DERMATOLOGICAL DIAGNOSIS

AN APPROACH TO DERMATOLOGICAL
DIAGNOSIS

• Definitive diagnosis may require the

information provided by a complete history,
physical examination, laboratory tests, and
histopathologic analysis.
• Here is an outline of a logical step-by-step
approach to dermatologic diagnosis
 Anamnesis
History of skin lesions. Seven key questions:
• When did it start?
• Does it itch, burn, or hurt?
• Where on the body did it start?
• How has it spread? (pattern of spread)
• How have individual lesions changed? (evolution)
• Provocative factors? (patient’s occupation,
immediate environment, seasonal variations,
physiological states, foods, prescription or
nonprescription drugs etc.)
• Previous treatment(s).
 Anamnesis
General history of present illness as indicated by clinical
situation, with particular attention to constitutional and
prodromal symptoms:
1. Acute illness syndrome (fever, sweats, chills, headache,
nausea, vomiting, etc.)?
2. Chronic illness syndrome (fatigue, anorexia, weight loss,
malaise)?
3. Review of systems.
4. Past medical history (operations, illnesses, allergies,
medications, habits, atopic history).
5. Family medical history (particularly of skin disorders and of
atopy).
6. Social history (occupation, hobbies, exposure, travel).
7. Sexual history.
 Physical Examination

General physical examination as indicated by

clinical presentation and differential diagnosis,
with particular attention to vital signs,
lymphadenopathy, hepatomegaly,
splenomegaly, joints.
 Physical Examination
Dermatologic examination – detailed physical examination of skin,
hair, and mucous membranes.
A. Four cardinal features:
1. Distribution (be sure to examine scalp, mouth, palms and soles):
a. Extent or involvement: circumscribed, regional, generalized, universal? What
percentage of the body surface is involved (the palm is roughly equivalent to
1%)?
b. Pattern: symmetry, exposed areas, sites of pressure, intertriginous areas?
c. Characteristic location: flexural, extensor, intertriginous, glabrous, palms and
soles, dermatomal, trunk, lower extremities, exposed areas, etc.?
2. Type of lesion: macule, papule, nodule, vesicle, etc.?
3. Shape of individual lesions: annular, iris, arciform, linear, round,
oval, umbilicated, etc.?
4. Arrangement of multiple lesions: isolated, scattered, grouped,
herpetiform, zosteriform, annular, arciform, linear, reticular, etc.?
 Physical Examination
B. Three major characteristics:
1. Color:
a. If diffuse: red, brown, gray-blue, orange-yellow, etc.; or if
circumscribed: red, violaceous, orange, yellow, lilac, livid,
brown, black, blue, gray, white, etc.?
b. Does color blanch with pressure (diascopy test)?
c. Wood’s lamp examination of pigmentary alterations: Is contrast
enhanced?
2. Consistency and feel of lesion: soft, doughy, firm, hard, “infiltrated”,
dry, moist, mobile, tender?
3. Anatomic component(s) of skin primarily affected: Is the process
epidermal, dermal, subcutaneous, appendageal, or a combination
of these?
 Physical Examination
Special procedures for dermatologic diagnosis are:
• palpation of the lesion – reveals the consistence, texture, deepness,
stratification, “infiltrated” character, mobility, temperature, fluctuation, etc.
• diascopy or vitropressure reveals dermal modifications (apple jelly sign –
hyaline yellowish-brown color of papules and nodules), vascular changes
(erythema, purpura, telangiectasia)
• instrumental dermatoscopy – important for pigmentary, vascular, neoplastic
lesions, etc.
• raclage of lesions reveals hyperkeratotic scales (dermatomycosis) and
parakeratotic scales (psoriasis), grattage triad in psoriasis (oil spot, terminal
film, pinpoint dots of blood – bloody dew), Besnier’s sign in lupus
erythematosus, latent desquamation in tinea versicolor
• dermographism - white, red and mixed type, persistency, elevation level
• appreciation of pain, temperature, touch perception (an important sign in
leprosy)
• appreciation of sebaceous and sweat glands function (for acne, ichthyoses,
dishidrosis, etc.)
 Physical Examination
Specific instrumental and laboratory investigations
confirming dermatologic diagnosis:

• skin biopsy (histopathologic analysis)

• Gram’s stain (microscopic examination),
• cytologic preparation,
• bacteriologic and fungal cultures
• confirming the diagnosis of scabies
• patch testing to confirm contact dermatitis, etc.
 DERM ABC - SKIN LESIONS
Primary lesions
Lesion Description Example
Macule A flat, circumscribed area of altered skin color Vitiligo, purpura HS
pityriasis versicolor
Papule A small circumscribed elevation of the skin(<0.5cm) Molluscum cont.
Plaque Elevated solid confluence of papules (>0.5 cm) Psoriasis
Nodule/ A solid, circumscribed elevation whose greater part Erythema nodosum,
tubercle lies beneath the skin surface Tertiar syphilis,
Lepra
Weal A transient, slightly raised lesion, usually with a pale Urticaria
centre and a pink margin

