Common Shapes and Configurations of Lesions

Grouped

Clusters of lesions (e.g., vesicles of contact dermatitis)

Common Shapes and Configurations of Lesions

Linear

A scratch, streak, line or stripe

Common Shapes and Configurations of Lesions

Target

Iris, resembles iris of eye, concentric rings of color in lesions (e.g., erythema multiforme)

Common Shapes and Configurations of Lesions

Zosteriform

Linear arranges along a unilateral nerve route (e.g., herpes zoster)

Common Shapes and Configurations of Lesions

Polycyclic

Annular lesions grow together (e.g., lichen planus, psoriasis)

Primary Skin Lesions

Macule

Solely a color change, flay and circumscribed, of less than 1 cm.

Examples: freckles, flat nevi, hypo pigmentation, petechiae, measles, scarlet fever

Primary Skin Lesions

Patch

Macule that are larger than 1 cm.

Examples: mongolian spot, vitiligo, cafe au last spot, chloasma, measles rash

Primary Skin Lesions

Nodule

Solid, elevated, hard or soft, larger than 1 cm. May extend deeper into dermis than papule.

Examples: xanthoma, fibroma, intradermal nevi

Primary Skin Lesions

Tumor

(Nodule you can palpate) Larger than a few centimeters in diameter, firm or soft, deeper into dermis; may be benign or malignant, although "tumor" implies "cancer" to most people.

Examples: lipoma, hemangioma

Primary Skin Lesions

Papule

Something you can feel (i.e., solid, elevated, circumscribed, less than 1 cm diameter) caused by superficial thickening in epidermis.

Examples: elevated nevus (mole), lichen planus, molluscum, wart (verruca)

Primary Skin Lesions

Plaque

Papules coalesce to form surface elevation wider than 1 cm. A plateau-like, disk-shaped lesion.

Examples: psoriasis, lichen planus

Primary Skin Lesions

Wheal

Superficial, railed, transiet, and erythematous; slightly irregular shaped from edema (fluid held diffusely in the tissues).

Examples: mosquito bite, allergic reaction, dermographism

Primary Skin Lesions

Urticaria (Hives)

Wheals coalesce to form extensive reaction, intensely pruritic

Primary Skin Lesions

Vesicle

Elevated cavity containing free fluid, up to 1 cm; a "blister." A clear serum flows if wall is ruptured.

Examples: herpes simplex, early varicella (chicken pox), herpes zoster (shingles), contact dermatitis

Primary Skin Lesions

Bulla

Larger than 1 cm diameter; usually single chambered (unilocular); superficial in epidermis; thin walled an ruptures easily.

Examples: friction blister, pemphigus, burns, contact dermatitis

Primary Skin Lesions

Cyst

Encapsulated fluid-filled cavity in dermis or subcutaneous later, tensely elevating skin.

Examples: sebaceous cyst, wen

Primary Skin Lesions

Pustule

Turbid (infected) fluid - pus - in the cavity. Circumscribed and elevated

Examples: impetigo, acne

Secondary Skin Lesions

Crust

Thickened, dried-out exudate when vesicles/pustules burst or dry up.

Color can be red-brown, honey, or yellow, depending on fluid ingredients (blood, serum, pus).

Examples: impetigo (dry, honey-colored), weeping eczematous dermatitis, scab after abrasion

Secondary Skin Lesions

Scale

Compact, desiccated flakes of skin, dry or greasy, silvery or shite, from shedding of dead excess keratin cells.

Examples: after scarlet fever or drug reaction (laminated sheets), psoriasis (silver, mica like), seborrheic dermatitis (yellow, greasy), eczema, ichthyosis (large, adherent, laminated), dry skin

Secondary Skin Lesions

Fissure

Linear crack with abrupt edges; extends into dermis; dry or moist.

Examples: cheilosis - at corners of mouth caused by excess moisture; athlete's foot

Secondary Skin Lesions

Erosion

Scooped out but shallow depression. Superficial; epidermis lost; moist but no bleeding; heals without scar because erosion does not extend into dermis

Secondary Skin Lesions

Ulcer

Deeper depression extending into dermis, irregular shape; may bleed; leaves car when heals.

