Derma 3

DERMATOLOGY
Morphology of skin lesions

signs & Investigations
Done by Team leader

Meshaal AlOtaibi Meshaal AlOtaibi
From slides doctor’s notes team’s notes from book important

Morphology
Skin lesions are divided into :
o Primary lesion : Basic lesion.
Primary lesions Features

Only discoloration of the skin :
Macule/patch o Macule = ( <0.5 cm)
o Patch = (> 0.5 cm)
Elevated lesion without depth
Papule/plaque o Papule = (< 0.5 cm)
o Plaque = ( > 0.5 cm)
Elevated lesion + has a depth
Nodule
o 0.5 cm in diameter
Elevated lesion + has a depth
Cyst
contains fluid or semisolid material
Linear tunnel in the epidermis
Burrow  scabies mite
Elevation that contains clear fluid
Vesicle/bulla o Vesicle = (< 0.5 cm)
o Bulla = (> 0.5 cm)
Pustule Elevation contains pus
Blood gunder the skin (Extra-vasation )
Purpura
 red or purple discolorations of the skin
Wheal Firm, edematous plaque
o Secondary lesions : Develop during evolution of skin disease created by scratching or infection
 Secondary skin lesions are those changes in the skin that result from primary
skin lesions, either as a natural progression or as a result of a person
manipulating (e.g. scratching or picking at) a primary lesion.
 Excoriation
 Erosion
 Scale
 Fissure
 Ulcer
 Lichenification
 Scar
Primary lesions
1- Macule
Flat circumscribed discoloration that lacks surface elevation or
depression (<0.5 cm).
2- Patch
Flat circumscribed skin discoloration; a large Macule (> 0.5cm).
3- Papule
Elevated, Solid lesion < 0.5cm in diameter.

Notice color and surface changes
e.g
o Umblicated,
o Keratotic
o Papillomatous
o Flat topped.
4- Plaque
Elevated
Solid confluence or expansion of papules
> 0.5 (lacks a deep component ).
5- Nodule 6- Cyst
Elevated
Solid lesion > 0.5 cm in diameter Nodule that contains fluid or semisolid
with deep component material.
7- Blisters ( Vesicle & bulla ) 8- Pustule
Vesicle:
 Elevation that contains purulent
 Elevation that contains clear fluid.
fluid (pus)
Bulla:
 large vesicle
10- Purpura: 11- Burrow
Extra-vasation of red blood cells

Linear tunnel in the epidermis
giving non- blanchable erythema
induced by scabies mite
12- Wheal
Firm, edematous plaque that is

evanescent (short lived)
and pruritic; a hive
Secondary Lesions
1- Scale: 2- Crust
 Thick stratum cornium A collection of cellular debris, dried

serum and blood . Antecedent primary
lesion usually a vesicle,
bulla, or pustule.
3- Erosion 4- Excoriation :
A partial focal loss of epidermis

that heals without scarring.
Linear erosion induced by scratching
5 – Fissure 6- Ulcer
A full thickness focal loss of epidermis

Vertical loss of epidermis and dermis with
and dermis; heals with scarring
sharply defined walls: crack in skin
7 - Scar:
A collection of new connective tissue; may be :
o hypertrophic
o Atrophic
 implies dermo-epidermal damage
8 - Lichenification:
Increased skin markings secondary

to scratching
 Occur in chronic eczema

Specialized Terminology
 Sclerosis
Hardening of the skin, (Skin is un-pinchable )
 How to describe the lesion ]VERY IMPROTANT[ !!
Number of Name of
Texture Border Color Surface the lesion
Location
the lesion
Multiple well-defined regular erythematous scaly patch occupying (location of lesion)

Important signs
NIKOLSKY SIGN
Rubbing of apparently normal skin induce

Blistering
Seen in :
o Pemphigus vulgaris
o Toxic epidermal necrolysis (TEN)
The epidermis is detached and slipping free from

the dermis with slight pressure
AUSPITZ SIGN
SIGN
Removal of scale on top of a red papule produces bleeding

points
(pinpoint hemorrhage from superficial dermal capillaries.)
Seen in PSORIASIS
occurs because the capillaries under the epidermis are

