CONTENTS

MJsaillaneous Benign Neoplasms and Hyperplasias 174

Seborrheic Keratosis 174
Becker Nevus (BN) 177
'!Hchoepitheliorna 178
Syringoma 179
Cylindroma 180
Sebaceous Hyperplasia 181
Nevus Sebaceous 181
Epidermal Nevus 182
Benign Dermal and Subcutaneous Neoplasms and Hyperplaslas 183
Lipoma 183
Dermatofibroma 184
Hypertrophic Scars and Keloids 185
Infantile Digital Fibromatosis 188
Skin Tag 188

PHOTOSENSITIVITY, PHOTO-INDUCED DISORDERS,

AND DISORDERS BY IONIZING RADIATION 189
Skin Read:lons to Sualigbt 189
Acute Sun Damage (Sunburn) 191
Drug-/Chemical-Induced Photosensitivity 193
Phototoxic Drug-/Chemical-Induced Photosensitivity 194
Systemic Phototoxic Dermatitis 194
Topical Phototoxic Dermatitis 196
Phytophotodennatitis (PPD) 197
Photoallergic Drug/Chemical-Induced Phololiensitivity 199
Polymorphous Light Eruption (PMLE) 202
Solar Urticaria 204
Photo-Exacerbated Derm.atoses 205
Metabolic Photoaensitiftty-the Porphyrias 205
Porphyria Cutanea Tarda 206
Variegate Porphyria 210
Erythropoieti.c Protoporphyria 211
Chronic PhotodamaJe 213
Dermatoheliosis ("Photoaging'") 213
Solar Lentigo 215
Chondrodermatitis Nodularis Helicis 216
Actinlc Keratosis 217
Skin B.eadions to Ion.lz.l.Da RadiatiDD 217
Radiation Dermatitis 217

Epidermal Preamcen and Cancers 221

Actinic Keratosis 221
Cutaneous Hom 225
Arsenical Keratoses 225
Squamous Cell Carcinoma In Situ 227
 CONTENTS

Invasive Squamous Cell Carcinoma 230

Keratoacanthoma 235
Basal Cell Carcinoma (BCC) 236
Basal Cell Nenu Syndrome (BCNS) 244
Mallpant Appendage Thmon 246
Merkel Cell Cardnoma 246

SECTION 12

MELANOMA PRECURSORS AND PRIMARY CUTANEOUS MELANOMA 248

PreaanoR of Cutaneous Melanoma 248

Dysplastic: Melanoc:ytic: Nevus (DN) 248
Congenital Melanocytic: Nevus (CMN) 253
Cutaneous Mdanoma 256
Melanoma In Situ (MIS) 258
Lentigo Maligna Melanoma (LMM) 260
Super.fidal Spreading Melanoma (SSM) 262
Nodular Melanoma (NM) 267
Desmoplastic Melanoma (DM) 270
Acral Lentiginous Melanoma (ALM) 271
Amelanotic Melanoma 273
Malignant Melanoma of the Mucosa 274
Metastatic Melanoma 274
Staging of Melanoma 277
Prognosis of Melanoma 278
Management of Melanoma 278

Vdiligo 280
~Aiblni1J11 287
Melasma 289
Pipnentary <llanps Followiq Inftammatlon of the Skin 290
Hyperpigmentation 290
Hypopigmentation 293

PART II DERMATOLOGY AND INTERNAL MEDICINE 297

THE SKIN IN IMMUNE, AUTOIMMUNE, AUTOINFLAMMATORY, AND

RHEUMATIC DISORDERS 298
Urticaria and .Aapoeclema 298
Erythema Mulliforme (EM) Syndrome 306
Cryoppinopathia (CAPS) 311
Lichen Planus (LP) 312
Deb¢ DJ.seaae 317
Dermatomyositis 320
CONTENTS

