Dermatology

Image Bank
 Index
Sl.No. Chapter Pg.No.

1. Skin: Basic Structure and Function 09

2. Cutaneous signs and diagnosis 11
3. Dermatitis 16
4. Psoriasiform Disorders 22
5. Lichenoid and Granulomatous Disorders 27
6. Neutrophilic, Eosinophilic, and Mast Cell Disorders 30
7. Epidermal Necrolysis 31
8. Disorders of Cornification 34
9. Vesiculobullous Disorders 37
10. Connective Tissue and Rheumatologic Disorders 41
11. Subcutaneous Tissue Disorders 55
12. Melanocytic Disorders 57
13. Acneiform Disorders 62
14. Disorders of Eccrine and Apocrine Sweat Glands 65
15. Disorders of the Hair and Nails 67
16. Disorders Due to the Environment 72
17. Psychosocial Skin Disease 74
18. Paediatric Dermatology 75
19. Neoplasia 80
20. Metabolic, Genetic, and Systemic Diseases 89
21. Infections 96
 9

Basic Structure and Function

Cross section of the skin and panniculus.

During the first weeks of life, the

fetus is covered by a layer of
nonkeratinizing cuboidal cells called The epidermis can be divided into the
the periderm. Later, the periderm is innermost basal layer (stratum
replaced by a multilayered epidermis. germinativum), the malpighian or prickle
layer (stratum spinosum), the granular
layer (stratum granulosum), and the
horny layer (stratum corneum). On the
palms and soles, a pale clear to pink
Dermis & ectoderm are
layer, the stratum lucidum, is noted just
[NEET119]
derived from ectoderm. above the granular layer

Reference:Fitzpatrick’s Dermatology(pg 49 )
Andrews diseases of skin
 10

Apocrine units develop as outgrowths of the infundibular or upper

portion of the hair follicle.

The coiled secretory gland is located at the junction of the dermis and
subcutaneous fat. It is lined by a single layer of cells, which vary in appearance
from columnar to cuboidal. This layer of cells is surrounded by a layer of
myoepithelial cells. Apocrine coils appear more widely dilated than eccrine coils

Cross section of anagen bulb demonstrating

pigment within matrix.

Vertical section of telogen hair demonstrating “flamethrower” appearance of club

hair.
 11

Cutaneous signs and diagnosis

Macule, Circumscribed area of change in skin Papule: Solid lesion, <0.5 cm;
color without any change in consistency

Plaque: Area of altered skin consistency with a

Nodule: Solid lesion, >0.5 cm surface area of which is greater than its depth

Andrews diseases of skin

 12

Wheal: Evanescent, pale erythematous Blister: Circumscribed, elevated,

raised lesion which disappears within superficial fluid filled lesion
24-48 hr

Crust: Yellow brown collection of

Scale: Flakes of stratum corneum keratin and serum

Lichenification, Thickening and

hyperpigmentation of skin with Burrow: Serpentine, thread-like, grayish
increased skin markings curvilinear lesion, diagnostic of scabies
 13

Apple-jelly sign, sarcoidosis. Atypical targetoid lesions, Stevens-

Johnson syndrome due to medication.
 14

Violaceous Gottron papules, dermatomyositis. Yellow, necrobiosis lipoidica diabeticorum.

Annular lesion, granuloma annulare. Reticular eruption, livedo racemosa.

Serpiginous erythema, jellyfish sting.

Nummular lesion, nummular dermatitis.
 15

Erythematous plaques studded with sheets

Macular depigmentation, vitiligo. of pustules, pustular psoriasis.

Whitish grouped papules of lichen nitidus. Ulcer of the lip, chancre of primary syphilis.

Vesicles, bullae, and erosions;

bullous pemphigoid.

Q. Identify the lesion.

Annular, arcuate, and polycyclic

configurations; granuloma annulare.
 16

Dermatitis
Atopic Dermatitis

A child presents with itchy hyper pigmented

plaque with exudation on the flexural of the
elbow and back of knee as shown.What is the
most probable diagnosis ?
A.Psoriasis C.Dermatitis herpetiformis
B.Atopic dermatitis D.Pemphigus

Flexural involvement in
childhood atopic dermatitis
Severe, widespread atopic dermatitis.

Reference:Fitzpatrick’s Dermatology(pg363 )
 17

Atopic hand dermatitis.

Itching infant with atopic dermatitis.

Periocular atopic dermatitis

Prurigo-like papules in adult

atopic dermatitis.

Edematous, erythematous eyelids with

lichenification and hyperpigmentation
in an adolescent with atopic dermatitis.
Recurrent herpes simplex in atopic dermatitis.
 18

Nummular Eczema, Lichen Simplex Chronicus,

and Prurigo Nodularis
NUMMULAR ECZEMA

Coin-shaped plaques with pinpoint erosions and excoriations

Lichen simplex chronicus

lichenification, hyperpigmentation, and hypopigmentation with excoriation.

 19
PRURIGO NODULARIS

Multiple itchy nodules mainly on the extremities, especially on the anterior

surfaces of the thighs and legs. A linear arrangement is common.

Allergic Contact Dermatitis

Allergic contact dermatitis to para-phenylenediamine. A, Notice the eczema

on the distribution of the hair-line and behind the ears. B, Dermatitis on the
forehead where the bangs came in contact with the skin of the same patient. [MEET/18]

-
A child has a rash as shown in the picture .His
family history is positive for asthma . What
could be the most probable diagnosis

Allergic contact cheilitis. Fragrances and

flavorings are among the most common
causes of contact allergy in patch-tested
patients with cheilitis.
 20

Allergic Contact Dermatitis Syndrome

Stage 1: Localized allergic contact dermatitis
Stage 2: Regional dissemination of allergic contact dermatitis
Stage 3A: Generalized or distant involvement of allergic contact dermatitis
Stage 3B: Systemic exposure resulting in systemic contact dermatitis

Persistent patch test reaction to gold. Patch-test grading.

Nickel dermatitis caused by earring.

Acute shoe dermatitis
 21

Seborrheic Dermatitis
Seborrheic dermatitis is a common inflammatory skin disease affecting various age
groups.
Erythematous, greasy, scaling patches and plaques appear on scalp, face, ears,
chest, and intertriginous areas.
Severe forms, like generalized erythroderma, rarely occur.
Etiology is unclear but may be related to abnormal immune mechanism,
Malassezia, sebaceous glands, and individual susceptibility.
Treatment is based on symptomatic control.

Pityriasis amiantacea

Masses of sticky silvery scales adhere

to the scalp and cause matting of
hairs they surround.
large plates of thick, silvering scale
firmly adherent to both the scalp and
hair tufts and is attributed to diffuse
hyperkeratosis and parakeratosis with
follicular keratosis surrounding each
hair with a sheath of corneocytes and
debris.
 22

Psoriasiform Disorders
psoriasis
A chronic disorder with polygenic predisposition combined with triggering environmental
factors such as trauma, infection, or medication.
Erythematous scaly papules and plaques; pustular and erythrodermic eruptions occur.
Most common sites of involvement are scalp, elbows, knees, hands, feet, trunk, and nails.

Chronic plaque psoriasis

Well-demarcated, raised, red plaque with a white scaly surface

Guttate psoriasis
Eruption of small (0.5–1.5
cm in diameter) papules Fissured and geographic tongue
over the upper trunk and in patient with generalized
proximal extremities pustular psoriasis

Reference:Fitzpatrick’s Dermatology(pg 457)

 23

Psoriatic arthritis
Arthritis mutilans with osteolysis Erythrodermic psoriasis
of phalanges and metacarpals Instead of thick, adherent, white scale,
there is superficial scaling. Lose excessive
heat because of generalized vasodilatation,
and this may cause hypothermia.

