Dermatovenereology Departement / Division dr. Moh. Hoesin Hospital / Medical Faculty UNSRI

2012

The art of diagnosisDiseases have characteristic morphology and distribution

The diagnosis and treatment of skin diseases :rest on the physician's ability to use the lexicon of dermatology, to recognize the basic and sequential lesions of the skin, and to recognize the various patterns in which they occur in a variety of diseases and syndromes.

“Dermatology lexicon" : a set of terms that denote types of skin lesion

standard terminology

- the first step in generating a differential diagnosis- consistency in : clinical documentation, research, &

communication with other physicians.e.g. :Once a lesion has been described as a pearly, flesh-colored, telangiectatic, ulcerated nodule DD/ utama : basal cell carcinoma

Macule

• A macule is a circumscribed, flat lesion that differs fromsurrounding skin because of its color.

e.g : hyperpigmentation, hypopigmentation, vascular abnormalities, erythema, purpura.

Papule

• Papule is a solid, elevated lesion less than 0.5 cm in size in which a significant portion projects above the plane of the surrounding skin.

Plaque

• Plaque is a solid plateau-like elevation or palpable flat lesion, has a diameter larger than 0.5 cm.

• Well-defined, reddish, scaling plaquesthat coalesce to cover large areas of the back and buttocks

Nodule

• Nodule is a solid, round or ellipsoidal, palpable lesion that has a diameter larger than 0.5 cm.

Wheal• Wheal or hives or urtica is a

rounded or flat-topped papule or plaque that is characteristically evanescent, disappearing within hours.

• These lesions are the result of edema in the upper portion of the dermis.

Vesicle and bulla

• A vesicle is a fluid- filled cavity or elevation smaller than or equal to 0.5 cm, whereas a bulla (blister) measures larger than 0.5 cm.

Pustule• Pustule is a circumscribed,

raised cavity in the epidermis or infundibulum

containing pus.

Erosion

• Erosion is a moist, circumscribed, usually depressed lesion that results from loss of all or a portion of the viable epidermis.

Fissures

Fissure is a linear loss of continuity of the skin's surface or mucosa that results from excessive tension or decreased elasticity of the involved tissue.

Ulcer

• Ulcer is a defect in which the epidermis and at least the upper (papillary) dermis has been removed.

Crust

• Crusts are hardened deposits that result when serum, blood, or purulent exudate dries on the surface of the skin.

Scale

• Scale is flat plate or flake arising from the outer-most layer of the stratum corneum.

Cyst

Cyst is an encapsulated cavity or sac lined with a true epithelium that contains fluid or semisolid material (cells and cell products such as keratin).

Atrophy

• Atrophy refers to a diminution in the size of a cell, tissue, organ, or part

of the body.

Lichenification is represents thickening of skin and accentuation of skin markings.The process results from

repeated rubbing and frequently develops in persons with atopy.

Lichenification

Excoriations are surface excavations of epidermis that result from scratching and are frequent findings in patients experiencing pruritus.

Excoriations

Scar

• A scar arises from proliferation of fibrous tissue that replaces previously normal collagen after a wound or ulceration breaches the reticular dermis.

• A scar may be hypertrophic (A) or atrophic (B)

• Erythema is the lesions caused by capillary dilatation

• Telangiectases are permanent dilatations of capillaries that may or may not disappear with application of pressure

• Purpura is the lesions caused by extravasated red blood cells

• Petechiae are small, pinpoint purpuric spots that are often seen in thrombocytopenic states

• Ecchymoses are larger, bruiselike purpuric lesions.

• Infarct is an area of cutaneous necrosis resulting from occlusion ofblood vessels, as in vasculitis and bacterial embolism

• Tumor is a general term for any mass, benign or malignant, and is sometimes used to indicate a large nodule.

Telangiectasia Purpura

Infarct

Shape, Arrangement, and Distribution of Lesions

Once the type or types of lesions have been identified, one needs to describe their shape, arrangement, and pattern of distribution

characteristics in morphologic diagnosis

example : a single scaly plaque on a patient's trunk may have a broad differential diagnosis, but the same plaques symmetrically distributed on the elbows, knees, and umbilicus would be highly suggestive of psoriasis.

Shape or configuration of skin lesions

1. Annular : ring-shaped; implies that the edge of the lesion differs from the center, either by being raised, scaly, or differing in color (e.g : granuloma annulare, tinea corporis).

