Made WardhanaBag/SMF I. Kes. Kulit & KelaminFK Unud/RS Sanglah Denpasar

Primary Lesions Efloresensi PrimerPrimary lesions are the first to appear and are due to the disease or abnormal state.  This must be distinguished from secondary or induced lesions.

Macule: flat, nonpalpable circumscribed area of change in the skin. Macules are < 1-2 cm in size.

1. Macules may be the result of (A) hyperpigmentation (e.g. brown as in lentigos), (B) depigmentation (e.g. vitiligo),  (C) vascular dilation (e.g. erythema)

2. Multiple well-defined macules of various shapes and sizes.  In this case, the macules blanch upon pressure(diascopy) and thus are due to inflammatory vasodilation.

Hiperemia : pelebaran pembuluh darahRoseolaTeleangiektasi

Hemoragi : perdarahan dibawah kulitPtekhie titik-titik perdarahanVibises linierEkhimosis bercak-bercak perdarahan

Untuk membedakan dengan hiperemia dilakukan tes DIASKOPI

Pigmentasi : perubahan warna kulitHiperpigmentasiHipopigmentasiDepigmentasi

Papule: small solid elevation of skin generally < 5 mm in diameter. The majority of the papule elevation projects above the plane of the surrounding skin. Papules may be flat-topped, as in lichen planus; or dome shaped, as in xanthomas; or spicular, if related to hair follicles.

1. Papules may result from (A) dermal metabolic deposits, (B) localized dermal cellular infiltrates, (C) localized hyperplasia of dermal or epidermal cellular elements. 2. Two firm dome-shaped papules - dermal melanocytic nevi.

3. Multiple well-defined and coalescing papules - lichen planus. 

Nodule: palpable, solid, round, or ellipsoidal lesion. Its depth of involvement and/or palpability differentiate it from a papule rather than its diameter (although nodules are usually larger than papules: > 5 mm diameter). Nodules can involve any layer of the skin and can be edematous or solid. Based on the anatomical component(s) involved, there are five types of nodules: epidermal, epidermal-dermal, dermal,  dermal-subdermal, and subcutaneous.

1. Nodule can be located in (A) the dermis and subcutaneous layer or in (B) the epidermis.

2. Firm well-defined nodule with a smooth and glistening surface through which dilated capillaries (telangiectasia) can be seen; there is central crusting due to tissue breakdown and thus ulceration - nodular basal cell carcinoma

3. Multiple nodules varying in size - melanoma metastases

4. VESICLEVesicles are raised lesions less than 1 cm. in diameter that are filled with clear fluid.

Confluent

Bulla (blister): circumscribed, elevated lesion that is < 5 mm in diameter containing serous (clear) fluid. A vesicle/bulla is the technical term for blisters. Vesicle walls can be so thin that the contained serum, lymph, blood, or extracellular fluid is easily seen. Fluid can be accumulated within or below the epidermis. Bulla: A vesicle with a diameter > 5 mm. 

1. (A) subcorneal vesicle - fluid just below stratum corneum, (B) spongiotic vesicles - intercellular edema.

2. Multiple translucent subcorneal vesicles, extremely fragile leading to crushing (arrows).

3. (A) acantholytic vesicles - cleavage within epidermis due to intercellular attachment loss, (B) Balloondegeneration of epidermal cells in certain viral infections leads to vesicles.

4. Herpes zoster - as explained in 4B.

5. Subepidermal vesicles due to changes in dermal-epidermal junction

6. Multiple subepidermal vesicles.  Vesicles have arisen on normal or erythematous skin.  Some vesicles have collapsed and crusted.    

Pustule: superficial, elevated lesion that contains pus (pus in a blister). Pustules may vary in size and shape. The color may appear white, yellow, or greenish-yellow depending on the color of the pus. Pus is composed of leukocytes with or without cellular debris. It may also contain bacteria or may be sterile.

1. A pustule is basically a papule containing pus.

2. Superficial, subcorneal pustules - pustular psoriasis.

Cyst: an epithelial lined cavity containing liquid or semisolid material (fluid, cells, and cell products). A spherical or oval papule or nodule may be a cyst if, when palpated, is resilient (feels like an eyeball).

1. Most common are (A) epidermal cysts, lined by squamous epithelium and produce keratinous material. (B) Pilar cysts, lined by multilayered epithelium which does not mature through the granular layer.

2. Bluish, resilient cyst filled with mucous material - adnexal tumor (cystic hidradenoma).

Plaque: palpable, plateau-like elevation of skin, usually more than 2 cm in diameter and rarely more than 5 mm in height. Often formed by a convergence of papules, as in psoriasis.