Nail with oil spot of psoriasis

Nail pitting and distal

onycholysis in psoriasis.
 24

Inverse psoriasis “Napkin” Psoriasis

Psoriasis lesions may be localized Napkin psoriasis, or psoriasis in the diaper
in the major skin folds, such as area, is characteristically seen in infants
the axillae, the genitocrural between 2 and 8 months of age.
region, and the neck.

Auspitz sign -
point of bleeding after the scale is removed.

Pustular psoriasis
Attacks are characterized by fever that lasts
several days and a sudden generalized eruption
of sterile pustules 2 to 3 mm in diameter
 25

Pityriasis Rubra Pilaris

Follicular hyperkeratotic papules that coalesce into scaly, reddishorange–colored plaques,
which may progress to erythroderma with well-demarcated islands of normal skin.

Islands of sparing

Generally symmetric and diffuse, with

characteristic small islands of normal
skin within the affected areas. There is
a hyperkeratosis of the palms and
soles , with a tendency to fissures.

Salmon-colored
appearance, presents with
classical islands of
healthy skin over the
trunk, distinct areas of
follicular hyperkeratosis,
and a waxy palmoplantar
keratoderma
 26

PITYRIASIS LICHENOIDES

Polymorphous appearance ranging from

early erythematous papules to scaling
brown-red lesions and tan-brown
involuting, flat papules, and macules.

Pityriasis Rosea
Classically begins as an isolated 3- to 5-cm oval plaque on the trunk with a collarette
of fine scale just inside the periphery, which plaque is called a herald patch.

A nonscaly purpuric primary plaque A typical primary plaque (herald patch) of

(herald patch) of pityriasis rosea. pityriasis rosea, demonstrating an oval
shape and fine scale inside the periphery of
the plaque.

Vesicular pityriasis rosea,

showing typical primary plaque
and secondary papulovesicles.
Note Christmas tree distribution.
 27

Lichenoid and Granulomatous Disorders

Lichen planus
■ Lichen planus is an idiopathic T cell–mediated process without a clear autoantigen.
■ The lesions are well-marginated, flat-topped, red-violet polygonal papules.
■ The distribution is symmetrical and grouped lesions affect the flexural aspects of
the arms and legs.
Flat-topped, polygonal, sharply defined
papules of violaceous color, grouped and
confluent. The surface is shiny and reveals
fine white lines (Wickham striae). Note the
hyperpigmentation of resolving lesions.

Koebner phenomenon
Trauma induces disease "

[NEET 20]

Lichen planus of the nail. Q. Identify the phenomenon?

Annular lichen planus.

Lichen plants of palms and soles

Reference:Fitzpatrick’s Dermatology(pg 527)

 28

Hypertrophic lichen planus. Well-marginated, acanthotic and papillomatous, dull-violet

plaques are noted over the anterior shin. Areas of postinflammatory hyperpigmentation
as well as superficial varicosities, signifying venous stasis, are noted.

Granuloma Annulare
A localized ring of beaded papules on the extremities is typical; generalized,
subcutaneous, perforating, and patch subtypes also occur.

A, Typical annular lesion of granuloma A, Generalized granuloma annulare. Small

annulare on a finger. papular lesions that are too small to exhibit
B, A larger annular lesion of granuloma annular configuration. B, Multiple annular
annulare on the dorsum of the hand. lesions on the lower arm.
 29
Sarcoidosis
Sarcoidosis is a multisystem disease characterized by granulomatous inflammation
of unknown etiology commonly occurring in the lung and the skin, but any organ
system can be affected.

Periorbital papular lesions.

Lupus pernio

Sarcoidosis Diascopy revealing “apple-jelly” coloration.

 30

Neutrophilic, Eosinophilic, and Mast Cell Disorders

Pyoderma Gangrenosum

Pathergic pyoderma gangrenosum lesions

occurring along a thoracotomy scar site.
Note central ulceration, violaceous
borders, and peripheral rim of erythema.

Established lesion of classic ulcerative

pyoderma gangrenosum showing well-
defined ulceration, undermining, and
surrounding zone of erythema Bullous pyoderma gangrenosum lesion showing
collapsed roof of blister and superficial erosive
quality of the subsequent ulceration.

Urticaria and Angioedema

Skin disorder characterized by local transient skin or mucosal edema (wheal) and an area of
redness (erythema) that typically accompany itchy sensations and diminish within 1 day.

Reference:Fitzpatrick’s Dermatology(pg 587)

 31
Epidermal Necrolysis
Stevens-Johnson Syndrome and Toxic Epidermal Necrolysis

Confluent purpuric and erythematous macules evolving to flaccid blisters and

epidermal detachment often start on the upper trunk and spread to the limbs
associated with mucous membrane involvement.

Nikolsky sign, or dislodgement of the

epidermis by lateral pressure, is positive
on erythematous zones

A, Early eruption. Erythematous dusky B, Early presentation with vesicles and blisters.
red macules (flat atypical target Note the dusky color of blister roofs, strongly
lesions) that progressively coalesce and suggesting necrosis of the epidermis.
show epidermal detachment.

C, Advanced eruption. Blisters and D, Full-blown epidermal necrolysis characterized

epidermal detachment have led to by large erosive areas reminiscent of scalding.
large confluent erosions.

Reference:Fitzpatrick’s Dermatology(pg 733)

 32

Cutaneous Reactions to Drugs

Drug hypersensitivity syndrome: phenytoin.

Exanthematous drug eruption: ampicillin. Symmetric, bright red, exanthematous
Symmetrically arranged, brightly eruption, confluent in some sites; the
erythematous macules and papules, which patient had associated lymphadenopathy.
are discrete in some areas and confluent
in others on the trunk and discrete on
the extremities.

Fixed drug eruption: tetracycline. A Skin necrosis in a patient after 4

welldefined plaque on the knee, merging days of warfarin therapy.
with 3 satellite lesions. The large plaque
exhibits epidermal wrinkling, a sign of
incipient blister formation.
 33

Superficial erythema annulare centrifugum.

A large annular
plaque with
trailing scale Multiple lesions
behind the demonstrated
advancing epidermal changes
erythematous with a trailing
edge. scale.
 34

Disorders of Cornification
ICHTHYOSIS

XLINKED RECESSIVE ICHTHYOSIS

Scaling may begin in the newborn
period and is usually most prominent
on the extensor surfaces, although
there is significant involvement of
the flexural areas.

Collodion infant.
The infant is 36 hours old and is covered
with a macerated membrane that shows
fissures; note ectropion and eclabium. The
condition may develop over time into
various clinical phenotypes, including
autosomal recessive congenital ichthyosis
and self-healing collodion baby.

AUTOSOMAL RECESSIVE
CONGENITAL ICHTHYOSIS
LAMELLAR ICHTHYOSIS PHENOTYPE
The LI phenotype of ARCI
is apparent at birth, and
the newborn usually
presents encased in a
collodion membrane

Reference:Fitzpatrick’s Dermatology(pg 775)

 35
Harlequin ichthyosis

Note the rudimentary ears and the

distorted appearance as a result of the
thick “plates” of stratum corneum.

Trichothiodystrophy

Autosomal recessive disorder that includes a broad spectrum of clinical

phenotypes linked by the characteristic features of sulfur deficient,
brittle hair that exhibits alternating birefringence (tiger tail banding)
when viewed under polarizing microscopy
 36

Epidermolytic Ichthyosis
Epidermolytic ichthyosis (EI) comprises what
used to be called nonbullous congenital
ichthyosiform erythroderma, epidermolytic
hyperkeratosis (EHK), and ichthyosis bullosa
of siemens. EI is usually manifested by
blisters at or shortly after birth.

