PSORIASIS.

Psoriasis is a common cause of peristomal skin disease because it may appear in irritated or
traumatized skin (Koebners
phenomenon) and because it is associated with inflammatory bowel disease (Chapter 18).
Peristomal psoriasis presents as a
glazed erythema similar to flexural psoriasis (eFig. 97-9.3 in online edition) and can be
treated in the same way with topical
corticosteroids although, at the peristomal site, a nongreasy base should be selected (Table
97-1). The diagnosis is usually
unmistakable being part of more generalized involvement (eFig. 97-9.4 in online edition) but
localized peristomal involvement
is described.21 Resolution of psoriasis under hydrocolloid occlusion has been described,22
which is of relevance to stoma
patients because 50% of cases of peristomal psoriasis will resolve if a bag is selected with a
thicker, hydrocolloid-only
barrier. Where the patient can tolerate the stoma being temporarily unprotected from leaks,
ultraviolet (UV) phototherapy is
effective as for psoriasis elsewhere. The mucous membranes of the stoma should be protected
from UV light. Although
irritating topical psoriasis treatments are not usually tolerated, some patients have had success
with creams containing
hydrocortisone 1% and coal tar 3%, the application being left on the skin for 1 hour each day
(Table 97-1, Point 3).
Superficial X-ray (Grenz-ray) therapy has been used in recalcitrant cases
Fitzpatricks 1574

POLYCYCLIC AROMATIC HYDROCARBONS.

Exposure to polycyclic aromatic hydrocarbons (PAHs) accounts for most of the reported
occupational skin tumors.122 PAHs
are hydrophobic, nonpolar compounds that form DNA adducts120 and act as complete
carcinogens.123 Coal tar and petroleum
products such as tar, pitch, coke, carbon black (soot), creosote, anthracene, crude paraffin,
asphalt, fuel and diesel oils,
lubrication and coolant oils, and untreated mineral oils, as well as oils, waxes, and tars from
the distillation products of shale
oil and lignite, contain PAHs.124 High occupational exposures to PAHs can occur in several
industries and occupations (see
Table 212-4), and workers can be exposed to PAHs through inhalation or skin contact. The
risk for melanoma, as well as
internal cancers, has been reported to be increased in oil refinery workers.125
An association between scrotal cancers and the use of cutting oils has been noted, probably
related to the addition of shale
oil.126 Used engine oil has also been associated with a case of extramammary Paget disease of
the scrotum and groin in a
patient with longstanding occupational exposure.127 Creosote used in wood treatment has
been suggested as a cause of skin and

lip cancer when associated with sunlight exposure.128 Roofers and road pavers are also at
increased risk for skin cancers and
internal cancers due to the potential carcinogenicity of bitumen and of PAHs from coal tar
products.129 Tar refinery workers
are at increased risk of developing nonmelanoma skin cancers, mainly on facial areas,
forearms, and hands.130 Use of topical
tar products to treat dermatologic disease has been suggested to pose a skin cancer risk but
has never been documented to do
so.
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ANTI-INFLAMMATORY AGENTS
Anti-inflammatory agents in atopic dermatitis, 175176

COAL TAR
Coal tar has been used to treat inflammatory dermatoses for up to 2 millennia, although
currently it is used primarily to treat
psoriasis.10 Coal tar has been shown to inhibit DNA synthesis and mitosis in epidermal cells,
an effect potentiated by
ultraviolet A exposure.11 Coal tar also has anti-infective, antipruritic, photosensitizing, and
vasoconstrictive effects and, with
repeated applications, causes epidermal atrophy. The precise mechanism by which it treats
inflammatory skin diseases has not
been fully described.
In 1925, Goekerman pioneered the concomitant use of coal tar and ultraviolet B therapy for
psoriasis.
Coal tar has historically been messy to use, has an unpleasant odor, and can stain clothing,
making its use challenging for
some. Newer formulations, however, might be better tolerated.12,13 Systemic adverse effects
are uncommon, whereas local
adverse effects can include tar folliculitis, acneiform eruptions, irritant dermatitis, burning,
and stinging, allergic contact
dermatitis, atrophy, telangiectases, pigmentation, exfoliative dermatitis, and
keratoacanthomas.10 Although occupational
exposure to coal tar has been associated with increased risk of developing skin cancer,
epidemiologic
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