1. Structure, Function, and Disorders of the Integument Chapter 44 Mosby items and derived items © 2010, 2006 by Mosby, Inc., an affiliate of Elsevier Inc.

2. 2 Integument: Overview  Skin is the largest organ; covers the entire body  Accounts for approximately 20% of the body’s weight  Accessory structures of hair, nails, and glands  Primary function is to protect the body  Barrier against microorganisms, ultraviolet radiation, loss of body fluids, and the stress of mechanical forces  Regulates body temperature  Involved in the production of vitamin D  Touch and pressure receptors provide important protective functions and pleasurable sensations

3. Mosby items and derived items © 2010, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. 3 Layers of the Skin  Epidermis  Dermis  Subcutaneous

4. Mosby items and derived items © 2010, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. 4 Layers of the Skin

5. Mosby items and derived items © 2010, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. 5 Layers of the Skin  Epidermis  Stratum basale  Stratum germinativum  Stratum spinosum  Stratum lucidum  Stratum corneum

6. Mosby items and derived items © 2010, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. 6 Layers of the Skin  Epidermis  Keratinocytes Keratin Keratin  Melanocytes  Langerhans cells  Merkel cells

7. Mosby items and derived items © 2010, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. 7 Layers of the Skin  Dermis  Collagen, elastin, reticulum, and a gel-like ground substance  Hair follicles, sebaceous glands, sweat glands, blood vessels, lymphatic vessels, nerves  Fibroblasts, mast cells, macrophages  Subcutaneous layer  Adipocytes  Dermal, subcutaneous collagen continuous

8. Mosby items and derived items © 2010, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. 8 Layers of the Skin  Dermal appendages  Nails  Hair  Sebaceous glands  Eccrine and apocrine sweat glands  Blood supply  Papillary capillaries

9. Mosby items and derived items © 2010, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. 9 Nails

10. 10 Aging and Skin Integrity  Integumentary system reflects changes from genetic and environmental factors  The skin becomes thinner, drier, wrinkled, and demonstrates changes in pigmentation  Shortening and decrease in number of capillary loops  Fewer melanocytes and Langerhans cells  Atrophy of sebaceous, eccrine, and apocrine glands  Changes in hair color  Fewer hair follicles and growth of thinner hair

11. Mosby items and derived items © 2010, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. 11 Clinical Manifestations of Skin Dysfunction  Macule  Papule  Patch  Plaque  Wheal

12. Mosby items and derived items © 2010, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. 12 Clinical Manifestations of Skin Dysfunction  Nodule  Tumor  Vesicle  Bulla  Pustule

13. Mosby items and derived items © 2010, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. 13 Clinical Manifestations of Skin Dysfunction  Cyst  Telangiectasia  Scale  Lichenification  Keloid  Scar

14. Mosby items and derived items © 2010, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. 14 Clinical Manifestations of Skin Dysfunction  Excoriation  Fissure  Erosion  Ulcer  Atrophy

15. Mosby items and derived items © 2010, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. 15 Clinical Manifestations of Skin Dysfunction  Pressure ulcers  Pressure ulcers result from any unrelieved pressure on the skin, causing underlying tissue damage Pressure Pressure Shearing forces Shearing forces Friction Friction Moisture Moisture

16. Mosby items and derived items © 2010, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. 16 Clinical Manifestations of Skin Dysfunction  Pressure ulcers: risk factors  Older adults in hospitals and nursing homes  Neurologic disorders that result in loss of mobility and/or sensation (spinal cord injuries, dementia, or cerebrovascular disease)  Immobilization  Incontinence  Debilitation

17. Mosby items and derived items © 2010, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. 17 Clinical Manifestations of Skin Dysfunction  Pressure ulcers: risk factors  Lying in bed without changing position or relieving pressure over an extended period  Lying for hours on hard imaging and operating tables  Chronic diseases accompanied by anemia, edema, renal failure, malnutrition, sepsis, and urinary or fecal incontinence  Coarse bed sheets used for turning by dragging, which produces a shearing force

18. Mosby items and derived items © 2010, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. 18 Clinical Manifestations of Skin Dysfunction  Pressure ulcers: risk factors for the critically ill  Norepinephrine infusion  APACHE II score  Fecal incontinence  Anemia  Age greater than 60 years  Renal insufficiency  Length of hospital stay  Individuals with darkly pigmented skin because early signs of skin damage may not be clearly visible