Lupua Erythematolus (LE) 324

Systemic Lupus Erythematosus (SLB) 326
Subacute Cutaneous Lupus Erythematosus (SCLB) 330
Chronic Cutaneous Lupus Btythematoau.s (CCLE) 332
Chronic Lupus PannJ.cul.Ws (CLP) 335
Uvedo Retkularia 336
Raynaud Phenommon 337
Scleroderma 339
Scleroderma-Lib Conditione 343
Morphea 343
Uchen SdmMUS et AttophiCUI (ISA) 347
yucq}itfa 349
Hypersemitivity Vuculitis 349
Henoch-Schonlein Pmpura 351
Polyarteritis Nodosa. 352
Granul.omatos:18 with Polyangitis 353
Giant Cell Arteritis 355
Urticarial Vasculitis 356
Nodular Vasculitis 357
Pigmented Pw.paric Dermatoses (PPD) 358
Kawasaki D.lseue 359
Reac:tlve A:rthritfs (formerly Reiter Syndrome) 362
Sarc:oldoeil 364
Granuloma AnnulaR (GA) 368
Systemic AL Amyloidosis 370
Systemic AA Amyloidosis 372
Loc:alizcd Cutaneous Amyloidom 372

374
Skin D:laeaaea Aaaociated with Diabetea Mdlitua 374
Diabetic Bullae 375
"Diabetic Foot" and Diabetic Neuropathy 376
Diabetic Dermopathy 377
Neaobl.osis lJpo1dlca 378
Cu8hlng Syndrome and Hyperc:o.rtlc:lam 379
Grave& Disease anclllf.perthyroidlsm 380
Hypothyrolcllsm and Myudema 380
Addilon Diseue 382
Metabolic ed Nutritiood Conditions 383
Xanthomas 383
Xanthe1amaa 385
Xanthoma Te.n.dineum 385
Xanthoma Thberosum. 385
Eruptive Xanthoma 387
Xanthoma Striatum Palmate 388
No.nuolipemic Plane Xanthoma 389
Sauvy 389
Ac.quired Zinc Defidenc:y and Acrodermatitis Enteropcthfc:a 391
Pellagra 393
 CONTENTS

Gout 394
Skin Dileues in Prc:pumcy 395
Cholelta&is of Pregnancy (CP) 396
Pemphigoid Gestatioms (PeG) 396
Polymorphic Eruption of Pregnancy (PEP) 397
Prurigo of Pregnancy and Atopic Eruption of Pregnancy (AEP) 398
Pustular Psoriasis ln. Pregnancy 398
Skin Manlfestatlons of Obesity 398

Pteudounthoma Elutic:am 399

1\Jberoua Scleroslt (TS) 400
Neurofibromatosia (NF) 403
Hereditary llemonhagic Tebmgiectuia 407

408
Adleroaderoaia, Arterial Imu11idmcy, and Atheroemholizaf.ion 408
'lhromboaDgiitia Obliterans (TO) 412
'lhrombopblebiti• and Deep Venoua 'lhromholil 413
QroDic: Vmoutlnsuflic:iency (CVI) 414
Most CommonJ.e&IFoot Ulcers 419
Uvedoid Vaaculltis (LV) 421
QroDic: I;ymphatlc: Imutlidency 422
Pressure Ulcen 423

42e
<lusUicatlon ofSkin. Change. 426
Caldphyluls 426
Nephrogenic: Fihroslllg Dermopathy (NFD) 428
Ac-quired Perforating Dermatoles 429

Muc:oc:utaneoua Signa ofSyltemic Cancen 430

Ouaification ofSkin Signs of Syltemic Cancer 430
Metastatic Cancer to the Skin 431
Mammary Paget Disease 436
Extramammary Paget Disease 437
Cowden Syndrome (Multiple Hamartoma Syndrome) 438
Peutz-Jegbers Syndrome 440
Glucagonoma Syndrome 441
Malignant Acanthosis Nlgrlcans 443
Paraneoplastic Pemphigus (PNP) (Paraneoplastic Autoimmune
Multiorgan Syndrome) 443
 CONTENTS

444
'lhromboqtopeaic Purpura 444
Diueminated lntnmllcular Coagulation 445
Cryoslobnlinemia 448
Lenkania Cutis 450
Langerbam Cell Histioqtoail 453
Mutoqrtolil Syndrome~ 457

Adult T Cell Leuhmia!Lymphoma 461

Cul:aneoul T Cell Lymphoma 462
MyaJiis Fungoldee (MF) 462
Mycosis Fungoides Variants 468
S~zary Syndrome 470
Lymphomatoid Papulosis 470
Cutaneous Anaplastic Large Cell Lymphomas (CALCI.a) 472
Cutaneous B Cell Lymphoma 473
Kapod Sarcoma (KS) 474
AngiOIIU'COma 479
Denwrtofibrosar Pmtuhenna (DFP) 480
Atypical Fibmnndboma (AFX) 481

