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 Fitzpatrick’s
Dermatology
Ninth Edition

EDITORS
SEWON KANG, MD, MPH
MASAYUKI AMAGAI, MD, PhD
ANNA L. BRUCKNER, MD, MSCS
ALEXANDER H. ENK, MD
DAVID J. MARGOLIS, MD, PhD
AMY J. McMICHAEL, MD
JEFFREY S. ORRINGER, MD

VOLUME I

New York Chicago San Francisco Athens London Madrid Mexico City
Milan New Delhi Singapore Sydney Toronto

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 SEWON KANG, MD, MPH
Noxell Professor and Chair
Department of Dermatology
Johns Hopkins School of Medicine
Dermatologist-in-Chief
Johns Hopkins Hospital
Baltimore, Maryland

MASAYUKI AMAGAI, MD, PhD

Professor and Chair
Department of Dermatology
Keio University School of Medicine
Tokyo, Japan

ANNA L. BRUCKNER, MD, MSCS

Associate Professor of Dermatology and Pediatrics
University of Colorado School of Medicine
Section Head, Pediatric Dermatology
Children’s Hospital Colorado
Aurora, Colorado

ALEXANDER H. ENK, MD
Professor and Chair
Department of Dermatology
University of Heidelberg
Heidelberg, Germany

DAVID J. MARGOLIS, MD, PhD

Professor of Dermatology and Epidemiology
Department of Dermatology
Department of Biostatistics and Epidemiology
University of Pennsylvania Perelman School of Medicine
Philadelphia, Pennsylvania

AMY J. McMICHAEL, MD
Professor and Chair
Department of Dermatology
Wake Forest University School of Medicine
Winston-Salem, North Carolina

JEFFREY S. ORRINGER, MD
Professor and Chief
Division of Cosmetic Dermatology
Department of Dermatology
University of Michigan
Ann Arbor, Michigan

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 CONTENTS

Contributors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xiii 10 The Immunological Structure of the Skin . . . . . .130

Georg Stingl & Marie-Charlotte Brüggen
Preface . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xxix

Acknowledgments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xxxi 11 Cellular Components of the Cutaneous

Immune System . . . . . . . . . . . . . . . . . . . . . . . . . . . .143
Johann E. Gudjonsson & Robert L. Modlin

Volume One 12 Soluble Mediators of the Cutaneous

Immune System . . . . . . . . . . . . . . . . . . . . . . . . . . . .159
Allen W. Ho & Thomas S. Kupper

PART 1 FOUNDATIONS OF CLINICAL 13 Basic Principles of Immunologic Diseases

DERMATOLOGY in Skin (Pathophysiology of Immunologic/
Inflammatory Skin Diseases) . . . . . . . . . . . . . . . . .192
1 Fundamentals of Clinical Dermatology: Keisuke Nagao & Mark C. Udey
Morphology and Special Clinical
Considerations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1 14 Skin Barrier . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .206
Erin H. Amerson, Susan Burgin, & Kanade Shinkai Akiharu Kubo & Masayuki Amagai

2 Pathology of Skin Lesions . . . . . . . . . . . . . . . . . . . .18 15 Epidermal and Dermal Adhesion. . . . . . . . . . . . .232

Rosalie Elenitsas & Emily Y. Chu Leena Bruckner-Tuderman & Aimee S. Payne

3 Epidemiology and Public Health 16 Microbiome of the Skin. . . . . . . . . . . . . . . . . . . . . .253

in Dermatology . . . . . . . . . . . . . . . . . . . . . . . . . . . . .40 Heidi H. Kong
Junko Takeshita & David J. Margolis
17 Cutaneous Photobiology . . . . . . . . . . . . . . . . . . . .265
Thomas M. Rünger

PART 2 STRUCTURE AND FUNCTION 18 Genetics in Relation to the Skin . . . . . . . . . . . . . .289

Etienne C. E. Wang, John A. McGrath,
OF SKIN & Angela M. Christiano
4 Developmental Biology of the Skin . . . . . . . . . . . .49
Luis Garza 19 Carcinogenesis and Skin. . . . . . . . . . . . . . . . . . . . .310
Kenneth Y. Tsai & Andrzej A. Dlugosz
5 Growth and Differentiation of the Epidermis . . . .62
Terry Lechler 20 Pigmentation and Melanocyte Biology . . . . . . . .328
Stephen M. Ostrowski & David E. Fisher
6 Skin Glands: Sebaceous, Eccrine, and
Apocrine Glands . . . . . . . . . . . . . . . . . . . . . . . . . . . .70 21 Neurobiology of the Skin . . . . . . . . . . . . . . . . . . . .351
Christos C. Zouboulis Sonja Ständer, Manuel P. Pereira,
& Thomas A. Luger
7 Biology of Hair Follicles . . . . . . . . . . . . . . . . . . . . . .89
George Cotsarelis & Vladimir Botchkarev

8 Nail . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .106
PART 3 DERMATITIS
Krzysztof Kobielak
22 Atopic Dermatitis . . . . . . . . . . . . . . . . . . . . . . . . . .363
Eric L. Simpson, Donald Y. M. Leung,
9 Cutaneous Vasculature . . . . . . . . . . . . . . . . . . . . . . 116
Lawrence F. Eichenfield, & Mark Boguniewicz
Peter Petzelbauer, Robert Loewe, & Jordan S. Pober

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 23 Nummular Eczema, Lichen Simplex 38 Subcorneal Pustular Dermatosis
Chronicus, and Prurigo Nodularis . . . . . . . . . . . .385 (Sneddon-Wilkinson Disease) . . . . . . . . . . . . . . . .617
Jonathan I. Silverberg Franz Trautinger & Herbert Hönigsmann

24 Allergic Contact Dermatitis . . . . . . . . . . . . . . . . . .395 39 Autoinflammatory Disorders . . . . . . . . . . . . . . . .621

Jake E. Turrentine, Michael P. Sheehan, Takashi K. Satoh & Lars E. French
& Ponciano D. Cruz, Jr.
40 Eosinophilic Diseases . . . . . . . . . . . . . . . . . . . . . . .649
25 Irritant Dermatitis . . . . . . . . . . . . . . . . . . . . . . . . . .414 Hideyuki Ujiie & Hiroshi Shimizu
Susan T. Nedorost
41 Urticaria and Angioedema. . . . . . . . . . . . . . . . . . .684
26 Seborrheic Dermatitis . . . . . . . . . . . . . . . . . . . . . . .428 Michihiro Hide, Shunsuke Takahagi,
Dae Hun Suh & Takaaki Hiragun

27 Occupational Skin Diseases . . . . . . . . . . . . . . . . . .438 42 Mastocytosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .710

Contents

Andy Chern, Casey M. Chern, & Boris D. Lushniak Michael D. Tharp

PART 4 PSORIASIFORM DISORDERS PART 7 REACTIVE ERYTHEMAS

28 Psoriasis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .457 43 Erythema Multiforme . . . . . . . . . . . . . . . . . . . . . . .723
Johann E. Gudjonsson & James T. Elder Jean-Claude Roujeau & Maja Mockenhaupt

29 Pityriasis Rubra Pilaris . . . . . . . . . . . . . . . . . . . . . .498 44 Epidermal Necrolysis (Stevens-Johnson

Knut Schäkel Syndrome and Toxic Epidermal Necrolysis) . . . .733
Maja Mockenhaupt & Jean-Claude Roujeau
30 Parapsoriasis and Pityriasis Lichenoides . . . . . .505
Stefan M. Schieke & Gary S. Wood 45 Cutaneous Reactions to Drugs . . . . . . . . . . . . . . .749
Kara Heelan, Cathryn Sibbald, & Neil H. Shear
31 Pityriasis Rosea . . . . . . . . . . . . . . . . . . . . . . . . . . . .518
Matthew Clark & Johann E. Gudjonsson 46 Erythema Annulare Centrifugum and Other
Figurate Erythemas . . . . . . . . . . . . . . . . . . . . . . . . .765
Christine S. Ahn & William W. Huang

PART 5 LICHENOID AND

GRANULOMATOUS DISORDERS
PART 8 DISORDERS OF CORNIFICATION
32 Lichen Planus . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .527
Aaron R. Mangold & Mark R. Pittelkow 47 The Ichthyoses . . . . . . . . . . . . . . . . . . . . . . . . . . . . .775
Keith A. Choate & Leonard M. Milstone
33 Lichen Nitidus and Lichen Striatus . . . . . . . . . . .554
Aaron R. Mangold & Mark R. Pittelkow 48 Inherited Palmoplantar Keratodermas . . . . . . . .816
Liat Samuelov & Eli Sprecher
34 Granuloma Annulare . . . . . . . . . . . . . . . . . . . . . . .564
Julie S. Prendiville 49 Keratosis Pilaris and Other Follicular
Keratotic Disorders . . . . . . . . . . . . . . . . . . . . . . . . .867
35 Sarcoidosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .572 Anna L. Bruckner
Richard Marchell
50 Acantholytic Disorders of the Skin . . . . . . . . . . . .877
Alain Hovnanian

PART 6 NEUTROPHILIC, EOSINOPHILIC, 51 Porokeratosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .901

Cathal O’Connor, Grainne M. O’Regan,
AND MAST CELL DISORDERS & Alan D. Irvine
36 Sweet Syndrome . . . . . . . . . . . . . . . . . . . . . . . . . . .587
Philip R. Cohen & Razelle Kurzrock
PART 9 VESICULOBULLOUS DISORDERS
37 Pyoderma Gangrenosum . . . . . . . . . . . . . . . . . . . .605
Natanel Jourabchi & Gerald S. Lazarus 52 Pemphigus . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .909
vi Aimee S. Payne & John R. Stanley

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 53 Paraneoplastic Pemphigus. . . . . . . . . . . . . . . . . . .934 69 Relapsing Polychondritis . . . . . . . . . . . . . . . . . . . 1186
Grant J. Anhalt & Daniel Mimouni Camille Francès

54 Bullous Pemphigoid . . . . . . . . . . . . . . . . . . . . . . . .944

Donna A. Culton, Zhi Liu, & Luis A. Diaz
PART 11 DERMAL CONNECTIVE
55 Mucous Membrane Pemphigoid . . . . . . . . . . . . .960 TISSUE DISORDERS
Kim B. Yancey
70 Anetoderma and Other Atrophic Disorders
56 Epidermolysis Bullosa Acquisita . . . . . . . . . . . . .971 of the Skin . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1193
David T. Woodley & Mei Chen Catherine Maari & Julie Powell

57 Intercellular Immunoglobulin (Ig) 71 Acquired Perforating Disorders . . . . . . . . . . . . .1203

A Dermatosis (IgA Pemphigus) . . . . . . . . . . . . . .981 Garrett T. Desman & Raymond L. Barnhill

Contents
Takashi Hashimoto
72 Genetic Disorders Affecting Dermal
58 Linear Immunoglobulin A Dermatosis and Connective Tissue . . . . . . . . . . . . . . . . . . . . . . . . .1212
Chronic Bullous Disease of Childhood . . . . . . . .992 Jonathan A. Dyer
Matilda W. Nicholas, Caroline L. Rao,
& Russell P. Hall III

59 Dermatitis Herpetiformis . . . . . . . . . . . . . . . . . . .1002 PART 12 SUBCUTANEOUS TISSUE

Stephen I. Katz
DISORDERS
60 Inherited Epidermolysis Bullosa. . . . . . . . . . . . . 1011
73 Panniculitis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1251
M. Peter Marinkovich
Eden Pappo Lake, Sophie M. Worobec,
& Iris K. Aronson

74 Lipodystrophy . . . . . . . . . . . . . . . . . . . . . . . . . . . .1295
PART 10 AUTOIMMUNE Abhimanyu Garg
CONNECTIVE TISSUE AND
RHEUMATOLOGIC DISORDERS
61 Lupus Erythematosus . . . . . . . . . . . . . . . . . . . . . .1037 PART 13 MELANOCYTIC DISORDERS
Clayton J. Sontheimer, Melissa I. Costner,
& Richard D. Sontheimer 75 Albinism and Other Genetic Disorders
of Pigmentation . . . . . . . . . . . . . . . . . . . . . . . . . . .1309
62 Dermatomyositis . . . . . . . . . . . . . . . . . . . . . . . . . .1061 Masahiro Hayashi & Tamio Suzuki
Matthew Lewis & David Fiorentino
76 Vitiligo . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1330
63 Systemic Sclerosis . . . . . . . . . . . . . . . . . . . . . . . . .1086 Khaled Ezzedine & John E. Harris
Pia Moinzadeh, Christopher P. Denton,
Carol M. Black, & Thomas Krieg 77 Hypermelanoses . . . . . . . . . . . . . . . . . . . . . . . . . .1351
Michelle Rodrigues & Amit G. Pandya
64 Morphea and Lichen Sclerosus . . . . . . . . . . . . . . 1106
Nika Cyrus & Heidi T. Jacobe

65 Psoriatic Arthritis and Reactive Arthritis . . . . . 1127 PART 14 ACNEIFORM DISORDERS

Ana-Maria Orbai & John A. Flynn
78 Acne Vulgaris . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1391
Carolyn Goh, Carol Cheng, George Agak,
66 Rheumatoid Arthritis, Juvenile Idiopathic
Andrea L. Zaenglein, Emmy M. Graber,
Arthritis, Adult-Onset Still Disease, and
Diane M. Thiboutot, & Jenny Kim
Rheumatic Fever . . . . . . . . . . . . . . . . . . . . . . . . . . 1146
Warren W. Piette
79 Rosacea . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1419
Martin Steinhoff & Jörg Buddenkotte
67 Scleredema and Scleromyxedema . . . . . . . . . . . 1163
Roger H. Weenig & Mark R. Pittelkow
80 Acne Variants and Acneiform Eruptions. . . . . .1448
Andrea L. Zaenglein, Emmy M. Graber,
68 Sjögren Syndrome . . . . . . . . . . . . . . . . . . . . . . . . . 1170
& Diane M. Thiboutot
Akiko Tanikawa
vii

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 96 Solar Urticaria. . . . . . . . . . . . . . . . . . . . . . . . . . . . .1650
PART 15 DISORDERS OF ECCRINE Marcus Maurer, Joachim W. Fluhr, & Karsten Weller
AND APOCRINE SWEAT GLANDS
97 Phototoxicity and Photoallergy. . . . . . . . . . . . . .1657
81 Hyperhidrosis and Anhidrosis . . . . . . . . . . . . . .1459 Henry W. Lim
Anastasia O. Kurta & Dee Anna Glaser
98 Cold Injuries . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1666
82 Bromhidrosis and Chromhidrosis . . . . . . . . . . .1469 Ashley N. Millard, Clayton B. Green,
Christos C. Zouboulis & Erik J. Stratman

83 Fox-Fordyce Disease . . . . . . . . . . . . . . . . . . . . . . .1475 99 Burns . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1679

Powell Perng & Inbal Sander Benjamin Levi & Stewart Wang

84 Hidradenitis Suppurativa . . . . . . . . . . . . . . . . . .1480

Ginette A. Okoye
Contents

PART 18 PSYCHOSOCIAL SKIN DISEASE

100 Delusional, Obsessive-Compulsive, and
PART 16 DISORDERS OF THE HAIR Factitious Skin Diseases . . . . . . . . . . . . . . . . . . . .1693
Mio Nakamura, Josie Howard, & John Y. M. Koo
AND NAILS
85 Androgenetic Alopecia . . . . . . . . . . . . . . . . . . . . .1495 101 Drug Abuse . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1705
Ulrike Blume-Peytavi & Varvara Kanti Nicholas Frank, Cara Hennings, & Jami L. Miller

86 Telogen Effluvium . . . . . . . . . . . . . . . . . . . . . . . . .1507 102 Physical Abuse . . . . . . . . . . . . . . . . . . . . . . . . . . . .1717

Manabu Ohyama Kelly M. MacArthur & Annie Grossberg

87 Alopecia Areata . . . . . . . . . . . . . . . . . . . . . . . . . . .1517

Nina Otberg & Jerry Shapiro
PART 19 SKIN CHANGES ACROSS
88 Cicatricial Alopecias . . . . . . . . . . . . . . . . . . . . . . .1524 THE SPAN OF LIFE
Nina Otberg & Jerry Shapiro
103 Neonatal Dermatology . . . . . . . . . . . . . . . . . . . . .1727
89 Hair Shaft Disorders . . . . . . . . . . . . . . . . . . . . . . .1537 Raegan Hunt, Mary Wu Chang, & Kara N. Shah
Leslie Castelo-Soccio & Deepa Patel
104 Pediatric and Adolescent Dermatology. . . . . . .1750
90 Hirsutism and Hypertrichosis. . . . . . . . . . . . . . .1555 Mary Wu Chang
Thusanth Thuraisingam & Amy J. McMichael
105 Skin Changes and Diseases in Pregnancy . . . . .1765
91 Nail Disorders . . . . . . . . . . . . . . . . . . . . . . . . . . . .1568 Lauren E. Wiznia & Miriam Keltz Pomeranz
Eckart Haneke
106 Skin Aging. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1779
Michelle L. Kerns, Anna L. Chien, & Sewon Kang

PART 17 DISORDERS DUE TO THE 107 Caring for LGBT Persons in Dermatology . . . .1792
Howa Yeung, Matthew D. Mansh,
ENVIRONMENT
Suephy C. Chen, & Kenneth A. Katz
92 Polymorphic Light Eruption . . . . . . . . . . . . . . . . 1611
Alexandra Gruber-Wackernagel
& Peter Wolf
PART 20 NEOPLASIA
93 Actinic Prurigo . . . . . . . . . . . . . . . . . . . . . . . . . . . .1628
108 Benign Epithelial Tumors, Hamartomas,
Travis Vandergriff
and Hyperplasias. . . . . . . . . . . . . . . . . . . . . . . . . .1799
Jonathan D. Cuda, Sophia Rangwala,
94 Hydroa Vacciniforme . . . . . . . . . . . . . . . . . . . . . .1634
& Janis M. Taube
Travis Vandergriff
109 Appendage Tumors of the Skin . . . . . . . . . . . . .1820
95 Actinic Dermatitis . . . . . . . . . . . . . . . . . . . . . . . . .1639
Ruth K. Foreman & Lyn McDivitt Duncan
Robert S. Dawe
110 Epithelial Precancerous Lesions . . . . . . . . . . . . .1857
viii Markus V. Heppt, Gabriel Schlager, & Carola Berking

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 111 Basal Cell Carcinoma and Basal Cell 127 Fabry Disease . . . . . . . . . . . . . . . . . . . . . . . . . . . . .2292
Nevus Syndrome . . . . . . . . . . . . . . . . . . . . . . . . . .1884 Atul B. Mehta & Catherine H. Orteu
Jean Y. Tang, Ervin H. Epstein, Jr., &
Anthony E. Oro 128 Calcium and Other Mineral Deposition
Disorders . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .2307
112 Squamous Cell Carcinoma and Janet A. Fairley & Adam B. Aronson
Keratoacanthoma. . . . . . . . . . . . . . . . . . . . . . . . . .1901
Anke S. Lonsdorf & Eva N. Hadaschik 129 Graft-Versus-Host Disease . . . . . . . . . . . . . . . . . .2320
Kathryn J. Martires & Edward W. Cowen
113 Merkel Cell Carcinoma . . . . . . . . . . . . . . . . . . . . .1920
Aubriana McEvoy & Paul Nghiem 130 Hereditary Disorders of Genome Instability
and DNA Repair . . . . . . . . . . . . . . . . . . . . . . . . . .2342
114 Paget’s Disease . . . . . . . . . . . . . . . . . . . . . . . . . . . .1934 John J. DiGiovanna, Thomas M. Rünger, &
Conroy Chow, Isaac M. Neuhaus, & Roy C. Grekin Kenneth H. Kraemer

Contents
115 Melanocytic Nevi . . . . . . . . . . . . . . . . . . . . . . . . . .1944 131 Ectodermal Dysplasias . . . . . . . . . . . . . . . . . . . . .2372
Jonathan D. Cuda, Robert F. Moore, & Klaus J. Busam Elizabeth L. Nieman & Dorothy Katherine Grange

116 Melanoma . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1982 132 Genetic Immunodeficiency Diseases . . . . . . . . .2394

Jessica C. Hassel & Alexander H. Enk Ramsay L. Fuleihan & Amy S. Paller

117 Histiocytosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .2018 133 Skin Manifestations of Internal

Astrid Schmieder, Sergij Goerdt, & Jochen Utikal
118 Vascular Tumors . . . . . . . . . . . . . . . . . . . . . . . . . .2042
Kelly M. MacArthur & Katherine Püttgen
119 Cutaneous Lymphoma . . . . . . . . . . . . . . . . . . . . .2072
Martine Bagot & Rudolf Stadler
120 Cutaneous Pseudolymphoma . . . . . . . . . . . . . . .2108
Werner Kempf, Rudolf Stadler, & Martine Bagot
121 Neoplasias and Hyperplasias of
Muscular and Neural Origin . . . . . . . . . . . . . . . .2130
Hansgeorg Müller & Heinz Kutzner
Organ Disorders. . . . . . . . . . . . . . . . . . . . . . . . . . .2425
Amy K. Forrestel & Robert G. Micheletti
134 Cutaneous Paraneoplastic Syndromes . . . . . . .2441
Manasmon Chairatchaneeboon & Ellen J. Kim
135 The Neurofibromatoses . . . . . . . . . . . . . . . . . . . .2465
Robert Listernick & Joel Charrow
136 Tuberous Sclerosis Complex . . . . . . . . . . . . . . . .2480
Thomas N. Darling
137 Diabetes and Other Endocrine Diseases . . . . . .2493
April Schachtel & Andrea Kalus

122 Lipogenic Neoplasms . . . . . . . . . . . . . . . . . . . . . .2172

Thomas Mentzel & Thomas Brenn
PART 22 VASCULAR DISEASES
Volume Two 138 Cutaneous Necrotizing Venulitis . . . . . . . . . . . .2527
Nicholas A. Soter

PART 21 METABOLIC, GENETIC, AND 139 Systemic Necrotizing Arteritis . . . . . . . . . . . . . .2539

Peter A. Merkel & Paul A. Monach
SYSTEMIC DISEASES
123 Cutaneous Changes in Nutritional 140 Erythema Elevatum Diutinum . . . . . . . . . . . . . .2562
Disease . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2199 Theodore J. Alkousakis & Whitney A. High
Albert C. Yan
141 Adamantiades–Behçet Disease . . . . . . . . . . . . . .2567
124 The Porphyrias . . . . . . . . . . . . . . . . . . . . . . . . . . . .2234 Christos C. Zouboulis
Eric W. Gou & Karl E. Anderson
142 Kawasaki Disease . . . . . . . . . . . . . . . . . . . . . . . . .2580
125 Amyloidosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .2258 Anne H. Rowley
Peter D. Gorevic & Robert G. Phelps
143 Pigmented Purpuric Dermatoses . . . . . . . . . . . .2590
126 Xanthomas and Lipoprotein Disorders . . . . . . .2273 Alexandra Haden & David H. Peng
Vasanth Sathiyakumar, Steven R. Jones, &
Seth S. Martin 144 Cryoglobulinemia and
Cryofibrinogenemia . . . . . . . . . . . . . . . . . . . . . . .2599
Julio C. Sartori-Valinotti & Mark D. P. Davis ix

Kang_DIGM-FM_Vol-I.indd 9 08/12/18 5:31 pm

 145 Raynaud Phenomenon . . . . . . . . . . . . . . . . . . . . .2613
Drew Kurtzman & Ruth Ann Vleugels PART 24 FUNGAL DISEASES
160 Superficial Fungal Infection . . . . . . . . . . . . . . . . .2925
146 Malignant Atrophic Papulosis
Lauren N. Craddock & Stefan M. Schieke
(Degos Disease) . . . . . . . . . . . . . . . . . . . . . . . . . . .2630
Dan Lipsker
161 Yeast Infections. . . . . . . . . . . . . . . . . . . . . . . . . . . .2952
Iris Ahronowitz & Kieron Leslie
147 Vascular Malformations . . . . . . . . . . . . . . . . . . .2636
Laurence M. Boon, Fanny Ballieux,
162 Deep Fungal Infections . . . . . . . . . . . . . . . . . . . . .2965
& Miikka Vikkula
Roderick J. Hay
148 Cutaneous Changes in Arterial, Venous, and
Lymphatic Dysfunction . . . . . . . . . . . . . . . . . . . .2669
Sabrina A. Newman
PART 25 VIRAL DISEASES
Contents

149 Wound Healing . . . . . . . . . . . . . . . . . . . . . . . . . . .2700 163 Exanthematous Viral Diseases . . . . . . . . . . . . . .2989

Afsaneh Alavi & Robert S. Kirsner Vikash S. Oza & Erin F. D. Mathes

164 Herpes Simplex . . . . . . . . . . . . . . . . . . . . . . . . . . .3021

Jeffrey I. Cohen
PART 23 BACTERIAL DISEASES
165 Varicella and Herpes Zoster. . . . . . . . . . . . . . . . .3035
150 Superficial Cutaneous Infections and
Myron J. Levin, Kenneth E. Schmader,
Pyodermas . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .2719
& Michael N. Oxman
Lloyd S. Miller
166 Poxvirus Infections . . . . . . . . . . . . . . . . . . . . . . . .3065
151 Cellulitis and Erysipelas . . . . . . . . . . . . . . . . . . . .2746
Ellen S. Haddock & Sheila Fallon Friedlander
David R. Pearson & David J. Margolis
167 Human Papillomavirus Infections . . . . . . . . . . .3095
152 Gram-Positive Infections Associated with
Jane C. Sterling
Toxin Production . . . . . . . . . . . . . . . . . . . . . . . . . .2757
Jeffrey B. Travers
168 Cutaneous Manifestations of HIV
and Human T-Lymphotropic Virus . . . . . . . . . .3107
153 Necrotizing Fasciitis, Necrotizing Cellulitis,
Adam D. Lipworth, Esther E. Freeman,
and Myonecrosis . . . . . . . . . . . . . . . . . . . . . . . . . .2770
& Arturo P. Saavedra
Avery LaChance & Daniela Kroshinksy
169 Mosquito-Borne Viral Diseases . . . . . . . . . . . . .3135
154 Gram-Negative Coccal and
Edwin J. Asturias & J. David Beckham
Bacillary Infections . . . . . . . . . . . . . . . . . . . . . . . .2782
Breanne Mordorski & Adam J. Friedman

