Topic 17. Primary Lesions of the Skin

7/28/2019 Topic 17. Primary Lesions of the Skin

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Dermatologic Diagnosis

Examination of the patient

A dermatological dg. is based on both lesions distribution and on their morph. and configuration.

For ex. an area ofseborrhoeic dermatitis may look very like an area ofatopic dermatitis so the key

to dg. lies in the location: Seborrhoeic dermatitis affects scalp, forehead, eyebrows, nasolabial folds and central chest Atopic dermatitis typically affects the antecubital and popliteal fossae.

Components of the Dermatologic Evaluation

1) Patient age and history history taking should include:

Time line - where and when the problems started Symptoms (severe itch, mild itch, pain) General medical history

Medication and allergies Occupation and recreation, travel Family and household contacts The patients own view in the likely cause

Time line

How long have any lesions been present? Have they changed in time?

Patients will tell you how long they have had the lesion which is CURRENTLY worrying them and will

not begin at the beginning of their problem.

Where did the problem first appear? Does it appear or spread to other body parts?

Patients will show you a lesion on a visible part of their body, and will not tell you about large lesion at

for ex. their back ask for ALL lesions and their localization.

Symptoms there are 7 most important questions to evaluate symptoms:

1. Localization - Where is it?2. Quality - What is it like?3. Quantity or Severity - How bad is it?4. Timing - When did it start? How long does it last? How often does it come?5. The setting in which it occurs, including environmental factors, personal activities, emotional

reactions, or other circumstances that may have contributed to the illness.6. Factors that make it better or worse.7. Associated manifestations.

In dermatology, the symptoms are usually itch and/or pain.

Severe itch associated with conditions such as scabies, atopic eczema, contact dermatitis,dermatitis herpetiformis.

Mild itch associated with many conditions such as psoriasis, drug eruptions, bullous pemphigoid Pain is a symptom of vasculitis and pemphigus.


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General medical history

There are many skin signs which may be the first marker of an internal disease (for ex. DM)

ask about underlying diseases, family history, previous hospitalizations, allergies.

Occupational and recreational history

Ask the patient about his environment (including contact with animals).

May be particularly important in conditions such as contact dermatitis. Ask about reaction to sunlight exposure Lupus erythematosus, for ex. is aggravated by sunlight.

Travel For example, South America visit 6 weeks ago may explain the crusted sore on the wrist

(localized form of leishmaniasis).

Family and household history

Ask about first degree relatives and houshold contact (do not have to be family members). Infections such

as scabies may infect both relatives, and other contacts.

2) Examination of the skin

1. Characteristics (primary, secondary) later2. Location of lesion3. Description of the lesion4. Distribution (groups, disseminated) and Pattern

Location of lesions

Frequent association b/w common skin diseases and body site

Scalp - psoriasis, seborrhoeic dermatitis, fungal infec. Face - Atopic dermatitis, acne, rosacea, seborrhoeic dermatitis, lupus erythematosus, and other

photosensitive problems

Body flexures - seborrhoeic dermatitis, psoriasis, fungal infec., candida infections Feet - toe webs (fungal infec.), soles (juvenile plantar dermatosis), dorsa (contact dermatitis)

Disease Common siteAcne vulgaris face and upper part of back

Atopic dermatitis flexor sites of limbs

Herpes zoster vesicles in a unilateral dermatoma

Light-sensitive eruption light exposed areas

Pityriasis rosea trunk, upper parts of limbs

Psoriasis extensor sites of limbs

Seborrhoeic dermatitis face, head, neck

Do not forget to check the nails, hair, and mucous mem!!!


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Description of the lesion

1. Color salmon-pink, lilac, violet2. Nature uniform, irregular, patchy...3. Form: Configuration, border, and surface

Annular = circular or ring-shaped.

Arcuate = curved. Circinate = arched or rounded border. Discoid, nummular = disk or coin-shaped. Gyrate = wave-like. Iris or cockade = target-like Serpiginous = winding, twisting (snake-like).

4. Border Sharp (well-circumscribed) or vague (blurred).5. SurfaceSmooth, rough, warty, vegetating, glistening, dull, dome-shaped, umbilicated...6. Consistency Soft, doughy, hard, fluctuant, lobed, knotty, moveable, fixed, attached to 7.

Smell foul-smelling

8. Temperature hot, warmDistribution and patterns

Linear: Following a line. Lines of Blaschko: Following embryologic skin lines Retiform and reticulate: net-like. Grouped Herpetiform: Arranged in clusters, grape-like.

