Primary Skin Lesions

and Differential
Diagnoses
(An Intro to Dermatologic Diagnosis
for the 3rd Yr. Medical Student)

By Ma. Socorro W. Toledo, MD, FPDS

Skin Lesions

 I. Macules/Patches; Papules/Plaques
 II. Wheals
 III. Nodules
 IV. Ulcers
 V. Blisters = Vesicles/ Bullae
I. Macules/Patches;
Papules/ Plaques
 A. SLE
 B. Exfoliative Dermatitis
 C. Hyperpigmented Lesions
 D. Hypopigmented Lesions
 E. Alopecia
 F. Purpura
 G. Leprosy
 H. Cutaneous Lymphoma
I. Macules/patches or
papules/plaques
A. Systemic Lupus
Erythematosus (SLE)
 4/11 criteria: Malar rash, discoid rash,
photosensitivity, oral ulcers
 11 criteria involve cutaneous(4),
musculoskeletal, hematologic, renal,
pulmonary, cardiac, immunologic,
nervous system abnormalities
Gilliam Classification of
LE skin lesions
1. LE-specific skin disease (cutaneous LE):
LE-specific on histopathology
 a. acute CLE– localized (malar or butterfly rash),
generalized erythema
 b. subacute CLE– annular, papulosquamous
 c. chronic CLE
i..classic discoid
ii. hypertrophic/verrucous
iii. lupus profundus or
lupus panniculitis
iv. Lupus tumidus (urticarial)
v. Mucosal dle – oral, conjunctival
Gilliam Classification of
LE skin lesions
2. LE-nonspecific skin disease:
Not LE-specific on histology
 Vasculitis
 Alopecia
 Bullae
 Leg ulcers
 Urticaria
 Nodules
 Acanthosis nigricans
Pathogenesis
 Triggers:
UV radiation, infection, drug and chemical
exposure, cigarette smoking

 Example of a mechanism:
UV light induces expression of “neoantigens”
(i.e intracellular antigens like Ro/SS-A,
La/ SS-B and calreticulin displaced to
keratinocyte cell surface)  target of a
dysregulated immune attack.
B. Exfoliative dermatitis
(Erythroderma)
 Characterized by erythema and extensive scaling of skin (70%
or more)
 Scaling may be thick or thin, of large sheets or small flakes of
skin, exudative or thickly crusted
 Constitutional signs and symptoms are present
 Chilliness  (+)inability of cutaneous blood vessels to constrict
 Hospitalization : For laboratory work-ups, proper therapeutics
and nutrition, patient convenience
 Varied etiologic factors: Inflammatory dses, Infectious dses,
Malignancies
 Skin biopsy by a dermatologist is IMPERATIVE
 Prognosis: Very good to grave depending on etiology
 Therapy : Months or years
Psoriasis (exfoliative)
Psoriasis (exfoliative)
Psoriasis (exfoliative)
Psoriasis (exfoliative)
PSORIASIS
PSORIASIS
PSORIASIS
 C. Hyperpigmented
Lesions
a. Post-inflammatory hyperpigmentation
b. Acanthosis nigricans
c. Amyloidosis –cutaneous/ systemic
d. Reaction to drugs (eg minocycline)
heavy metals, exogenous agents
e. Congenital d/o: Mongolian spot
f. Idiopathic: Ashy dermatosis
D. Hypopigmented Lesions
 VITILIGO
 - Loss of melanocytes
 - Etiology(?): autoimmunity,
autocytotoxicity, neurohumoral factors
 – most often associated with diseases of
the thyroid gland (hypo/hyperthyroidism)
 - localized (focal, segmental, acrofacial)
or generalized
To be continued on pt 2
Continued from pt 1
E. ALOPECIA

-Definition: Loss of hair

- Most common area: Scalp
- SLE – scarring or nonscarring alopecia
- Syphilis – “moth-eaten” appearance
- Other causes: anemia, thyroid disorders,
infections
- Idiopathic
Patchy Non-scarring
Alopecia
F. PURPURA

- Extravasation of blood
- Nonblanching (as opposed to
telangiectasia)
Example:
Hypersensitivity Vasculitis
Etiologies: Infections, Drug Reactions
G. LEPROSY

Macules, patches
Papules, plaques
Nodules
H. Cutaneous Lymphoma
(Mycosis fungoides)

Patch stage
Plaque stage
Nodular Stage
II. Wheals = Urticaria

A. Primary or idiopathic
B. Secondary Varied etiology:
1. contact urticaria
2. food
3. drugs
4. physical urticaria
5. infectious etiology - UTI, PTB, Hepatitis, HIV
6. systemic disease - SLE, hyperthyroidism
7. genetic origin - hereditary angioedema