155 The Skin in Infective Endocarditis, Sepsis,

Septic Shock, and Disseminated
Intravascular Coagulation . . . . . . . . . . . . . . . . . .2815
Joseph C. English III & Misha Rosenbach
156 Miscellaneous Bacterial Infections with
Cutaneous Manifestations . . . . . . . . . . . . . . . . . .2827
Scott A. Norton & Michael A. Cardis
157 Tuberculosis and Infections with Atypical
Mycobacteria . . . . . . . . . . . . . . . . . . . . . . . . . . . . .2858
Aisha Sethi
158 Actinomycosis, Nocardiosis, and
Actinomycetoma . . . . . . . . . . . . . . . . . . . . . . . . . .2876
Francisco G. Bravo, Roberto Arenas,
& Daniel Asz Sigall
159 Leprosy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .2892
Claudio Guedes Salgado, Arival Cardoso de Brito,
x Ubirajara Imbiriba Salgado, & John Stewart Spencer
PART 26 SEXUALLY TRANSMITTED
DISEASES
170 Syphilis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .3145
Susan A. Tuddenham & Jonathan M. Zenilman
171 Endemic (Nonvenereal) Treponematoses . . . . .3173
Francisco G. Bravo, Carolina Talhari,
& Khaled Ezzedine
172 Chancroid . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .3186
Stephan Lautenschlager & Norbert H. Brockmeyer
173 Lymphogranuloma Venereum . . . . . . . . . . . . . .3193
Norbert H. Brockmeyer & Stephan Lautenschlager
174 Granuloma Inguinale . . . . . . . . . . . . . . . . . . . . . .3202
Melissa B. Hoffman & Rita O. Pichardo

Kang_DIGM-FM_Vol-I.indd 10 08/12/18 5:31 pm

 175 Gonorrhea, Mycoplasma, and Vaginosis. . . . . .3207 189 Antihistamines . . . . . . . . . . . . . . . . . . . . . . . . . . . .3451
Lindsay C. Strowd, Sean McGregor, & Rita O. Pichardo Michael D. Tharp

190 Cytotoxic and Antimetabolic Agents . . . . . . . . .3463

Jeremy S. Honaker & Neil J. Korman
PART 27 INFESTATIONS, BITES,
AND STINGS 191 Antiviral Drugs . . . . . . . . . . . . . . . . . . . . . . . . . . .3493
Zeena Y. Nawas, Quynh-Giao Nguyen,
176 Leishmaniasis and Other Protozoan Khaled S. Sanber, & Stephen K. Tyring
Infections . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .3223
Esther von Stebut 192 Immunosuppressive and
Immunomodulatory Drugs . . . . . . . . . . . . . . . . .3517
177 Helminthic Infections . . . . . . . . . . . . . . . . . . . . . .3251 Drew Kurtzman, Ruth Ann Vleugels, & Jeffrey Callen
Kathryn N. Suh & Jay S. Keystone
193 Immunobiologics: Targeted Therapy Against

Contents
178 Scabies, Other Mites, and Pediculosis . . . . . . . .3274 Cytokines, Cytokine Receptors, and Growth
Chikoti M. Wheat, Craig N. Burkhart, Factors in Dermatology . . . . . . . . . . . . . . . . . . . .3531
Craig G. Burkhart, & Bernard A. Cohen Andrew Johnston, Yoshikazu Takada, & Sam T. Hwang

179 Lyme Borreliosis. . . . . . . . . . . . . . . . . . . . . . . . . . .3287 194 Molecular Targeted Therapies . . . . . . . . . . . . . . .3558

Roger Clark & Linden Hu David Michael Miller, Bobby Y. Reddy, & Hensin Tsao

180 The Rickettsioses, Ehrlichioses, and 195 Antiangiogenic Agents . . . . . . . . . . . . . . . . . . . . .3590

Anaplasmoses . . . . . . . . . . . . . . . . . . . . . . . . . . . .3306 Adilson da Costa, Michael Y. Bonner,
Maryam Liaqat, Analisa V. Halpern, Justin J. Green, & Jack L. Arbiser
& Warren R. Heymann
196 Other Topical Medications . . . . . . . . . . . . . . . . . .3610
181 Arthropod Bites and Stings . . . . . . . . . . . . . . . . .3324 Shawn G. Kwatra & Manisha Loss
Robert A. Schwartz & Christopher J. Steen
197 Photoprotection . . . . . . . . . . . . . . . . . . . . . . . . . . .3623
182 Bites and Stings of Terrestrial and Jin Ho Chung
Aquatic Life . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .3338
Camila K. Janniger, Robert A. Schwartz,
Jennifer S. Daly, & Mark Jordan Scharf
PART 29 PHYSICAL TREATMENTS
198 Phototherapy . . . . . . . . . . . . . . . . . . . . . . . . . . . . .3635
PART 28 TOPICAL AND SYSTEMIC Tarannum Jaleel, Brian P. Pollack, & Craig A. Elmets

TREATMENTS 199 Photochemotherapy and Photodynamic

Therapy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .3664
183 Principles of Topical Therapy . . . . . . . . . . . . . . .3363
Herbert Hönigsmann, Rolf-Markus Szeimies,
Mohammed D. Saleem,
& Robert Knobler
Howard I. Maibach, & Steven R. Feldman
200 Radiotherapy . . . . . . . . . . . . . . . . . . . . . . . . . . . . .3687
184 Glucocorticoids . . . . . . . . . . . . . . . . . . . . . . . . . . .3382
Roy H. Decker & Lynn D. Wilson
Avrom Caplan, Nicole Fett, & Victoria Werth

185 Retinoids . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .3395

Anna L. Chien, Anders Vahlquist, PART 30 DERMATOLOGIC SURGERY
Jean-Hilaire Saurat, John J. Voorhees, & Sewon Kang
201 Cutaneous Surgical Anatomy . . . . . . . . . . . . . . .3697
186 Systemic and Topical Antibiotics . . . . . . . . . . . .3407 Arif Aslam & Sumaira Z. Aasi
Sean C. Condon, Carlos M. Isada,
& Kenneth J. Tomecki 202 Perioperative Considerations in
Dermatologic Surgery . . . . . . . . . . . . . . . . . . . . . .3706
187 Dapsone. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .3423 Noah Smith, Kelly B. Cha, & Christopher Bichakjian
Chee Leok Goh & Jiun Yit Pan
203 Excisional Surgery and Repair,
188 Antifungals . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .3436 Flaps, and Grafts . . . . . . . . . . . . . . . . . . . . . . . . . .3726
Mahmoud Ghannoum, Iman Salem, Adele Haimovic, Jessica M. Sheehan,
& Luisa Christensen & Thomas E. Rohrer xi

Kang_DIGM-FM_Vol-I.indd 11 08/12/18 5:31 pm

 204 Mohs Micrographic Surgery . . . . . . . . . . . . . . . .3761 211 Noninvasive Body Contouring . . . . . . . . . . . . . .3857
Sean R. Christensen & David J. Leffell Murad Alam

205 Nail Surgery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .3774 212 Treatment of Varicose Veins and

Robert Baran & Olivier Cogrel Telangiectatic Lower-Extremity Vessels. . . . . . .3871
Daniel P. Friedmann, Vineet Mishra,
206 Cryosurgery and Electrosurgery. . . . . . . . . . . . .3791 & Jeffrey T. S. Hsu
Justin J. Vujevich & Leonard H. Goldberg
213 Chemical Peels and Dermabrasion. . . . . . . . . . .3895
Gary Monheit & Bailey Tayebi

PART 31 COSMETIC DERMATOLOGY 214 Liposuction Using Tumescent

Local Anesthesia . . . . . . . . . . . . . . . . . . . . . . . . . .3906
207 Cosmeceuticals and Skin Care C. William Hanke, Cheryl J. Gustafson,
in Dermatology . . . . . . . . . . . . . . . . . . . . . . . . . . .3803
Contents

William G. Stebbins, & Aimee L. Leonard

Leslie Baumann
215 Soft-Tissue Augmentation . . . . . . . . . . . . . . . . . . 3911
208 Fundamentals of Laser and Lisa M. Donofrio & Dana L. Ellis
Light-Based Treatments . . . . . . . . . . . . . . . . . . . .3820
Omer Ibrahim & Jeffrey S. Dover 216 Botulinum Toxin . . . . . . . . . . . . . . . . . . . . . . . . . .3921
Richard G. Glogau
209 Laser Skin Resurfacing: Cosmetic
and Medical Applications . . . . . . . . . . . . . . . . . .3834 217 Hair Transplantation . . . . . . . . . . . . . . . . . . . . . . .3931
Bridget E. McIlwee & Tina S. Alster Robin H. Unger & Walter P. Unger

210 Nonablative Laser and Light-Based Therapy: Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3951

Cosmetic and Medical Indications . . . . . . . . . . .3846
Jeffrey S. Orringer

Videos can be accessed via the following link: mhprofessional.com/fitzderm9evideos

Chapter Number: Title Video Number: Title

Chapter 159: Leprosy Video 159-1: Sensitivity Test Monofilament

Video 159-2: Drop Foot
Video 159-3: Walking Impairment
Chapter 205: Nail Surgery Video 205-1: Lateral Longitudinal Biopsy
Video 205-2: Biopsy of the Distal Matrix
Video 205-3: Tangential Shave Excision
Video 205-4: Biopsy of Onychopapilloma