Vesicle A small, circumscribed, fluid-containing elevation Eczema,

(<0.5 cm) herpes simplex
Bulla Similar to vesicle but larger (>0.5 cm) Pemphigus,
bullous pemphigoid
Pustule A collection of pus Acne, impetigo
 DERM ABC - SKIN LESIONS
Secondary lesions
Scale Thickened, loose, readily detached fragments of Psoriasis, ichthyosis,
stratum corneum pityriasis versicolor
Crust Dried exudate Impetigo, eczema
Excoriation A shallow abrasion often caused by scratching Atopic dermatitis
Ulcer An excavation due to loss of tissue exceeding the Venous stasis
basement membrane and deeper ulceration
Scar A permanent lesion that results from the process CLE
of repair by replacement with connective tissue
Lichenification Areas of increased epidermal thickness with Atopic dermatitis
accentuation of skin
Erosion A moist, circumscribed, depressed lesion that Pemphigus, eczema
results from loss of the viable epidermis
Fissures Linear cleavages or cracks in the skin and may be Palmar/plantar
painful psoriasis, tinea pedis
Vegetation

Macule (sec.) A flat, circumscribed area of altered skin color After any primary
lesion
 Macula
A macule is a circumscribed, flat lesion that differs from surrounding skin
because of its color. Macules may have any size or shape. They may be:
• Dyschromic
hyperpigmented (darker skin) – junctional nevi, café au lait
(neurofibromatosis)
hypopigmented (lighter skin) – vitiligo, tuberous sclerosis
• Vascular by capillary dilatation
inflammatory – roseola (less than 1cm diameter) seen in secondary
syphilis; erythema (greater than 1cm diameter) seen in eczema, drug-
induced; erythroderma (involving all skin surface) seen in psoriasis,
lichen planus, drug-induced, etc.;
non-inflammatory – telangiectasis (permanent dilatation of capillaries
that may or may not disappear with application of pressure) seen in
lupus eruthematosus, dermatomyositis, rosacea, etc.
• Vascular by red cell extravasation or purpuric macules (don’t disappear
or blanch by pressure) – petechiae (less then 5 mm); purpura (greater
than 5 mm); ecchymoses are larger, bruiselike purpuric lesions, all are
seen in vasculites
MACULA
 Macula

Tinea versicolor Dermatită seboreică

Dermatită de contact Intertrigo candidozic

 Papula
• A papule is a small solid, elevated lesion less than 0,5 cm in
diameter. The elevation can be a result of metabolic deposits,
localized hyperplasia of cellular components of the epidermis
or dermis, or localized cellular infiltrates in the dermis.
• Papules may have a variety of shapes. They may be:
acuminate (miliaria rubra);
surmounted with scale of keratin (secondary syphilis);
dome-shaped (molluscum contagiosum);
flat-topped (lichen planus).
• Papules by color: red – psoriasis; copper – secondary syphilis;
violet – lichen planus; yellow – xanthomatosis.
• Papules may be follicular and perifollicular – acne, folliculitis,
Darier’s disease.
PAPULA
 Plaque
Is a mesa-like elevation that occupies a
relatively large surface area (more than 0,5 cm
in diameter) in comparison with its height
above skin level. Plaques are often formed by
a confluence of papules, as in psoriasis. The
typical psoriatic lesion is a raised,
erythematous plaque with layers of silvery
scale.
PAPULES and PLAQUES

Syphilis (secondary) Psoriasis

 Nodule
• Is a palpable, solid, round or ellipsoidal lesion. Depending upon
the anatomic component(s) primarily involved, nodules are of five
main types:
1. epidermal (keratoacanthoma, verruca vulgaris, basal cell
carcinoma);
2. epidermal-dermal (nevi, malignant melanoma, invasive
squamous cell carcinoma, mycosis fungoides);
3. dermal (granuloma annulare, dermatofibromas);
4. dermal-subdermal (erythema nodosum, superficial
thrombophlebitis);
5. subcutaneous (lipomas).
• Nodules in the dermis and subcutis may indicate systemic
disease and result from inflammation, neoplasms, or metabolic
deposits in the dermis or subcutaneous tissue. For example, late
syphilis, tuberculosis, the deep mycosis, xanthomatosis,
lymphoma, and metastatic neoplasms all can present as
cutaneous nodules. A gumma is the granulomatous nodular
lesion or tertiary syphilis and leproma is the same in leprosy
NODULE
 Noduli

Basal cell carcinoma Kaposi’s sarcoma

Hemangioma Squamous cell carcinoma Melanoma

 Wheals
• A wheal is rounded or flat-topped elevated lesion disappearing within hours.