Zosteriform: Following a dermatome Discrete: Solitary. Confluent: Blending together. Chessboard pattern: Arranged in rectangular patterns. Disseminated: Randomly distributed.

Distribution over skin surface

Degree of spread: Localized, regional, generalized (widespread), universal. Limited to certain areas (such as palms and soles or scalp).

Specific patterns: Symmetrical, asymmetrical, light-exposed skin, lightprotected skin,intertriginous areas, seborrheic areas, pressure points, sites of predilection.

Relation to skin appendages

Each lesion centered about a hair, producing a distinctive pattern.

Interfollicular Not involving hairs. Palmoplantar Limited to palms and soles, thus not connected with hairs. Favoring regions with large concentrations ofsebaceous glands or sweat glands.


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Description of complex findings

The following terms are frequently used in dermatologic descriptions but are not traditionally considered

primary or secondary lesions.

Atrophy: Loss of skin substance. Angioedema is a diffuse swelling caused by edema extending to the subcutaneous tissue. Ecchymosis: Large area of extravasation of erythrocytes. Enanthem: Abrupt appearance of mucosal lesions, similar to exanthem. Erythema: Redness of the skin Erythroderma: Diffuse redness of the entire skin, usually associating with scaling. Exanthem: Abrupt appearance of diffuse or generalized similar skin lesions (usually represents viral

infection or drug reaction).

Lichenification: Response of skin to chr. rubbing, leading to thickening with accentuated markings. Livedo: Blue-red discolour. of skin due to passive congestion of vessels, often with net-like pattern. Papilloma is a nipple-like projection from the skin. Petechiae: Tiny areas of extravasation of blood, usually pinhead-size. Poikiloderma: Combination of telangiectases, atrophy and reticulate hyperpigmentation Rhagade or fissure: Linear split or defect, extending into dermis and often originating from an

orifice.

Purpura: a larger macule or papule of blood in the skin.Such blood-filled lesions do not blanch if a glass lens is pushed against them (diascopy).

Sclerosis: Hardening and thickening of skin, so that it is less freely moveable, often associated withcontraction so that involved area lies below level of normal skin.

Sinus: Tract lined with epithelium, often discharging secretions. Suggillation: Synonym for ecchymosis, also used for bruise or contusion. Comedo is a plug of greasy keratin wedged in a dilated pilosebaceous orifice.

- Open comedones black-heads.- Closed comedo the follicle opening is covered by skin so it looks like a pinhead-sized,

ivory-coloured papule.

Burrow is a linear or curvilinear papule, with some scaling, caused by a scabies mite. Telangiectases: visible, irreversible dilatation of small cutaneous blood vessels

Description of General Skin Condition, Vascular Status, and associated findings

General terms:Xerotic (dry), seborrheic (oily), ichthyotic (scaly), actinic damage, atrophic, thickened, abnormal

texture, hyper-, hypo- or anhidrotic.

Vascular status: Cyanotic, pale, cold, warm, edematous, with varicosities, necrotic. Nature of wound healing:

- Central or peripheral healing, with scarring or atrophy.- Pigmentary changes, erosion or ulcer, crust, or scale.

Dynamics of lesion: All lesions in same stage or lesions in different stages. Associated findings: Lymphadenopathy, fever, malaise, as examples.


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Topic 17 - Primary lesions of the skin

Skin lesions can be classified into Primary or Secondary

In differentiating 10 and 20 lesions, 20 lesions typically follow 10 lesions but are less characteristic,

therefore, dermatologic classification begins with search for primary lesions.

Primary lesions are the basic elements of skin morphology, they can undergo a variety of changes to

become secondary lesions

First signs of the skin disease. As a physician you usually see the 20lesion on the patient must ask what the lesion first looked. Characteristics of the lesion, lesion size and the relationship to skin MUST be described.

Types of primary lesions

1) Macule / patch2) Infiltrative primary skin lesions papule/plaque, tuber, nodule/node3) Exsudative primary skin lesions urtica/wheal, vesicle/bulla, pustule

Macule / patch

Circumscribed, flat, NOT palpable discoloration of the skin

Macule < 0.5 cm in size. Patch > 0.5 cm

The skin pigmentation can be classified as

Endogenous pigment hemoglobin, melanin or Exogenous pigment Vascular origin

Possible colors and their common causes

Red: Hyperemia (erythema)- Telangiectases- Leakage of blood (Purpura, Petechia, Ecchymosis, suggillation (bruise))

Blue: Cyanosis, hematoma (black eye), dermal melanin Brown: Dermal and epidermal melanin, hemosiderin White: Anemia, vasoconstriction, loss of melanin Yellow: Carotenoids, bile, solar elastosis (Premature aging of the skin) Gray-black: Epidermal melanin, heavy metals, tar, dithranol, foreign Bodies

Vitiligo


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Associated pathologies and examples

1. Ephelis (freckles) hyper-pigmentation. For ex. Puetz-Jeger sy.Peutz-Jeghers sy.

AD inherited disorder serine/threonine protein kinase 11 (STK11) gene mutation

characterized by intestinal hamartomatous polyps in association with a distinct pattern of skinand mucosal macular melanin deposition.