19. Mosby items and derived items © 2010, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. 19 Clinical Manifestations of Skin Dysfunction  Pressure ulcers  Stages I. Nonblanchable erythema of intact skin I. Nonblanchable erythema of intact skin II. Partial-thickness skin loss involving epidermis or dermis II. Partial-thickness skin loss involving epidermis or dermis III. Full-thickness skin loss involving damage or loss of subcutaneous tissue III. Full-thickness skin loss involving damage or loss of subcutaneous tissue IV. Full-thickness skin loss with damage to muscle, bone, or supporting structures IV. Full-thickness skin loss with damage to muscle, bone, or supporting structures Unstageable if wound bed covered with eschar Unstageable if wound bed covered with eschar

20. Mosby items and derived items © 2010, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. 20 Clinical Manifestations of Skin Dysfunction  Keloids  Elevated, rounded, and firm  Claw-like margins that extend beyond the original site of injury  Excessive collagen formation during dermal connective tissue repair  Common in darkly pigmented skin types and burn scars  Type III collagen is increased

21. Mosby items and derived items © 2010, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. 21 Keloids

22. Mosby items and derived items © 2010, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. 22 Clinical Manifestations of Skin Dysfunction  Pruritus  Itching  Most common symptom of primary skin disorders  Itch is carried by specific unmyelinated C-nerve fibers and is triggered by a number of itch mediators  CNS can modulate the itch response  Pain stimuli at lower intensities can induce itching  Chronic itching can result in infections and scarring due to persistent scratching

23. Mosby items and derived items © 2010, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. 23 Disorders of the Skin  Inflammatory disorders  Dermatitis or eczema most common  Various types of dermatitis  Generally characterized by pruritus, lesions with indistinct borders, and epidermal changes

24. Mosby items and derived items © 2010, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. 24 Inflammatory Disorders  Allergic contact dermatitis  Caused by a hypersensitivity type IV reaction  Allergen comes into contact with skin, binds to carrier protein to form sensitizing antigen; Langerhans cells process antigen, carry it to T cells, which become sensitized to antigen  Manifestations Erythema, swelling, pruritus, vesicular lesions Erythema, swelling, pruritus, vesicular lesions

25. Mosby items and derived items © 2010, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. 25 Allergic Contact Dermatitis

26. Mosby items and derived items © 2010, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. 26 Inflammatory Disorders  Atopic dermatitis  Type I hypersensitivity—activation of mast cells, eosinophils, T lymphocytes, other inflammatory cells  Causes red, weeping crusts and chronic inflammation, lichenification  Irritant contact dermatitis  Nonimmunologic inflammation of the skin  Chemical irritation from acids or prolonged exposure to irritating substances  Symptoms similar to allergic contact dermatitis  Treatment—remove stimulus

27. Mosby items and derived items © 2010, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. 27 Atopic Dermatitis

28. Mosby items and derived items © 2010, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. 28 Inflammatory Disorders  Stasis dermatitis  Occurs in the legs as a result of venous stasis, edema, and vascular trauma  Sequence of events: erythema, pruritus, scaling, petechiae, ulcerations  Seborrheic dermatitis  Inflammation of the skin involving the scalp, eyebrows, eyelids, nasolabial folds, and ear canals  Scaly, white, or yellowish plaques

29. Mosby items and derived items © 2010, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. 29 Stasis and Seborrheic Dermatitis

30. Mosby items and derived items © 2010, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. 30 Papulosquamous Disorders  Psoriasis  Chronic, relapsing, proliferative skin disorder  T-cell immune-mediated skin disease  Scaly, thick, silvery, elevated lesions, usually on scalp, elbows, or knees caused by a high rate of mitosis in the basal layer  Shows evidence of dermal and epidermal thickening  Epidermal turnover goes from 26-30 days to 3-4 days  Cells do not have time to mature or keratinize

31. Mosby items and derived items © 2010, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. 31 Psoriasis

32. Mosby items and derived items © 2010, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. 32 Papulosquamous Disorders  Psoriasis  Plaque psoriasis  Inverse psoriasis  Guttate psoriasis  Pustular psoriasis  Erythrodermic psoriasis

