Milia and Keratin Cysts

Milia are very common, benign, keratin-filled cysts. Primary milia are typically seen in infants but also may occur in children and adults. Secondary milia are observed in a number of blistering disorders and following dermabrasion. Milia en plaque and multiple eruptive milia are distinct entities.

The eMedicine Pediatrics article Milia may be of interest, as may the Medscape Dermatologic Surgery Resource Center.

Pathophysiology: Milia are tiny epidermoid cysts. The cysts may be derived from the pilosebaceous follicle. Primary milia arise on facial skin bearing vellus hair follicles.  Secondary milia result from damage to the pilosebaceous unit.

Frequency in the United States:
Primary milia in newborns are so common that they can be considered normal (occurring in approximately half of all infants). Multiple eruptive milia and milia en plaque are rare entities.

Race : No racial predilection is recognized.
Sex : Sexual prevalence is equal for primary and secondary milia. Eruptive milia and milia en plaque occur more frequently in women.
Age : Milia occur in persons of all ages but are typically found in infants.

Clinical History
Milia are asymptomatic. In children and adults, they usually arise around the eye. Eruptive milia, as the name suggests, have a rapid onset, often within a few weeks.

Physical
* Skin lesions
o Milia are superficial, uniform, pearly white to yellowish, domed lesions measuring 1-2 mm in diameter.
o In milia en plaque, multiple milia arise on an erythematous plaque.
* Skin distribution
o Primary milia, in term infants, occur on the face, especially the nose. They also may be found on the mucosa (Epstein pearls) and palate (Bohn nodules).
o Primary milia in older children and adults develop on the face, particularly around the eyes.
o Milia have been observed to occur in a transverse, linear distribution along the nasal groove in some children.
o Secondary milia are found anywhere on the body at the sites affected by the predisposing condition.
o Eruptive milia occur on the head, neck, and upper body.
o Milia en plaque manifests as distinct plaques on the head and neck. Plaques have been described in the postauricular area, unilaterally or bilaterally, the cheeks, the submandibular plaques, and on the pinna.

Causes
* Primary milia are believed to arise in sebaceous glands that are not fully developed, explaining the high prevalence in newborn infants.
* Secondary lesions arise following blistering or trauma due to disruption of the sweat ducts. Milia have been described in association with many disorders, including bullous pemphigoid, inherited and acquired epidermolysis bullosa, bullous lichen planus, porphyria cutanea tarda, and burns. Skin trauma from dermabrasion or radiotherapy can result in milia formation.
* Secondary milia have arisen from a bullous contact dermatitis and a photocontact allergy to sunscreen.

They have also arisen following treatment of cutaneous leishmaniasis and after topical nitrogen mustard ointment for plaque stage mycosis fungoides.
* Secondary milia have been described following potent topical corticosteroid use.
* Milia are a feature of a number of very rare genodermatoses (eg, Bazex-Dupré -Christol syndrome).  Both primary milia and multiple eruptive milia have been reported as familial disorders with autosomal dominant inheritance.
* The etiology of milia en plaque is unknown.

Medical Care
No topical or systemic medications are effective on primary and secondary milia. Single case reports have demonstrated the success of topical isotretinoin, oral etretinate and minocycline in treating patients with milia en plaque.

Surgical Care
Milia can be safely left alone, but if the patient requests treatment, then incision with a cutting-edge needle and manual expression of the contents are effective. This can be performed without local anesthetic. A paper clip has been successfully used to express the contents of the cyst. Milia en plaque has been treated effectively with electrodesiccation, carbon dioxide laser, dermabrasion, and cryosurgery.

Skin Conditions: Is it a Skin Tag or a Mole?

There are several skin lesions that are very common and almost always benign (non-cancerous). These conditions include moles, freckles, skin tags, benign lentigines, and seborrheic keratoses.

Moles

Moles are growths on the skin that are usually brown or black. Moles can appear anywhere on the skin, alone or in groups. Most moles appear in early childhood and during the first 20 years of a person’s life. Some moles may not appear until later in life. It is normal to have between 10-40 moles by adulthood.

As the years pass, moles usually change slowly, becoming raised and/or changing color. Often, hairs develop on the mole. Some moles may not change at all, while others may slowly disappear over time.

