2 - CUTANEOUS SiGNS AND DIAGNOSIS

Question 1

original lesions are known as the

Answer 1

primary lesions

Question 2

primary lesions continue to full development or be modified by regression, trauma, or other extraneous factorsand they are called

Answer 2

Secondary lesions

Question 3

Enumerate examples of primary lesions

Answer 3

• macules (or patches),
• papules (or plaques),
• nodules,
• tumors,
• wheals,
• vesicles,
• bullae, and
• pustules.

Question 4

are variously sized, circumscribed changes in skin color, without elevation or depression (nonpalpable)

Answer 4

Macules (Maculae, Spots)

They may be circular, oval, or irregular and may be distinct in outline or may fade into the surrounding skin. Macules may constitute the whole lesion or part of the eruption or may be merely an early phase. If the lesions become slightly raised, they are then designated papules or, in some cases, morbilliform eruptions.

Question 5

large macule, 1 cm or greater in diameter, as may be seen in nevus flammeus or vitiligo.

Answer 5

patch

Question 6

circumscribed, solid elevations with no visible fluid, varying in size from a pinhead to 1 cm

Answer 6

Papules

They may be acuminate, rounded, conical, flat topped, or umbilicated and may appear white (as in milium), red (eczema), yellowish (xanthoma), or black (melanoma).

Question 7

If capped by scales, papules are known as squamous papules, and the eruption is called

Answer 7

papulosquamous

Question 8

The term “maculopapular” should not be used. There is no such thing as a “maculopapule,” although there may be both macules and papules in an eruption. Typically, such eruptions are called

Answer 8

morbilliform

Question 9

broad papule (or confluence of papules), 1 cm or more in diameter

Answer 9

plaque

It is generally flat but may be centrally depressed.

Question 10

morphologically similar to papules but are larger than 1 cm in diameter.

Answer 10

Nodules

Nodules most frequently are centered in the dermis or subcutaneous fat.

Question 11

soft or firm, freely movable or fixed masses of various sizes and shapes, but usually are greater than 2 cm in diameter

Answer 11

Tumors

They may be elevated or deep seated and in some cases are pedunculated (neurofibromas). Tumors have a tendency to be rounded. Their consistency depends on the constituents of the lesion. Some tumors remain stationary indefinitely, whereas others increase in size or break down.

Question 12

evanescent, edematous, plateaulike elevations of various sizes

Answer 12

Wheals (Hives)

They are usually oval or of arcuate contours, pink o red, and surrounded by a “flare” of macular erythema. Wheals may be discrete or may coalesce. These lesions often develop quickly (minutes to hours). Because the wheal is the prototypic lesion of urticaria, diseases in which wheals are prominent are frequently described as “urticarial” (e.g., urticarial vasculitis). Dermatographism, or pressure-induced whealing, may be evident.

Question 13

circumscribed, fluid-containing elevations 1–10 mm in size

Answer 13

Vesicles

They may be clear from serous exudate or red from serum mixed with blood. The apex may be rounded, acuminate, or umbilicated, as in eczema herpeticum. Vesicles may be discrete, irregularly scattered, grouped (e.g., herpes zoster), or linear, as in allergic contact dermatitis from urushiol (poison ivy/oak). Vesicles may arise directly or from a macule or papule and generally lose their identity in a short time. They may break spontaneously or develop into bullae through coalescence or enlargement. The inflammatory process may lead to pustule formation. When the contents are of a seropurulent character, the lesions are known as vesicopustules. Vesicles have either a single cavity (unilocular) or several compartments (multilocular).

Question 14

rounded or irregularly shaped blisters containing serous or serosanguineous fluid. They differ from vesicles only in size, being larger than 1 cm

Answer 14

Bullae

They are usually unilocular but may be multilocular. Bullae may be located superficially in the epidermis, so their walls are flaccid and thin and subject to rupture spontaneously or from slight injury. After rupture, remnants of the thin walls may persist and, together with the exudate, may dry to form a thin crust. Alternatively the broken bleb may leave a raw and moist base, which may be covered with seropurulent or purulent exudate. Less frequently, irregular vegetations may appear on the base (as in pemphigus vegetans). When subepidermal, the bullae are tense, do not rupture easily, and are often present when the patient is examined.

