Morphology:

How to describe what you see

Basic Dermatology Curriculum

Last updated September 2018

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 Goals and Objectives
▪ The purpose of this module is to learn how to
best describe skin lesions
▪ After completing this module, the learner will
be able to:
• List all primary lesions that occur in the skin
• List secondary lesions or findings occurring on
primary lesions
• Use at least 5 different terms in describing
arrangements of lesions
• Use at least 5 different terms in describing
shapes of primary lesions
• Describe cutaneous findings based on a clinical
image using accurate dermatologic nomenclature

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 Morphology
▪ The word morphology is used by dermatologists to
describe the form and structure of skin lesions
▪ The morphologic characteristics of skin lesions are
key elements in establishing the diagnosis and
communicating skin findings
▪ There are two steps in establishing the morphology
of any given skin condition:
1. Careful visual and tactile inspection
2. Application of correct descriptors

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 Visual and Tactile Inspection
▪ Accumulate detailed information about the
visual and tactile aspects of the skin findings
▪ Be able to communicate an accurate
description so someone who cannot see what
you are describing can get an accurate mental
picture of what you are describing
▪ Question 1
• How would you describe the item depicted on the
next slide?

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 Question 1

• How would you

describe the object to
the right?
• Be as detailed as can
be!

Images courtesy of UT
Southwestern
Department of
Dermatology. 5
 Question 1
This is a 7mm deep
maroon-red, discoid
plastic circular object that
has targetoid rings of an
alternating shiny and dull
surface texture and is
slightly invaginated from
the periphery to the
center, where there are
also two horizontally
arranged holes. It casts a
Images courtesy of UT
Southwestern slight shadow.
Department of
Dermatology.

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 Question 1
This is a deep maroon-red, discoid plastic 7mm circular
object that is 0.5mm thick and has targetoid rings of an
alternating shiny and dull surface texture and is slightly
invaginated from the periphery to the center, where there
are also two horizontally arranged holes. It casts a slight
shadow. Images courtesy of UT
This description identifies: Southwestern
Department of
1. Color: deep maroon-red
Dermatology.
2. Shape: discoid
3. Secondary features: targetoid with central
invagination and two central holes arranged
horizontally
4. Texture: alternating shiny and dull surface
5. Size 7mm
6. Palpability: indicated by shadow and
thickness

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 Application of correct descriptors
• We have just reviewed careful visual
inspection

• We will now define the terms

dermatologists use to describe skin lesions

• We will then have a series of cases for you

to practice describing so you can use the
correct descriptors.

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 Primary Lesions: What are they?
• Primary lesions are like saying what “family”
a particular disease belongs to.
• Similar to botany, where you might say it is a
tree, shrub, or a flower.
• More than one morphology can be present in
some conditions. However, once you choose
the lesion type that is present, it helps
‘narrow’ the possibilities of what the disease
might be.
• i.e. if you see vesicles—you know this is not
a lesion of psoriasis.

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 Primary Lesions: What are they?
The main primary lesions are:
• Macule, patch: Flat, color change only
• Papule, plaque: raised, palpable
• Vesicle, bulla: serous fluid-filled space in
epidermis
• Wheal: an edematous papule or plaque
• Nodule, tumor: raised lesion deeper in skin
• Pustule, furuncle, abscess: pus-filled space
• Cyst: a sac-like nodule that has an epithelial
lining containing fluid or debris

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 Primary lesions: Macule/Patch

▪ (L. macula, “spot”)

▪ Indicates a flat color
change in the skin
<1cm in size.
▪ A macule is flat; if you
can feel it, then it is not
a macule.

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Examples of Macules

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 Primary lesions: Macule/Patch
▪ A patch is also a flat
color change in the
skin, but patches
larger than macules
▪ If it’s flat and >1 cm,
it is a patch

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Examples of Patches

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Primary Lesions: Papule/Plaque
▪ (L. papula, “pimple”)
▪ Papules are solid raised
lesions <1 cm. They can
sometimes be flat and
depressed ie. lower than
the skin surface

▪ Papules are due to an

increase in the number of
cells or a change in the
connective tissue in
epidermis or dermis

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Examples of Papules

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 Primary Lesions: Papule/Plaque
▪ Plaques are raised lesions > 1
cm
• They are palpable
• Usually will cast a shadow with
tangential lighting
▪ Due to a change in the number
of cells or connective tissue in
epidermis or superficial dermis
▪ Plaques can sometimes be
depressed, i.e. lower than the
skin surface

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Examples of Plaques

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 Primary Lesions: Wheal

• Wheal: an edematous
papule or plaque.