What Causes a Mole?

Moles occur when cells in the skin grow in a cluster instead of being spread throughout the skin. These cells are called melanocytes, and they make the pigment that gives skin its natural color. Moles may darken after exposure to the sun, during the teen years, and during pregnancy.

Types of Moles

• Congenital nevi are moles that appear at birth. Congenital nevi occur in about one in 100 people. These moles may be more likely to develop into melanoma (cancer) than are moles that appear after birth. A mole or freckle should be checked if it has a diameter of more than 7 mm or any characteristics of the ABCDEs of melanoma.

• Dysplastic nevi are moles that are larger than average (larger than a pencil eraser) and irregular in shape. They tend to have uneven color with dark brown centers and lighter, uneven edges. These moles tend to be hereditary (passed on from parent to child through genes). People with dysplastic nevi may have more than 100 moles and have a greater chance of developing melanoma, a serious form of skin cancer. Any changes in a mole should be checked by a dermatologist to detect skin cancer.

How Do I Know if a Mole Is Cancer?

Most moles are not dangerous. The only moles that are of medical concern are those that look different than other existing moles or those that first appear after age 20. If you notice changes in a mole’s color, height, size or shape, you should have a dermatologist (skin doctor) evaluate it. You also should have moles checked if they bleed, ooze, itch, appear scaly, or become tender or painful.

Examine your skin with a mirror or ask someone to help you. Pay special attention to areas of your skin that are often exposed to the sun, such as the hands, arms, chest, neck, face, and ears.

If your moles do not change over time, there is little reason for concern. If you see any signs of change in an existing mole, if you have a new mole, or if you want a mole to be removed for cosmetic reasons, talk to your dermatologist.

The following ABCDEs are important characteristics to consider when examining your moles. If a mole displays any of the signs listed below, have it checked immediately by a dermatologist. It could be cancerous.

• Asymmetry. One half of the mole does not match the other half.
• Border. The border or edges of the mole are ragged, blurred, or irregular.
• Color. The color of the mole is not the same throughout or has shades of tan, brown, black, blue, white, or red.
• Diameter. The diameter of a mole is larger than the eraser of a pencil.
• Elevation.A portion of the mole appears elevated, or raised from the skin.

Melanoma is a form of skin cancer. The most common location for melanoma in men is the back and in women, it is the lower leg. Melanoma is the most common cancer in women ages 25 to 29.

How Are Moles Treated?

If a dermatologist believes a mole needs to be evaluated further or removed entirely, he or she will either remove the entire mole, or first take just a small tissue sample of the mole to examine thin sections of the tissue under a microscope (a biopsy). This is a simple procedure. (If the dermatologist thinks the mole might be cancerous, cutting through the mole will not cause the cancer to spread.)

If the mole is found to be cancerous, and only a small section of tissue was taken, the dermatologist will remove the entire mole by cutting out the entire mole and a rim of normal skin around it, and stitching the wound closed.

Reviewed by doctors at The Cleveland Clinic Department of Dermatology.

Skin Tag Removal at Home

If you are embarrassed or irritated from a funny little piece of extra skin somewhere on your person, you may have a skin tag.

Skin tags (medical name: acrochordon) as it turns out are a common condition, basically a benign tumor, or growth of skin, on various part of the body–most commonly the eyelids, nose, cheek, neck, armpits, upper chest and groin.   More women (especially pregnant women) than men get skin tags, and skin tags increase in both genders with age, diabetes, and obesity.  Skin tags usually don’t cause any serious health problems, but are unwanted for aesthetic reasons or because of the minor irritation they can cause.

Getting rid of a skin tag is relatively simple, as the suggestions below show.

Removing skin tags with a scalpel or scissors is a common and easy way to get rid of skin tags at home. Make sure the blade you use is sharp and sanitized (use an open flame, rubbing alcohol, or hydrogen peroxide), and cut as quickly and closely to the healthy skin as you can. Some bleeding may occur, but shouldn’t last for more than a minute. Tweezers may also be used to pull the skin tag off. Getting rid of skin tags this way will likely be painful, and you might want to numb the area first with an ice cube, or other cold substance.

