D e rm a to lo g ia p e d ia t r ic a : le le s io n i e le m e n ta r i

D o t t . A n g e lo M i la z z o

P e d ia t r a d i F a m ig l ia

R e s p o n s a b i le d e l la R e te d i D e rm a to lo g ia P e d ia t r ic a d e l la R e g io n e S ic i l ia

S o c ie t à E u r o p e a d i D e rm a to lo g ia P e d ia t r ic a

D o c e n te d i P e d ia t r ia d i F a m ig l ia a l l ’U n iv e r s i t à d i C a ta n ia

Primary lesions• T h e r e a r e n o u n iv e r s a l ly a g r e e d u p o n d e f in i t io n s o f te rm s o r ,

in p a r t ic u la r , d im e n s io n s o f p r im a r y le s io n s . • Macule - c ir c u m s c r ib e d a r e a o f s k in , u p to 1 .0 c m , w i t h a

c h a n g e f r o m n o rm a l s k in c o lo r , w h ic h is n e i t h e r r a is e d a b o v e n o r d e p r e s s e d b e lo w th e s u r r o u n d in g s k in . M a n y u s e th e te rm fo r le s io n s m u c h g r e a te r th a n 1 .0 c m . T e rm d o e s n o t in c lu d e purpura.

• Patch - a f la t , c i r c u m s c r ib e d , d is c o lo r a t io n o f s k in o r m u c o u s m e m b r a n e g r e a te r th a n 1 .0 c m in d ia m e te r .

• Papule - d is c r e t e s o l id a r e a o f s k in th a t is e le v a te d b y p a lp a t io n a b o v e th e s u r r o u n d in g s k in and le s s th a n 1 c m in d ia m e te r . V a r ia t io n s in c lu d e a c c u m in a te , k e r a t o t ic , f la t-to p p e d , fo l l ic u la r , u m b i l i c a t e d , p e d u n c u la t e d , n e c r o t i t ic a n d o t h e r s .

• Plaque - s im i la r to a p a p u le b u t g r e a te r th a t 1 .0 c m in d ia m e te r . O f t e n fo rm e d b y th e c o n f lu e n c e o r c o a le s c e n c e o f p a p u le s . S e c o n d a r y fe a t u r e s m a y in c lu d e , a m o n g o th e r s , a t r o p h y , l ic h e n i f ic a t io n o r h y p e r k e r a t o s is .

Vesicles

• Vesicle - a c i r c u m s c r ib e d f lu id -f i l le d le s io n le s s th a n 1 .0 c m in d ia m e te r t h a t is u s u a l ly e le v a te d a b o v e th e s u r r o u n d in g s k in . M a y b e d e s c r ib e d a s s o l i t a r y , g r o u p e d , u m b i l ic a t e d , d y s h id r o t ic , s p o n g io t ic , m u l t i-lo c u la r o r u n i-lo c u la r .

• Bulla - a c i r c u m s c r ib e d f lu id -f i l le d le s io n g r e a t e r t h a n 1 .0 c m in d ia m e te r t h a t is u s u a l ly e le v a te d a b o v e th e s u r r o u n d in g s k in . M a y a t t a in d ia m e te r s o f s e v e r a l c m s a n d a r e d e s c r ib e d a s te n s e , o r f la c id .

• Pustule - d e s c r e t e e le v a t e d v e s ic le o r b u l la o f s k in , u s u a l ly s m a l l , c o n t a in in g p u r u le n t e x u d a t e c o m p o s e d o f in f la m m a to r y le u k o c y t e s (p u s ), w i t h o r w it h o u t c e l lu la r d e b r is . M a y b e s u p e r f ic ia l, d e e p -s e a t e d , f o l l ic u la r , g r o u p e d , e t c . a n d m a y a r is e s e c o n d a r i ly f r o m a v e s ic le .

N o d u le s – T u m o r s

• Nodule - d e s c r e t e , s o l id , p a lp a b le , r o u n d o r o v a l (e l ip s o id a l) le s io n o f th e s k in m e a s u r in g u p to 1 .0 c m in d ia m e te r (o r lo n g a x is ). A p p l ie s to p r o c e s s e s in v o lv in g a n y o r a l l le v e ls o f th e s k in , a n d is a g e n e r a l te rm fo r a n y m a s s , b e n ig n o r m a l ig n a n t .

