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Clinical Dermatology
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For Ruth, Patricia and Arlene
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Clinical Dermatology
J.A.A. Hunter
OBE BA MD FRCP (Edin)
Professor Emeritus of Dermatology
University of Edinburgh
The Royal Infirmary
Edinburgh
J.A. Savin
MA MD ChB FRCP DIH
Former Consultant Dermatologist
The Royal Infirmary
Edinburgh
M.V. Dahl
BA MD
Professor and Chair
Department of Dermatology
Mayo Clinic Scottsdale
Scottsdale, USA, and
Professor Emeritus
University of Minnesota Medical School
Minneapolis, Minnesota, USA
THIRD EDITION
Blackwell
Science
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© 1989, 1995, 2002 by Blackwell Science Ltd
a Blackwell Publishing company
Blackwell Science, Inc., 350 Main Street, Malden, Massachusetts 02148-5018, USA
Blackwell Science Ltd, Osney Mead, Oxford OX2 0EL, UK
Blackwell Science Asia Pty Ltd, 550 Swanston Street, Carlton, Victoria 3053, Australia
The right of the Author to be identified as the Author of this Work has been asserted in accordance
with the Copyright, Designs and Patents Act 1988.
All rights reserved. No part of this publication may be reproduced, stored in a retrieval system, or
transmitted, in any form or by any means, electronic, mechanical, photocopying, recording or
otherwise, except as permitted by the UK Copyright, Designs and Patents Act 1988, without the prior
permission of the publisher.
First published 1989
Reprinted 1990, 1992, 1994
Second edition 1995
Reprinted 1996, 1999
Third edition 2002
Reprinted 2003
Library of Congress Cataloging-in-Publication Data
Hunter, J. A. A.
Clinical dermatology / J.A.A. Hunter, J.A. Savin, M.V. Dahl.— 3rd ed.
p. ; cm.
Includes index.
ISBN 0-632-05916-8
1. Skin—Diseases. 2. Dermatology.
[DNLM: 1. Skin Diseases—diagnosis. 2. Skin Diseases—therapy. WR
140 H945c 2002] I. Savin, John. II. Dahl, Mark V. III. Title.
RL71 .H934 2002
616.5—dc21
2002007252
ISBN 0-632-05916-8
A catalogue record for this title is available from the British Library
Set in 9/12 Sabon by Graphicraft Limited, Hong Kong
Printed and bound in Denmark by Narayana Press, Odder
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Contents
Preface to the third edition, vi
Preface to the first edition, viii
Introduction, ix
1 Skin disease in perspective, 1
2 The function and structure of the skin, 7
3 Diagnosis of skin disorders, 29
4 Disorders of keratinization, 41
5 Psoriasis, 48
6 Other papulosquamous disorders, 63
7 Eczema and dermatitis, 70
8 Reactive erythemas and vasculitis, 94
9 Bullous diseases, 107
10 Connective tissue disorders, 119
11 Disorders of blood vessels and lymphatics, 132
12 Sebaceous and sweat gland disorders, 148
13 Regional dermatology, 162
14 Infections, 189
15 Infestations, 224
16 Skin reactions to light, 233
17 Disorders of pigmentation, 242
18 Skin tumours, 253
19 The skin in systemic disease, 283
20 The skin and the psyche, 294
21 Other genetic disorders, 300
22 Drug eruptions, 307
23 Medical treatment, 314
24 Physical forms of treatment, 321
Formulary 1: Topical treatments, 328
Formulary 2: Systemic medication, 340
Index, 355
v
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Preface to the third edition
Five years is a long time in modern medicine, and expanding role of lasers, ‘sun sense’, and the drug treat-
we feel that the moment has come for Clinical ment of AIDS are good examples of these. In addition,
Dermatologyto move into its third edition. As before, some new subjects, such as cutaneous anthrax, have
every chapter has been updated extensively, but our been forced into the new edition by outside events.
aim is still the sameato create an easily read text that We welcome you to our third edition.
will help family doctors to get to grips with a subject
many still find confusing, despite the increasingly
stodgy sets of guidelines that now land regularly on Acknowledgements
their desks.