Remove skin tags by freezing them off with liquid nitrogen (cyrotherapy).  Liquid nitrogen is a common treatment for skin growths. When applied to a skin tag, liquid nitrogen will destroy the cell tissue quickly and efficiently. Getting rid of skin tags with cyrotherapy may cause some minor pain and scarring, and the liquid nitrogen should not be applied to the same area of skin more than once a week.
Electrosurgery, or electrolysis, is an effective way to get rid of skin tags. This procedure is usually performed by a professional, who will use an electric needle to destroy the skin tag growth, as well as any additional growth beneath the skin. Electrolysis is usually fast and permanent, with minor scarring.

You can also remove skin tags by cutting off their blood supply. Use thread or string to tie off the skin tag close to the healthy skin to cut off the blood supply, which will eventually cause the skin tag to fall off (usually after a day or two). Depending on the location of the skin tag, you may either need help tying the string tight enough to be effective, or be unable to use this method (unless you don’t mind having a piece of string
hanging from your nose) to get rid of skin tags.

Cover skin tags in certain areas with a band aid to avoid further irritation before treatment, or to avoid treatment. Skin tags in areas like the armpits, the groin, the chest, and the back (basically any area that rubs against clothing or other skin on a frequent basis) are prone to irritation, which can cause skin tags to worsen, and in turn cause getting rid of skin tags to become more difficult or painful.

Treating Skin Conditions
If you don’t feel confident about diagnosing skin tags, see a dermatologist before attempting to treat yourself. There are numerous other, more serious, skin problems that may require more serious attention and different treatment than skin tags.These include moles, warts, freckles, and general skin damage from sun or chemicals.

Birt-Hogg Dube syndrome is a rare genetic disorder characterized by skin problems, especially noncancerious tumors occuring in hair follicles on the face, neck and chest. The presence of this syndrome can increase a person’s risk of other internal cancerous tumours and cysts. While it’s highly unlikely that you have this disorder, something like this is a good reason for you to consult a health professional if you are at all unsure about or unfamiliar with diagnosing or treating skin tags, or any other skin disorder.

Milia and Seborrheic Keratosis

Milia, also known as milk spots or oil seeds, are benign, keratin-filled cysts that can appear just under the epidermis or on the roof of the mouth. They are commonly associated with newborn babies but can appear on people of all ages. They are usually found around the nose and eyes, and sometimes on the genitalia, often mistaken by those infected as warts or other STDs.

In children milia often disappears within two to four weeks. In adults it may require removal by a physician or an esthetician. Milia can sometimes be a result of harsh face washes or from repeated heat stress from hot showering on people with sensitive skins. Milia can be confused with stubborn whiteheads.

A seborrheic keratosis (also known as “Seborrheic verruca,” “Senile keratosis,” and “Senile wart”) is a noncancerous benign skin growth that originates in keratinocytes. Like liver spots, seborrheic keratoses are seen more often as people age. In fact they are sometimes humorously referred to as the “barnacles of old age”.

They appear in various colors, from light tan to black. They are round or oval, feel flat or slightly elevated (like the scab from a healing wound), and range in size from very small to more than 2.5 centimetres (1.0 in) across. They can resemble warts, though they have no viral origins. They can also resemble melanoma skin cancer, though they are unrelated to melanoma as well. Because only the top layers of the epidermis are involved, seborrheic keratoses are often described as having a “pasted on” appearance. Some dermatologists refer to seborrheic keratoses as “seborrheic warts”, however these lesions are usually not associated with HPV, and therefore such nomenclature should be discouraged.

Classification

Seborrheic keratoses may be divided into the following types:

* Common seborrheic keratosis (Basal cell papilloma, Solid seborrheic keratosis)
* Reticulated seborrheic keratosis (Adenoid seborrheic keratosis)

Reticulated seborrheic keratosis (also known as “Adenoid seborrheic keratosis”) is a common benign cutaneous condition characterized by a skin lesion with a dull or lackluster surface, and with keratin cysts seen histologically.