• Wheals are typically

transient,
circumscribed, elevated
papules or plaques,
often with erythematous
borders and pale
centers. Image courtesy of UT
Southwestern
Department of
Dermatology.

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 Primary lesion: Vesicle/Bulla
▪ (L. vesicula, “little
bladder”; bulla,
“bubble”)
▪ Vesicles are serous
fluid-filled papules
(small blisters)
▪ A large (> 1cm)
blister is called a
bulla
vesicle bulla

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Examples of Vesicles and Bullae

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 Primary Lesions: Nodule/Tumor
▪ (L. nodulus, “small
knot”)
▪ >1 cm in diameter
▪ Usually have a rounded
surface and is caused
by an accumulation of
cells or change in
connective tissue in the
deep dermis or
subcutis.

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Examples of Nodules

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 Primary Lesions: Nodule/Tumor

• Tumors are solid,

firm lesions that
can be exophytic,
endophytic, or level
with the skin
surface.
• Tumors are usually
> 5cm. Images courtesy of UT
Southwestern
Department of
Dermatology.

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 Primary Lesions: Cyst

• Cyst: a sac-like nodule

that usually has an
epithelial lining
containing fluid or other
debris
• The cystic contents are
usually produced as by-
products of the epithelial
lining. Images courtesy of UT
Southwestern
Department of
Dermatology.

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 Primary Lesions:
Pustules/Furuncles/Abscess
▪ Pus is made up of
leukocytes and a thin
fluid called liquor
puris (L. “pus liquid”)
▪ A pustule is a
small
circumscribed
raised lesion that
contains pus
▪ See also furuncle
and abscess pustules of psoriasis

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 Primary Lesions: Review
• We have now reviewed all of the primary lesions that exist in
the skin.
• Remember, primary lesions are like saying what “family” a
particular disease belongs to.
• The main primary lesions are:
• Macule, patch: Flat, color change only
• Papule, plaque: raised, palpable, can sometimes be
depressed, ie. lower than the skin surface
• Vesicle, bulla: serous fluid-filled space in epidermis
• Wheal: an edematous papule or plaque
• Nodule, tumor: raised lesion deeper in skin
• Pustule, furuncle, abscess: pus-filled space
• Cyst: a sac-like nodule that has an epithelial lining containing
fluid or debris

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 Secondary Lesions:
What are they?
Secondary Lesions : changes that occur superimposed upon the primary lesion. They
can be from outside manipulation or due to evolution of the primary lesion.
Secondary Lesions
• Erosion: loss of the epidermis
• Ulceration: loss of the epidermis and part of the dermis.
• Scale: excess accumulation of “dead skin”/ fragments of stratum corneum
• Crust: adherent, dried serum, exudate or blood on the skin
• Atrophy: thinning of the skin—can be in the epidermis, dermis, or subcutaneous fat
• Lichenification: thickening of the epidermis with accentuation of the normal skin lines
• Fissure: a linear crack in the epidermis
• Excoriation: loss of epidermal integrity due to scratching
• Scar/Keloid: permanent fibrotic changes that result from damage extending into the
dermis, keloids extend beyond the borders of the original defect.
• Erythema: indicates vascular dilation, blanchable red or pink hue in the skin. Erythema is
not a color.

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Blanching vs. Non-blanching

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 Secondary Lesions:
Erythema vs. Purpura
Severe acute allergic contact dermatitis to
topical antibiotic ointment
• Erythema: can range from
pink to deep red hue in the
skin due to vasodilation.
Indicates vascular
inflammation or dilation.
Erythema is not a color.

• Petechiae, Purpura and

Ecchymoses: bleeding that
occurs in the skin from
small pinpoint→
centimeter→ large patches
– Purpuric lesions do not Retiform (angulated) purpura that often occur in
blanch with diascopy acute medium vessel (ANCA)vasculitis
or vascular occlusion (calciphylaxis, DIC, etc)
 Secondary Lesions:
Erosion/Ulceration
▪ Erosions are loss of part or all
of the epidermis
▪ They sometimes occur after a
vesicle forms and the top
peels off (pictured below)
▪ They ooze serous fluid and
become crusted

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 Secondary Lesions:
Erosion/Ulceration
▪ (L. ulcus, “sore”)
▪ Ulcers are complete loss of the
epidermis in addition to part of the
dermis, they can be shallow or deep
▪ Ulcers usually heal with scarring;
erosions usually do not cause scars.