33. Mosby items and derived items © 2010, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. 33 Papulosquamous Disorders  Pityriasis rosea  Benign, self-limiting inflammatory disorder  Usually occurs during winter months  Herald patch Circular, demarcated, salmon-pink, 3- to 4-cm lesion Circular, demarcated, salmon-pink, 3- to 4-cm lesion

34. Mosby items and derived items © 2010, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. 34 Pityriasis Rosea Herald Patch

35. Mosby items and derived items © 2010, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. 35 Papulosquamous Disorders  Lichen planus  Benign, inflammatory disorder of the skin and mucous membranes  Unknown origin, but T cells, adhesion molecules, inflammatory cytokines, and antigen presenting cells are involved  Nonscaling violet-colored, 2- to 4-mm lesions  Wrists, ankles, lower legs, genitalia

36. Mosby items and derived items © 2010, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. 36 Lichen Planus

37. Mosby items and derived items © 2010, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. 37 Papulosquamous Disorders  Acne vulgaris  Inflammatory disease of the pilosebaceous follicles  Acne rosacea  Inflammation of the skin that develops in adulthood  Lesions Erythematotelangiectatic, papulopustular, phymatous, and ocular Erythematotelangiectatic, papulopustular, phymatous, and ocular Associated with chronic, inappropriate vasodilation resulting in flushing and sensitivity to the sun Associated with chronic, inappropriate vasodilation resulting in flushing and sensitivity to the sun

38. Mosby items and derived items © 2010, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. 38 Papulosquamous Disorders  Lupus erythematosus  Inflammatory, autoimmune disease with cutaneous manifestations  Thought to be an altered immune response to an unknown antigen or response to UV wavelengths with the development of self-reactive T and B cells, decreased number of regulatory T cells, and increased proinflammatory cytokines  Autoantibodies and immune complexes cause tissue damage

39. Mosby items and derived items © 2010, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. 39 Papulosquamous Disorders  Discoid lupus erythematosus  Restricted to the skin  Photosensitivity  Butterfly pattern over the nose and cheeks  Subtype of systemic lupus erythematosus (SLE)  Leads to SLE in approximately 5% of cases

40. Mosby items and derived items © 2010, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. 40 Discoid Lupus Erythematosus

41. Mosby items and derived items © 2010, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. 41 Vesiculobullous Disorders  Diseases that have different causes and clinical courses but share the common characteristic of vesicle, or blister, formation  Pemphigus  Erythema multiforme

42. Mosby items and derived items © 2010, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. 42 Vesiculobullous Disorders  Pemphigus  Rare, chronic, blister-forming disease of the skin and oral mucous membranes  Blisters form in deep or superficial epidermis  Autoimmune disease caused by circulating IgG autoantibodies The antibodies are against the cell surface adhesion molecule, desmoglein in the suprabasal layer of the epidermis The antibodies are against the cell surface adhesion molecule, desmoglein in the suprabasal layer of the epidermis

43. Mosby items and derived items © 2010, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. 43 Vesiculobullous Disorders  Pemphigus  Tissue biopsies demonstrate autoantibody presence  Types Pemphigus vulgaris (severe) Pemphigus vulgaris (severe) Pemphigus foliaceus Pemphigus foliaceus Pemphigus erythematosus Pemphigus erythematosus

44. Mosby items and derived items © 2010, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. 44 Vesiculobullous Disorders  Bullous pemphigoid  More benign disease than pemphigus vulgaris  Bound IgG and blistering of the subepidermal skin layer  Subepidermal blistering and eosinophils distinguish pemphigoid from pemphigus

45. Mosby items and derived items © 2010, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. 45 Bullous Pemphigoid

46. Mosby items and derived items © 2010, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. 46 Vesiculobullous Disorders  Erythema multiforme  Acute recurring disorder of skin and mucous membranes  Associated with allergic or toxic reactions to drugs or microorganisms  Caused by immune complexes formed and deposited around dermal blood vessels, basement membranes, and keratinocytes  “Bull’s-eye” or target lesion Erythematous regions surrounded by rings of alternating edema and inflammation Erythematous regions surrounded by rings of alternating edema and inflammation

