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- 1. Morphology of skin lesions and Approach to Dermatologic Diagnosis Dr.Tesfamariam (R2) Nov , 2018
- 2. Outline Part 1 -Approach to dermatologic diagnosis Introduction History taking Physical examination Investigations Part 2 Morphology of skin disease
- 3. Introduction • A patient and thorough approach to evaluation of patients is important • Knowledge and appropriate use of dermatological terminology “dermatology lexicon” are fundamental.
- 4. • HISTORY TAKING CHIEF COMPLAINT AND HISTORY OF THE PRESENT ILLNESS Duration condition Periodicity Evolution Location Severity Ameliorating and Exacerbating Factors Preceding illness, new medications, new topical products, Therapies tried,
- 5. …cont • PAST MEDICAL HISTORY • Medication History • Allergies • Social History • Family History • Constitutional symptoms (fatigue, weight loss, fever, chills, night sweats ……….)
- 6. Physical examination • General appearance (initial clinical impression) • Detailed examination of: Skin ,Mucus membrane, Nails, Hair, and genitalia • There are 4 cardinal features in describing a skin lesion Type of lesion(macule, papule…..) Shape of individual lesions(annular, round, oval….) Arrangement ( solitary, grouped….) Distribution (generalized, dermatomal….) • Additionally colour of a lesion should be characterized
- 7. • PALPATION ▫ Superficial (e.g., scaly, rough, smooth) ▫ Deep (e.g., firm, rubbery, mobile) ▫ Deviation in temperature (hot, cold) ▫ Presence of tenderness • Other aspects of physical examination Vital signs Abdominal examination for hepatosplenomegaly and Lymph node examination
- 8. • IDEAL CONDITIONS : ▫ Excellent lighting: bright light that simulates the solar spectrum. Without good lighting, subtle but important details may be missed. Fully undressed: wearing only a gown Underwear, socks & shoes AND Any makeup or eyeglasses. ▫ Examining table: comfortable ▫ Examining room: Temperature Disinfecting materials Having a chaperone: opposite genders 8
- 9. • RECOMMENDED TOOLS; ▫ Physician's eyes & hands : the essential tools, but Magnifying tool: magnifying glass, or dermatoscope. Bright focused light: flashlight or penlight Glass slides or a hand magnifier for diascopy. Alcohol pads or surface oil: remove scale Gauze pads or tissues with water: removing makeup. 9
- 10. • RECOMMENDED TOOLS ▫ Gloves: Infectious condition ; MM, vulvar & genital areas ; Procedure ▫ Ruler: measuring lesions. ▫ Scalpel blades: # 15 (scraping) & # 11 (incising) ▫ Camera: photographic documentation. ▫ Wood's lamp (365 nm): highlighting subtle pig. changes. 10
- 11. Investigation's
- 12. Investigation's CBC, ESR,OFT,FBS/RBS ,Urine analysis Serological tests (SLE, Viral infections and STDS) Radiological & imaging techniques
- 13. Part 2 Morphology of skin lesions • Introduction ▫ Knowledge & appropriate use of ‘dermatology lexicons’ – a set of terms that denotes types of skin lesions, are fundamental • The morphologic characteristics of skin lesions are key elements in establishing diagnosis and communicating skin findings
- 14. • Includes: ▫ Type of the lesion Primary Secondary ▫ Shape of the lesion ▫ Arrangement ▫ Distribution
- 15. • 1-Primary lesions ▫ Papule ▫ Macule ▫ Patch ▫ Plaque ▫ Nodule ▫ Vesicle ▫ Pustule ▫ Bulla ▫ Wheal ▫ telangectasia 2 –Secondary lesions • Sequential/develop as the lesion evolve or are created by scratching or infection ▫ Scale ▫ Crust ▫ Erosion ▫ Ulcer ▫ Excoriation ▫ fissure ▫ Lichenification ▫ Atrophy ▫ scar
- 17. Flat lesions • MACULE ▫ flat circumscribed alteration in the color of the skin or mucous membrane ▫ < 0.5 cm • PATCH ▫ it is a flat area of skin or mucous membranes with a different color from its surrounding ▫ >0.5 cm
- 18. • ERYTHEMA ▫ Blanchable pink to red color of skin or mucous membrane ▫ Due to dilatation of arteries and veins in the papillary and reticular dermis • Erythroderma ▫ Generalized deep redness of the skin involving > 90 % BSA
- 19. Raised lesions
- 20. PAPULE • a solid, elevated lesion less than 0.5 cm • papulosquamous lesions - Papules surmounted with scale • Sessile, pedunculated, dome- shaped, flat-topped, rough, smooth, umbilicated
