1 DERMATOLOGY

CHAPTER

Stratum corneum Dead keratinocytes Layers of epidermis

Come Corneum
Stratum lucidum
Lets Lucidum
Get Granulosum
Lamellar granules
Stratum Sun Spinosum
granulosum Burn Basale

S. Corneum
Keratinocyte Acellular (dead cells)
Flattened keratinocytes
Langerhans cells
No nucleus
Stratum
spinosum
S. Lucidum
Only present in palms and soles

S. Granulosum
Melanocyte
1. Keratohyaline granules produce filligrin
Merkel cell (defect causes Ichthyosis)
Stratum basale 2. Lamellar (Odland) bodies form a water
barrier (defect causes asteatotic eczema)
Sensory neuron
Dermis
"Dense irregular"
connective tissue
S. Spinosum
Thickest layer
Spinous process (Acanthocytes)
Desmoglein protein binds the
Desmoglein broken down acanthocytes
causes Acantholysis
APCs of epidermis, Langerhan's cells are
present in this layer.

Acanthocytes Seen in
Langerhan's cell
histocytosis

Desmoglein Birbeck Granules

Acantholytic cell (tennis racket shaped)

S. Basale (2 M)
1. Merkel cell : Touch receptor (slow
Primary acantholysis Secondary acantholysis adapting sensory)
Desmoglein broken down Ballooning of Keratinocytes 2. Melanocytes : Has dendritic processes
1. Pemphigus vulgaris (tzank cells) that supply keratinocytes
2. SSSS 1. HSV 1/2
2. Varicella Infections Epidermal melanin unit : 1 : 36
3. Darrier's disease
Epidermal turnover time : 28 + 28 = 56 days
4. Haley Haley disease
 Psoriasis
m/c type : Psoriasis vulgaris
Associated with Psoriatic arthropathy (DIP joint inv)
Scalp, trunk and extensor surfaces involved mostly
hyperkeratinisation of
epidermis and leaky
dermal vessels

Hyper + Parakeratosis

Agranulosis

Erythematous papulosquam. Psoriatic nails

Pustules of Kogoj
rash with silvery scales Irregular pitting
(Hallmark of Psoriasis) Oil drop sign
Sub-ungual Rete ridges
"Regular nail pitting seen in hyperkeratotis
Alopecia areata" Salmon patches

Parakeratosis + Hyperkeratotis
Grattage test
Munro's microabscess (stratum corneum)
Scrap the lesion Stratum Granulosum absent (Agranulosis)
with a glass slide Pustules of Kogoj (stratum spinosum)
Petechial spots seen Rete ridges (elongation of epidermis into dermis)
(Auspitz sign)
Auspitz Sign :
pinpoint bleeding under the
Koebner's Phenomenon
skin's surface (Grattage test)
aka Isomorphic Phenomenon
Shown by LVP (Lichen Planus. Vitiligo, Psoriasis)
Pseudo-Koebner's shown by viral warts
Reverse Koebner's shown by Psoriasis
Types of Psoriasis

Chronic Plaque Guttate Pustular

psoriasis Psoriasis Psoriasis

Most common type h/o URTI h/o sudden steroids withdrawal

Involves extensor surfaces and scalp DOC : Macrolides DOC : Acitretin (Teratogenic : washout period of 3 years)
Management :
1. < 10% BSA : Topical steroids Pustular psoriasis in preg. : Impetigo herpetiformis
2. > 10% BSA : Methotrexate (DOC) DOC : Systemic Steroids (only indication of systemic
or Narrow Band UVB Inverse Psoriasis steroids in psoriasis management)
3. Gockerman Regime : Coal tar
(5hrs/day) + NB UVB
Follows a different pattern of distribution to chronic
plaque psoriasis.
It affects ‘Intertriginous’ areas - points where skin
touches/rubs together.
Scaling is absent in this type
Areas affected include the axilla, groin and genital area,
inframammary folds and gluteal cleft.
 Lichen Planus
Cause is multifactorial
(asso with Hep C and malignancies)
Females > Males
Oral lichen planus is the most common form.
Bilaterally symmetric lesions
Wickham's striae (Pathognomic)

Nail and Scalp involvement Wickham's striae: whitish lines, visible

within the lesion in a lace like pattern
Oral white patch
Planar (flat toped lesions)
Purple (violaceous)
Pruritic

Removed Not removed

Candida 1. Lichen Planus (rule out Hep C)
2. Oral hairy leukoplakia (EBV)

