Primary and secondary skin lesions Dr. István Juhász Dept. Dermatology Univ.of Debrecen Med.Health Sci. Center Debrecen, Hungary Skin lesions • Correct morphological diagnosis • Macroscopic picture - histological confirmation • primary skin lesions - first direct symptoms of the pathological events • secondary skin lesions - consequential signs and symptoms as the pathological events progress over time • Monomorphic / polymorphic picture Skin lesions • • • • • • • • Primary Macule Papule Tuber Nodus Urtica (wheal) Vesicle/ bulla/ spongiosis Pustule • • • • • • • • • • • • Secondary Squama Crusta Excoriation Erosion Fissura Fistula Ulcer Cicatrix Lichenification Atrophia Sclerosis Primary skin lesions Macule Papule Tuber Nodus Urtica (wheal) Vesicle/ bulla/ spongiosis Pustule Primary skin lesions Macules PIGMENTED melanin blood driven pigment VASCULAR functional organic drugs and chemicals Infiltrative lesions: papule, plaque, nodule, tumor, seropapule Exsudative lesions: urtica , vesicle, bulla, lacuna, pustula Primary skin lesions • Macule (< 1 cm) • Patch (> 1 cm) • Localised lesion in the niveau of surrounding skin, different only in its colour. • Pigment surplus/ hyperpigmentation • Pigmentation in the dermis (Tyndall’s phenomenon) • Pigment loss/ hypopigmentation/ depigmentation brown blue white Extravasation of blood: 1. purpura – red – deposit of blood or blood pigment 2. petechia - brown/red - deposit of blood or b. pigm. Active hyperemia erythema Passive hyperemia cyanosis Macula+fine scaling = maculosquamous lesions (Pityriasis rosea) Teleangiectasia = permanent capillary dilatation Primary skin lesions • Papule • Cellular infiltration localized only to the papillary dermis with flowerbed-like borders. Size < 10mm, • Plaque >10mm • Papulous eruptions, • Common part of a polymorphic picture, very common lesion. Papule: 1. Epidermal papules: verruca vulgaris 2. Dermal papules: superficial dermal tissue growth. Syphilitic papules. 3. Mixed dermo-epidermal papules. Psoriasis vulgaris, Lichen planus Tuber (protuberance): reminds of a papule, sits in the deeper layers of the cutis, size of a bean or cherry, firm resistance. May be subject to ulceration or scarring. E.g.: tuber in lupus vulgaris apple-jelly like structure Nodule: firm, < 1cm, circumscribed cellular mass reaching into subcutis. E.g.: rheumatic nodule, erythema nodosum Gumma: granulomatous infiltrate, with epiteloid cells deep in lowest third of cutis and subcutis. Elasthic, firm palpating with a tendency to exulcerate ( ulcer), very often leaves a scar (cicatrix) when heals. Tumor: large cellular mass, affecting skin’s full-thickness tumor neoplasm • benign - malignant • multiple - solitary Urtica / wheal: Round or flat transitory elevated lesion – circumscribed edema of the upper dermis. Vasolability - dermografism. Disappears in hours (IgE). If permanent: immunkomplex origin must be ruled out. - intact epidermis - no scaling Angiooedema: urticaria in an area with very loose subcutis (face, mouth, scrotum) Pink/brown macule urtica = Darier’s sign = mastocytosis = urticaria pigmentosa Mechanical stress may produce urticas, called urticaria factitia Vesicle: small, circumscribed, eleveated lesion containing fluid, < 5 mm. Bulla (blister): > 5 mm, Blister content: serum or blood (serous or hemorrhagic vesicle or bulla) Spongiosis: Intercellular heavy edema in the epidermis Due to viruses the epidermal cells may show intracellular edema, "balloon-like degeneration" – the vesicles appear with a central depression. Spongiosis: intracellular accumulation of epidermal fluid to be seen with a microscope only Acantholysis: rupture of intercellular bridges and desmosomes Epidermolysis: Epidermis is detached from dermis Vesicle: small, circumscribed elevated lesion containing fluid < 5 mm. Subcorneal vesicle: herpes zoster impetigo Bulla (blister): protruding lesion with fluid inside, > 5 mm, Intraepidermal pemphigus vulgaris loose (flaccid) Bulla (blister): protruding lesion with fluid inside, > 5 mm, Subepidermal • pemphigoid tense • dermatitis herpetiformis • porphyria cutanea tarda Cysta: • Sack containing fluid or semi-solid material • Barrier – cyst wall • fluid, cells, metabolic products nodus: cysta: Firm on palpation Fluctuates on palpation Pustule: circumscribed, elevated purulent blister containing leukocytes Pustule: It may contain bacteria, but may also be sterile. Secondary skin lesions Squama (scales) Crusta (scab) Erosion (...) Excoriation Fissure, rhagas (rupture) Fistule Ulcer (...) Cicatrix (scar) Lichenification Atrophia (...) Sclerosis Squama (scale): increased desquamation that can be easily scraped off. Usually seen: after sunburn psoriasis pityriasis rosea syphilis papulosquamous lesion = exfoliating papule maculosquamosus lesion = exfoliating macule psoriasis Crust (scab): Dried-out exudate of serum, blood or purulent origin thin / easily removable - - thick / adherent yellow (serum) yellowish-green (purulent exudate) brown (blood; hemorrhagic crust) Folliculitis: cone-shaped, noncicatrizing inflammation of the hair follicle localized around the hair shaft Ostiofolliculitis: inflammation of the hair follicle localized at its opening Furuncle: deep, necrotizing folliculitis with the accumulation of pus Abscess: localized cavity filled with pus, that cannot be seen from the surface. Hyperemic, tender, hot. Fistule: opening of a pusfilled cavity or a slot between abscesses releasing its content onto the skin surface. Erosion: circumscribed, oozing, partial or full-thickness loss of epidermis with a sharp border erosion of great proportions = denudation (e.g: in pemphigus) Fissure, rhagas (skin rupture): Painful, linear break penetrating deep into the skin with abrupt walls. Usually seen on hands and feet, over joints. Excoriation: dotted or linear superficial epidermal defect, due to scratching of skin (excoriation). Scabies, Ekzema linear dot-like pruritus - excoriation Ulcer (ulcus): Circumscribed loss of tissue, affecting both dermis and epidermis. Important features: localisation, borders, depth, base. Obstruction of blood vessel Node Neoplasm } Exulceration Cicatrix (scar): Residual tissue that remains after the transformation of granulation tissue associated with the healing of wounds affecting the dermis. Its chatacteristic is the total absence of glyphae and skin appendages. Wound tissue repair scar Types: normotrophic, atrophic, hypertrophic. Lichenification: Secondary lesion with cobblestone-like surface and firm palpation. Associated with chronic inflammation. Atrophia (involution): reduction of the size of tissue or limb Sclerosis: Circumscribed or diffuse hardening of skin Morphea, Scleroderma, Stasis dermatitis Calcinosis: circumscribed deposition of bonelike material (following protracted tissue inflammation) Gangrene: Severe necrosis that may be either dry or wet. Arterial blocade: bluish-black color Poikiloderma atrophia + teleangiectasia + hyper- and hypopigmentation radiodermatitis dermatomyositis mycosis fungoides lupus erythematosus
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