• Tumor - a te rm u s e d b y s o m e fo r a "n o d u le " g r e a te r th a n 1 .0 c m in d ia m e te r . A p p l ie s to p r o c e s s e s in v o lv in g a n y o r a l l le v e ls o f th e s k in , a n d is a g e n e r a l te rm fo r a n y m a s s , b e n ig n o r m a l ig n a n t .

U r t ic a r ia

• Wheal - a n e v a n e s c e n t , r o u n d o r i r r e g u la r , o f t e n f la t-t o p p e d e le v a t io n o f s k in w i t h a p a le r e d c o lo r , a r is in g f r o m e d e m a in th e s u p e r f ic ia l d e rm is . M a y v a r y f r o m 2 -3 m m to 1 0 o r m o r e c m in d ia m e te r , w i t h r o u n d o r a r c u a te c o n f ig u r a t io n s . S h o u ld b e d is t in g u is h e d f r o m angioedema, a m a s s iv e e d e m a in v o lv in g th e e n t i r e d e rm is a n d s u b c u ta n e o u s t is s u e s .

Secondary lesions• Scar - a h a r d p la q u e o f d e n s e f ib r o t ic t is s u e c o v e r e d b y a th in

e p id e rm is . A m a r k o f in ju r y f r o m a n y s o r t o f p r o c e s s (p h y s ic a l o r p a th o lo g ic ).

• Atrophy - A t r o p h y u s u a l ly r e f e r s to th in n in g o f th e e p id e rm is le a v in g a n e a s i ly w r in k le d a n d /o r s h in y s u r f a c e . A t r o p h y m a y a ls o a p p ly t o d e rm a l a n d /o r s u b c u t a n e o u s t is s u e , w i t h o r w i t h o u t c h a n g e s in th e e p id e rm is .

• Ulcer - lo s s o f s k in t is s u e o r s u b s t a n c e f r o m th e s u r f a c e d o w n w a r d , le a v in g a n u n c o v e r e d o r d e n u d e d w o u n d th a t is s lo w to h e a l.

• Erosion - a s u p e r f ic ia l d e n u d a t io n o f t h e s k in , u s u a l ly im p ly in g th e lo s s o f t h e e p id e rm is .

• Fissure - a v e r t ic a l s p l i t t in g o r s e p a r a t io n o f th e s k in . • Crust - d r ie d s u r f a c e f lu id , o f t e n s e r o u s (in s p is s a te d s e r u m ) in

n a tu r e , w i t h o r w i t h o u t t is s u e d e b r is . F o r p u r p o s e s o f th is d o c u m e n t th is in c lu d e s th e te rm "s c a b ".

S e c o n d a r y le s io n s

• Excoriation - a s c r a t c h m a r k , o f t e n w i t h d e n u d a t io n o f th e s k in to fo rm a s m a l l u lc e r . E x p o s u r e o f th e c o r iu m b y m e c h a n ic a l r e m o v a l o f th e e p id e rm is .

• Scale - a th in f la k e o f e p i t h e l iu m (m o s t ly c o m p o s e d o f c o r n e o c t y e s ) w h ic h is s e p a r a t e d f r o m th e u n d e r ly in g in t a c t s k in p r o p e r .

• Lichenification - a th ic k e n in g o f th e s k in s u r f a c e and a n in c r e a s e o f s k in m a r k in g s , u s u a l ly s e e n w i t h c h r o n ic c o a le s c e n c e o f p a p u la r le s io n s , e s p e c ia l ly a to p ic e c z e m a .

• Vegetating - a lu s h ly g r o w in g , p r o l i f e r a t in g , p r o c e s s , u s u a l ly w i t h e le v a te d o r e x o p h y t ic fe a tu r e s .

• Linear / Figurate - te c h n ic a l ly not s e c o n d a r y f e a t u r e s , b u t in c lu d e d h e r e s o le ly o u t o f c o n v e n ie n c e . T h e s e a r e configurations th a t s k in le s io n s m a y a s s u m e , w h ic h a id in th e i r d ia g n o s t ic id e n t i f ic a t io n . F ig u r a t e in c lu d e s g e o m e t r ic a l s h a p e s (e .g . a n n u la r , a r c i f o rm , c y c l ic , e t c .).