47. Mosby items and derived items © 2010, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. 47 Vesiculobullous Disorders  Erythema multiforme  Bullous lesions form erosions and crusts when they rupture  Affects the mouth, air passages, esophagus, urethra, and conjunctivae  Severe forms Stevens-Johnson syndrome (bullous form) Stevens-Johnson syndrome (bullous form) Toxic epidermal necrolysis Toxic epidermal necrolysis

48. Mosby items and derived items © 2010, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. 48 Erythema Multiforme

49. Mosby items and derived items © 2010, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. 49 Infections  Bacterial infections  Folliculitis Infection of hair follicles Infection of hair follicles Staphylococcus aureus common cause Staphylococcus aureus common cause  Furuncles “Boils” are an inflammation of the hair follicles “Boils” are an inflammation of the hair follicles Develop from preceding folliculitis; spread through follicular wall into the surrounding dermis Develop from preceding folliculitis; spread through follicular wall into the surrounding dermis S. aureus common causative organism S. aureus common causative organism

50. Mosby items and derived items © 2010, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. 50 Furuncle

51. Mosby items and derived items © 2010, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. 51 Infections  Bacterial infections  Carbuncles Collection of infected hair follicles Collection of infected hair follicles Erythematous, painful, swollen mass that drains through many openings Erythematous, painful, swollen mass that drains through many openings Abscesses may develop Abscesses may develop Chills, fever, malaise: systemic symptoms that occur during early stages of lesion development Chills, fever, malaise: systemic symptoms that occur during early stages of lesion development

52. Mosby items and derived items © 2010, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. 52 Infections  Bacterial infections  Cellulitis Infection of the dermis and subcutaneous tissue Infection of the dermis and subcutaneous tissue Usually caused by Staphylococcus or group B streptococci Usually caused by Staphylococcus or group B streptococci  Erysipelas An acute superficial infection of the upper dermis (a superficial form of cellulitis) An acute superficial infection of the upper dermis (a superficial form of cellulitis) Most often caused by group A streptococci Most often caused by group A streptococci  Impetigo A superficial lesion of the skin A superficial lesion of the skin Caused by coagulase-positive Staphylococcus or α- hemolytic streptococci Caused by coagulase-positive Staphylococcus or α- hemolytic streptococci

53. Mosby items and derived items © 2010, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. 53 Infections  Viral infections  Herpes simplex virus (HSV) Eight types Eight types DNA virus DNA virus HSV-1 usually causes infection of the cornea (herpes keratitis), mouth (gingivostomatitis), and labia (labialis) HSV-1 usually causes infection of the cornea (herpes keratitis), mouth (gingivostomatitis), and labia (labialis)  Contact with infected saliva  “Cold sore” or “fever blister” the most common manifestation HSV-2 causes genital infections HSV-2 causes genital infections  Skin-to-skin mucous membrane contact during viral shedding  Vertical transmission from mother to neonate is associated with significant neonatal morbidity and mortality

54. Mosby items and derived items © 2010, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. 54 Infections  Viral infections  Herpes zoster (shingles)/varicella (chickenpox) Caused by herpes varicella-zoster virus (VZV) Caused by herpes varicella-zoster virus (VZV)  Initial infection with varicella followed years later by herpes zoster Pain and paresthesia localized to the affected dermatome (cutaneous area innervated by a single spinal nerve) followed by vesicular eruptions along a facial, cervical, or thoracic lumbar dermatome Pain and paresthesia localized to the affected dermatome (cutaneous area innervated by a single spinal nerve) followed by vesicular eruptions along a facial, cervical, or thoracic lumbar dermatome

55. Mosby items and derived items © 2010, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. 55 Herpes Simplex Virus

56. Mosby items and derived items © 2010, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. 56 Warts  Benign lesions caused by human papillomavirus (HPV)  Diagnosed by visualization  Condylomata acuminata  Venereal warts  Highly contagious, sexually transmitted  Cauliflower-like lesions occur in moist areas, along the glans of the penis, vulva, and anus  Oncogenic HPV a primary cause of cervical cancer

57. Mosby items and derived items © 2010, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. 57 Fungal Infections  Fungi causing superficial skin lesions are called dermatophytes  Fungal disorders called mycoses; mycoses caused by dermatophytes are termed tinea  Tinea capitis (scalp)  Tinea pedis (athlete’s foot)  Tinea corporis (ringworm)  Tinea cruris (groin, jock itch)  Tinea unguium (nails) or onychomycosis