* Stucco keratosis (Digitate seborrheic keratosis, Hyperkeratotic seborrheic keratosis, Serrated seborrheic keratosis, Verrucous seborrheic

keratosis) Stucco keratosis (also known as “Digitate seborrheic keratosis,” “Hyperkeratotic seborrheic keratosis,” “Serrated seborrheic keratosis,” and “Verrucous seborrheic keratosis”) is a common benign cutaneous condition characterized by a skin lesion with a dull or lackluster surface, and with church-spire-like projections of epidermal cells around collagen seen histologically.

* Clonal seborrheic keratosis
Clonal seborrheic keratosis is a common benign cutaneous condition characterized by a skin lesion with a dull or lackluster surface, and with round, loosely packed nests of cells seen histologically.

* Irritated seborrheic keratosis (Basosquamous cell acanthoma, Inflamed seborrheic keratosis)

* Seborrheic keratosis with squamous atypia

Seborrheic keratosis with squamous atypia is a less common cutaneous condition characterized by a skin lesion with a dull or lackluster surface, and with round, loosely packed nests of cells seen histologically.

* Melanoacanthoma (Pigmented seborrheic keratosis)

Melanoacanthoma (also known as “Pigmented seborrheic keratosis”) is a common, benign, darkly pigmented cutaneous condition characterized by a skin lesion with a dull or lackluster surface.

* Dermatosis papulosa nigra

Dermatosis papulosa nigra (DPN) is a condition of many small, benign skin lesions on that face that closely simulate seborrheic keratoses, a condition generally presenting on dark-skinned individuals.

They should not be confused for Leser-Trélat sign, a sudden explosion of lesions due to a growing tumor.

* The sign of Leser-Trélat

The Leser-Trélat sign is the explosive onset of multiple seborrheic keratoses (many pigmented skin lesions), often with an inflammatory base. This can be an ominous sign of internal malignancy as part of a paraneoplastic syndrome. In addition to the development of new lesions, preexisting ones frequently increase in size and become symptomatic. It is named for Edmund Leser and Ulysse Trélat.

Although most associated neoplasms are gastrointestinal adenocarcinomas (stomach, liver, colorectal and pancreas), breast, lung, and urinary tract cancers, as well as lymphoid malignancies are associated with this impressive rash. It is likely that various cytokines and other growth factors produced by the neoplasm are responsible for the abrupt appearance of the seborrheic keratoses. In some cases, paraneoplastic acanthosis nigricans accompanies the sign of Leser-Trélat.

Variances of Seborrheic Keratosis:

Dermatosis Papulosis Nigra: Often are small papules. Pinpoint to a few millimeters in size. More commonly found in dark-skinned persons.

Stucco Keratosis: Often are light brown to off-white. Pinpoint to a few millimeters in size. Often found on the distal tibia, ankle, and foot.

Diagnosis: Visual diagnosis is made by the “stuck on” appearance, horny pearls or cysts embedded in the structure. Darkly pigmented lesions can be hard to distinguish from nodular melanomas. If in doubt, a skin biopsy should be performed. Thin seborrheic keratoses on facial skin can be very difficult to differentiate from lentigo maligna even with dermatoscopy.

Clinically, epidermal nevi are similar to seborrheic keratoses in appearance. Epidermal nevi are usually present at or near birth. Condylomas and warts can clinically resemble seborrheic keratoses, and dermatoscopy can be helpful. On the penis and genital skin, differentiation between condylomas and seborrheic keratoses can be difficult and may require a skin biopsy.

Treatment
When correctly diagnosed, no treatment is necessary. There is a small risk of localized infection caused by picking at the lesion. If a growth becomes excessively itchy or is irritated by clothing or jewelry, it can be removed by cryosurgery.

Small lesions can be treated with light electrocautery. Larger lesions can be treated with electrodessication and curettage, shave excision, or cryotherapy. When correctly performed, removal of seborrheic keratoses will not cause much visible scarring except in darkly colored persons.

Cause
The cause of seborrheic keratosis is unclear. Because they are common on sun-exposed areas such as the back, arms, face, and neck, ultraviolet light

may play a role, as may genetics.[8] A mutation of a gene coding for a growth factor receptor, (FGFR3), has been associated with seborrheic keratosis.