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Secondary Lesions: Fissure and Excoriation

• Fissure: a linear
crack of the skin
that extends into
the dermis
• Excoriation: areas
of trauma to the
skin that result from
rubbing or
scratching
koebnerization of lichen planus

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 Secondary Lesions: Scale and Crust
• Scale: flakes or plates of
compacted, desquamated
layers of stratum corneum

• Crust: a “scab”, crust can be

hemorrhagic, serous or
purulent.
– Dry plasma or exudate on the
skin
 Secondary Lesions:
Atrophy and Lichenification

• Atrophy: thinning of the

epidermis, dermis or
subcutaneous fat
– in this photo there is epidermal atrophy
with dermal sclerosis: the epidermis is
thinned making the dermal vasculature
visible through the skin surface

• Lichenification: thickening
of the epidermis with
exaggeration of normal
skin lines. Usually due to
chronic rubbing or
scratching of an area. lichenification due to chronic nickel
contact dermatitis (belt buckle)
 Secondary Lesions:
Scars and Keloids
• Scar: permanent fibrotic
changes that occur on the
skin following damage to
the dermis
– Keloids are notable for
the fact that the scar is
raised and tissue
extends beyond the
edges of the original
wound.
 Shapes and Distributions
• Also important in describing lesions is where the lesions occur on the body, what surface
texture and shape each lesion has, and how they are arranged with respect to one
another.
Lesion Shapes:
• Nummular/Discoid/Round: all describe coin-shaped lesions
• Annular: ring-shaped
• Arcuate: shaped like an arc.
• Serpiginous: wavy like a snake
• Figurate/Polycyclic: lots of different ring shapes, rings within rings
• Retiform/Reticulate: web or net-like.
• Mammillated ‘nipple like’: bumpy, like a cobblestone road
• Umbilicated: centrally indented
• Targetoid: lesions with a bulls-eye, or concentric rings or varying colors
Distributions:
• Discrete/Scattered: lesions are separate from one another
• Clustered (Agminated): grouped together in a bunch but not running together
• Coalescing: grouped and starting to merge into one another
• Focal: just in one anatomic location
• Generalized: over the ENTIRE body

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 Distribution / Configuration
▪ To learn more about distributions, click
here:
• http://bit.ly/itkitk
▪ To learn more about configurations, click
here:
• http://bit.ly/kbRI9Q
• These links take you to LearnDerm, a free
resource for learning morphology terms

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 Morphology Terminology: Practice

• Now you have the terms you need

• Let’s practice your descriptions with cases

• Do the best you can – like learning any new

language, it takes practice!

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 Case One: Skin Exam
▪ Mr. F is a 32-year-old man who presents to his primary care provider with
“blotches” on his upper back, chest, and arms for several years. They are
more noticeable in the summertime.

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 Case One, Question 1
▪ Look carefully at all clues
in the photographs.
▪ There are many right
ways to describe
something. Be creative
▪ Are these lesions
elevated, flat, or
depressed?

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Case One, Question 1
If you don’t feel an elevation or
depression as your finger runs
across the skin, they are flat
– Small, flat lesions are called
macules

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 Case One, Question 2
Review the prior image and this new
image, then describe the following
features.
– What size are they?
• 1 cm to several centimeters in size
– What shape are they?
• Figurate
– What color are they?
• Lack pigment entirely
– How regular and distinct is the border?
• Well-circumscribed
– How are they configured?
• Clustered/coalescing
– How are they distributed?
• Predominantly distributed on extensor
surfaces

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 Diagnosis

• Dr. D does a woods light exam and it accentuates the depigmented

nature of the macules and patches

• Mr. F's history and exam findings are consistent with vitiligo. To learn
more about vitiligo go to Blotches: Light Rashes.

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 Review: Macule vs Patch

MACULE (<1cm)
PATCH (>1cm)

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 Case Two: Skin Exam
▪ Mr. K is a 36-year-old man who presents with four years of itchy, flaky spots
on his elbows, knees, and lower back. They have not improved with
moisturizers.

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 Case Two
▪ How would you describe these skin
findings?
▪ Be as detailed as possible!

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Case Two, Question 1

• Are these lesions

raised, flat, or
depressed?
• Imagine running your
finger over them.
– These are raised
– Large (>1cm), plateau-
like, raised lesions are
called plaques

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Case Two, Question 1
How else can you describe
them?
– Size?
• 6-10cm in size
– Shape? round/ nummular
– Color?
• Pink to red, erythematous
(blanchable)
– Sharp borders?
• Well-demarcated.
– Secondary
changes/features?
• Thick scale
– Distribution?
• Knees, lower back/extensor
surfaces, symmetrical

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 Diagnosis
▪ Mr. K’s skin exam shows:
• Several 3-10 cm pink round sharply circumscribed scaly plaques
on his extensor elbows, knees, lower back, and gluteal cleft
▪ Mr. K has psoriasis. The primary lesion in this case of psoriasis is a
plaque with thick adherent “micaceous” scale.
▪ Diseases that cause scaly plaques are called papulosquamous
disorders.