- 21. PLAQUE • a solid plateau-like elevation • large surface area in comparison with its height above the normal skin level • has a diameter larger than 0.5 cm • further described by size shape, color, and surface change
- 22. NODULE • a nodule is a solid, round or ellipsoidal, palpable lesion • diameter >0.5 cm • According to anatomy: o (1) epidermal, (2) epidermal– dermal, (3) dermal, (4) dermal– subdermal, and (5) subcutaneous. • Can have different consistency, color and shape
- 23. • Tumor, ▫ also sometimes included under the heading of nodule, ▫ is a general term for any mass, benign or malignant. A gumma is, specifically, the granulomatous nodular lesion of tertiary syphilis
- 24. CYST • is an encapsulated cavity or sac lined with a true epithelium that contains fluid or semisolid material • Its spherical or oval shape results from the tendency of the contents to spread equally in all directions
- 25. wheal • Is a transient swelling of the skin, which last only a few hours • also known as hives or urticaria • are the result of edema produced by the escape of plasma through the vessel walls, in the upper portion of the dermis • variable size/shape
- 26. • Angioedema is a deeper, edematous reaction that occurs in areas with very loose dermis and subcutaneous tissue such as the lip, eyelid, or scrotum
- 27. Comedon • Is a hair follicle that is dilated & plugged with keratin & lipids • It can be: Open/black head – when the PSU is open to the surface of the skin with a visible keratinous plug Closed – a closed infundibulum with whitish keratin in which the follicular opening is unapparent
- 28. calcinosis • Is a deposit of calcium in the dermis & subcutaneous tissues • Appreciated as hard, whitish nodules, or plaques, with or without visible alteration in the skin surface.
- 29. horn • a hyperkeratotic conical mass of cornified cells arising over an abnormally differentiating epidermis. • A clinical example is verruca vulgaris
- 30. Scar • An abnormal proliferation of fibrous tissues that replaces previously normal collagen • Usually follows ulceration, surgery or infection breaching the reticular dermis • Are initially thick/raised & pink but with time become white & atrophic • Adenexal structures are destroyed
- 31. • Hypertrophic scars typically take the form of firm papules, plaques, or nodules. • Keloid scars are also elevated. Unlike hypertrophic scars keloids exceed, with web-like extensions, the area of initial wound. • Atrophic scars are thin depressed plaques
- 33. vesicle • fluid-filled cavity or elevation smaller than or equal to 0.5 cm • Primarily filled with clear fluid • May become pustular, umbilicated or an erosion
- 34. Bulla • Elevated, circumscribed and may be of any size over 0.5 cm • Filled with clear fluid • The amount of pressure required to collapse the lesion may help predict whether the bulla is intraepidermal or subepidermal
- 35. pustule • A circumscribed raised cavity in the epidermis or infundibulum containing pus • collection of leukocytes, cellular debris +/- bacteria • May vary in size & in certain situation may coalesce & form ‘lakes’ of pus • Generally heal without scarring
- 36. ABSCESS FURUNCLE • A localized collection of purulent material deep in the dermis or subcutaneous -tissue • Is a pink warm, tender, erythematous, fluctuant nodule • A deep necrotizing folliculitis with suppuration • Usually > 1cm with central necrotic plug & overlying pustule
- 38. Erosion moist, circumscribed, depressed lesion results from loss of a portion or all of the viable epidermal or mucosal epithelium. May result from trauma/scratching, maceration, rupture of vesicle / bullae, or epidermal necrosis Unless secondarily infected, heal without scarring e.g TEN
- 39. Ulcer • defect in which the epidermis and at least the upper (papillary) dermis have been destroyed. • defect heals with scarring. • Borders may be rolled, undermined, punched out, jagged, or angular. • The base may be clean, ragged, or necrotic.