Examples: stasis ulcer, pressure sore, chancre

Secondary Skin Lesions

Excoriation

Self-inflected abrasion; superficial; sometimes crusted; scotches from intense itching.

Examples: insect bites, scabies, dermatitis, varicella

Secondary Skin Lesions

Scar

After a skin lesion is repaired, normal tissue is lost and repealed with connective tissue (collagen). This is a permanent fibrotic change.

Examples: healed area of surgery or injury, acne

Secondary Skin Lesions

Atrophic Scar

The resulting skin level is depressed with loss of tissue, a thinning of the epidermis.

Example: striae

Secondary Skin Lesions

Lichenification

Prolonged, intense scratching eventually thickens skin and produces tightly packed papules; looks like surface of moss (or lichen)

Secondary Skin Lesions

Keloid

A benign excess of scar tissue beyond sites of original injury, surgery, acne, ear piercing, tattoos, infections, burns. Looks smooth, rubbery, shiny and "clawlike"; feels smooth and firm. Found in ear lobes, back of neck, scalp, chest, and back; may occur months to years after initial trauma.

Most common ages are 10-30 years; higher incidence in Blacks, Hispanics, and Asians

Vascular Lesions

Hemangiomas

Caused by a benign proliferation of blood vessels in the dermis

Vascular Lesions

Port-Wine Stain (Nevus Flammmeus)

A large, flat, macular patch covering the scalp or face, frequently along the distribution of CN V (5).

Color is dark red, bluish, or purplish and intensifies with crying, exertion, or exposure to heat or cold. The marking consists of mature capillaries.

Present at birth and usually does not fade.

The use of yellow lasers now makes photo ablation of the lesion possible, with minimal adverse effects.

Vascular Lesions

Strawberry Mark (Immature Hemangioma)

A raised bright red area with well-defined border about 2-3 cm in diameter.

It does not blanch with pressure. It consists of immature capillaries, it is present at birth or develops in the first few months, and usually disappears by age 5-7 years.

Requires no Tx, although parental and peer pressure may prompt Tx

Vascular Lesions

Cavernous Hemangioma (Mature)

A reddish-blue, irregularly shaped, solid and spongy mass of blood vessels. It may be present at birth, may enlarge during first 10-15 months, and does not involute spontaneously.

Vascular Lesions

Telangiectasia

Telangiectases; Caused by vascular dilation; permanently enlarged and dilated blood vessels that are visible on the skin surface

Vascular Lesions

Spider or Star Angioma

Telangiectases; A fiery red, star-shaped marking with a solid circular center. Capillary radiations edited from the central arterial body.

With pressure, note a central pulsating body and blanching of extended legs.

Develops on face, neck, or chest; may babe associated with pregnancy, chronic liver disease, or estrogen therapy or may be normal

Vascular Lesions

Venous Lake

Telangiectases; A blue-purple dilation of venues and capillaries in a star-shaped, linear or flaring pattern.

Pressure causes them to empty or disappear. Located on the legs near varicose veins and also on the face, lips, ears, and chest

Vascular Lesions

Purpuric Lesions

Caused by blood flowing out of breaks in the vessels. RBCs and blood pigments are deposited in the tissues (extravascular). Difficult to see in dark-skinned people

Vascular Lesions

Petechiae

Purpuric; Tiny punctate hemorrhages, 1-3 mm, round and discrete; dark red, purple, or brown in color.

Caused by bleeding from superficial capillaries; will not blanch.

May indicate abnormal clotting factors.

In dark-skinned people petechiae are best visualized in areas of lighter melanization (e.g., the abdomen, buttocks, and solar surface of the forearm). When the skin is black or very dark brown, petechiae cannot be seen on the skin.

Most of the diseases that cause bleeding and micro embolism formation such as thrombocytopenia, subacute bacterial endocarditis, and other septicemias are characterized by petechiae in the mucous membranes and on the skin. Thus you should inspect for petechiae in the mouth, particularly in the buccal mucosa and in the conjunctivae

Vascular Lesions

Ecchymosis

Purpuric; A purplish patch resulting from extravasation of blood into the skin, >3 mm in diameter

Vascular Lesions

Purpura

Purpuric; Confluent and extensive patch of petechiae and ecchymoses, >3 mm, flat, red to purple, macular hemorrhage.

