Skin Diseases

Question 1

What skin disease is characterized by a fast turnover of epidermal cells that does not allow for adequate differentiation of cells? How does it present clinically?

Answer 1

• Psoriasis
• Patient presents with patches of thick, red skin with silvery-white scales that itch or burn, typically on the elbows, knees, scalp, trunk, palms, and soles of the feet.
• Dry, cracked skin that itches or bleeds.

Question 1

Which autoimmune disease affects elder patients presenting with bullae?

Answer 1

• Bullous pemphigoid
• An autoimmune blistering disease, typically affects older patients.
• Autoantibodies form to antigens directly beneath the basal layer of the epidermis at the dermo-epidermal junction.
• Clinically, presents as tense bullae on an erythema base on the skin.

Question 2

Skin lesion that is flat, smaller than 1 cm, not filled with any material.

Coul be a freckle too.

Answer 2

Macule

Question 3

Similar to macule, only equal to or larger than 1 cm.

Answer 3

Patch

Question 4

A lesion that is raised but may have a depressed center portion. Is superficial with a solid content and is smaller than 1 cm.

Answer 4

Papule

Question 5

Lesion that is raised but can be also depressed, with a solid content, is well-defined measuring larger or equal to 1 cm. Can sometimes form out of coalesced papules.

Answer 5

Plaque

Question 6

A raised lesion measuring more or equal to 1 cm with a content that can be either solid or fluid. In contrast with a papule - it is larger and originates deeper.

Answer 6

Nodule

Question 7

A raised lesion sized less than 1 cm. Of dome or flaccid shape with liquid content that can be clear, serous or hemorrhagic. Often with very thin roof and arises from cleavage at superficial level.

Answer 7

Vesicle

Question 8

A raised lesion larger or equal 1 cm with a clear, serous or hemorrhagic fluid content. Can be tense or flaccid too.

Answer 8

Bulla (pl. bullae)

Question 9

A raised lesion of less than one cm, with a purulent content, of superficial depth.

Answer 9

Pustule

Question 10

Depressed lesion of ANY size with no content. It is a focal loss of epidermal tissue with no loss of dermis. Heals with no scarring. It is seen with some inflammatory diseases. Can be secondary to bulla.

Answer 10

Erosion

Question 11

A depressed lesion of any size with no content. There is a loss of epidermis and at least a portion of dermis sometimes hypodermis - deeper than just an erosion. Leaves a scar. Can be secondary.

Answer 11

Ulcer

Question 12

Circumscribed (within limits) of irregular shape and size. Transient (short lasting) <48h. Result of cutaneous edema. Often pale, sometimes red. Often accompanied by itching. Involved in urticaria (hives).

Answer 12

Wheal

Question 13

Can be of multiple colors with size at least 3 mm.

Answer 13

Ecchymosis (aka bruise)

Question 14

Of deep red/reddish/purple color. Small, 1-3 mm size. Round and flat. Sometimes found on mucous membranes.

Answer 14

Petechiae

Question 15

Of deep red/reddish/purple color. Larger than petechiae, irregularly shaped and sometimes palpable.

Answer 15

Purpura

Question 16

Which three primary lesions are caused by blood leaving vessels and do not blanch when pressure is applied on them?

Answer 16

Ecchymosis, petechiae and purpura.

Question 17

A secondary lesion due to stratum corneum cells accumulation. It is characterized by flakes that can be large or tiny and adherend or loose.

Answer 17

Scale

Question 18

A dried exudate (mass) of body fluids. Can be yellow or red from either serous fluid or blood.

Answer 18

Crust

Question 19

A distinctive thickening of the skin with skin-fold markings. A result of chronic scratching/rubbing.

Answer 19

Lichenification

Question 20

Bulla and nodule can turn into what secondary lesions?

Answer 20

Erosion and ulcer.
Bulla becomes unroofed and nodule ulcerates.

Question 21

Erosion that is linear and angular. May be covered with crust. Is caused by scratching.

Answer 21

Excoriation

Question 22

A lesion on skin caused by past trauma or inflammation. May be erythematous, hypopigmented or hyperpigmented. Hair follicles may be destroyed.