Macular Lesions

• Brown• Grey Slate Blue• Black• White• Pink - Red• Yellow• Scale

Brown Macular Lesions• · Ephilides • · Neurofibromatosis• · Albright's disease • · Peutz Jeghers syndrome Peutz Jeghers syndrome • · Xeroderm pigmentosum · Xeroderm pigmentosum • · Acropigmentation • · Seborrheic keratosis • · Neurocutaneous melanosis • · Nieman-Pick disease • · Melasma (Chloasma) • · Kwashiokor • · Photochemical reactions· Photochemical reactions• · Berlock dermatitis • · Ultraviolet light (sun tan) • · Thermal radiation - Erythema ab igne• · Becker's nevus • · Hemochromatosis

Brown Macular Lesions• · Trauma • · Post-inflammatory hyperpigmentation • · Malignant melanoma • · Lentigo melanoma • · Mastocytosis (urticaria pigmentosa) • · Encephalitis (chronic) • · Cronkhite - Canada syndrome • · Tatoo • · Reticular acropigmentation of Kitamura • · Dermatopathia pigmentosa reticularis • · Fanconi's syndrome • · Riehl's melanosis • · Periorbital melanosis • · Franceschetti - Jadassohn syndrome • · Gaucher's disease • · Dyskeratosis congenita • · Addison's disease

Grey Slate Blue Macular Lesions

• Oculodermal melanocytosis (Nevus of Ota) • Dermal melanocytosis (Mongolian spot) • Blue melanocytic nevus • Incontinentia pigmenti • Franceschetti - Jadassohn syndrome • Hemochromotosis • Chronic nutritional insufficiency • Fixed drug eruption • Pinta • Erythema dyschromicum perstans • Malignant melanoma • Tatoo • Maculae cerulae • Ochronosis • Metastatic melanoma

• Black Macular Lesions• Melanocytic nevus • Malignant melanoma • Ecchymosis (blue-black) • White and Hypomelanotic Macular Lesions• Vitiligo• Albinism • Piebaldism Piebaldism • Vogt-Koyanagi-Harada syndrome• Tuberous sclerosis • Waardenburg's syndrome • Hyperthyroidism • Hypoparathyroidism • Addison's disease • Hypopituitarism • Pernicious anemia • Halo nevus (Leukoderma acquisitum centrifugum - Hyde and Sutton) • Nevus depigmentosus • Leprosy - tuberculoid • Pityriasis alba • Chediak-Higashi syndrome • Post-inflammatory depigmentation • Phenylketonuria (pigment dilution) • Alezzandrini's sundrome • Idiopathic guttate hypomelanosis • Syphilitic leukoderma (L2) • Scleroderma / morphea

Black and white Macular Lesions

Pink – red - yellow Macular Lesions

• Exanthems • Drug eruptions • Telangiectasia • Nevus flammeus (Port wine stain - salmon patch) • Jaundice • Xanthomata (plantar - plantar) • Xanthelasma (sometimes paplable) • Carotenemia • Pseudoxanthoma elasticum • Necrobiosis lipoidica diabeticorum• Amyloidosis (primary) • Fordyce condition • Solar elastosis

Macules with Scale

• Tinea versicolor• Seborrheic keratosis • Pityriasis alba

Papular Lesions

• With Scale• Koebner Phenomenon• Facial Papule(s)

Papulo-squamous differential

• Pityriasis rosea• Psoriasis• Lichen planus• Pityriasis rubra pilaris• Parapsoriasis• Secondary syphilis• Tinea versicolor• Tinea corporis• Seborrheic dermatitis• Drug reaction - lichenoid (e.g. atabrine, gold,

isoniazid)

Koebner Phenomenon

• Lichen planus• Eczema (active) • Psoriasis

• Auto-inoculation: Verruca, Molluscum contagiosum, etc.)

Flesh Colored Papules• Adenoma sebaceum of Pringle • Basal cell carcinoma• Intraepidermal nevus • Acrochordon • Dermatofibroma • Verruca vulgaris / plana • Molluscum contagiosum• Syringoma • Acne cyst • Hidrocystoma

– Apocrine – Eccrine

• Epithelioid inclusion cyst ("Sebaceous" cyst) • Epithelioma adenoides cystica / Trichoepithelioma • Neurofibroma • Nevus lipomatous superficialis • Nodular elastoidosis (with cysts and comedones) / (Favre - Racouchot syndrome) • Lichen amyloidosis • Lipoid proteinosis • Trichofolliculoma • Milia • Colloid milium • Metastatic lesions

