT a type of wart

Infectious agent: Poxvirus

Self-limiting epidermal infection (6 months)

Common in children

Can be an STD

Do NOT abrade: this will spread lesions

Lice and Mites

Mites or “Scabies”: Sarcoptes scabiei

Burrow under the skin; fecal waste is allergen

Spread through intimate contact

Signs and symptoms of mites:

Scabies: reddish or grayish tracks on the skin (these are the burrows) (Fig. 1.14)

Locations: finger webs, ankles, anywhere!

Unrelenting itchiness, worse at night


Pesticidal soap – for body, linens, clothes

For patient and people in close contact


Head lice: Pediculus humanus capitis

Live in head hair; suck blood from scalp

Spread through soft surfaces (clothing, hats, upholstery, etc.)

Symptoms of head lice:

Nits (brown or white) (Fig. 1.16)


Secondary dermatitis

Head lice treatment:

Pesticidal shampoo

Nit comb, nit-picking


Body Lice: Pediculus humanus humans

Live in clothing, not on hosts

Eradicated with good hygiene, tea tree oil soap


Pubic Lice or “Crabs”: Pthirus pubis

Infest pubic hair and any other coarse body hair (Fig. 1.18)

Spread through intimate contact

Itching, may be worse at night

Pesticidal shampoo (like head lice)

Massage for clients with lice or mites?

Systemically contraindicated until the infestation is over


Acne Vulgaris

Inflammation of pilosebaceous unit, usually on face, chest, or back (Fig. 1.21)

Sterile inflammatory response to excess sebum and bacterial fatty acids causes hyperkeratinization → keratin plug in os of follicle = comedone

If comedone ruptures and leak into dermis, immune response → pustule, nodule, cyst with inflammation

Occurs in up to 80% of the population

Contributing factors:

Hormonal imbalances

Testosterone production

Liver congestion

Bacterial activity: Propionibacterium acnes


Signs and symptoms (types of lesions):

Open comedones: blackhead (oxidized keratin)

Closed comedones: whitehead (keratin plug)

Pimples: pustule

Cysts: large comedomes due to repeated rupture and recapsulation



Liver support

Rx: Antibiotics, Retinoids, OCPs


Local contraindication – may aggravate/spread lesions

Don’t use alcohol after a session (???)

Consider water-based lotion

Rosacea (not often called Acne rosacea)

Idiopathic chronic skin condition

Affects the skin mostly around the nose and cheeks

Triggers include:

Sunlight, wind, extreme temperatures

Food and drinks


Signs and symptoms: 4 Stages:

Pre-rosacea: flushing, no itch

Vascular rosacea: telangiectasias develop; the nose, eyes, and eyelids may be involved

Inflammatory rosacea: papules and pustules develop, but not the same causative agent as acne vulgaris

Rhinophyma: skin is permanently red, thickened, bumpy


Palliative interventions to reduce appearance of lesions


Avoidance of triggers


No specific cautions unless work on the face increases symptoms; other work is safe


Dermatitis = skin inflammation

Eczema = to boil over

Vague enough?

Not from an infectious source

Epidermal eruptions with intercellular edema

Acute: Itchy vesicles or juicy papules (edema)

Chronic: Itchy lichenification (hyperkeratosis)

Related to hypersensitivity reactions


Eczema: overreactive systemic immune response to an internal allergen that manifests in skin

Incidence: affects 1:7 babies and children

“Grow out of it”: only 3% adults

Cause: Type I Hypersensitivity Reaction

B-cells release IgE antibodies against specific foreign protein (antigen)

Activated mast cells release histamine and other cytokines

Massive, rapid inflammatory response

Also associated with:

Genetics: family history of atopic disease (eczema, allergic rhinitis/sinusitis, asthma)

Fatty acid deficiency

Monocyte malfunction, high levels IgE, excessive histamine

Food allergy

May be aggravated by harsh detergents and chemicals, irritating fabrics, climate, stress, etc.