Netherton Syndrome
Inherited autosomal recessive disorder of
cornification. It may first appear as severe
congenital generalized exfoliative
erythroderma in infancy. Then children
develop migratory annular and polycyclic
patches of ichthyosis linearis circumflexa.
Lesions predominate on the trunk and
extremities, and appear as a polycyclic
serpiginous eruption characterized by
constantly changing patterns.

XERODERMA PIGMENTOSUM BLOOM SYNDROME (BLOOM-TORRE-

Autosomal recessive disorder MACHACEK SYNDROME)
characterized by defective DNA Characterized by photosensitive
thymidine dimer excision repair, telangiectatic erythema in the butterfly
extreme sun sensitivity, freckling, area of the face (which can be very similar
and skin cancer. to RTS) along with dwarfism.
 37

Vesiculobullous Disorders
PEMPHIGUS VULGARIS
A patient comes with lesions in the skin.Biopsy was done and
histology of lesion is as shown.
What is the probable diagnosis ?
A.Mycosis fungoides
B.Lepromatous leprosy
C.Pemphigus
D.Leishmaniasis
[INICET 2021]
Pemphigus vulgaris: erosions on mucous
membranes and skin; flaccid blisters on skin.
Pemphigus foliaceus: crusted, scaly skin lesions.
Extensive erosions due to blistering.
Almost the entire back is denuded. Note
intact, flaccid blisters at the lower border
of eroded lesions.

Flaccid blisters Oral erosions

A 30yr old patient came with flaccid bullae
on her skin which are easy to
rupture.Biopsy revealed suprabasal
split.What is the most probable
diagnosis ?
A.Pemphigus vulgaris
B.P.vegetans
C.P.foliaceous
D.Erythema multiforme [NEET 2021]

Reference:Fitzpatrick’s Dermatology(pg 909)

 38

Bullous pemphigoid.

A, Large, tense bullae, some of which

are denuded on the upper leg.
B, An example of the noninflammatory
form of bullous pemphigoid.
C, Urticarial and erythema
multiforme–like lesions of bullous
pemphigoid on the thighs.

intraepidermal neutrophilic
IgA dermatosis–type
intercellular IgA dermatosis showing
atypical pustular skin lesion with so-
called sunflower-like configuration.
 39

Dermatitis Herpetiformis

DERMATITIS HERPETIFORMIS
(DUHRING DISEASE)
Chronic, relapsing, severely pruritic
disease characterized by grouped,
symmetric lesions on extensor surfaces,
the scalp, nuchal area, and buttocks.

This patient has many firm-topped vesicles and

Extensive eruption with bullae, some erosions, and residual
grouped papules, vesicles, hyperpigmentation. Some of the vesicles are
and crusts on the back. arranged in an annular pattern.

The rash responds rapidly to dapsone

therapy and, in many patients, to strict
adherence to a glutenfree diet.
 40

Epidermolysis bullosa

Epidermolysis bullosa is a family of inherited genodermatoses characterized by

blistering in response to minor trauma.
Blistering level categories are the simplex, hemidesmosomal, junctional, and
dystrophic subtypes.

Characteristic blister formation on

trunk and arm in patient with Dowling-
Trauma-induced blistering from clothing
Meara epidermolysis bullosa simplex.
in patient with localized epidermolysis
bullosa simplex.

Widespread blistering at birth in an infant

Widespread blistering in an infant with
with Herlitz junctional epidermolysis bullosa.
generalized epidermolysis bullosa
simplex.
 41

Connective Tissue and Rheumatologic Disorders

Lupus Erythematosus

Localized acute cutaneous lupus

erythematosus. Erythematous, slightly
edematous, sharply demarcated
erythema is seen on the malar areas in
a “butterfly” distribution.

Generalized acute cutaneous lupus erythematosus. (ACLE)

A, Well-demarcated patches of B, Closeup view of periungual

erythema with fine overlying scale on erythema and grossly visible
the dorsal aspect of the hands, fingers, telangiectasia. Although these lesions
and periungual areas. Note the can be seen in lupus erythematosus,
characteristic sparing of the knuckles, they are much more typical of
which are preferentially involved in dermatomyositis.
dermatomyositis.

Reference:Fitzpatrick’s Dermatology(pg 1037)

 42

toxic epidermal necrolysis

An extremely acute form of ACLE is rarely seen that can simulate TEN

A, Widespread erythematous B, Similar changes over the arm.

papules with vesiculobullous
changes over the trunk.

C, Severe epidermal loss and denuding D, Painless palatal ulceration

over the face in a 16-year-old boy. characteristic of systemic lupus
erythematosus was present as opposed
to severe mucosal involvement of TEN.
 43

CHRONIC CUTANEOUS LUPUS ERYTHEMATOSUS

Classic discoid lupus erythematosus

Typical early erythematous plaque on

Sharply demarcated, round-to-ovoid slightly
the forehead demonstrating
indurated, erythematous plaques on the
hyperkeratosis and accentuation of
neck and face. Most plaques show a mild
follicle orifices in a 60-year-old man
degree of hyperkeratosis, and some show
with a 25-year history of cutaneous
dermal atrophy. Noninflamed areas of
lupus erythematosus. The lesion had
hypopigmentation and scarring mark the
been present for 3 months; no dermal
sites of prior lesions that have resolved.
atrophy was present at this stage.

Dermatomyositis
Systemic autoimmune disease with a bimodal distribution affecting children and adults,
characterized by inflammation and damage to the skin and muscle.

Red ill-defined macules on the medial and

Heliotrope sign. Violaceous to pink lateral canthi, often seen in conjunction
erythema and edema on the upper eyelid. with the heliotrope sign.
 44

Sontheimer’s Proposed Diagnostic Criteria for Cutaneous Dermatomyositis

V-neck sign. Red, ill-defined Shawl sign. Pink to red thin patches and
telangiectatic patches on the plaques, often with thin white scale, on the
upper chest. upper posterior back characteristic of the
shawl sign.
 45
Most characteristics finding of a child with dermatomyositis ?
A.Gottron papules
B.Photosensitivity
C.Nail bed capillary changes
D.Malar rash [INICET 2021]

Gottron papules. Light pink, ill-defined papules

over the proximal and distal interphalangeal
joints, few with central umbilication. Deep red
erythema, edema of the proximal nailfolds,
and dilated nailfold capillaries are evident.

Holster sign. On the lateral thigh

Gottron sign. Ill-defined violaceous
are illdefined pink papules coalescing
erythema on the knees is seen, which has
into plaques are seen with scale and
follicular accentuation in this patient.
follicular accentuation.

Systemic Sclerosis
 46

A, Sclerodactyly with dermatogenous Typical scleroderma facial

contractures (restricted mobility of digital physiognomy with hypermimia,
joints) and salt-and-pepper microstomia, telangiectasias, and a
hyperpigmentations and hypopigmentations. beaked nose.
B, Microstomia (radial furrowing around the
mouth) with frenulum sclerosis.
Raynaud phenomenon

A, Raynaud phenomenon with typical discoloration (blue-white pallor), localized mostly

at fingers and/or toes as the result of vasospasm. Coldness and emotional stress are
the most frequent triggers for these attacks. B, Limited disease with puffy fingers.
 47

LICHEN SCLEROSUS
Infrequent chronic inflammatory dermatosis with anogenital and
extragenital manifestations.

