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Describing skin lesions in following
points-
Basic lesions in
Size
Shape
Dermatology
Symmetry
Surface area
Name of the Doctor :-
Type of lesion
Dr. Shivi Nijhawan
Colour and pigmentation
Distribution over body surface
Main shapes of skin lesions:-
Shape Description Examples Stellate Star-shaped Lesions of meningococcal
septicaemia
Discoid A filled circle Discoid eczema, psoriasis
(nummular) Digitate Finger-shaped Chronic superficial dermatosis
Petaloid Discoid lesions which have merged Seborrhoeic dermatitis on
together trunk
Arcuate Incomplete circles Urticaria Linear Straight line Koebner reaction to a scratch in lichen
planus or psoriasis
Annular Open circles with different central Tinea corporis,
skin compared with rim granuloma annulare Serpiginous Snake-line Cutaneous larva migrans
Polycyclic Circles which have merged together Psoriasis
Whorled Swiriling pattern Epidermal naevi, late- stage
Livedo Chicken-wire criss-cross pattern Erythema ab igne, incontinentia pigmenti.
polyarteritis nodosa,
microvascular occlusion
disorders
Reticulate Fine lace-like pattern Oral lichen planus
Target Multiple concentric rings Erythema multiforme
Discoid (nummular) shape Petaloid shape
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ARCUATE LIVEDO RETICULATE
ANNULAR
TARGET STELLATE DIGITATE LINEAR
SERPIGINOUS WHORLED
•Dermatomal/zosteriform:-
Unilateral & along a
dermatome.
[Link] zoster, zosteriform
nevi.
•Blaschkoid- arranged along line
of skin cell migration( line of
blaschko) due to mosaicism.
•Whorled appearance with V
shaped over back.
•S shaped over trunk
•Longitudinal on limbs.
•Eg. Incontinentia pigmenti
Verrucous epidermal nevus
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PATTERN OF LESIONS
SCATTERED, DISSEMINATED &
Useful terminology to describe patterns include :-
EXANTHEMATOUS- eg. Many drug eruptions, viral
exanthemata.
AGMINATE- clustered, eg. acne agminota, agminate nevi.
SPREAD- patterns of sparing like-
GROUPED/ CLUSTER- characteristic of some infection(
Island of sparing…orange-red erythema of pityriasis
Eg. Herpetic vesicles, molluscum contagiosum, plane rubra pilaris.
warts) , flea bites
Sparing within skin folds in papuloerythroderma of
ofuji.
SATELLITE- a cluster of lesions around a larger central
Areas shielded by clothing/ wristwatch spared in
lesion. [Link] IgA diseases/ chronic bullous diseases of
photosenstivity.
childhood.
CONFLUENT- lesion merging together, locally or
SYMMETRICAL- often endogenous eg. Psoriasis.
widespread. [Link].
The lesions of the skin
COLOUR OF SKIN AND OF LESIONS
Flat Surface Fluid Vascular
Normal skin colour is due to melanin, phaeomelanin, Raised Depressed change filled
haemoglobin, oxyhaemoglobin and carotenoids. Papule Erosion Macule Scale Vesicle Purpura
Plaque Ulcer Patch Crust Bulla Telangiectasia
colour Examples Nodule Atrophy Erythema Excoriation Pustule Infarct
Black Melanin eg. Some naevi, melanoma. Cyst Poikiloderm Erythroderma Fissure Furuncle
Deeply situated blood/melanin [Link], blue naveus a
Purple Vascular lesions eg. angiomas Wheal Sinus Lichenification Abscess
Violaceous Lichen planus Scar Striae kertoderma
Pink-red Psoriasis comedo Burrow Eschar
White-ivory morphoea Horn Sclerosis
White(or pale Vitiligo, naevus anamicus Calcinos
pink,depending on is
vascularity)
Orange Hemosiderin eg. Lichen aureus.
