Hemorrhoids: what the dermatologist should know.

Anorectal disorders are common and more than one half of the population will experience one at some time during their lives. It is important for the clinician to recognize the differences between internal and external hemorrhoids and other anorectal problems such as fissures, abscesses, fistulas, skin tags, and a variety of dermatologic conditions because the treatment is often different. This article will discuss the anatomy, pathophysiology, diagnosis, and treatment of internal and external hemorrhoids.

Scabies in AIDS.

Human immunodeficiency virus/acquired immune deficiency syndrome (HIV/AIDS) will be the most common disease triggering crusted (Norwegian) scabies. Scabies should be suspected in any atypical itching (or non) rash in HIV/AIDS patients. Attempt to prove the diagnosis by doing a skin scraping, or if negative, a skin biopsy. Unusual forms of scabies in HIV/AIDS can be divided into crusted scabies and atypical (exaggerated) scabies. Therapy requires the sequential use of scabicides, usually over a longer period than is required to clear an ordinary case of scabies. Compliance is a concern, and the scabicides are best administered under supervision whenever possible. Isolating the index patient and treating the environment of patients with crusted or atypical scabies is much more significant than in ordinary scabies. The transmission in hospitals of ordinary scabies from an index patient with crusted scabies to other patients, health care workers, etc, is common. Protective measures and early diagnosis and therapy are essential.

Scabies therapy--1993.

The addition of permethrin as a scabicide with low toxicity adds significantly to our therapeutic options for typical and special forms of scabies. Detailed specific management suggestions, as well as a scabies instruction sheet, are included. The management of crusted (Norwegian) scabies and scabies in human immunodeficiency virus-acquired immune deficiency syndrome (HIV/AIDS) is more difficult and may require, particularly in those intensely immunosuppressed, repeated treatment with scabicides and sometimes sequential use of several agents. Tolerance (resistance) to lindane was suggested in Central America but also in South America, Haiti, Egypt, and in clusters in the United States.

Tufted angioma (angioblastoma). A benign progressive angioma, not to be confused with Kaposi's sarcoma or low-grade angiosarcoma.

Twenty patients are described with an unusual form of angiomatous proliferation, which most commonly arose on the neck and upper trunk in young persons. Because of the histologic finding of small circumscribed angiomatous tufts and lobules scattered in the dermis, we suggest the term tufted angioma for this lesion. Over half the angiomas developed within the first 5 years of life, but only three patients reportedly had lesions at birth. The clinical course was variable, but most of the lesions slowly extended, eventually covering a large part of the trunk and neck in some patients. Despite the progressive spread of angiomas, they appear to be benign, and malignant change has not been encountered. The microscopic appearance of the angiomatous tufts shows some similarity to the angiomatous tissue of strawberry angioma, but the angiomatous lobules are much larger and extend deeper in the latter condition. Cell marker studies suggest that the cell lobules of the angiomas consist of closely packed blood capillary endothelial and perithelial cells. Familiarity with distinctive histologic features of tufted angioma should prevent these lesions from being misdiagnosed as either Kaposi's sarcoma or as angiosarcoma.

Acquired "tufted" angioma (progressive capillary hemangioma). A distinctive clinicopathologic entity related to lobular capillary hemangioma.

Three young patients affected by intradermal and subcutaneous vascular proliferations are presented. The lesions were acquired and developed as solitary or multiple erythematous patches and plaques in the upper thorax, neck, and scalp. Light-microscopic examination revealed a deep-seated vascular growth with a distinctly lobular pattern. Ultrastructural and immunocytochemical studies demonstrated the cellular proliferation to be composed of endothelial and perithelial cells, the latter predominating. These cases are interpreted as examples of the vascular disorder described as progressive capillary hemangioma and acquired "tufted" angioma. We believe that it represents a distinctive clinicopathologic entity that is closely related histogenetically and perhaps pathogenetically to the entity recently renamed lobular capillary hemangioma.

Scabies, a current pandemic.

Scabies, caused by the itch mite and transmitted by skin-to-skin contact, is being seen in pandemic proportion. In the United States this infestation is seen in patients of all ages and socioeconomic levels. Scabies is often misdiagnosed, and the classic form occurs less frequently in the current cycle. Differential diagnosis includes most pruritic dermatoses. Diagnosis should be made with certainity, preferably by identification of the mite, before therapy is begun. Modern scabicides are high effective.

Scabies in children.

We are in the midst of a pandemic of scabies. Classic scabies is seen less frequently in the current cycle. The infestation frequently occurs in special forms, the differential diagnosis of which includes nearly every pruritic dermatosis. The cause of the current pandemic is not clear but there is evidence that immunologic factors, particularly delayed hypersensitivity, play a principal role. The diagnosis should be made with certainty, preferably by identifying the mite prior to instituting therapy. The modern scabicides are highly effective. A recent re-evaluation of the risk-benefit relationships of lindane has led to altered therapeutic routines.

Scabies and pediculosis.

There has been a recent notable increase in scabies and pediculosis pubis and pediculosis capitis. Once the diagnosis is established (preferably by demonstrating the mite or louse), therapy includes consideration of a risk to benefit ratio, explanation of the nature of the infestation to the patient, application of appropriate therapeutic techniques, and follow-up procedures. Resistance of the Sarcoptes mite to modern scabicides has been suggested but not proved. Resistance of the head louse and body louse to modern pediculicides has been reported in other countries but not in the United States.

Today's scabies.

In the past several years there has been a noticeable increase of scabies in the United States; the magnitude of this is not known. An expanding epidemic continues in most parts of the world. Scabies is frequently seen in many guises that may be difficult to diagnose: scabies in the clean, scabies incognito, nodular scabies, animal-transmitted scabies, scabies in infants, scabies with syphillis, and Norwegian scabies. If the diagnosis cannot be confirmed by identifying the mite, synthesis of suggestive features may establish the diagnosis. Recently adopted children from foreign countries, especially southeastern Asia, have had a high frequency of scabies, which may appear after the children arrive in the United States. Acute glomerulonephritis may develop in patients whose scabetic lesions are complicated by a Virulent nephritogenic streptococcal strain.