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Tracking down the metabolic basis of a remarkable human single-gene genetic disease provided the insight required to discover drugs to prevent prostate gland growth in aging men (benign prostatic hyperplasia, BPH) and prevent hair loss in men (male pattern baldness). Victims of this genetic disease are born with the appearance of females and are recognized as such. However, at puberty, they undergo a transformation and develop the characteristics of males. The underlying genetic defect is a mutation in the gene that codes for the enzyme 5-alpha reductase (5AR), which promotes conversion of testosterone (T) into the more potent male sex hormone dihydrotestosterone (DHT). Lack of sufficient DHT in utero prevents the full expression of male anatomy at birth, an issue that is corrected at the time of puberty when a surge of male sex hormones occurs. These men have a very small prostate gland that never grows, do not lose their hair, and do not get acne. This strongly suggests that DHT is the causative agent of BPH, male pattern baldness, and acne. An inhibitor of 5AR would create the functional equivalent of the genetic defect and would be expected to be effective in shrinking an enlarged prostate gland and slowing or preventing hair loss and acne in men. Finasteride is such an inhibitor and has met expectations. It is marketed as Proscar for BPH and Propecia for male pattern baldness. Finasteride is a teratogen (can cause birth defects) and has not been developed for acne for that reason.

This chapter looks at the process by which spots form on the skin, considering various contributing factors, before then moving on to a discussion of the treatment of spots and acne. It aims to debunk the myth that spots and acne develop just because you are dirty; instead, the way hair follicles become blocked by grease is detailed, and the role of hormones in this process explained. The types of spots that can develop as a result are discussed, and the creams and tablets available to treat these are explained. One tablet treatment—known as isotretinoin—is mentioned in more detail, in order to address the risks, benefits, and side effects of this particular medication.

This chapter provides an evidence-based approach to the condition known as hidradenitis suppurativa (HS), covering the symptoms, diagnosis, and management of the painful spots caused by HS. HS is a complex condition, and the causes are not completely understood. As with other inflammatory skin conditions, both genes and environment play a role. It gives an explanation of the apocrine glands, and the process by which they become blocked and inflamed in HS, before then moving on to the potential triggers—in particular smoking and weight—associated with the condition. Treatment of HS, including preventative steps, tablet options, and surgical management, are also evaluated in detail.

The skin is an organ that serves many functions in maintaining homeostasis in the body (Bryant, 2000). A wide range of diseases manifest in changes in the skin and its appendages, and because the skin is visible and its disorders are often disfiguring, skin disorders can cause emotional and psychological stress for children and their families (Ball & Bindler, 2007). Skin diseases affect 20–33% of the population at any one time, seriously interfering with activities in 10% (Byrant, 2000). Epidemiological evidence suggests that many cases of skin disease do not reach the general practitioner (GP) or even the local pharmacist; nevertheless, each year about 15% of the population consult their GPs about skin complaints (Bryant, 2000). Skin disorders are among the most common health problems in children (Butcher & White, 2005). The infant and child are possibly more vulnerable to the effects of skin disorders and breakdown due to their underdeveloped integumentary system. Understanding the normal condition of the skin can help in the identification of abnormal signs and prompt treatment of skin disorders (Butcher & White, 2005). This chapter will focus on the integumentary system of the child, with reference to the normal structure of the skin together with common alterations and injuries to the skin of the child and the skills required for their nursing management. At the end of this chapter you should be able to do the following: ● Understand the normal child skin anatomy and physiology. ● Understand the fundamentals of a skin assessment in a child. ● Develop an awareness of the management of common skin alterations. ● Understand the nature and treatment of a child with a skin injury. The skin of an infant or child is normally fundamentally the same as that of an adult, although the blood and nerve supplies are immature and the dermis thinner, with less collagen and fewer elastic fibres. This means that the skin is fragile and can be more easily damaged through physical and mechanical trauma (Turnball, 2007). The skin of a newborn is found to have lanugo, which is a very fine, soft, and unpigmented coat of hairs covering its body until it is shed about 14 days after birth.

Examination of the face and hands can identify significant skin diseases and also provide clues to the presence of underlying systemic disease. Many patients ignore even malignant skin tumours because they are often painless, subtle in appearance, and may be slow-growing. Dental healthcare professionals should be aware of how to recognize malig­nant skin tumours. If suspicious, but unsure of the nature of the lesion, the patient should be referred to their general medical practitioner for further evaluation. If malignancy is obvious, then an urgent referral to an appropriate specialist (dermatologist, plastic surgeon, or oral and max­illofacial surgeon) should be made using the ‘2-week wait’ (2WW) path­way (Chapter 1). Benign lesions and inflammatory diseases are more common and are important considerations in the differential diagnosis of head and neck skin abnormalities. It is important that the dental healthcare professional should be able to recognize common skin infections involving the oro-facial region. Some infections, such as erysipelas, can mimic cellulitis associated with a dental infection. When infection is diagnosed, it is vital to consider the underlying or predisposing factors, as these may be not only important diagnoses, but also may require treatment to achieve an effective clin­ical outcome. The adage ‘infection is the disease of the diseased’ is a useful reminder when dealing with patients presenting with infection. Direct inoculation of Streptococcus into skin through minor trauma is the most common initiating factor for erysipelas, which occurs in iso­lated cases. Infection involves the upper dermis and, characteristically, spreads to involve the dermal lymphatic vessels. Clinically, the disease starts as a red patch that extends to become a fiery red, tense, and indurated plaque. Erysipelas can be distinguished from cellulitis by its advancing, sharply defined borders and skin streaking due to lymphatic involvement. The infection is most common in children and the elderly, and whilst classically a disease affecting the face, in recent years it has more frequently involved the leg skin of elderly patients. Although a clinical diagnosis can be made without laboratory testing, and treat­ment is antibiotic therapy, when the diagnosis is suspected in dental practice, referral to a medical practitioner is recommended.