• Wheals (hives or urticaria), are the result of edema in the upper portion of
the dermis – edema of dermal papila. Wheals may be tiny of 3-4 mm in
diameter, as in cholinergic urticaria, or as giant urticaria of 10-12 cm caused
by penicillin hypersensitivity.

• Stroking of the skin may produce wheals in some normal persons; this
phenomenon is called dermographism and is one of the physical urticarias.
When it is associated with significant itching, it is called symptomatic
dermographism.

• Angioedema is a deep, edematous urticarial reaction that occurs in areas

with very loose dermis and subcutaneous tissue, such as the lip.

• Laryngeal edema !!! which may cause airway obstruction.

 WHEAL

Urticaria pigmentosa
 Vesicles and bullae
• A vesicle is a circumscribed, elevated lesion that contains fluid.
Often the vesicle walls are so thin that they are translucent and
the serum, lymph, blood, or extracellular fluid is visible.
• A vesicle with a diameter greater than 0,5 cm is a bulla.
• Vesicles and bullae arise from cleavage at various levels of the
skin; the cleavage may be within the epidermis (epidermal), or at
or below the dermal-epidermal interface (subepidermal).
Cleavage just beneath the stratum corneum produces a
subcorneal vesicle or bulla, as in impetigo.
• Intraepidermal vesication may result from intercellular edema
(spongiosis), as characteristically seen in delayed hypersensitivity
reactions of the epidermis (contact eczematous dermatitis) and
in dishidrotic eczema.
• Spongiotic vesicles may be detectable microscopically but may
not be clinically apparent as vesicles.
VESICLE AND BULAE

Dermatitis herpetiformis
Eczema
 Vesicles and bullae
• Loss of intercellular bridges, or desmosomes, is known as
acantholysis, and this type of intraepidermal vesication is
seen in pemphigus vulgaris, where the cleavage is usually just
above the basal layer. In pemphigus foliaceus the cleavage
occurs just below the sub-corneal layer.
• Viruses cause a curious “ballooning degeneration” of
epidermal cells, as in herpes zoster, herpes simplex, variola,
and varicella. Viral bullae often have a depressed
(“umbilicated”) center.
• Pathologic changes at the dermal-epidermal junction may
lead to subepidermal vesicles and bullae, as are seen in
pemphigoid, bullous erythema multiforme, porphyria catanea
tarda, dermatitis herpetiformis, and some forms of
epidermolysis bullosa.
Bule – pemfigus vulgar
 Pustule
• A pustule is a circumscribed, raised lesion that contains a purulent
exudate (pus), can be sterile or non-sterile
• Pustules may vary in size and shape and, depending on the color
of the exudate, may appear white, yellow, or greenish yellow.
• Can be follicular and non-follicular.
• Pustules are characteristic for rosacea, pustular psoriasis, Reiter’s
disease, and some drug eruptions, especially those due to
bromide or iodide; Vesicular lesions of some viral diseases
(varicella, variola, vaccinia, herpes simplex, and herpes zoster), as
well as the lesions of dermatophytosis, may become pustular.
• A Gram’s stain and culture of the exudate from pustules should
always be performed.
PUSTULE
 Erosions
• An erosion is a moist, circumscribed, usually
depressed lesion that results from loss of all or a
portion of the viable epidermis.
• After the rupture of vesicles or bullae, the moist
areas remaining at the base are called erosions.
Extensive areas of denudation due to erosions
may be seen in bullous diseases such as
pemphigus.
• Unless they become secondarily infected,
erosions usually do not scar.
• If inflammation extends into the papillary dermis,
an ulcer is present and scarring results, as in
vaccinia and variola, and less often in herpes
zoster and varicella.
EROSION AND ULCER
 Ulcers
• An ulcer is a lesion in which there has been destruction of the
epidermis and at least the upper (papillary) dermis involved.
• Ulcers are healing through scarring.
• Certain features that are helpful in determining the cause of
ulcers and that must be considered in describing them
include location, borders, base, discharge, and any associated
topographic features of the lesion or surrounding skin such as
nodules, excoriations, varicosities, hair distribution, presence
or absence of sweating, and adjacent pulses. Stasis ulcers are
accompanied by pigmentation and, occasionally, by edema or
sclerosis.
• Ulceration occurs in granulomatous nodules of various types
due to deep fungi, tuberculosis, syphilis, and yaws, as well as
in a variety of parasitic and bacteriologic disorders. Nodules
adjacent to ulcerations suggest granulomatous or neoplastic
disease.
 Scar
• A scar occurs wherever ulceration has taken place and
reflects the pattern of healing in those areas.
• Scars may be hypertrophic or atrophic.
• They may be sclerotic, or hard, as a consequence of
collagen proliferation.
• The scarred epidermis is thin, generally without normal
skin lines and without appendages. A depressed scar
may resemble the primary atrophy.
• Scars may occur in the course of acne, some
porphyrias, herpes zoster, and varicella. Raynaud’s
disease, syphilis, tuberculosis (especially on the face),
leprosy, or carcinoma may produce mutilations, or a
loss of tissue that alters major anatomic structures.
SCARS
ATROPHY
 Scaling (desquamation)
• Abnormal shedding or accumulation of stratum corneum in perceptible flakes
is called scaling.
• Under normal circumstances the epidermis is completely replaced every 27
days. The cornified cell is packed with fllamentous proteins, normally does not
contain a nucleus and is usually lost imperceptible.
• When keratinocytes production occurs at an increased rate, as in psoriasis,
immature keratinocytes that retain nuclei reach the skin surface – this is called
parakeratosis.
• Parakeratotic scales - in psoriasis, scales may appear in thin sheets or
accumulate massively, suggesting the appearance of an oyster shell.
• Orthokeratotic scales - densely adherent scales that have a gritty feel like
sandpaper are typically seen in solar keratosis; fishlike scale occurs in a group
of disorders known as ichthyoses, other - dermatophyte infections, pityriasis
rosea, secondary and tertiary syphilis.
SCALE
 Crusts
(encrusted exudates)
• Crusts result when serum, blood, or purulent exudate dries
on the skin surface, and are characteristic of pyogenic
infections.
• Crusts may be thin, delicate, and friable, or thick and
adherent.
• Crusts are yellow when formed from dried serum, green or
yellow-green when formed from purulent exudate, or brown
or dark red when formed from blood.
• Crusts may be present in acute eczematous dermatitis and
impetigo (honey-colored, glistening crusts).
• When the exudate or crust involves the entire epidermis, the
crusts may be thick and adherent: this condition is known as
ecthyma. A scutula is a small, yellowish, cupshaped crust
especially characteristic of superficial fungal infection of the
scalp caused by Trichophyton schoenleinii.
CRUST
 Excoriations