A, Early sclerosis and significant B, Sclerosis of the frenulum and

hemorrhage on the glans in early increased vulnerability with bleeding
lichen sclerosus. upon sexual intercourse.

C, Significant sclerosis of the glans D, In addition to the well-demarcated white

and conglutination with the vulvar plaque that is classic for lichen
preputium in advanced lichen sclerosus, the waxy and crinkled texture,
sclerosus. Note narrowing of the purpura (small arrows), and erosions (large
urethral orifice and hemorrhage. arrow) are diagnostic.
 48

RHEUMATOID ARTHRITIS
Symmetric arthritis of the proximal interphalangeal and
metacarpophalangeal joints most common.
Skin findings quite varied, including papules, plaques, and nodules with
multiple histologic types, vasculitis/Bywaters lesions, pyoderma
gangrenosum/Felty ulcers.

Rheumatoid nodules. Severely Rheumatoid neutrophilic dermatosis.

affected joints of a patient with Lesions are erythematous urticarial
rheumatoid arthritis with overlying papules that often coalesce into plaques
rheumatoid nodules. in a patient with rheumatoid arthritis.

Felty syndrome ulcer. A

Bywaters lesions. Note the purpuric
refractory ulcer on the foot of a
papule on the dorsal finger.
patient with rheumatoid arthritis
and hypersplenism.
 49

Juvenile idiopathic arthritis.

The classic sJIA eruption has been

a very transient salmon pink
mostly macular eruption

ADULTONSET STILL DISEASE

Multisystem syndrome that can mimic

infection.
Classic eruption is well described, but several
new atypical variants are now recognized.
Lesions are discrete pink to red macules and
slightly edematous papules.

RHEUMATIC FEVER

Erythema marginatum of rheumatic

fever. Enlarging and shifting transient
annular and polycyclic lesions.
50
 51

SCLEREDEMA

Acute skin induration characterized by

dermal mucinosis and mild sclerosis.

Waxy, nonpitting induration of back skin.

SCLEROMYXEDEMA
Chronic, progressive condition characterized by dermalfibrosis and
mucinosis and normal thyroid function.

Thickened bound-down skin of the back.

Marked, nodular induration of

facial skin with accentuation
of skin folds.
Confluent lichenoid
papules and
indurated skin of
the hand and wrist.
 52

Sjögren Syndrome
Chronic, multisystem autoimmune disease, characterized by chronic inflammation
involving the exocrine glands.
Salivary and lachrymal glands are affected predominantly, leading to dry mouth
and dry eyes.

The characteristic tongue of patients Non-palpable purpura with

with Sjögren syndrome. A red and pigmentation in a patient with
fissured tongue with characteristic primary Sjögren syndrome.
atrophy of the filiform papillae.
 53

Pernio-like eruption in a patient with

primary Sjögren syndrome.
Annular erythema associated with
primary Sjögren syndrome in a young
female patient presented with figurate
annular erythema with raised border.

EHLERSDANLOS SYNDROMES

Defects in the Type V collagen gene most commonly cause the classical subtype.
Cutaneous features include varying degrees of skin fragility and
hyperextensibility. The classical subtype exhibits soft, velvety skin that bruises
easily and wounds that heal as thin, atrophic, gaping scars.
Extracutaneous manifestations include hypermobile joints with frequent
dislocations, complications with pregnancy and delivery, and, less commonly,
cardiovascular manifestations, particularly aortic root dilation.

Classical Ehlers-Danlos syndrome.

Dermal elasticity is demonstrated. Unlike
cutis laxa, the skin returns to original
shape after stretching.
 54

Hyperextensibility of digits

Chronic discolored scars on the shin and ankle after repeated

trauma. This is often associated with firm subcutaneous nodules
that can be confused with subcutaneous granuloma annulare. Note
the widened scars along the anterior shin (arrow).

MARFAN SYNDROME

Autosomal dominant; caused by mutations in

fibrillin 1 (FBN1; chromosome 15q21.1).

Cutaneous features include striae

distensae (twothirds of patients),
inguinal or incisional hernias, and,
rarely, elastosis perforans serpiginosa.
Extracutaneous manifestations include
hyperextensible joints, upward lens
displacement, skeletal abnormalities,
and cardiac aberrations, such as aortic
aneurysm and rupture.
 55

Subcutaneous Tissue Disorders

ERYTHEMA NODOSUM Erythema induratum.

Erythematous subcutaneous nodules and

Symmetric, tender,
plaques of lower legs; common on calves, but
erythematous, nodules, and
also on anterolateral legs, feet, and thighs;
plaques on the anterior aspects
Associated with venous insufficiency; more
of the lower extremities.
frequent in middle-aged women.

LIPODERMATOSCLEROSIS

Chronic lipodermatosclerosis with

champagne bottle/bowling pin
Chronic lipodermatosclerosis (LDS) with mild
deformity.
erythema of the medial lower leg, indicating
presence of active inflammation. Cellulitis-like
plaques on the medial lower leg

Reference:Fitzpatrick’s Dermatology(pg1251 )
 56
Lipodystrophy
Lipodystrophies are genetic or acquired disorders characterized by selective loss
of body fat. The extent of fat loss determines the severity of associated
metabolic complications such as diabetes mellitus, hypertriglyceridemia, hepatic
steatosis, and acanthosis nigricans.

Congenital Familial partial Acquired Acquired partial Highly active

generalized lipodystrophy generalized lipodystrophy antiretroviral
lipodystrophy lipodystrophy therapyinduced
lipodystrophy.

Phenotype of patients with joint contractures, muscle atrophy, microcytic

anemia, and panniculitis induced lipodystrophy (JMP) syndrome
 57

Melanocytic Disorders
Albinism
Oculocutaneous albinism is a group of rare genetic disorders with autosomal recessive
inheritance, characterized by hypopigmentation of skin, hair, and eyes.

A, OCA1A, 7-month-old boy. He B, OCA4, 2-year and 10-month-old

demonstrates complete lack of melanin, girl. Her hair and irides are brown, but
and the irides are translucent and reddish the skin is not as pale as for OCA1A.

Hermansky-Pudlak syndrome (HPS)

Autosomal recessive genetic disorder characterized by hypopigmentation of skin, hair,
and eyes accompanied by nonpigmentary symptoms, including bleeding diathesis,
caused by platelet storage pool de›ciency and accumulation of ceroid in tissues.

C, Hermansky-Pudlak syndrome type 4

(HPS4), 6-year-old girl . Blonde hair, white
skin, and light gray irides with nystagmus are
seen. Purpura is also seen on her lower leg.

Reference:Fitzpatrick’s Dermatology(pg 1309)

 58

Vitiligo
Autoimmune disease of the skin that causes depigmentation through T-
cellmediated destruction of melanocytes.

Clinical signs of lesional activity include confetti, trichrome, and inflammatory

lesions, as well as koebnerization.

Symmetrical patchy Mucosal vitiligo, limited to the lips.

depigmentation of vitiligo.

Mixed vitiligo, made up of a segmental Linear depigmentation in

lesion on the back plus additional bilateral locations of skin trauma.
lesions in remote areas.
 59

Inflammatory vitiligo characterized by

erythema and scaling at the margin of the
depigmented lesion.
Multiple scattered macules of
confetti depigmentation in vitiligo.