xii

Kang_DIGM-FM_Vol-I.indd 12 08/12/18 5:31 pm


Sumaira Z. Aasi, MD
Clinical Professor, Dermatology,
Clinical Professor (By Courtesy),
Surgery–Plastic and Reconstructive
Surgery, Dermatology–North
Campus, Stanford University,
Redwood City, California [201]
George Agak, PhD
Research Scientist, Dermatology/
Medicine, David Geffen School of
Medicine at UCLA, Los Angeles,
California [78]
Christine S. Ahn, MD
Resident Physician, Wake Forest
School of Medicine, Winston Salem,
North Carolina [46]
Iris Ahronowitz, MD
Assistant Professor of Clinical
Dermatology, Keck School
of Medicine, University of
Southern California, Los Angeles,
California [161]
Murad Alam, MD, MSCI, MBA
Professor of Dermatology,
Otolaryngology, and Surgery,
Vice-Chair, Department of
Dermatology, Chief, Section of
Cutaneous and Aesthetic Surgery,
Director, Micrographic Surgery and
Dermatologic Oncology Fellowship,
Northwestern University, Chicago,
Illinois [211]
Afsaneh Alavi, MSc, MD, FRCPC
Assistant Professor of Dermatology,
Women’s College Hospital,
University of Toronto, Toronto,
Ontario, Canada [149]
Theodore J. Alkousakis, MD
Assistant Clinical Professor,
University of Colorado School of
Medicine, Medical Director, Adult
Dermatology, Aurora, Colorado [140]
Tina S. Alster, MD
Director, Washington Institute
of Dermatologic Laser Surgery,
Clinical Professor of Dermatology,
Georgetown University Medical
Center, Washington, DC [209]
Kang_DIGM-FM_Vol-I.indd 13
CONTRIBUTORS
Masayuki Amagai, MD, PhD
Professor and Chair, Department
of Dermatology, Keio University
School of Medicine, Tokyo,
Japan [14]
Erin H. Amerson, MD
Associate Professor, University
of California, San Francisco,
Department of Dermatology,
San Francisco, California [1]
Karl E. Anderson, MD, FACP
Departments of Preventive
Medicine and Community Health,
and Internal Medicine (Division of
Gastroenterology and Hepatology),
University of Texas Medical Branch,
Galveston, Texas [124]
Grant J. Anhalt, MD
Professor of Dermatology and
Pathology, Department of
Dermatology, Johns Hopkins
Hospital, Baltimore, Maryland [53]
Jack L. Arbiser, MD, PhD
Emory University School
of Medicine, Department of
Dermatology, Atlanta Veterans
Affairs Medical Center, Atlanta,
Georgia [195]
Roberto Arenas, MD
Mycology Section, Dr. Manuel Gea
Gonzalez General Hospital, Mexico
City, Mexico [158]
Adam B. Aronson, MD
Resident Physician, Dermatology,
University of Iowa Carver College
of Medicine, Iowa City, Iowa [128]
Iris K. Aronson, MD
University of Illinois at Chicago,
Chicago, Illinois [73]
Arif Aslam, MBChB, MRCP (UK),
MRCGP, MRCP (Dermatology)
Consultant Dermatologist and Mohs
Surgeon, St Helens and Knowsley
Teachings Hospitals NHS Trust,
St Helens, United Kingdom [201]
Edwin J. Asturias, MD
The Jules Amer Chair in
Community Pediatrics, Children’s
Hospital Colorado, Associate
Professor of Pediatrics and
Epidemiology, Division of Pediatric
Infectious Diseases, University
of Colorado School of Medicine,
Center for Global Health, Colorado
School of Public Health, Aurora,
Colorado [169]
Martine Bagot, MD, PhD
Department of Dermatology,
Hôpital Saint-Louis, Paris,
France [119, 120]
Fanny Ballieux, MD
Resident, Center for Vascular
Anomalies, Division of Plastic
Surgery, Cliniques Universitaires
St Luc and University of Louvain,
Brussels, Belgium [147]
Robert Baran, MD
Honorary Professor, Nail Disease
Center, Cannes, France [205]
Raymond L. Barnhill, MD
Professor, Department of Pathology,
Institut Curie, and University of
Paris Descartes Faculty of Medicine,
Paris, France, Department of
Pathology, Paris, France [71]
Leslie Baumann, MD
Board Certified Dermatologist,
Baumann Cosmetic and Research
Institute, Miami, Florida [207]
J. David Beckham, MD
Associate Professor, Director of
the Infectious Disease Fellowship
Training Program, Division of Adult
Infectious Diseases, University
of Colorado School of Medicine,
Denver, Colorado [169]
Carola Berking, MD
Department of Dermatology,
University Hospital Munich,
Ludwig-Maximilian University
(LMU), Munich, Germany [110]
08/12/18 5:31 pm
 Christopher Bichakjian, MD
Department of Dermatology,
University of Michigan Health
System, Ann Arbor, Michigan [202]
Carol M. Black, MD, FRCP
Centre for Rheumatology and
Connective Tissue Diseases, UCL
Medical School, Royal Free Hospital,
London, United Kingdom [63]
Ulrike Blume-Peytavi, MD
Department of Dermatology and
Allergy, Charité-Universitätsmedizin,
Berlin, Germany [85]
Contributors
Mark Boguniewicz, MD
Professor, Division of Allergy
and Immunology, Department of
Pediatrics, National Jewish Health
and University of Colorado School
of Medicine, Denver, Colorado [22]
Michael Y. Bonner, BA
Emory University School
of Medicine, Department of
Dermatology, Atlanta, Georgia [195]
Laurence M. Boon, MD, PhD
Coordinator of the Center for
vascular Anomalies, Division
of Plastic Surgery, Cliniques
Universitaires St Luc and Human
Molecular Genetics, de Duve
Institute, University of Louvain,
Brussels, Belgium [147]
Vladimir Botchkarev, MD,
PhD, FRSB
Professor and Deputy Director,
Centre for Skin Sciences, University
of Bradford, United Kingdom,
Adjunct Professor, Department of
Dermatology, Boston University
School of Medicine, Boston,
Massachusetts [7]
Francisco G. Bravo, MD
Associate Professor of Dermatology
and Pathology, Universidad
Peruana Cayetano Heredia, Lima,
Peru [158, 171]
Thomas Brenn, MD, PhD
Consultant Dermatopathologist
and Honorary Senior Lecturer,
Department of Pathology NHS
Lothian University Hospitals Trust
and the University of Edinburgh,
Edinburgh, United Kingdom [122]
Norbert H. Brockmeyer
Walk In Ruhr (WIR) Center for
Sexual Health and Medicine,
Department of Dermatology,
Venerology and Allergology,
xiv Ruhr-Universität Bochum, Bochum,
Germany [172, 173]
Kang_DIGM-FM_Vol-I.indd 14
Anna L. Bruckner, MD, MSCS
Associate Professor of Dermatology
and Pediatrics, University of
Colorado School of Medicine,
Section Head, Pediatric
Dermatology, Children’s Hospital
Colorado, Aurora, Colorado [49]
Leena Bruckner-Tuderman,
MD, PhD
Professor and Chair of Dermatology,
Medical Center-University of
Freiburg, Freiburg, Germany [15]
Marie-Charlotte Brüggen,
MD, PhD
Department of Dermatology,
University Hospital Zurich, Zurich,
Switzerland [10]
Jörg Buddenkotte, MD, PhD
Academic Research Scientist,
Department of Dermatology and
Venereology, Hamad Medical
Corporation, Doha, Qatar [79]
Susan Burgin, MD
Assistant Professor, Beth Israel
Deaconness Medical Center,
Harvard Medical School,
Department of Dermatology, Boston,
Massachusetts [1]
Craig G. Burkhart, MD
Sylvania, Ohio [178]
Craig N. Burkhart, MD
The University of North Carolina
at Chapel Hill, Chapel Hill, North
Carolina [178]
Klaus J. Busam, MD
Professor of Pathology and
Laboratory Medicine, Weill Medical
College of Cornell University,
Department of Dermatopathology
and Pathology, Memorial Sloan
Kettering Cancer Center, New York,
New York [115]
Jeffrey Callen, MD
Professor of Medicine
(Dermatology), University
of Louisville, Chief, Division
of Dermatology, Louisville,
Kentucky [192]
Avrom Caplan, MD
Department of Dermatology,
Hospital of the University of
Pennsylvania, Philadelphia,
Pennsylvania [184]
Michael A. Cardis, MD
Department of Dermatology,
Washington Hospital Center/
Georgetown University,
Washington, DC [156]
Arival Cardoso de Brito,
MD, PhD
Full Professor, Dermatology, Pará
Federal University, Belém, Pará,
Brazil [159]
Leslie Castelo-Soccio,
MD, PhD
Assistant Professor of Pediatrics
and Dermatology, The Children’s
Hospital of Philadelphia and
University of Pennsylvania Perlman
School of Medicine, Philadelphia,
Pennsylvania [89]
Kelly B. Cha, MD, PhD
Department of Dermatology,
University of Michigan Health
System, Ann Arbor, Michigan [202]
Manasmon
Chairatchaneeboon, MD
Clinical Instructor in Dermatology,
Department of Dermatology,
Faculty of Medicine Siriraj Hospital,
Mahidol University, Bangkok,
Thailand [134]
Mary Wu Chang, MD
Clinical Professor of Dermatology
and Pediatrics, University of
Connecticut School of Medicine,
Farmington, Connecticut [103, 104]
Joel Charrow, MD
Professor of Pediatrics, Feinberg
School of Medicine, Northwestern
University, Ann and Robert H.
Lurie Children’s Hospital of
Chicago, Division of Genetics, Birth
Defects and Metabolism, Chicago,
Illinois [135]
Mei Chen, PhD
Director, USC Laboratories for
Investigative Dermatology, The
Keck School of Medicine, University
of Southern California, Los Angeles,
California [56]
Suephy C. Chen, MD, MS
Vice Chair and Associate Professor
of Dermatology, Emory University
School of Medicine, Atlanta,
Georgia [107]
Carol Cheng, MD
Assistant Clinical Professor of
Dermatology/Medicine, David
Geffen School of Medicine at UCLA,
Los Angeles, California [78]
08/12/18 5:31 pm
 Andy Chern, MD, MPH
Captain, Medical Corps, United
States Army, Associate Program
Director, Occupational and
Environmental Medicine Residency
Program, Uniformed Services
University of the Health Sciences, F.
Edward Hébert School of Medicine,
Department of Preventive Medicine
and Biostatistics, Bethesda,
Maryland [27]
Casey M. Chern, MD
Captain, Medical Corps, United
States Army, Dermatology Resident,
National Capital Consortium
Dermatology Residency Program,
Walter Reed National Military
Medical Center, Bethesda,
Maryland [27]
Anna L. Chien, MD
Assistant Professor, Department
of Dermatology, Johns Hopkins
School of Medicine, Baltimore,
Maryland [106, 185]
Keith A. Choate, MD, PhD
Professor of Dermatology, Genetics
and Pathology, Yale University
School of Medicine, New Haven,
Connecticut [47]
Conroy Chow, MD
Assistant Professor, Department
of Dermatology, Loma Linda
University, Loma Linda,
California [114]
Luisa Christensen, MD
Center for Medical Mycology,
University Hospitals Cleveland
Medical Center, Case Western
Reserve University, Cleveland,
Ohio [188]
Sean R. Christensen, MD, PhD
Assistant Professor of Dermatology,
Section of Dermatologic Surgery,
Yale University School of Medicine,
New Haven, Connecticut [204]
Angela M. Christiano, PhD
Department of Dermatology,
Department of Genetics and
Development, Columbia University,
New York, New York [18]
Emily Y. Chu, MD, PhD
Assistant Professor of Dermatology,
Hospital of the University of
Pennsylvania, Perelman School
of Medicine, Philadelphia,
Pennsylvania [2]
Kang_DIGM-FM_Vol-I.indd 15
Jin Ho Chung, MD, PhD
Professor and Chairman,
Department of Dermatology, Seoul
National University College of
Medicine, Seoul, Korea [197]
Matthew Clark, MD
Dermatology Resident, University
of Michigan Department of
Dermatology, Ann Arbor,
Michigan [31]
Roger Clark, DO
Assistant Professor of Medicine,
Tufts Medical Center, Brigham and
Women’s Faulkner Hospital, Boston,
Massachusetts [179]
Olivier Cogrel, MD
Dermatologic Surgery and Laser
Unit, Dermatology Department,
CHU Bordeaux, Hôpital Saint-
André, Bordeaux, France [205]
Bernard A. Cohen, MD
Johns Hopkins Hospital Baltimore,
Maryland [178]
Jeffrey I. Cohen, MD
Chief, Laboratory of Infectious
Diseases, National Institute of
Allergy and Infectious Diseases,
National Institutes of Health,
Bethesda, Maryland [164]
Philip R. Cohen, MD
Professor of Dermatology,
University of California San Diego
School of Medicine, San Diego,
California [36]
Sean C. Condon, MD
Department of Dermatology,
Cleveland Clinic, Cleveland,
Ohio [186]
Melissa I. Costner, MD
Associate Clinical Professor,
Dermatology, UT Southwestern
Medical School, North Dallas
Dermatology Associates, Dallas,
Texas [61]
George Cotsarelis, MD
Milton B. Hartzell Professor and
Chair, Department of Dermatology,
Perelman School of Medicine
University of Pennsylvania,
Director, Program on Epithelial
Regeneration and Stem Cells,
University of Pennsylvania
Institute for Regenerative Medicine,
Philadelphia, Pennsylvania [7]
Edward W. Cowen, MD
Head, Dermatology Consultation
Service, Dermatology Branch,
Center for Cancer Research,
National Cancer Institute, National
Institutes of Health, Bethesda,
Maryland [129]
Lauren N. Craddock, MD
Department of Dermatology,
University of Wisconsin-Madison,
Madison, Wisconsin [160]
Ponciano D. Cruz, Jr., MD
Distinguished Professor, Paul
Bergstresser Endowed Chair in
Contributors
Dermatology, Department of
Dermatology, The University of
Texas, Chief of Dermatology, North
Texas Veterans Affairs Medical
Center, Dallas, Texas [24]
Jonathan D. Cuda, MD
Assistant Professor of Dermatology,
Johns Hopkins School of Medicine,
Baltimore, Maryland [108, 115]
Donna A. Culton, MD, PhD
Department of Dermatology,
University of North Carolina at
Chapel Hill, Chapel Hill, North
Carolina [54]
Nika Cyrus, MD
Department of Dermatology,
Parkland Health and Hospital
System, Dallas, Texas [64]
Adilson da Costa, MD
Emory University School
of Medicine, Department of
Dermatology, Atlanta, Georgia [195]
Jennifer S. Daly, MD
Clinical Chief, Infectious Diseases
and Immunology, Professor of
Medicine, Microbiology and
Physiological Systems, University
of Massachusetts Medical School,
Worcester, Massachusetts [182]
Thomas N. Darling, MD, PhD
Professor and Chair of Dermatology,
Uniformed Services University
of the Health Sciences, Bethesda,
Maryland [136]
Mark D. P. Davis, MD
Professor of Dermatology, Mayo
Clinic College of Medicine,
Department of Dermatology,
Rochester, Minnesota [144]
xv
08/12/18 5:31 pm
 Robert S. Dawe, MBChB,
MD(Glasg), FRCP(Edin)
Consultant Dermatologist and
Honorary Reader in Dermatology,
Department of Dermatology and
Photobiology Unit, NHS Tayside
and University of Dundee, Dundee,
Scotland [95]
Roy H. Decker, MD, PhD
Associate Professor, Vice Chair
and Director of Clinical Research,
Department of Therapeutic
Radiology, Yale School of Medicine,
New Haven, Connecticut [200]
Contributors
Christopher P. Denton, PhD,
FRCP
Centre for Rheumatology and
Connective Tissue Diseases, UCL
Medical School, Royal Free Hospital,
London, United Kingdom [63]
Garrett T. Desman, MD
Assistant Professor of Pathology
and Dermatology, Icahn School of
Medicine at Mount Sinai, New York,
New York [71]
Luis A. Diaz, MD
Department of Dermatology,
University of North Carolina at
Chapel Hill, Chapel Hill, North
Carolina [54]
John J. DiGiovanna, MD
Senior Research Physician, DNA
Repair Section, Dermatology
Branch, Center for Cancer Research,
National Cancer Institute, National
Institutes of Health, Bethesda,
Maryland [130]
Andrzej A. Dlugosz, MD
Poth Professor of Cutaneous
Oncology, Departments of
Dermatology and Cell and
Developmental Biology, University
of Michigan Medical School, Ann
Arbor, Michigan [19]
Lisa M. Donofrio, MD
Associate Clinical Professor,
Department of Dermatology, Yale
School of Medicine, Yale University,
New Haven, Connecticut [215]
Jeffrey S. Dover, MD, FRCPC
SkinCare Physicians, Chestnut Hill,
Massachusetts [208]
Lyn McDivitt Duncan, MD
Professor of Pathology,
Harvard Medical School,
Chief, Dermatopathology Unit,
Department of Pathology,
xvi Massachusetts General Hospital,
Boston, Massachusetts [109]
Kang_DIGM-FM_Vol-I.indd 16
Jonathan A. Dyer, MD
Associate Professor of Dermatology
and Child Health, Departments of
Dermatology and Child Health,
University of Missouri, Columbia,
Missouri [72]
Lawrence F. Eichenfield, MD
Chief, Pediatric and Adolescent
Dermatology, Professor of
Dermatology and Pediatrics, Vice
Chair, Department of Dermatology,
University of California, San Diego
School of Medicine, San Diego,
California [22]
James T. Elder, MD, PhD
Kirk D. Wuepper Professor of
Molecular Genetic Dermatology,
Department of Dermatology,
University of Michigan, Ann Arbor,
Ann Arbor, Michigan [28]
Rosalie Elenitsas, MD
Professor of Dermatology, Director
of Dermatopathology, Hospital of
the University of Pennsylvania,
Perelman School of Medicine,
Philadelphia, Pennsylvania [2]
Dana L. Ellis, MD
Clinical Instructor, Department
of Dermatology, Yale School of
Medicine, Yale University,
New Haven, Connecticut [215]
Craig A. Elmets, MD
Professor and Emeritus Chair,
Department of Dermatology,
University of Alabama at
Birmingham, The Birmingham
VA Medical Center, Birmingham,
Alabama [198]
Joseph C. English III, MD
Professor of Dermatology,
University of Pittsburgh,
Department of Dermatology, UPMC
North Hills Dermatology, Wexford,
Pennsylvania [155]
Alexander H. Enk, MD
Professor and Chair,
Department of Dermatology,
University of Heidelberg,
Heidelberg, Germany [116]
Ervin H. Epstein, Jr., MD
Children’s Hospital of Oakland
Research Institute, UCSF, Oakland,
California [111]
Khaled Ezzedine, MD, PhD
Professor, Department of
Dermatology, Hôpital Henri
Mondor, EA EpiDermE
(Epidémiologie en Dermatologie
et Evaluation des Thérapeutiques),
UPEC-Université Paris-Est Créteil,
Créteil, France [76, 171]
Janet A. Fairley, MD
John S. Strauss Professor and
Chair, Department of Dermatology,
University of Iowa Carver College
of Medicine, Iowa City, Iowa [128]
Steven R. Feldman, MD, PhD
Department of Dermatology,
Wake Forest University School of
Medicine, Winston-Salem, North
Carolina [183]
Nicole Fett, MD, MSCE
Associate Professor of Dermatology,
Department of Dermatology,
Oregon Health and Science
University, Portland, Oregon [184]
David Fiorentino, MD, PhD
Professor in the Department of
Dermatology and the Department
of Immunology and Rheumatology
at Stanford University School
of Medicine, Redwood City,
California [62]
David E. Fisher, MD, PhD
Edward Wigglesworth Professor
and Chairman, Department of
Dermatology, Harvard Medical
School, Director, Melanoma
Program MGH Cancer Center,
Director, Cutaneous Biology
Research Center, Massachusetts
General Hospital, Boston,
Massachusetts [20]
Joachim W. Fluhr, MD
Oberarzt, Charité-
Universitätsmedizin Berlin, Klinik
für Dermatologie, Venerologie und
Allergologie, Berlin, Germany [96]
John A. Flynn, MD, MBA, MEd
Professor and Associate Dean of
Medicine, Johns Hopkins University,
Baltimore, Maryland [65]
Ruth K. Foreman, MD, PhD
Instructor of Pathology, Harvard
Medical School, Dermatopathology
Unit, Department of Pathology,
Massachusetts General Hospital,
Boston, Massachusetts [109]
08/12/18 5:31 pm
 Amy K. Forrestel, MD
University of Pennsylvania,
Department of Dermatology,
Philadelphia, Pennsylvania [133]
Camille Francès, MD
AP-HP, Hôpital Tenon, Université
Paris VI, Service de Dermatologie-
Allergologie, Paris, France [69]
Nicholas Frank, MD
Dermatology Resident, Vanderbilt
University Medical Center,
Department of Internal Medicine,
Division of Dermatology, Nashville,
Tennessee [101]
Esther E. Freeman, MD, PhD
Assistant Professor of Dermatology,
Harvard University Medical
School, Director, Global Health
Dermatology, Massachusetts
General Hospital, Department
of Dermatology, Boston,
Massachusetts [168]
Lars E. French, MD
Professor and Chairman,
Department of Dermatology,
University of Zurich, Zurich,
Switzerland [39]
Sheila Fallon Friedlander, MD
Professor of Dermatology and
Pediatrics, University of California,
San Diego School of Medicine, Rady
Children’s Hospital, San Diego,
San Diego, California [166]
Adam J. Friedman, MD
Associate Professor of Dermatology,
Director of Translational Research,
Residency Program Director,
Department of Dermatology, George
Washington School of Medicine
and Health Sciences, Washington,
DC [154]
Daniel P. Friedmann, MD
Westlake Dermatology Clinical
Research Center, Westlake
Dermatology and Cosmetic Surgery,
Austin, Texas [212]
Ramsay L. Fuleihan, MD
Professor of Pediatrics,
Northwestern University Feinberg
School of Medicine, Chicago,
Illinois [132]
Abhimanyu Garg, MD
Professor of Internal Medicine,
Chief, Division of Nutrition and
Metabolic Diseases, Department of
Internal Medicine and the Center
for Human Nutrition, Distinguished
Chair in Human Nutrition Research,
Dallas, Texas [74]
Kang_DIGM-FM_Vol-I.indd 17
Luis Garza, MD, PhD
Associate Professor, Department
of Dermatology, Johns Hopkins
School of Medicine, Baltimore,
Maryland [4]
Mahmoud Ghannoum,
PhD, EMBA
Center for Medical Mycology,
University Hospitals Cleveland
Medical Center, Case Western
Reserve University, Cleveland,
Ohio [188]
Dee Anna Glaser, MD
Interim Chair and Professor,
Director Cosmetic and Laser
Surgery, Director of Clinical
Research, Department of
Dermatology, Saint Louis University
School of Medicine, St. Louis,
Missouri [81]
Richard G. Glogau, MD
Clinical Professor of Dermatology,
University of California,
San Francisco, San Francisco,
California [216]
Sergij Goerdt, MD
Professor of Dermatology, Chair
of Dermatology, Department
of Dermatology, Venereology
and Allergology, University
Medical Center and Medical
Faculty Mannheim, University
of Heidelberg, Mannheim,
Germany [117]
Carolyn Goh, MD
Assistant Clinical Professor of
Dermatology/Medicine, David
Geffen School of Medicine at UCLA,
Los Angeles, California [78]
Chee Leok Goh, MD, MBBS,
M. Med (Int. Med), MRCP (UK),
FRCP (Edin), Hon FACD, FAMS
(Dermatology)
Clinical Professor, National Skin
Centre, Singapore [187]
Leonard H. Goldberg, MD
DermSurgery Associates, Houston,
Texas [206]
Peter D. Gorevic, MD
Professor of Medicine, Division
of Rheumatology, Icahn School of
Medicine at Mount Sinai, New York,
New York [125]
Eric W. Gou, MD
Department of Internal Medicine,
Division of Gastroenterology
and Hepatology, University of
Texas Medical Branch, Galveston,
Texas [124]
Emmy M. Graber, MD, MBA
Dermatologist, The Dermatology
Institute of Boston, Boston,
Massachusetts [78, 80]
Dorothy Katherine Grange, MD
Professor of Pediatrics, Division of
Genetics and Genomic Medicine,
Department of Pediatrics,
Washington University School of
Medicine, St. Louis, Missouri [131]
Clayton B. Green MD, PhD
The Marshfield Clinic, Marshfield,
Wisconsin [98]
Contributors
Justin J. Green, MD
Division of Dermatology, Cooper
Medical School of Rowan
University, Camden,
New Jersey [180]
Roy C. Grekin, MD
Professor of Dermatology, Director,
Dermatologic Surgery and Laser
Center, University of California,
San Francisco, San Francisco,
California [114]
Annie Grossberg, MD
Associate Director, Dermatology
Residency Program, Assistant
Professor, Departments of
Dermatology and Pediatrics, Johns
Hopkins University, Baltimore,
Maryland [102]
Alexandra Gruber-
Wackernagel, MD
Medical University of Graz,
Research Unit for Photodermatology,
Department of Dermatology,
Medical University of Graz, Graz,
Austria [92]
Johann E. Gudjonsson,
MD, PhD
Assistant Professor, Department of
Dermatology, Frances and Kenneth
Eisenberg Emerging Scholar of
the Taubman Medical Research
Institute, University of Michigan,
Ann Arbor, Michigan [11, 28, 31]
Cheryl J. Gustafson, MD
St. Vincent Carmel Medical Center,
Carmel, Indiana [214]
Eva N. Hadaschik, MD
Department of Dermatology,
University Hospital Heidelberg,
Heidelberg, Germany [112]
Ellen S. Haddock, AB, MBA
University of California, San
Diego School of Medicine, La Jolla,
California [166] xvii
08/12/18 5:31 pm
 Alexandra Haden, MD
Assistant Professor of Clinical
Dermatology, Department of
Dermatology, University of
Southern California, Los Angeles,
California [143]
Adele Haimovic, MD
SkinCare Physicians, Chestnut Hill,
Massachusetts [203]
Russell P. Hall III, MD
J. Lamar Callaway Professor,
Department of Dermatology, Duke
University Medical Center, Durham,
North Carolina [58]
Contributors
Analisa V. Halpern, MD
Division of Dermatology, Cooper
Medical School of Rowan
University, Camden, New
Jersey [180]
Eckart Haneke, MD, PhD
Clinical Professor (em) of
Dermatology, Department of
Dermatology, Inselspital, University
of Berne, Bern, Switzerland [91]
C. William Hanke, MD,
MPH, FACP
St. Vincent Carmel Medical Center,
Carmel, Indiana [214]
John E. Harris, MD, PhD
Associate Professor, University
of Massachusetts Medical School,
Worcester, Massachusetts [76]
Takashi Hashimoto, MD
Professor and Director, Kurume
University Institute of Cutaneous
Cell Biology, Kurume, Fukuoka,
Japan [57]
Jessica C. Hassel, MD
Section Head, DermatoOncology,
Department of Dermatology and
National Center for Tumor Diseases,
University Hospital Heidelberg,
Heidelberg, Germany [116]
Roderick J. Hay, DM, FRCP,
FRCPath, FMedSci
Professor, Department of
Dermatology, Kings College
Hospital, Denmark Hill, London,
United Kingdom [162]
Masahiro Hayashi, MD, PhD
Associate Professor of Dermatology,
Yamagata University Faculty of
Medicine, Yamagata, Japan [75]
xviii
Kang_DIGM-FM_Vol-I.indd 18
Kara Heelan, MB BCh, BAO
Dermatology Department,
University College London
Hospitals, London, United
Kingdom [45]
Cara Hennings, MD
University of Tennessee/Erlanger
Medical Center, Chattanooga,
Tennessee [101]
Markus V. Heppt, MD
Department of Dermatology,
University Hospital Munich,
Ludwig-Maximilian University,
Munich, Germany [110]
Warren R. Heymann, MD
Division of Dermatology, Cooper
Medical School of Rowan
University, Camden,
New Jersey [180]
Michihiro Hide, MD, PhD
Department of Dermatology,
Institute of Biomedical and Health
Sciences, Hiroshima University,
Hiroshima, Japan [41]
Whitney A. High, MD, JD, MEng
Associate Professor of Dermatology
and Pathology, University of
Colorado School of Medicine,
Director of Dermatopathology
(Dermatology), Aurora,
Colorado [140]
Takaaki Hiragun, MD, PhD
Department of Dermatology,
Institute of Biomedical and Health
Sciences, Hiroshima University,
Hiroshima, Japan [41]
Allen W. Ho, MD, PhD
Resident Physician, Department
of Dermatology, Harvard Medical
School, Boston, Massachusetts [12]
Melissa B. Hoffman, MD
Resident, Dermatology, Wake Forest
School of Medicine, Winston Salem,
North Carolina [174]
Jeremy S. Honaker, CNP, PhD
Assistant Professor, Department of
Dermatology, Case Western Reserve
University, Cleveland, Ohio [190]
Herbert Hönigsmann, MD
Professor of Dermatology,
Emeritus Chairman, Department of
Dermatology, Medical University of
Vienna, Vienna, Austria [38, 199]
Alain Hovnanian, MD, PhD
Professor of Genetics, Department
of Genetics, Imagine Institute for
Genetic Diseases, Necker Hospital
for Sick Children, University Paris
Descartes-Sorbonne Paris Cité,
Paris, France [50]
Josie Howard, MD
Clinical Faculty, Departments
of Psychiatry and Dermatology,
University of California, San
Francisco, San Francisco,
California [100]
Jeffrey T. S. Hsu, MD
Clinical Assistant Professor,
Department of Dermatology,
University of Illinois College of
Medicine at Chicago, Co-Director
of Dermatologic, Laser and
Cosmetic Surgery, The Dermatology
Institute of DuPage Medical Group,
Naperville, Illinois [212]
Linden Hu, MD
Professor of Microbiology and
Medicine, Tufts University
School of Medicine, Boston,
Massachusetts [179]
William W. Huang, MD, MPH
Associate Professor of Dermatology,
Residency Program Director, Wake
Forest School of Medicine, Winston
Salem, North Carolina [46]
Raegan Hunt, MD, PhD
Assistant Professor of Dermatology
and Pediatrics, Texas Children’s
Hospital, Baylor College of
Medicine, Houston, Texas [103]
Sam T. Hwang, MD, PhD
Department of Dermatology,
University of California Davis
School of Medicine, Sacramento,
California [193]
Omer Ibrahim, MD
SkinCare Physicians, Chestnut Hill,
Massachusetts [208]
Alan D. Irvine, MD, DSc
Paediatric Dermatology and
National Children’s Research
Centre, Our Lady’s Children’s
Hospital Crumlin, Dublin, Clinical
Medicine, Trinity College, Dublin,
Ireland [51]
Carlos M. Isada, MD
Department of Infectious Disease,
Cleveland Clinic, Cleveland,
Ohio [186]
08/12/18 5:31 pm
 Heidi T. Jacobe, MD, MSCS
Associate Professor, Department
of Dermatology, UT Southwestern
Medical Center, Dallas, Texas [64]
Tarannum Jaleel, MD
Instructor, Department of
Dermatology, Duke Medical Center,
Durham, North Carolina [198]
Camila K. Janniger, MD
Clinical Professor, Dermatology,
Rutgers New Jersey Medical School,
Englewood, New Jersey [182]
Andrew Johnston, PhD
Department of Dermatology
University of Michigan School
of Medicine, Ann Arbor,
Michigan [193]
Steven R. Jones, MD
Ciccarone Center for the Prevention
of Heart Disease, Division of
Cardiology, Department of
Medicine, Johns Hopkins Hospital,
Baltimore Maryland [126]
Natanel Jourabchi, MD
Resident Dermatology Physician,
Johns Hopkins School of Medicine,
Baltimore, Maryland [37]
Andrea Kalus, MD
Associate Professor, University of
Washington School of Medicine,
Division of Dermatology, Seattle,
Washington [137]
Sewon Kang, MD, MPH
Noxell Professor & Chair,
Department of Dermatology,
Johns Hopkins School of Medicine,
Dermatologist-in-Chief, Johns
Hopkins Hospital, Baltimore,
Maryland [106, 185]
Varvara Kanti, MD
Department of Dermatology
and Allergy, Charité-
Universitätsmedizin, Berlin,
Germany [85]
Kenneth A. Katz, MD,
MSc, MSCE
Department of Dermatology,
Kaiser Permanente, San Francisco,
California [107]
Stephen I. Katz, MD, PhD
National Institute of Arthritis and
Musculoskeletal and Skin Diseases,
Bethesda, Maryland [59]
Kang_DIGM-FM_Vol-I.indd 19
Werner Kempf, MD
Kempf and Pfaltz, Histologische
Diagnostik, Department of
Dermatology, University Hospital
Zurich, Zurich, Switzerland [120]
Michelle L. Kerns, MD
Research Fellow, Department
of Dermatology, Johns Hopkins
School of Medicine, Baltimore,
Maryland [106]
Jay S. Keystone, MD, MSc
(CTM), FRCPC
Professor of Medicine, University
of Toronto, Tropical Disease Unit,
Division of Infectious Diseases,
Toronto General Hospital, Toronto,
Ontario, Canada [177]
Ellen J. Kim, MD
Sandra J. Lazarus Associate
Professor in Dermatology,
Department of Dermatology,
Perelman School of Medicine at
the University of Pennsylvania,
Perelman Center for Advanced
Medicine, Philadelphia,
Pennsylvania [134]
Jenny Kim, MD, PhD
Professor of Dermatology/
Medicine/Nutrition, David Geffen
School of Medicine at UCLA,
Los Angeles, California [78]
Robert S. Kirsner, MD, PhD
Chairman and Harvey Blank
Professor, Department of
Dermatology and Cutaneous
Surgery, Professor, Department of
Public Health Sciences, University
of Miami Miller School of Medicine,
Miami, Florida [149]
Robert Knobler, MD
Associate Professor of Dermatology,
Department of Dermatology,
Medical University of Vienna,
Vienna, Austria [199]
Krzysztof Kobielak, MD, PhD
Group Leader of Laboratory of
Stem Cells, Development and
Tissue Regeneration, Centre of
New Technologies, University of
Warsaw, Warsaw, Poland, Principal
Investigator, Department of
Developmental and Cell Biology,
University of California, Irvine,
Irvine, California [8]
Heidi H. Kong, MD, MHSc
Investigator, Dermatology Branch,
Center for Cancer Research,
National Cancer Institute, National
Institutes of Health, Dermatology
Branch Bethesda, Maryland [16]
John Y. M. Koo, MD
Professor, Psoriasis, Phototherapy,
and Skin Treatment Center and
Psychodermatology Clinic,
Department of Dermatology,
University of California
San Francisco, San Francisco,
California [100]
Contributors
Neil J. Korman, MD, PhD
Professor, Department of
Dermatology, Case Western Reserve
University, Cleveland, Ohio [190]
Kenneth H. Kraemer, MD
Chief, DNA Repair Section,
Dermatology Branch, Center for
Cancer Research, National Cancer
Institute, National Institutes of
Health, Bethesda, Maryland [130]
Thomas Krieg, MD, FRCP
Department of Dermatology and
Venerology, University of Cologne,
Cologne, Germany [63]
Daniela Kroshinksy, MD, MPH
Associate Professor, Harvard
Medical School, Director of Inpatient
Dermatology, Director of Pediatric
Dermatology, Massachusetts
General Hospital/ MassGeneral
Hospital for Children, Boston,
Massachusetts [153]
Akiharu Kubo, MD, PhD
Department of Dermatology,
Keio University School of Medicine,
Tokyo, Japan [14]
Thomas S. Kupper, MD
Thomas B. Fitzpatrick Professor,
Department of Dermatology,
Brigham and Women’s Hospital,
Harvard Medical School, Boston,
Massachusetts [12]
Anastasia O. Kurta, DO
Dermatology Resident, Department
of Dermatology, Saint Louis
University School of Medicine,
St Louis, Missouri [81]
xix
08/12/18 5:31 pm
 Drew Kurtzman, MD
Assistant Professor of Medicine
(Dermatology), Director, Connective
Tissue Disease Clinic, Director,
Immunobullous Disease Clinic,
The University of Arizona, Tucson,
Arizona [145, 192]
Razelle Kurzrock, MD
Professor of Medicine and Chief,
Division of Hematology and
Oncology; Senior Deputy Center
Director, Clinical Science; and
Director, Center for Personalized
Cancer Therapy and Clinical Trials
Office, University of California,
Contributors
San Diego Moores Cancer Center,
San Diego, California [36]
Heinz Kutzner, MD
Dermatopathology Friedrichshafen,
Friedrichshafen, Germany [121]
Shawn G. Kwatra, MD
Department of Dermatology,
Johns Hopkins School of Medicine,
Baltimore, Maryland [196]
Avery LaChance, MD, MPH
Dermatology Resident, Harvard
Combined Dermatology Residency
Training Program, Massachusetts
General Hospital, Boston,
Massachusetts [153]
Eden Pappo Lake, MD
University of Illinois at Chicago,
Chicago, Illinois [73]
Stephan Lautenschlager, MD
Associate Professor University of
Zurich, Chairman Outpatient Clinic
of Dermatology and Venereology,
City Hospital Triemli, Zurich,
Switzerland [172, 173]
Gerald S. Lazarus, MD
Professor of Dermatology and
Medicine, Johns Hopkins School of
Medicine, Baltimore, Maryland [37]
Terry Lechler, PhD
Associate Professor of Dermatology,
Duke University Medical Center,
Durham, North Carolina [5]
David J. Leffell, MD
David Paige Smith Professor
of Dermatology and Professor
of Surgery (Otolaryngology
and Plastic), Section Chief of
Dermatologic Surgery, Yale
University School of Medicine,
New Haven, Connecticut [204]
xx
Kang_DIGM-FM_Vol-I.indd 20
Aimee L. Leonard, MD
New England Dermatology
and Laser Center, Springfield,
Massachusetts [214]
Kieron Leslie, MBBS,
DTM&H, FRCP
Professor of Clinical Dermatology,
Dermatology Department,
University of California,
San Francisco, San Francisco,
California [161]
Donald Y. M. Leung, MD, PhD
Department of Pediatrics, National
Jewish Health, University of
Colorado Denver, Denver,
Colorado [22]
Benjamin Levi, MD
Director, Burn, Wound and
Regenerative Medicine Laboratory,
Assistant Professor of Surgery,
Ann Arbor, Michigan [99]
Myron J. Levin, MD
Section of Pediatric Infectious
Diseases, Department of Pediatrics,
University of Colorado School of
Medicine, Aurora, Colorado [165]
Matthew Lewis, MD, MPH
Clinical Assistant Professor in
the Department of Dermatology
at Stanford University School
of Medicine, Redwood City,
California [62]
Maryam Liaqat, MD
Division of Dermatology, Cooper
Medical School of Rowan
University, Camden,
New Jersey [180]
Henry W. Lim, MD
Emeritus Chair, Department of
Dermatology, Henry Ford Hospital,
Senior Vice President for Academic
Affairs, Henry Ford Health System,
Detroit, Michigan [97]
Dan Lipsker, MD, PhD
Professor of Dermatology, Faculté de
Medicine, Université de Strasbourg
and Clinique Dermatologique,
Hôpitaux Universitaires, Strasbourg,
France [146]
Adam D. Lipworth, MD
Assistant Professor of Dermatology,
Harvard University Medical
School, Director, Program
for Infectious Diseases of the
Skin, Director of Clinical Care
Redesign, Dermatology, Brigham
and Women’s Hospital, Boston,
Massachusetts [168]
Robert Listernick, MD
Professor of Pediatrics, Feinberg
School of Medicine, Northwestern
University, Ann and Robert H. Lurie
Children’s Hospital of Chicago,
Division of General Academic
Pediatrics, Chicago, Illinois [135]
Zhi Liu, PhD
Department of Dermatology,
University of North Carolina at
Chapel Hill, Chapel Hill, North
Carolina [54]
Robert Loewe, MD
Associate Professor, Department of
Dermatology, Medical University
Vienna, Vienna, Austria [9]
Anke S. Lonsdorf, MD
Department of Dermatology,
University Hospital Heidelberg,
Heidelberg, Germany [112]
Manisha Loss, MD
Department of Dermatology Johns
Hopkins School of Medicine,
Baltimore, Maryland [196]
Thomas A. Luger, MD
Center of Chronic Pruritus,
Department of Dermatology,
University of Münster, Münster,
Germany [21]
Boris D. Lushniak, MD, MPH
Rear Admiral, United States Public
Health Service (Retired), Professor
and Chair, Preventive Medicine and
Biostatistics, Uniformed Services
University of the Health Sciences,
F. Edward Hébert School of
Medicine, Department of Preventive
Medicine and Biostatistics,
Bethesda, Maryland [27]
Catherine Maari, MD, FRCPC
Associate Clinical Professor,
Division of Dermatology, Montreal
University Health Center, University
of Montreal, CHU Sainte-Justine,
Montreal, Quebec, Canada [70]
Kelly M. MacArthur, MD
Chief Resident, Department
of Dermatology, Johns
Hopkins University, Baltimore,
Maryland [102, 118]
Howard I. Maibach, MD
Department of Dermatology,
University of California, San
Francisco School of Medicine,
San Francisco, California [183]
08/12/18 5:31 pm
 Aaron R. Mangold, MD
Assistant Professor of Dermatology,
Mayo Clinic, Scottsdale,
Arizona [32, 33]
Matthew D. Mansh, MD
Resident in Dermatology, University
of Minnesota, Minneapolis,
Minnesota [107]
Richard Marchell, MD
Associate Professor of Dermatology
and Dermatologic Surgery,
Residency Program Director,
Medical University of
South Carolina, Charleston,
South Carolina [35]
David J. Margolis, MD, PhD
Professor of Dermatology and
Epidemiology, Department of
Dermatology, Department of
Biostatistics and Epidemiology,
University of Pennsylvania
Perelman School of Medicine,
Philadelphia, Pennsylvania [3, 151]
M. Peter Marinkovich, MD
Attending Physician, VA Palo Alto
Health Care System, Associate
Professor and Director, Blistering
Disease Clinic, Department of
Dermatology, Program in Epithelial
Biology, Stanford University
School of Medicine, Stanford,
California [60]
Seth S. Martin, MD, MHS
Ciccarone Center for the Prevention
of Heart Disease, Division of
Cardiology, Department of
Medicine, Johns Hopkins Hospital,
Baltimore Maryland [126]
Kathryn J. Martires, MD
Clinical Assistant Professor,
Department of Dermatology,
Stanford University School of
Medicine, Palo Alto, California [129]
Erin F. D. Mathes, MD
Associate Professor of Clinical
Dermatology, University of
California, San Francisco,
San Francisco, California [163]
Marcus Maurer, MD
Charité–Universitätsmedizin Berlin,
Department of Dermatology and
Allergy, Berlin, Germany [96]
Aubriana McEvoy
University of Washington, Seattle,
Washington [113]
Kang_DIGM-FM_Vol-I.indd 21
John A. McGrath, MBBS, PhD
St John’s Institute of Dermatology,
King’s College London, London,
United Kingdom [18]
Sean McGregor, DO
Resident physician, Wake Forest
University School of Medicine,
Winston-Salem,
North Carolina [175]
Bridget E. McIlwee, DO
Dermatology Resident, Division of
Dermatology University of North
Texas Health Science Center, Fort
Worth, Texas [209]
Amy J. McMichael, MD
Professor and Chair, Department
of Dermatology, Wake Forest
University School of Medicine,
Winston-Salem,
North Carolina [90]
Atul B. Mehta, MA, MB, BChir,
MD, FRCP, FRCPath
Professor, University College
London, Royal Free Campus
and Royal Free London NHS
Foundation Trust, London,
United Kingdom [127]
Thomas Mentzel, MD
Consultant Dermatopathologist
and Associated Professor,
Dermatopathologie Bodensee,
Friedrichshafen, Germany [122]
Peter A. Merkel, MD, MPH
Chief, Division of Rheumatology,
Professor of Medicine and
Epidemiology, University of
Pennsylvania, Philadelphia,
Pennsylvania [139]
Robert G. Micheletti, MD
University of Pennsylvania,
Department of Dermatology,
Philadelphia, Pennsylvania [133]
Ashley N. Millard, MD
Marshfield Clinic, Marshfield,
Wisconsin [98]
David Michael Miller, MD, PhD
Clinical Fellow in Medicine,
Division of Hematology/
Oncology, Beth Israel Deaconess
Medical Center, Clinical Associate,
Department of Dermatology,
Massachusetts General Hospital,
Boston, Massachusetts [194]
Jami L. Miller, MD
Department of Internal Medicine,
Division of Dermatology, Vanderbilt
University Medical Center,
Nashville, Tennessee [101]
Lloyd S. Miller, MD, PhD
Associate Professor of Dermatology,
Infectious Diseases and Orthopaedic
Surgery, Johns Hopkins School of
Medicine, Baltimore, Maryland [150]
Leonard M. Milstone, MD
Professor Emeritus of Dermatology,
Yale University School of Medicine,
New Haven, Connecticut [47]
Daniel Mimouni, MD
Associate Professor of Dermatology,
Department of Dermatology,
Beilinson Hospital, Petach Tikva,
Israel, Faculty of Medicine, Tel Aviv
Contributors
University, Tel Aviv, Israel [53]
Vineet Mishra, MD
Assistant Clinical Professor,
Division of Dermatology and
Cutaneous Surgery, The University
of Texas Health Science Center
at San Antonio, San Antonio,
Texas [212]
Maja Mockenhaupt, MD, PhD
Dokumentationszentrum schwerer
Hautreaktionen (dZh), Department
of Dermatology, Medical Center,
University of Freiburg, Freiburg,
Germany, Dokumentationszentrum
schwerer Hautreaktionen (dZh),
Department of Dermatology,
Medical Center and Medical Faculty,
University of Freiburg, Freiburg,
Germany [43, 44]
Robert L. Modlin, MD, PhD
Klein Professor of Dermatology,
Distinguished Professor of Medicine
and Microbiology, Immunology
and Molecular Genetics, Chief,
Division of Dermatology, Vice
Chair for Cutaneous Medicine
and Dermatology Research,
David Geffen School of Medicine,
UCLA Med-Derm, Los Angeles,
California [11]
Pia Moinzadeh, MD
Department of Dermatology and
Venerology, University of Cologne,
Cologne, Germany [63]
Paul A. Monach, MD, PhD
Division of Rheumatology,
Immunology, and Allergy, Brigham
and Women’s Hospital, Chief,
Rheumatology Section, VA Boston
Healthcare System, Boston,
Massachusetts [139]
Gary Monheit, MD
Total Skin and Beauty Dermatology,
Birmingham, Alabama [213]
xxi
08/12/18 5:31 pm
 Robert F. Moore, MD
Resident in Anatomic Pathology,
Department of Pathology, Johns
Hopkins Hospital, Baltimore,
Maryland [115]
Breanne Mordorski, BA
Nanodermatology Research Fellow,
Department of Medicine (Division
of Dermatology), Albert Einstein
College of Medicine, Bronx,
New York [154]
Hansgeorg Müller, MD
Dermatopathology Friedrichshafen,
Friedrichshafen, Germany [121]
Contributors
Keisuke Nagao, MD, PhD
Dermatology Branch, National
Institutes of Health, Bethesda,
Maryland [13]
Mio Nakamura, MD
Clinical Research Fellow, Psoriasis,
Phototherapy, and Skin Treatment
Center, Department of Dermatology,
University of California,
San Francisco, San Francisco,
California [100]
Zeena Y. Nawas, MD
University of Texas Health Science
Center, Houston, Texas [191]
Susan T. Nedorost, MD
Professor, Dermatology and
Environmental Health Sciences,
Case Western Reserve University,
Director, Graduate Medical
Education, University Hospitals
Cleveland Medical Center,
Cleveland, Ohio [25]
Isaac M. Neuhaus, MD
Associate Professor of Dermatology,
University of California,
San Francisco, San Francisco,
California [114]
Sabrina A. Newman, MD
Assistant Professor of Dermatology,
Director, Inpatient Dermatology,
University of Colorado School
of Medicine, Anschutz Medical
Campus, Aurora, Colorado [148]
Paul Nghiem, MD, PhD
University of Washington, Seattle,
Washington [113]
Quynh-Giao Nguyen, MD
Baylor College of Medicine,
Houston, Texas [191]
xxii
Kang_DIGM-FM_Vol-I.indd 22
Matilda W. Nicholas, MD, PhD
Assistant Professor, Department
of Dermatology, Duke University
Medical Center, Duke University
Medical Center, Durham,
North Carolina [58]
Elizabeth L. Nieman, MD
Assistant Professor of Dermatology,
Division of Dermatology,
Department of Medicine,
Washington University School of
Medicine, St. Louis, Missouri [131]
Scott A. Norton, MD, MPH, MSc
Chief of Dermatology, Children’s
National Medical Center,
Washington, DC [156]
Cathal O’Connor, MD
Paediatric Dermatology, Our Lady’s
Children’s Hospital, National
Children’s Research Centre, Our
Lady’s Children’s Hospital Crumlin,
Dublin [51]
Grainne M. O’Regan, PhD,
FRCPI
Paediatric Dermatology, Our Lady’s
Children’s Hospital, National
Children’s Research Centre, Our
Lady’s Children’s Hospital Crumlin,
Dublin [51]
Manabu Ohyama, MD, PhD
Professor and Chairman,
Department of Dermatology, Kyorin
University School of Medicine,
Tokyo, Japan [86]
Ginette A. Okoye, MD
Assistant Professor of Dermatology,
Johns Hopkins School of Medicine,
Baltimore, Maryland [84]
Ana-Maria Orbai, MD, MHS
Assistant Professor of Medicine,
Director Psoriatic Arthritis Program,
Johns Hopkins Arthritis Center,
Johns Hopkins School of Medicine,
Division of Rheumatology,
Baltimore, Maryland [65]
Anthony E. Oro, MD, PhD
Department of Dermatology,
Stanford University, School
of Medicine, Redwood City,
California [111]
Jeffrey S. Orringer, MD
Professor and Chief, Division
of Cosmetic Dermatology,
Department of Dermatology,
University of Michigan, Ann Arbor,
Michigan [210]
Catherine H. Orteu, MBBS, BSc,
MD, FRCP
University College London, Royal
Free Campus and Royal Free
London NHS Foundation Trust,
London, United Kingdom [127]
Stephen M. Ostrowski,
MD, PhD
Instructor of Dermatology, Harvard
Medical School, Department of
Dermatology, Cutaneous Biology
Research Center, Massachusetts
General Hospital, Boston,
Massachusetts [20]
Nina Otberg, MD
Hair Clinic, Skin and Laser Center
Potsdam, Potsdam, Germany,
Otberg Medical, Hair Transplant
Center Berlin–Potsdam, Berlin,
Germany [87, 88]
Michael N. Oxman, MD
Division of Infectious Diseases,
Department of Medicine, University
of California, San Diego and
Infectious Diseases Section, Medical
Service, Veterans Affairs San Diego
Healthcare System, San Diego,
California [165]
Vikash S. Oza, MD
Assistant Professor of Dermatology
and Pediatrics, The Ronald
O. Perelman Department of
Dermatology, New York University
School of Medicine, New York,
New York [163]
Amy S. Paller, MD
Walter J. Hamlin Professor and
Chair, Department of Dermatology,
Professor of Pediatrics,
Northwestern University Feinberg
School of Medicine, Chicago,
Illinois [132]
Jiun Yit Pan, MBBS, MCI (NUS),
GDOM (NUS), DTM&H (Lond),
FRCP (Edin)
Dermatologist, National Skin
Centre, Singapore [187]
Amit G. Pandya, MD
Department of Dermatology, The
University of Texas, Southwestern
Medical Center, Dallas, Texas [77]
Deepa Patel, BS
Clinical Research Fellow, The
Children’s Hospital of Philadelphia,
Philadelphia, Pennsylvania [89]
08/12/18 5:31 pm
 Aimee S. Payne, MD, PhD
Associate Professor of Dermatology,
University of Pennsylvania,
Philadelphia, Pennsylvania [15, 52]
David R. Pearson, MD
Assistant Professor of Dermatology,
University of Minnesota School
of Medicine, Minneapolis,
Minnesota [151]
David H. Peng, MD, MPH
Chair, Department of Dermatology,
University of Southern California,
Los Angeles, California [143]
Manuel P. Pereira, MD, PhD
Center of Chronic Pruritus,
Department of Dermatology,
University of Münster, Münster,
Germany [21]
Powell Perng, MD
Johns Hopkins School of Medicine,
Department of Dermatology,
Baltimore, Maryland [83]
Peter Petzelbauer, MD
Professor of Microvascular Research,
Department of Dermatology,
Medical University Vienna, Vienna,
Austria [9]
Robert G. Phelps, MD
Professor, Departments of
Dermatology and Pathology, Icahn
School of Medicine at Mount Sinai,
New York, New York [125]
Rita O. Pichardo, MD
Associate Professor of Dermatology,
Wake Forest University School of
Medicine, Winston-Salem, North
Carolina [174, 175]
Warren W. Piette, MD
Chair, Division of Dermatology,
Department of Medicine, John
H Stroger, Jr. Hospital of Cook
County, Professor, Department
of Dermatology, Rush University
Medical Center, Chicago,
Illinois [66]
Mark R. Pittelkow, MD
Professor of Dermatology, Mayo
Clinic, Chair of Dermatology,
Scottsdale, Arizona [32, 33, 67]
Jordan S. Pober, MD, PhD
Bayer Professor of Translational
Medicine and Professor of
Immunobiology, Pathology and
Dermatology, Department of
Immunobiology, Yale School
of Medicine, New Haven,
Connecticut [9]
Kang_DIGM-FM_Vol-I.indd 23
Brian P. Pollack, MD, PhD
Assistant Professor, Departments
of Dermatology and Pathology/
Laboratory Medicine, Emory
University School of Medicine, The
Atlanta VA Medical Center, Atlanta,
Georgia [198]
Miriam Keltz Pomeranz, MD
Associate Professor of Dermatology,
The Ronald O. Perelman
Department of Dermatology,
New York University School of
Medicine, Chief of Dermatology,
NYC Health + Hospitals/Bellevue,
New York, New York [105]
Julie Powell, MD, FRCPC
Clinical Professor, Dermatology and
Pediatrics, University of Montreal,
Director, Pediatric Dermatology,
CHU Sainte-Justine, Montreal,
Quebec, Canada [70]
Julie S. Prendiville, MB, FRCPC
Clinical Professor in Pediatrics,
University of British Columbia,
Head, Division of Pediatric
Dermatology, BC Children’s
Hospital, Vancouver, British
Columbia, Canada [34]
Katherine Püttgen, MD
Assistant Professor of
Dermatology and Pediatrics, Johns
Hopkins University, Baltimore,
Maryland [118]
Sophia Rangwala, MD
Fellow, Dermatopathology, Johns
Hopkins School of Medicine,
Baltimore, Maryland [108]
Caroline L. Rao, MD
Assistant Professor, Department
of Dermatology, Duke University
Medical Center, Duke University
Medical Center, Durham,
North Carolina [58]
Bobby Y. Reddy, MD
Clinical Fellow, Department of
Dermatology, Wellman Center for
Photomedicine, Massachusetts
General Hospital, Boston,
Massachusetts [194]
Michelle Rodrigues, MBBS
(Hons), FACD
Chroma Dermatology, Melbourne,
Australia, Department of
Dermatology, St Vincent’s Hospital,
Fitzroy, Victoria, Australia [77]
Thomas E. Rohrer, MD
SkinCare Physicians, Chestnut Hill,
Massachusetts [203]
Misha Rosenbach, MD
Assistant Professor, Dermatology
and Internal Medicine Associate
Program Director, Dermatology
Residency Director, Inpatient
Dermatology Consult Service
Director, Cutaneous Sarcoidosis
Clinic, Perelman Center for
Advanced Medicine, Dermatology
Administration, Philadelphia,
Pennsylvania [155]
Jean-Claude Roujeau MD, PhD
Emeritus Professor of Dermatology,
Université Paris-Est Créteil (UPEC),
Créteil, France, Department of
Contributors
Dermatology, Université Paris-Est
Créteil, Créteil, France [43, 44]
Anne H. Rowley, MD
Professor of Pediatrics and of
Microbiology/Immunology,
Feinberg School of Medicine,
Northwestern University Attending
Physician, Division of Infectious
Diseases, Ann and Robert H. Lurie
Children’s Hospital of Chicago,
Chicago, Illinois [142]
Thomas M. Rünger, MD, PhD
Professor of Dermatology,
Pathology, and Laboratory
Medicine, Department of
Dermatology, Boston University
School of Medicine, Boston,
Massachusetts [17, 130]
Arturo P. Saavedra, MD, PhD
Associate Professor of Dermatology,
Harvard University Medical School,
Vice-Chairman for Clinical Affairs
and Medical Director, Massachusetts
General Hospital, Boston,
Massachusetts [168]
Mohammed D. Saleem,
MD, MPH
Department of Dermatology,
Wake Forest University School of
Medicine, Winston-Salem,
North Carolina [183]
Iman Salem, MD
Center for Medical Mycology,
University Hospitals Cleveland
Medical Center, Case Western
Reserve University, Cleveland,
Ohio [188]
Claudio Guedes Salgado,
MD, PhD
Associate Professor, Pará Federal
University, President of the Brazilian
Leprosy Society, Marituba, Pará,
Brazil [159]
xxiii
08/12/18 5:31 pm
 Ubirajara Imbiriba Salgado,
MD
Full Professor, Dermatology, Pará
State University, Belém, Pará,
Brazil [159]
Liat Samuelov, MD
Senior Physician, Department of
Dermatology, Tel-Aviv Sourasky
Medical Center, Tel-Aviv, Israel [48]
Khaled S. Sanber, MD, PhD
Baylor College of Medicine,
Houston, Texas [191]
Inbal Sander, MD
Contributors
Assistant Professor of Dermatology
and Pathology, Johns Hopkins
School of Medicine, Baltimore,
Maryland [83]
Julio C. Sartori-Valinotti, MD
Assistant Professor of Medicine
and Dermatology, Mayo Clinic
College of Medicine, Department
of Dermatology, Rochester,
Minnesota [144]
Vasanth Sathiyakumar, MD
Ciccarone Center for the Prevention
of Heart Disease, Division of
Cardiology, Department of
Medicine, Johns Hopkins Hospital,
Baltimore Maryland [126]
Takashi K. Satoh, MD, PhD, MSc
Postdoctoral Research Fellow,
Department of Dermatology
University of Zurich, Zurich,
Switzerland [39]
Jean-Hilaire Saurat, MD
Professor Emeritus, University of
Geneva, Genève, Switzerland [185]
April Schachtel, MD
Dermatology Resident, University
of Washington School of Medicine,
Division of Dermatology, Seattle,
Washington [137]
Knut Schäkel, MD
Professor and Vice Chair of
Dermatology, Department of
Dermatology, University Hospital,
Ruprecht-Karls-University
Heidelberg, Heidelberg,
Germany [29]
Mark Jordan Scharf, MD
Clinical Professor of Dermatology,
University of Massachusetts
Medical School, Worcester,
Massachusetts [182]
xxiv
Kang_DIGM-FM_Vol-I.indd 24
Stefan M. Schieke, MD
Assistant Professor, Department
of Dermatology, School of
Medicine and Public Health,
University of Wisconsin-Madison,
Medical Science Center, Madison,
Wisconsin [30, 160]
Gabriel Schlager, MD
Department of Dermatology,
University Hospital Munich,
Ludwig-Maximilian University,
Munich, Germany [110]
Kenneth E. Schmader, MD
Duke University Medical Center
and Geriatric Research Education
and Clinical Center (GRECC),
Durham VA Medical Center.
Durham, North Carolina [165]
Astrid Schmieder, MD
Senior Consultant, Section Head,
Allergology, Psoriasis Competence
Center, Department of Dermatology,
Venereology and Allergology,
University Medical Center and
Medical Faculty Mannheim,
University of Heidelberg,
Mannheim, Germany [117]
Robert A. Schwartz, MD, MPH,
DSc (Hon), FRCP Edin, FAAD
Professor and Head, Dermatology,
Professor of Medicine, Professor of
Pediatrics, Professor of Pathology,
Rutgers New Jersey Medical School,
Visiting Professor, Rutgers School of
Public Affairs and Administration,
Honorary Professor, China
Medical University, Shenyang,
China [181, 182]
Aisha Sethi, MD
Associate Professor of Dermatology,
Director Yale Dermatology Global
Health Program, Department of
Dermatology, Yale University
School of Medicine, New Haven,
Connecticut [157]
Kara N. Shah, MD, PhD
Kenwood Dermatology, Cincinnati,
Ohio [103]
Jerry Shapiro, MD, FRCPC
Hair Clinic, The Ronald. O.
Perelman Department of
Dermatology, New York University
School of Medicine, New York,
New York [87, 88]
Neil H. Shear, MD, PhD
Division of Dermatology,
Department of Medicine,
Sunnybrook Health Sciences Centre,
University of Toronto, Division
of Dermatology, Department of
Medicine, Sunnybrook Health
Sciences Centre, Toronto, Ontario,
Canada [45]
Jessica M. Sheehan, MD
Derick Dermatology, Northbrook,
Illinois [203]
Michael P. Sheehan, MD
Dermatology Physicians, Columbus,
Indiana [24]
Hiroshi Shimizu, MD, PhD
Professor and Chairman,
Department of Dermatology,
Hokkaido University Graduate
School of Medicine, Sapporo,
Japan [40]
Kanade Shinkai, MD, PhD
Associate Professor, University
of California, San Francisco,
Department of Dermatology,
San Francisco, California [1]
Cathryn Sibbald, BScPhm, MD
Department of Dermatology,
Sunnybrook Health Sciences Centre,
University of Toronto, Division
of Dermatology, Department of
Medicine, Sunnybrook Health
Sciences Centre, Toronto, Ontario,
Canada [45]
Daniel Asz Sigall, MD
Mycology Section, Dr. Manuel Gea
Gonzalez General Hospital, Mexico
City, Mexico [158]
Jonathan I. Silverberg, MD,
PhD, MPH
Assistant Professor of Dermatology,
Preventive Medicine and Medical
Social Sciences, Northwestern
University Feinberg School of
Medicine, Director, Northwestern
Medicine Multidisciplinary Eczema
Center, Director, Patch Testing
Clinic, Northwestern Memorial
Hospital, Chicago, Illinois [23]
Eric L. Simpson, MD, MCR
Department of Dermatology,
Oregon Health and Science
University, Portland, Oregon [22]
Noah Smith, MD
Department of Dermatology,
University of Michigan Health
System, Ann Arbor, Michigan [202]
08/12/18 5:31 pm
 Clayton J. Sontheimer, MD
Acting Assistant Professor, Pediatric
Rheumatology, University of
Washington School of Medicine,
Seattle Children’s Hospital, Seattle,
Washington [61]
Richard D. Sontheimer, MD
Professor, Dermatology, University
of Utah School of Medicine,
Salt Lake City, Utah [61]
Nicholas A. Soter, MD
Professor of Dermatology, New
York University School of Medicine,
Medical Director, Skin and Cancer
Unit, Tisch Hospital, New York,
New York [138]
John Stewart Spencer, PhD
Associate Professor, Microbiology,
Immunology and Pathology,
Colorado State University,
Fort Collins, Colorado [159]
Eli Sprecher, MD, PhD
Professor and Chair, Department
of Dermatology, Tel Aviv Sourasky
Medical Center, Tel-Aviv, Israel and
Department of Human Molecular
Genetics and Biochemistry, Sackler
Faculty of Medicine, Tel Aviv
University, Tel Aviv, Israel, Tel Aviv,
Israel [48]
Rudolf Stadler, MD, PhD
University Clinic for Dermatology,
Johannes Wesling Medical Centre,
University of Bochum, Minden,
Germany [119, 120]
Sonja Ständer, MD
Center of Chronic Pruritus,
Department of Dermatology,
University of Münster, Münster,
Germany [21]
John R. Stanley, MD
Professor, Department of
Dermatology, Perelman School
of Medicine, University of
Pennsylvania, Philadelphia,
Pennsylvania [52]
William G. Stebbins, MD
Vanderbilt University, Nashville,
Tennessee [214]
Christopher J. Steen, MD, FAAD
Portland, Maine [181]
Kang_DIGM-FM_Vol-I.indd 25
Martin Steinhoff, MD, PhD
Chairman, Department of
Dermatology and Venereology,
Hamad Medical Corporation, Doha,
Qatar, Clinical Professor, Weill-
Cornell University-Qatar, School
of Medicine, and Qatar University,
Medical School, Doha, Qatar,
Professor, UCD Charles Institute
for Translational Dermatology,
University College Dublin, Dublin,
Ireland [79]
Jane C. Sterling, MB, BChir, MA,
FRCP, PhD
Cambridge University Hospitals
NHS Foundation Trust, Department
of Dermatology, Addenbrooke’s
Hospital, Cambridge University
Hospitals NHS Foundation Trust,
Cambridge, United Kingdom [167]
Georg Stingl, MD
Professor and Chair, Division of
Immunology, Allergy and Infectious
Diseases (DIAID), Department of
Dermatology, Medical University of
Vienna, Vienna, Austria [10]
Erik J. Stratman, MD
Clinical Professor, Department
of Dermatology, University of
Wisconsin School of Medicine
and Public Health, Marshfield,
Wisconsin [98]
Lindsay C. Strowd, MD
Assistant Professor of Dermatology,
Wake Forest University School of
Medicine, Winston-Salem,
North Carolina [175]
Dae Hun Suh, MD, PhD
Professor, Department of
Dermatology, Seoul National
University College of Medicine,
Acne and Rosacea Research
Laboratory, Seoul National
University Hospital, Seoul,
South Korea [26]
Kathryn N. Suh, MD, FRCPC
Associate Professor of Medicine,
University of Ottawa, Division of
Infectious Diseases The Ottawa
Hospital, Ottawa, Ontario,
Canada [177]
Tamio Suzuki, MD, PhD
Professor and Chairman of
Dermatology, Yamagata University
Faculty of Medicine, Yamagata,
Japan [75]
Rolf-Markus Szeimies, MD, PhD
Professor of Dermatology,
Department of Dermatology
and Allergology Klinikum Vest
Academic Teaching Hospital
Ruhr-University of Bochum,
Recklinghausen, Germany [199]
Yoshikazu Takada, PhD
Department of Dermatology,
University of California Davis
School of Medicine, Sacramento,
California [193]
Shunsuke Takahagi, MD, PhD
Department of Dermatology,
Contributors
Institute of Biomedical and Health
Sciences, Hiroshima University,
Hiroshima, Japan [41]
Junko Takeshita, MD,
PhD, MSCE
Assistant Professor of Dermatology
and Epidemiology, Department
of Dermatology, Department of
Biostatistics and Epidemiology,
University of Pennsylvania
Perelman School of Medicine,
Philadelphia, Pennsylvania [3]
Carolina Talhari, MD
Associate Professor of Dermatology,
State University of Amazonas,
Manaos, Brazil [171]
Jean Y. Tang, MD, PhD
Department of Dermatology,
Stanford University, School
of Medicine, Redwood City,
California [111]
Akiko Tanikawa, MD, PhD
Assistant Professor, Department
of Dermatology, Keio University
School of Medicine, Tokyo,
Japan [68]
Janis M. Taube, MD
Associate Professor of Dermatology,
Johns Hopkins School of Medicine,
Section Head, Dermatopathology,
Baltimore, Maryland [108]
Bailey Tayebi, MD, MBA
Total Skin and Beauty Dermatology,
Birmingham, Alabama [213]
Michael D. Tharp, MD
The Clark W. Finnerud, MD
Professor and Chair, Department
of Dermatology, Rush University
Medical Center, Chicago,
Illinois [42, 189]
xxv
08/12/18 5:31 pm
 Diane M. Thiboutot, MD
Professor of Dermatology, Associate
Dean of Clinical and Translational
Research Education, Penn State
University College of Medicine,
Hershey, Pennsylvania [78, 80]
Thusanth Thuraisingam,
MD, PhD
Division of Dermatology, McGill
University, Montreal, Quebec,
Canada [90]
Kenneth J. Tomecki, MD
Department of Dermatology,
Cleveland Clinic, Cleveland,
Contributors
Ohio [186]
Franz Trautinger, MD
Professor of Dermatology and
Venereology, Karl Landsteiner
University of Health Sciences,
Chairman, Department of
Dermatology and Venereology,
University Hospital of St. Pölten,
St. Pölten, Austria [38]
Jeffrey B. Travers, MD, PhD
Chair of Pharmacology and
Toxicology, Professor of
Dermatology, Boonshoft School of
Medicine at Wright State University,
Dayton, Ohio [152]
Kenneth Y. Tsai, MD, PhD
Associate Member, Departments
of Anatomic Pathology and
Tumor Biology, Section Head,
Non-Melanoma Skin Cancer
and Treatment, Donald A. Adam
Melanoma and Skin Cancer Center
of Excellence, Moffitt Cancer Center,
Tampa, Florida [19]
Hensin Tsao, MD, PhD
Professor of Dermatology, Head,
Skin Cancer Genetics Laboratory/
Wellman Center for Photomedicine,
Director, Massachusetts General
Hospital Melanoma and Pigmented
Lesion Center/Department
of Dermatology, Director,
Massachusetts General Hospital
Melanoma Genetics Program/
MGH Cancer Center, Boston,
Massachusetts [194]
Susan A. Tuddenham,
MD, MPH
Division of Infectious Diseases,
Bayview Medical Center, Johns
Hopkins University, Baltimore,
Maryland [170]
xxvi
Kang_DIGM-FM_Vol-I.indd 26
Jake E. Turrentine, MD
Assistant Professor, Division of
Dermatology, Department of
Medicine, Augusta University,
Augusta, Georgia [24]
Stephen K. Tyring, MD, PhD
University of Texas Health Science
Center, Houston, Texas [191]
Mark C. Udey, MD, PhD
Dermatology Branch, National
Institutes of Health, Bethesda,
Maryland [13]
Hideyuki Ujiie, MD, PhD
Assistant Professor, Department of
Dermatology, Hokkaido University
Graduate School of Medicine,
Sapporo, Japan [40]
Robin H. Unger, MD
American Board of Hair Restoration
Surgery, International Society of
Hair Restoration Surgeons, Assistant
Clinical Professor, Dermatology, Mt.
Sinai School of Medicine, New York,
New York [217]
Walter P. Unger, MD, FRCP (C)
American Board of Dermatology,
American Board of Hair Restoration
Surgery, International Society of
Hair Restoration Surgeons, Clinical
Professor, Dermatology, Mt. Sinai
School of Medicine, New York,
New York [217]
Jochen Utikal, MD
Professor of Dermatology, Section
Head Dermato-Oncology, Skin
Cancer Unit, German Cancer
Research Center (DKFZ),
Department of Dermatology,
Venereology and Allergology
University Medical Center and
Medical Faculty Mannheim,
University of Heidelberg,
Mannheim, Germany [117]
Anders Vahlquist, MD
Professor, Department of Medical
Sciences, Dermatology and
Venereology, Uppsala University,
Uppsala, Sweden [185]
Travis Vandergriff, MD
Assistant Professor of
Dermatology and Pathology,
Director of Dermatopathology,
UT Southwestern Medical Center,
Dallas, Texas [93, 94]
Miikka Vikkula, MD, PhD
Head of Laboratory of Human
Molecular Genetics, de Duve
Institute, University of Louvain,
Brussels, Belgium [147]
Ruth Ann Vleugels, MD, MPH
Associate Professor, Harvard
Medical School, Director,
Autoimmune Skin Diseases
Program, Director, Connective
Tissue Diseases Clinic, Department
of Dermatology, Brigham and
Women’s Hospital, Boston,
Massachusetts [145, 192]
Esther von Stebut, MD
Associate Professor of Dermatology
and Infectious Diseases, Department
for Dermatology, University Medical
Center, Johannes Gutenberg-
University, Mainz, Germany [176]
John J. Voorhees, MD, FRPC
Duncan and Ella Poth Distinguished
Professor and Chairman,
Department of Dermatology,
University of Michigan Medical
School, Ann Arbor, Michigan [185]
Justin J. Vujevich, MD
Vujevich Dermatology Associates,
Pittsburgh, Pennsylvania [206]
Etienne C. E. Wang, BA(Hons),
MBBS, MA, MPhil
National Skin Center, Singapore,
Department of Dermatology,
Columbia University, New York,
New York [18]
Stewart Wang, MD, PhD
Professor, Department of Surgery,
Chief, Burn Surgery, Division of
Plastic Surgery, Department of
Surgery, University of Michigan
Health Systems, Ann Arbor,
Michigan [99]
Roger H. Weenig, MD
Associated Skin Care Specialists,
Fridley, Minnesota [67]
Karsten Weller, MD
Department of Dermatology and
Allergy, Allergie-Centrum-Charité,
Charité-Universitätsmedizin Berlin,
Berlin, Germany [96]
Victoria Werth, MD
Professor of Dermatology,
Department of Dermatology,
University of Pennsylvania
School of Medicine, Philadelphia,
Pennsylvania [184]
Chikoti M. Wheat, MD
Johns Hopkins School of Medicine,
Baltimore, Maryland [178]
08/12/18 5:31 pm
 Lynn D. Wilson, MD, MPH,
FASTRO
Professor, Vice Chairman and
Clinical Director, Department
of Therapeutic Radiology, Yale
School of Medicine, New Haven,
Connecticut [200]
Lauren E. Wiznia, MD
The Ronald O. Perelman
Department of Dermatology,
New York University School of
Medicine, New York,
New York [105]
Peter Wolf, MD
Professor of Dermatology
and Bioimmunotherapy, Vice
Chair of the Department of
Dermatology, Medical University
of Graz, Research Unit for
Photodermatology, Department of
Dermatology, Medical University of
Graz, Graz, Austria [92]
Gary S. Wood, MD
Johnson Professor and Chairman,
Department of Dermatology, School
of Medicine and Public Health,
University of Wisconsin-Madison,
Madison, Wisconsin [30]
Kang_DIGM-FM_Vol-I.indd 27
David T. Woodley, MD
Professor and Emeritus Founding
Chair, Department of Dermatology,
The Keck School of Medicine,
University of Southern California,
Los Angeles, California [56]
Sophie M. Worobec, MD
University of Illinois at Chicago,
Chicago, Illinois [73]
Albert C. Yan, MD, FAAP, FAAD
Chief, Section of Pediatric
Dermatology, Children’s Hospital of
Philadelphia, Professor, Pediatrics
and Dermatology, Perelman School
of Medicine at the University
of Pennsylvania, Philadelphia,
Pennsylvania [123]
Kim B. Yancey, MD
Professor and Chair, Department of
Dermatology, University of Texas
Southwestern Medical Center,
Dallas, Texas [55]
Howa Yeung, MD
Chief Resident in Dermatology,
Emory University School of
Medicine, Atlanta, Georgia [107]
Andrea L. Zaenglein, MD
Professor of Dermatology and
Pediatrics, Penn State College of
Medicine, Penn State/ Hershey
Medical Center, Hershey,
Pennsylvania [78, 80]
Jonathan M. Zenilman, MD
Division of Infectious Diseases,
Bayview Medical Center, Johns
Hopkins University, Baltimore,
Maryland [170]
Christos C. Zouboulis, MD, PhD
Departments of Dermatology,
Venereology, Allergology and
Contributors
Immunology, Dessau Medical
Center, Brandenburg Medical
School Theodor Fontane, Dessau,
Germany [6, 82, 141]
xxvii
08/12/18 5:31 pm