numerous and twisted, and very close to the surface.
Removing a scale or scraping the skin basically rips open
the very top-most capillaries, resulting in bleeding
Koebner’s phenomenon
SIGN
Trauma to the skin produce certain diseases
(skin lesions which appear at the site of injury)
Seen in :
a.Psoriasis
b.Vitiligo
c.Lichen planus.
d.Warts.
After injury to the skin, new psoriasis plaques can flare

up at the site of injury, or old ones spread. For this
reason, it is important for psoriatics to avoid skin
damage wherever possible.
DERMATOGRAPHISM
SIGN
Firm stroking of the skin produce erythema and wheal
Seen in:
o Physical urticaria
o Patient with atopy.
When you scratch the normal skin => edema and

erythema => skin becomes raised and inflamed
(YOU CAN WRITE ON SKIN)
INVESTIGATIONS
Wood’s lamp :
Produces long wave UVL (360 nm)
Useful in :
 Tinea Versicolor-Yellow green flourescence
 Tinea Capitis -yellow green flourescence in
( M.canis, M. Andouini)
 Erythrasma –coral red flourescence

 Vitiligo - Milky white.
KOH preparation for fungus
Cleanse skin with alcohol Swab.

Scrape skin with edge of microscope slide onto a second
microscope slide
Put on a drop of 10% KOH

Apply a cover slip and warm gently
Examine with microscope objective lens
 You may see hyphae and/ or spores
Tzank smear :
Important in diagnosing :
o Herpes simplex or VZV (multinucleated giant cells)

o Pemphigus Vulgaris (acantholytic cells).
METHOD :
Select a fresh vesicle.
De-roof and scrape base of the vesicle.
Smear onto a slide.
Fix with 95% alcohol.
Stain with Giemsa stain.
Examine under microscope
Prick test
Put a drop of allergen containing solution
A nonbleeding prick is made through the drop.
After 15-20 mins the antigen is washed , the

reaction is recorded.
A positive test shows urticarial reaction at site of

prick.
Detects immediate-type IgE mediated reaction

Emergency theraputic measures should be available in
case of anaphylaxis.
PATCH SKIN TEST

Important in contact dermatitis
Select the most probable substance causing dermatitis
Apply the test material over the back

Read after 48 & 72 hr. look for (erythema, edema,
vesiculation)
Positive patch test showing erythema and edema.

In severe positive reaction vesicles may be seen
 Test type 4 reaction Cell mediated immunity

SKIN PUNCH BIOPSY
Clean skin with alcohol

Infiltrate with 1-2% xylocaine with adrenaline
Rotate 2-6 mm diameter
Punch into the lesions
Lift specimen and cut at base of lesion

Put in 10% formalin
“For Immunoflourescence put in normal saline”
Direct immunoflouresence DIF :

Used to diagnose autoimmune diseases e.g.
 PemphigusVulgaris
 Bullous pemphigoid
Detects immunoglobulinand complement deposits in skin.
Fluorescence will be noted if immunoglobulin deposits are :
Intercellularly between the

epidermal cells as in
 pemphigus vulgaris
OR
at the Basement membrane zone as in

 bullous pempigoid
Indirect ImmunoFluorescence : IDIF
Detect auto antibodies in the serum
It is used to confirm a diagnosis
o To differentiate between bullous diseases
o To monitor disease activity
Topical therapy and others.
A wide variety of topical agents are available.

Delivers the drug to target site.
If the lesion is dry -wet it

if wet -dry it.
(Golden rule)
Wet compresses - dries wet lesions.

Like KMNO4
Wet compresses are

o Antibacterial
o Cause debridment
o Suppress inflammation.
Topical drugs consist of :

Active substance like steroids, antimicrobial agents and vehicle
(Vehicle: Is the base in which the active ingredient is dispersed.)
Topical steroids side effects :

- Atrophy and striae.
- Telangiectasia and purpura.
- Masking the initial lesion.
- Perioral dermatitis and rosacea or ACNE.
- Systemic absorption.
- Tachyphylaxis. (sudden loss of response)
Guidelines regarding steroid use:

Avoid high potency steroid on flexures and face.
Avoid high potency steroid in children.
Avoid use for extended periods of time.
Creams are mixture of oils and water in which the active
substance is dispersed.
 white in color- useful in folds.
Used in acute eczema
Ointments are primarily grease. They are useful in dry

lesions
e.g. petrolatum jelly and mineral oil.
 They are translucent

Used in eczema
Gels are mixtures of propylene glycol and water.