13 year old boy comes to OPD with patchy depigmented skin on chest and
abdomen in segmented distribution as shown in the
image.Depigmentation started an year back and has not changed for last
few months.Mother gives history of use of topical steroids which was
ineffective.What is the most probable diagnosis ?
A.Segmental vitiligo
B.Focal vitiligo
C.Piebaldism
D.Nevus depigmentosus

[INICET 2021]
 60
Hypermelanoses

Peutz-Jeghers syndrome.
Lentigines, which are dark-brown to gray-blue,
appear on the lips, around the mouth, and on the
Classic Mongolian spots in the fingers. Lip macules may, over time, disappear.
lumbosacral region and aberrant
or extrasacral Mongolian spots
on the back.

Acanthosis nigricans is Amiodarone hyperpigmentation.

characterized by thickened This patient exhibits a striking amiodarone-
hyperpigmented velvety skin induced, slate-gray pigmentation of the face.
most often noted on the neck, The blue color (ceruloderma) is a result of the
axilla, popliteal and antecubital deposition of a brown pigment in the dermis,
fossae, and inguinal folds contained in macrophages and endothelial cells.
 61

Café-au-lait macule
Nevus of Becker
Light-brown–tan–dark-brown well-
Presents with acquired
demarcated homogenously
circumscribed hyperpigmentation.
hyperpigmented macules or patches
Most commonly found on the trunk.
can be noted anywhere on the body.
Usually associated with
hypertrichosis.
 62

Acneiform Disorders
Acne Vulgaris
(1) follicular epidermal hyperproliferation,
(2) sebum production,
(3) the presence and activity of Propionibacterium acnes,
(4) inflammation and immune response.

Closed comedone. The follicular Open comedone. Resembles the

infundibulum is distended, filled with closed comedone with the exception
keratin and sebum, and the follicular of a patulous follicular ostium.
epithelium is attenuated. The
follicular ostium is narrow.

Inflammatory papule. Acute and Nodule. The follicle is filled with acute
chronic inflammatory cells surround inflammatory cells. With the rupture of
and infiltrate the follicle, which shows the distended follicle, there is a foreign
infundibular hyperkeratosis. body granulomatous response.

Reference:Fitzpatrick’s Dermatology(pg1391 )
 63

Rosacea

Signs and symptoms for rosacea include flushing, transient erythema, persistent
erythema, telangiectasia, papules, pustules, phymata, edema, pain, stinging or
burning, and (very rarely) pruritus.

A, Persistent erythema in patients with rosacea. B, Although mostly

symmetrical, persistent erythema can present with asymmetrical distribution
and intensity based on underlying trigger factor.
 64

A, Acne fulminans. An eruptive form of acne with extensive inflammatory papules

and nodules on the face, coalescing with ecchymoses and crusting. B and,
Eruptive, uniform friable papules over the chest and back with crusting. D,
Resultant keloid scars in the same patient.
 65

Disorders of Eccrine and Apocrine Sweat Glands

Hyperhidrosis

Positive starch iodine test result in A patient with pathologic gustatory

a patient with primary axillary sweating and a positive starch iodine
hyperhidrosis. test result.

ANHIDROSIS

A patient with segmental

anhidrosis (yellow) with
compensatory left-sided
hemihyperhidrosis (purple) caused
by a right greater than left-sided
upper thoracic spinal cord injury
(sodium alizarin sulfate indicator
powder).

Reference:Fitzpatrick’s Dermatology(pg 1459)

 66

Miliaria results from obstruction of

eccrine sweat ducts and occurs in
conditions of increased heat and
humidity

Fox-Fordyce disease with skin-colored

papules involving the axilla
A rare, itchy, chronic papular eruption
localized to apocrine gland–bearing areas
of the body with unclear etiology.

Hidradenitis Suppurativa
Chronic and debilitating inflammatory disorder of the hair follicles that localizes to
intertriginous and anogenital regions of the body.

Multiple inflammatory nodules of

Inflammatory subcutaneous
hidradenitis suppurativa in the axilla.
nodule of hidradenitis
suppurativa with adjacent
scars from previous lesions.
 67

Disorders of the Hair and Nails

Alopecia Areata
Alopecia areata is a nonscarring hair disorder.
Clinically, it presents with well-demarcated round or oval bald spots on the
scalp or other parts of the body.

Patch of alopecia area with

exclamation point hair.

Patch of alopecia areata with mild peachy [ÑEETi9]

erythema and some fine residual hairs. Identify the condition shown in
the image?

Patient with alopecia areata totalis Patient with alopecia areata of the eyebrows.

Reference:Fitzpatrick’s Dermatology(pg 1495)

 68

TRICHORRHEXIS NODOSA

TN presents as brittle, easily broken,

and lusterless hair with white nodular
swellings at irregular intervals along
the hair shaft.

TRICHOTHIODYSTROPHY

Trichoschisis refers to a localized

absence of cuticle that leads to
exposure and a clean transverse
fracture of the hair shaft.
Trichoschisis is associated with low-
sulfurcontaining hair seen in
trichothiodystrophy (TTD)

Tiger tail pattern

TRICHORRHEXIS INVAGINATA

Trichorrhexis invaginata (bamboo

hair) is commonly associated with
Netherton syndrome and is
characterized by invagination of the
distal hair shaft into the proximal
portion.

Golf-tee appearance of hair

shaft under light microscopy.
 69

Hirsutism
Terminal body hair growth in women in a male distribution.

Hirsutism of the lateral face and

jawline in the young woman. Dark terminal hair of the upper lip and
chin in a middle-age woman.
Hypertrichosis

Hair growth that is excessive in a

localized or diffuse pattern not
considered to be in a male pattern
distribution.

Nail Disorders

Rudimentary double nail of the little toe.

Leukonychia punctata
 70

Muehrcke lines in hypoalbuminemia Splinter hemorrhages in a

after more than 7 weeks of high fever. patient with chronic diarrhea.

Multiple red lines in dyskeratosis follicularis Darier (A) and white

lines in Hailey-Hailey disease (B)

Multiple Beau lines in a patient

under cyclic chemotherapy.
 71

Recurrent herpes simplex

Proximal white subungual onychomycosis.
 72

Disorders Due to the Environment

Polymorphic Light Eruption
A pruritic, erythematous, symmetrically
distributed, eruption of variable interindividual
morphology (in most cases papular) on sun-
exposed skin areas, within hours to days of
exposure, with full resolution in several days.
Macular polymorphic light eruption on the
back of a middle-aged woman.

Bullous frostbite following contact

with a cold steel sheet.

Photoexacerbated seborrheic
dermatitis, affect-ing the face only at
sites of predilection for the seborrheic
eruption.

Bullous frostbite following contact

with a cold steel sheet. '
[NEET ]
18

Cutis marmorata
occurs due to
Perniosis or chilblains, is a condition of localized inflammatory exposure to Cold
lesions caused by continued exposure to cool temperatures temperature

Reference:Fitzpatrick’s Dermatology(pg1611 )
 73

Degrees of burns

Second degree burns with blisters.

First and second

degree burn.

Extensive third degree burns with eschar

 74

Psychosocial Skin Disease

Purpura and erosions on the soft, Linear purpura representing the

padded areas of the buttock and thighs, interdigital spaces from a hand slap. Note
representing very obvious abuse. the inferior triangular shape that
corresponds to the finger web space.

Bite marks

Trichotillomania. This extensive alopecia

resulted from pulling and plucking hairs by
the 17-yearold patient. Hairs are broken at
different lengths throughout the scalp.

Track marks from intravenous drug use on

the upper extremity.

