Pathology: General Notes
Impetigo
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
Prevention
Keep open lesions clean and covered when possible
Massage?
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
Treatment:
Hot compresses
Incision and drainage
Antibiotics
Massage?
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:
Dermatophytosis
Mycosis
Ringworm
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
Treatment:
Topical or oral anti-fungals
Sodium selenite shampoo
Massage?
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%?
Communicability:
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)
Genital
Whitlow: paronychial (Fig. 1.11)
Gladiatorum: wrestlers
Triggers:
Physical or emotional stress
Hormonal changes
Sunlight
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
Complications:
Secondary infection
Increased risk of spreading HIV
Increased risk of cervical cancer (HPV)
Encephalitis/meningitis
Treatment:
Antivirals to shorten episode (prevention in frequent cases)
Massage?
Systemic Contraindication for systemic symptoms
Local contraindication during outbreaks, prodromic stage
Isolate linens and treat accordingly
Be careful of spreading from therapist to client!
Warts
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)
Treatment:
Abrade and apply salicylic acid (compound W), duct tape, raw potato…
Liquid nitrogen, lasers
Immune support
Warts are suggestible–many folk remedies
Massage?
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
Treatment:
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)
Itching
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
Stress
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
Treatment:
Hygiene
Liver support
Rx: Antibiotics, Retinoids, OCPs
Massage?
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
Stress
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
Treatment:
Palliative interventions to reduce appearance of lesions
Antibiotics
Avoidance of triggers
Massage?
No specific cautions unless work on the face increases symptoms; other work is safe
Dermatitis/Eczema
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
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
Treatment:
Avoid triggers
Good hydration of skin
Topical steroids (have some risks) or immunomodulators
Massage?
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
Hives
Also called urticaria
Allergic: Type I Hypersensitivity Reaction activates cutaneous mast cells
Food allergy
Bee sting
Medication
Stress reactions
Emotions
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)
Treatment:
Antihistamines; steroidal anti-inflammatories
Massage?
Systemic Contraindication: acute hives; angioedema (esp if respiratory symptoms)
Local contraindication: subacute
Be careful about allergenic oils
Psoriasis
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?
Triggers
Physical trauma: rubbing, scratching
Stress
Food allergies?
Strep throat (guttate psoriasis)
Incidence:
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
Complications:
2° Infection
Treatment:
Topical applications
Oral medications: steroids, retinoids, psoralen, cytotoxic drugs
Treatments may be applied with UV radiation
Most treatments are temporarily successful
Massage?
Local contraindication acutely
Watch for signs of cracking or compromised skin
Moles
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
Treatment:
Nothing
Removing them
Massage?
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:
Distribution:
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
Radiation
Perfusion chemotherapy
Interferon Therapy
Massage? Local contraindication
May be systemically contraindicated depending on stage, treatments, etc.
Consult with health care team!
Burns
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
Treatment:
1st and 2nd degree: antibiotic ointment, lotion, covering if necessary
3rd degree: IV fluids and antibiotics, debridement, skin grafts, plastic surgery
Massage?
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)
Massage?
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
Diabetes?
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
Treatment:
Antibiotic ointment; debridement and skin grafts
Massage?
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)
Treatment:
Cortisone injection; collagen injection; dermabrasion
Massage?
Only when there is no risk of infection
Cross fiber friction
Ichthyosis
Pathologically dry skin; can be primary or secondary
Signs and symptoms:
Diamond-shaped scales (Fig. 1.46)
Treatment:
Change bathing habits to reduce drying, preserve sebum coating
Massage?
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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