Question 15

Define Nikolsky Sign

Answer 15

diagnostic maneuver of putting lateral pressure on unblistered skin in a patient with a bullous eruption; a positive result occurs when the epithelium shears off.

Question 16

Define Asboe-Hansen sign

Answer 16

extension of a blister to adjacent, unblistered skin when pressure is put on the top of the blister.

Question 17

small elevations of the skin containing purulent material, usually necrotic inflammatory cells

Answer 17

Pustules

They are similar to vesicles in shape and usually have an inflammatory areola. Pustules are usually white or yellow centrally but have a red tinge if they also contain blood. They may originate as pustules or may develop from papules or vesicles, passing through transitory early stages, during which they are known as papulopustules or vesicopustules.

Question 18

Enumerate the secondary lesions

Answer 18

• scales,
• crusts,
• erosions,
• ulcers,
• fissures, and
• scars

Question 19

dry or greasy, laminated masses of keratin

Answer 19

Scales

The body ordinarily is constantly shedding imperceptible tiny, thin fragments of stratum corneum. When the formation of epidermal cells is rapid or the process of normal keratinization is disturbed, pathologic exfoliation results, producing scales. These scales vary in size; some are fine, delicate, and branny, as in tinea versicolor, whereas others are coarser, as in eczema and ichthyosis, and still others are stratified, as in psoriasis. Scales vary in color from white-gray to yellow or brown from the admixture of dirt or melanin. Occasionally, they have a silvery sheen from trapping of air between their layers; these are micaceous scales, characteristic of psoriasis. When scaling occurs it usually suggests a pathologic process in the epidermis, and parakeratosis is often present histologically.

Question 20

dried serum, pus, or blood, usually mixed with epithelial and sometimes bacterial debris.

Answer 20

Crusts (Scabs)

When crusts become detached, the base may be dry or red and moist.

Question 21

punctate or linear abrasion produced by mechanical means, usually involving only the epidermis but sometimes reaching the papillary layer of the dermis.

Answer 21

Excoriations and Abrasions (Scratch Marks)

Excoriations are caused by scratching with the fingernails in an effort to relieve itching. If the skin damage is the result of mechanical trauma or constant friction, the term “abrasion” may be used.

Frequently, there is an inflammatory areola around the excoriation or a covering of yellowish dried serum or red dried blood. Excoriations may provide access for pyogenic microorganisms and he formation of crusts, pustules, or cellulitis, occasionally associated with enlargement of the neighboring lymphatic glands. In general, the longer and deeper the excoriations, the more severe is the pruritus that provoked them. Lichen planus is an exception, however, in which pruritus is severe, but excoriations are rare.

Question 22

linear cleft through the epidermis or into the dermis.

Answer 22

Fissures (Cracks, Clefts)

These lesions may be single or multiple and vary from microscopic to several centimeters in length with sharply defined margins. Fissures may be dry or moist, red, straight, curved, irregular, or branching. They occur most often when the skin is thickened and inelastic from inflammation and dryness, especially in regions subjected to frequent movement. Such areas are the tips and flexural creases of the thumbs, fingers, and palms; the edges of the heels; the clefts between the fingers and toes; at the angles of the mouth; the lips; and around the nares, auricles, and anus. When the skin is dry, exposure to cold, wind, water, and cleaning products (soap, detergents) may produce a stinging, burning sensation, indicating microscopic fissuring is present. This may be referred to as chapping, as in “chapped lips.” When fissuring is present, pain is often produced by movement of the parts, which opens or deepens the fissures or forms new ones.

Question 23

Loss of all or portions of the epidermis alone, as in impetigo

Answer 23

Erosions

It may or may not become crusted, but it heals without a scar.

Question 24

rounded or irregularly shaped excavations that result from complete loss of the epidermis plus some portion of the dermis.

Answer 24

Ulcers

They vary in diameter from a few millimeters to several centimeters (Fig. 2.7). Ulcers may be shallow, involving little beyond the epidermis, as in dystrophic epidermolysis bullosa, the base being formed by the papillary layer, or they may extend deeply into the dermis, subcutaneous tissues, or deeper, as with leg ulcers. Ulcers heal with scarring.

Question 25

composed of new connective tissue that has replaced lost substance in the dermis or deeper parts resulting from injury or disease, as part of the normal reparative process.