Pterigium of nails
1st line : Topical steroids
2nd like : Oral steroids
3rd line : Methotrexate

lichen plano pilaris

Scarring Alopecia

Lichen Nitidus

Hyperkeratotis without Parakeratosis : Orthokeratosis

Ortho bro listening to LP
Hypergranulosis (Wickham's striae)
S. Basale degeneration : Max Joseph Space
Apoptotic cells : Civatte Bodies

Nodular lesions Hyper-granulosis

Claw catching a ball sign

Psoriasis Lichen Planus

1. Hyperkeratosis with 1. Hyperkeratosis without
parakeratosis parakeratosis (Orthokeratosis)
2. Munro's microabscess 2. Apoptotic Civatte bodies
3. Agranulosis 3. Hypergranulosis
4. Pustules of Kogoj 4. Max Joseph space
5. Rete ridges
Other Papulo-Squamous disorders
Pityriasis Rosea Pityriasis versicolor

Meatball on spaghetti
app. on KOH mount
Christmas tree pattern Herald patch

Starts with a mother lesion known as Herald Patch Hypo + Hyperpigmented lesions
Collarette (cigarette paper like) scales Fungal infection by M.Furfur
Christmas tree pattern Culture : SDA + Olive oil (lipophilic)
HHV 6/7 Fried egg colonies
Spares palm and soles on KOH mount : meatball on spaghetti 🍝 appearance
Reassure (spontaneous recovery) on wood lamp : Yellow

Christmas tree patterns Fried egg patterns

1. Colonies : M.furfur, Mycoplasma
1. Rash : P.Rosea
2. Appearance : Hairy cell Leukemia,
2. Cataract : Myotonic dystrophy
oligodendroglioma
3. Neurologic Urinary bladder

Ichthyosis
Ichthyosis

Ichthyosis X linked Lamellar

Vulgaris Ichthyosis Ichthyosis

Fishnet pattern over limbs Fishnet pattern Baby born with membrane
Antibodies against filligrin protein only over trunk (Colloidon baby)
in str. granulosum Membrane sheds off f/b
fishnet in trunk
 Bullous Disorders
Bullous lesion

Vesico-bullous disorders Mechano-bullous disorders

bullous lesion + h/o trauma
EB Congenita : Newborn
Epidermolysis Bullosa
EB Aquisita : Old age

EB Simplex Junctional EB Dystrophic EB

Keratin 5/14 Basement Dermis affected
Epidermal Dermal In epidermis membrane Laminin 322
tense bullae (Pemphigoid) Heals without scarring BP-180 Type 7 collagen
flaccid bullae, rupture easily

Chronic bullous disease of childhood Associated with celiac disease

Bullous pemphigoid
Linear IgA disease Dermatitis herpetiformis
Tense bullae + Pruritis (eosinophilia) Peri-oral/Peri-genital string of pearls Pruritis on extensor surfaces
IgG and C³ deposited at dermo- appearance IgA deposition in picket fence
epidermal junction Linear IgA deposition on IF fashion on IF
BPAg (Bullous Pemphigoid antigen) DOC : Dapsone DOC : Dapsone
Steroid pulse treatment
d/d : Zn deficiency which causes
Acrodermatitis enteropathica
(Peri oral/genital lesions + Diarrhoea)

St. Granulosum St. spinosum Other conditions showing

(Subcorneal split) (Suprabasal split)
positive Nikolsky
No oral involvement Oral involvement
1. SSSS (Ritter's Syndrome)
Pemphigus foliaceous Pemphigus vulgaris 2. SJS and TEN Pseudo Nikolsky Sign
DSG - 1 involved DSG - 3 involved
Flaccid bulla
Vulga3is
Nikolsky sign (+)

Drug induced pemphigus

Occurs 1 year after taking the drug
Common drugs implicated are "PCR"
1. Penicillamine
2. Captopril
3. Rifampicin

Fishnet pattern on IF Suprabasal split

IgG/C³ deposition Row of tombstones appearance Rx of pemphigus vulgaris
Pulse steroid treatment
 Pigmentation Disorders
Pigmentation disorders

Hyper pigmentation Hypo pigmentation

disorders disorders

Epidermal Dermal
Brown lesions Slate gray/blue (due to Tyndall effect)
On wood's lamp : Accentuation No accentuation on wood's lamp
Since it's blue, aka ceruloderma
[also a s/e of Amiodarone]

Melasma/Chloasma Chik's sign Becker's nevus

Increased estrogen/progesterone Seen in chikungunya Epidermal (brown)
stimulate melanocytes to cause nevus at back
hyperpigmentation. "becker - back"
1. Chloasma (mask of pregnancy) Associated with
GLOW in pregnancy - Chlo hypertrichosis
2. Melasma (photosensitive) seen
in non pregnant.