Seen in generalized disorders such has thrombocytopenia and scurvy. Also occurs in old age such as blood leaks from capillaries in response to minor trauma and diffuses through dermis.

Common Lesions in Children

Diaper Dermatitis

Red, moist, maculopapular patch with poorly defined borders in diaper area, extending along inguinal and gluteal foods.

Hx of infrequent diaper changes or occlusive coverings. Inflammatory disease caused by skin irritation from ammonia (in urine), heat, moisture, occlusive diapers

Common Lesions in Children

Imeptigo

Moist, thin-riffed vessels with thing, erythematous base. Rupture to form thick, honey-colored crusts.

Highly contagious bacterial infection of skin; most common in infants and children. Infection can spread to other body areas and other children and adults by direct contact

Common Lesions in Children

Intertrigo (Candidiasis)

Scaling red, moist patches with sharply demarcated borders, some loose scales. Usually in genital area extending along inguinal and gluteal folds.

Aggravated by rhine, feces, heat, and moisture; the Candida fungus infects the superficial skin layers.

Common Lesions in Children

Atopic Dermatitis (Eczema)

Erythematous papule and vesicles, with weeping, oozing, and crusts. Lesions usually on scalp, forehead, cheeks, forearms and wrists, elbows, backs of knees. Paroxysmal and severe pruritus. Family Hx of allergies.

Common Lesions in Children

Measles (Rubeola) in Dark Skin & Light Skin

Red-purple maculopapular blotchy rash in dark skin and light skin on third or fourth day of illness. Rash appears first behind ears and spreads over face and then over neck, trunk, arms, and legs; looks "coppery" and does not blanch.

Also characterized by Koplik spots in mouth- bluish white, red-based elevations of 1-3 mm.

Common Lesions in Children

German Measles (Rubella)

Pink, papular rash (similar to measles but paler) first appears on face, then spreads. Distinguished from measles by presence of neck lymphadenopathy and absence of Koplik spots

Common Lesions in Children

Chickenpox (Varicella)

Small ,tight vesicles first appear on tune and spread to face, arms, and legs (not palm or soles). Shiny vesicles on erythematous based are commonly described as the "dewdrop on a rose petal." Vesicles erupt in succeeding crops over several days; they become pustules and then crusts. Intensely pruritic.

Common Skin Lesions

Primary Contact Dermatitis

Local inflammatory reaction to an irritant in the environment or an allergy. Characteristic location of lesions gives clue.

Often erythema shows first, followed by swelling, wheals (or urticaria), or maculopapular vessels, scales. Frequently accompanied by intense pruritus.

Example: poison ivy

Common Skin Lesions

Allergic Drug Reaction

Erythematous and symmetric rash, usually generalized. Some drugs produce urticarial rash or vesicles and bullae. Hx of drug ingestion

Common Skin Lesions

Tinea Corporis (Ringworm of the Body)

Scales - hyper pigmented in whites, depigmented in dark-skinned people; on chest, abdomen, backs of arms forming multiple circular lesions with clear centers

Common Skin Lesions

Tinea Pedis (Ringworm of the Foot)

"Athlete's foot" fungal infection, first appears as small vesicles between toes, on sides of feet, and on soles; grows scaly and hard.

Found in chronically warm, moist feet: children after gym activities, athletes, aging adults who cannot dry their feet well

Common Skin Lesions

Labial Herpes Simplex (Cold Sores)

HSV infection has prodrome of skin tingling and sensitivity. Lesion then erupts with tight vesicles followed by pustules and produces acute gingivostomatitis with many shallow, painful ulcers.

Common location is upper lip; also in oral mucosa and tongue

Common Skin Lesions

Tinea Versicolor

Fine, scaling, round patches of pink, tan or white (thus the name) that do not tan in sunlight, caused by a superficial fungal infection.

Usually distribution is on neck, trunk, and user arms - a shirt-sleeved turtleneck sweater area.

Most common in otherwise health young adults. Responds to oral anti fungal medication

Common Skin Lesions

Herpes Zoster (Shingles)

Small, grouped vesicles emerge along route of cutaneous sensory nerve, then pustules, then crusts. Caused by varicella zoster virus (VZV), a reactivation of the dormant virus of chickenpox.