A much-treasured legacy of Dr. Thomas B. Fitzpat-
rick, who served as editor-in-chief for the first four
editions of the book, Fitzpatrick’s Dermatology in
General Medicine (DIGM) has always aimed to be a
comprehensive source of information for those inter-
ested in the clinical and basic science of dermatol-
ogy. Indeed, from the very first edition of Fitzpatrick’s
DIGM, printed in 1971, this authoritative textbook
has been grounded in science. We have continued
this tradition in the ninth edition of the book whilst
rearranging the discussion to make it more reader
friendly and to minimize repetition. With coverage
of subject matters expanding beyond General Medi-
cine, we have appropriately modified the book title
to Fitzpatrick’s Dermatology. Important general basic
science concepts are extensively covered in dedicated
chapters appearing in an early section of the book,
allowing subsequent clinical chapters to focus on rel-
evant disease-specific pathophysiology in addition
to clinical features, diagnosis, clinical course, and
management.
Dermatology is a particularly visual specialty. In
the preparation of this edition of the book, we have
placed special emphasis on display items (in the form
of clinical images, tables, and algorithmic summa-
ries), as we strongly believe that these components
are vital for the complete understanding of all read-
ers, but particularly for those in training. What better
way to optimize the visual content provided in our
chapters than to seek input from trainees themselves?
We had trainees review every chapter and provide
feedback on additional display items they would find
useful.
Kang_DIGM-FM_Vol-I.indd 29
PREFACE
To further enhance the utility of this gold-standard
textbook we have also improved the indexing. A good
index is imperative to allow readers, including busy
practicing clinicians, to easily and quickly find the
particular information about a concept, condition, or
therapy that they are interested in at any given time.
We hope that you agree the improved indexing allows
you to achieve this aim.
No modern textbook is complete without an online
presence. The ninth edition is also available in the
online format, and we plan to regularly post online
updates to the book as new studies and/or guide-
lines are published. You will also have access to other
useful features in the online version of Fitzpatrick’s
Dermatology on AccessMedicine.com.
Finally, as a completely new group of editors that is
diverse in expertise and international in location of prac-
tice, we have endeavored to build on the achievements
of previous editorial groups led by Drs. Thomas B.
Fitzpatrick, Irwin M. Freedberg, Klaus Wolff, and
Lowell A. Goldsmith, whilst providing fresh insight
into the content, new thinking regarding the optimal
structure of the book, and ultimately helping the book
to evolve into the most relevant resource for the modern
practicing or trainee dermatologist or skin biologist.
Sewon Kang
Masayuki Amagai
Anna L. Bruckner
Alexander H. Enk
David J. Margolis
Amy J. McMichael
Jeffrey S. Orringer
08/12/18 5:31 pm
 ACKNOWLEDGMENTS
We thank the many expert authors who wrote chap-
ters for the ninth edition of Fitzpatrick’s Dermatology.
We greatly appreciate the time they dedicated to creat-
ing their masterpieces and acknowledge how difficult
it must have been to fit the task in with the demands
of their dermatology practice, teaching, and research.
We are truly grateful. We also appreciate their patience
with the editorial team while we reviewed the sub-
missions and then reviewed them again because we
wanted to carefully consider all the visual elements
included in the book.
With regard to visual elements, we owe much grati-
tude to Noori Kim and Hester Lim who took the time
to carefully read every individual chapter and provide
detailed feedback on what additional display items
they thought would aid the reader. With more than 200
chapters included in the book, we appreciate the sheer
enormity of this task and their dedication to attention
to detail.
As a completely new editorial board, we are very
grateful for the engagement, advice, and encouragement
afforded to us by the previous editor-in-chief Lowell
A. Goldsmith. We truly appreciate the time and effort
he invested to enable the smooth transition of editorial
direction for the new edition of this much-loved book.
A special shout-out to Karen Edmonson, our
straight-talking and very patient senior editor at
Kang_DIGM-FM_Vol-I.indd 31
McGraw-Hill Education who kept the whole edito-
rial team motivated and helped to bring our ideas to
fruition, and to our editorial project manager Bryony
Mearns, who helped to coordinate submission and
review of the 217 chapters, keep on top of the status
of each chapter, and encourage authors and editors to
progress with their book-related tasks. We also appre-
ciate the efforts of Kim Davis and Sonam Arora who
expertly coordinated everything from submission
of the finalized chapters to the McGraw-Hill team
through to print publication.
Finally, we are truly grateful for the understand-
ing and patience of our families. Without their sup-
port, this textbook would never have been completed.
A book like Fitzpatrick’s Dermatology demands many
evening and weekend hours that would normally be
spent with loved ones, and we thank them for allow-
ing us to dedicate many of these hours to Fitzpatrick’s
Dermatology.
Sewon Kang
Masayuki Amagai
Anna L. Bruckner
Alexander H. Enk
David J. Margolis
Amy J. McMichael
Jeffrey S. Orringer
08/12/18 5:31 pm