Answer 22

Scar

Question 23

An acquired loss of substance ex. loss of epidermis. From shiny quality to cigarette paper wrinkling. Can cause depression after loss in subcutaneous tissue or dermis. Underlying vessels may be revealed.

Answer 23

Atrophy

Question 24

A linear lesion (crack). May be on skin or mucosa. Resulting from an excessive tension or decreased elasticity of the tissue.

Answer 24

Fissure

Question 25

What is dermatitis?

Answer 25

A broad term describing conditions causing skin inflammation.

Question 26

What are the three signs of acute dermatitis? What are signs and symptoms associated with it?

Answer 26

Pruritus Erythema Vesiculation Symptoms -Burning -Stinging -Itching ** Signs ** -Sharply demarcated plaques -Superficial edema, fluid filled blisters or crusting erosions -Might see varying patterns

Question 27

What are the three signs of chronic dermatitis? What are signs and symptoms associated with it?

Answer 27

Pruritus Xerosis Lichenification **Symptoms** -Itching -Dryness -Peeling **Signs** -Plaques, lichenification, dry/scaling, chapping -Erythema, fissures, crusting, thickening

Question 28

What does demarcation mean in dermatology?

Answer 28

Abrupt transitions between areas of darker and lighter pigmentation

Question 29

What is a Congenital Melanocytic Nevus (CMN)? What are its characteristics?

Answer 29

It is a large congenital nevi that has an increased risk of becoming a melanoma. Comes in any size <1.5 cm to even >20 cm. It appears as a raised lesion that often darkens over the time, commonly presents with hypertrichosis (excessive hair growth). Biopsy or surgical intervention is recommended if large.

Question 30

What are three commonly acquired nevi?

Answer 30

Question 31

Which nevi is located between epidermis and dermis layers(does not go below epidermis)?

Answer 31

Junctional Nevi.

Question 32

Which nevi are found in dermis layer? What cells do they originate from? What color are they?

Answer 32

Dermal nevi, brown raised lesions that develop from melanocytes of dermis.

Question 33

What features does compound nevi have?

Answer 33

Encompassing both junctional and intradermal nevi. Typically raised and uniform in color, light brown and brown.

Question 34

What kind of lesion is this?

Answer 34

Nevus spilus. Presents from the first year of life. Often hairless brown patch with speckled brown/black macules/papules. Very rare transformation into melanoma.

Question 35

What kind of lesion is this?

Answer 35

Becker's nevus. Light brown, slightly elevated, common hair growth, not malignant and its treatment is cosmetic.

Question 36

What kind of lesion is this?

Answer 36

Halo nevus. Develops characteristic white border around. Most common in children. Consider biopsy if atypical of evolving.

Question 37

What kind of lesion is this?

Answer 37

Spitz nevus. Rapidly growing, solitary, pink-red papuloNodule. Usually appears suddenly. Can be difficult to distinguish from melanoma - histology exam recommended. Complete excision often recommended, however often unnecessary.

Question 38

What kind of lesion is this?

Answer 38

Blue nevus. A form of papule or a macule smaller than 1cm. Grey/black or blue appearance makes it hard to distinguish from melanoma.

Question 39

What kind of lesion is this?

Answer 39

Actinic Keratosis. Considered pre-cancerous. Pink or erythematous or thin plaques with rough gritty scale, may be tender. Common in sun exposed areas and often on males. More common with age, fair skin (type I and II) and immunosuppression.

Question 40

What is the progression of AK disease?

Answer 40

1. Photodamage 2. Early AK 3. Full AK 4. SCC (squamous cell carcinoma)

Question 41

What are the main treatments of actinic keratosis lesion?

Answer 41

Treatment is selected based on number of lesions, their location and thickness. * Cryotherapy * Efudex (5-fluorouracil) - chemotherapy cream, 2-3 weeks regime * Aldara (Imiquimod) - immune response modifier * Photodynamic therapy PDT * chemical peels

Question 42

What is SCCIS? What is it's other name?

Answer 42

Squamous Cell Carcinoma In Situ. Bowen's disease.

Question 43

What is this lesion? It is similar to common dermatitis conditions.