Eczema signs and symptoms (types of eczema):

Atopic Dermatitis = classic eczema

Most common

Infants: head, diaper area

Children/Adults: face, neck, wrists, dorsum of hands/feet, joint flexures

Itchy red bumps/blisters

Patches of itchy, red, flaky, dry skin (Fig. 1.22)

Can be weepy or so dry it cracks or lichenified

Dyshidrotic Eczema

Associated with atopic disease

Itchy, weeping blisters on palms, soles, or sides of digits (Fig. 1.23)

Nummular Eczema

Circular/oval red, weeping patches with crusts

Commonly trunk, legs and buttocks (Fig. 1.24)

Seborrheic Dermatitis = cradle cap

Chronic, superficial inflammatory response to Pityrosporum ovale in hairy regions with active sebaceous glands

Red patches with yellowish greasy scaling

Scalp, eyebrows, nose, pre-sternum and skin folds

Contact Dermatitis

Contact irritant dermatitis:

Due to substance directly toxic to skin (acids, alkalis, solvents)

Anyone would have a similar reaction

Phototoxic reactions: lime juice, celery, carrot greens, drugs

Contact allergic dermatitis: Type IV Hypersensitivity Reaction

Allergic reaction at the site of contact 24-48 hrs after exposure

Common allergens:

Nickel (watchband, earrings, etc.) (Fig. 1.25)

Ingredients in personal hygiene products

Adhesives, latex

Poison ivy, oak, sumac: oleoresins

Photoallergic reactions:

PABA (sunblock)

St John’s Wort

Signs and symptoms of contact dermatitis:

Range from mildly irritated to acutely red, swollen itchy

Other types of dermatitis:

Neurodermatitis = lichen simplex chronicus

Confluence of small eczematous eruptions that eventually lichenify

Due to chronic scratching!

Stasis dermatitis

Related to poor circulation: venous insufficiency or stasis (thrombophlebitis, DM, CHF)

Pitting edema; dusky red discoloration; thickened, scaly, weepy, itchy

May ulcerate

Complications of eczema/contact dermatitis:

Secondary infection

Itch-scratch cycle


Avoid triggers

Good hydration of skin

Topical steroids (have some risks) or immunomodulators


It depends on…

The severity of the problem

If the skin is intact

Local Contraindications:

Active eczema: open, itchy, inflamed

Active dyshidrotic eczema

Active contact dermatitis

Active neurodermatitis

Systemic Contraindications:

All acute dermatitis until inflammation has subsided

Stasis dermatitis: no circulatory massage


Also called urticaria

Allergic: Type I Hypersensitivity Reaction activates cutaneous mast cells

Food allergy

Bee sting


Stress reactions


Physical: Sunlight, Heat/sweating, Cold, Pressure

Signs and symptoms:

Acute dermal edema

Wheal: Hot, red, itchy, raised (edematous) areas with central pallor

Individual wheals that may join together in larger patches

Dermographism: wheal and flare response to scratching skin

Angioedema: acute dermal and subQ edema (usually larger area)


Antihistamines; steroidal anti-inflammatories


Systemic Contraindication: acute hives; angioedema (esp if respiratory symptoms)

Local contraindication: subacute

Be careful about allergenic oils


Abnormal epidermal proliferation resulting in accumulation of stratum corneum & inflammation

Epidermis replaced in 2-4 days vs. 30 days

Flares and remission

Cause is not well understood

Genetic: 1/3 cases

T-cell dysfunction: autoimmune disease?

Vitamin D deficiency?


Physical trauma: rubbing, scratching


Food allergies?