SKIN DISEASES IN ORGAN AND BONE MARROW TRANSPLANTATION 482

""'-"...:....0.._
Mo8t Common lnfectiou AIIOdakd with Orpn Thmsplantation 482
Skin Cancers Aaaodakd with Orpn Tranaplanbrtion 483
Graft-Ve1'8118-Hoat Diaeue (GVHD) 483
Aa1fe Cutaneous GVHD 484
Chronic Cutaneous GVHD 487

489
Advene Cutaneous Drug ReactiODJ 489
Eunthematous Drug Rea<:t:ionJ 494
Pustular EraptlODI 496
Dl'1J8-Inducecl Acute Urtlc:aria, Angioedema, Edema. and Anaphylam 498
FiDel Drug Eruption 499
Dl'1J8 Hypenensltlvity Syndrome 501
Dl'1J8-Inducecl Pigmentation 502
Pseudoporphyria 505
ACDR-Related Necroais 506
ACDR-Related to Chemotherapy 509
 CONTENTS

513
Body Dylmorpbic Syndrome (BDS) 513
Dcl.uaiona ofParuito8U 513
Neurotic BD:oriatimu and 'JiichotilloJIUDia 515
FactitioDI!l Synclromea (MtiDchhausen Syndrome) 517
Cutaneous SigiU of Injecting I>rug Use 518

PART Ill DISEASES CAUSED BY MICROBIAL AGENTS 521

BACTERIAL COLONIZATIONS AND INFECTIONS OF SKIN

AND SOFT TISSUES 522
Erythrasma 522
Pitted Keratolysla 524
Trichomycotda 525
Intertrigo 526
Impetigo 528
Abecess. FaWcalltis. Funmde. ancl Carbuncle 533
Soft-Twue Infection 541
Celluli.tU 541
NeaotiziDB Soft-TWue 1112d:ion1 547
Lympbangitil 548
Wound Infed:lon 550
D.laorden CaUHd by Todn-Produdns Baderia 553
Staphylococca.l. Scalded-Skin Syndrome 553
Toxic Shock Syndrome 555
Scarlet Fever 556
Cutaneous Anthrax 557
Cutaneous Diphtheria 559
Cutaneous NtuardUJ Infections 559
Richtb:ial Diaorclen 560
Tick Spotted FevenJ 561
Rocky MollDtain Spotted Fever 562
Rickettsialpm: 563
Infedm Bndocarditl.l 564
Septda 566
Meningoc:occallnfed:lon 567
Bartonella lnfectlonl 569
Cat-Scratch Disease (CSD) 569
Badllary Angiomatosis (BA) 571
Talaremia 572
Cutaneous haulottunuu Aerugln01a ID&dimu 573
Myc:oblldcriallnH:d::ionl 573
Hansen Disease (Leprosy) 574
Cutaneous Thberculosis 579
Nontuberculous Mycobacterial Infections 583
 CONTENTS

Mycobacterium Marinum Infection 583

Mycobacterium Ulcertms Infection 585
Mycobacterium Portuitum Complex Infections 586
Lyme D.iaeale 589

__
...._
SECTION 26
FUNGAL INFECTIONS OF THE SKIN, HAIR, AND NAILS
Introduction
SM
594
Superficial Fu.npllnf.edlons 594
Candld1uls 594
Cutaneous Candidiasis 595
Oropharyngeal Candidias!B 598
Genital Candidiasis 602
Chronic Mucocutaneous Candidiasis 603
Disseminated Candidiasis 605
T"mea Venicolor 606
7m:1Jo.sportm ~ODS 611
T"mea N"apa 612
Dermatophytosell 613
Tinea Pedis 616
Tinea Manuum. 619
Tinea Cruris 622
Tinea Corporis 624
Tinea Fac.ialis 628
Tinea Incognito 630
Dermatoplrytoeea of Hair 630
Tinea Capitis 631
Tinea Barbae 634
Majocchi Granuloma 636
lnvuive and Diueminatril FaDgal.IDfectiona 637
Subcutaneous Mycoses 637
Sporotrichosis 637
Phaeohyphomycoses 639
Cryptococcosls 641
Histoplasmosis 642
Blastomycosis 644
Coccidioidomycosis 646
Penicilliosis 647

Introduction 649
Porriru• Dkeua 649
Molluscwn Contagiorum 649
Human Or£ 653
Milkers' Nodule5 655
Smallpox 655
 CONTENTS