Acute appearance, unilateral, does not cross midline. Commonly on trunk, can be anywhere.

If on ophthalmic branch of CN V (5), it poses risk to eye. Most common in adults 50+.

Pain is often severe and long lasting in adults, called potherpetic neuralgia.

Common Skin Lesions

Erythema Migrans of Lyme Disease

Lyme disease (LD) is not fatal but may have serious arthritic, cardiac, or neurologic sequelae. It is caused by a spirochete bacterium carried by the black or dark brown deer tick - common in NE, upper Midwest, and CA (with cases occurring in people who spend time outdoors) in May-Sept.

First stage (early localized LD) has distinctive bull's eye, red macular or papular rash in 50% of the cases. Rash radiates from site of bite (5 cm or larger) with some central clearing; usually located in axillae, midriff, inguina, or behind knees, with regional lymphadenopathy.

Rash fades in 4 weeks; untreated individual then may have disseminated disease with fatigue, anorexia, fever, chills, or joint or muscle aches.

Antibiotic Tx shortens symptoms and decreases wish for sequelae.

Common Skin Lesions

Psoriasis

Scaly, erythematous patch, with silvery scales on top. Usually on scalp, outside of elbows and knees, low back, and anogenital area.

Malignant Skin Lesions

Basal Cell Carcinoma

Usually starts as a skin-colored papule (may be deeply pigmented) with a pearly translucent top and overlaying telangiectasia (broken blood vessel).

Then develops rounded. pearly borders with central red ulcer or looks like large open pore with central yellowing.

Most common form of skin cancer; slow but inexorable growth. Basal cell cancers occur on sun-exposed areas of face, ears, scalp, shoulders

Malignant Skin Lesions

Squamous Cell Carcinoma

Squamous cell cancers arise from actinic keratoses or de novo. Erythematous scaly patch with sharp margins, 1 cm or more.

Develops central ulcer surrounding erythema.

Usually on hands or head, areas exposed to UV radiation. Less common than basal cell carcinoma, but grows rapidly

Malignant Skin Lesions

Malignant Melanoma & Metastatic Malignant Melanoma

Potentially lethal lesions that are the malignant transformation of melanocytes. May arise from preexisting nevus or de novo.

Usually brown; can be tan, black, pink-red, purple, or mixed pigmentation. Often irregular or notched borders. May have scaling, flacking, oozing texture.

Common locations: trunk and back; legs in women; and palms, soles of feet, and nails in Blacks.

Risk factors are UV radiation from sun exposure and indoor tanning and family Hx. Rates are increasing in White meant over 55 years old and White women of all ages.

Melanoma is the most common cancer in women ages 25-29 years old and ins most common (after breast cancer) in women ages 30-34 years.

Abnormal Conditions of Hair

AIDS-related Kaposi Sarcoma: Patch Stage

Kaposi sarcoma (KS) is a vascular tumor and is the most common tumor in HIV-infected persons. Considered an AIDS-defining illness, KS can occur at any stage of HIV infection.

Multiple patch-stage early lesions are faint pink on the temple and beard area. They could easily be mistaken for bruises or nevi or be ignored.

Abnormal Conditions of Hair

Toxic Alopecia

Patchy, asymmetric balding that accompanies severe illness or use of chemotherapy in which growing hearts are lost and resting hairs are spared. Regrowth occurs after illness or discontinuation of toxin

Abnormal Conditions of Hair

Tinea Capitis (Scalp Ringworm)

Rounded, patchy hair loss on scalp, leaving broken-off hairs, pustules, and scales on skin.

Caused by fungal infection; lesions may fluoresce blue-green under Wood's light.

Usually seen in children and frames; highly contagious; may be transmitted by another person, by domestic animals or from soil

Abnormal Conditions of Hair

Alopecia Areata

Sudden appearance of sharply circumscribed, round or oval balding patch, usually with smooth, soft hairless skin underneath.

Cause UKN; when limited to a few patches, personal usually has complete regrowth

Abnormal Conditions of Hair

Traumatic Alopecia: Traction Alopecia

Linear or oval patch of hair loss along hair line, a part, or scattered distribution.

Caused by train from hair rollers, tight braiding, tight ponytail, barrettes.