2. Round/nummular/discoid: coin-shaped; usually a round to oval lesion with uniform morphology from the edges to the center (e.g : nummular eczema, plaque-type psoriasis, discoid lupus).

3. Polycyclic : formed from coalescing circles, rings, or incomplete rings (e.g : tinea corporis)

4. Arcuate : arc-shaped; often a result of incomplete formation of an annular lesion (e.g : urticaria, subacute cutaneous lupus erythematosus).

5. Linear : resembling a straight line; often implies an external contactant or Koebner phenomenon has occurred in response to scratching. single lesion (e.g : a scabies burrow, poison ivy dermatitis) multiple lesions (e.g : lichen nitidus or lichen planus).

6. Reticular : net-like or lacy in appearance, with somewhat regularly spaced rings or partial rings and sparing of intervening skin (e.g., livedo reticularis, cutis marmorata).

7. Serpiginous : serpentine or snake-like (e.g : cutaneous larva migrans).

8. Targetoid : target-like, with at least three distinct zones (e.g : erythema multiforme)

9. Whorled : like marble cake, with two distinct colors interspersed in a wavy pattern; usually seen in mosaic disorders in which cells of differing genotypes are interspersed (e.g : incontinentia pigmenti, hypomelanosis of Ito)

Arrangement of Multiple Lesions

1. Grouped/herpetiform : lesions clustered together (e.g : herpes zoster).

2. Scattered : irregularly distributed.

Distributions of Multiple Lesions1. Dermatomal/zosteriform : unilateral and lying in the distribution of

a single spinal afferent nerve root. (e.g : herpes zoster).

2. Blaschkoid : following lines of skin cell migration during embryogenesis; generally longitudinally oriented on the limbs and circumferential on the trunk, but not perfectly linear. Implies a mosaic disorder (e.g : incontinentia pigmenti).

3. Lymphangitic : lying along the distribution of a lymph vessel. e.g : cellulitis due to a staphylococcal or streptococcal infections.

4. Sun exposed : occurring in areas usually not covered by clothing, namely the face, and dorsal hands (e.g : photodermatitis, polymorphous light eruption, squamous cell carcinoma).

5. Sun protected : occurring in areas usually covered by one or more layers of clothing. (e.g : parapsoriasis, mycosis fungoides).

6. Acral : occurring in distal locations, such as on the hands, feet, wrists, and ankles (e.g : palmoplantar pustulosis, chilblains).

7. Truncal : occurring on the trunk or central body.

8. Extensor : occurring over the dorsal extremities, overlying the extensor muscles, knees, or elbows (e.g., psoriasis).

9. Flexor : overlying the flexor muscles of the extremities, the antecubital and popliteal fossae (e.g : atopic dermatitis).

10.Intertriginous : occurring in the skin folds : axillae, inguinal folds, inner thighs, inframammary skin. (e.g., candidiasis).

11.Localized : confined to a single body location (e.g., cellulitis).

12.Generalized : widespread. (e.g., viral exanthems, drug eruption).

13.Bilateral symmetric : occurring with mirror-image symmetry on both sides of the body (e.g., vitiligo, plaque-type psoriasis).

14.Universal : involving the entire cutaneous surface. (e.g., erythroderma, alopecia universalis).

Shape and arrangement of lesions

Lesions in the distribution described by Blaschko for developmental

Scattered lesion.

Targetoid lesion. Grouped: clustered Whorled : marbled appearance

Annular lesion

Nummular lesion.

Polycyclic lesion

Arcuate lesion

Linear distribution

Reticular lesion

Serpiginous lesion

• Diascopy test :

The application of pressure with two glass slides or an unbreakable clear lens on a red lesion is asimple and reliable method for differentiating redness due to vascular dilatation (erythema) from redness due to extravasated erythrocytes or erythrocyte products (purpura). If the redness remains under the pressureof the slide, the lesion is purpuric.

• Pemphigus vulgaris. The bulla has been extended by applying pressurewith the finger (Nikolsky's sign)

• Tzanck preparation showing multinucleate giant epidermal cell(Giemsa's stain). (Courtesy of Arthur R. Rhodes, MD)

Referensi

Garg A, Levin N.A, Bernhard J.D, Structure of Skin Lesions and Fundamentals of Clinical Diagnosis. In:Wolf K, Goldsmith L, Katz S Gilchrest B, Paller A, Leffell D,editors. Fitzpatrick’s Dermatology in General Medicine. 7th ed. New York:Mc.Graw Hill Company;2008.p. 23-40.

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