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
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Primary
Macule
Papule
Tuber
Nodus
Urtica (wheal)
Vesicle/ bulla/ spongiosis
Pustule
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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