Clinicopathologic Correlations

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Skin disorders are frequently perplexing to the examiner. When an examiner sees a rash, the common thought is ''Where do I begin?'' All too often, the examiner may become frustrated

Figure 8-21

Secondary Skin Lesions Below the Skin Plane

Lesion Characteristics

Erosion Loss of part or all of the epidermis; surface is moist

Ulcer Loss of epidermis and dermis;

may bleed

Fissure Linear crack from epidermis into dermis

Excoriation A superficial linear, or ''dug out,'' traumatized area, usually self-induced

Atrophy Thinning of skin with loss of skin markings

Sclerosis Diffuse or circumscribed hardening of skin

Examples

Rupture of a vesicle

Stasis ulcer, chancre

Cheilitis, athlete's foot

Abrasion, scratch mark

Striae

Erosion

Erosion

Pathological Atrophy Examples

Atrophy

Excoriation

Atrophy

Excoriation

Secondary Skin Lesions Above the Skin Plane

Lesion

Characteristics

Examples

Scaling

Heaped-up keratinized cells; exfoliated

Dandruff, psoriasis

epidermis

Crusting

Dried residue of pus, serum, or blood

Scabs, impetigo

Vascular Skin Lesions
Vascular Skin Lesions

Lesion

Characteristics

Examples

Erythema

Pink or red discoloration of the skin, secondary to dilatation of blood vessels, that blanches with pressure

Petechiae

Reddish-purple; nonblanching; smaller than 0.5 cm

Intravascular defects

Purpura

Reddish-purple; nonblanching; greater than 0.5 cm

Intravascular defects

Ecchymosis

Reddish-purple; nonblanching; variable size

Trauma, vasculitis

Telangiectasia

Fine, irregular dilated blood vessels

Dilatation of capillaries

Spider angioma

Central red body with radiating spider-like arms that blanch with pressure to the central area

Liver disease, estrogens

Miscellaneous Skin Lesions

Lesion

Characteristics

Examples

Scar

Replacement of destroyed dermis by fibrous tissue; may be atrophic or hyperplastic

Healed wound

Keloid

Elevated, enlarging scar growing beyond boundaries of wound

Burn scars

Lichenification

Roughening and thickening of epidermis; accentuated skin markings

Atopic dermatitis

Physical Clinical Diagnosis
J // ' Ecchymosis

Figure 8-23

Figure 8-23

and not even attempt to make a diagnosis. Dermatologic terms are complicated, and the names of dermatologic disorders may be intimidating. Often the descriptions of skin disorders in textbooks are more confusing than helpful.

There are more than 2500 separately named dermatologic diagnoses. Most of these diseases occur in low frequencies;only 10 to 15 common conditions constitute about 50% of all dermatologic diagnoses. If the 50 most common conditions were considered, a diagnosis could be rendered for over 95% of all patients.

In approaching a skin lesion, the examiner must do the following:

1. First, identify the primary lesion.

2. Second, identify its distribution.

3. Third, identify any associated findings.

4. Fourth, consider the age of the patient.

Skin diseases evolve and their manifestations change. A lesion may evolve from a blister to an erosion, from a vesicle to a pustule, or from a papule to a nodule or tumor.

Descriptive Dermatologie Terms Lesion Characteristics

Annular Ring-shaped

Arcuate Partial rings

Bizarre Irregular or geographic pattern not related to any underlying anatomic structure

Circinate Circular

Confluent Lesions that run together

Discoid Disc-shaped without central clearing

Discrete Lesions that remain separate

Eczematoid An inflammation with a tendency to vesiculate and crust

Generalized Widespread

Grouped Lesions that are clustered together

Iris Circle within a circle; a bull's-eye lesion

Keratotic Horny thickening

Linear In lines

Multiform More than one type of shape of lesion

Papulosquamous Papules or plaques associated with scaling

Reticulated Lacelike network

Serpiginous Snakelike, creeping

Telangiectatic Relatively permanent dilatation of the superficial blood vessels

Universal Entire body involved

Zosteriform* Linear arrangement along a nerve distribution

Examples

Ringworm Syphilis

Factitial dermatitis

Childhood exanthems Lupus erythematosus

Eczema

Herpes simplex Erythema multiforme Psoriasis

Poison ivy dermatitis Erythema multiforme Psoriasis

Oral lichen planus Cutaneous larva migrans Osler-Weber-Rendu disease

Alopecia universalis Herpes zoster

*Also known as dermatomal.

*Also known as dermatomal.

Pinhead Syndrome
Figure 8-24
How Skin Lightening Act Diagram

There are many common skin disorders or lesions with which the examiner should be familiar. Illustrated in the figures in this chapter are examples of some of these conditions; these cross-sectional diagrams illustrate the locations of these abnormalities in the skin and the involvement of the various skin layers in the pathogenesis of the conditions. The text describes the primary lesions.

A common wart is a common, benign growth usually caused by an infection of an epidermal cell by a virus. These firm nodules with rough, keratinous surfaces range in size from pinhead to pea size and can coalesce to form an extensive bed. There is vacuolation of the epidermis with scaling and an upward growth of the dermal papilla. Figure 8-25 illustrates a cross section through a wart. Two examples of finger warts are pictured in Figure 8-26.

Warts can also occur on the soles of the feet (plantar verruca), where they have a distinctive appearance because of constant pressure. They are very painful owing to the constant pressure, which forces the keratinous material into the deeper tissue. An example of a plantar wart on the heel is shown in Figure 8-27A. Notice the keratotic lesion with a yellow center, within which are visible areas of multiple red to black dots that represent hemorrhage from the tips of the dermal papillae. Classically, there is interruption of the normal skin lines as well. Figure 8-27B shows the excised lesion. Notice the depth of the lesion when viewed horizontally. Because warts are in the epidermis, excision just to the level of the dermis is sufficient for complete removal with minimal to no scarring.