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 Review: Papule vs Plaque

PAPULE (<1cm)
PLAQUE (>1cm)

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 Case Three
Mr. B is a 28-year-old man who presents with four
days of pain and blisters on his left chest.

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Case Three, Questions
How would you describe
these skin findings?
• Are these lesions raised,
flat, or depressed?
• Do they have fluid in
them?
– small, raised, fluid-filled
lesions are called vesicles

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Case Three
How else can you
describe them?
– Size?
• Each vesicle is 1-3mm
– Shape/Distribution?
• they are monomorphic
and clustered or
grouped in a
dermatomal pattern.
– Color?
• They are filled with
clear fluid on a deep
pink edematous base.

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 Distribution / Configuration
▪ Part of describing lesions is noting distribution
and configuration
▪ Distribution means location(s) on the body
▪ Configuration means how the lesions are
arranged or relate to each other
• Lesions are grouped but also
follow a linear pattern around the
trunk
• This is an example of a segmental
or dermatomal distribution

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 Diagnosis
▪ Mr. B’s skin exam shows:
• Grouped 2-5 mm vesicles on an erythematous base in a
unilateral, dermatomal configuration on the left chest
▪ Mr. B has herpes zoster aka “shingles”. The primary lesions
of Group A herpes viruses (HHV 1-3) are vesicles.

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 Review: Seeing the skin
▪ To describe what you see on the skin, first
determine the primary lesion
• Is it raised, flat, or depressed?
• Is it small or large?
• Is it fluid-filled?
▪ The table in the next slide summarizes most
of the terms used to describe the skin. We
have already reviewed many of them. Click
on the others to learn more.

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 Review: Seeing the skin
In your descriptions, include adjectives that
help describe the primary lesions. Make sure
to consider:
▪ Size
▪ Shape
▪ Color
▪ Texture
▪ Configuration
▪ Distribution

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 Take Home Points
▪ To describe the skin, first inspect closely
▪ Second, determine if the lesion is raised, flat, or
depressed and its size.
▪ Then, pick the term for the lesions that fits best!
▪ Finally, use adjectives relating to the shape,
color, texture, distribution, and configuration to
further describe the lesion.
▪ See the resources at the end for further
reading.

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 Acknowledgements
▪ This module was developed by the American Academy of
Dermatology’s Medical Student Core Curriculum Workgroup
from 2008-2018.
▪ Primary authors: Patrick McCleskey, MD, FAAD; Peter A. Lio,
MD, FAAD; Jacqueline C. Dolev, MD, FAAD; Amit Garg, MD,
FAAD.
▪ Peer reviewers: Heather W. Goff, MD, MPH; Ron Birnbaum,
MD; Timothy G. Berger, MD, FAAD.
▪ Revisions: Sarah D. Cipriano, MD, MPH, Jessica
Kaffenberger, MD, Joslyn Kirby, MD,
▪ 2018 Review and Update by Heather W. Goff, MD. Peer
Reviewed by Sylvia Parra, MD, and Joslyn Kirby, MD. MEd,
MS.

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 Resources
▪ Berger T, Hong J, Saeed S, Colaco S, Tsang M, Kasper R. The Web-Based
Illustrated Clinical Dermatology Glossary. MedEdPORTAL; 2007. Available
from: www.mededportal.org/publication/462.
▪ Morphology illustrations are from the Dermatology Lexicon Project, which is
now maintained by the American Academy of Dermatology as DermLex.
▪ Dolev JC, Friedlaender JK, Braverman, IM. Use of fine art to enhance visual
diagnostic skills. JAMA 2001; 286(9), 100-2.
▪ Habif TP. Clinical Dermatology: a color guide to diagnosis and therapy, 4th
ed. New York, NY: Mosby; 2004.
▪ James WD, Berger TG, Elston DM. Andrews’ Diseases of the Skin, 11th ed.
Elsevier; 2011:12-17.
▪ Marks Jr JG, Miller JJ. Lookingbill and Marks’ Principles of Dermatology, 4th
ed. Elsevier; 2006.
▪ Review primary lesions and other morphologic terms at
http://www.logicalimages.com/educationalTools/learnDerm.htm.

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