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It is important to maintain cleanliness and to ensure that the perianal area is dried after washing. Acrocyanosis must be distinguished from the Raynaud phenomenon, which occurs episodically with triphasic colour changes and often involves just a few digits. At present no certain conclusion can be made about the relative risk of contact sensitization in atopic patients. This is probably the result of frequent medicament usage at these sites, occlusive skin conditions and preexisting skin damage. Although the vast majority of naevi follow this course, there are some cases of both common and atypical naevi that evolve into radial growth phase melanomas. Thalidomide given to pregnant mothers was, and anticonvulsants (phenytoin, valproic acid, lamotrigine, carbamazepine) and corticosteroids may be, associated with an increased incidence. The two common types seen are vestibulodynia (localized provoked vulval pain) and generalized vulvodynia (generalized spontaneous vulval pain). The block is generally permanent, and is not associated with structural cardiac abnormalities such as septal defects. Many patients who undergo surgery for potentially implicated causes such as haemorrhoids continue to have symptoms. In such cases, if the trauma poses the greater immediate risk, the patient may be initially stabilized in a trauma centre before being transferred to a burn unit. Lentiginosis profusa is a rare condition, with innumerable lentigines present at birth or arising early in life, without systemic Disease course and prognosis Freckles are benign lesions and often fade with age. Patch testing is best undertaken with plastic chambers if this diagnosis is suspected. We have seen several granulomatous and lichenoid reactions confined to the red parts of tattoos but none of our patients has been allergic to mercurials. Other reported sequelae of jellyfish stings include erythema nodosum [37], cold urticaria [38] and Mondor disease [39]. Fetal skin shares the same desmoglein 3 profile as adult oral mucosa so that neonatal pemphigus is more likely to occur if the mother has oral disease. Contact dermatitis may flare premenstrually, and cutaneous reactivity to patch testing may vary according to the stage of the menstrual cycle [14], with patch tests to nickel being less intense during the ovulatory than the progestagenic phase [15]. The immunohistochemical profile is different from the surrounding keratinocytes, indicating premature keratinization. The testing process involves plasma sampling for drugspecific IgE, skin prick testing, intradermal testing and challenge testing. Analgesics are indicated in zoster, although the pain may prove refractory to even potent analgesics [15,16], when antidepressants such as amitriptyline and fluphenazine may have a place [17,18]. However, confusion can occur if they are given extensive avoidance advice for materials of no relevance to their dermatitis, and therefore advice should be targeted. Vulval involvement may be associated with skin changes on the scalp and changes at other flexural sites. Any new subcutaneous nodule arising on a naevus of Ota should be further investigated histologically to exclude the possibility of melanoma. Occasionally, pernicious anaemia can also produce red areas or patterns of red lines. Investigations the diagnosis is usually made by direct microscopy and the culture of skin scrapings. Lead has effects on multiple organs including peripheral neuropathy, problems with learning and memory function, erythrocyte fragility, Fanconilike syndrome, plumbism gout (saturnine gout), increased blood urate concentrations and urate crystals in the joints, hypertension, altered cardiac electrophysiology, infertility, hypothyroidism, hypopituitarism, lead lines in the bones, impaired bone growth, shortened stature and gastrointestinal toxicity resulting in lead colic and leadinduced constipation. However, for nicorandil ulceration histology is nonspecific, typically with mild, chronic inflammation.