In black girls up to 15 years of age, hair care practices or cornrows and using chemical relaxers are associated with traction alopecia, perhaps because cornrows pull the hair at the roots and chemical relaxers weak hate strength of the hair shaft

Abnormal Conditions of Hair

Seborrheic Dermatitis (Cradle Cap)

Thick, yellow-to-white, greasy, adherent sales with mild erythema on scalp and forehead; very common in early infancy.

Resembles eczema lesions, except that cradle cap is distinguished by absence of pruritus, presence of "greasy" yellow-pink lesions, and negative family Hx of allergy

Abnormal Conditions of Hair

Folliculitis ("Razor Bumps")

Superficial inflammatory infection of hair follicles. Multiple pustules, "whiteheads," with hard visible at venter and erythematous base.

Usually involves face and neck and is common in Black men (45-85% prevalence) and Hispanic men.

Occurs after shaving when growing out hairs curl in on themselves and pierce the skin, making a foreign body inflammatory reaction.

Abnormal Conditions of Hair

Trichotillomania

Traumatic self-induced hair loss usually the result of compulsive twisting or plucking. Forms irregularly shaped patch, with broken-off, stub like hairs of varying lengths, person is never completely bald.

Occurs as child rubs or twists area absently while falling asleep, reading, or watching TV.

In adults it can be a serious problem and is usually a sign of a personality disorder

Abnormal Conditions of Hair

Hirsutism

Excess body hair in females forming a male sexual pattern (upper lip, face, chest, abdomen, arms, legs); caused by endocrine for metabolic dysfunction, or occasionally is idiopathic

Abnormal Conditions of Hair

Furuncle and Abscess

Red, swollen, hard, tender, pus-filled lesion caused by acute localized bacterial (usually staphylococcal) infection; usually on back of neck, buttocks, occasionally on wrists or ankles.

Furuncles are caused by infected hair follicles, whereas abscesses are caused by traumatic introduction of bacteria into skin. Abscess are significantly larger and deeper and furuncles

Abnormal Conditions of Nails

Scabies

Intensely pruritic contagion caused by the scabies mite. Mites form a linear or curved elevated burrow on the fingers, web spaces of hands, and wrists.

Other family members are usually infected. The patient cannot stop scratching.

Abnormal Conditions of Nails

Paronychia

Red, swollen, tener inflammation of the nail folds. Acute paronychia is usually a bacteria infection with push in the proximal nail fold, pain and throbbing.

Chronic paronychia is most often fungal infection from a break in the cuticle in those who perform "wet" work

Abnormal Conditions of Nails

Beau Line

Transverse furrow or groove. A depression across the nail that extends down to the nail bed. Occurs with any trauma that temporarily impairs nail formation such as acute illness, toxic reaction, or local trauma. Dent appears first at cuticle and moves forward as the nail grows.

Abnormal Conditions of Nails

Onychomycosis

This is a slow, persistent fungal infection of the fingernails and more often toenails, common in older adults.

Fungus causes change in color (green where nail plate separated from bed0, texture, and thickness, with nail crumbling or breaking and loosening of nail plate, usually beginning at the distal edge and progressing proximally

Abnormal Conditions of Nails

Splinter Hemorrhages

Red-brown linear streaks from damage to nail bed capillaries. They occurs with systemic diseases (vasculitis) and with trauma or sports-related injuries (soccer)

Abnormal Conditions of Nails

Late Clubbing

Inner edge of nail elevates; nail bed angle is greater than 180 degrees. Distal phalanx looks rounder, wider, and shiny.

Clubbing may result from increased platelet-dereived growth factor.

Diseases that disrupt normal pulmonary circulation (chronicling inflammation, bronchial tumors, heart defect with right to left shunts) cause fragmented platelets to become trapped in the fingertip vasculature, releasing platelet-derived growth factor and promoting growth of the vessels.

Clubbing usually develops slow avery years if the primary disease is treated, clubbing can be reversed

Abnormal Conditions of Nails

Pitting

Sharply defined putting and crumbling of nails with distal detachment often occurs with psoriasis

Abnormal Conditions of Nails

Habit-Tic Dystrophy

Depression down middle of mail or multiple horizontal ridges, caused by continuous picking of cuticle by another finger of same hand, which causes injury to nail based and nail matrix