Skin disorders

I & II

Laurie C. Clark, D.O.

October 15, 2013

Objectives
1)To be able to describe various skin lesions using
appropriate terminology
2) To be able to identify various dermatological
conditions
based on clinical findings and
appearance of lesions
3) To be able to discuss basic treatment concepts
of
various dermatological conditions

Dermatologic macroscopic terms

(from first aid)
Macule: flat discoloration < 1 cm
Patch: Macule > 1 cm
Papule: Elevated skin lesion < 1 cm
Plaque: Papule > 1 cm
Vesicle: Small fluid-containing blister

Dermatologic macroscopic terms

(from first aid)
Wheal: Transient vesicle
Bulla: Large fluid-containing blister
Keloid: Irregular, raised lesion resulting from scar
tissue
hypertrophy
Pustule: Blister containing pus
Crust: Dried exudates from a vesicle, bulla, or
pustule

Pigmented Lesions
Common benign pigmented lesions:

1)melanocytic nevi (normal moles)

2)freckles and lentigines (flat brown spots that
gradually appear in sun-exposed areas)
3)seborrheic keratosis

Question
A 70 year-old male presents to the
office with chief complaint of a large
lesion on his face. It has been present
for about a year, and his wife has
asked him to have it checked out. It
does not itch, bleed or ulcerate. It has
irregular borders, but no color
variation. It has a stuck-on
appearance.

This lesion most likely represents which

of the following?

1. Malignant
melanoma
2. Seborrheic
keratosis*
3. Atopic
dermatitis
4. Psoriasis
5. Actinic keratosis

20%

20%

20%

20%

20%

Seborrheic keratosis
Benign plaques
Beige to brown; can be black
Velvety or warty appearance
stuck on appearance
Very common
No treatment necessary

Scaling Lesions
Common scaling lesions:
1) Atopic dermatitis (eczema)
2) Lichen simplex chronicus (self perpetuating scratchitch cycle)
3) Psoriasis
4) Pityriasis Rosea
5) Seborrheic dermatitis and dandruf
6) Fungal infections

Tinea
Tinea
Tinea
Tinea

corporis (body; ringworm)

cruris (groin; jock itch)
pedis (feet; athletes foot)
versicolor (usually on trunk)

question
A 3 year-old child is brought to the clinic
with chief complaint of pruritic, scaling,
erythematous rash on bilateral cheeks,
popliteal and antecubital folds. It seems to
be worse in the winter.

Which of the following is the

most likely diagnosis?
1. Atopic
dermatitis*
2. Psoriasis
3. Seborrheic
dermatitis
4. Tinea corporis
5. Herpes zoster

20%

20%

20%

20%

20%

Atopic dermatitis
Pruritic and exudative
Most common locations are face, neck, upper trunk and
antecubital and popliteal folds
Personal or family history of allergies and/or asthma
Onset in childhood
Treatment: Avoidance of drying or irritating skin factors,
emollients after bathing, and topical corticosteroids as
needed.

Vesicular Lesions
Common vesicular lesions:
1) Herpes simplex (fever blister)
2) Herpes zoster (shingles)
3) Dyshidrosis (or, pompholyx)

question
A 55 year-old male presents to the clinic
with severe pain on left side of trunk which
was followed 48 hours later by eruption of
a rash. Physical exam reveals grouped
vesicles distributed on left trunk. Patient
denies exposure to poison oak or poison
ivy. Which of the following is the most
likely diagnosis for this patient?

Which of the following is the most likely

diagnosis

1. Tinea corporis
2. Herpes simplex
3. Impetigo
4. Herpes zoster*
5. Allergic contact
dermatitis

20%

20%

20%

20%

20%

Herpes zoster (shingles)

Pain along a dermatome
Unilateral (occassional few vesicles may appear outside of
dermatome
Usually on face or trunk
Treatment: oral antiviral medication, systemic corticosteroids,
various treatments for postherpetic neuralgia

Recommend vaccination for persons aged 60 and

older

Weeping or Crusted Lesions

Common weeping or crusted lesions:

1)Impetigo

2)Allergic contact dermatitis

question
A 3 year-old boy is brought to your
office by his mother with chief
complaint of a rash on his face which
has worsened over the last few days.
The lesion consists of honey-colored
crusted superficial erosions.

Which of the following is the most likely

finding in this pt?

1. Positive viral
culture
2. Positive fungal
culture
3. Elevated
eosinophils
4. Positive
bacterial
culture*
5. Microscopic ova

20%

20%

20%

20%

20%

impetigo
Superficial pus filled blisters that rupture easily
Macules, vesicles, pustules, bullae
Honey-colored crusted superficial erosions
Positive gram stain and bacterial culture
Treatment: topical and/or systemic antibiotics

Pustular Disorders
Common pustular disorders:

1)

Acne vulgaris

2)

Rosacea

3)

Folliculitis

4)

Milaria (heat rash)

5)

Cutaneous candidiasis

question
A 45 year-old female presents to the
office with chief complaint of chronic
erythema, pustules and papules on
her cheeks, nose and chin. She also
reports exacerbation of lesions with
spicy food, alcohol, sunlight and
exercise.