Strep throat (guttate psoriasis)


About 5 million US

Types of psoriasis

Psoriasis vulgaris: most common form

Guttate psoriasis: <2%

Explosion of small circular lesions on trunk

Typically after strep infection

Pustular psoriasis: rare

Small non-infectious pustules on plaques or palms/soles

Erythroderma: very rare

Generalized psoriasis with extreme redness and systemic symptoms

Can be life threatening

Signs and symptoms:

Itchy psoriatic plaques

Raised reddish lesions with silvery scale and sharp margins (Figs. 1.28, 1.29)

Distribution: scalp, hairline, extensor surface of joints, intergluteal cleft

Inverse pattern: skin folds (umbilicus, axilla, inframammary, inguinal, integluteal fold) and genitalia (no scale)

Pitted nails

Psoriatic arthritis: 5% cases; DIPs


2° Infection


Topical applications

Oral medications: steroids, retinoids, psoralen, cytotoxic drugs

Treatments may be applied with UV radiation

Most treatments are temporarily successful


Local contraindication acutely

Watch for signs of cracking or compromised skin


Also called nevi

Benign neoplasm

Many melanocytes making melanin in one spot

Appear between age 6 mos and 35 years

Signs and symptoms:

Typically small (under 5 mm)

One-colored: tan to blue-black

Round or oval (symmetrical)

Flat or raised, smooth or warty

May grow course, dark hairs

Note: can darken or itch during adolescence and pregnancy

Risk of changing to melanoma:

Any change in a mole should be examined by a dermatologist

Large congenital nevus: 6-12% risk

Dysplastic nevus (atypical mole): ABCDE

Asymmetry in shape

Border is irregular, indistinct, or ill-defined

Color is mottled or mixed (brown, black, purple0

Diameter is usually large, greater than the tip of a pencil eraser (6.0 mm)

Enlargement or increased elevation is one of the most important signs of malignant melanoma



Removing them


No contraindications

Therapists may be able to see moles that clients cannot

Skin Cancer

Cells in the epidermis suffer genetic mutations and begin to replicate uncontrollably

Most commonly diagnosed form of cancer (1/3)

40-50% people over 65 years

Special risk factors:

Pale skin

History of severe sunburn; sunny climate, spends time outside

Immune compromised

Increasing age

Toxic exposures

Red Flags

Moles that change: ABCDE

Any sore that doesn’t heal

Massage for skin cancer? Depends on the type of cancer, and the types of treatments

AK, BCC are safest for massage; locally avoid lesions and/or recent incision sites

SCC, malignant melanoma may require adjustments based on treatment options; consult with the oncologist for more information

Actinic Keratosis

Actinic Keratosis (AK): a precancerous neoplasm (Figs. 1.30, 1.31)

On lips: actinic cheilitis

Inside mouth: leukoplakia

Bowen’s disease: squamous cell carcinoma in situ

Signs and symptoms of AK:

Occurs mainly on sun exposed skin (face, ears, or hands)

Brown or red scaling lesion with a crust

A sore that doesn’t heal

Complications of AK:

5% of lesions may become squamous cell carcinoma

Treatment for AK:

Lesions are removed before they turn to SCC

Massage: safe

Refer all questionable skin lesions to PCP

Squamous Cell Carcinoma

Squamous cell carcinoma (SCC)

Malignant neoplasm of keratinocytes; potentially metastatic

Often begins as AK (0.5% risk of mets)

May begin at site of chronic injury: chronic ulcers, burn scar, radiation, smoking (9% risk of mets)

About 22% of all skin cancers

Signs and symptoms of SCC:

A sore that doesn’t heal on sun-exposed skin (ears, hands, lips) or mucosa (mouth)

Often looks red, ulcerated, crusted or aggressive

Treatment for SCC:

Lesions are removed with a large margin

Evaluation for signs of metastasis

Radiation may follow

Massage? Local contraindication; may be systemically contraindicated.  Discuss with health care team

Basal Cell Carcinoma

Basal cell carcinoma (BCC)

Malignancy of basal cells

Most common skin cancer: 75-90% of all skin cancer diagnoses

Least dangerous form: rarely metastasizes (<0.003%)

(Figs. 1.32, 1.33, 1.34)

Signs and symptoms of BCC:

A sore that doesn’t heal

Face, esp nose:

Round, pearly nodule with blood vessels and sunken middle

Edges or top may ulcerate and crust; “Rodent ulcer”

Back and Trunk:

Flat sores that crust

Other less distinct lesions may also grow

Treatment for BCC: Lesions are removed

Massage? Local contraindication despite no metastasis

Malignant Melanoma

Malignant melanoma

Cancer of the melanocytes

Least common, most dangerous form of skin cancer

3-5% of all diagnoses

Leading cause of death by skin cancer

Signs and symptoms of malignant melanoma:


Often in areas of sun exposure or chronic irritation

Men: trunk, neck, head vs. Women: extremities

May develop in mucosal epithelium!