8. malignancy
Physical urticaria

a. Pressure urticaria - e.g.dermographism

b. Solar urticaria
c. Heat urticaria
d. Cold urticaria
e. Exercise-induced urticaria
f. Vibration-induced urticaria
III. Nodules
a. Hereditary/ metabolic disorders
- Neurofibroma
- Xanthoma
- Myxedema (in hyperthyroidism)
b. Infection: Leprosy
c. Malignancy : leukemia/lymphoma cutis
d. Autoimmune disorders: SLE
e. Congenital malformations: hemangioma
f. Inflammatory d/o: Panniculitis
IV. Ulcers
a. Infection
b. Malignancy

c. Disorders of the circulatory system

1. Stasis ulcers 2* to venous insufficiency
2. Ulcers 2* to thromboembolism/ infarction

d. Metabolic diseases –
e.g.Necrobiosis lipoidica diabeticorum
e. Idiopathic – e.g. pyoderma gangrenosum
V. Blistering disorders
a. Burns
b. Infection – viral, bacterial, fungal
c. Contact dermatitis

d. Autoimmune diseases –
Pemphigus, Bullous pemphigoid,
Epidermolysis bullosa, SLE

e. Endocrine diseases – diabetic bulla

f. Nutritional disorders - zinc deficiency
Skin Lesions

 I. Macules/Patches; Papules/Plaques
 II. Wheals
 III. Nodules
 IV. Ulcers
 V. Blisters = Vesicles/ Bullae
I. Macules/Patches;
Papules/ Plaques
 A. SLE
 B. Exfoliative Dermatitis
 C. Hyperpigmented Lesions
 D. Hypopigmented Lesions - Vitiligo
 E. Alopecia
 F. Purpura – Hypersensitivity Vasculitis
 G. Leprosy
 H. Cutaneous Lymphoma (a.k.a. MF)
COMMON
DERMATOSES
Definition of Terms
 DERMATOSES = Entire spectrum of skin disorders
(inflammatory, congenital, neoplastic, etc.)

 DERMATITIS = Inflammatory diseases of the skin

 ECZEMA = Inflammatory diseases asstd with

intraepidermal edema (spongiosis)
 vesiculation
ECZEMA
(Greek eksein = to boil out)
 Acute/ subacute/ chronic

 3 GROUPS:
I. Contact dermatitis
II. Atopic dermatitis
III. Other Eczemas
Classification: Eczema
I. CONTACT DERMATITIS – allergic /
irritant
II. ATOPIC DERMATITIS
III. OTHER ECZEMAS
a. Nummular/ discoid dermatitis
b. Seborrheic dermatitis
c. Stasis dermatitis
d. Hand and foot eczema (palmoplantar
pompholyx)
Allergic CONTACT
DERMATITIS
(Nickel Dermatitis)
Allergic CONTACT
DERMATITIS
Chronic CONTACT
DERMATITIS
CONTACT DERMATITIS
Irritant CONTACT
DERMATITIS
Reaction to a peeling agent Secondary bacterial infection
Irritant CONTACT
DERMATITIS
ATOPIC DERMATITIS
(erythrodermic)
ATOPIC DERMATITIS
FACE : eyelids/ periorbital
darkening/ Dennie-Morgan Extensor limbs
infraorbital folds/ cheilitis
 ATOPIC
ATOPIC DERMATITIS
DERMATITIS
EXCORIATIONS / EROSIONS EXTENSOR LIMBS
ATOPIC DERMATITIS
FACE, NECK ANTECUBITAL FOSSAE, FLEXURE
ATOPIC DERMATITIS, resolved
ATOPIC DERMATITIS
Atopic cheilitis Face, lateral neck
 ATOPIC
ATOPIC DERMATITIS
DERMATITIS
Extensor surface of arms Extensor legs (shins)
ATOPIC DERMATITIS
LATERAL NECK
EYELIDS, LIPS: Atopic blepharitis, atopic cheilitis
ATOPIC DERMATITIS
EXTENSOR ARMS, ANTECUBITAL FOSSAE EXTENSOR LEGS, EXCORIATIONS, EROSIONS
 ATOPIC
ATOPIC DERMATITIS
DERMATITIS
Keratosis pilaris Neck involvement
ATOPIC DERMATITIS
Hypo-orbital lines
Atopic blepharitis (eyelids)
(Dennie-Morgan folds)
ATOPIC DERMATITIS
ATOPIC DERMATITIS
Popliteal vaults
Peri-axillary vaults
ATOPIC DERMATITIS
LATERAL NECK LIMBS/ FLEXURES
ATOPIC DERMATITIS
Extensor surface Autoeczematization/ id reaction
ATOPIC DERMATITIS
(early)
ANTECUBITAL FOSSAE POPLITEAL VAULTS
ATOPIC DERMATITIS
(late)
Scars due to chronic
ATOPIC DERMATITIS
ATOPIC DERMATTITIS
ATOPIC DERMATTITIS
ATOPIC DERMATTITIS
 ATOPIC DERMATTITIS