Foundations of Clinical
Dermatology
Chapter 1 :: Fundamentals of Clinical Dermatology:
Morphology and Special Clinical
Considerations
:: Erin H. Amerson, Susan Burgin,
& Kanade Shinkai
AT-A-GLANCE
■ Skin diseases have characteristic morphology and
distribution.
■ Morphologic characteristics and reaction
patterns of the skin suggest disease
pathophysiology, helping focus the differential
diagnosis.
■ The history is indispensable in elucidating
complex diagnoses.
■ Knowledge and appropriate use of dermatologic
terminology is essential.
■ The comprehensive mucocutaneous examination,
including hair and nails, should always be
performed.
THE ART AND SCIENCE
OF DERMATOLOGIC
DIAGNOSIS
The diagnosis and treatment of cutaneous diseases
requires the physician’s ability to recognize the pri-
mary lesions and reaction patterns of the skin, and to
put these visual clues into context with the patient’s
history and overall health. In this chapter, we discuss a
fundamental approach to the patient presenting with a
skin problem. We introduce the technical vocabulary of
dermatologic description, also known as morphology.
Accurately identifying morphology is an essential step
Kang_CH001_p0001-0017.indd 1
1
PA RT
in generating a differential diagnosis. Use of standard
dermatologic terminology is also critical for effective
clinical documentation, research, and communication
with other health care providers.
The process of examining and describing skin lesions
requires perception of subtle details: appreciation of a
specific hue of erythema, a shape or distribution, or the
presence of characteristic findings on nails or mucous
membranes often hold the key to the correct diagno-
sis. Repeated patient encounters help to train the eye
to recognize such patterns. With time and experience,
the physician can associate clinical skin findings with
histopathologic features, enabling a rich understand-
ing of the pathophysiology of skin disease, as well as
clinical-pathologic correlation.
APPROACH TO THE
PATIENT
HISTORY
Dermatology is a visual specialty, and some skin con-
ditions may be diagnosed at a glance. History may be
crucial in complex cases, such as the patient with rash
and fever, or the patient with generalized pruritus.
There is therapeutic value in receiving a patient’s nar-
rative thread, as they feel heard, and they may reveal
information relevant to treatment choice or invite
opportunities for education and reassurance. In prac-
tice, many dermatologists take a brief history, perform
a physical examination, then undertake more detailed
05/12/18 4:47 pm
 1 questioning based on the differential diagnosis that the
examination suggests.
In taking a history from a patient presenting with a
new skin complaint, the physician’s primary goal is to
establish a diagnosis, with a secondary goal of evaluat-
ing the patient as a candidate for therapy. In patients
whose diagnosis is already established, the physician’s
goals are to reevaluate the original diagnosis, monitor
disease progress and complications, and modify treat-
ment accordingly.
Table 1-1 presents an approach to obtaining the
history in a patient presenting with a skin problem.
The physician may choose to customize the history
depending on whether the chief complaint is a growth
Part 1
or an eruption, a nail or hair disorder, or another con-
dition, and whether it is a new problem or a followup
visit for an ongoing condition.
::
Foundations of Clinical Dermatology
PHYSICAL EXAMINATION
SCOPE OF THE COMPLETE
CUTANEOUS EXAMINATION
The complete cutaneous examination includes
inspection of the entire skin surface, including often-
overlooked areas such as the scalp, eyelids, ears,
genitals, buttocks, perineum, and interdigital spaces;
the hair; the nails; and the mucous membranes of the
eyes, nose, mouth, genitals, and anus. Patients pre-
senting with a highly focused complaint, such as a
single wart or acne, may not require a comprehensive
skin examination in routine clinical practice. There are
many advantages to performing a complete cutaneous
examination, including identification of potentially
harmful lesions, such as skin cancers, providing reas-
surance for benign skin findings, locating additional
diagnostic clues (Wickham’s striae on the buccal
mucosa in lichen planus, for instance), opportunities
for patient education (eg, lentigines are a sign of sun
damage and suggest the need for improved sun pro-
tection), and an opportunity to convey the physician’s
concern about the patient’s skin health through a thor-
ough examination. A thorough evaluation increases
the possibility of making a diagnosis at the bedside
and mitigates the risk of overlooking another diagno-
sis. A guide to performing the physical examination
of the patient presenting with a skin problem is pre-
sented in Table 1-2.
IDEAL CONDITIONS FOR THE
COMPLETE SKIN EXAMINATION
A complete skin examination is most effective when
performed under ideal conditions. Excellent lighting,
preferably bright, natural light, is paramount; with-
out good lighting, subtle but important details may
2 be missed. The patient should be fully undressed,
and gowned with additional draping, if desired.
Kang_CH001_p0001-0017.indd 2
TABLE 1-1
History Taking in Dermatologic Diagnosis
Chief Complaint and History of the Present Illness
■ Duration: When the condition was first noted and dates of
recurrences or remissions
■ Timing: Constant, intermittent, worst at night, worst in winter
■ Evolution: How the condition has changed or progressed
over time
■ Location: Where lesions were first noted, and how they have
spread, if applicable
■ Symptoms: Pruritus, pain, bleeding, nonhealing, change of preex-
isting skin lesions, associated with fever or other systemic signs
■ Severity: Ask patient to rate severity of pain or pruritus on a
10-point scale to follow severity over time
■ Ameliorating and Exacerbating Factors: Sun exposure, heat, cold,
trauma, exposures (such as chemicals, medications, cosmetics,
perfumes, plants, or metals), relation to menses or pregnancy
■ Preceding illness, new medications, new topical products, or
exposures
■ Therapies tried, including nonprescription or home remedies, and
response to therapy
■ Prior similar problems, prior diagnosis, results of biopsies or other
studies performed
Medical History
■ A history of all chronic illnesses, particularly those that may mani-
fest in the skin, (diabetes, renal and hepatic disease, infection with
HIV or other viruses, polycystic ovarian syndrome, lupus, thyroid
disease) and those that are associated with skin disease (asthma,
allergies)
■ History of surgical procedures, including organ transplantation
■ Immunosuppression: iatrogenic, infectious, or inherited
■ Pregnancies
■ Psychiatric disease
■ History of blistering sunburns, exposure to arsenic or ionizing
radiation
■ Medication History: A detailed history, including prescriptions,
nonprescription medications, vitamins, dietary supplements,
herbal remedies, with particular attention to those medications
started recently
■ Allergies: To medications, foods, environmental antigens, and
contactants
■ Social History: Occupation, hobbies and leisure activities, alcohol
and tobacco use, illicit drug use, sexual history (including high-risk
activities for sexually transmitted diseases), diet, bathing habits,
pets, living conditions (eg, alone, with family, homeless, in an insti-
tution), history of travel or residence in endemic areas for infectious
diseases, cultural or religious practices
■ Family History: Of skin disease, atopy (atopic dermatitis, asthma,
hay fever) or skin cancer
■ Review of Systems: May be focused or comprehensive depending
on the diagnosis (asking about specific symptoms that may accom-
pany a dermatologic condition, such as joint symptoms in psoriasis;
asking a comprehensive ROS in the setting of cutaneous signs of
systemic disease such as palpable purpura)
Underwear, socks, shoes, makeup, and eyeglasses
should be removed. The examining table should be
at a comfortable height, with a head that reclines, an
extendable footrest, and gynecologic stirrups. The
examining room should be at a comfortable tempera-
ture for the lightly dressed patient. It should contain a
sink for hand washing and disinfecting hand foam, as
patients are reassured by seeing their physician wash
05/12/18 4:47 pm
 TABLE 1-2
Physical Examination in Dermatologic Diagnosis
General Impression of the Patient
■ Well or ill
■ Obese, cachectic, or normal weight
■ Skin Color: Degree of pigmentation, pallor (anemia), jaundice
■ Skin Temperature: Warm, cool, or clammy
■ Skin Surface Characteristics: Xerosis (dryness), seborrhea
(excessive oil), turgor, hyper- or hypohidrosis (excessive or
decreased sweating), and texture
■ Degree of Photoaging: Lentigines, actinic purpura, rhytides
Morphology
■ Define the primary lesion
■ Describe their color, texture
■ Describe any secondary changes
■ Describe their shape and configuration
■ Describe the Distribution of Lesions: Localized (isolated), grouped,
regional, generalized, universal, symmetrical, sun-exposed, flexural,
extensor extremities, acral, intertriginous, dermatomal, follicular
Aspects of General Physical Examination That May Be Helpful
■ Vital signs
■ Abdominal examination for hepatosplenomegaly
■ Pulses
■ Lymph node examination (especially in cases of suspected infec-
tion and malignancy)
hands before the examination. If the patient and physi-
cian are of opposite genders, having a chaperone in the
room may be required.
RECOMMENDED TOOLS FOR THE
COMPLETE SKIN EXAMINATION
Although the physician’s eyes and hands are the
only essential tools for examination of the skin, the
following are often useful and highly recommended:
■ A magnifying tool such as a loupe, magnifying
glass, and/or dermatoscope.
■ A bright focused light such as a flashlight or
penlight.
■ Glass slides for diascopy and viral direct fluorescent
antibody (DFA) testing, fungal scrapings and touch
preparations, Tzanck smears, scabies prep.
■ Alcohol pads to remove scale or surface oil.
■ Gauze pads or tissues with water for removing
makeup.
■ Gloves: when any contagious condition is
suspected, when contact with body fluids is
possible, when examining mucous membranes and
genital areas, and when performing any procedure.
■ A ruler for measuring lesions.
■ No. 15 and No. 11 scalpel blades for scraping and
incising lesions, respectively.
■ Diagnostic solutions: potassium hydroxide
solution, oil, Tzanck smear, bacterial, viral, and
fungal culture media.
■ A camera for photographic documentation.
■ A Wood lamp (365 nm) for highlighting subtle
pigmentary changes.
Kang_CH001_p0001-0017.indd 3
TECHNIQUE OF THE 1
DERMATOLOGIC PHYSICAL
EXAMINATION
Consistency in a comprehensive mucocutaneous
examination is essential to ensure that no areas are
overlooked. One approach to the complete skin exami-
nation is presented here. First, observe the patient at
a distance for general impressions (eg, asymmetry
due to a stroke, cachexia, jaundice). Next, examine the
patient in a systematic way, usually from head to toe,
uncovering one area at a time to preserve patient mod-
esty. Move the patient and the illumination as needed
for the best view of each body area. Sometimes side
Chapter 1 :: Fundamentals of Clinical Dermatology
lighting best reveals depth and details of skin lesion
borders. Palpate lesions to determine whether they are
soft, firm, tender, or fluid-filled. A magnifier worn on
the head leaves both hands free for palpation of lesions.
Certain lesions, especially pigmented lesions, are
best examined with a dermatoscope to identify char-
acteristic concerning features. Mucosal sites should
be carefully examined with additional illumination
with a penlight or flashlight. During the examination,
patients may be reassured by the physician’s reporting
of benign lesions as they are encountered.
Special examination techniques for hair and nail dis-
orders are discussed in Chaps. 85 through 91.
After completing the examination, it is important
to document the skin findings, including the type of
lesions and their locations, either descriptively or on
a body map. Specific documentation using photogra-
phy and triangulation based on anatomic landmarks
is particularly important for lesions suspicious for skin
malignancy undergoing biopsy, so that the exact loca-
tion may be found and definitively treated at a later
date.
INTRODUCTION TO
MORPHOLOGY
Joseph Jakob von Plenck’s (1738–1807) and Robert
Willan’s (1757–1812) work in defining basic morpho-
logic terminology laid the foundation for the descrip-
tion and comparison of fundamental lesions, thereby
facilitating characterization and recognition of skin
disease.
The eminent dermatology professors Wolff and John-
son have asserted: to read words, one must recognize
letters; to read the skin, one must recognize the basic
lesions. The “letters,” or elemental building blocks of
morphology, are the primary lesion and secondary
(epidermal) change. The skilled clinician uses macro-
scopic characteristics noted on examination to under-
stand where and what types of microscopic pathologic
changes are present, achieving clinical–pathologic
correlation. For example, flat-topped or planar pap-
ules and plaques tend to be processes affecting the
epidermis and superficial dermis, while dome-shaped 3
or nodular lesions often exhibit deeper infiltration into
05/12/18 4:47 pm
 1 the dermis or subcutis. Scaling or crusting indicates
that the epidermis is affected, while a smooth, intact
surface on a palpable lesion reflects a purely dermal or
subcutaneous process.
The combination of primary morphology and sec-
ondary change (or absence of secondary change) deter-
mine a diagnostic category, also known as the “reaction
pattern.” For example, when the primary lesion is a cir-
cumscribed papule or plaque with scale, it likely falls
into the “papulosquamous” reaction pattern, which
suggests a specific set of diagnostic possibilities. Once
the reaction pattern has been determined, a differential
diagnosis comes into focus. This differential diagnosis
may be further honed by other lesional characteris-
Part 1

tics, including shape or color, and the arrangement of

lesions in relationship to one another (configuration)
Figure 1-1 Macule, petechiae.
and on the body (distribution).
It is important for the dermatologist in training to
::

be aware that variation and ambiguity in definitions of

Foundations of Clinical Dermatology

morphologic terms exist among the dermatology com- FLAT (NONPALPABLE)

munity. For example, in dermatology textbooks, a pap-
ule has been described as no greater than 1 cm in size,
no less than 0.5 cm, or ranging from the size of a pin-
head to that of a split pea. In this chapter, the authors
have selected definitions that reduce the subjectivity
inherent in some morphologic frameworks.
PRIMARY LESIONS
Macule: A macule is flat, even with the surface level
of surrounding skin or mucous membranes, and per-
ceptible only as an area of color different from the sur-
rounding skin or mucous membrane. Macules are less
than 1 cm in size (Fig. 1-1).

