Tutorial A: The Primary Lesions

Primary lesions are physical changes in the skin considered to be caused directly by the
disease process. Types of primary lesions are rarely specific to a single disease entity.

1.MACULE
A macule is a change in the color of the skin. It is flat, if you were to close your eyes and
run your fingers over the surface of a purely macular lesion, you could not detect it. A
macule greater than 1 cm. may be referred to as a patch.

2. PAPULE
A papule is a solid raised lesion that has distinct borders and is less than 1 cm in diameter.
Papules may have a variety of shapes in profile (domed, flat-topped, umbilicated) and may
be associated with secondary features such as crusts or scales.

3. NODULE
A nodule is a raised solid lesion more than 1 cm. and may be in the epidermis, dermis, or
subcutaneous tissue.

4. TUMOR

A tumor is a solid mass of the skin or subcutaneous tissue; it is larger than a nodule.
(Please bear in mind this definition does not at all mean that the lesion is a neoplasm.)

5. PLAQUE
A plaque is a solid, raised, flat-topped lesion greater than 1 cm. in diameter. It is analogous
to the geological formation, the plateau.

6. VESICLE
Vesicles are raised lesions less than 1 cm. in diameter that are filled with clear fluid.

7. BULLAE
Bullae are circumscribed fluid-filled lesions that are greater than 1 cm. in diameter.

8. PUSTULE
Pustules are circumscribed elevated lesions that contain pus. They are most commonly
infected (as in folliculitis) but may be sterile (as in pustular psoriasis)

9. WHEAL
A wheal is an area of edema in the upper epidermis.

10. BURROW
Burrows are linear lesions produced by infestation of the skin and formation of tunnels (e.g.,
with infestation by the scabitic mite or by cutaneous larva migrans).

11. TELANGIECTASIA
Telangiectasia are the permanent dilatation of superficial blood vessels in the skin and may
occur as isolated phenomena or as part of a generalized disorder, such as ataxia
telangiectasia.

Tutorial B: The Secondary Lesions

Secondary lesions may evolve from primary lesions, or may be caused by external forces
such as scratching, trauma, infection, or the healing process. The distinction between a
primary and secondary lesion is not always clear.

12. SCALE
Scale consists of flakes or plates that represent compacted desquamated layers of stratum
corneum. Desquamation occurs when there are peeling sheets of scale following acute
injury to the skin.

13. CRUST
Crusting is the result of the drying of plasma or exudate on the skin. Please remember that
crusting is different from scaling. The two terms refer to different phenomena and are not
interchangeable. One can usually be distinguished from the other by appearance alone.

14. ATROPHY
Atrophy is thinning or absence of the epidermis or subcutaneous fat.

15. LICHENIFICATION
"Lichenification" refers to a thickening of the epidermis seen with exaggeration of normal
skin lines. It is usually due to chronic rubbing or scratching of an area.

16. EROSION
Erosions are slightly depressed areas of skin in which part or all of the epidermis has been
lost.

17. EXCORIATION
Excoriations are traumatized or abraded skin caused by scratching or rubbing.

18. FISSURE
A fissure is linear cleavage of skin which extends into the dermis.

19. ULCERATION
Ulcerations occur when there is necrosis of the epidermis and dermis and sometimes of the
underlying subcutaneous tissue.

20. SCAR
Scars are the permanent fibrotic changes that occur on the skin following damage to the
dermis. Scars may have secondary pigment characteristics.

21. ESCHAR
An eschar is a hard, usually darkened, plaque covering an ulcer implying extensive tissue
necrosis, infarcts or gangrene.

22. KELOIDS
Keloids are an exaggerated connective tissue response of injured skin that extend beyond
the edges of the original wound.

23. PETECHIAE, PURPURA, AND ECCHYMOSES

Three terms that refer to bleeding that occurs in the skin are petechiae, purpura, and
ecchymoses. Generally, the term "petechiae" refers to smaller lesions. "Purpura" and
"ecchymoses" are terms that refer to larger lesions. In certain situations purpura may be
palpable. In all situations, petechiae, ecchymoses, and purpura do not blanch when pressed.
If there is any question, press on the lesions carefully with a glass slide. Don't break the
slide or cut the patient.