Etymology
The term “seborrheic keratosis” combines the adjective form of seborrhea, keratinocyte (referring to the part of the epidermis that produces keratin), and the suffix -osis, meaning abnormal.

Staph Wound Infections and Staphylococcus aureus

Staph Wound Infections and Methicillin Resistant Staphylococcus aureus

Staphylococcus aureus, also called S. aureus or “staph,” is a bacterium that frequently colonizes the human skin and is present in the nose of about 25-30% of U.S. adults. S. aureus can exist in this form without harming its host or causing symptoms. However, if there is a break in the patient’s skin from a wound or surgery, or if there is a depression in the person’s immune system, then colonizing S. aureus can cause an infection. Staph frequently causes localized skin infections, such as folliculitis, furuncles, and impetigo. It can also cause abscesses and spread into the bones (osteomyelitis), lungs (staphylococcal pneumonia), blood (bacteremia or sepsis), heart (endocarditis – which can damage the heart valves), and other organs. Staph may also infect others as it can be passed from both infected and colonized people to other people through skin contact or through sharing contaminated objects, such as towels or razors.

Hospital-acquired infections
Staph infections acquired while a patient is in a hospital, long-term care facility, or other health care setting have been a challenge for many years. The confined population and the widespread use of antibiotics have led to the development of antibiotic-resistant strains of S. aureus. These strains are called methicillin resistant staphylococcus aureus (MRSA), named after the antibiotic treatment that was developed in 1960 to treat penicillin-resistant strains. Infections caused by MRSA are frequently resistant to a wide variety of antibiotics and are associated with ignificantly higher rates of morbidity and mortality, higher health care costs, and longer hospital stays than infections caused by methicillin susceptible S. aureus. Risk factors for MRSA infection in the hospital include surgery, prior antibiotic therapy, admission to intensive care, exposure to a MRSA-colonized patient or health care worker, being in the hospital more than 48 hours, and having an indwelling catheter or other medical device that goes through the skin.

One strategy that may be used in an effort to control the spread of infection includes active surveillance for the detection of MRSA in patients admitted to intensive care units (ICUs) and other high risk areas. Another approach is to screen all patients admitted to a health care facility. Community-acquired infections
MRSA infections have increased in importance in the community in recent years because they have been associated with a growing number of outbreaks and deaths in non-medical settings where individuals are in close contact such as prisons, day care facilities, military units, and contact sports. These infections are occurring in people who do not have classic MRSA risk factors as described above. A significant number of those affected have had to be hospitalized for what appears to be a simple but persistent skin infection or for pneumonia that develops after a bout of influenza.

Until recently, part of the problem with community-acquired MRSA (CA-MRSA) has been a lack of awareness in the medical community and the community at large. Historically, physicians have treated staph infections, based on their severity, with either over-the-counter triple-antibiotic ointments or with a standard course of antibiotics. They did not routinely order cultures to identify the organism and its antibiotic susceptibility profile unless the infection appeared extensive or the initial treatment was unsuccessful. With CA-MRSA, however, these conventional therapy options have frequently failed. A significant number of those affected have been hospitalized and a few previously healthy patients have died.

Investigations of these outbreaks have revealed that the CA-MRSA was spread from infected or colonized patients to those around them through skin contact (such as sports-related cuts and abrasions), through droplets from the respiratory tract, or through exposure to contaminated objects, such as shared sports equipment, towels, toys, or playground equipment. Investigations have also revealed that the S. aureus strains involved in CA-MRSA are genetically distinct from those that have been causing hospital-acquired MRSA. The CA-MRSA are resistant to methicillin and related antibiotics (oxacillin, dicloxacillin, nafcillin) and erythromycin but remain susceptible to many other antibiotics.

Laboratory Tests

The purpose of culturing wound infections is to identify the bacteria causing the infection and to determine the susceptibility of the microorganism to available antibiotics. If an infection is due to MRSA, it should be investigated to determine the source of the infection. This is especially important in CA-MRSA to prevent further cases from occurring.

