Departemen Ilmu Kesehatan Kulit dan

Kelamin Fakultas Kedokteran UNSRI/RSMH

Palembang
2008
Dr. M. Izazi HP, Sp.KK
The art of diagnosis
Diseases have characteristic morphology and distribution
The diagnosis and treatment of skin diseases :
rest on the physician's ability to use the lexicon of dermatology, to
recognize the basic and sequential lesions of the skin, and to recognize the
various patterns in which they occur in a variety of diseases and syndromes.

Dermatology lexicon" : a set of terms that denote types of skin lesion

standard terminology

- the first step in generating a differential diagnosis
- consistency in : clinical documentation, research, &
communication with other physicians.
e.g. :
Once a lesion has been described as a pearly, flesh-colored, telangiectatic,
ulcerated nodule DD/ utama : basal cell carcinoma


Macule
A macule is a
circumscribed, flat lesion
that differs from
surrounding skin because
of its color.
e.g : hyperpigmentation,
hypopigmentation,
vascular abnormalities,
erythema, purpura.
Papule
Papule is a solid,
elevated lesion less
than 0.5 cm in size in
which a significant
portion projects above
the plane of the
surrounding skin.
Plaque
Plaque is a solid
plateau-like elevation
or palpable flat lesion,
has a diameter larger
than 0.5 cm.

Well-defined, reddish,
scaling plaques
that coalesce to cover
large areas of the back
and buttocks
Nodule
Nodule is a solid, round or
ellipsoidal, palpable lesion
that has a diameter larger
than 0.5 cm.

Wheal
Wheal or hives or urticaria is a
rounded or flat-topped papule or
plaque that is characteristically
evanescent, disappearing within
hours.
These lesions are the result of
edema in the upper portion of the
dermis.
Vesicle and bulla
A vesicle is a fluid- filled
cavity or elevation smaller
than or equal to 0.5 cm,
whereas a bulla (blister)
measures larger than 0.5 cm.
Pustule
Pustule is a circumscribed,
raised cavity in the
epidermis or infundibulum
containing pus.
Erosion
Erosion is a moist,
circumscribed, usually
depressed lesion that
results from loss of all
or a portion of the viable
epidermis.

Fissures
Fissure is a linear loss
of continuity of the
skin's surface or
mucosa that results
from excessive tension
or decreased elasticity
of the involved tissue.

Ulcer
Ulcer is a defect in which the
epidermis and at least the
upper (papillary) dermis has
been removed.
Crust
Crusts are hardened
deposits that result when
serum, blood, or purulent
exudate dries on the
surface of the skin.
Scale
Scale is flat plate or flake
arising from the outer-
most layer of the stratum
corneum.
Cyst
Cyst is an encapsulated
cavity or sac lined with a
true epithelium that contains
fluid or semisolid material
(cells and cell products such
as keratin).
Atrophy
Atrophy refers to a
diminution in the size of a
cell, tissue, organ, or part
of the body.

Lichenification is represents
thickening of skin and
accentuation of skin markings.
The process results from
repeated rubbing and frequently
develops in persons with atopy.


Lichenification
Excoriations are
surface excavations of
epidermis that result
from scratching and are
frequent findings in
patients experiencing
pruritus.

Excoriations
Scar
A scar arises from
proliferation of fibrous
tissue that replaces
previously normal
collagen after a wound or
ulceration breaches the
reticular dermis.
A scar may be
hypertrophic (A) or
atrophic (B)

Erythema is the lesions caused by capillary dilatation

Telangiectases are permanent dilatations of capillaries that may or may
not disappear with application of pressure

Purpura is the lesions caused by extravasated red blood cells

Petechiae are small, pinpoint purpuric spots that are often seen in
thrombocytopenic states

Ecchymoses are larger, bruiselike purpuric lesions.

Infarct is an area of cutaneous necrosis resulting from occlusion of
blood vessels, as in vasculitis and bacterial embolism

Tumor is a general term for any mass, benign or malignant, and is
sometimes used to indicate a large nodule.






Telangiectasia
Purpura
Infarct
Shape, Arrangement, and
Distribution of Lesions

Once the type or types of lesions have been identified,
one needs to describe their shape, arrangement, and
pattern of distribution

characteristics in morphologic diagnosis

example : a single scaly plaque on a patient's trunk may
have a broad differential diagnosis, but the same plaques
symmetrically distributed on the elbows, knees, and
umbilicus would be highly suggestive of psoriasis.
Shape or configuration of skin lesions

1. Annular : ring-shaped; implies that the edge of the lesion differs from the
center, either by being raised, scaly, or differing in color
(e.g : granuloma annulare, tinea corporis).