Which of the following would be the

best treatment for rosacea?
1. Topical antibiotic medication **
2. Oral antifungal medication
3. Topical antiviral medication
4. Oral antiviral medication
5. Topical steroid medication

Erythemas
Common erythemas:
1) Reactive erythemas
Urticaria and angioedema
Erythema multiforme (acute inflammatory skin disease;
symmetric erythematous lesions; history of recurrence; target
lesions with central clearing and concentric rings)
Erythema migrans (unique cutaneous eruption from early stage
of Lyme disease; gradual expansion of redness around papule
at site of bite; advancing border is red, raised and free of scale)

Erythemas (contd)

2) Infectious erythemas
Erysipelas St anthonys fire
Group A Strep
Face
Red, hot, painful
F chills

Cellulitis bacterial infection of the dermis

Question - Erysipelas
A 60 year-old female presents to the
emergency department with a
painful, circmscribed, hot,
erythematous area on her face. She
also complains of fever, chills and
feeling generally ill.

Which of the following is the best

treatment for this?
1. Incision and drainage of lesion
2. Tapered dose of oral steroids
3. Topical antibiotic ointment
4. I.V. antibiotics **
5. I.V. antifungal

erysipelas
Superficial form of cellulitis; usually on face
Caused by beta-hemolytic strep Group A

Strep =GAS
Pain, chills, fever, and systemic toxicity
Treatment: bed rest; I.V. antibiotics for first 48
hours followed by 7 day course of oral
antibiotics

Blistering Diseases
Common blistering diseases:

Pemphigus
Bullous pemphigoid
Dermatitis herpetiformis

Question - Pemphigus
A 35 year old male presents to the
clinic with recurring outbreaks of
bullae. Ulcerations of the mucous
membranes often precede the
skin lesions.

Which of the following is the most

likely diagnosis?
1. Herpes Zoster
2. Pemphigus **
3. Folliculitis
4. Erythema nodosum
5. Photodermatitis

pemphigus
Relapsing crops of bullae which are tender
and painful when rupture
Often preceded by mucous membrane lesions
Autoimmune disorder
Treatment: systemic corticosteroids, and
antibiotics if indicated

Papules
Common papule disorders:
1)Warts (verrucous papules)
2)Callousities and corns of feet or toes
3)Molluscum contagiosum

Example of papule

Question Molluscum contagiosum

A 6 year-old boy is brought to the
clinic by his mother with chief
complaint of multiple dome-shaped
waxy umbilicated papules. The child
is otherwise healthy and
asymptomatic.

Which of the following is the most

likely diagnosis?
1. Common warts
2. Scabies
3. Varicella
4. Milaria
5. Molluscum contagiosum **

Violaceous to Purple Papules and

Nodules
Common violaceous to purple papules and
nodules:
Lichen planus (inflammatory pruritic
disease of skin and mucous
membranes;pruritic, violaceous, flat-topped
papules with fine white streaks and symmetric
distribution; lacey mucosal lesions)
Kaposi Sarcoma

Question - Kaposi sarcoma **

A 35 year-old HIV positive male who
is taking immunosuppressive
medications presents to the clinic
with purple plaques and nodules
noted on his upper extremities. He
also has mild swelling and pain
associated with lesions.

Which of the following is the most

likely diagnosis?
1. Erythema nodosum
2. Scabies
3. Kaposi sarcoma **
4. Squamous cell carcinoma
5. Dermatitis medicamentosa

Kaposi sarcoma
Malignant skin lesion
Primarily seen with HIV infection
Is an AIDS-defining illness
Stopping immunosuppressive therapy may
result in improvement of skin lesion
Can also be present in lungs and GI tract

Pruritis
Common causes of pruritis:
1) Dry skin
2) Psychiatric disorders
3) Atopic dermatitis
4)
Anogenital pruritis
5) Scabies
6) Pediculosis
7) Skin lesions due to other arthropods

question
A 22 year-old woman presents to the clinic
with chief complaint of intensely pruritic
generalized rash. She is having difficulty
sleeping due to the itching. Physical exam
reveals vesicles and pustules in the web
spaces of the hands, around the wrists and
elbows, axillae and breasts. She
states that her 2 year-old son has
similar symptoms.

Which one of the following is

correct?
1. Treatment should include both topical steroids and oral
antibiotics
2. Treatment should focus on relieving pruritis while
condition clears on its own without specific treatment
3. Treatment should consist of both topical and oral
antibiotics
4. Treatment should include topical antifungal medication
5. Treatment should focus on killing mites and controlling
dermatitis **

Inflammatory Nodules
Common causes of inflammatory nodules:

1) Erythema nodosum
2) Furunculosis (boils)
3) Carbuncles (several coalescing furuncles)

Question - EN
18 year-old female presents to the clinic with chief
complaint of recent onset of painful red nodules on
the front of both legs. Her past medical history is
negative. Her only
medication is oral contraceptives.
Prior to the onset of lesions she had
a fever and malaise.