Mongolian spots Nevus of OTA Nevus of ITO

Seen in infants Ota : eye 👁️ 🧱
Ito - at back
Lumbo-sacral region No Hypertrichosis
Benign, reassure parents

White forlock Contact leukoderma Nevus anemicus

aka Chemical Leukoderma Due to vasoconstriction
1. Hydroquinone : Rubber in slippers α receptor dysfunction
2. PTBP (para tert. butyl phenol) : Bindi
3. Parabutyl Catechol : Hair dye
Heterochromia iridis Islands of sparing

Wardenburg Piebaldism
Syndrome (NCC migration defect)
AD transmission
Mutation in C Kit gene
Erythemas

Erythema Erythema
Nodosum Marginatum
Tender nodules on skin due to Transient lesions asso. with ARF
inflammation of s/c fat mARFginatum
Asso. with
1. Drugs : Sulfa drugs
2. Sarcoidosis (Lofgren sx)
3. IBD
4. TB
5. Behcet Sx

Erythema Migrans
Single and large target lesion on trunk
Earliest manifestation of lyme's disease
Borrelia migrates with lashing motility

Erythema
Multiforme
Typical target lesions on hand
Associated with
Infections Drugs
1. HSV (m/c) 1. NSAIDS
2. Mycoplasma 2. Chloroquine

Chloroquine also causes

Bull's eye maculopathy

Atypical target lesions

seen with SJS/TEN
Erythema gratum ripens
Para neoplastic syndrome associated
with adenocarcinoma
 Acne Vulgaris
Pathophysiology
1. Excess sebum production Most common trigger for acne is puberty.
2. Follicular plugging with sebum and keratinocytes During puberty, surges in androgens stimulate sebum
3. Colonization of follicles by an anaerobe Cutibacterium production and hyperproliferation of keratinocytes
acnes (formerly Propionibacterium acnes)
4. Release of inflammatory mediators

Comedones
Characteristic of acne

Treatment
1. Comedones: Topical retinoid (tretinoin)
2. Mild inflammatory acne: Topical retinoid + (Topical Benzoyl peroxide / Topical antibiotics)
3. Moderate acne: Oral antibiotic + topical therapy
4. Severe acne: Oral isotretinoin
5. Nodulo-Cystic acne (Acne conglobata): Intralesional triamcinolone

Rosacea
h/o triggers : emotional states, spicy food
Flushing
Telengiectasia
Nasolabial folds (+) d/d is Malar rash of SLE

Nasolabial folds involved Nasolabial folds spared

Rosacea Malar/butterfly rash of SLE

 Sweat Glands

Sweat glands

Apocrine Eccrine
Axilla, groin Everywhere else
Ass. with hair follicles (Causes miliaria when blocked)
Causes Fox Fordyce disease Fordyce spots seen on lips
when blocked Overgrowth of ectopic sebaceous glands
**Unrelated Fox Fordyce disease

1. Miliaria crystillina : Non inflamed

2. Miliaria rubra : Itchy, red
3. Miliaria profunda : Deep, large
papules/pustules

Hiradenitis Suppurata
Acanthosis Nigricans
Complication of fox fordyce dis.
aka inverse acne Marker of
Obesity and smoking are risk factors Insulin resistance/PCOD/T²DM
Treatment : Surgical Metabolic sx. , Obesity
GI adenoma
sinuses + induration

Ca2+ ATPase channel disorders

Associated with Desmoglein dysfunction
Example of primary acantholysis

Ca2+ ATPase channel disorders

Darrier's disease Hailey Hailey disease

2A2 2C1

Crop grains/ ronds V shaped nail lesion Raised erythematous H/P : Dilapidated brick wall
plaques in axilla appearance
A looks like V : 2A2

2 see 1 (2C1) hailey comet

break a brick wall

Longitudinal lines in nail

Alopecia
Hair Loss

Scarring Non Scarring

1. Discoid Lupus erythematosus 1. Tenogen effluvium (tension/stress/child birth)
2. Lichen planus 2. Anagen effluvium (chemotherapy)
3. Tinea Capitis 3. Trichotillomania (accessible areas)
4. Alopecia areata
2° Syphilis causes both scarring and non scarring 5. Trichotillomania
6. Androgenic alopecia