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Other rarities include Merkel cell carci noma [7], malignant eccrine poroma [8], malignant schwannoma [4,9] and solitary reticulohistiocytic granuloma of the scrotum [10]. A similar condition can be seen in competitive cyclists, but it has been suggested that the injury is thermal rather than the result of friction [35]. Investigations Diagnosis is usually obvious though trauma from activities such as dental flossing may mimic angular stomatitis. Nodular thickening of the subcutaneous tissues is usually first detected between the second and 21st days of life. In firstdegree frostbite there is partial skin freezing, with erythema, oedema and hyperaemia, but no blisters or necrosis. Surveys of deaths from snake bite in Australia [8,9] have shown that the majority were due to brown snakes. Sensitivity to Cupressocyparis leylandii trees has been associated with concomitant colophony allergy. Bone marrow transplantation (haematopoietic stem cell transplantation) Oral complications are common and can be a major cause of morbidity following bone marrow transplantation. Precipitating factors of pain in chronic pain syndromes include sitting, defecation and psychological stress. Chronic oedema, resembling keloid, of the penis has been caused by a condom catheter for neurogenic bladder [5]. Skin colonisation by Malassezia species in neonates: a prospective study and relationship with neonatal cephalic pustulosis (neonatal acne). Half of affected patients present as emergencies with an acute pilonidal abscess; the remainder have chronic, fluctuating discomfort associated with a foulsmelling discharge from one or more sinus openings [12]. Dermatologyspecific quality of life has been shown to improve significantly more in those patients who are patch tested, because of more accurate diagnosis and earlier intervention [3,4,5]. Fourthdegree frostbite necessitates major amputation and is complicated by systemic effects [6]. Resources Further information Medscape, subcutaneous fat necrosis of the newborn: emedicine. The minor criteria include: (i) the presence of lamellar fibrosis or concentric eosinophilic fibrosis; (ii) neovascularization; (iii) an inflammatory response; and (iv) the fusion of rete ridges. Taste sensation can be tested by placing the tongue across the terminals of a pocket torch battery when a metallic taste may be obvious. The precise nature of the material should be ascertained by questioning the patient and examining the product label. Antihistamines and sodium cromoglicate (disodium cromoglycate) appear to have little effect, whereas both prednisolone (dose >15 mg/day) [2] and potent topical steroids [3] suppress allergic patch test reactions. Contact dermatitis may start at one site, but commonly other sites are subsequently involved, and sometimes several regions simultaneously. Histology may show a leukocytoclastic vasculitis of the small blood vessels on a skin biopsy. It is a chronic condition that is resistant to treatment and its cause is unknown [4,5]. It may also occur if there are perennial symptoms because of broad band photosensitivity, and covered site involvement. Severe oedematous and weeping eruptions are not uncommon, and widespread generalized eruptions can develop if exposure continues. Misdiagnoses include constitutional pompholyx, urticaria or recurrent angiooedema, and disseminated herpes simplex. Epidemiology Incidence and prevalence these vary considerably according to the irritant and profession involved (Table 130. The production of an IgA autoantibody suggests either that a crossreacting antigen enters via the mucosa or that an IgA diathesis exists in affected patients [3]. With organic solvents and chemicals the choice of glove material may vary [43]; advice may be found on the material safety data sheet of each product. Genetics A variety of genotypes can present with the phenotpype of collodion baby. Storage in small jars has the drawbacks of oxidation, drying and evaporation of volatile test substances.

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At this juncture, it is imperative that the patient is transported to a facility with the capacity to provide care for the thermally injured patient; however, at times, patients need to be transported to the nearest care facility for stabilization. Pathology the commonest histological picture is of a phototoxic reaction, with epidermal necrosis, apoptotic keratinocytes and mild inflammation [28]. Silicone dressings are recommended for areas of exposed dermis, while an absorbent nonadherent dressing should be applied as a secondary layer to collect exudate and protect lesional skin. Iatrogenic swelling and lymphoedema Congenital defects of the inguinal canal and other noninguinal peritoneal leaks can lead to scrotal and penile swelling as a manifes tation of dialysate oedema in patients with endstage renal failure treated by continuous ambulatory peritoneal dialysis [3]. In identifying the primary and/or major cause of a contact dermatitis, antecedent and aggravating causes should not be neglected. Lining mucosa (buccal, labial and alveolar mucosa, floor of mouth, ventral surface of tongue, soft palate, lips) is nonkeratinized, with broad rete ridges and connective tissue papillae and abundant elastic fibres in the lamina propria [4,5]. An extensive eruption of scattered pinkish red macules and papules is present at birth or appears within a few hours. Firm stroking of the skin may elicit purpura in amyloidosis, is routinely used to diagnose dermographism, and has also been used to study the early lesions of vasculitis [7] and to confirm a diagnosis of delayed pressure urticaria [8]. Some patients develop persistent reactions to portions of the adhesive barrier with no demonstrable allergic component. Type of reaction Test site Upper back Lower back Upper arm Forearm Irritant (%) 100 50 52 38 36 Allergic (%) 100 95 72 74 50 Patch test dose If petrolatum is used as the vehicle and disposable syringes are the containers, a length of 5 mm of test substance in a vehicle will suffice. However, an earlier study of naevi in pregnancy demonstrated no significant changes [3]. Toxicity is usually due to industrial exposure, Investigations Increased selenium levels can be demonstrated by serum concentrations greater than 2 mg/L. Dermatitis, as well as being caused by leakage, may also be due to