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Kaposi's Sarcoma in AIDS

When Kaposi's sarcoma, a malignant tumor, accompanies AIDS, it may appear in many forms: macules, papules, plaques, or nodules almost anywhere on the body. Lesions are often multiple and may involve internal structures. On the left are ovoid, pinkish red plaques that typically lengthen along the skin lines. They may become pigmented. On the right is a purplish red nodule on the foot.

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(Sources of photos: Basal Cell Epithelioma: Rapini R. Squamous Cell Carcinoma, Actinic Keratosis, and Seborrheic Keratosis—Sauer GC: Manual of Skin Diseases, 5th ed. Philadelphia, JB Lippincott, 1985; Kaposi's Sarcoma in AIDS—De Vita VT Jr, Hellman S, Rosenberg SA [eds]: AIDS: Etiology, Diagnosis, Treatment, and Prevention. Philadelphia, JB Lippincott, 1985)

TABLE 4-5 ■ Benign and Malignant Nevi

Malignant Melanoma

Learn the "ABCDEs" of melanoma from these reference standard photographs from the American Cancer Society:

Benign Nevus

The benign nevus, or common mole, usually appears in the first few decades. Several nevi may arise at the same time, but their appearance usually remains unchanged. Note the following typical features and contrast them with those of atypical nevi and melanoma:

■ Sharply defined borders

■ Uniform color, especially tan or brown

■ Flat or raised surface

Changes in these features raise the the spectre of atypical (.dysplastic) nevi, or melanoma. Atypical nevi are varied in color but often dark and larger than 6 mm, with irregular borders that fade into the surrounding skin. Look for atypical nevi primarily on the trunk. They may number more than 50 to 100.

Malignant Melanoma

Learn the "ABCDEs" of melanoma from these reference standard photographs from the American Cancer Society:

■ Irregular Borders, especially notching (Fig. B)

■ Variation in Color, especially mixtures of black, blue, and red (Figs. B, C)

Review melanoma risk factors such as intense year-round sun exposure, blistering sunburns in childhood, fair skin that freckles or burns easily (especially if blond or red hair), family history of melanoma, and nevi that are changing or atypical, especially if >50. Changing nevi may have new swelling or redness beyond the border, scaling, oozing, or bleeding, or sensations such as itching, burning, or pain.

On darker skin, look for melanomas under the nails, on the hands, or on the soles of the feet.

(Courtesy of American Cancer Society; American Academy of Dermatology)

Pressure ulcers, also termed decubitus ulcers, usually develop over body prominences subject to unrelieved pressure, resulting in ischemic damage to underlying tissue. Prevention is as important as identification and treatment: inspect the skin thoroughly for early warning signs of erythema that blanches with pressure, especially in patients with risk factors. Pressure ulcers form most commonly over the sacrum, ischial tuberosities, greater trochanters, and heels. A commonly applied staging system, based on depth of destroyed tissue, is illustrated below. However, note in Stage I the skin is still intact and is not yet an ulcer; ulcers with necrosis or eschar must be debrided before they can be staged; and ulcers do not necessarily progress sequentially through the four stages. Inspect ulcers for signs of infection, including drainage, odor, cellulitis, or necrosis. Fever, chills, and pain suggest possible underlying osteomyelitis. Assessment should address the patient's overall physical and mental health, including: comorbid conditions such as vascular disease, diabetes, immune deficiencies, collagen vascular disease, malignancy, psychosis, or depression; nutritional status; pain and level of analgesia; risk of recurrence; psychosocial factors such as learning ability, social supports, and lifestyle; and any evidence of polypharmacy, overmedication, or abuse of alcohol, tobacco, or illicit drugs.

Risk Factors for Pressure Ulcers

■ Decreased mobility, especially if accompanied by increased pressure or ■ Fecal or urinary incontinence movement causing friction or shear stress ■ Presence of fracture

■ Decreased sensation, from brain or spinal cord lesions or peripheral nerve disease ■ Poor nutritional status or low albumin

■ Decreased blood flow from hypotension or microvascular disease such as diabetes or atherosclerosis

Stage I

Pressure-related alteration of intact skin, with changes in temperature (warmth or coolness), consistency (firm or boggy), sensation (pain or itching), or color (red, blue, or purple on darker skin; red on lighter skin)

Stage III

Full-thickness skin loss, with damage to or necrosis of subcutaneous tissue that may extend to, but not through, underlying muscle

Stage II

Partial-thickness skin loss or ulceration involving the epidermis, dermis, or both

Stage IV

Full-thickness skin loss, with destruction, tissue necrosis, or damage to underlying muscle, bone, or supporting structures o

(Source of photos: National Pressure Ulcer Advisory Panel. Reston, VA)

TABLE 4-7 ■ Findings in or Near the Nails

Clubbing of the Fingers

In clubbing, the distal phalanx of each finger is rounded and bulbous. The nail plate is more convex, and the angle between the plate and the proximal nail fold increases to 180° or more. The proximal nail fold, when palpated, feels spongy or floating. Causes are many, including chronic hypoxia from heart disease or lung cancer and hepatic cirrhosis.

Onycholysis

Onycholysis refers to a painless separation of the nail plate from the nail bed. It starts distally, enlarging the free edge of the nail to a varying degree. Several or all nails are usually affected. Causes are many.

Paronychia

A paronychia is an inflammation of the proximal and lateral nail folds. It may be acute or, as illustrated, chronic. The folds are red, swollen, and often tender. The cuticle may not be visible. People who frequently immerse their nails in water are especially susceptible. Multiple nails are often affected.

Terry's Nails

Terry's nails are mostly whitish with a distal band of reddish brown. The lunulae of the nails may not be visible. These nails may be seen with aging and in people with chronic diseases such as cirrhosis of the liver, congestive heart failure, and non-insulin-dependent diabetes.

White Spots (Leukonychia)

Trauma to the nails is commonly followed by white spots that grow slowly out with the nail. Spots in the pattern illustrated are typical of overly vigorous and repeated manicuring. The curves in this example resemble the curve of the cuticle and proximal nail fold.

Transverse White Lines (Mees' Lines)

These are transverse lines, not spots, and their curves are similar to those of the lunula, not the cuticle. These uncommon lines may follow an acute or severe illness. They emerge from under the proximal nail folds and grow out with the nails.

Psoriasis

Small pits in the nails may be early signs of psoriasis but are not specific for it. Additional findings, not shown here, include onycholysis and a circumscribed yellowish tan discoloration known as an "oil spot" lesion. Marked thickening of the nails may develop.

Beau's Lines

Beau's lines are transverse depressions in the nails associated with acute severe illness. The lines emerge from under the proximal nail folds weeks later and grow gradually out with the nails. As with Mees' lines, clinicians may be able to estimate the timing of a causal illness.

(Sources of photos: Clubbing of the Fingers, Paronychia, Onycholysis, Terry's Nails—Habif TP: Clinical Dermatology: A Color Guide to Diagnosis and Therapy, 2nd ed. St. Louis, CV Mosby, 1990; White Spots, Transverse White Lines, Psoriasis, Beau's Lines—Sams WM lr, Lynch PJ: Principles and Practice of Dermatology. New York, Churchill Livingstone, 1990)

Getting to Know Anxiety

Getting to Know Anxiety

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