Answer 43

Squamous cell carcinoma in situ. Similar to eczema or psoriasis. It is an erythematous, well demarcated, hyperkeratotic patch or plaque.

Question 44

What are common treatments of Bowen's disease?

Answer 44

Surgical excision has the highest cure rate, should be performed when **invasive SCC cannot be excluded**. ED & C (electrodessication and curettage) cryotherapy topical 5-FU Imiquimod PDT

Question 45

What kind of lesion is this? What are risk factors of developing it?

Answer 45

Squamous cell carcinoma. It is an erythematous, scaly papulonodule/plaque with adherent white scale, can appear eroded. It is a common type of lesion. Risk factors of this lesion: * sun exposure * male gender * older age * fair skin * genetic syndromes * immunosuppression * HPV * radiation * arsenic Possibility to metastasize (~3-4%)-increased risk if immunosuppressed, located on lip/ear, larger size, poorly differentiated.

Question 46

What are treatments of SCC?

Answer 46

* Wide local excision (WLE) * Mohs surgery (the surgeon removes thin layers of skin one layer at a time and examines each layer under a microscope to determine if any cancer remains.) * ED & C * radiation if unable to perform surgery Wound may be closed with advancement flaps or skin grafts depending on the location and size of defect

Question 47

What kind of lesion is this?

Answer 47

Basal cell carcinoma. MOST common skin cancer and most common cancer in humans. Pink pearly papule with a central depression, telangiectasias (arborizing vessels) and rolled borders. If left untreated they become locally destructive but they are usually slow growing and RARELY metastasize.

Question 48

What are treatments for BCC?

Answer 48

* Treatment depends on the subtype and location * WLE * Mohs surgery * ED & C * radiation * Topical 5-FU and Imiquimod used for superficial BCC * Vismodegib (inoperable or metastatic BCC)

Question 49

What are these lesions?

Answer 49

Seborrheic Keratosis (SK)

Question 50

How to determine SK from Melanoma?

Answer 50

* Smooth SK’s can mimic a melanoma * Different surface features of the two lesions * Melanomas are usually smooth with a variation in height, color and density * Melanomas do not have cysts on their surfaces. SK’s are uniform in their appearance (dermoscopy). * When in doubt, biopsy before treating it | right SK left melanoma

Question 51

What are the common treatments for SK?

Answer 51

* Watchful waiting (monitor the lesions) * Treat if cosmetic concern or if lesion(s) inflamed * Treat with cryotherapy (liquid nitrogen, LN2) * Can result in hypopigmentation or post-inflammatory erythema * Scab forms and lesion falls off with the scab * Curettage (gently scrape off with a curette) * Above treatments should leave little to no scarring * Shave removal

Question 52

What are these lesions?

Answer 52

Dermatosis Papulosa Nigra. SK type, raised, dome shaped papules.

Question 53

What does pedunculated mean?

Answer 53

Having, growing on, or being attached by a peduncle.

Question 54

A benign proliferation of dilated vessels. ## Footnote What are the treatment for this disease?

Answer 54

**Angioma**. Benign proliferation of dilated vessels; well-defined red, purple or black papules or macules Asymptomatic; increasing number with age Location: Typically on the trunk (cherry) or face (spider, venous lake). ## Footnote Continue to monitor. Can be shaved or curetted, electrocautery and pulse dye laser can be used. DO NOT FREEZE the blood vessels.

Question 55

Compare 3 characteristics of how to distinguish milium from syringoma.

Answer 55

Milium vs Syringoma white vs flesh colored smaller vs larger dome-shaped vs flat-topped

Question 56

What are syringomas?

Answer 56

Small sweat duct tumors without malignant potential Small, flat-topped skin colored papules usually found on the lower eyelid Treatment: Electrodessication, snip excision, curettage.

Question 57

Answer 57

**Sebaceous Gland Hyperplasia** (SGH) * Small benign tumors that are enlarged sebaceous glands * Well-defined yellow papules that appear waxy and have a central umbilication/depression. Asymptomatic * Mainly found on the forehead, cheeks and nose (T-zone) * SGH with telangiectasia can resemble BCC. Usually SGH are soft and a BCC feels a little firmer. Gently squeezing the SGH will sometimes elicit a small globule of sebum * Etiology is unknown

Question 58

What kind of lesion is this? Describe it. What is the treatment?