58. Mosby items and derived items © 2010, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. 58 Tinea Pedis

59. Mosby items and derived items © 2010, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. 59 Fungal Infections  Candidiasis  Caused by Candida albicans  Normally found on skin, in GI tract, and in vagina  C. albicans can change from a commensal organism to a pathogen Local environment of moisture and warmth, systemic administration of antibiotics, pregnancy, diabetes mellitus, Cushing disease, debilitated states, age younger than 6 months, immunosuppression, and neoplastic diseases Local environment of moisture and warmth, systemic administration of antibiotics, pregnancy, diabetes mellitus, Cushing disease, debilitated states, age younger than 6 months, immunosuppression, and neoplastic diseases

60. Mosby items and derived items © 2010, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. 60 Vascular Disorders  Cutaneous vasculitis  Results from immune complexes in the small blood vessels Develops from drugs, bacterial infections, viral infections, or allergens Develops from drugs, bacterial infections, viral infections, or allergens  Lesions Palpable purpura progressing to hemorrhagic bullae with necrosis and ulceration Palpable purpura progressing to hemorrhagic bullae with necrosis and ulceration

61. Mosby items and derived items © 2010, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. 61 Cutaneous Vasculitis

62. Mosby items and derived items © 2010, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. 62 Vascular Disorders  Urticaria  Due to type I hypersensitivity reactions to allergens  Histamine release causes endothelial cells of the skin to contract Causes leakage of fluid from the vessels Causes leakage of fluid from the vessels  Treatment Antihistamines and steroids Antihistamines and steroids

63. Mosby items and derived items © 2010, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. 63 Urticaria

64. Mosby items and derived items © 2010, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. 64 Vascular Disorders  Scleroderma  Sclerosis of the skin that can progress to internal organs  Associated with several antibodies  Lesions exhibit massive deposits of collagen with inflammation, vascular changes, and capillary dilation  Skin is hard, hypopigmented, taut, and tightly connected to underlying tissue

65. Mosby items and derived items © 2010, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. 65 Vascular Disorders  Scleroderma  Facial skin becomes very tight  Fingers become tapered and flexed; nails and fingertips can be lost from atrophy  Mouth may not open completely  50% of patients die within 5 years

66. Mosby items and derived items © 2010, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. 66 Scleroderma

67. Mosby items and derived items © 2010, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. 67 Insect Bites  Ticks  Lyme disease, Rocky Mountain spotted fever  Mosquitoes  Malaria, yellow fever, dengue fever, filariasis, St. Louis encephalitis  Flies  Painful bites  Urticaria, mild bleeding

68. Mosby items and derived items © 2010, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. 68 Benign Tumors  Seborrheic keratosis  Keratoacanthoma  Actinic keratosis  Nevi (moles)

69. Mosby items and derived items © 2010, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. 69 Cancer  Basal cell carcinoma  Squamous cell carcinoma  Malignant melanoma  Kaposi sarcoma

70. Mosby items and derived items © 2010, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. 70 Frostbite  Skin injury from exposure to extreme cold  Affects fingers, toes, ears, nose, cheeks  “Burning reaction” is caused by alternating cycles of vasoconstriction and vasodilation  Inflammation and reperfusion part of the pathophysiology

71. Mosby items and derived items © 2010, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. 71 Disorders of the Hair  Male-pattern alopecia  Genetically predisposed response to androgens  Androgen-sensitive and androgen-insensitive follicles  Female-pattern alopecia  Elevated levels of the serum adrenal androgen dehydroepiandrosterone sulfate  No loss of hair along the frontal hairline

72. Mosby items and derived items © 2010, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. 72 Disorders of the Hair  Alopecia areata  Autoimmune T-cell–mediated inflammatory disease against hair follicles that results in baldness  Hirsutism  Androgen-sensitive areas Abnormal growth and distribution of hair on the face, body, and pubic area in a male pattern that occurs in women Abnormal growth and distribution of hair on the face, body, and pubic area in a male pattern that occurs in women

73. Mosby items and derived items © 2010, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. 73 Disorders of the Nail  Paronychia  Acute or chronic infection of the cuticle  Onychomycosis  Fungal or dermatophyte infection of the nail plate