HUIIUID. Papillomariraa ID&dimul 656

Human Papillomavirus: Cutaneous Diseases 658
Sylltemic Vll'lll.IJW:ctiom with E:unthems 665
Rubella 667
Measles 669
Enterov1tal. Infectlons 671
Hand-Foot-and-Mouth Disease 671
Herpangina 673
Erythema Infectl.osum 674
Gianotti-Crosti Syndrome 675
Arbovirus 676
Dengue 677
Chik:ungunya 678
Zib. 679
Herpett Simpla Virua DiKue 679
Nongenltal Herpes Simpl.a 682
Neonatal Herpes Simplex 686
Ecuma Herpeticum. 688
Herpes Simple~: with Host Defense Defects 690
Varicella Zoster VIrus Diseue 693
VZV: Varic:ella 694
VZV: Herpes Zoster 696
VZV: Host Defmse Defects 701
H1UW1D. Herpesviras-6 and 7 DfJeale 704
HUIIUID. ImmUDOdeficimcy Vu:u Dileue 706
Acute HIV Syndrome 709
E011inophilic Pollicul.i.ti& 710
Papular Prurltic Eruption ofHIV 711
Photosensitivity in HlV Disease 712
Oral Hairy Leukoplakia 712
.Adverse Cutaneous Drug Eruptions in HIV Disease 713
Variations .In Common Mucocutaneous Disorders in HlV Disease 717

..........- ARTHROPOD BITES, STINGS, AND CUTANEOUS INFESTATIONS

Cutaneous Read:ions to Arthropod Bites 720
Pedlc:alotla Capitis 726
Peclic:alotls Corporis 728
Peclic:alotls Pabil 729
Demodid.dosll 731
Scabia 732
Cutaneous Lana Mip'aDs 739
Water-ANoc:iatcd Dilc:uea 741
Schistosome CercarlaJ. Dermatitis 741
Seabathe.r's Eruption 742
Cn.1daria Envenomations 742
 CONTENTS

LeiJbmanlasl• 744
Human American TrypiDOIOIDiasi• 749
Human African 1\'ypanoaOllliua 750
Cubuu:cnu Am.ebiuia 751

Human Papillomaviru11: Anogenitallnfedionl 752

Genital Warts 753
HPV: Squamous Cell Carcinoma In Situ (SCCIS) and
Invasive sec of Anogenital skin 756
Herpa Simpla. Virus: Genital Dltea~e 760
Nelslerl4 Gcmorrltoeu DI.Jease 765
Neisseria GonorriJoeae: Gonorrhea 766
Syphilis 767
Primary Syphilis 768
Secondary Syphilis 770
Latent Syphilis 775
Tertiary/Late Syphills 775
Congenital Syphilis 777
Lymphogranuloma Venereum 778
Chancroid 779
Donovanotis 781

PART IV SKIN SIGNS OF HAIR, NAIL, AND MUCOSAL DISORDERS 783

Biology ofHair Growth Cycles 784

Hair LOis: Alopecia 786
Pattern Hair Loss 786
Alopecia Areata 791
Telogen Bffiuvium 794
Anagen Effiuvium 797
Ciad:ricial or Salrring Alopec:ia 798
ExceH Hair Growth 805
Hirsutism 805
Hypertrichosis 808
 CONTENTS

Normal Nail Appamtua 809

Components of the Normal Nail Apparatus 809
Local Disorders of NaB Apparatus 810
Chronic Paronychia 810
Onycholysis 811
Green Nail Syndrome 812
Onychauxis and Onychogryphosis 812
Psychiatric Disorders 813
Nall Apparatus Involvement of Cutaneoua DiseaiC8 813
Psoriasis 813
Lichen Planus (LP) 815
Alopecia Areata (AA) 817
Darter Disease (Darler-White Disease. Keratosis Follicularls) 817
Chemical Irritant or Allergic Damage or Dermatitis 818
Neoplums of the Nail Apparabu 818
Myxoid Cysts of Digits 819
Longitudinal Mdanonychia 819
Acrolenliginous Melanoma (ALM) 820
Squamow Cell Carcinoma 820
IDfec:tl.ou ofthe Nail Apparatae 821
Acute Paronychia 822
Felon 822
Candida Onychia 823
Tinea Unguium/Onychomyrosis 824
Nall Sips ofMultisystem Dileua 827
Transverse or Beau Unes 827
Leukonychia 828
Yellow Nail Syndrome 829
Periungual Fi.bl'oma 830
Splinter Hem.orrbazea 830
Nall Fold/Perlu.ngaal Ery1:hema and Telaqiectaala 831
Koilonychia 833
Clubbed NailJ 833
Drug-Induced Nad Changes 834