2. Round/nummular/discoid: coin-shaped; usually a round to oval lesion
with uniform morphology from the edges to the center
(e.g : nummular eczema, plaque-type psoriasis, discoid lupus).

3. Polycyclic : formed from coalescing circles, rings, or incomplete rings
(e.g : tinea corporis)

4. Arcuate : arc-shaped; often a result of incomplete formation of an annular
lesion (e.g : urticaria, subacute cutaneous lupus erythematosus).
5. Linear : resembling a straight line; often implies an external contactant or
Koebner phenomenon has occurred in response to scratching.
single lesion (e.g : a scabies burrow, poison ivy dermatitis)
multiple lesions (e.g : lichen nitidus or lichen planus).

6. Reticular : net-like or lacy in appearance, with somewhat regularly spaced
rings or partial rings and sparing of intervening skin
(e.g., livedo reticularis, cutis marmorata).

7. Serpiginous : serpentine or snake-like
(e.g : cutaneous larva migrans).

8. Targetoid : target-like, with at least three distinct zones
(e.g : erythema multiforme)

9. Whorled : like marble cake, with two distinct colors interspersed in a
wavy pattern; usually seen in mosaic disorders in which cells of differing
genotypes are interspersed
(e.g : incontinentia pigmenti, hypomelanosis of Ito)
Arrangement of Multiple Lesions
1. Grouped/herpetiform : lesions clustered
together (e.g : herpes zoster).
2. Scattered : irregularly distributed.
Distributions of Multiple Lesions
1. Dermatomal/zosteriform : unilateral and lying in the distribution of a
single spinal afferent nerve root. (e.g : herpes zoster).

2. Blaschkoid : following lines of skin cell migration during
embryogenesis; generally longitudinally oriented on the limbs and
circumferential on the trunk, but not perfectly linear.
Implies a mosaic disorder (e.g : incontinentia pigmenti).

3. Lymphangitic : lying along the distribution of a lymph vessel.
e.g : cellulitis due to a staphylococcal or streptococcal infections.

4. Sun exposed : occurring in areas usually not covered by clothing,
namely the face, and dorsal hands (e.g : photodermatitis, polymorphous
light eruption, squamous cell carcinoma).

5. Sun protected : occurring in areas usually covered by one or more layers
of clothing. (e.g : parapsoriasis, mycosis fungoides).

6. Acral : occurring in distal locations, such as on the hands, feet, wrists,
and ankles (e.g : palmoplantar pustulosis, chilblains).


7. Truncal : occurring on the trunk or central body.

8. Extensor : occurring over the dorsal extremities, overlying the extensor
muscles, knees, or elbows (e.g., psoriasis).

9. Flexor : overlying the flexor muscles of the extremities, the
antecubital and popliteal fossae (e.g : atopic dermatitis).

10. Intertriginous : occurring in the skin folds : axillae, inguinal folds, inner
thighs, inframammary skin. (e.g., candidiasis).

11. Localized : confined to a single body location (e.g., cellulitis).

12. Generalized : widespread. (e.g., viral exanthems, drug eruption).

13. Bilateral symmetric : occurring with mirror-image symmetry on both
sides of the body (e.g., vitiligo, plaque-type psoriasis).

14. Universal : involving the entire cutaneous surface. (e.g., erythroderma,
alopecia universalis).
Shape and arrangement of lesions
Lesions in the distribution
described by Blaschko for
developmental
Scattered lesion.
Targetoid lesion. Grouped: clustered
Whorled : marbled appearance
Annular lesion
Nummular lesion.
Polycyclic lesion
Arcuate lesion
Linear distribution
Reticular lesion
Serpiginous lesion
Diascopy test :
The application of pressure with two glass slides or an
unbreakable clear lens on a red lesion is a
simple and reliable method for differentiating redness due to
vascular dilatation (erythema) from redness due to
extravasated erythrocytes or erythrocyte products (purpura).
If the redness remains under the pressure
of the slide, the lesion is purpuric.
Pemphigus
vulgaris. The bulla
has been extended
by applying
pressure
with the finger
(Nikolsky's sign)
Tzanck preparation
showing
multinucleate giant
epidermal cell
(Giemsa's stain).
(Courtesy of
Arthur R. Rhodes,
MD)