Reference:Fitzpatrick’s Dermatology(pg 1693)

 75

Paediatric Dermatology

Milia Erythema toxicum

Distended sebaceous
Most common normal skin finding
glands on face and neck
on 2nd or 3rd day
Normal skin finding
Red coloured papules and pustules -
eosinophilia infiltrates
Appears on trunk and face, never at birth

Bohn’s nodule
Epithelial inclusion cyst
Seen in gingiva Epstein pearls
Epithelial inclusion cyst
Seen in hard palate
 76

Mongolian spot
Salmon patch/ stroke bite Congenital dermal melanocytosis
Commonly seen in Nape of neck and forehead Macule due to increased melanocytes
Due to dilated blood vessels (vascular ectasias) Seen in lumbosacral area
Rx: Regress by 1- 3 yrs Disappear by 1 year of age

HYMEN TAGS
HARLEQUIN COLOUR CHANGE
Due to autonomic dysfunction of
cutaneous blood vessels

Port wine stain/ Sturgeon Weber syndrome

Sporadic
Neurocutaneous disorders
Also known as nevus
flammeus
Appears at birth
Persist throughout life.
77
 78

Kawasaki disease:

(A) Red and cracked lips (B) palmar rash and swelling

Diffuse erythematous rash seen

in a patient with dengue

Staphylococcal Scalded Skin Syndrome

Mediated by hematogenously spread

exotoxin produced by S. aureus present in
infected site distant from the involved skin

Erythema and tenderness is followed

by superficial peeling of skin
 79

Conjunctival congestion and

morbilliform rash in a child with measles
Polymorphic rash of chickenpox

vesicular rash of hand-foot-mouth disease

The rash resembles a 'slapped
cheek' in erythema infectiosum

Neonatal tetanus
Necrotic rash in spotted fever
 80

Neoplasia

SEBORRHEIC KERATOSIS Keratinocytic epidermal nevus

Usually begin as well-circumscribed tan presenting as brown verrucous plaques
brown patches or thin plaques with pseudo- arranged along Blaschko lines on
horn cysts (keratotic invaginations). flexural neck

Hidradenoma is a solitary,
indistinct dermal nodule
Epidermoid cysts (follicular cyst-
Hidradenoma presents as a solitary
infundibular type, keratin cyst, epidermal
dermal nodule that can be solid and/or
cyst, epidermal inclusion cyst, or
cystic, and ranges from flesh-colored
epithelial cyst) are most commonly the
to red to bluish in color
result of plugged pilosebaceous units.
Domeshaped protuberance

Reference:Fitzpatrick’s Dermatology(pg 1799)

 81

ACTINIC KERATOSES
Precursor lesions of cutaneous Bowen disease (BD) is
squamous cell carcinoma (SCC). squamous cell carcinoma
Multiple well-defined hypertrophic actinic (SCC) in situ.
keratoses on the decollete of a middle- Large plaque of Bowen disease of the leg.
aged female

Oral leukoplakia of the left cheek

in a 65-year-old male with chronic HIV
infection and a history of smoking.
Note the irregular and verrucous
surface (nonhomogeneous variant).

genital Bowen disease (GBD) variant

shows variably pigmented and
erythematous papules, mainly located on
the shaft of the penis.
 82

BASAL CELL CARCINOMA

Squamous Cell Carcinoma

Classical clinical presentation of cutaneous

squamous cell carcinoma (SCC). Two
nodular SCCs and several actinic keratoses
as precursor lesions are present on the
forehead in the setting of field cancerization
on heavily sun-damaged skin.
 83

keratoacanthoma
Typical clinical presentation of a
keratoacanthoma on the forehead as a
sharply circumscribed symmetric nodule
with the characteristic horn-filled crater in
the middle.

Merkel cell carcinoma (MCC)

is an increasingly common
neuroendocrine skin cancer that is
associated with ultraviolet (UV) light
exposure, advanced age, immune
suppression, and the Merkel cell
polyomavirus (MCPyV).

Paget’s Disease
Uncommon intraepithelial adenocarcinoma occurring in apocrine gland-bearing
skin in patients older than age 50 years.

Paget’s disease of the nipple. Scrotal extramammary Paget’s disease.

Erythematous and scaly plaque Moist, eroded, oozing plaque on the
involving the nipple and areola. scrotum of an older man.
 84

Melanocytic Nevi
Pigmented neoplasms of melanocytes that
are evident at birth or shortly thereafter.
Giant congenital pigmented nevus in the
bathing trunk distribution. Note the satellite
nevi.

Nevus spilus —spotted nevus

Speckled lentiginous nevus,
zosteriform lentiginous nevus
Pigmented neoplasm of melanocytes
that develops during infancy or early
childhood.

BLUE NEVUS
A group of lesions composed of deeply pigmented
spindle or epithelioid melanocytes in the dermis;
includes common blue, cellular blue, combined
blue, and atypical cellular blue lesions
Lesions appear as blue, blue-gray, or blue-black
papules, nodules, or plaques.

Q. Elderly man with a long standing mole over the

face which is increasing in size and showing
irregular borders.Diagnosis.?
[MEET '2O ; AIIMS rpt ] Superficial spreading melanoma
 85
Melanoma

Superficial spreading melanoma, in A with extensive signs of regression

(whole center of the lesion)

C, ulcerated amelanotic nodular melanoma; D, pigmented nodular melanoma;

E, lentigo maligna melanoma; F, acral lentiginous melanoma;

 86

G, subungual melanoma with H, ulcerated desmoplastic melanoma.

melanonychia striata;

Langerhans cell histiocytosis

Translucent, roseyellowish, crusted papules or papulovesicles, eczematous

lesions, hemorrhagic papules and nodules, petechiae, noduloulcerative mucosal
lesions, and nail involvement

Rose-yellowish papules on the abdominal

area of an infant suffering from
extensive Langerhans cell histiocytosis.

“Candida intertrigo”–like eruptions in

the genital area of an infant with
Langerhans cell histiocytosis.
 87

ROSAIDORFMAN DISEASE SINUS

HISTIOCYTOSIS WITH MASSIVE
LYMPHADENOPATHY

Lymphadenopathy, cutaneous
nodules, and plaques

JUVENILE XANTHOGRANULOMA

JXG usually manifests with both solitary and multiple (oligolesional)

papules or nodules that are usually located on the face, neck, and upper
trunk, and on other body parts, including lungs, bone, heart, and GI tract.
Early lesions show a reddish-brown color (A). Mature lesions have a
reddish-yellow appearance (B)
 88
NEUROFIBROMA
Neurofibromas are benign nerve sheath
proliferations that are composed of all
elements of a peripheral nerve.
(a) localized neurofibromas,
(b) diffuse neurofibromas,
(c) plexiform neurofibromas.

Clinical photograph showing multiple

neurofibromas on the back of a patient with
neurofibromatosis Type I (“NF1 microdeletion
syndrome”).