- 40. Atrophy • Refers to a shrinking in the size of a cell, tissue, organ, or part of a body Epidermal: Transparent—visible vessels Glossy/loss of skin texture Paper thin, wrinkled Dermal:- loss of CT Circumscribed depression Sc Tissue Substantial depression
- 41. Sclerosis • refers to a circumscribed or diffuse hardening or induration of the skin that results from dermal fibrosis. • It is detected more easily by palpation, • the skin may feel board-like, immobile, and difficult to pick up • e.g morphea
- 42. Burrow Sinus • Is a wavy thread-like tunnel through the outer portion of the epidermis excavated by a parasite • Is a tract connecting deep suppurative cavities to each other or to the surface of the skin • The contents of the cavity, usually pus, fluid or keratin • Usually noted on the scalp, neck, axilla, groin & rectum
- 43. POIKILODERMA • Refers to the combination of atrophy, telangiectasia, and varied pigmentary changes (hyper- and hypo-) over an area of skin. • This combination of features may give rise to a dappled appearance to the skin.
- 44. Striae • Are linear depression of the skin • Result from changes of the reticular dermis that occur with rapid stretching of the skin • The surface may be thin or wrinkled • pink to red in color & raised later become paler & flat
- 45. Surface changes
- 46. SCALE, DESQUAMATION (SCALING ) Abnormal shedding or accumulation of stratum corneum in noticeable flakes Is a disordered epidermal differentiation leading to accumulation of stratum corneum become apparent as scale Normally, the epidermis is replaced completely every 27 days Ranges in size from fine dust-like particles to extensive parchment-like sheets
- 48. Types of scales Pityriasiform small, fine, bran-like Psoriasiform (Micaceous/ostraceous) Silivery & brittle, plates of sheets like-mica or accumulate in heaps like-oytershell Ichthyosiform (fish-like) Large scales, regular polygonal plates arranged in a parallel rows or in a diamond patterns Gritty Densely adherent scale with a sandpaper texture. Seborrheic Thick, waxy or greasy, yellow to brown flakes Exfoliative Splits of the epidermis in finer scales or in sheets Follicular Appear as keratotic plugs, spines or filaments
- 49. typical herald patch of pityriasis rosea, demonstrating an oval shape and fine scale inside the periphery of the plaque 17/03/2019 49
- 50. Crusts • Are hard deposits of dried serum, pus, or blood, usually mixed with epithelial and sometimes bacterial debris • appearance depends on the nature of the secretion Yellowish brown -serous Yellowish green -purulent Reddish black -blood • can be superficial & friable/thick & adherent
- 51. Excoriation ▫ Small superficial defect— epidermis, papillary dermis Local trauma scratching itchy skin conditions
- 52. Fissure • A linear loss of continuity of the skin`s surface or mucosa • Result from excessive tension or decreased elasticity of the involved tissues • Frequently occurs in the palms & soles & transition areas
- 53. Eschar Keratoderma • circumscribed, adherent, hard, black crust on the surface of the skin that is moist initially, protein rich, and avascular • Implies tissue necrosis, infarction, gangrene, deep burns, or other ulcerative processes • An excessive hyperkeratosis of the stratum corneum that results in yellowish thickening of the skin • Usually on the palms & soles • Can be inherited (abnormal keratin formation) or acquired (mechanical stimulation)
- 54. Lichenification LSC • reactive thickening of the epidermis • induced by repeated rubbing of the skin • change in the collagen of the underlying superficial dermis the skin lines are accentuated so that the surface looks like a washboard/bark of a tree
- 55. VASCULAR LESIONS
- 56. Telangectasia • Are persistent dilatations of small capillaries in the superficial dermis • Visible as fine, bright, non- pulsatile red lines or net-like patterns on the skin • May or may not disappear with application of pressure/diascopy
- 57. Purpura Extravasation of red blood from cutaneous vessels into skin or mucous membranes results in reddish-purple lesions Petechiae - small, pin point purpuric macules Ecchymoses - larger, bruise-like purpuric patches Haematoma- swelling from gross bleeding.