Answer 25

Scars

Their size and shape are determined by the form of the previous destruction. Scarring is characteristic of certain inflammatory processes and is therefore of diagnostic value. The pattern of scarring may be characteristic of a particular disease. Lichen planus and discoid lupus erythematosus, for example, have inflammation that is in relatively the same area anatomically, yet discoid lupus characteristically causes scarring as it resolves, whereas lichen planus rarely results in scarring of the skin.

Both processes, however, cause scarring of the hair follicles when occurring on the scalp. Scars may be thin and atrophic, or the fibrous elements may develop into neoplastic overgrowths, as in hypertrophic scars or keloids. Some individuals and some areas of the body, especially the anterior chest and upper back, are especially prone to hypertrophic scarring. Scars first tend to be pink or violaceous, later becoming white, glistening, and, rarely, hyperpigmented. Scars are persistent but usually become softer, less elevated, and less noticeable over years.

Question 26

Abnormalities of melanin pig mentation (e.g., vitiligo, melasma) are more clearly visible under

Answer 26

ultraviolet (UV) light

Question 27

Pigmented lesions, especially in infants, should be rubbed in an attempt to elicit ______ (whealing), as seen in ______

Answer 27

Darier sign

urticaria pigmentosa

Question 28

Lesions may appear over the entire body or may follow the lines of ______ (pityriasis rosea), _______ (herpes zoster), or lines of _______ (epidermal nevi)

Answer 28

Lesions may appear over the entire body or may follow the lines of cleavage (pityriasis rosea), dermatomes (herpes zoster), or lines of Blaschko (epidermal nevi)

Question 29

Small lesions arranged around a large one are said to be in a _______arrangement.

Answer 29

corymbose (corymbiform)

Question 30

Concentric annular lesions are typical of borderline Hansen disease and erythema multiforme. These are sometimes said to be in a _____ pattern, referring to the tricolor cockade hats worn by French revolutionists.

Answer 30

“cockade”

Question 31

Grouped lesions of various sizes may be called

Answer 31

agminated

Question 32

The _____ effect modifies the color of skin and of lesions by the selective scattering of light waves of different wavelengths.

Answer 32

Tyndall effect

The blue nevus and mongolian spots are examples of this light dispersion effect, in which brown melanin in the dermis appears blue-gray.

Question 33

The color of lesions may be valuable as a diagnostic factor. Dermatologists should be aware that there are many shades of pink, red, and purple, each of which tends to suggest a diagnosis or disease group.

Interface reactions such as lichen planus or lupus erythematosus are described as ______. Lipid-containing lesions are ____, as in xanthomas (Fig. 2.10) or steatocystoma multiplex. The _____color of pityriasis rubra pilaris is characteristic.

Answer 33

The color of lesions may be valuable as a diagnostic factor. Dermatologists should be aware that there are many shades of pink, red, and purple, each of which tends to suggest a diagnosis or disease group. Interface reactions such as lichen planus or lupus erythematosus are described as violaceous. Lipid-containing lesions are yellow, as in xanthomas (Fig. 2.10) or steatocystoma multiplex. The orange-red (salmon) color of pityriasis rubra pilaris is characteristic.

Question 34

Patches lighter in color than the normal skin may be completely depigmented or may have lost only part of their pigment (hypopigmented). This is an important distinction because certain conditions are or may be hypopigmented, such as ________

Answer 34

• tinea versicolor,
• Hansen disease,
• ash-leaf macules of tuberous sclerosis,
• hypomelanosis of Ito,
• seborrheic dermatitis, and
• idiopathic guttate hypomelanosis.

Question 35

Give examples of diseases with true depigmentation

Answer 35

• vitiligo,
• nevus depigmentosus,
• halo nevus,
• scleroderma,
• morphea, or
• lichen sclerosus.

Question 36

Give examples of conditions wih epidermal hyperpigmentation

Answer 36

• nevi,
• melanoma,
• café au lait spots,
• melasma, and
• lentigines.

Question 37

Dermal pigmentation occurs subsequent to many inflammatory conditions (_______) or from deposition of metals, medications, medication-melanin complexes, or degenerated dermal material (_____)

Answer 37

postinflammatory hyperpigmentation

ochronosis

Question 38

Discoid lupus, for example, causes _______ with characteristic dyspigmentation.

Answer 38

scarring alopecia