Alopecia areata Androgenic Alopecia

Autoimmune condition
Asso. with Type 1 DM, Hashimoto thyroiditis
"Going bald overnight"
Nails : Regular pitting
Exclamatory mark sign !
Male pattern Female pattern
aka Hamilton aka Ludwig
pattern hair loss pattern hair loss

TOC :
1. Minoxidil
No inflammation Lymphocytes around hair bulb 2. Finasteride
No scarring Swarm of bees appearance

Stages of hair growth

Trichotillomania
Shedding: Exogen
Psychiatric condition
(Impulse control disorder)
Hair loss from accessible
areas

90% hair in this Proximal hair

phase shaft keratinised. "ACT"
Clubbing

State of latency : Kenogen

Nails

Half and Half nails Terry's nail Muehrcke's nails

Seen in renal failure Seen in heart failure Seen in hypoalbuminemia
2 kidneys 2 zones Terry : Three (reversible with albumin infusion)

Koilonychia (Spoon shaped)

Seen in iron deficiency anemia

Wood's Lamp

Tinea Capitis : Blue - Green

Pityriasis versicolor : Yellow
Erythrasma : Brilliant coral red
Vitiligo : Bright white (milky)
Tuberous Sclerosis : Pale white

Uses UV-A light

Barium Silicate + NiO filter
Erythrasma
365 nm 365 days in a year Caused by Cornybacterium Minutissimum
 Dermatitis
Dermatitis

Atopic Contact
dermatitis dermatitis
aka Eczema aka Irritant dermatitis
Associated with high serum IgE levels More common in incidence over atopic
Family h/o atopy such as asthma or allergic dermatitis
rhinitis Can occur in anyone exposed to the irritant
Onset < 2 yr of age (mostly seen in children) Common irritants : Poison ivy, sumac, oak
Involves predominantly flexural aspect
Involves forehead and cheeks in < 4 yr

Patch test
For allergic dermatitis
Read at 48 hrs and 96 hours

Hives (Urticaria)
A skin rash triggered by a reaction to food, medicine or other irritants (allergic)
Can be acute or chronic (> 6 weeks)

Hives Dermographism (seen in chronic urticaria)

Skin Malignancies

BCC (Rodent ulcer) Pautrier's microabscess

Raised pearly nodules Seen in mycosis fungoides (Cutaneous T cell lymphoma)
m/c cutaneous malignancy Epidermotropism : Lymphocytic movement towards epidermis
Good prognosis Cerebriform nuclei
On H/E : true palisading When disseminated in blood : Scezary syndrome
T/t : Exctracorporeal photopheresis

True palisading

Cutaneous horn
Seen in actinic keratitis
Giant melanocytic nevus Hair present on the nevus Premalignant for Sq.cell carcinoma

Melanocytic nevus
Can transform into malignant melaoma Bowen's disease
Intra-epidermal sq.
cell carcinoma
Low potential of
invasive malignancy
Malignant melanoma Undergoes spont.
Most important resolution
prognostic marker is
depth of the melanoma
"Breslow's depth"
Seborrheic keratosis
Para neoplastic
syndrome
aka sign of Leser Trelat
 Neurocutaneous Syndromes

Neurofibromatosis type 1 Neurofibromatosis type 2

Associated tumors Features of melanocyte dysfunction Associated tumors

Meningiomas

Optic glioma Lisch nodules Early-onset

bilateral cataract Bilateral vestibular schwannoma
Axillary and inguinal
freckling Spinal tumors
(e.g., ependymomas)
Multiple café au lait
Pheochromocytoma spots Skin nodules
(e.g., schwannomas)

Bone involvement
Multiple neurofibromas (e.g. scoliosis,
bone dysplasia)

Tuberous sclerosis
Skin Brain

Hamartoma
Giant cell astrocytoma
Seizures
Intellectual disabilitiy
Adenoma sebaceum
Heart
Ash-leaf spots
(3 or more)

Cardiac
rhabdomyomas

Shagreen patch
Kidney

Renal angiomyolipoma

Renal cysts

Renal cell carcinoma

Ungual fibroma

Sturge Weber Syndrome

CNS

Leptomeningeal vascular
malformations, leading to:

Seizures All neurocutaneous syndromes show

Intellectual disability AD transmission
except
Sturge Weber Syndrome
Glaucoma

Stroke-like episodes
Port-wine stain (e.g., hemianopia,
(nevus flammeus) hemiparesis)
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