continuous occlusion and repeated stripping of the skin. Arygyria: the intradermal "photograph," a manifestation of passive photosensitivity. Management Appropriate antibiotic therapy and supportive care is needed in severe infections. Management Treatment involves stopping the offending drug and the use of topical corticosteroid. Both these toxins attack desmoglein 1 (a desmosomal protein), so mucosal involvement does not occur (this is analogous to pemphigus foliaceus, which has the same target antigen) [4,5]. The floor of the mouth and posterolateral margin of the tongue is an area where tumours may start. In a recent series of atypical exanthems, morphol ogy and laboratory investigations led to an aetiological diagno sis in 77% of cases [6]. When material has penetrated the skin there is usually a phase of acute inflammation in response to the injury. There is an increased number of fibroblastlike cells in early lesions, whereas these are diminished or predominantly at the margin in advanced ones. Nonsensitizing compounds that require metabolic activation are prohaptens, while prehaptens are compounds with no or low sensitizing potential that are activated externally. The overall prevalence estimates do not seem to depend much on age, race or geographical origin of the study group. In the surgical approach, favoured by burns specialists, biological dressings or skin grafts are applied to denuded areas under a general anaesthetic. Fibreglass dermatitis is a wellknown example of a physical irritant contact dermatitis and was first described in 1942 [24]. Beryllium usage in dental material has resulted in beryllium stomatitis and hypersensitivity reactions [5]. Complications and comorbidities Vaginal adenosis has been associated with vaginal adenocarcinoma [1]. Infection with Sarcoptes scabiei var hominis can cause nodules on the buttocks and perineum. Syringomas are the most common, but histology from a biopsy is the only way to make a definite diagnosis.

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Elastic on shower caps and hair dye caps can cause dermatitis in the retroauricular area. The histological diagnosis of an atypical Spitz tumour should be approached more aggressively and treated with a wide margin resection following the guidelines of melanoma resection. The grading scores for each test can be used to monitor the disease during treatment. Although the exact contribution to oral defence made by salivary IgA antibodies is difficult to assess, some patients who have IgA deficiency suffer from oral infections, and in animals it is possible to induce protective salivary IgA antibodies to cariesproducing organisms such as Streptococcus mutans. At this concentration, weak irritant reactions are quite common, especially in atopics, but lower concentrations will miss relevant positives [51]. Pustular lesions show intrafollicular accumulation of eosinophils immediately below the stratum corneum. Immunobullous diseases Cicatrizing conjunctivitis associated with immunobullous disorders Definition and nomenclature Cicatrizing conjunctivitis is conjunctival inflammation with progressive scarring. Introduction and general description Anetoderma is due to loss of elastic tissue in the dermis and presents with atrophic lesions that often herniate. There is evidence in animals that ciclosporin suppresses allergic contact dermatitis [4], but most reported clinical studies have been undertaken on chronic hand eczemas of mixed aetiology. In some studies as many as half of the relevant positive reactions were unexpected. Causative organisms the Grampositive acidfast organisms responsible for actinomycosis are predominantly Actinomyces israelii and A. Clinical features History the patient describes intense itching which may keep them awake at night. Colophony may be modified, thereby altering its allergenicity with the development of new allergens [14,15]. The prevalence of positive patch tests in those attending for routine testing in North America is high, with 9. Investigations Investigations should be guided by the clinical presentation of the patient but may include a full blood count and/or blood film, protein electrophoresis, an autoimmune screen, cryoglobulins and cold agglutinins. In older people, many sensitivities will be of past relevance only, and there will be a higher prevalence of medicament sensitivity. The histology of a photoallergic reaction is similar to allergic contact dermatitis with spongiosis and an intense lymphocytic perivascular infiltrate in the dermis [5]. Lichen simplex Part 10: sites, sex, age Lichen simplex is common around the male genitalia. Acute blepharitis is a clearly defined group of conditions, for which the causes are summarized in Table 109. The authors demonstrated a preponderance of autoantibody positivity in the noncorticosteroid treated group as compared to the group who received corticosteroid, suggesting a possible protective role for this treatment [31]. Surgery may very occasionally be required for infantile haemangioma in the proliferative phase if functional impairment or ulceration cannot be managed medically. Investigation may also be indicated for plaquetype infantile haemangiomas on the face and lower trunk and before treatment with blockers. If medical treat ment with ultrapotent topical steroid is not possible or fails, then surgery is indicated. The differential diagnosis includes purpura fulminans, erythema multiforme, urticarial disease and Kawasaki disease. No pattern of hand eczema is characteristic of a particular aetiology, and it is important to emphasize that allergic contact dermatitis may mimic constitutional patterns. Biopsy with immunofluorescence is often indicated to exclude keratosis, chronic ulcerative stomatitis with stratified epitheliumspecific antinuclear antibodies, lichen sclerosus, lupus erythematosus, malignancy and other disorders. The upper lip includes the philtrum, a midline depression, extending from the columella of the nose to the superior edge of the vermilion zone [3]. Modulation of the hypermetabolic response to trauma: temperature, nutrition and drugs. In this study no difference in survival or in the risk of metastases was observed compared with matched controls [235]. The allergencarrying Langerhans cells travel via the afferent lymphatics to the paracortical areas of the regional lymph nodes, where they become apposed to T lymphocytes.