ATOPIC XEROSIS ANTECUBITAL FOSSAE(flexure)

 ATOPIC DERMATTITIS
ATOPIC DERMATTITIS
LATERAL NECK EXCORIATIONS/ EROSIONS with
secondary bacterial infection
ATOPIC DERMATTITIS
ATOPIC DERMATTITIS
EXTENSOR LIMB (+) EXCORIATIONS
NUMMULAR/discoid
dermatitis
Tinea corporis a.k.a.
Differential diagnosis  “ringworm”
NUMMULAR/discoid
dermatitis
NUMMULAR/ discoid dermatitis
Uncomplicated With secondary bacterial
infection
NUMMULAR/ discoid
dermatitis
NUMMULAR/ discoid
dermatitis
NUMMULAR/ discoid
dermatitis
SEBORRHEIC DERMATITIS
Hand dermatitis (palmar
pompholyx)
Hand dermatitis
(Pompholyx)
PALMAR SURFACE VESICLES / ERYTHEMA
Hand dermatitis
(Pompholyx)
PLANTAR POMPHOLYX
STASIS DERMATITIS
Varicosities, medial ankle Stasis ulcer
TREATMENT
A. Topical
1. Steroids – hydrocortisone, dexamethasone,
mometasone, methylprednisolone, triamcinolone,
betamethasone, clobetasol, fluocinolone
2. Antibiotics – gram-positive coverage, broad-spectrum
3. Immunomodulatory drugs - tacrolimus

B. Systemic
1. Antihistamines – sedating/ nonsedating
2. Antibiotics
3. Steroids – prednisone, methylprednisolone,
hydrocortisone
4. Immunomodulatory durgs – cyclosporine
TREATMENT

C. Phototherapy
Use of ultraviolet light:
1. UVA-1  atopic dermatitis
2. Narrow-band UVB

D. Intralesional injections of corticosteroids

COMMON SKIN
INFECTIONS
A. BACTERIAL
B. FUNGAL
C. VIRAL
BACTERIAL

1. Impetigo
2. Ecthyma
3. Cellulitis
4. Folliculitis furunclecarbuncle
IMPETIGO (in atopic patient)
Atopic dermatitis with
secondary bacterial infection Fine yellow crusts
PYODERMA (Chronic eczema with
secondary bacterial infection)
PYODERMA (Chronic
eczema with secondary
bacterial infection)
ECTHYMA
Typically shins and dorsal feet Ulcers with raw base and
elevated edges
ECTHYMA
ECTHYMA
Ulcers with raw base
and elevated edges
STASIS ULCER with secondary
bacterial infection (cellulitis)
Ill-defined red, hot, painful Infection involves the dermis
plaque of CELLULITIS and subcutaneous tissue
Differential diagnoses:
Tinea cruris, erythrasma, psoriasis
LEPROSY
Indurated plaques  alae & cheeks Secondary bacterial infection
LEPROSY
FUNGAL
1. SUPERFICIAL (1-2mm)
3 genera of dermatophytes:
a. Trichophyton
b. Microsposum
c. Epidermophyton

2. DEEP MYCOSIS / SYSTEMIC 

inhalation or direct contact
FUNGAL
SUPERFICIAL FUNGAL INFECTIONS:
a.k.a. DERMATOPHYTOSIS (Tinea,
ringworm)
Classified according to site:
1. Tinea capitis
2. Tinea faciale
3. Tinea corporis
4. Tinea pedis / manuum
5. Tinea unguium (onychomycosis)
Tinea corporis
Active raised border Peripheral scaling
TINEA PEDIS
TINEA PEDIS
Onychomycosis & Tinea pedis
Onychomycosis &Tinea pedis
ONYCHOMYCOSIS INTERDIGITAL involvement
VIRAL

1. Human papilloma virus (HPV)

 Verruca ( warts)

2. Varicella zoster virus (VZV)

 a. Varicella (chickenpox )
b. Herpes zoster
HERPES ZOSTER
Early stage : Papules, vesicles Later stage: More vesicles, dermatomal spread
 HERPES
HERPES ZOSTER
ZOSTER
Late stage: Clearly vesicular Clearly dermatomal
HERPES ZOSTER:
very late stage or inadequate treatment
HERPES ZOSTER:
very late stage or inadequate treatment
Herpes zoster in a young child
Herpes zoster with secondary
bacterial infection