2. Porphyria cutanea tarda (PCT)Metabolic disease involving hyper- or hypo-pigmentation thatoccur on sun exposed skin..

3. Fixed drug eruption a hyperpigmented macule (or a bullous plaques) Round, erythematous or purple, recur at the same site each time the drug is taken. may occur after taking salicylic acid

4. Vitiligo hypo-pigmentation of the skin due to dysfunction of melanocytes.An autoimm. disease usually due to auto reactive T cells killing melanocytes.

5. Halo/Sutton nevuspigmented nevus surrounded by a hypopigmented macular border (whitespot). Sometimes it can disappear.

6. Incontinentia pigmentiRare x-linked inherited hypopigmentation disorder, seen in babies.7. Purpura bleeding into the skin.

Palpable Purpura not a macule, it is a sign of supf. vasculitis (type III HS reaction)8. Exogenous pigment tattoo considered to be a macule.9. Erythema e calore hyperpigmentated erythema.

If you feel the skin and it is a bit more firm, there is probably an cellular content in the lesion and it is

not a macule.

Infiltrative primary skin lesionsall have cellular infiltration

1) Papule/plaque Papule small solid elevation of the skin 0.5 cm diameter but w/o substantial depth.- They have infiltrated T ly-s.- Papules may become confluent and form plaques- Associated pathologies: Lichen planus, Psoriasis (papule/plaque),

Erythema multiforme

2) Tuber - cellular infiltration involving the entire depth of the dermis.3) Nodule/node - circumscribed, elevated cellular infilt. in the dermis and subcutis

often round, solid lesion > 0.5 cm in diameter. A large nodule (>1cm) is referred to as a tumour (BCC, Lipoma, Wart,

Furuncle) Tumors may courteously be called large nodules, especially if benign.

Plaques (psoriasis)

Papule


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Exsudative primary skin lesions (collection of fluid)

1)Wheals/urtica (hive) Transient papule or plaque caused by dermal edema Wheal is an elevated white compressible evanescent area. It is often surrounded by a red axon-mediated flare. Usually < 2 cm. May last several hours

2) Vesicle, bulla intraepidermal acantholytic subepidermal

Vesicle small (up to 0.5 cm in diameter) circumscribed collection of

fluid in the epidermis or below the basal layer

Result of vesicles: oozing, crusts, scaling.

Bulla Larger collection of fluid (> 0.5 cm). can be intraepidermal or subepidermal.

3) PustuleA circumscribed, supf. cavity of the skin that contains pus in or below the epidermis

Primary pustules (sterile) pustular psoriasis Secondary (pyogenic infec.) impetigo

Lesions characteristic for pathological conditions

Macules Infec. exanthemas measles, rubella, scarlet fever Drug eruptions

Papules Lichen planus Lichen simplex chronicus (localized neurodermatitis) Metabolic disorders (deposition of uric acid...) Prurigo Epizoonosis Lymphocytoma, lymphomas Drug eruptions Atopic dermatitis Bact. 20 syphilis, TB, leprosy Leishmaniasis Sarcoidosis Rosacea Warts Molluscum contagiosum

Vesicle


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Nodules Deeper vasculitis (erythema nodosum, nodular vasculitis) Gumma (30 syphilis), leprosy Leishmaniasis Sarcoidosis, granuloma annulare Tophus Tumors, lymphomas

Vesicles Virus vesicles (zoster, herpes simplex, varicella) Contact dermatitis, mostly allergies Recurrence and spread of eczematous lesions by absorption of allergens

(percutaneous, oral ...)

Dermatitis herpetiformis (Duhrings disease) Fungal disease, epizoonosis Miliaria

Pustules Acne and acne-like conditions (drug-induced acne) Mercury dermatitis Pustular psoriasis Persistent palmoplantar pustolosis Reiters disease Epizoonoses Fungal infections Pyodermas (folliculitis barbea)

Topic 17. Primary Lesions of the Skin

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