Schwannomas
Schwannomas are benign encapsulated
nerve sheaths neoplasms derived from
the proliferation of Schwann cells and
lack axons.
Schwannoma on the scalp of a child with
neurofibromatosis Type II.

leiomyosarcomas
Malignant smooth muscle tumor comprising 2
subtypes with respect to location and prognosis:
dermal leiomyosarcomas arising from the arrector
pili or genital smooth muscle and subcutaneous
leiomyosarcomas

Cutaneous leiomyosarcoma on the nose. A firm nodule with

erythema and hyperpigmentation of the involved skin is seen.
 89

Metabolic, Genetic, and Systemic Diseases

PROTEINENERGY MALNUTRITION

Kwashiorkor Marasmus

Reference:Fitzpatrick’s Dermatology(pg2199 )
 90

The “flaky paint” or “crazy pavement”

dermatitis of kwashiorkor.
If a child experiences intermittent periods
of kwashiorkor and improved nutrition,
alternate bands of light and dark color
within the hair shaft may be observed and
has been referred to as the “flag sign”

Vitamin deficiency
Vitamin A deficiency

Bitot’s spots Keratomalacia

Typical perifollicular hyperkeratosis of the chest

 91

Vitamin D deficiency Vitamin B2 deficiency

Riboflavin
deficiency.
Angular
stomatitis with
maceration

Phrynoderma

A girl child presented with rough surfaced lesions over elbows,knee(extensor surface), dry eyes and night blindness.
What is the dermatological finding shown in the pic ?
A. Eczema C. Keratosis Pilaris Rubro
B. Icthyosis D. Phrynoderma

VITAMIN B3 NIACIN

Glove” or “gauntlet” exudative and

crusted lesions on the hands.
CNIEETÉO]

The image given shows deficiency of? “Casal’s necklace” on the neck
with facial involvement.
Painful pruritic dermatitis in photoexposed areas
May be vesicular, crusted, and develops into scaly, keratotic plaques
Dorsum of hands (“gauntlet”), neck (“Casal’s necklace”),
dorsa of feet (“gaiter” of pellagra); butterfly distribution in face
 92

Mineral deficiency

Zinc deficiency

B, Hands. The fingers are

enlarged, and there are paronychia
A, There are plaques of dry, scaly,
and bright erythema on the terminal
eczematous skin around the buttocks. The
phalanges.
lesions often become secondarily infected
with Candida albicans.
Acrodermatitis Enteropathica

B, This crusted and scaly, erosive, and

A, Patient with acrodermatitis
sharply demarcated eruption appeared
enteropathica. These clinical findings
shortly after weaning. The child was highly
resolved within 2 weeks of initiating zinc
irritable, whining and crying, and had
supplementation.
diarrhea.
 93

DISORDERS OF DNA REPAIR

XERODERMA PIGMENTOSUM
Xeroderma pigmentosum (XP) is an autosomal recessive disease
characterized by sun sensitivity, with approximately 50% of patients
having acute burning on minimal sun exposure.

C, Corneal clouding, prominent

conjunctival blood vasculature, and
A, Pigmentary changes, loss of lashes.
atrophy, dryness, and cheilitis in
a 16-year-old patient.

B, Cheek of a 14-year-old patient with

D, Myriad pigmented macules of varying
pigmented macules of varying size and
sizes and intensities and scattered
intensity, actinic keratosis, basal cell
hypopigmented areas on the back, with
carcinoma, and a surgical scar.
marked sparing of the sun-protected
buttocks of a 14-year-old patient.
 94

Neurofibromatosis Type 1

Café-au-lait spots.

Axillary freckling.

Plexiform neurofibroma with overlying

hyperpigmentation and hypertrichosis. Cutaneous neurofibromas with
overlying hyperpigmentation.
 95

Tuberous Sclerosis Complex

Skin lesions include hypomelanotic macules, “confetti” lesions, facial
angiofibromas, fibrous cephalic plaques, shagreen patches, and ungual
fibromas.

Hypomelanotic ash-leaf macules Confetti-like hypopigmented macules on

on the lower leg of a child with the lower leg of an adult with tuberous
tuberous sclerosis complex. sclerosis complex.

The forehead fibrous plaque in tuberous The shagreen patch in tuberous sclerosis
sclerosis complex is often pink-red and complex is a firm, bumpy plaque that is
has a bumpy surface and irregular outline. usually located on the lower back.
 96

Infections
Bacterial Diseases

Staphylococcus aureus: impetigo. Erythema and honey-

colored crusting on the nose and upper lip area (A), which can
spread to involve the entire centrofacial region (B)

A carbuncle characteristically
presents as an extremely painful
Pseudofolliculitis barbae. lesion at the nape of the neck, the
Multiple papules in the lower beard back, or thighs
area caused by ingrowing of the [MEET 119]

curved hair shaft in a black man who Q. What is the causative organism for
the condition in the image.?
shaves.

Reference:Fitzpatrick’s Dermatology(pg 2719)

 97

Staphylococcus aureus
Staphylococcus aureus whitlow (felon).
paronychia. An abscess is
A pyogenic granuloma arose 1 week after trauma
seen in the dorsum of the
to the bulb of the thumb. A week later, the bulb
finger, beginning in a small
became swollen, erythematous, and very tender.
break in the cuticle.
Abscess formation is seen with loculation of pus.

Erythrasma is a superficial bacterial

infection of the skin characterized by
well-defined but irregular reddish-brown
patches, occurring in the intertriginous
areas, or by fissuring and white
maceration in the toe clefts.

Bullous impetigo in a child. Note

blisters filled with cloudy fluid and
lesions that have ruptured, leading to
erosions and crusting.
 98

Cellulitis with swelling, erythema,

and tenderness.

Erysipelas: sharply demarcated,

bright red, edematous plaques
resulting from superficial lymphatic
infiltration.
Tuberculosis

Scrofuloderma

Lupus vulgaris

Q. Identify the image and the

appropriate treatment ? [MEET 120]
 99

Leprosy
A chronic granulomatous disease affecting mainly the skin and nerves caused by the
obligate intracellular pathogen Mycobacterium leprae.

Indeterminate leprosy. Macular

hypochromic lesion on the lower back.

Tuberculoid leprosy. A well-

circumscribed lesion, with a central
macular hypochromic and atrophic
appearance, and a peripheric group of
papules distributed in annular pattern.

Leonine facies. Lepromatous patient with

diffuse nodules and infiltration on the face,
resulting in a lion’s face appearance.

Infantile nodular leprosy. Presence of 2

tuberous lesions on the face of a child
from a family where 2 adults were
diagnosed with multibacillary leprosy.
 100
Lepromatous leprosy. Multiples nodules
(hansenomes or lepromes) disseminated
throughout the skin, associated to diffuse
infiltration.

A leprosy patient in his multibacillary state and on multidrug therapy presents with severe rashes on the already
existing lesions.He shows neurological involvement too.What is the next best ?
A. Stop ALT and Start steroids
B. Stop ALT and Start Thalidomide
C. Continue ALT and Start Steroids
D. Continue ALT and Start Thalidomide [NEET 2021]

Fungal Diseases
Tinea barbae.
A, Superficial type. Scattered
follicular papules, pustules, and small
nodules, which may be easily mistaken
for Staphylococcus aureus folliculitis.

B, Kerion type. Sharply demarcated red

edematous nodule studded with multiple
yellowish weeping pustules. Note hairs have
been lost from this nodule.
 101
Tinea capitis “gray patch” type.
A large, round, hyperkeratotic
plaque of alopecia, a result of
breaking off of hair shafts close to
the surface, gives the appearance of
a mowed wheat field on the scalp of a
child.

Tinea cruris. Annular

erythematous plaques with a
raised scaling border expanding
from the inguinal on the inner
thighs and pubic region.
[MEET 120]

Q. Identify the image?

A 10yr old male child came to OPD with C/O mild painful swelling in the scalp
for past 3 months.She has a dog as pet.What is the most probable diagnosis ?
A. Folliculitis
B. Abscess
C. Kerion
D. Epidermoid cyst
 102
Tinea pedis

A, Interdigital type. C, Bullous type.