Preexisting mole begins to change: ABCDE

Types of malignant melanoma:

Superficial spreading melanoma (Fig. 1.37)

Multicolored, slightly raised, spreading

Lentigo melanoma (Fig. 1.38)

Flat, brown discoloration

Acral lentiginous melanoma (Fig. 1.39)

Non-caucasian; hands, feet, nailbeds

Nodular melanoma (Fig. 1.40)

Most aggressive and invasive: pigmented elevated lesion

Treatment of malignant melanoma:

Excision with a clean border


Perfusion chemotherapy

Interferon Therapy

Massage? Local contraindication

May be systemically contraindicated depending on stage, treatments, etc.

Consult with health care team!






Damaged proteins in skin cells cause tissue death

Heat, friction, electricity, corrosive chemicals, etc…

Damaged skin can’t provide protective functions

Signs and symptoms (types of burns):

1st degree: superficial epidermis (Fig. 1.41)

Redness, heat, pain (mild inflammation)

Mild sunburn, diaper rash


2nd degree: epidermis, dermis (Fig. 1.42)

Redness, blisters, pain, swelling


3rd degree: epidermis, dermis, subcutaneous (Fig. 1.43)

White, gray or black charred skin weeping fluid with surrounding 2nd and 1st degree

May involve muscle, bone, etc.

Centrally less pain than 2nd degree

Skin may contract as it heals


1st and 2nd degree: antibiotic ointment, lotion, covering if necessary

3rd degree: IV fluids and antibiotics, debridement, skin grafts, plastic surgery


Systemic Contraindication: acute, possibly except very mild 1st degree burn (e.g. sunburn)

Local Contraindication: subacute

May help with pain management for 3rd degree burn recovery

Consult with health care team for best results

Be careful about nerve damage leading to numbness

Open Wounds and Sores

Lesion: any wound or injury to skin (or other tissue)


Broken skin is an invitation for infection

Evaluate whether a lesion indicates a local or systemic contraindication

Decubitus ulcers

Also called pressure sores, bedsores, and trophic ulcers

Cause: Mechanical pressure on capillaries prevents blood flow à tissue degeneration and failure to heal à necrosis and ulceration

Begins in epidermis

Progresses deeper into dermis and subQ and muscle

High risk groups: elderly, underweight, male, non-ambulatory, incontinent


Signs and symptoms:

Change in temperature; discoloration; pain and itching in early stages

Later: an open sore that doesn’t heal (Fig. 1.44)

Locations: buttocks, sacrum, heels, elbows

Complications: secondary infection, sepsis


Antibiotic ointment; debridement and skin grafts


More valuable as a preventative than a treatment option

Open sores =  local contraindication

Scar Tissue

Process of healing a skin injury:

Basal cells migrate across the wound

Divide to form new strata; keratinize

Scab falls off when new tissue forms underneath

Scar tissue that overflows the wound:

Hypertrophic scar

Keloid scar (Fig. 1.45)


Cortisone injection; collagen injection; dermabrasion


Only when there is no risk of infection

Cross fiber friction


Pathologically dry skin; can be primary or secondary

Signs and symptoms:

Diamond-shaped scales (Fig. 1.46)


Change bathing habits to reduce drying, preserve sebum coating


Can be helpful if no underlying contraindications are present

Be careful about friable skin


Effects of Aging

Epidermal thinning

Decreased numbers of Langerhans cells

Decreased vitamin D3 production

Decreased melanocyte activity

Decreased glandular activity (sweat and oil glands)

Reduced blood supply

Decreased function of hair follicles

Reduction of elastic fibers

Decreased hormone levels

Slower repair rate

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