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Prophylactic systemic antimicrobial therapy may increase skin colonization, particularly with Candida albicans, therefore antibiotics should only be given if there are clinical signs of infection. Contamination of clothing, animals, garden tools, firewood, fishing rods and golf clubs may also act as sources of contact. This finding does not exclude lichen sclerosus or other der matoses, since the prepuce may not be the seat of the disease, but might contribute to it. Earplugs for noise protection may contain antiseptics, dyes, rubber and plastic chemicals, and finishes including formaldehyde resins. Once the reaction has occurred it is advisable to discontinue the triggering drug. Synthetic androgens have proven useful in reducing the frequency and duration of attacks [1,2]. Primary Raynaud phenomenon (also called Raynaud disease) is idiopathic and occurs as an isolated innocuous disorder (Box 125. Management Destructive techniques such as electrocautery and curettage may be effective. In mild cases, treatment with emollient alone has been shown to be as effective as a weak topical steroid [3]. There is evidence from some centres that perfume allergy is increasing quite significantly [1]. Management If genital Crohn disease is the presenting problem it is important to involve a gastroenterologist in management, as these patients need a full workup to assess if there is intestinal disease as well. Within hours, this membrane dries and cracks, and bleeding may occur along the resulting fissures. Damage continues to occur until all of the agent has chemically reacted or has been neutralized as a result of treatment. The techniques have evolved into a generally standardized methodology worldwide, although there are some variations, particularly with regard to reading times and test units. In the woman with extensive undifferentiated disease, surgery would be mutilating physically and distressing psychologically, and does not guarantee a cure as the risk of recurrence is significant. Nevertheless, there is good evidence of a high prevalence of allergy to lanolin in medicaments applied to varicose eczema [13,14]. Repeated microscopic skin stripping when changing appliances may also contribute to dermatitis reactions [4]. Cellular heterogeneity and atypical cytology (higher nuclear to cytoplasmic ratios, hyperchromatism and abnormal nuclear borders) are additional findings supportive of an atypical lesion [190]. Chalazion [5] this lesion represents a chronic granulomatous inflammatory reaction around a blocked sebaceous gland. The macules are less than 2 cm in diameter, seen especially on the vermilion of the lips, gingiva, buccal mucosa or palate. It is therefore anticipated that sensitization rates will fall very significantly. For example, the lesions in only one of nine patients in one study had any relationship to food intake [19]. Urea and melamine formaldehyde resin finishes are now being superseded by others, such as dimethylolalkyl carbamate, dimethylolethylene urea, dihydroxydimethylethylene urea and other similar reactive cyclic urea resins. Exposure to leather furniture has induced eczematous flares on the back, calves, arms and feet in sensitized subjects [35]. In this text the terms multifocal infantile haemangioma, with or without extracutaneous involvement, will be used.