Inflammatory disorders eg. Pityriasis rubra pilaris
Primary lesions- basic reaction patterns of skin with
Types of skin lesions categorized as- definite morphology or native appearance of skin
lesions (such as papule)
Primary
Secondary
Special
Secondary lesions- reflect the effects of exogenous
factors or temporal changes (such as “scales” or
“crusts”) that evolve during the course of a skin disease.
Special skin lesions - specific for certain disease.
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Primary skin lesions- Macule
A Circumscribed alternation in colour of
• Macule the skin. (not palpable)
• Patch
Size-0.5cm-1cm
• Papule
• Plaque Subclassified as-(depending upon color)
• Pustule Hypopigmented/depigmented macules
• Nodule
• Vesicle Hyperpigmented macules
• Bulla Also other color([Link],red, violet)
• Abscess Eg. Epithelid(freckle)
• Wheal
• Cyst Lentigo
• Angioedema Petechiae
• Purpura, petechiae & ecchymosis
Hypopigmented- Hyperpigmented macules-
Decrease in number of melanocytes/ melanin. Due to hypermelanocytosis/ hypermelanosis in skin.
Eg- Pityriasis alba,
Pityriasis versicolor Increased melanin in epidermis (Number of melanocyte is
Tuberous sclerosis fixed)- in freckles & melasma give brown to black color
Nevus depigmentosus
Leprosy Increased number of melanocytes seen in- lentigo
simplex & lentigo maligna.
Total absence of melanocytes give rise to chalk-white
depigmented [Link]-vitiligo.
Brown coloured macules
Melanin present in dermis produce bluish-grey tinge
Beckers neveus Freckl
eg. Mongolian spot, nevus of ota, cellular blue nevus.
e
Postinflammatory hyperpigmentation have both
epidermal & dermal component
Cafe-au-lait spot
Fixed drug eruption
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Blue coloured macules Erythema- Red coloured macules
Mongolian spot Nevus of ota Blue
naevus Increased blood flow through skin caused by capillary
dilatation produce erythematous(pink) macules.
Easily blanched by pressure( positive diascopy) as in
macular viral & drug rashes
Psoriasis
Drug eruptions Secondary
syphilis
Patch Papule
A large macule is called patch (>1cm in size). A circumscribed palpable elevation, less than 0.5cm in
Often hypo-or hyperpigmented. diameter.
Also other colors(eg. Blue,violet) Elevation due to increased thickness of epidermis or
Eg :- Vitiligo, Melasma, Dermal melanocytosis( Mongolian cells within dermis.
spot) Examination include-
shape,color,umblication,distribution, configuration,and
MELASMA VITILIGO tenderness.
[Link] keratosis, cherry hemangioma,
molluscum contagiosum, lichen nitidus
Plaque
Dermal – Granuloma annulare, Sarcoidosis, Hypertrophic
An elevated area of skin, usually defined as 2cm or more scar-Keloid, Morphea
in diameter.
Formed by extension or coalescence of either papules (in
psoriasis) or nodules( in granuloma annulare)
Granuloma annulare Hypertrophic
May have secondary changes( [Link], crust)
scar-Keloid
Primarily epidermal- psoriasis, lichen simplex chronicus,
nummular dermatitis.
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Pustule Vesicular lesions(varicella, herpes simplex,
A visible accumulation of free pus. herpes zoster) may turn into pustular.
Occur within pilosebaceous follicle or sweat duct. Herpes zoster
Pustules seen in- ACNE, Folliculitis, Scabies
Folliculitis ACNE
Gram’s stain & culture of purulent exudates is
essential
Nodule Vesicle
A solid mass in the skin, observed as an elevation or
Visible accumulations of clear fluid within or beneath
can be Palpable. epidermis.
greater than 0.5 cm in diameter. Small (less than 0.5cm in diameter) and often grouped.
It involve epidermis & dermis, dermis & subcutis, or May become pustular, umbilicated or an erosion.
subcutis alone.
Eg. Herpex simplex, varicella or zoster, dermatitis
Consist of fluid, other extracellular material (eg. herpetiformis, dyshidrotic eczema.