Diseuea of the Ups 835

Angular Cheilitis (Perleche) 835
Actinlc Cheilitis 835
ConditiOlll of the Tempe. Palate. aDd MancUble 836
Fissured Tongue 836
Black or White Hairy Tongue 838
Oral Hairy Leukoplakia 838
Migratory Glossitis 838
Palate and Mandibular Torus 839
CONTENTS

Diaeua of the Gingiva. Periodontium, and MUCOUII Membnm.a 839

Gingivi.ti& and Periodont.i& 839
Lichen PliUI.U& 840
.Acute Neaotlzlng Ulcerative Glnglviti8 841
Gingival Hyperpwia 842
Aphthous Ulc::eration 842
Leukoplakia 844
Premalignant andMalignaDt NeoplUD18 848
Dysplasia and Squamous Cell Carcinoma In Sltu (SCCIS) 848
Oral Invasive Squamous CeU Carcinoma 849
Oral Verrucous Carcinoma 850
Oropharyngeal Melanoma 851
Submuc:oalNodalu 852
Mucocele 852
Irritation Fibroma 852
Cutaneous Odontogenic (Dental) Abscess 853
Cutan~us D:isorderalnvoJ:ring the Mouth 854
Pemphigus Vulgar:!s (PV) 854
Paraneoplastic Pemphigus 855
Bullous Pemphigoid 856
Cicatricial Pemphigoid 857
Sy3temic Diseases Involving the Mouth 857
Lupus Erythematosus 858
Stevens-Johnson Syndromefl'oJ:ic Ff!idermal Necrolysis 859

Peuly Penile Papalea 860

Sehaceoua GlaDd Promineuce 861
ADJiokeratoma 861
Scleroeina Lymp.hanaitia ofPenis 861
Lymphedema of the Genltalia 862
Plasma Cell Balanitis and Vul'ritis 863
Phlmoals, Paraphlmods, BalanltlsXerotka Obliterans 864
Muc.oartaneous Dieorden 865
Genital (Penile/Vulvar/Anal) Lentiginoses 865
Vitiligo and Leukoderma 866
Psoriasis Vulgaris 866
Lichen Planus 868
Lichen Nitidus 869
Lichen Sclero&us 869
Migratory Necrolytic Erythema 872
Genital Aphthous Ul.ce.ratio.ns 872
Eczematous Dermatitia 872
Allergic Contact Dermatitis 872
.Atopic De.nuatitis, Lichen Simplex Chronicus. Pruritus Ani 873
Fixed Drug Eruption 874
Premalignant and MalignaDt Letlone 874
Squamous Cell Carcinoma (SCC) In Situ 874
 CONTENTS

HPV-Induced Int:raepi.thclial Neoplasia (IN) and Squamous

Cell Carcinoma In Situ 876
Invasive Anogenital Squamous Cell Carcinoma 876
Invasive sec of Penis 876
Invasive sec of Vulva an
Invasive sec of Cutaneous Anus an
Genital Verrucous Carcinoma an
Malignant Melanoma of the Anogenital Region an
Emama.mmary Paget Diaease a79
Kaposi Sarcwna a80
Anogeaital Iafectioas 880

GENERALIZED PRURITUS WITHOUT SKIN LESIONS

(PRURITUS SINE MATERIA)

APPENDICES 885

APPENDIX A: Differential Diagnods of Pltpnented. Leaioaa 886

APPENDIX B: Drug Uae in PreJD&IlCY 891
APPENDIX C-1: l>ermlrtDlop: Manifatatioua of Diaeua
ID8ided by Biologic Warfare/Biotamriml 893
APPENDIX C-2: Chemical Biotarorism and Industrial Accid£D.ta 894