Nodular Lesions

• Nodules on Legs• Nodules around Joints

Nodules on the Legs• Erythema nodosum• Subacute nodular migratory panniculitis • Weber-Christian disease (relapsing febrile nodular panniculitis) • Superficial migratory thrombophlebitis • Acute pancreatitis with nodular subcutaneous fat necrosis • Polyarteritis nodosa • Insect bites • Sarcoidosis• Erythema induratum (Bazin) • Erythema nodosum leprosum • Trichophyton rubrum granuloma (Majocchi) • Zirconium and Silicon granuloma • Deep fingal infection • Actinomycosis, blastomycosis, sporotrichosis, coccidioidmycosis • Meningococcal or pneumococcical septicemia • Kaposi's sarcoma - other neoplasm • Rheumatoid nodules • Sweet's syndrome - usually tender plaque(s) • Behcet's disease • Parasites (leishmaniasis, echinococcosis, cysticercosis, shistosomiasis,

onchocerciasis, myiasis) • Rothman-Makai syndrome

Nodules around Joints• Arthritis – Rheumatoid arthritis – Gouty tophi (Tophaceous gout)

• Infectious disease – Papulonecrotic tuberculid - elbows, fingers

• Metabolic disease – Xanthoma tuberosum – Calcinosis cutis

• Neoplasms – Myxoid cyst

• Miscellaneous – Erythema elevatum diutinum – Reticulohistiocytoma

Tumor Lesions - Differential by Color

• Brown• Black - Grey• Blue• Pink - Red - Purple• Skin Colored - Yellow - Fawn – Orange

• Painful Dermal Tumors

Brown• Malignant melanoma • Spitz nevus• Melanocytic nevus • Pyogenic granuloma (brown to red) • Seborrheic keratosis • Comedone • Basal cell carcinoma • Acanthoma (brown to pink) • Histiocytoma • Skin tags (Acrochordons) • Clear cell acanthoma • Trichofolliculoma • AActinic keratosis ctinic keratosis • Squamous cell carcinoma Squamous cell carcinoma • Paget's disease • Nevus of Ota (brown to blue) • Neuroma (brown, pink or purple) • Leiomyoma (dusky brown-pink-red) • Hidradenoma papilliferum (reddish-brown when ulcerated) • Sarcoidosis

Black-Grey

• Melanocytic nevus • Blue Nevus • Malignant melanoma • Seborrheic keratosis • Basal cell carcinoma • Paget's disease (pink-grey-yellow) • Hematoma • Thrombosed plantar wart • Apocrine hidrocystoma (blue-grey-black) • Bowen's disease • Granuloma telangiectaticum (blue-black) • Eccrine hidrocystoma

Blue

• Blue nevus • Malignant melanoma • Neurofibroma • Histiocytoma • Thrombosed plantar wart • Apocrine hydrocystoma (blue-grey-black) • Nevus of Ota (blue-brown) • Granuloma telangiectaticum (blue-black) • Kaposi's sarcoma (dark blue or purple) • Lymphangiosarcoma of Stewart and Treves (dusky

blue to red) • Eccrine hidrocystoma

Pink - Red - Purple

• Spitz nevus• Pyogenic granuloma• Malignant melanoma • Hemangioma (purple) • Keratoacanthoma (flesh colored to red) • Histiocytoma • Eccrine poroma (acrospiroma) (pink to livid

red) • Hidradenoma papilliferum (ma be reddish

brown) • Dermal cylindroma (pink to red)

Skin Colored - Yellow - Fawn - Orange

• Basal cell carcinoma - Examples at the Image Database. Basal cell carcinoma - Examples at the Image Database. • Seborrheic keratosis Seborrheic keratosis • Sweat gland nevus (orange - red - brownSweat gland nevus (orange - red - brown) ) • Trichoepithelioma (pink - yellow) Trichoepithelioma (pink - yellow) • Sebaceous adenoma (yellowSebaceous adenoma (yellow) • Sebaceous carcinoma (yellow - orange) • Milium (white - yellow) • Steatocystoma multiplex (yellow) • Syringoma (yellow - mauve - translucent) • Actinic keratosis (yellow) • Neurolemmoma (pink - grey - yellow) • Eccrine spiradenoma (flesh colored) • Syringoma papilliferum (flesh colored)

• Painful Dermal Tumors• Angiolipoma • Angioleiomyoma • Eccrine spiradenoma • Glomus tumor • Neuroma • Neurolemmoma • Leiomyoma

Vesicular / Bullous Lesions

• Vesicular / Bullous Lesions• Epidermal• Subepidermal• Hands• Grouped• Umbilicated

Epidermal Vesicular / Bullous Lesions

• Pemphigus vulgaris • Pemphigus erythematosus (Senear-Usher

Syndrome) • Pemphigus foliaceus • Pemphigus vegetans • Benign familial pemphigus (Hailey and