A squamous cell carcinoma is a malignant neoplasm of keratocytes in the epidermis and is locally invasive into the dermis. The tumor results in a scaling, crusting nodule or plaque that can ulcerate and bleed. Squamous cell carcinoma is a potentially dangerous lesion that can infiltrate the surrounding structures and metastasize to lymph nodes and other organs. The causes include ultraviolet radiation, x-radiation, polycyclic hydrocarbons (e.g., tar, mineral oils, pitch, and soot), mucosal diseases (e.g., lichen planus and Bowen's disease), scars, chronic

Can Plantar Warts Dangerous
Figure 8-26 A and B, Warts.
Plantar Wart Severe

Figure 8-27 Plantar wart. A, Note the keratotic lesion with the yellow center and areas of hemorrhage within. B, After excision.

Figure 8-27 Plantar wart. A, Note the keratotic lesion with the yellow center and areas of hemorrhage within. B, After excision.

skin disorders, genetic diseases (e.g., albinism and xeroderma pigmentosum), and human papillomavirus. The tumor develops predominantly on areas of skin exposed to sunlight. The latency from carcinogenic exposure to the development of the tumor may be as long as 25 to 30 years. Two examples of squamous cell carcinoma of the skin are pictured in Figure 8-28. Notice that the lesions are ulcerated with firm, raised indurated margins. Figure 11-11 also shows a patient with a squamous cell carcinoma and a malignant melanoma of the ear lobule. A squamous cell carcinoma on the lip of another patient is pictured in Figure 8-29. Notice the round, centrally ulcerating tumor. Figure 8-30 illustrates a cross section through a squamous cell carcinoma.

A basal cell carcinoma is a malignant neoplasm of the basal cells of the epidermis and is the most common skin malignancy. The epidermis is thickened, and the dermis may be invaded by the malignant basal cells. It may manifest as a lesion with a pearly, rolled, well-defined margin and a central ulcerated depression. Although sunlight is an important etiologic factor, basal cell carcinomas are almost always seen on the face and rarely in other sun-exposed areas. They are slow-growing tumors and rarely metastasize, in contrast to squamous cell carcinomas.

Squamous Cell Malignant Neoplasm
Figure 8-28 Squamous cell carcinoma of the skin. A, Ear. B, Face.
Figure 8-29 Squamous cell carcinoma of lip.

They are locally invasive, and when located near the eye or nose, they may invade the cranial cavity. If ulceration, bleeding, and crusting occur, a rodent ulcer is said to be present. Any nonhealing lesion should be carefully evaluated for the possibility of a basal cell carcinoma. Figures 8-31 to 8-33 illustrate the typical features of a basal cell carcinoma.

A melanoma is a malignant neoplasm of the melanocytes of the epidermis. If untreated or unrecognized, a melanoma progresses to fatal metastases. Most melanomas have a prolonged superficial, or horizontal, growth phase in which there is a progressive lateral expansion. With time, the melanoma enters the vertical, or deep, phase by penetrating into the dermis, and metastatic spread may occur.

Malignant melanomas are the most common malignancy seen by dermatologists. The incidence of malignant melanoma is increasing faster than that of any other form of malignancy. Most melanomas have atypical pigmentation in the epidermis, such as shades of red, white, gray, blue, brown, and black, all in a single lesion. There are four types of malignant melanoma: lentigo maligna melanoma, superficial spreading melanoma, nodular malignant melanoma, and acral-lentiginous malignant melanoma. Figure 8-34 shows the typical features of a lentigo maligna melanoma on the face. The lentigo maligna melanoma is seen frequently in the geriatric population. This type of melanoma has a prolonged horizontal growth phase and appears in areas of sun-exposed, sun-damaged skin. The superficial spreading variety (Fig. 8-35) is the most common type of melanoma (70% of all melanomas). Typically, an irregularly colored plaque has sharp notches and variegation of pigment. If it is diagnosed early, the prognosis is excellent, with a 5-year survival rate of 95%. Figure 8-36 illustrates a cross section through a melanoma. Vertical growth and deep invasion follow the spreading phase of superficial malignant melanomas. Figure 8-37 shows another superficial spreading melanoma that has developed vertical growth. The nodular melanoma is the second most common type, seen in approximately 15% of cases of melanoma. Unlike the superficial spreading type, these melanomas are usually black, brown, or dark blue and tend to grow rapidly for months.

Melanomas occur predominantly in white individuals and have a predilection for the back in men and women and for the anterior tibial areas in women. In general, lesions on the back, axillae, neck, and scalp (the so-called BANS area) tend to have a worse prognosis than do melanomas on the extremities. A great contrast between the risk of acquiring melanoma and basal or squamous cell carcinoma is that basal and squamous cell carcinomas occur more

Squamous Cell Carcinoma Cross Section
Figure 8-30 Cross section through a squamous cell carcinoma. Note the invasion into the dermis.

Figure 8-31 Cross section through a basal cell carcinoma.

Figure 8-31 Cross section through a basal cell carcinoma.

Cross Section Rosacea

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How To Deal With Rosacea and Eczema

Rosacea and Eczema are two skin conditions that are fairly commonly found throughout the world. Each of them is characterized by different features, and can be both discomfiting as well as result in undesirable appearance features. In a nutshell, theyre problems that many would want to deal with.

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Responses

  • leslie
    What is cell carcinoma skin of tibia?
    3 years ago
  • AMANUEL LUWAM
    Can verrucas be dangerous?
    2 years ago

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