INDEX 897
This page intentionally left blank
 PREFACE
"Time is change; we measure its passage by how much things alter.•
Nadine Gordlmer
Thirty-four years ago in 1983, the first edition
of this book appeared and has been expanded
pari passu with the major developments that
have occurred in dermatology over the past
three and a half decades. Dermatology is now
one of the most sought-after medical specialties
because the burden of skin disease has become
enormous and the many new innovative thera-
pies available today attract large patient popula-
tions.
The Color Atlas and Synopsis of Clinical Der-
matology has been used by thousands of pri-
mary care physicians, dermatology residents,
dermatologists, internists, and other health
care providers principally because it facilitates
dermatologic diagnosis by providing color pho-
tographs of skin lesions and, juxtaposed, a suc-
cinct summary outline of skin disorders as well
as the skin signs of systemic diseases.
The eighth edition has been extensively revised,
rewritten, and expanded by new material. Around
30% of the old images have been replaced by new
ones and additional images have been added
There is a complete update of etiology, pathogen-
esis, management, and therapy. There is also an
online version. For this edition, videos containing
clinical material relevant to the text are available
at: mhprofessi.onal.com/mediacenter.
xxiii
This page intentionally left blank
 ACKNOWLEDGMENT

Our secretary, Renate Kosma, worked hard to
meet the demands of the authors. In the present
McGraw-Hill team, we appreciated the counsel
of Karen Edmonson, Senior Sponsoring Editor,
and Robert Pancotti, Senior Project Develop-
ment Editor.
Karen was the major force behind this edition.
Her good nature, good judgment, loyalty to the
authors, and, most of all. patience guided us to
make an even better book.
 HOW TO USE THIS BOOK
The Color Atlas and Synopsis of Clinical Derma-
tology is proposed as a "field guide" to the recog-
nition of skin disorders and their management.
The skin is a treasury of important lesions that
can usually be recognized clinically. Gross mor-
phology in the form of skin lesions remains the
hard core of dermatologic diagnosis. Therefore,
tills text is accompanied by more than 900 color
photographs illustrating skin diseases, skin
manifestation of internal diseases, infections,
tumors, and incidental skin findings in other-
wise well individuals. We have endeavored to
include information relevant to gender derma-
tology and a large number of images showing
skin disease in different ethnic populations. This
Atlas covers the entire field of clinical dermatol-
ogy but does not include very rare syndromes
or conditions. With respect to these, the reader
is referred to another McGraw-Hill Publication:
Fitzpatrick's Dermatology in General Medicine,
8th edition, 2012, edited by Lowell A. Gold-
smith, Stephen I. Katz, Barbara A. Gilchrest,
Amy S. Paller, David J. Letfell, and Klaus Wolff.
This text is intended for all physicians and
other health care providers, including medi-
cal students, dermatology residents, internists,
oncologists, and infectious disease specialists
dealing with diseases with skin manifestations.
For nondermatologists, it is advisable to start
with "Approach to Dermatologic Diagnosis" and
"Outline of Dermatologic Diagnosis" to famil-
iarize themselves with the principles of derma-
tologic nomenclature and lines of thought
The Atlas is organized into four parts, subdi-
vided into 35 sections, and there are three short
appendices. Each section has a color label that is
reflected by the bar on the top of each page. This
is to help the reader find his or her bearings rap-
idly when leafing through the book. Each dis-
ease is labeled with the respective ICDlO codes.
xxvii
 HOW TO USE THIS BOOK
APPROACH TO DERMATOLOGIC DIAGNOSIS
There are two distinct clinical situations regard-
ing the nature of skin changes:
I. The skin changes are incidental findings in
well and ill individuals noted during the
routine general physical examination:
• "Bumps and blemishes": many asymp-
tomatic lesions that are medically incon-
sequential may be present in well and ill
persons, and may not be the reason for
their visit to the physician; every general
physician should be able to recognize
these lesions to differentiate them from
asymptomatic but important, e.g., malig-
nant, lesions.
o Important skin lesions not noted by the
patient but that must not be overlooked
by the physician: e.g., dysplastic nevi,
melanoma. basal cell carcinoma. squa-
mous cell carcinoma. cafe-au-lait m.acules
in von Recldinghausen disease, and xan-
thomas.
II. The skin changes are the chiefcomplaint of
the patient:
• "Minor" problems: e.g., localized itchy
rash, "rash:' rash in groin, nodules such as
common moles and seborrheic keratoses.
• K4-S": serious skin signs in sick patients.
SERIOUS SKIN SIGNS IN SICK PATIENTS
o Generaliud red rash with fever:
• Viral exanthems.
• Rickettsial exanthems.
• Drug eruptions.
• Bacterial infections with toxin produc-
tion.
o Generalized red rash with blisters and
prominent mouth lesions:
• Erythema multiforme (major).
• Toxic epidermal necrolysis.
• Pemphigus.
OUTLINE OF DERMATOLOGIC DIAGNOSIS
In contrast to other fields of clinical medicine,
patients should be examined before a detailed
history is taken because patients can see their
lesions and thus often present with a history that
is flawed with their own interpretation of the
origin or causes ofthe skin eruption. Also, diag-
• Bullous pemphigoid.
• Drug eruptions.
• Generaliud red rash with pustules:
• Pustular psoriasis {von Zumbusch).
• Drug eruptions.
• Generaliud rash with vesicles:
• Disseminated herpes simplex.
• Generalized herpes zoster.
• Varicella.
• Drug eruptions.
• Generalized red rash with scaling over
whole body:
• Exfoliative erythroderma.
• Generalized wheals and soft-tissue swelling:
• Urticaria and angioedema.
• Generaliud purpura:
• Thrombocytopenia.
• Purpura fulminans.
• Drug eruptions.
• Generalized purpura that can be palpated:
• Vasculitis.
• Bacterial endocarditis.
• Multiple skin infarcts:
• Meningococcemia.
• Gonococcemia.
• Disseminated intravascular coagulopathy.
• Localized skin infarcts:
• Calciphylaxis.
• Atherosclerosis obliterans.
• Atheroembolization.
• Warfarin necrosis.
• Antiphospholipid antibody syndrome.
• Facial inflammatory edema with fever:
• Erysipelas.
• Lupus erythematosus.
• Dermatomyositis.
nostic accuracy is higher when objective exami-
nation is approached without preconceived
ideas. However, a history should always be
obtained but if taken during or after the visual
and physical examination, it can be streamlined
and more focused following the objective find-