Patch: A patch, like a macule, is a flat area of skin

PRIMARY MORPHOLOGY or mucous membranes with a different color from
its surrounding. Patches are 1 cm or larger in size
The primary morphology describes 3 lesional charac- (Fig. 1-2).
teristics: size, topography, and the character of con-
tents (Table 1-3). The primary morphology should
be the “noun” which all other “adjectives” (such
RAISED (PALPABLE)
as color, shape, size, texture) describe. A macule or PRIMARY LESIONS
patch is not palpable (a color change only) and raised
or depressed lesions that are palpable are papules or
Papule: A papule is an elevated or depressed lesion
less than 1 cm in size, which may be solid or cystic.
plaques. Erosions and ulcerations may be primary or
Among other characteristics, papules may be fur-
secondary.
ther described by their topography. Some examples
include papules that are sessile, pedunculated, dome-
shaped, flat-topped, filiform, mammillated, acuminate
TABLE 1-3 (conical), or umbilicated (Fig. 1-3).
Primary Morphology
PRIMARY
LESION SIZE TOPOGRAPHY CONTENTS

Macule <1 cm Flat N/A (color change only)

Patch ≥1 cm Flat N/A (color change only)
Papule <1 cm Raised/Depressed Solid
Plaque ≥1 cm Raised/Depressed Solid
Nodule ≥1 cm Raised Solid or fluid
Vesicle <1 cm Raised Fluid (serum, blood,
lymph)
Bulla ≥1 cm Raised Fluid (serum, blood,
lymph)
Pustule <1 cm Raised Fluid (pus)
Erosion Any Depressed N/A
4 Ulceration Any Depressed N/A
Figure 1-2 Patch, fixed drug eruption.

Kang_CH001_p0001-0017.indd 4 05/12/18 4:47 pm


Figure 1-3 Papule, lichen nitidus.
Plaque: A plaque is a solid plateau-like elevation
or depression that has a diameter of 1 cm or larger
(Fig. 1-4).
Nodule: A nodule is a palpable lesion greater than
1 cm with a domed, spherical or ovoid shape. They
may be solid or cystic. Depending on the anatomic
component(s) primarily involved, nodules are of
5 main types: (1) epidermal, (2) epidermal–dermal,
(3) dermal, (4) dermal–subdermal, and (5) subcutane-
ous. Texture is an important additional feature of nod-
ules: firm, soft, boggy, fluctuant, etc. Similarly, different
surfaces of nodules, such as smooth, keratotic, ulcer-
ated, or fungating, also help direct diagnostic consider-
ations (Fig. 1-5). Tumor, also sometimes included under
the heading of nodule, may be used to describe a more
irregularly shaped mass, benign or malignant.
FLUID-FILLED PRIMARY LESIONS
Vesicle and Bulla: A vesicle is a fluid-filled pap-
ule smaller than 1 cm (Fig. 1-6), whereas a bulla (blister)
measures 1 cm or larger (Fig. 1-7). By definition, the
wall is thin and translucent enough to visualize the
contents, which may be clear, serous, or hemorrhagic.
Figure 1-4 Plaque, psoriasis.
Kang_CH001_p0001-0017.indd 5
1
Chapter 1 :: Fundamentals of Clinical Dermatology
Figure 1-5 Nodule, lymphoma cutis.
Vesicles and bullae arise from cleavage at various
levels of the epidermis (intraepidermal) or the dermal–
epidermal interface (subepidermal), sometimes extend-
ing into the dermis. The tenseness or flaccidity of the
vesicle or bulla may help determine the depth of the
split. However, reliable differentiation requires histo-
pathologic examination of the blister edge.
Pustule: A pustule is a circumscribed, raised papule
in the epidermis or infundibulum containing visible
pus. The purulent exudate, composed of leukocytes
with or without cellular debris, may contain organisms
or may be sterile. The exudate may be white, yellow,
or greenish-yellow in color. Pustules may vary in size
and, in certain situations, may coalesce to form “lakes”
of pus. When associated with hair follicles, pustules
may appear conical and contain a hair in the center
(Fig. 1-8).
Figure 1-6 Vesicle, bullous lupus erythematosus. Note
brown incipient crusts marking the sites of earlier blisters 5
now ruptured.
05/12/18 4:47 pm
 1 TABLE 1-4
Types of Scale
TYPE OF SCALE DESCRIPTION

Craquelé/xerotic Desquamation giving the appearance of dried,

cracked skin. Combination of hyperkeratosis
and fissuring, which appears like the cracked
bed of a dry river.
Cutaneous horn Conical projection of compact stratum corneum.
Exfoliative/ Scales split off from the epidermis in finer scales
desquamative or in sheets.
Follicular Scales appear as keratotic plugs, spines, or
filaments.
Part 1

Gritty Densely adherent scale with a sandpaper

Figure 1-7 Vesicles and bullae, linear IgA disease. texture.
Ichthyosiform Scales are regular, polygonal plates arranged in
::

parallel rows or diamond patterns (fish-like,

Foundations of Clinical Dermatology

tessellated, Fig. 1-9).

SECONDARY CHANGE Keratotic/ Scales appear as thick, compact, adherent layers

(EPIDERMAL OR SURFACE hyperkeratotic of stratum corneum.

CHANGE)
Scale is a macroscopic finding indicating a change in
the epidermis, usually the stratum corneum. Scale
may have many different descriptive characteristics,
for instance, soft, rough, gritty, bran-like, or micaceous
(Table 1-4).
Crust describes dried fluid on the skin’s surface due
to serum, blood, pus, or a combination. When crust
is round or oval, it points to the former presence of a
vesicle, bulla or pustule (as seen in Fig. 1-6). Linear or
angulated crusts are indicative of excoriations. Other
specialized types of crust include eschar, which is dry,
adherent, and dark red-purple, brown, or black in color
and signals skin necrosis (Fig. 1-11), or fibrin, which is
a soft, yellow crust on the surface of some ulcers.
Lichenification is a thickening and accentuation of
the skin lines that results from repeated rubbing or
scratching of the skin. It is found primarily in chronic
eczematous processes or neurogenic processes
(Fig. 1-12).
Lamellar Scales are thin large plates or shields attached in
the middle and looser around the edges.
Pityriasiform Scale is small and branny.
Psoriasiform Scale is silvery and brittle and forms thin plates
(micaceous and in several loose sheets, like mica (micaceous
ostraceous) scale). Large scales may accumulate in heaps,
giving the appearance of an oyster shell
(ostraceous scale, Fig. 1-10).
Seborrheic Scales are thick, waxy or greasy, yellow-to-
brown, flakes.
Shellac-like Scale is shiny with a sheet-like desquamating
edge, like peeling paint
Wickham striae Scale appears as a lacy white pattern overlying
violaceous flat-topped papules.
Atrophy of the epidermis results in a shiny quality
with “cigarette-paper” wrinkling. Atrophy of the der-
mis results in a depressed lesion.
A fissure is a linear loss of continuity of the skin’s
surface or mucosa that results from excessive tension

6
Figure 1-8 Pustule, pustular psoriasis. Figure 1-9 Ichthyosiform scale, ichthyosis vulgaris.

Kang_CH001_p0001-0017.indd 6 05/12/18 4:47 pm


Figure 1-10 Ostraceous scale, psoriasis.
or decreased elasticity of the involved tissue. Fissures
frequently occur on the palms and soles where the
thick stratum corneum is least expandable.
OTHER LESIONAL
CHARACTERISTICS
In addition to primary morphology, other features of
lesions can be important in narrowing a differential
diagnosis; sometimes, these other characteristics are
the most important determinants of the differential.
For instance, the most notable feature of a rash or
lesion might be its shape or distribution, which points
the clinician to a specific list of possible diagnoses.
COLOR
Perhaps the most important additional feature of a
lesion other than primary morphology is color. The
experienced dermatologist will notice subtle varia-
tions in hue and saturation of a particular color, and
can ascribe meaning to these variations. The most
Figure 1-11 Eschar overlying stellate purpura, calciphylaxis.
Kang_CH001_p0001-0017.indd 7
1
Chapter 1 :: Fundamentals of Clinical Dermatology
Figure 1-12 Lichenification, lichen simplex chronicus.
common types of color on the skin are variations
in brown (hyperpigmentation) and red (erythema),
which will be discussed in depth below. Other colors
and their histopathologic correlations are described in
Table 1-5.
Brown: Brown color is most often representative
of melanin, either within melanocytes or outside of
melanocytes. Less frequently, a brown hue also may
be caused by deposition of other pigments, cells, or
materials in the dermis (such as deposition of hemo-
siderin, amyloid, or mucin; certain types of inflamma-
tion, including inflammation that is granulomatous,
histiocytic, plasmacytic, or mixed). Mast cells induce
melanin production in the overlying epidermis, often
leading to brown color overlying the focus of mast cells
in the dermis. Melanin in the epidermis, whether con-
tained within or outside of melanocytes, appears tan to
muddy brown; when it is very concentrated, as in some
nevi or melanomas or heavily pigmented seborrheic
keratoses, it may appear brown-black. Melanin in the
dermis, either within melanocytes or extracellular, may
appear brown, gray, or blue. This gray-blue color results
from the “Tyndall effect,” named for the 19th-century
physicist John Tyndall, who described the preferential
transmission of longer wavelengths (blue photospec-
trum) when particles are suspended in a medium
(in this case, melanin or other brown pigment suspended
in the dermis). Differentiation between epidermal and
dermal melanin also can be aided by a Wood lamp, which
accentuates epidermal but not dermal melanin.
Oxidized keratin, (within an infundibular cyst, for
instance) and foreign pigmentation (such as tattoos)
can also exhibit the Tyndall effect when located in the
dermis.
When the epidermis is inflamed or damaged, mela-
nin often drops to into the dermis. Therefore, many
subacute, chronic, or recently resolved epidermal
inflammatory diseases or injuries have a brown or gray-
brown tone. The more constitutive pigment in an indi-
vidual’s skin, the more prominent these changes will be.
Red: Also known as “erythema,” red can have infi- 7
nite hues. Pale red, pink, or purple may result from
05/12/18 4:47 pm
 1 TABLE 1-5
Implications of Color Changes in Altered Skin
COLOR PATHOLOGY DIAGNOSTIC EXAMPLES

White Reduced or absent melanin synthesis Tinea versicolor, vitiligo

Keratin Milium
Calcium deposit Calcinosis cutis
Scar Atrophie blanche
Black Dense melanin Melanoma
Intraepidermal hemorrhage Talon noir
Necrosis Cutaneous anthrax
Oxidized keratin (brown to black) Open comedone
Part 1

Brown Melanin Melanocytic nevus, melasma

Red-brown Hemosiderin (“cayenne pepper”) Pigmented purpuric dermatosis
::

Granulomatous inflammation (“apple jelly”) Sarcoidosis (Fig. 1-15)

Foundations of Clinical Dermatology

Histiocytic inflammation Langerhans cell histiocytosis

Mixed inflammation Granuloma faciale
Plasmacytic inflammation (“copper”- or “ham”-colored) Secondary syphilis
Mast cell inflammation Urticaria pigmentosa
Mucin deposition Pretibial myxedema
Amyloid deposition Lichen amyloidosis
Infiltration with smooth muscle Cutaneous leiomyoma
Subacute or chronic epidermal inflammation Subacute lupus erythematosus
Red Vascular dilation or congestion Erysipelas
Neutrophilic inflammation Sweet syndrome
Vascular neoplasm Cherry angioma
Pink or salmon Acute inflammation with dilation of superficial dermal vessels Eczema, drug eruptions, urticaria, pityriasis rubra
pilaris, psoriasis
Orange Granulomatous inflammation with histiocytes having abundant cytoplasm Juvenile xanthogranuloma
Yellow Pus Folliculitis
Lipid Xanthelasma
Histiocytic inflammation Necrobiosis lipoidica (Fig. 1-16)
Elastolysis Pseudoxanthoma elasticum
Sebaceous glands Sebaceous hyperplasia
Bilirubin Jaundice
Green Deep hemosiderin Ecchymosis
Pyocyanin pigment Pseudomonas infection
Myeloperoxidase Chloroma
Tissue eosinophilia Wells syndrome
Blue/gray Deep dermal melanin Blue nevus
Deep deposition of other pigment Argyria, tattoo
Violet to lilac Acute lymphocytic inflammation with dilation of deep dermal blood vessels Borders of evolving morphea, dermatomyositis,
lichen planus
Plum Vascular neoplasm Kaposi sarcoma
Dense lymphocytic inflammation Lymphoma cutis
Malignant neoplasm Nodular amelanotic melanoma
Hemorrhage Ecchymosis

inflammation leading to hyperemia (subtle vascular to purple hue can result from the either malformed or
dilation). More saturated red to purple can indicate ectopic blood vessels (Fig. 1-13) or extravasated erythro-
8 intense hyperemia or vascular congestion (also called cytes (petechiae or purpura, see “vascular reaction pat-
rubor, as seen in erysipelas); even more saturated red tern” below). Variations in the hue of erythema are vast

Kang_CH001_p0001-0017.indd 8 05/12/18 4:47 pm

 1

Chapter 1 :: Fundamentals of Clinical Dermatology

Figure 1-13 Purple papules, Kaposi sarcoma.

and provide subtle clues to the type of inflammation

present. True red is often associated with neutrophilic
inflammation (as seen in cellulitis or Sweet syndrome);
red-purple (violaceous erythema, Fig. 1-14) with lym-
phocytic inflammation (lymphoma cutis, connective
tissue disease, interface reactions such as lichen planus).
Granulomatous inflammation may appear red-brown
(sarcoidosis, marked by the classis “apple jelly” color
seen in Fig. 1-15, or a juvenile xanthogranuloma) to Figure 1-15 Apple-jelly sign, sarcoidosis.
orange or yellow (Fig. 1-16, necrobiosis lipoidica). One
major caveat is that the true hue of erythema is easiest
to visualize in acute conditions affecting fair skin. Sub- relation to one another. For example, annular or linear
acute or chronic conditions, particularly with epidermal may be the shape of a single plaque, or a configuration
involvement, will have epidermal alteration causing of discrete papules. Demarcation refers to the edge of
epidermal pigment drop-out into the dermis, making an individual lesion and whether it is sharply defined
lesions appear more brown or gray. Hemorrhage can from or blends into the surrounding skin.
also alter the hue, making lesions appear more purple.
Annular: Ring-shaped; implies that the edge of the
lesion has a color and/or texture change that is more
SHAPE AND CONFIGURATION prominent on the leading edge than the center (as seen
OF LESIONS in granuloma annulare, tinea corporis, erythema annu-
lare centrifugum) (Fig. 1-17).
“Shape” describes an individual macule, patch, pap-
ule, or plaque; “configuration” refers to shapes made Round/Nummular/Discoid: Coin-shaped;
from the arrangement of individual primary lesions in solid circle or oval; usually with uniform morphology

9
Figure 1-14 Violaceous Gottron papules, dermatomyositis. Figure 1-16 Yellow, necrobiosis lipoidica diabeticorum.

Kang_CH001_p0001-0017.indd 9 05/12/18 4:47 pm

 1Part 1
Figure 1-17 Annular lesion, granuloma annulare.
::
Foundations of Clinical Dermatology
from the edges to the center (nummular eczema,
plaque-type psoriasis, discoid lupus) (Fig. 1-18).
Arcuate: Arc-shaped; often a result of incomplete
formation of an annular lesion (urticaria, subacute
cutaneous lupus erythematosus).
Linear: Resembling a straight line; often implies
an external contactant or Koebner phenomenon has
occurred in response to scratching; may apply to a
single lesion (such as a scabies burrow, poison ivy der-
matitis, or bleomycin pigmentation) or to the arrange-
ment of multiple lesions (as seen in lichen nitidus or
lichen planus).
Geographic: A shape similar to a land mass; edges
are reminiscent of a coastline
Reticular or Retiform: Net-like or lacy in
appearance, with somewhat regularly spaced rings or
crossing lines with sparing of intervening skin (as seen
in livedo reticularis, cutis marmorata) (Fig. 1-19).
10
Figure 1-18 Nummular lesion, nummular dermatitis.
Kang_CH001_p0001-0017.indd 10
Figure 1-19 Reticular eruption, livedo racemosa.
Stellate: Having multiple angulated edges, resem-
bling a star (Fig. 1-11).
Serpiginous: Serpentine or snake-like (cutaneous
larva migrans, for instance, in which the larva migrates
this way and that through the skin in a wandering pat-
tern) (Fig. 1-20).
Targetoid: Target-like, with a center darker than
the periphery. Typical targets (eg, erythema multi-
forme) have 3 zones: a dark red-purple or dusky cen-
ter, encircled by a paler pink zone, followed by a rim
of darker erythema. Atypical targets have just 2 zones,
a dark or dusky center with a paler pink rim. Note
that both have a center darker in comparison to the
outer zone; if the center is paler than the outer zone, it
should be termed “annular” (Fig. 1-21).
Whorled: Like marble cake, with 2 distinct col-
ors interspersed in a wavy pattern; usually seen in
mosaic disorders in which cells of differing genotypes
are interspersed (as seen in incontinentia pigmenti,
hypomelanosis of Ito, linear and whorled nevoid
hypermelanosis).
Figure 1-20 Serpiginous erythema, jellyfish sting.
05/12/18 4:47 pm

Figure 1-21 Atypical targetoid lesions, Stevens-Johnson
syndrome due to medication.
Grouped/Herpetiform: Lesions clustered
together (a classic example is herpes simplex virus
reactivation noted as grouped vesicles on an erythem-
atous base; also seen with certain arthropod bites).
Scattered: Sparse lesions that are irregularly
distributed.
Polycyclic: Formed from coalescing circles, rings,
or incomplete rings (as seen in urticaria, subacute cuta-
neous lupus erythematosus) (Fig. 1-22).
Figure 1-22 Polycyclic eruption, pityriasis rosea.
Kang_CH001_p0001-0017.indd 11
DISTRIBUTIONS OF MULTIPLE 1
LESIONS
Dermatomal/Zosteriform: Unilateral and lying
in the distribution of a single spinal afferent nerve root;
the classic example is herpes zoster (Chap. 165).
Blaschkoid: Following lines of skin cell migration
during embryogenesis; generally longitudinally ori-
ented on the limbs and circumferential on the trunk,
but curvilinear rather than perfectly linear; described
by Alfred Blaschko and implies a mosaic disorder
(such as incontinentia pigmenti, inflammatory linear
verrucous epidermal nevus).
Chapter 1 :: Fundamentals of Clinical Dermatology
Lymphangitic and Sporotrichoid: Lying
along the distribution of a lymph vessel; implies an
infectious agent that is spreading centrally from an
acral site. Lymphangitic lesions are usually a red
streak along a limb due to a staphylococcal or strepto-
coccal cellulitis. When individual papules or nodules
lie along the distribution of a lymphatic network, this
pattern is termed “sporotrichoid” and suggests a par-
ticular infectious differential.
Sun Exposed/Photodistributed: Occurring
in areas usually not covered by clothing, namely the
face, dorsal hands, and a triangular area correspond-
ing to the opening of a V-neck shirt on the upper
chest (examples include photodermatitis, subacute
cutaneous lupus erythematosus, polymorphous light
eruption, squamous cell carcinoma). Photo-accentuated
means the sun-exposed skin has a more dense distribu-
tion of lesions compared to non-sun-exposed skin.
Sun Protected: Occurring in areas usually cov-
ered by one or more layers of clothing; usually a der-
matosis that is improved by sun exposure (such as
parapsoriasis, mycosis fungoides).
Acral: Occurring in distal locations, such as on the
hands, feet, wrists, ankles, ears, or penis.
Truncal: Occurring on the trunk or central body.
Extensor: Occurring over the dorsal extremities,
overlying the extensor muscles, knees, or elbows
(psoriasis is a classic example).
Flexor: Overlying the flexor muscles of the extremi-
ties, the antecubital and popliteal fossae (childhood
atopic dermatitis, for instance).
Intertriginous: Occurring in the skin folds, where
2 skin surfaces are in contact, namely the axillae, ingui-
nal folds, inner thighs, inframammary skin, and under
an abdominal pannus; often related to moisture and
heat generated in these areas.
Seborrheic: Favoring the hair-bearing locations
of the skin, including scalp, eyebrows, beard, central
chest, axillae, genitals. Also often favors the nasolabial
and postauricular creases.
11
Follicular: Papules centered around hair follicles.
05/12/18 4:47 pm
 1 TABLE 1-6
A Selection of Cutaneous Diagnostic Signsa
CUTANEOUS SIGN DESCRIPTION SIGNIFICANCE

Apple-jelly sign A yellowish hue is produced from pressure on the lesion Noted in granulomatous processes (Fig. 1-15)
with a glass slide
Asboe–Hansen sign Lateral extension of a blister with downward pressure Noted in blistering disorders in which the pathology is
above the basement membrane zone
Auspitz sign Pinpoint bleeding at the tops of ruptured capillaries with Not entirely sensitive or specific for psoriasis
forcible removal of outer scales from a psoriatic plaque
Buttonhole sign A flesh-colored, soft papule feels as though it can be Noted in a neurofibroma
pushed through a “buttonhole” into the skin
Carpet tack sign Horny plugs at the undersurface of scale removed from a Noted in lesions of chronic cutaneous lupus
Part 1

lesion
Darier sign Urticarial wheal produced in a lesion after it is firmly Noted in urticaria pigmentosa and rarely with cutaneous
rubbed with a finger or the rounded end of a pen; the lymphoma or histiocytosis
::

wheal, which is strictly confined to the borders of the

Foundations of Clinical Dermatology

lesion, may not appear for several minutes

Dermatographism Firmly stroking unaffected skin produces a wheal along Symptomatic dermatographism represents a physical
the shape of the stroke within seconds to minutes urticaria
Pseudo-Darier sign Transient induration of a lesion or piloerection after Noted in congenital smooth muscle hamartoma
rubbing
Fitzpatrick (dimple) Dimpling of the skin with lateral compression of the Characteristic of dermatofibroma
sign lesion with the thumb and index finger produces
dimpling as a result of tethering of the epidermis to
the dermal lesion
Nikolsky sign Lateral pressure on unblistered skin with resulting shearing Noted in blistering disorders in which the pathology is above
of the epidermis the basement membrane zone; relevant entities include
pemphigus vulgaris and toxic epidermal necrolysis
a
Others are discussed in the chapters on diseases in which the signs occur.

Localized: Confined to a single body location.

TABLE 1-7
Generalized: Widespread. A generalized eruption Papulosquamous Reaction Pattern—Common
consisting of inflammatory (red) lesions is called an Examples
exanthem (rash). A macular exanthem consists of mac-
Psoriasis
ules, a papular exanthem of papules, a vesicular exan-
Lichen planus
them of vesicles, etc.
Pityriasis rosea
Pityriasis rubra pilaris
Bilateral Symmetric: Occurring with mirror- Pityriasis lichenoides chronica
image symmetry on both sides of the body. Syphilis (secondary)
Mycosis fungoides (MF)/parapsoriasis
Universal: Involving the entire cutaneous surface Drug (lichenoid, pityriasis rosea-like)
(as in erythroderma, alopecia universalis). Subacute and discoid lupus, dermatomyositis
Table 1-6 describes some clinically relevant maneuvers Tinea corporis
that point to particular cutaneous or systemic diseases. Tinea versicolor
Seborrheic dermatitis
Nutritional deficiency

REACTION PATTERNS Lichenoid id reaction

Porokeratosis
Superficial basal cell carcinoma
Certain combinations of primary and secondary mor-
Squamous cell carcinoma in situ
phologies point the clinician to a subset of diseases.
Groups of diagnoses that share similar morphologic Toolbox
History
characteristics are termed “reaction patterns,” suggest-
Distribution
ing a particular list of differential diagnosis. Reaction
Examine scalp, nails, mucous membranes
patterns are an especially useful tool when no charac- KOH preparation, fungal culture
teristic shape, configuration, or distribution is apparent. Rapid plasma reagin (RPR)
12 Determining the reaction pattern can also help guide Biopsy for routine histology
workup (Tables 1-7 through 1-15) and initial treatment.