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Formaldehyde, which is continuously liberated from formaldehyde resins in floors and walls, may elicit contact dermatitis in very sensitive people. These may cause perianal inflammation, ulceration and scarring and lead to anal stenosis. Ulceration due to biting an anaesthetized lower lip or tongue following a dental local analgesic injection is a fairly common problem in young children. Distant metastatic spread is assessed by computed tomography of the thorax, abdomen and pelvis. The lips therefore feel slightly nodular and the labial arteries are readily felt. Extensive epidermal detachment is accompanied by a greatly increased metabolic demand [31]. Key clinical features distinguishing the different variants of atopic eye disease are summarized in Table 109. Perniosis develops symmetrically on the acral skin, in particular the fingers and toes, but other body extremities may also be involved including the heels, lower legs, nose and ears. Direct immunofluorescence is generally negative, even by immunoelectron microscopy, and this provides the best means of distinguishing this disorder from pemphigoid gestationis should there be any diagnostic doubt [8]. Correctly used, permanent hair dyes are applied to the hair and not the scalp, followed by oxidation and rinsing. In general, the prevalence of allergy reflects the amount of nystatin/ neomycin sulphate/gramicidin/triamcinolone acetonide cream being used in the catchment area of those being tested, as this is the usual source of sensitization. Variation in allergen content over time of acrylates/methacrylates in patch test preparations. In contrast, in secondary Raynaud phenomenon there are structural vascular changes, most clearly delineated in patients with systemic sclerosis. Irritant contact dermatitis started under finger rings in 12% of women and 2% of men [47]. Clinical features Epidemiology History Patients complain of painful erosions in flexural sites, particularly the axillae and inguinal folds. Other glaucoma treatments reported as causing contact dermatitis include the parasympathomimetic pilocarpine, the sympathomimetics apraclonidine, brimonidine and dipivefrine, the carbonic anhydrase inhibitor dorzalamide and the prostaglandins latanoprost and bimatoprost. It has been reported as a useful marker of chronic pancreatitis because local heat relieves the abdominal pain [9] but also occurs when heat is applied for other real and imagined pains [10], including cancer [11]. Patch testing can be used to generate information on individuals, groups of patients and allergens, and also to assess risk factors in groups of workers and particular subgroups of the population. There is some controversy regarding agents such as poviodineiodine; however, evidence from non randomized controlled trials has supported their use for these specific types of ulcers (Table 124. Skin biopsies should be performed from both the central blanched areas and the purplish livedo areas to increase the diagnostic yield as changes may be present in either or both areas. The tail of the stingray carries serrated spines containing venom glands surrounded by an integumentary sheath. The drugs that are most commonly associated with the induction of papulopustular eruptions are listed in Box 120. New chemicals have been introduced to replace older, more sensitizing ones, not always successfully. Excessive frictional forces will Body site There are great differences between body sites, mainly because of differences in skin thickness [3,15]. A doubleblind, placebocontrolled study demonstrated the efficacy of nifedipine in clearing existing chilblains and preventing the development of new lesions [14]. Other diseases and infections Sexually transmitted diseases 1 Singhrao T, Higham E, French P.

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Medical control with antibiotics then allows surgical intervention in the form of circumcision. This also applies to other potential domestic and work exposures such as polishes, waxes, coatings and oils. The ulcer is attributed to continual pulsation from the large artery running parallel to the surface, although the exact mechanism is obscure [1,2]. Energy is inversely proportional to wavelength, therefore most biological effects are seen at shorter wavelengths. The prevalence of malignant transformation in leukoplakias ranges from 3 to 33% over 10 years; homogeneous leukoplakias are only very occasionally premalignant, but speckled or verrucous leukoplakias are more likely to be premalignant. However, it is essential to establish whether the injury has been inflicted by an adult or another child by assessing the size of the dentition from the marks on the skin. There is also some benefit from spreading onto the conjunctival surface in treating other aspects of the disease. This can lose some of its protection after 5 years due to photodegradation, so may need replacement [12]. Pathophysiology It is unclear whether pathogenetically they represent a mere coexistence of two different naevic populations or if they derive from a single cell proliferation differentiating into two different types of naevi. Thus guidance when prescribing topical corticosteroids either in pregnancy or in women of potential childbearing age should be to use the minimum potency required and for a restricted time period, in order to minimize any potential risk to the fetus. A recent murine study showed that pregnancy appeared to promote melanoma metastasis through enhanced lymphangiogenesis [7]. When stimulated by an antigen, leukocytes produce a significant level of procoagulant that activates the extrinsic cascade of blood clotting. The responsible organism, Listeria monocytogenes, may be transmitted to humans principally through contaminated foods [1]. The eruptive appearance of melanotic macules and papules in the anogenital region may be associated with advanced meta static adenocarcinoma [6]. Neonatal bullous eruption as a result of transient porphyrinemia in a premature infant with hemolytic disease of the newborn. It is important to distinguish rarer causes of extensive hair loss in infancy, including vitamin Dresistant rickets [3]. Management Laser treatment has been reported to be useful in those who are unresponsive to topical steroids or retinoids [8]. Involvement of the penis may be with blisters, erosions, ulcers, transcoronal adhesions, scarring and phimosis [6,7,8]. The risk of acquiring genital warts is significantly reduced by using condoms [8]. After some months, it resembles a patch of scleroderma, ivory white in colour with a surrounding lilac ring. These chemicals are contained in tar, fuel oils, lubricating oils and greases, oil shale and bitumen. Clinically, atypical lesions should be biopsied and the histology critically reviewed [13,14]. Ideally, any reaction to the mix should be followed up by testing to the constituents and to lidocaine. Muscle fatigue and weakness are common, probably because of incomplete muscle contraction. A much higher return of relevant allergy, mainly inducing hand dermatitis, was seen in Israel, particularly in mechanics. For cosmetic reasons, a variety of depigmenting topical agents and dermatological procedures such as chemical peels, lasers and photodynamic therapy reduces their pigmentation (see Chapters 159 and 160) [8].