- 58. • Infarct An area of cutaneous necrosis resulting from a bland or inflammatory occlusion of blood vessels Cutaneous infarct present as tender, dusky reddish-grey macule or firm plaque
- 59. SHAPE OR CONFIGURATION OF SKIN LESIONS Annular ;Ring-shaped Round/nummular/disc oid ;Coin-shaped; usually a round to oval lesion with uniform morphology from the edges to the center Polycyclic; Formed from coalescing circles, rings, or incomplete rings urticaria,
- 60. • Reticular ;Net-like or lacy in appearance, • Serpiginous ;Serpentine or snake-like • cutaneous larva migrans, • Linear : Resembling a straight line; often implies an external contactant
- 61. Arcuate ;Arc-shaped; often a result of incomplete formation of an annular lesion Targetoid : Targetlike, with at least three distinct zones Whorled : Like marble cake, with two distinct colors interspersed in a wavy pattern;
- 62. Arrangement of lesions • Grouped/herpet iform in which lesions are clustered together • Scattered in which lesions are irregularly distributed
- 63. Distribution of lesions • Dermatomal/zosteriform: Unilateral and lying in the distribution of a single spinal afferent nerve root
- 64. Distribution… • Blaschkoid following lines of skin cell migration during embryogenesis; generally longitudinally oriented on the limbs and circumferential on the trunk, but not perfectly linear
- 65. Distribution… • Sun exposed: Occurring in areas usually not covered by clothing, namely the face, dorsal hands, and a triangular area corresponding to the opening of a V-neck shirt on the upper chest • Sun protected: Occurring in areas usually covered by one or more layers of clothing;
- 66. Distribution… • Acral: Occurring in distal locations, such as on the hands, feet, wrists, and ankles • Truncal: Occurring on the trunk or central body.
- 67. Distribution… • Extensor: Occurring over the dorsal extremities, overlying the extensor muscles, knees, or elbows • Flexor: Overlying the flexor muscles of the extremities, the antecubital and popliteal fossae
- 68. Distribution… • Intertriginous: Occurring in the skin folds, where two skin surfaces are in contact • Localized: Confined to a single body location
- 69. Distribution… • Generalized: Widespread • Bilateral symmetric: Occurring with mirror-image symmetry on both sides of the body • Universal: Involving the entire cutaneous surface
- 70. Cutaneous signs ▫ Auspitz sign---------------- psoriasis Pin point bleeding from ruptured capillaries ▫ Dariers sign---------------- urticaria pigmentosa, Urticarial wheal- after rubbing with a pen ▫ Nikolsky sign--------------- PV, TEN Lateral pressure on unblistered skin- shearing of the epidermis ▫ Apple jelly sign------------- granulomatous processes Yellowish hue –when pressed with glass slide ▫ Dermatographism------ Symptomatic physical urticaria Firmly stroking unaffected skin produces a wheal along the line of stroke ▫ Oil drop sign--------------- onycholysis in psoriasis, etc. Area of yellowish discoloration on the nail bed
- 71. • References • Fitzpatrick’s Dermatology in General Medicine, Eighth Edition • Bolognia dermatology third edition • Rook’s Textbook of Dermatology, 8th edition • Up todate 21.2