Kang_CH001_p0001-0017.indd 12 05/12/18 4:47 pm

 TABLE 1-8 TABLE 1-9
1
Eczematous Reaction Pattern—Common Vesiculobullous Reaction Pattern—Common
Examples Examples
Same or Similar Histology Pustules
Atopic Psoriasis
Irritant contact Acute generalized exanthematous pustulosis (AGEP)
Allergic contact Sneddon–Wilkinson/IgA pemphigus
Nummular Candida
Dyshidrosis Dishidrotic Herpes Simplex Virus (HSV) or Varicella Zoster Virus (VZV) infections
Xerotic/asteatotic Follicular pustules (acne/rosacea, bacterial folliculitis; Majocchi
Stasis granuloma, pityrosporum folliculitis, eosinophilic folliculitis)
Photoallergic drug eruption Impetigo
Actinic dermatitis/actinic prurigo Miliaria pustulosa
Id or “autoeczematization”

Chapter 1 :: Fundamentals of Clinical Dermatology

Vesicles/Bullae
Eczematous drug eruption Acute eczematous process
Seborrheic dermatitis Allergic contact dermatitis
Lichen simplex chronicus Bullous arthropod
Mimickers-Scraping, Biopsy May Be Helpful HSV/VZV
Scabies Coxsackie
Tinea Bullous tinea
Some blistering disorders (bullous pemphigoid, dermatitis Autoimmune blistering diseases
herpetiformis) Porphyria cutanea tarda, pseudoporphyria
Mycosis fungoides Polymorphous light eruption
Nutritional deficiency Inherited blistering diseases
Polymorphous light eruption Impetigo
Toolbox Miliaria crystallina
History Bullous diabeticorum
Distribution Vesicles/Pustules as Secondary Processes
Examine scalp, nails, mucous membranes Infection (cellulitis, necrotizing fasciitis, deep fungal, atypical
Patch testing mycobacteria, leishmaniasis, scabies, nocardiosis)
Scraping (scabies, KOH) Edema
Biopsy for routine histology, direct immunofluorescence (DIF) Chemical/thermal/Ultraviolet burn
Bacterial culture, HSV culture (if superinfection suspected) Necrosis
Fixed drug eruption, erythema multiforme, Stevens–Johnson
syndrome, Toxic epidermal necrolysis
Neutrophilic dermatoses (leukocytoclastic vasculitis, Sweet syndrome,
pyoderma gangrenosum)
The first step to determining the reaction pattern is Halogenodermas
identifying the primary lesion. In generalized erup- Toolbox
tions, or when mixed morphologies are present, it is History
useful to go to the edge of a larger lesion or group of Distribution
lesions to determine the primary morphology. It is Examine scalp, nails, mucous membranes
important to note that some diseases with variable KOH and/or fungal culture—blister roof, pustule
morphologies may fall into more than one reaction Bacterial culture—blister fluid, pustule
pattern. DFA, Viral culture—blister base
Biopsy for routine histology, DIF, tissue culture (bacterial,
mycobacterial, fungal)

REACTION PATTERNS WITH ECZEMATOUS

SURFACE CHANGE
PAPULOSQUAMOUS
In papulosquamous eruptions, the primary lesion is
a relatively thin or flat-topped papule or plaque with
scale. Crust or lichenification is usually not present.
Histopathologically, these processes involve the epi-
dermis and superficial to mid-dermis. Individual
papules or plaques are typically well demarcated, and
there is often normal skin visible between each discrete
papule or plaque (Table 1-7).
Eczematous eruptions consist of thin erythematous
papules and plaques with epidermal change. On
the surface of an acute eczematous process, there is
enough epidermal spongiosis (edema between kera-
tinocytes) to cause the formation of serous crust-
ing, microvesicles, or sometimes frank bullae. When
microvesicles collapse, they form characteristic tiny
round crusts often admixed with scale and subtle or
overt fissuring. When subacute to chronic, the sur-
face is often dry, scaly, fissured, and/or lichenified
from rubbing or scratching. Compared with papulo- 13
squamous eruptions, eczematous primary lesions are

Kang_CH001_p0001-0017.indd 13 05/12/18 4:47 pm

 1 TABLE 1-10 TABLE 1-11
Dermal “Plus” Reaction Pattern—Common Macular Reaction Pattern—Common Examples
Examples
Pink
Infections Vascular anomaly or neoplasm (such as nevus simplex)
Mycobacteria: TB and atypical mycobacteria Exanthems (drug, viral)
Fungal: kerion, subcutaneous mycoses, deep fungal mycoses, Macular granuloma annulare, interstitial granulomatous
mycetomas drug eruption
Parasites: leishmaniasis, Chagas, nodular scabies Tinea versicolor (can induce scale)
Bacteria: bartonella, botryomycosis, blastomycosis-like pyoderma, Red
anthrax, gonococcus, syphilitic gumma Red to red-purple
Viral: molluscum, disseminated VZV, verrucous HSV, poxviruses Vascular anomaly or neoplasm (such as telangiectasia,
Neoplasias: Kaposi sarcoma, SCC, BCC, Merkel cell carcinoma, port-wine stain)
amelanotic melanoma, metastases, etc. Petechiae (due to trauma, thrombocytopenia, Rocky Mountain
Inflammatory: Neutrophilic (Sweet syndrome, pyoderma
Part 1

spotted fever, Parvovirus, scurvy)

gangrenosum, halogenodermas), lymphoma (tumor-stage CTCL, Ecchymosis
B-cell lymphomas), sarcoidosis, polyarteritis nodosa, palisaded Red to red-brown
neutrophilic and interstitial granulomatous dermatitis Pigmented purpura
::

Toolbox Telangiectasia macularis eruptive perstans (TMEP)

Foundations of Clinical Dermatology

History Erythema ab igne

Distribution Fixed drug eruption
Examine scalp, nails, mucous membranes, lymph nodes Brown
Culture surface (viral, bacterial, fungal) Melasma
Biopsy for routine histology Lentigo
Biopsy for culture (bacterial, fungal, mycobacterial) Junctional melanocytic nevus
Melanoma
Some birthmarks (Café au lait macule, nevus spilus)
typically ill demarcated, and individual lesions vary Postinflammatory pigmentation
widely in their size and spacing. Because most eczema- Tinea versicolor
Patch-stage KS
tous eruptions share a common histology, the distribu-
Flat warts
tion and history are key in differentiating among them
Diabetic dermopathy
(Table 1-8).
White
Vitiligo
VESICULOBULLOUS Contact leukoderma
Inherited (piebaldism, ash-leaf macule, nevus anemicus)
Sometimes vesicles and bullae are quite obvious; other Postinflammatory pigmentation
times, when all the blisters have ruptured, the clini- Pityriasis alba
cian must recognize their “footprints”—clues to their Hypopigmented MF
recent presence. Because blisters are filled with fluid, Tuberculoid leprosy
Guttate hypomelanosis
when they collapse, they often leave behind round,
Flat warts
oval, arcuate, or geographic erosions or crusts. When
Progressive macular hypomelanosis
small ruptured vesicles are grouped together, as in her- Bier spots
pes simplex, they form crust with “scalloped” edges.
Gray/Blue
Other subtle clues include erosions with “mauserung”
Blue nevus
desquamation, a rumpled rim of epidermis hanging Nevus of Ota
from the erosion’s edge, or milia, which can result from Mongolian spot
healing of deeper blisters (Table 1-9). Lichen planus pigmentosa and related disorders
Some diseases with prominent surface change defy Drug effect (minocycline, amiodarone, hydroxychloroquine)
categorization into papulosquamous, eczematous, or Deposition (ochronosis, silver)
vesculobullous reaction patterns. The astute clinician Tattoo
can recognize an eruption as difficult to characterize Toolbox
and is aware this actually suggests a differential diag- History
nosis in itself. Some examples include scabies, acan- Shape
tholytic diseases (Grover, Darier disease), some drug Distribution
eruptions, some “id” reactions, and some paraneoplas- Examine mucous membranes
Wood lamp
tic conditions.
KOH (for tinea versicolor)
Biopsy for routine histology

DERMAL “PLUS”
These are dermally infiltrated papules, nodules or
14 plaques with surface change: hyperkeratotic scale, crust,
vesicles, pustules, erosion, or ulceration (Table 1-10).

Kang_CH001_p0001-0017.indd 14 05/12/18 4:47 pm

 TABLE 1-12 TABLE 1-13
1
Dermal Reaction Pattern—Common Examples Subcutaneous Reaction Pattern
Inflammatory Inflammatory
Neutrophils (Sweet syndrome, pyoderma gangrenosum, Erythema nodosum
neutrophilic eccrine hidradenitis) Lupus and other connective tissue-related panniculitis
Lymphocytes (tumid lupus, cutaneous lymphoid hyperplasia, Subcutaneous Sweet syndrome, GA, sarcoidosis (Darier-Roussy)
morphea, lichen sclerosus)
Infectious
Histiocytes (xanthomas, xanthogranulomas, granuloma
Erythema induratum
annulare, sarcoidosis, Rosai-Dorfman, Multicentric
Nocardia, actinomyces
Reticulohistiocytosis, palisaded neutrophilic, and interstitial
granulomatous dermatitis) Physical
Mixed (erythema elevatum diutinum, granuloma faciale) Traumatic
Mastocytoma Cold
Plasmacytoma Other

Chapter 1 :: Fundamentals of Clinical Dermatology

Well syndrome Lipodermatosclerosis
Angiolymphoid hyperplasia with eosinophilia Enzyme-mediated (pancreatic, alpha-1 antitrypsin)
Infectious Steroid and other drug injections
Cellulitis, Erysipelas, bartonella (Bacillary angiomatosis, Subcutaneous fat necrosis of the newborn
cat scratch) Panniculitis-like CTCL
Mycobacteria (TB, leprosy, atypical mycobacteria) Toolbox
Subcutaneous and deep fungal infection History
Neoplastic Distribution
Kaposi sarcoma (plaque, tumor-stage) Biopsy for routine histology, tissue culture
Lymphomas (CTCL, B-cell)
Leukemia cutis
Adnexal neoplasms
Vascular neoplasms DERMAL
BCC, SCC, nevus, melanoma, spindle cell neoplasms,
Merkel cell A dermal reaction pattern is a papule or plaque with-
Cutaneous metastases out surface change where the infiltrative process is in
Keloid, hypertrophic scar the dermis (Table 1-12).
Dermatofibroma, Dermatofibrosarcoma protuberans
Depositional
Colloid milium SUBCUTANEOUS
Amyloid
Mucin Subcutaneous reaction pattern is a deeper papule
Gout or plaque, usually without surface change, though
Calcium occasionally they may ulcerate and crust. The infil-
Toolbox trative or inflammatory process is in the subcutis
History (Table 1-13).
Distribution
Examine lymph nodes, mucous membranes
Biopsy for routine histology, tissue culture PURPURIC
Purpura are red or purple macules, patches, papules,
or plaques that result from bleeding into the skin.
Because blood has extravasated, they do not blanch
REACTION PATTERNS when pressure is applied. They may range in color
from true red to red-purple or magenta to red-brown
WITHOUT SURFACE (“cayenne pepper”). Purpuric macules are sometimes
CHANGE called “petechiae”; purpuric patches are sometimes
called “ecchymoses.” Ecchymosis may also overlie a
plaque or nodule from dermal or subdermal hemor-
In the absence of surface change, the epidermis and its
rhage, known as hematoma, and may appear yellow-
melanin are unaltered, often allowing color and topog-
green when a few days old. Purpuric papules, or
raphy to be the defining characteristics. Shape, config-
“palpable purpura,” typically represent inflammation
uration, and distribution are also helpful.
of small vessels associated with hemorrhage, as in leu-
kocytoclastic vasculitis, a coagulopathy affecting small
vessels, as in cryoglobulinemia, or very small emboli.
MACULAR Purpuric plaques represent ischemia, embolism, infarc-
tion, intravascular infection, or inflammation of small-
Macules can derive their color changes from changes medium or medium vessels, that may lead to necrosis 15
in the epidermis or dermis (Table 1-11). of the overlying epidermis. These can manifest as pink

Kang_CH001_p0001-0017.indd 15 05/12/18 4:47 pm

 1 TABLE 1-14 TABLE 1-15
Purpuric Reaction Pattern—Common Examples Erythemas
Vasculitis Exanthems
Small vessel Viral
Hypersensitivity vasculitis (to drug or infection) Bacterial (toxic shock syndrome, scarlet fever, meningococcus,
Henoch–Schoenlein purpura (IgA vasculitis) mycoplasma)
ANCA+ Drug (morbilliform eruption, drug-induced hypersensitivity
Connective-tissue disease associated syndrome)
Medium vessel Graft-vs-host disease
Polyarteritis nodosa Kawasaki disease
Churg–Strauss Miliaria rubra
Levamisole hypersensitivity Figurate
Macular arteritis Erythema annulare centrifugum
Part 1

Infectious Deep gyrate erythemas

Meningococcemia Erythema migrans
Purpura fulminans Erythema marginatum
Ecthyma gangrenosum
::

Urticaria/Urticaria
Hyperinfection strongyloidiasis Urticaria
Foundations of Clinical Dermatology

Aspergillus, mucor, and other vasculotropic fungi Neutrophilic urticaria

Embolic Papular urticaria
Cholesterol emboli Urticarial vasculitis
Septic emboli (endocarditis and others) Dermal hypersensitivity reaction
Vasculopathy Polymorphous eruption of pregnancy
Calciphylaxis Urticarial bullous pemphigoid
Cryoglobulin, cryofibrinogen Acute hemorrhagic edema of childhood
Antiphospholipid antibody syndrome, livedoid vasculopathy, Targetoid
livedo racemosa Erythema multiforme
Coumadin/heparin necrosis Mycoplasma-induced rash and mucositis
Levamisole hypersensitivity Fixed drug eruption
Other hypercoagulable states Urticarial vasculitis
Other Paraneoplastic pemphigus
Vascular or intravascular neoplasms (Kaposi sarcoma, Rowell-type lupus
angiosarcoma, intravascular lymphoma) Toolbox
Cutis marmorata History
Petechiae (trauma, thrombocytopenia, Rocky Mountain spotted Distribution
fever, Parvovirus, scurvy) Examine mucous membranes
Ecchymoses Biopsy for routine histology, DIF
Toolbox Viral studies
History Other lab workup depending on morphology and history
Distribution
Other lab workup depending on morphology and history
Biopsy for routine histology
■
Biopsy for DIF
Morbilliform erythemas are exanthems that
Biopsy for tissue culture
are typically consist of diffuse symmetric
blanching pink, red, or magenta macules and
papules.
■ Figurate erythemas are annular, arcuate, or
papules (usually medium vessels) or stellate dark polycyclic blanching pink to red plaques. They
purple plaques (Fig. 1-23), and may be accompanied generally do not have surface change, with the
by pink, red, or purple net-like (“retiform”) hyper- exception of erythema annulare centrifugum,
emia (“livedo”). If the overlying epidermis becomes which exhibits prototypical “trailing scale.”
necrotic, bullae, ulcer, and/or eschar may form at the ■ Urticarial erythemas are pink, blanching
surface (Table 1-14). macules, papules, or plaques, often exhibiting a
characteristic “wheal and flare” appearance, with
ERYTHEMAS blanching of the skin surrounding the primary
lesion (Fig. 1-24).
Erythemas are blanching red-pink macules, patches, ■ Targetoid erythemas have at least 2 zones of color,
papules, or plaques, or a combination, usually with- with a darker center compared to the periphery.
out surface change. This reaction pattern may be sub- The center often has a “dusky,” or gray-violet, hue,
divided into morbilliform erythemas, figurate erythemas, owing to epidermal necrosis, or vesiculates as the
16 urticarial erythemas, and targetoid erythemas (Table 1-15). necrotic epidermis detaches.

Kang_CH001_p0001-0017.indd 16 05/12/18 4:47 pm

Another random document with
no related content on Scribd:
Wagner created it. It was the “Nibelungen.”
And what occurred, when in the summer of 1876, this colossal work,
the glory of modern art as well as of modern culture, one might say
of all the culture of the world, for every nation was represented there,
was at last produced in an artistic manner worthy of it?
“Here is one who first gave me faith in my work, when no one knew
anything of me,” said the artist, in the midst of a joyful company, at
the close of the first performance. “But for him perhaps you would
not have had a note from me to-day. It is my dear friend, Franz
Liszt.”
All this shows that what he did was only the fulfillment of duty. With
him, as with one of the greatest spirits of all the centuries, it was his
pride to be of service in his art. The proud words apply to him who
truly feels the greatness which he himself helps to create, beyond
and above all else in universal service, “genie oblige.”
 CHAPTER V.
REFLEXIONS.