1. Plaques occupy a relatively large surface area in comparison with its height above the skin.

2. Well-defined, reddish, scaling plaques.

Wheal: URTICAtransitory, compressible papule or plaque of dermal edema.

1. The papule or plaque is usually rounded or flat-toped, and evanescent, disappearing within hours. The borders of a wheal are sharp, but not stable and can move from involved to adjacent uninvolved areas over hours. The epidermis is not affected. Wheals can be pale red or white (especially in the center) if edema is sufficient to compress superficial vessels. Wheals are a common allergic reaction.

2. A wheal may be large coalescing plaques as in this allergic reaction.

3. An eruption of wheals is termed urticaria and usually itches.

Secondary Lesions – Efloresensi SekunderResult from the natural evolution of primary lesions (eroded area left by bursting vesicle) or from the patient's manipulation of the primary lesion (scratching).  

Scale – Skwama : accumulation or abnormal shedding of horny layer keratin (stratum corneum) in perceptible flakes. The change may be primary or secondary. Scales usually indicate inflammatory change and thickening of the epidermis. The may be fine, as in pityriasis; white and silvery, as in psoriasis; or large and fish-like, as in ichtyosis.1. (A) Parakeratotic scale (with retained nuclei) can be seen in psoriasiform epidermal hyperplasia.  (B) Actinic keratosis is a densely adherent scale with gritty feel due to a localized increase in stratum corneum. 2. Typical psoriasis scaling

3. Scales may build up to form an asbestos-like layer covering the underlying lesion.

Ulcer: circumscribed area of skin loss extending through the epidermis and at least part of the dermis (papillary).

1. Basically, it's a "hole in the skin". Ulcers usually result from the impairment of vascular and nutrient supply to the skin.

2. Gigantic ulcer, red granulating base with punched out borders.

Crust- Krusta : dried serum, blood, or pus on the surface of skin.

1. May be thin, delicate, and friable or thick and adherent. Crusts are yellow, if from serum; green or yellow-green if from pus; or brown or dark red if formed from blood. Characteristic of pyogenic infections.

2. Crusts that occur as honey-coloured, delicate, glistening particulates are typical of - Impetigo.

Erosion: moist, circumscribed, usually depressed lesion due to loss of all or part of the epidermis

1. Often results from eruptions of vesicles and bullae. Seen in infection from herpes viruses and in pemphigus.

2. Toxic epidermal necrosis causes erosion.Excoriation: linear or punctate superficial excavations of epidermis caused by scratching, rubbing, or picking.

Lichenification: chronic thickening of the skin along with increased skin markings. Results from scratching or rubbing.

1. Note the increased skin markings.

Atrophy: paper-thin, wrinkled skin with easily visible vessels. Results from loss of epidermis, dermis or both. Seen in aged, some burns, and long-term use of highly potent topical corticosteroids.

1. (A) Dermal atrophy manifests as a depression in the skin.  (B) Epidermal atrophy manifests as thin almost transparent skin; may not retain normal skin lines.

2. Dermal and epidermal atrophy. There is loss of normal skin texture, thinning and wrinkling.

Scar- Jaringan Parut : replacement of normal tissue by fibrous connective tissue at eh site of injury to the dermis. Scars may be hypertrophic, atrophic, sclerotic or hard due to collagen proliferation. Reflects pattern of healing in the affected area.

1. (A) Hypertrophic or (B) atrophic scar.

2. Hypertrophic scar.

3. EROSIONErosions are slightly depressed areas of skin in which part or all of the epidermis has been lost.

FISSURE -- RHAGADEA fissure is linear cleavage of skin which extends into the dermis.

1. LINEAR LESIONSLinear lesions occur in a line or band-like configuration. This descriptive term may apply to a wide variety of disorders. (One should be certain that the lesions are not following a dermatome.)

SUSUNAN LESI

2. KOEBNER PHENOMENONThe Koebner phenomenon, also called the isomorphic response, refers to the appearance of lesions along a site of injury. This phenomenon is seen in a variety of conditions; for example, lichen planus, warts, molluscum contagiosum, psoriasis, lichen nitidus, and the systemic form of juvenile rheumatoid arthritis.

3. GUTTATEGuttate lesions look as though someone took a dropper and dropped this lesion on the skin. Guttate lesions are characteristic of one form of psoriasis, though that is not the only example.

5. ANNULARAnnular lesions are seen in a ring shape. Tinea corporis, erythema migrans (the lesion associated with lyme disease), and granuloma annulare are three common examples.

6. CONFLUENTConfluent lesions tend to run together.