B, Moccasin type. Patchy erythema
The interdigital space Ruptured bullae,
and scaling in a moccasin distribution
is macerated with erosions and erythema
on the foot. The arciform pattern of
opaque white scales on the plantar aspect
scales is characteristic.
and has erosions. of the great toe.
Candida intertrigo

A, Erythematous papules becoming B, Erythematous plaques with erosion and

confluent over the inguinal area satellite papules
with prominent satellite papules

C, Diaper candidiasis demonstrated D, Erosio interdigitalis blastomycetica

erythematous, partially eroded demonstrating an erythematous plaque with
plaques, and satellite papules. prominent maceration in the interdigital webspace.
 103

Pityriasis (tinea) versicolor. A, Multiple round to oval salmon-colored

patches over the trunk. B, Salmoncolored patches and thin plaques on the
shoulder and upper arm with fine overlying scale.

Viral Diseases

Measles. The pathognomonic Koplik spots

of measles appear as tiny white lesions—
“grains of sand”— surrounded by an
erythematous halo. They precede the
generalized rash by 1 to 2 days.

Measles. Classic morbilliform exanthem with red

papules spreading from forehead and
postauricular area to neck, trunk and then
extremities.
 104

Rubella. Erythematous macules PARVOVIRUS B19

The characteristic rash begins with
and papules appearing initially on the
confluent, erythematous, edematous
face and spreading to trunk, arms,
plaques on the malar eminences, the
legs within 24 hours.
“slapped cheeks”

Coxsackievirus A6–associated
hand-footmouth disease with perioral
distribution.
Morbilliform rash in
Epstein-Barr virus
infection.
 105

Classic hand-foot-mouth disease in a toddler. A, Vesicles and

surrounding erythema on the tongue. B and C, Elliptical, “football-
shaped” vesicles with halo of erythema on the palms and soles.

Herpes virus

Herpes simplex virus infection.

Herpetic whitlow. Painful, grouped,
confluent vesicles on an erythematous,
edematous base at the distal finger
where the first (and presumed Eczema herpeticum. Confluent and discrete
primary) symptomatic infection crusted erosions associated with erythema and
occurred. edema of the face of a child (A) and man (B) with
atopic dermatitis. Note the monomorphic vesicles
and punched out erosions.
 106

Varicella

Typical cases of varicella in two 4-year-old children. Note the presence of

lesions in all stages of development and erosions at sites of excoriation.

Early vesicles with surrounding Crusted lesions in the same

erythema (“dewdrops on rose petals”) in child on rash day 3.
an immunocompetent child with varicella

Many large pustules and umbilicated

pustules in a 21-year-old woman who
was febrile and “toxic” and had varicella
pneumonia.
 107
Herpes zoster

A, Classical herpes zoster in the left T4 dermatome. Note the concentration of

lesions in areas of the dermatome innervated by the posterior primary division and
the lateral branch of the anterior primary division of the left T4 spinal nerve.
B. Right T10 herpes zoster with numerous pustular lesions.

D, Clustered vesicular lesions of

herpes zoster.

C, Early lesions of herpes zoster.

Note the closely grouped vesicles on
a confluent erythematous base, in
contrast to the discrete randomly
distributed vesicles of varicella

E, Left T8 herpes zoster with numerous

pustular lesions and early crusting.
 108

Herpes zoster involving cranial nerves.

Left ophthalmic herpes zoster with Severe right ophthalmic herpes

involvement of the nasociliary branch, zoster with involvement of the
as evidenced by lesions on the tip and nasociliary nerve and eye, as well
side of the nose (Hutchinson sign). as superficial gangrene.

Molluscum contagiosum.

A, Discrete, solid, skin-colored papules, 1 to 2 mm in diameter with

central umbilication. B, Multiple, scattered, and discrete lesions,
some of which are inflamed.
 109

SKIN HUMAN PAPILLOMAVIRUS

Warts on the knee.

Multiple warts on the hand with

periungual warts affecting nail
growth.

Rash of classical dengue. Diffuse maculopapular rash associated

with West Nile virus infection.
 110

Zika virus infection

Edema and erythema of the malar Macular rash on the abdomen.

region of the face and conjunctival
injection.

Hyperemia and petechiae in the hard palate. Tender, mobile, soft lymph node,

SCABIES

Several thread-like burrows are present

in the web spaces of the fingers and on
the knuckles, a common location for
these lesions in scabies. [NEET 119 ]
Crusted scabies. Hyperkeratotic
Patient presents with pruritis of inter
plaques populated with thousands digital clefts of left hand as shown in the
of mites. image. Identify the condition?
 111
Sexually transmitted disease

Annular plaques of secondary syphilis on

the face, colloquially referred to as
“nickels and dimes.”
Papules of secondary
syphilis on the penis.

Condyloma lata, presenting as moist,

flattopped plaques on the buttocks.

Disfiguring gummatous
infiltration of the glabella and
forehead with scattered
ulcerations in a 60-year-old
Sharply marginated, necrotic ulcers of
woman with late benign syphilis.
secondary syphilis described as “rupioid,”
covered by thick, dirty crusts (like oyster
shells).
 112
GONORRHEA
Bacterial infection by Neisseria gonorrhoeae, gram-negative,

:
aerobic coccus-shaped bacterium found in pairs.
CLINICAL FEATURES
Cutaneous Findings :
i. In Men :
- Most common manifestation is Urethritis,
- Characterized by a spontaneous, often profuse, cloudy
or purulent discharge from the penile meatus
- Mucosal membrane inflammation in the anterior
urethra leads to pain or burning upon urination and
meatal erythema and swelling
Acute gonorrhea in a male manifesting as
ii.In Women : creamy purulent discharge from the urethra.
- Endocervix is a common site of local infection.
- Symptoms includes mucopurulent discharge, vaginal
pruritus, and dysuria.
Proctitis is a manifestation of gonococcal infection
: Non cutaneous findings :
i. Pharyngitis
ii. Pelvic Inflammatory Disease :
- Fitz-Hugh–Curtis syndrome, involving inflammation
of the liver capsule, is associated with genitourinary
tract infection

A migrant worker came with complains of urethral discharge after a week

of unprotected sexual intercourse and complains of burning micturition.
Which among the following is the most probable causative organism ?
A. E.coli
B. Gonorrhea >

C.Ureaplasma
D.Trichomoniasis
 113

Reference :
http://naco.gov.in/sites/default/files/Syndromic%20Poster_REDUCED.pdf
 114

3.Match the following :

STD kit Conditions used for A.i-a,ii-c,iii-b,iv-f
i.Green a.Vaginal discharge B.i-b,ii-d,iii-e,iv-a
ii.Grey b.Lower abdominal pain C.i-a,ii-d,iii-b,iv-f
iii.Yellow c.Urethral discharge
D.i-a,ii-c,iii-b,iv-e
iv.White d.Bubo
e.Genital ulcer - Herpes
f.Genital ulcer - Non herpes [INICET 2021]
 115
Genital herpes

Herpes simplex virus: Positive Giemsa smear for Tzanck cells.

A giant, multinucleated keratinocyte on a Giemsa-stained
A, Primary genital herpes with vesicles. smear obtained from a vesicle base. Compare size of the
B, Primary herpetic vulvitis. giant cell to that of neutrophils also seen in this smear.

A, Genital herpes. Recurrent infection of the penis. Group of vesicles with

early central crusting on a red base arising on the shaft of the penis.
B, Genital herpes. Recurrent vulvar infection. Large, painful erosions on the
labia. Extensive lesions such as these are uncommon in recurrent genital
herpes in an otherwise healthy individual.

A patient presented to the STD clinic with grouped painful lesions as shown in the image.
Which of the following tests should be performed forthe diagnosis?
A.Tzanck smear for multinucleate giant cells C.Skin biopsy for HP bodies
B.Gram stain for gram negative cocci D.Tzanck smear for koilocyte
116