• Excoriations are superficial excavations of

epidermis that may be linear or punctate
and result from scratching.
• They are findings in all types of pruritus and
are concomitants of pruritic skin disease,
such as atopic eczema, dermatitis
herpetiformis, or infestations.
 Lichenification
• Repeated rubbing, especially in people with
chronic eczema, leads to areas of lichenification.
• Proliferation of keratinocytes and stratum
corneum, in combination with changes in the
collagen of the underlying dermis, causes
lichenified areas of skin to appear as thickened
plaques with accentuated skin markings.
• The lesions may resemble tree bark.
• They are findings in atopic dermatitis, chronic
eczema, neurodermitis, etc.
EXCORIATION LICHENIFICATION
 Fissures
• Fissures are linear cleavages or cracks in the skin
and may be painful.
• They occur particularly in palmar/plantar
psoriasis and in chronic eczematous dermatitis of
the hands and feet, especially after therapy that
has caused excessive drying of the skin.
• Fissures are frequently noted in perianal psoriasis
or at the angles of the mouth (perleche). Perleche
mat be caused by avitaminosis, moniliasis, ill-
fitting dentures, or unknown factors.
FISSURE
Spongiosis
Hyperkeratosis (ihtiozis lamelaris)
Parakeratosis, acantosis, papilomatosis
Acantholysis – pemfigus vulgaris
Hydropic degeneration, hypergranulosis
lichen planus
Band-like infiltrate in dermis –
lichen planus
Dermal edema (urticaria)
Septal panniculitis –
erythema nodosum
 The treatment of skin disease

•topical,
•systemic,
•intralesional,
•radiation
•surgical modalities
 Topical treatment:
vehicles+/-active ingredients
Lotion. A liquid vehicle, often aqueous or alcohol-based, which may
contain a salt in solution. A shake lotion contains an insoluble powder
(e.g. calamine lotion).
Cream. A semi-solid emulsion of oil-in-water; contains an emulsifier
for stability, and a preservative to prevent overgrowth of microorganisms.
Gel. A transparent semi-solid, nongreasy emulsion.
Ointment. A semi-solid grease or oil, containing little or no water but
sometimes with added powder; no preservative is usually needed; the
active ingredient is suspended rather than dissolved.
Paste. An ointment base with a high proportion of powder 50% (starch
or zinc oxide) producing a stiff consistency.
Fingertip unit – FTU:
the amount of cream or ointment that can
be applied to the terminal phalanx of
the index finger - one FTU equals 0,5 g.