Amyloid), inflammatory or neoplastic cells.
Dyshidrotic eczema Herpex
o Eg. Epidermal inclusion cyst simplex
o Lipoma
o Neurofibromas
o Panniculitis, [Link] Nodosum
o Lymphoma cutis
Bulla Abscess
Elevated, circumscribed A localized collection of pus deep in dermis or
More than 1 cm in diameter subcutaneous tissue.
Filled with clear fluid. Due to deep seated location, pus may not be visible
Bullous pemphigoid Fixed drug on skin surface but show sign of Inflammation.
eruption
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Whel( hives) Borders are sharpe but unstable, & tends to change
within hours
Shapes-may vary, being round, oval, geographic,
A transient area of dermal and hypodermal serpiginous, annular.
oedema,white, compressible and usually
evanescent.
Size-range from few mm to more than 10 cm
Characteristic lesion of urticaria.
It result from transient vascular reaction in upper
dermis in which there is both vasodilation &
increased permeability of capillaries give rise to
edema.
Stroking of normal skin may produce whel in quarter Cyst
of normal individuals-phenomenon k/s
dermographism. Any closed cavity or sac (normal or abnormal) with an
epithelial, endothelial or membranous lining &
containing fluid or semisolid material.
Wheals of cholinergic urticaria are very tiny & multiple
in number, induced on sweating. Resembles spherical nodule MUCOUS
RETENTION CYST
DERMOGRAPHISM
Soft/doughy, hard or fluctuant.
m/c cutaneous cysts are-
[Link] cysts
( keratinous cysts)
[Link] cysts
(originate from hair follicle)
Purpura, petechie &
Angioedema( Quincke’s edema) ecchymoses
Diffuse, deep, edematous reaction occurring in areas Extravasation of red cells in dermis produce pinpoint
with loose dermis, & subcutaneous tissue such as lip, purpuric lesions which donot blanch ( negative
eyelids, rarely larynx.
diascopy).
Purpuric lesions may be palpable or nonpalpable
Eg. Senile purpura, Henoch-schonlein purpura,
Thrombocytopenic purpura, Vasculitis
Persists for longer time and associated with dull
aching pain.
Laryngeal edema occur as part of anaphylactic
reaction due to insect stings, or drugs & may be fatal
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A punctate haemorrhagic spot, approx.1-2 mm in Secondary lesions
diameter called petechie.
Crust
Erosion
Excoriation
Ulcer
Scar
A macular area of haemorrhage more than 2 mm in Scale
diameter called ecchymoses( bruise).
Crust (Scabs)
Crusts consist of dried serum and other exudates.
Which might be either yellow/red.
Tinea capitis Impetigo
EROSION
Excoriation
A focal loss of epidermis, which heals without scarring.
Loss of skin substance, specifically produced by
It commonly follows a blister. scratching.
Eg:- Tinea pedis, Candidiasis
Tinea pedis candidiasis
Characteristically linear.
Seen in pruritic disorders-
atopic dermatitis & scabies.
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Ulcer(of skin)
Lichenification is a plaque of thickened skin with
accentuated skin markings caused by constant A loss of dermis and epidermis, often
rubbing, eg in area of lichen planus. With loss of the underlying tissues.
Scarring depends on the
depth of the ulcer
[Link],
Pyoderma gangrenosum
Decubitus
Palpation :-
Local rise of temperature & tenderness.
Exact dimensions-
depth
Induration /thickness of edge
- In chronic ulcer
Base
-Fixicity to undrlying structure
Bleeding on touch
- Malignant or chronic ulcer.
Types of ulcer edges
Types of Description Condition
chancroid
edge
Sloping Shallow ulcer with healthy Venous ulcer
granulation tisssue
Punched-out Full thickness loss of tissue from Vasculitic / arterial ulcers,
edges tertiary syphilis
Undermined Destruction of subcutaneous Tuberculous ulcers,
tissue more than skin pressure sores
Everted / Growth of tissue over & beyond SCC
exophytic edge.