We have selected the best elements of these guidelines Many of the clinical photographs come from the
for our new sections on treatment, which are there- collection of the Department of Dermatology at the
fore much more ‘evidence based’. However, if we had Royal Infirmary of Edinburgh and we wish to thank
to include only treatments based on flawless evidence, all those who presented them. We are most grateful
we would have to leave out too many old favourites to Graeme Chambers who has redrawn the previous
that have stood the test of time, but have still not been line drawings as well as creating the new figures for
evaluated properly. Next time perhaps. the third edition, and to Geraldine Jeffers, Julie Elliott
We have also reacted to a survey of our readers, and Stuart Taylor of Blackwell Publishing for their
which showed that most of them spend little time on help and encouragement in preparing this book.
the chapters devoted only to the structure, function We are also most grateful to the publishers for per-
and immunology of the skin. We have pruned these mission to use illustrations previously published in
back, but have put more physiology and pathology the following books:
into the relevant clinical chapters where it should be
of more use to a doctor struggling through a busy Champion, R.H., Burton, J.L., Ebling, F.J.G. (1992)
surgery. Textbook of Dermatalogy, 5th edn. Blackwell
Other changes too have been prompted by the helpful Scientific Publications, Oxford.
comments of our readers. They include a new chapter Edwards, C.R.W., Bouchier, I.A.D., Haslett, C.,
on regional dermatology, dealing with the special Chilvers, E.R. (1999) Davidson’s Principles and
problems of areas such as the mouth and the genitalia; Practice of Medicine, 17th edn. Churchill
the replacement of several unloved clinical pho- Livingstone, Edinburgh.
tographs; the insertion of a list of suggestions for fur- Gawkrodger, D.J. (1997) An Illustrated Colour
ther reading at the end of each chapter; more discussion Text of Dermatology. Churchill Livingstone,
of the ageing skin and of quality of life issues; and Edinburgh.
more emphasis on the types of surgery that can easily Kavanagh, G.M., Savin, J.A. (1998) Self Assessment
be undertaken by family doctors. More power to their Picture Tests: Dermatology. Mosby, London.
elbows. Munro, J., Campbell, I.W. (2000) Macleod’s Clinical
Finally, many important recent advances have entered Examination, 10th edn. Churchill Livingstone,
every chapter on their own merits. Dermatoscopy, the Edinburgh.
vi
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vii
PREFACE TO THE THIRD EDITION
Percival, G.H., Montgomery, G.L., Dodds, T.C.
Disclaimer
(1962) Atlas of Histopathology of the Skin, 2nd
edn. E.B. Livingstone, Edinburgh.
Although every effort has been made to ensure that
Savin, J.A., Hunter, J.A.A., Hepburn, N.C. (1997)
drug doses and other information are presented
Skin Signs in Clinical Medicine: Diagnosis in
accurately in this publication, the ultimate responsi-
Colour. Mosby-Wolfe, London.
bility rests with the prescribing physician. Neither the
Sayer, H.P., et al.(2001) Dermoscopy of Pigmented
publishers nor the authors can be held responsible for
Skin Lesions. EDRA Medical Publishing and New
any consequences arising from the use of information
Media, Milan.
contained herein. Any product mentioned in this pub-
lication should be used in accordance with the pre-
scribing information prepared by the manufacturers.