inga. 'Ihua, recognizing, analping. and properly
interpreting Bin leaiom are the line qua l1.Dil of
dermatologl.c diagnosis.
PHYSICAL EXAMINAnON
Appcarancc Uncomfortable, "tone,• well.
Vital Slpa Pulse, mpln.tton, temperature.
Skim ~ to Jad• The entire akin
should be inspected and this should include
mUOOUI membranes, genital and anal regions,
u well as hair md nails and peripheral lymph
node&. Reading the &kin Ia like reading a tat
The bu1c akin leaiOll.t are like the lettm of the
alphabet: their ahape, color, marg1Dation. and
other features combined will lead to words, and
their localization and distribution to a sentence
or pan.graph. 1h.e prerequisite of dermatologic
dlagnos!a .l.s thus the recognition of (1) the type
of akin lesion, (2) the color, (3) margination, (4)
consistency, (5) shape, (6) arrangement. and (7)
distribution of lesions.
Recognizing Letters: Types of Skin Lesions
• Macule (Latin: nuu:ula, "spot") A macule .l.s
a c:lrcumscrlbed area of change in akin color
FIGURE 1·1 Macule
FIGURE 1·2 Papule
HOW TO USE THIS BOOK
without elevation or depression. It is thus not
palpahle. Macule. can be well defined and
ill dcflned. MKulea may be of any silc or
color (Fig. 1-1). White, u in vitillgo; brown.
u 1n cafe-au-lait spots; blue, as in MoogoUan
spots; or red, as in permanent vascular abnor-
malities such as port-wine stains or capillary
dilatation due to inflammation (erythema).
Pressure ofa glass slide (diascopy) on the bor-
der of a red le.Uon detects the extravasatl.on of
red blood celh. If the redness remains under
pressure from the slide, the lesion is purpuric,
thai is, remltl from extravasated red blood
cella; if the redness disappea:rs. the lesion is
due to vascular dilatation. A rub consisting
of macules iJ called a maadar exanthem.
• Papule (Latin: papula, "plmph:-) A papule is
a super6dal. elevated. aolid lesion. generally
considered <OS em 1n diameter. Most of 1t Is
elevated above. rather than deep within, the
plane of the surrounding skin (Fig. 1-2). A
papule is palpable. It may be wcll defined or
ill defined. In papul.ca, the elewtion Is caused
by m.etabollc or locally produced deposits, by
loc:allzed cellular Jnftlt:rates, inflammatory or