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Actinic granuloma: an annular connective tissue disorder affecting sun and heatdamaged (elastotic) skin. Preparations containing tar or combinations of antibacterial, anticandidal and antifungal agents are also useful. Most instances of paraffinoma nowadays are caused by misguided attempts at tissue augmentation, often selfadministered. Pathophysiology Management Patients should be reassured about the benign nature of labial melanocytic macules. The spectrum of differentiation of the male urogenital tract is manifest in the expression of differing epithelial cytokeratins [4]. A dermatitis is also caused by other sponges, including Neofibularia nolitangere (the poison bun sponge) and Microciona prolifera (the red sponge). Investigations Technetium99 bone scintigraphy may be helpful in evaluating outcome in frostbite injury and indicating the level of amputation needed in severe cases [8]. Passively acquired maternal immunity persists for about 4 months, but then rapidly declines after the neonatal period [2]. Pathology the histology of genital warts is characterized by the koilocyte, a vacuolated squamous cell with a basophilic and pyknotic nucleus Mucinous cysts 112. The prevalence of allergy to nickel in under18s attending for patch tests in Denmark has decreased considerably, from 24. Many producers of work cleansers and creams now give a full ingredient list on the health and safety data sheet. Disease Chronic kidney disease of any cause Hyposalivation Halitosis/taste disturbance Leukoplakia Dental hypoplasia in children Renal osteodystrophy Post organ transplant (immunosuppressed) Bleeding tendency (especially if anticoagulated) Infections, particularly herpetic and candidal Bleeding tendency if anticoagulated Gingival hyperplasia if on ciclosporin Kaposi sarcoma (rarely) Hairy leukoplakia (rarely) Nephrotic syndrome Renal rickets (vitamin D resistant) Dental hypoplasia Delayed tooth eruption Dental hypoplasia (rarely) Enlarged pulp Table 110. Systemic immunosuppression may be needed if inflammatory complications of chronic disease. Transdermal therapeutic systems Sensitization has been reported to both active (clonidine, nicotine, nitroglycerin, oestradiol, norethisterone and testosterone, scopolamine, pyridostigmine bromide and fentanyl) and inactive (unspecified adhesives, acrylates, ethanol, menthol, hydroxypropylcellulose and polyisobutylene) ingredients. False positive reactions are commonly obtained if industrial chemicals are applied as patch tests undiluted [20]. Common contact allergens in the anogenital region include neomycin, fragrance and Balsam of Peru. However, the infection remains rare in infants, but when it does occur the diagnosis may be missed. Immediately after removal of the patch tests, there may be erythema from the stripping action of the tape, especially in dermographic subjects, and this must be allowed to settle. The prognosis of dermatitis due to nickel in jewellery and clothing is excellent if further use of nickelplated objects is avoided. The mechanisms of sun induced skin cancers are discussed elsewhere (see Chapter 9). Lesions may be single or multiple, rounded or oval, and peasized or many centimetres in diameter. As some allergens disappear from a given environment and others attain significance, it is important that a baseline series evolves. Clinical features History the condition presents at birth with blistering and erosions which heal with soft scars. An allergy may be missed on patch testing if the test material has been wrongly diluted in a material in which it is immiscible or insoluble. Reduced sensory nerve conduction velocity of the distal part of the radial nerve among patients with vibration syndrome.