CD3A01 21/5/05 11:45 AM Page viii
Preface to the first edition
Some 10% of those who go to their family doctors do aand of course their patients. We make no apologies
so with skin problems. We have seen an improvement for our emphasis on diagnosis and management, and
in the way these have been managed over the last accept that we cannot include every remedy. Here, we
few years, but the subject still baffles many medical mention only those preparations we have found to be
studentsaon both sides of the Atlantic. They find it useful and, to avoid too many trade names, we have
hard to get a grip on the soggy mass of facts served up tabulated those used in the UK and the USA in a
by some textbooks. For them we have tried to create Formulary at the back of the book.
an easily-read text with enough detail to clarify the We have decided not to break up the text by quoting
subject but not enough to obscure it. lists of references. For those who want to know more
There are many doctors too who are puzzled by there are many large and excellent textbooks on the
dermatology, even after years in practice. They have shelves of all medical libraries.
still to learn how to look at the skin with a trained While every effort has been made to ensure that the
eye. Anyone who denies that clinical dermatology is a doses mentioned here are correct, the authors and
visual specialty can never have practised it. In this book publishers cannot accept responsibility for any errors
we have marked out the route to diagnostic success with in dosage which may have inadvertently entered this
a simple scheme for recognizing primary skin lesions book. The reader is advised to check dosages, adverse
using many diagrams and coloured plates. effects, drug interactions, and contraindications in
We hope that this book will help both groupsa the latest edition of the British National Formulary
students and doctors, including some in general or Drug Information (American Society of Hospital
medicine and some starting to train as dermatologists Pharmacists).
viii
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Introduction
Our overall aim in this book has vehicle in which it should be put
been to make dermatology easy to up (Chapter 23). Correct choices
understand by the many busy doc- here will be repaid by good results.
tors who glimpsed it only briefly, if Patients may be quick to complain
at all, during their medical training. if they are not doing well: equally
All too often the subject has been they are delighted if their eruptions
squeezed out of its proper place can be seen to melt rapidly away.
in the undergraduate curriculum, Many of them are now joining in
leaving growing numbers who quail the quest for cosmetic perfection
before the skin and its reputed that is already well advanced in the
2000 conditions, each with its own USA and becoming more fashion-
diverse presentations. They can see able in the UK. Family doctors who
the eruptions clearly enough, but are asked about this topic can find
cannot describe or identify them. their answers in our new chapter
There are no machines to help on physical methods of treatment
Robert Willan used the Linnaean
them. Even official ‘clinical guide- (Chapter 24).
system of botanical classification to
lines’ for treatment are no use if a We do not pretend that all of the
divide skin diseases into eight orders.
diagnosis has not been made. Their problems in the classification of
patients quickly sense weakness and lose faith. We skin diseases have been solved in thisbook. Far from it:
hope that this book will give them confidence in their some will remain as long as their causes are still
ability to make the right diagnosis and then to pre- unknown, but we make no apology for trying to keep
scribe safe and effective treatment. our terminology as simple as possible. Many doc-
To do so they will need some understanding of tors are put off by the cumbersome Latin names left
the anatomy, physiology and immunology of the skin behind by earlier pseudo-botanical classifications.
(Chapter 2): but, as Robert Willan (1757–1812) (Figure) Names like painful nodule of the earor ear cornmust
(recently elected as ‘Dermatologist of the Millennium’) now be allowed to take over from more traditional
showed long ago, the simple steps that lead to a sen- ones such as chondrodermatitis nodularis helicis
sible working diagnosis must start with the identifica- chronica, and fist fights over the difference between
tion of primary skin lesions and the patterns these dermatitis and eczema must now stop.
have taken up on the skin surface (Chapter 3). After As well as simplifying the terminology, we have
this has been achieved, investigations can be directed concentrated mainly on common conditions, which
along sensible lines (Chapter 3) until a firm diagnosis make up the bulk of dermatology in developed coun-
is reached. Then, and only then, will the correct line of tries, though we do mention some others, which may
treatment snap into place. be rare, but which illustrate important general princi-
But another cloud of mystery has settled here, over ples.We have also tried to cut out as many synonyms
the subject of topical treatment. We attempt to blow and eponyms as possible. We have included some
this away with a few simple rules governing the selec- further reading at the end of each chapter for those
tion of the right active ingredient, and of the right wanting more information and, for the connoisseur,
ix