Sometimes they contain alcohol .
They are translucent and
 Best used in wet disorders and hairy regions
 mucose membrane
How much to use?
Finger tip unit:

The amount of cream/ointment expressed
from 5mm nozzle.
It weighs 0.5g.
It covers 2 hand units.
1- PHOTOTHERAPY MACHINE/NBUVB (narrowband uvb light therapy )
 Hand and feet narrow band UVB ( most common use in KKUH )
Vitiligo treated by NBUVB
Other indications include :

- psoriasis
- Lichen planus
- Eczema
2- Liquid nitrogen gun(Cryotherapy)

 Used to treat warts
3- Electric cautery
 Used to destroy skin tags
 Malignant tumors
Quiz
Bilateral yellow plaques Keratotic papillomatous skin colored

plaque
Umblicated pearly papules, some are Annular erythematous scaly plaque

grouped
Grouped vesicles on erythematous base Yellow crust, erosions, flaccid bulla on

erythematous base
1 cm cyst with telangiectasia Unilateral erythematous patch
Multiple erosions Linear nodules with ulceration
Erythematous papules Erosions, crusts, annular bullae

1- Which One of the following is a Primary lesion:
a) Crust.
b) Fissure.
c) Scale.
d) Ulcer.
e) Vesicle.
2- Pigmentation that cause by trauma called:

a) Ulcer.
b) Koebner phenomena.
c) Fissure.
d) Nikolsky's sign.
e) Parakeratosis.
3- What do you call a flat-topped elevation of the skin ( > 1 cm ):

a) Macule.
b) Papule.
c) Nodule.
d) Plaque.
e) Pustule.
4- A 10 years old boy presented to your clinic complaining of asymptomatic

white patches over face and body for few months. On examination there
were multiple well demarcated hypopigmentated macules and patches.
In this patient presentation how you would differentiate between a macule
and patch?
a) By the size
b) By the color
c) By the depth
d) By the consistency
ANS :
1- E
2- B
3- D
4- A

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DERMATOLOGY

Morphology of skin lesions

Done by Team leader

From slides doctor’s notes team’s notes from book important

Primary lesions Features

Elevated, Solid lesion < 0.5cm in diameter.

7- Blisters ( Vesicle & bulla ) 8- Pustule

Extra-vasation of red blood cells

Firm, edematous plaque that is

 Thick stratum cornium A collection of cellular debris, dried

A partial focal loss of epidermis

A full thickness focal loss of epidermis

 implies dermo-epidermal damage

Increased skin markings secondary

 Occur in chronic eczema

 How to describe the lesion ]VERY IMPROTANT[ !!

Multiple well-defined regular erythematous scaly patch occupying (location of lesion)

Rubbing of apparently normal skin induce

The epidermis is detached and slipping free from

Removal of scale on top of a red papule produces bleeding

occurs because the capillaries under the epidermis are

After injury to the skin, new psoriasis plaques can flare

When you scratch the normal skin => edema and

 Erythrasma –coral red flourescence

Cleanse skin with alcohol Swab.

Put on a drop of 10% KOH

 You may see hyphae and/ or spores

o Herpes simplex or VZV (multinucleated giant cells)

After 15-20 mins the antigen is washed , the

A positive test shows urticarial reaction at site of

Detects immediate-type IgE mediated reaction

PATCH SKIN TEST

Apply the test material over the back

Positive patch test showing erythema and edema.

 Test type 4 reaction Cell mediated immunity

Clean skin with alcohol

Lift specimen and cut at base of lesion

Direct immunoflouresence DIF :

Fluorescence will be noted if immunoglobulin deposits are :

Intercellularly between the

at the Basement membrane zone as in

Topical therapy and others.

A wide variety of topical agents are available.

If the lesion is dry -wet it

Wet compresses - dries wet lesions.

Wet compresses are

Topical drugs consist of :

Topical steroids side effects :

Guidelines regarding steroid use:

Ointments are primarily grease. They are useful in dry

 They are translucent

Gels are mixtures of propylene glycol and water.

How much to use?

Finger tip unit:

Vitiligo treated by NBUVB

Other indications include :

2- Liquid nitrogen gun(Cryotherapy)

Bilateral yellow plaques Keratotic papillomatous skin colored

Umblicated pearly papules, some are Annular erythematous scaly plaque