Tutorial C: Patterns and Distribution

Not only is the appearance of lesions important, but the pattern and distribution on the skin
is as well.

24. ANNULAR
Annular lesions are seen in a ring shape. Tinea corporis, erythema migrans (the lesion
associated with lyme disease), and granuloma annulare are three common examples.

25. DISCRETE
Discrete lesions tend to remain separate. This is a helpful descriptive term but has little
specific diagnostic significance.

26. CLUSTERED
Clustered lesions are those that are grouped together. They are commonly seen in herpes
simplex or with insect bites, for example.

27. CONFLUENT
Confluent lesions tend to run together.

28. DERMATOMAL, ZOSTERIFORM

Dermatomal, zosteriform lesions follow a dermatome. The lesions of varicella zoster (also
known as shingles) are the classic example, but there are other lesions which may assume
the same pattern.

29. ECZEMATOID
Eczematoid lesions are inflamed with a tendency toward clustering, oozing, or crusting.

30. FOLLICULAR
It is sometimes helpful to determine if lesions specifically involve the hair follicle.

31. GUTTATE
Guttate lesions look as though someone took a dropper and dropped this lesion on the skin.
Guttate lesions are characteristic of one form of psoriasis, though that is not the only
example.

32. IRIS OR TARGET LESIONS

Iris lesions are also known as target lesions and are a series of concentric rings. These have
a dark or blistered center. These lesions are frequently seen with erythema multiforme but
not exclusively so.

33. KOEBNER PHENOMENON

The Koebner phenomenon, also called the isomorphic response, refers to the appearance of
lesions along a site of injury. This phenomenon is seen in a variety of conditions; for
example, lichen planus, warts, molluscum contagiosum, psoriasis, lichen nitidus, and the
systemic form of juvenile rheumatoid arthritis.

34. LINEAR LESIONS

Linear lesions occur in a line or band-like configuration. This descriptive term may apply to a
wide variety of disorders. (One should be certain that the lesions are not following a
dermatome.)

35. MULTIFORM
Patients with multiform lesions have lesions of a variety of shapes.

36. RETICULAR
Reticular or net-like lesions can be seen in a variety of circumstances; e.g., very commonly
in newborns (or even grown children and adults) as cutis marmorata, or with livedo
reticularis. The former fades as the skin is warmed the latter becomes more florid.

37. SERPIGINOUS
Serpiginous lesions wander as though following the track of a snake.

38. UNIVERSALIS
Universalis refers to a widespread disorder that affects the entire skin.

39. SCARLATINIFORM
Scarlatiniform rashes have the pattern of scarlet fever. The patient with a scarlatiniform rash
has innumerable small red papules that are widely and diffusely distributed. Note that the
term scarlatiniform does not mean that the patient has scarlet fever, although by definition
all patients with scarlet fever have a scarlatiniform rash. Patients with a variety of other

conditions such as Kawasaki disease, viral infections, or drug reactions may have rashes
with the same pattern.

40. STRAWBERRY TONGUE

Patients with scarlet fever, Kawasaki disease or other conditions may develop a distinctive
appearance of their tongues. Because of its resemblance to the well-known berry, the
appearance is called "strawberry tongue."

41. MORBILLIFORM
The term "morbilliform" means that the patient has a rash that looks like measles. Patients
with measles will have the rash but patients with Kawasaki disease, drug reactions, or other
conditions may also have a morbilliform rash. The rash consists of macular lesions that are
red and are usually 2-10 mm in diameter but may be confluent in places.

42. SATELLITE LESIONS

The term is commonly used to describe a portion of the rash of cutaneous candidiasis in
which a beefy red plaque may be found surrounded by numerous, smaller red macules
located adjacent to the body of the main lesions.

43. PATTERNS OF INTENTIONAL OR UNINTENTIONAL

INJURY
One important category of skin lesions involve the form that skin lesions may take in cases
of child abuse or other intentional injury (bite marks, slap marks, strap marks, burns, etc.)
or in cases of unintentional injury. Abrasions are traumatically caused erosions.