Answer 58

**Lipoma** Benign subcutaneous tumor Present as soft, round, mobile lesions superficial to the muscle layer Commonly on the neck and trunk Can occur on extremities and scalp Composed of fat cells that clump together Can contain a fibrous framework (i.e. capsule) Removed by excision (derm vs. gen surg) Easier when smaller (done in office setting) Larger lipomas can create pain and compression-type symptoms – often need removal in the OR Removal not covered by insurance unless causing a problem

Question 59

What kind of lesion is this? Describe it. What is the treatment?

Answer 59

Epidermal Cysts * A.k.a. sebaceous cyst or epidermal inclusion cyst (EIC). ○ Develop in the follicular infundibulum ○ There are other types of cysts too * Can occur almost anywhere on the body ○ Most common: Face and trunk * Firm, elevated dermal lesion. Smooth and round. Mobile. Size can vary. * They usually have a narrow opening (punctum—black dot - think cyst) to the surface of the skin and the opening is keratin filled * Cysts can rupture into the dermis and an inflammatory reaction occurs. **Treatment** * Incise and drain inflamed, fluctuant cysts ○ Inside: foul-smelling, cheesy material * Excise larger, bothersome cysts * Pilar cyst: like epidermal cyst but on the scalp; doesn’t have a punctum

Question 60

What kind of lesion is this? Describe it. What is the treatment?

Answer 60

**Pyogenic Granuloma** (pyo-pus, genic-producing). * This benign vascular lesion grows/develops rapidly, but is painless * Typically a solitary nodule or papule that can bleed easily * Most common in kids and young adults * Location: fingers/toes, head/neck, trunk, lips, mouth (skin and mucous membranes) ○ Oral lesions seen more in women, especially during pregnancy **Treatment** *surgical or shave excision and curettage. Can resolve on their own, but do so slowly Can look like a type of melanoma. Biopsy!

Question 61

What kind of lesion is this? Describe it. What is the treatment?

Answer 61

**Keratoacanthoma (KA)** * Common “benign” epithelial tumor * Pink papule or nodule that develops an umbilicated, keratinous core * Most common sites: hands and arms (sun-exposed areas * Koebner Phenomenon * Difficult to distinguish from an SCC, so treated as an SCC. * Grow rapidly over a few weeks (helps to distinguish form other malignant types - BCC or SCC) **Treatment** Surgical excision

Question 62

What kind of skin lesion is this? What its etiology and treatment?

Answer 62

**Dermatofibroma** * Firm pink to brown papules that tend to have a dimple effect if you squeeze them (may need magnification to **see dimple**) * Etiology: usually a result of an inflammatory reaction to a bug bite or trauma * Commonly found on the lower legs, buttocks and upper arms **Treatment** * Monitor * Excision * Shave/punch * LN2

Question 63

What is the name for skin tags? What is the treatment?

Answer 63

**Acrochordons** Acro-top, chorde-string Skin-colored to brown pedunculated papules that range from tiny to 1cm in size (texture: fleshy) **Treatment:** Snip excision Cryotherapy

Question 64

What is the name of this lesion? What is the treatment?

Answer 64

**Cutaneous Horns** Hard keratin projection Occur more in sun-exposed areas **Differential diagnosis** Hypertrophic actinic keratosis Wart Squamous cell carcinoma 50% are benign, 50% are pre-malignant or malignant **Treatment:** Biopsy, concern for an SCC at the base of the lesion

Question 65

What is the name of this lesion? What is the treatment?

Answer 65

**Solar Lentigines** Solar lentigines Flat, brown macules 4th to 5th decade of life Gradually appear in sun-exposed areas Do not fade with cessation of sun exposure

Question 66

What does it indicate when a lesion does not blanch?

Answer 66

Blanching is caused by a temporary blood obstruction to the area. When applied pressure to the surface of the skin does not cause blanching, it means that there is a bleeding under the surface of the skin.