4-69
Objective: Signs
Using Basic Tools: Lesion: 1 mm to 3 cm, round to oval, slightly elevated, “stuck-on” appearing, papule or
plaque with variable pigmentary change; surface of lesion commonly has “warty” (verrucoid) appearance as it
matures and grows; face, trunk and extremities are common sites.
Assessment:
Diagnose based on clinical criteria
Differential Diagnosis: Early lesions: actinic keratosis, nevus. Later lesions: malignant melanoma,
pigmented basal cell carcinoma. Differentiating these conditions in the eld can be very difcult without expert
microscopic evaluation of a biopsy.
Plan:
Treatment
Primary: None is required for this benign lesion
Patient Education
General: This is a local benign proliferation of keratinocytes.
Follow-up Actions
Evacuation/Consultation Criteria: No need to evacuate. Consult dermatology as needed.
Skin: Contact Dermatitis
Lt Col Gerald Peters, USAF, MCIntroduction: The two main categories are allergic contact dermatitis (ACD) and irritant contact dermatitis
(ICD). The main difference is that an allergen will only cause problems such as dermatitis in those sensitized
to it. Even a tiny amount of allergen can cause a reaction in an allergic person, whereas an irritant will irritate
anyone, without previous sensitization, and the effects tend to be dose-related. ACD accounts for about 20%
of all contact dermatitis, and ICD for about 80%. Both ACD and ICD can be acute or chronic. History and
patterns of eruption can provide clues to the nature of the contact. Plants such as poison oak can leave
linear streaks of itchy, red papules and vesicles, corresponding to the leafy contact made with the skin. Nickel
is the most common ACD causative agent, often affecting the earlobes, from earrings, or the belly, from a
belt buckle. Nickel is part of the alloy in many metals. Shoes and boots have leather with traces of tanning
chemicals, as well as rubber and adhesives, all of which can cause ACD. Preservatives and fragrances in
beauty and health care products are often a problem. Neomycin is a very common cause of ACD (sensitizing
almost 10% of all people exposed to it). Beware of products containing neomycin, such as Neosporin
ointment. Formaldehyde, present in dry-cleaned clothes and released by some preservatives, is also a
common allergen. Many cases of ICD are puzzling because there is no problem upon exposure during warm
humid months, but in the colder, drier months of fall, winter and early spring, the barrier function of the skin
is compromised, increasing susceptibility to irritation. This is especially true of detergents, such as hand or
laundry soaps. Some cases of detergent ICD arise from overly vigorous cleansing due to the mistaken notion
that there is a fungal infection or some type of infestation. Some products, like cutting oil, can serve as both
an irritant and an allergen. Some patients with ACD or ICD know exactly what the offending agent is. Others
need education about some of the possibilities to allow them to figure out the problem later, particularly after
keeping a journal to correlate symptoms and exposures.
Subjective: Symptoms
Various skin reactions including wheals, erythema, hives, edema, papules, vesicles and others, depending on
the product and level of sensitization. Geometric or linear arrangements implicate a contactant substance.
Objective: Signs
Using Basic Tools: Asymmetric findings, like a skin reaction where a person carries the wallet or holds their