Basal cell epithelioma
Rolled Slowly growing edges with rolled
out appearance
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Scar
Pyoderma Replacement by fibrous tissue of another tissue that
gangrenosum Decubitus has been destroyed by injury or disease.
An atrophic scar is thin and wrinkled. Eg. acne ,
surgery, after trauma
A hypertrophic scar is elevated, with excessive growth
of fibrous tissue. Eg. keloid
Scale
A cribriform scar is perforated with multiple small
pits. A flat plate or flake of stratum corneum.
eg. Pyoderma gangrenosum
Eg. Psoriasis, Icthyosis
Lamellar/plate- Large, polygonal,thick,rigid Lamellar ichthyosis
Types of scales like scale(armor grey/brown firmly adherent
plate) scales
Types of scale Description Typical condition
Trailing scale Annular erythema with advancing Erythema annularis
flat/ elevated border & trailing centrifugum
Collarette scale Fine ,peripherally Pityriasis rosea scale at inner border with central
attached & centrally Miliaria area flattening
detached scale at edge Subsiding lesions of
of inflammatory lesion. furuncle Mica-like/ wafer- Thin adherent mica-like scale Pityriasis lichenoides
like scale attached at center of lichenoid chronica
Furfuraceous scale Inconspicuous loose Pityriasis versicolor firm reddish brown papule & free
(branny)/ pityriasiform scales made visible by at periphery
scales scratching ( scratch
sign) Double-edged Annular or polycyclic, flat patch Ichthyosis linmearis
scale with incomplet avancing double circumflexa (ILC),
Ichthyosiform scale Large and polygonal Ichthyosis vulgaris edge of peeling sccale. Netherton syndrome
fish-like scales
Cornflake scale Scale separates from lesions, Pemphigus foliaceous,
Micaceous scale Silvery-white scale Psoriasis leaving non-exudative red base flegel’s disease
Hystrix-like scale Porcupine-like muddy brown Ichthyosis hystrix
Limpet-like Conical heaped up Reiter’s syndrome adherent skin covering whole
mound of adherent body
scale
Coat of armor Rigid, taut, yellow-brown Harlequin ichthyosis
Greasy scale Moist, yellow-brown Seborrheic dermatitis adherent skin covering whole
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Special lesions
Burrow
Comedone
Milium
Telangiectasia
Target lesion
Calcinosis
Burrow Comedone
•A small tunnel in the skin that
•A plug of keratin and sebum in a
houses a parasite.
dialated pilosebaceous orifice.
•Such as scabies acarus.
•It is a serpentine tunnel
made by scabies mite in
Stratum corneum.
•It is of two types:
1) Open comedone (black head)
•The open end of the
tunnel has a papule
2) Closed comedone (white head)
Open comedone( blackhead)- impaction occurs in a Milium
dilated follicular orifice, visible as a black keratinous
mass.
Resulting from oxidation of sebaceous contents.
•It is a tiny white cyst containing
Lamellated keratin.
•Milia are seen on face- at
periorbital
Closed comedone(whitehead)- follicular opening are region.
closed & lesions appear as tiny papules, lighter in
color than surrounding skin.
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Telengiectasia Target lesion
These are less than 3 cm in diameter.
Have three or more zones:- usually a central area of
It is visible dilataion of dusky erythema or purpura.
capillaries of skin which A middle palar zone of oedema
blanch on pressure. An outer ring of erythema with well-defined edge.
[Link] multiforme
Eg:- Dermatomyositis,
Systemic sclerosis
Calcinosis Sinus
Occur due deposition of calcium in dermis or A cavity or track with blind ending.
subcutaneous tissue. Pus filled or keratin may drain out of sinus onto skin
surface.
Present as chalky white hard papules, plaques or Eg. Hidradenitis suppurativa.
nodules.
Primary calcinosis- occurring as a part of an underlying
metabolic abnormality
Secondary calcinosis- occurring at sites of previous
inflammation or within preexisting cutaneous lesions eg
epidermal cysts.
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