Which of the following is the most

likely diagnosis?
1. Dermatitis medicamentosa
2. Erythema multiforme
3. Furunculosis
4. Erythema nodosum **
5. Erythema migrans

Erythema nodosum
Tender, erythematous subcutaenous nodules on anterior
legs
May be preceded by fever, malaise and arthralgia
Slow regression over several weeks
Women: men ratio of 10:1
May be associated with infection or medications
May be associated with pregnancy or oral contraceptives

Erythema nodosum
Treatment:
Identify and treat underlying disorder, if
present
NSAIDs
Corticosteroids

photodermatitis
manifested as a:
phototoxicity ~ a tendency to sunburn more
easily than expected occur w/in 24hrs of sun
exposure

OR
photoallergy, a true immunologic reaction that
often presents with dermatitis
-Often drug induced: TMP-SMX, tetracyclines, hydrochlorothiazide
Photoallergic reactions, however, do not occur until one to three
days after the substance has come into contact with the body, since
they require activation of the immune system to mount the response

question
A 65 year old man presents with painful erythema and
edema of face, neck and bilateral hands. He was mowing
his lawn yesterday and did not use sunscreen. He states,
however, that he does this every weekend and has never
had a skin reaction like this before. Past medical history is
positive only for a new diagnosis of Stage I hypertension for
which he was recently started
on hydrochlorothiazide.

Which of the following is

true?
1. Antibiotics such as tetracyclines and trimethoprimsulfamethoxazole are rarely implicated in photodermatitis.
2. Contact dermatitis would not be included in the
for the above patient.

diferential

3. Lupus erythematosis would be included in the diferential for

the above patient. **
4. Application of sunscreen will always prevent photodermatitis.
5. If a patient has used a certain medication for over a month, it
should not be considered as a suspected cause for
photosensitivity.

Drug eruptions
Multiple types of drug eruptions:

1) Toxic erythema (most common; usually on trunk;

maculopapular)
2) Erythema multiforme major (target-like lesions)
3) Erythema nodosum (inflammatory cutaneous nodules
usually on extensor surfaces of legs)
4) Exfoliative dermatitis (red and scaly; entire skin surface)

Drug eruptions (contd)

5) Photosensitivity (sunburn, vescicles and papules in
photodistributed pattern; exaggerated response to UV
light)

6) Urticaria (red, itchy wheals)

7) Pityriasis rosea-like eruptions (oval, red, slightly raised

patches with central scale mainly on trunk)

question
A 20 year-old male presents to the clinic
with chief complaint of abrupt onset of
generalized, bilateral erythematous skin
rash. Three days previously he had
started a course of amoxicillin for a sinus
infection.
Past medical history is essentially
negative.

Which of the following is most

appropriate first step?
1. Topical steroid application
2. Discontinuation of antibiotic **
3. Skin biopsy
4. Complete blood count
5. Liver enzyme tests

 LOOK AT THE FOLLOWING SLIDES

DESCRIBE LESIONS
LOCATION
COLOR
TYPE OF LESION
SIZE OF LESION(S)
DISTRIBUTION

PROVIDE 3 POSSIBLE DIFFERENTIAL DIAGNOSES

26 y/o female with pruritic rash; no

meds or allergies

PITYRIASIS ROSEA
Common, mild acute inflammatory disease
Oval, fawn colored, scaly eruption
Christmas tree pattern; lesions follow cleavage lines of trunk
Herald patch precedes eruption by 1 2 weeks
Should usually get a serologic test for syphilis if any question
about diagnosis
Usually self-limiting and disappears within 6 weeks

6 month-old infant

Cutaneous candidiasis

Diaper dermatitis with superimposed

candidiasis. The skin folds are
involved and satellite lesions are
typically present at the periphery of
the involved area.

20 year-old male with sudden onset;

no meds or allergies

urticaria
Wheals (or hives) of urticaria
Itching is usually intense
Most are acute and self-limiting over 1 2 weeks
Chronic urticaria (> 6 weeks) may have
autoimmune basis

40 year old male with chronic rash;

also behind ears

Seborrheic dermatitis
Orange to salmon-colored erythematous plaques
covered with yellowish, greasy scale involve the
malar areas. Nasolabial folds may be included.
Seborrheic dermatitis afects the scalp, central face, and anterior chest. In
adolescents and adults, it often presents as scalp scaling (dandruf). Seborrheic
dermatitis also may cause mild to marked erythema of the nasolabial fold, often
with scaling. Stress can cause flare-ups. The scales are greasy, not dry, as
commonly thought

BIOPSY

Thank you!