Goethe’s Criticism on Winckelmann—The Poetical Necessity

—Winckelmann and the Plastic Art—Has Music a
Language?—Musicians and Musical Writers—Gluck’s
Writings—His War in Paris—A fierce Struggle with the
Theorists—Luther’s Indebtedness to Bach—Heinse and
his Writings—His Italian Visit—Reichardt, Rochlitz and
Schubart—Their Literary Characteristics—A criticism of
Marx—Liszt’s Contributions to Literature—His great
Literary Ability—The Place of Artists—List of his Works—
Goethe and Beethoven—Bettina’s Phantasies—Jean Paul
—Schumann—Liszt’s Criticism of the “Swan Song”—
Tribute from the “Gazette Musicale”—Selections from his
Writings.
Goethe writes in 1805, of Winckelmann, the author of the “History of
Modern Art”: “He sees ineffable works with the eye, he comprehends
them with the sense, yet he feels the unmistakable difficulty of
describing them in words and characters. The complete majesty, the
idea whence sprang the form, the feeling which aroused the sense of
beauty in him, he would communicate to the hearer or reader, and
while he musters the entire arsenal of his abilities, he realizes that it
is demanded of him to seize upon the strongest and worthiest he has
at command. He must be a poet, whether he realizes it or not.”
Thus Winckelmann became the originator of the reflective style of
statement in our language, which had not previously existed, and
what Goethe himself learned from it is shown very clearly in the
poetical description of the Greek myths, like Leda and the Swan, in
the second part of “Faust.”
Have we a similar language for the art of music, which reveals to us,
as it were, the nature, the soul-image of mankind as the plastic art
reveals its exterior? Have our language and literature acquired
afresh such far-reaching capabilities, such a fixed scope and self-
enrichment as the plastic art has, through Winckelmann? This
question is all the more worthy of attention since music, embodying
the very essence of things and not their appearance, reflecting the
idea of the world itself by its own hand and with its own power, is
more essentially poetical than the plastic art. We have in Liszt’s
writings a significant incentive to consider the question further.
It is certainly taking a narrow and one-sided view of musical talent, to
assert, like Riehl, that he who writes about music as a musician can
not be a correct musician. On the contrary, the truest tone-poets
among musicians have written the best about music, and in part
about their own, and at the same time by their clear comprehension
of the poetical idea in tone-poems have intensified the poetical force
of the language.
The first who wrote with a definite purpose as an artist, about the
peculiar form and the poetico-dramatic development of his art—for
we do not refer here to the old and learned musical pundits, was
Gluck, and this is specially manifest in his writings about his own
works. Partly consisting of prefaces to scores, partly of letters to
newspapers, these writings were prompted by the necessities of art
itself. That is, the free poetical movement of the composer and his
sympathetic delineation of the salient circumstances and phases of
life were assailed, and they tried to confine him to established forms,
to fine melodies of a set style, to a fashion as it were. Then the
German drew his sword, for the quarrel had been restricted mainly to
Paris and Italy, and thrust it sharply into the confused mass of
theoretical ideas, which are most prized by people who know little or
nothing of music. Drastic in comparison, striking in characterization,
mercilessly ridiculing all lordly authority, upon the literary, or true
throne, he settles in defiance of the theoretical, every concrete,
individual and intellectual question. When one considers the
peculiarly Italian or French text, there is something of Bismarck’s
style about it. How far removed from the theorist or delving fancy-
monger was this artist, who was at the same time a man of facts, a
practician! Although we notice some extremely striking and poetical,
though merely incidental images, such as only the creative spirit
would discover, there is little to be found of the externals of music,
that is of musical description, so that these writings produced an
admirable effect and furnished the proof that musical problems might
engage the attention of the highest literary circles. For the language
itself was of little account in this controversy, not even the two
foreign idioms, which Gluck, by the way, handled with great ease.
Another illustration forces itself upon us, as viewed from the
standpoint of Luther’s translation of the Bible, which unquestionably
belongs to the poetical literature of our fatherland, namely, that
music, poetically considered, lay at the basis of early German as a
language. Luther’s German sprang from the texts of Sebastian Bach,
the sublimity of which reached the highest point of all art and which
is as thoroughly German as the ordinary plain recitative is Italian.
Instrumental music was now closely allied to this language, and as
Gluck produced a poetical form upon the living basis of actual
language, which afterwards especially delighted Goethe and Schiller,
as it had Klopstock, and certainly must have had an influence upon
their poetry, so the later ones, by personal intercourse with Philip
Emanuel Bach in Hamburg, had the opportunity to perceive by actual
observation, that German instrumental music began to assume a
peculiarly German form. Mozart’s melodies, from the “Entfuehrung”
to the “Zauberfloete,” speedily proved that music in its “beloved
German” was not inferior to the highest beauties of the poetical
classics.
Their leading features were also closely connected. As Winckelmann
gained his talent for the representation of the plastic art through the
idea of language, from the antique, so the later ones had to go to the
immediate sources of music to find the necessary “inspiration,” as
Gluck denominated the creative faculty of our natures, for the
expression of their conceptions. Thus things were in a bad way. The
musicians did not understand writing and the writers knew little or
nothing about music.
Let us trace in the history of events the most striking features of both
styles of writing. In a literary sense Heinse was the first to treat of
music. This Thuringian was musical in the fullest sense, and since
the poet as a writer can not know much in this direction of his
endowments, the Musical Lexicon is literally correct when it
particularly specifies Heinse’s talent and mentions Hildegarde of
Hohenthal as ever memorable to the musician. How the charms of
the Italian landscape and the fascinations of this land of music work
upon him and impart to his style the warmth and color of that very
land itself! Above all else the sentient, nay more, the material aspect
of things preponderates, for how often in the sweet voice of a
soprano the sad “Benedetto il Coltello” has fallen upon his ravished
ear, and “his soul felt as if carried away by a flood.” Here for the first
time the effect of our art is definitely connected with the very
essence of speech, and the current histories of literature have
therefore taken little notice of this circumstance, because our classic
writers made it so. The effect of these writings first appeared when it
became known through the great masters of poetry in music, Mozart
and Beethoven, even more clearly about the year 1830, when
Heinrich Laube gave it new expression and Jean Paul illustrated it
with his lofty conceptions of the tone-art.
Now appear distinctive musical writers whose works belong both to
the domain of literature and music—Reichardt, Rochlitz and
Schubart, the latter by far the most prominent of the three. His “Ideas
of the Esthetics of Music” first appeared in 1806, after his death. The
“Spitz von Giebichenstein,” as Goethe called Reichardt, had a strong
intellectual basis and development. He understood Bach and Handel
in their colossal works and Gluck in his dramatic achievements. He
had not a correct idea of Mozart’s poetry and Beethoven’s powerful
blows almost overwhelmed his brain and heart. Yet what he has said
about the old classics is not without influence upon men like
Rochlitz, in Leipsic, and Marx, in Berlin, who have also
comprehended yet more clearly the free action of poetry in music.
“There spoke spirit to spirit,” says the latter of Reichardt’s analysis of
the Handel songs.
Frederick Rochlitz has done that work for Mozart, and Marx for
Beethoven, and in many circles of the reading public the first
knowledge and direct appreciation of this new world of music was
obtained from their writings. And yet the one always shows
something too much of authorship and but little of the free poetical
flow, while the other struggles and is too obscure in the expression of
the emotions which music awakens in him. He merely feels and does
not grasp the expression of it firmly and forcibly and thus neither of
them are far from the significance of an achievement like the
narrative of Winckelmann.
This is in the highest degree characteristic of Schubart, who was an
actual poet. With him begins that genuine musical authorship which
has gradually become a possession of our literature. This brings us
to the solid array of writers who were equally at home in both
provinces and thus could embody music in language as they had
acquired the talent for expression from literature. It includes, and
very prominently, too, Franz Liszt and his numerous musical writings.
Richard Wagner, as Heinrich Laube says, in that peculiarly able
sketch of his life, which appeared in the “Zeitung fuer die elegante
Welt,” in 1843, from an opera composer became a writer, by the
“Parisian stress.” An entirely different reason actuated Liszt. It was
the longing to secure for his art the name and master which it
required. “Errors and misunderstandings thwarted the desired
success,” says Wagner, speaking of that Weimar performance of
“Tannhauser,” by Liszt, in 1849. “What was to be done to meet the
requirements necessary to a good understanding on all sides? Liszt
comprehended it quickly and did it. He gave the public his own
judgment and impression of the work in a manner, the persuasive
eloquence and overwhelming efficacy of which have had no parallel.”
There is a notice in the “Journal des Debats,” of 1849, which
appeared in Leipsic in 1851, together with a second under the title of
“Lohengrin et Tannhauser de Richard Wagner,” with which
publication, translated into German, at Cologne, in 1852, Liszt also
makes his appearance as a writer.
And yet, not so; for when had he not expressed, pen in hand, the
extraordinary activity of his feelings and thoughts? Since 1836,
numerous outspoken and generous tributes of his had appeared, as
for instance that concerning the position of artists in the “Revue et
Gazette Musicale de Paris,” and it may be said not one of the artists
mentioned, Gluck, Mozart, Beethoven, Weber, Paganini, Berlioz,
Boieldieu, Meyerbeer, Thalberg, Auber, Schubert, Schumann, Field
and Mendelssohn, are left without description. These sketches an
delineations made such a great and immediate sensation that
Lamartine, who was so renowned at that time, declared he would
consider it a crime if Liszt did not exclusively devote himself to this
branch of his art. In addition to the writings, “De la Fondation-Goethe
a Weimar” (1849), “F. Chopin,” “The Gypsies and their Music in
Hungary,” and the numerous essays in the “Neue Zeitschrift fuer
Musik,” like the more important ones about “The Flying Dutchman”
(1854), and “Robert Franz” (1855), Liszt’s literary works, like
Wagner’s, form an imposing array of volumes, which are not second
in importance to those of any other art-writer and contribute an
essential addition to our general literature.
And how is it to-day with this musical authorship? The poet Schubart
in his “Esthetics of Music,” had only sounded the first notes of that
tone-language which, with the beginning of the opera was
incorporated with our art. The Italian language, which was its basis,
had reached the highest degree of perfection and the French of the
Gluck operas had scarcely increased the “speaking” which melody
had acquired by these idioms. All instrumental music speedily
assumed this character of personal language. It was as in the simple
lyric, the personal world-Ego that spoke in it. But when the German
language reached the height of its perfection and pervaded music,
entirely new beauties were revealed in our art. In one of his many
notes of travel, written at Vienna, in 1838, Liszt says that he has
listened to the songs of Franz Schubert with great pleasure and has
been often moved to tears by them, and he adds: “Schubert is the
most poetical of all musicians who have ever lived. The German
language impresses the mind wonderfully and the childlike purity and
melancholy shading with which Schubert’s music is permeated can
only be fully understood by a German.” This was true. The language
of Goethe and Schiller had come to music and bedewed it as with
heavenly blessings. It returned a hundred-fold what it had received in
the old-time choral. We know the almost extravagant reverence of
Gluck for Klopstock’s Odes and particularly for the
“Hermannschlacht.” Mozart had written “The Violet” and the spirit of
its language pervaded the “Zauberfloete,” notwithstanding the rough
verses of the librettist destroyed all its beauty of shading. At first
Beethoven averred there was nothing loftier than Klopstock. He
preferred the soaring flights of fancy of this ideal, poetical soul, but
when he came to know Goethe it was all over. “He has finished
Klopstock for me,” he said. Goethe’s friend Bettina heard him
declare: “Goethe’s poems exercise a great power over me, not alone
by the subject-matter, but also by the rhythm. I should be induced
and urged on to composition by these verses, which are constructed
upon a higher plane, as if with spiritual help, and bear in themselves
the secret of harmony.” So said Beethoven, the purport of his
judgment always being: “a musician is also a poet.” In fact, through
language, music has completely associated itself with personal
speech and what wonder is it that it now, again enkindled with
poetry, affected the world? From that time on there have been
masters of music who give us information about it and although they
are only instructors in the history and dogmas of music, the
professors of composition must state the essentially artistic and
poetical in words. In the perfection of language as applied to the
expression of musical things, these tone-masters have been
creatively constructive.
The first of these is C. M. Von Weber, whose famous and almost
world-wide critique on the “Eroica” appeared in 1809. In spite of his
jealous misunderstanding, he shows a closer conception of
Beethoven and particularly of music than any of the purely literary
critics of that time and we know that afterwards the composer of “Der
Freischuetz” wrote much and very well and commenced to compose
an artistic romance. A year later, Bettina wrote that “soulful fantasy
about music,” which in Goethe’s “Correspondence with a Child,”
made a powerful impression upon musical authors and inspired their
better natures. Rochlitz’s “Musikzeitung,” from 1809 to 1812,
contains Hoffmann’s analyses of the Beethoven symphonies, which
to-day would have secured him the title of “Wagnerian.” He not only
gave a wonderful flight and new character to language but he even
extended its limits, for he describes in the “Kreisleriana,” with nothing
but mere verbal expression, the mysteries of the art, its subject-
matter, the keys and their character. He enhanced the possibilities of
language, enriched its treasury of words and gave it a new
significance. He was enabled to do this as he was both musician and
author and in a different style from that Prussian Capellmeister,
Reichardt. He also declared that after he had once spoken of music,
thenceforth he could only discourse of it as a poet. And yet there is
in this still more of brilliancy than fire, more of the extravagant and
even fantastic than the striking power of poetry and soaring fancy
which Bettina’s simple poetical nature showed, the manifestations of
which gave Goethe such presages of the power of musical genius. It
was not merely the poetical nature, it was the actual poet, as in
Winckelmann’s revelation of the plastic art, that was needed to hit
the mark.
Let us be brief. Jean Paul’s deeply musical, poetical nature fired
Robert Schumann with the might of his spirit and with the heavenly
fire of true poetical perception, and inspiration. For the first time in
Germany, in his “Neue Zeitschrift fuer Musik,” he collected about him
the spirits who lived thoughtfully and contemplatively in their art. In
comparison with these poetical writers where are now those
theorists, Wendt, in whose writings Beethoven found thoughts full of
wisdom, and Thibaut with his “Parity of Music,” a little book certainly
expressing with fervor the beauty of music, which even to-day
reveals to many a spirit its better self? Added to these the
expressions of Mozart, in his letters about music, have come to light,
and Beethoven reveals his lofty regard for it in Bettina’s letters to
Goethe. The writings of the poet Heine about music are revived
again and from France an earnest spirit of art was wafted over to us
in the literary productions of that phenomenon, Hector Berlioz. We
recognize in this that music is not confined within the bounds of any
language and we almost imagine that its spirit and being must
actually dwell in the general modern idioms and thus impart to them
the distinctive characteristics of the old languages. For Liszt also—
and now we come to our subject—wrote in French and only in
French, and yet we can say that he has enriched, beautified and
extended the German language, for he wrote our modern speech
from the inner spirit, because he wrote from the spirit of music, which
above all belongs to us.
He thus begins his communication to the “Gazette Musicale” in 1838:
“Nearly fifteen years ago my father forsook his peaceful roof to go
with me into the world. He settled down in France, for he thought that
here was the fittest sphere for the development and perfection of my
genius, as he, in his simple pride, called my musical talents. Thus
early I forgot my home and learned to recognize France as my
fatherland.” He recompensed his new fatherland with his perfect use
of its language, which no native Frenchman to-day employs more
correctly, accurately or with better constructive ability than he, so that
the charge of “neologism and Germanism” which has been laid to
him is based for the most part only on a noticeable jealousy of his
extraordinary style. It is characterized by a vigor, power, delicacy and
richness which are at once surprising and fascinating. “A single
glance of his flashing eye” in the incorrect and beggarly translations
of him that have thus far appeared, tell us we have to do with a
Siegfried. One of his translators rightly asserts: “Liszt is as
unprecedented and unapproachable in his playing as he is
unparalleled and original in his style. They are his own possessions.
In both we feel the same genial inclinations, but even in the highest
flights of his inspirations he never mars their beauty. If one were to
find any fault it would only be with the exuberance of thought and the
riotous luxuriance of his fancy which is inexhaustible in pictures and
blending of color. This is only the natural result of the abundant
richness of his surroundings. When Englishmen and Germans in
their statements about music, especially where Beethoven is
concerned, complain of the obscurity and mystery of his meaning, it
is because music in its real form is still ‘a book with seven seals’ to
them.”
To specify his writings in detail would take too much space. It is
enough to state that Liszt was so familiar with the substance of all
the modern languages that he was enabled, by merely skimming
over them, to catch their general spirit and thus express the
corresponding sense and form of music, so that in reality, according
to the historical statement that we have given above, whenever
these writings have been translated into good German they have
broadened and perfected our language. One such translation
appeared long since. It is the volume, “Robert Franz.” The historical
and technical are certainly the weaker qualities of these writings, for
they belong to science and investigation, not to the art and the
creative faculty as a special province. And yet, in these respects, the
last named volume is very conspicuous. It contains an analysis of
what we call the “Lied,” which is more thorough in a historical and
theoretical sense than any that have ever been made. The entire
volume is characterized by calm consideration rather than by the
flight of inspiration.
To show how accurately and delicately Liszt could sketch a subject
which up to that time had not been treated, and how fruitful,
therefore, the statements are for the history of the art, we give a brief
illustration from his sketch of “Lohengrin,” with which, as a further
illustration of the style of all his writings, we close. He is speaking of
the melody with which the Knight of the Grail takes leave of his
marvelous guide, the swan: “Music had not, as yet, acquired those
types which the painter and poet have so often endeavored to
portray. It had not, as yet, expressed the purity of feeling and the
sacred sorrow which the angels and the beings above us, who are
better than we, feel, when they are exiled from heaven and sent into
our abode of trouble on errands of beneficence. We believe that
music, in this respect, need no longer envy the other arts, for we are
convinced that no one has yet expressed this feeling with such lofty
and even heavenly perfection.”
We may say here, as Goethe said of Winckelmann’s prose: “He must
be a poet, whether he realizes it or not.” As this description of the
forms of plastic art has enriched our language for a century with
illustrations which are familiar to every one, so the description of the
creation of these new spiritual forms which music has produced, will
give a deeper soul and new wings to language. Liszt’s writings for
that reason have done a special work for the German language, for
they display the all-pervading spirit of modern culture, and thus help
to build up the essential and ultimate form of language. The
introduction to his pathetically enthusiastic essay on “The Place of
the Artist,” which forms the close of this chapter, shows us that Liszt
was as real as he was ideal when he took up his pen in 1835,
impelled by his literary activity.
“Truly it were a beautiful and noble duty to establish the definite
place of musicians in our social life—to group together their political,
individual and religious ideas—to describe their sorrows, their
sufferings, their difficulties and their errors—to tear away the
coverings from their bleeding wounds, and to raise an energetic
protest against the pressing injustice and the shameless prejudice
which injures and torments them, and condescends to use them as
playthings—to examine their past, to disclose their future, to bring all
their titles of honor to light, to teach the public and the thankless
materialistic society of men and women whom we entertain and who
support us, whence we come, whither we go, the nature of our
mission, in a word, who we are—to teach them who those chosen
ones are who were ordained of God Himself to bear witness to the
highest feelings of humanity and cherish them with noble trust, these
divinely anointed ones who strike off the fetters which enshackle
men, who have stolen the holy fire from heaven, who invest life with
its material and thought with its form, and while they achieve for us
the realization of our ideals, draw us up with irresistible power to
their spiritual heights, to the heavenly revelations—who they are,
these human creators, these evangelists and priests of an
irredeemable religion, constantly increasing in mystery and
incessantly penetrating every heart—to preach and to prophesy all
this, which of itself is so loudly proclaimed, with still louder voice
even to the deafest ears, certainly were a beautiful and noble duty.”
Who has more nobly fulfilled this duty by the deeds and words of a
life-time than he!
 CHAPTER VI.
HARMONIES POETIQUES.

Liszt’s Tribute to Wagner—A New Form of Instrumental

Music—Liszt’s new Departure—The Symphonic Poem—
Its Essence and Characteristics—The Union of Poetry and
Music—Programme Music—How Liszt Developed his new
Forms—Analysis of Individual Works—Liszt’s Tribute to
Beethoven—His notice of “Egmont”—Beethoven as a
Pioneer—Fulfillment of Haydn’s Prophecy.
After the orchestral composition of Beethoven how many thought
they would be obliged to acknowledge that his great “Ninth” was also
to be the last symphony!
“There rose a towering genius, a sparkling, flaming spirit, summoned
to wear a double crown of fire and gold. He boldly dreamed, as poets
dream, to fix his aim so high that if it could ever be attained by art, it
would certainly happen at a time when the public was no longer
made up of that vacillating, heterogeneous, unprogressive, ignorant
and conceited crowd, which in our time sits in judgment and dictates
decrees, which the boldest scarcely venture to question.” Thus Liszt
once said of Wagner, and to whom does it apply with more force
than to himself?
Let us listen to an account of the new Siegfried-achievement which
has been famous for almost a quarter of a century. It is the flower of
the grand journalistic labor of a distinguished, theoretical musician of
the future, now dead, and only retouched and amplified in some
places to suit our more accurate estimate of things. It is in the “Neue
Zeitschrift fuer Musik,” of the year 1858, and thus reads: “Goethe
has already compared the progress of the physical sciences, as it
appeared to him, to a wanderer, who approaches the rising luminary,
and when it suddenly bursts upon him with blinding effulgence, is
forced to turn away, because he can not endure it. The
achievements in the musical world surpass this, for music pictures
the grandest phenomena of modern culture.
“Just as every one must see the grand future which Richard Wagner
has assured to the musical drama, so Liszt, by the freshness of his
individuality has animated instrumental music, in that he has utilized
its form for his purposes. The perception of the programme, the
union of the known and unknown, these are what instrumental music
have acquired for our time and for the future. Originally, music alone
was sufficient, now we have the totality of culture.
“In marked contrast with the earlier style is the Symphonic Poem,
which is extraordinarily striking in character. Such a title is the egg of
Columbus, and it expresses the thoroughly accurate knowledge of
the author. The poetical method was the only one left for progress, or
the combination of the instrumental work with a general texture of
poetical ideas, and thus complete mastery of the programme was
achieved. We see in Beethoven how one with perfect knowledge
seizes upon the fresh material of the intellectual life about him. It is
(as Liszt’s favorite scholar, Hans Von Buelow expresses it,) the
lamentation of the eagle whose flight is checked by the ardor of the
sunbeams, the mournful roar of the lion whom the impenetrable
darkness has overtaken. A newer, grander horizon looms up—a
spiritual world full of poetry.
“Liszt grasped this manifold material with the strength of his
imagination, and introduced it in the world of music. Having gradually
arrived at complete maturity he gave his attention to a great variety
of themes and taking them from the outer world he adapted them to
the inner. With Germans that feeling is uppermost and it arouses the
activity of the fancy. Reversing the process, the fancy seizes the
object and arouses activity of feeling. There are spirit-tones,
corresponding to the emotions of the soul, which form the substance
of the early music. One has the feeling that here humanity
approaches the highest questions, reflectively, not merely feeling
them intuitively. It is consequently a new form above the bounds of
music and musical knowledge, a spiritual form, yet coupled with a
corresponding artistic natural skill, a form of higher intelligence and
grander structure as time advanced and the relations of life were
increased, for the most of the earlier musicians only foreshadowed it.
We recognize, at a glance, the individuality of Liszt, and the
requirements demanded by our times as well as the absence of that
continual obtruding exclusiveness, that obstinate conservatism of the
earlier times of music. At the very foundation of this lies a strong and
solid individuality. Only the branches and twigs come in contact with
the outer world, thus leaving space for development and drawing
nourishment from it, while the trunk defies every storm. A brilliant,
sentient basis, a grand and powerful array of passion, a depth of
expression and spiritual value, a great, broad horizon, are the
results.
“In the single works we do not find the variety of tone, the
exuberance of emotion, nor the multitude of situations to be found in
the works of the earlier masters, but when we consider them as a
whole, their immense richness is disclosed. A great multitude of new
ideas appear as revealed in the music, taking the place of what had
been already settled and what was lost and gone. There was a
joyous astonishment when this new world arose and when one
realized its richness and diversity. There are the ‘Preludes,’ with their
naivete and simple but strong texture. With what sad and tender, yet
grand emotions the poet appears in ‘Tasso!’ A poetical glory
illuminates ‘Orpheus.’ Antique austerity, boldness and ruggedness
are the predominating peculiarities of ‘Prometheus.’ An enticing
fascination carries us to the height of the ideal in the ‘Berg
Symphony.’ Brilliancy, festal revelry, chivalrous elegance and
knightliness are the traits which characterize the ‘Festklaenge.’
German tenderness and intensity, German dignity and intellectual
power confront us in ‘Faust.’ The Adagio, called ‘Gretchen,’ fills our
very souls with the sad ecstatic words of Faust: ‘Can it be that
woman is so fair?’ A mystical meaning lies hidden in ‘Dante,’
fantastic weirdness in the ‘Hungaria,’ the sublimity of sorrow in the
‘Héroide funébre.’ Every work is a unit in itself, and as different
works represent different moods, they can be worked out with
greater sharpness and precision.”
Thus originated that richness of inward variety, that full scale of
human possibilities manifested in the complete development and
mastery of situations, which we call Liszt’s “Symphonic Poems.”
In closing, we may say, to quote from “The Meistersaenger”: “The
witnesses, I think, were well selected. Is your Hans Sachs on that
account disturbed?” The best literary test of the matter is contained
in Richard Wagner’s “Letters on Franz Liszt’s Symphonic Poems,”
which appeared in 1857. Liszt himself demonstrated his clear
understanding of the far-reaching progress he had made for his art in
his analysis of Beethoven’s “Egmont” music, in 1854.
“In ‘Egmont’ we recognize one of the first illustrations of the modern
period. A great musician derives his inspiration directly from the
works of a great poet,” says he. “At this time Beethoven appears to
us as bold and rich in meaning as he was uncertain and wavering in
his first attempts. When he composed these fragments he began to
open up a new path for art. With mighty hand he felled the first tree
in this hitherto unknown forest. Even while he cleared away the first
obstacles and laid his hand to his work he entered upon the path
himself. The world regarded this first step without particular attention,
but the time came when art advanced upon this path and found it
illuminated and laid out by him.”
Liszt describes himself when he thus characterizes the present
epoch of music: “Going back to antiquity and searching for material
scarcely anywhere do we fail to find a period of poetical life. Imagery
and color characterize the tone-work of the people of the Orient as
well as of the Occident. A full flooded magnetic stream unites poetry
and music, those two forms of human thought and feeling.” He
above all others has in reality done for music what was prophesied
by Joseph Haydn, the father of the symphony, who was the first to
invest it with a distinctively poetical character. At the close of his
days he declared that what was yet to happen in music would be far
greater than what had happened in it.
 CHAPTER VII.
CONSOLATION.

Liszt’s Great Resolve—Reply to a Scoffer—Religion and

Music—Religion at the Foundation of Culture—George
Sand’s Testimony—Relations of Religion and Music—
Music in the Catholic and Protestant Churches—
Peculiarities of the Musical Services—Influence of the
Catholic Church on Music—A gradual Lowering of the
Standards—Opera Music in the Church—Liszt’s Ambition
to Reform it—His Early Piety—Views on Church Music—
The Religious Element in his Compositions—The
Hungarian Coronation Mass—The Choral Mass—
Departure to Rome—Takes Orders—Why he did not
Remain—Germany his Field for Work.
“Is that then a life object?” was the reply of a Prussian school-
director on one occasion, when in answer to his question why Liszt
had specially taken orders, he was informed that in pursuance of his
life-mission it was indispensable for him to become a Capellmeister
of the Pope and Sistine chapel, in order to accomplish the reform of
Catholic church music. If we were also to make the reply to that
question, “Yes, perchance at this very time especially more important
than the elevation of education,” which would certainly turn the
school-man round and make him step aside, we should not encroach
upon the domain of politics, but strikingly characterize with this one
remark the sad indifference and ignorance of the entire, and for the
time the predominating multitude of our educated people, who make
and dominate our culture.
How can one, himself outside of the confession, after a little
reflection, have any doubt that the only ties which bind and unite the
immense mass of the people, besides the desperate occasions of
overwhelming necessity, are the ideal conceptions which religion
offers in a very crude and yet powerful and forcible shape? On that
account the church remains, let her be what she may, so long as this
is true, the only source for the great multitude of men which
approaches them with such conceptions, and, while it elevates them
above themselves and the ordinary necessities, makes them believe
in a human community and in mutual duties. Where again is the
substitute for such an indispensable institution, so long as we have
no other, which in a common union unites the masses upon a sure
foundation, and without which cement they would be dashed to
atoms. Even granting that state and culture have reached high
attainments, no one but a short-sighted person will say that they
have reached their utmost possibilities. It was this very feeling which,
following upon the mental intoxication of former centuries, and the
fearful ones that came after with their outbreaking revolutions and
wars, made all the stronger minds and more earnest spirits turn to
the existing assurance which we possess in ideal things as
permanent realities—Religion and the Church. “Religion is the true
cement of the social edifice. The more numerous the stones and
details, the stronger should be the cement that unites them,” writes
George Sand, in 1830, in the “Lettres d’un Voyageur.” That the
assaults of the Catholic church upon the State are as discreditable
as the insolent self-elevation of Protestant orthodoxy over all
intellectual work and culture, goes without saying. Now, as ever, the
church, still more the service, in both confessions, is the sure
foundation for all really educated people. Its loftiest purpose can only
be to improve the mind religiously and thus secure for it a higher
effectiveness. State and church must be regarded from the same
point of view as Alberich and Mime, who struggled for the ring upon
which depended the heritage and power of the world, while Siegfried
possessed it. And as it is rightly claimed on behalf of the Protestant
church that its purpose is to give to worship such a form and value
that it shall unite and satisfy, in itself, the noblest aspirations and the
essentially ideal wants of all mankind, so the Catholic church, as far
as a stranger may judge, fails not by earnest consideration and
inward endeavor, far removed from the clamor of the day and the
warring of dominating factions and parties in the church, to restore
again its world-conquering, because world-redeeming power, in that
it seeks to give that spirit to its worship in which is the real safety of
our time. And as it is not a matter of chance that art has been
awakened by this characteristic spirit of the later times, to which it
has given a new language, to give a fitting expression to the fullness
and depth of feeling, like the infinity of the spirit which springs from
the spirit itself, as it is not a matter of chance that music is pre-
eminently the daughter of the church and of its service, so from the
oldest to the most recent times, this daughter, who meanwhile has
become so unspeakably affluent and above all so independent, has
been loudly called upon to establish herself in the church and its
service in all the perfection and richness of her nature.
If the great difficulty with the Protestant service lies in the fact that it
does not easily assimilate music, and, so to speak, make it a part of
divine worship, so that its employment makes religious service
partake of the nature of a sacred concert, thereby destroying religion
itself, if in this case also, peculiar but in no way insuperable
difficulties stand in the way of such a result, on the other hand in the
Catholic service, music is an indispensable part of it and in the real
sense its central part, for transubstantiation, besides the elevation of
the Host, which is only a symbol, is felt as a deep inward reality in
the music, which at that instant is poured forth at the true Mass even
in the most insignificant church like a sacred flood, deeply refreshing
the hearts which turn to it. We may say that but for this recalling of
the wandering heart to the harmony of the Eternal and the All, but for
this return of the individual to the everlasting foundations of being, as
they are revealed in transubstantiation, we should not securely hold
that art which in its very essence reveals the fixity of the world,
outwardly as well as inwardly. It should also be said that the Catholic
service, that is, its highest attainment, the Mass, without its daughter,
Music, which in an actual sense is in turn its mother, or can at any
time become so, could not reach its ultimate possibilities and by its
life prolong its own.
There has been endless complaint that with the progress of its
dominion, which has immeasurably enhanced the outward pomp of
the church, and which has not scorned to make use of the dramatic
for its purposes, the music of its worship has become superficial and
theatrical. There is also a Jesuitic style in the music, and he who
perfects his artistic taste by the ever true and really classical, will find
good proofs in Beethoven’s greater Masses as well as in Mozart’s
“Requiem,” that since the seventeenth century the opera has
invaded the church, and that the peculiar fineries of the Saints’
statues of that time denominated the fundamental character of its
music. This is true of Germany as well as of the Roman countries,
and any one who has been to Italy knows to his own satisfaction that
the latest operatic melodies can be heard to-day upon the organ,
even in sublime St. Peter’s at Rome. From Mozart to Mendelssohn,
among musicians there is the same complaint of this impropriety,
and since Goethe, almost every writer on Italy has spoken of this
matter, which is a disgrace to the church and a calamity to the
religious elevation of the poor.
Under these circumstances, how could a nature like that of Liszt’s
hesitate? As we have seen over and over again, the modern way of
regarding things had become, in fact, his second nature, an
irresistible and yet spontaneous motive power in all his thoughts and
actions. We have an additional test of this artist, which brings us to
the very source of his life, even to the very basis of life itself. We
have the facts for our information, and need not contemplate the
phenomenon of Liszt as a reformer of art in his church in any sense
as a wonder or a mere accident. It rests upon the very foundation of
his life and it works accordingly.
“From youth up, Franz’s spirit was naturally inclined to devotion, and
his passionate feeling for art was blended with a piety which was
characterized by all the frankness of his age,” reads an entry in the
diary of his father, who died when the son was in his sixteenth year.
In 1857, Liszt himself speaks of the poor little church in his
Hungarian home, “in which, as a child, I had prayed with such ardent
devotion.” Even in his youth he thought that he was called to the
church, and it was only the earnest wish, at first, of his father, and
afterwards of his mother, an extremely kind-hearted Upper-Austrian,
that kept him in the path of art and its practice. The biographical
sketch in the “Gazette Musicale de Paris,” of 1834, to which we are
indebted for the first reliable accounts of Liszt, significantly says,