Hailey Disease) •  

Epidermal Vesicular / Bullous Lesions• Incontinentia pigmenti • Toxic epidermal necrolysis • Impetigo / Bullous impetigo • Bullous congenital ichthyosiform erythroderma • Epidermolysis bullosa simplex • Cockayne's disease (Recurrent bullous eruption of hands and feet) • Cantheridine • Miliaria crystallina • Miliaria rubra • Acrodermatitis enteropathica Acrodermatitis enteropathica • Eczematous blisters: Eczematous blisters:

– Allergic and contact dermatitis (e.g. garlic)Allergic and contact dermatitis (e.g. garlic)– Fungal: Inflammatory infections and id reactions Fungal: Inflammatory infections and id reactions – Dyshidrosis (Pompholyx) Dyshidrosis (Pompholyx) – Ultraviolet light Ultraviolet light – Others Others

• Bacterial vesicles / papulovesicles – Impetigo / Bullous impetigo – Meningococcemia-stretococcemia, often hemorrhagic

• Viral vesicles: – Hand, foot and mouth disease (Coxsackie A16)– Varicella - Zoster– Others

• Parasitic vesicles: – Scabies - Examples 

H a n d le s io n s• Vesicular / Bullous Lesions of the Hands Hand, foot and mouth disease (Coxsackie Vesicular / Bullous Lesions of the Hands Hand, foot and mouth disease (Coxsackie

AA1616) -) -• Acute eczematous dermatitis Acute eczematous dermatitis • Dermatophytid • Dyshidrotic eczema • Scabies - Examples• Bullous erythema multiforme - Example. • Epidermolysis bullosa syndromes - Examples: See Image Database• Congenital syphilis • Porphyria cutanea tarda • Erysipeloid • Physical factors • Viral: Herpes simplex, varicella - zoster, others. - Examples: See Image Database• Toxic epidermal necrolysis • Bullous lichen sclerosis et atrophicus • Fixed drug • Blister beetles

Subepidermal Vesicular / Bullous Lesions• Erythema multiforme

• Bullous Pemphigoid • Cicatricial pemphigoid (Benign mucosal pemphigoid) • Dermatitis herpetiformis • Dermolytic epidermolysis bullosa:

– Dominant – Recessive – Acquired - Examples

• Junctional epidermolysis bullosa • Mendes da Costa Syndrome (Macular dystrophic epidermolysis bullosa) • Porphyria cutanea tarda • Bullous lupus erythematosus • Bullous lichen planus • Fixed drug eruption (i.e. barbiturates) • Burns • Suction • Friction or shearing forces • Trauma (i.e. secondary to a bone fracture) • Lichen sclerosis et atrophicus • Urticaria pigmentosa • Vesicular polymorphous light eruption • Herpes gestationis • Ionizing radiation

Grouped Vesicles and Pustules

• Herpes simplex • Herpes zoster • Impetigo herpetiformis • Dermatitis herpetiformis • Herpes genitalis • Herpes gestationis • Subcorneal pustulosis

Pustular Lesions• Folliculitis • Candidiasis• Impetigo • Impetigo herpetiformis • Acne vulgaris • Chloracne • Steroid induced acne (e.g. dexamethasone) • Pustular drug eruption • Rosacea (Acne rosacea) - More examples• Erythema toxicum neonatorum • Transient neonatal pustular melanosis • Incontinentia pigmenti (1st stage) (usually vesiculobullous) • Perioral dermatitis • Pustular psoriasis

– Generalized pustular psoriasis of Zumbusch – Acrodermatitis continua

• Acropustulosis • Palmoplantar pustulosis • Subcorneal pustular dermatosis (of Sneddon-Wilkinson) • Eosinophilic folliculitis (Ofugi's disease) • Hidradenitis suppurativa • Folliculitis decalvans

Umbilicated Vesicles

• Varicella • Herpes simplex• Herpes zoster

Wheal or Urtica Lesions• Urticaria, NOS• Cholinergic urticaria • Physical urticaria, including dermagraphism • Contact urticaria • Systemic lupus erythematosus • Hypocomplementemic vasculitis • Insect bite • Drug eruption • Anaphylaxis • Erythema multiforme (early)

Cyst Lesions

Epidermoid cyst - ( Follicular infundibular cyst) • Pilar cyst (Tricholemmal cyst) • Dermoid cyst • Mucinous cyst • Hydrocystoma (blue hue)

– Eccrine – Apocrine (more blue)

• Milia • Thyroglossa • Bronchogenic cysts • Branchial cleft cyst