The primary laboratory tests performed are:

* Cultures of the affected areas. Fluid or pus from a wound, sputum, blood, joint fluid, or even breast milk (in the case of an infected breast) is collected and spread onto a thin layer of nutrient gel and/or grown in a nutrient broth. Sometimes, multiple samples are collected to evaluate different body sites or to attempt to detect bacteria that may be present in small numbers.
* Nasal cultures (collected by inserting a swab inside the nose) used to screen healthy people may also be ordered to determine whether someone has been colonized with MRSA and is a carrier. The cultured samples are incubated and examined for the growth of characteristic S. aureus colonies. If they are present, susceptibility testing is performed to determine whether the strain is MRSA.
* Nasal swabs may be collected to detect MRSA colonization based on rapid molecular tests, which do not grow the bacteria but detect their presence and antibiotic resistance by detecting the genes responsible for the methicillin resistance.

Identifying MRSA can sometimes be challenging. The population of staph that a person has tends to be mixed. This means that even if a patient has CA-MRSA or hospital-acquired MRSA, not all of the staph present will be equally resistant. Since resistant strains may grow more slowly than susceptible strains, there is the potential for missing them.

A variety of methods may be used to track different strains of MRSA. These are used in the investigation of the spread of MRSA within a community or region but are not used in the treatment of an individual patient.

Fungal Infections / Mycoses Overview

If you have ever had athlete’s foot or a yeast infection, you can blame a fungus. A fungus is actually a primitive vegetable. Mushrooms, mold and mildew are examples. Fungi live in air, in soil, on plants and in water. Some live in the human body. Only about half of all types of fungi are harmful.

Some fungi reproduce through tiny spores in the air. You can inhale the spores or they can land on you. As a result, fungal infections often start in the lungs or on the skin. You are more likely to get a fungal infection if you have a weakened immune system or take antibiotics.

Fungi can be difficult to kill. For skin and nail infections, you can apply medicine directly to the infected area. Oral antifungal medicines are also available for serious infections.

What are Fungal Infections?
Fungal infections represent the invasion of tissues by one or more species of fungi. They range from superficial, localized skin conditions to deeper tissue infections to serious lung, blood (septicemia) or systemic diseases. Some fungi are opportunistic while others are pathogenic, causing disease whether the immune system is healthy or not.

Fungi are one of four major groups of microorganisms (bacteria, viruses, parasites, and fungi). They that exist in nature in one of two forms: as unicellular yeasts or as branching filamentous molds (also may be spelled as “moulds”). Some fungi are dimorphic - they change from one form to another depending on their environment. While yeasts cannot be seen with the naked eye, molds can be seen as the fuzzy splotches on overripe fruit or stale bread, as mildew in the bathroom shower, and as mushrooms growing on a rotted log. There are more than 50,000 species of fungi in the environment, but less than 200 species are associated with human disease. Of these, only about 20 to 25 species are common causes of infection.

Most fungal infections occur because a person is exposed to a source of fungi such as spores on surfaces or in the air, soil, or bird droppings. Usually, there is a break or deficiency in the body’s immune system defenses and/or the person provides the “right environment” for the fungi to grow. Anyone can have a fungal infection, but certain populations are at an increased risk of fungal infections and recurrence of infections. These include organ transplant recipients, people who have HIV/AIDS, those who are on chemotherapy or immune suppressants, and those who have an underlying condition such as diabetes or lung disease.

Infections involving fungi may occur on the surface of the skin, in skin folds, and in other areas kept warm and moist by clothing and shoes. They may occur at the site of an injury, in mucous membranes, the sinuses, and the lungs. Fungal infections trigger the body’s immune system, can cause inflammation and tissue damage, and in some people may trigger an allergic reaction.

Many infections remain confined to a small area, such as between the toes, but others may spread over the skin and/or penetrate into deeper tissues. Those that progress and those that start in the lungs may move into the blood and be carried throughout the body. Some fungal infections may resolve on their own, but most require medical attention and may need to be treated for extended periods of time. Those that penetrate into the body typically increase in severity over time and, if left untreated, may cause permanent damage and in some cases eventually be fatal. A few fungal infections may be easily passed on to other people, while others typically only affect the infected person.

Fungal infections may be categorized by the part of the body that they affect, by how deeply they penetrate the body, by the organism causing the infection, and by the form(s) that the fungi take. Some organisms may cause both superficial and systemic infections.