TYPE OF SKIN LESIONS

Dermatovenereology Departement / Division

dr. Moh. Hoesin Hospital / Medical Faculty UNSRI
2011

The art of diagnosis

Diseases have characteristic morphology and distribution
The diagnosis and treatment of skin diseases :
rest on the physician's ability to use the lexicon of dermatology, to
recognize the basic and sequential lesions of the skin, and to recognize the
various patterns in which they occur in a variety of diseases and
syndromes.
Dermatology lexicon" : a set of terms that denote types of skin lesion
standard terminology
- the first step in generating a differential diagnosis
- consistency in : clinical documentation, research, & communication with
other physicians.
e.g. :
Once a lesion has been described as a pearly, flesh-colored, telangiectatic,
ulcerated nodule DD/ utama : basal cell carcinoma

Macule

A macule is a localized area of

colour change in the skin.
Macules can be
hyperpigmented,
hypopigmented, or
erythematous.

Papule

Papule is a solid,
elevation of the skin
less than 0.5 cm in
diameter.

Plaque

Plaque is a solid plateaulike elevation of the skin,

more than 0.5 cm in
diameter.

Nodule
Nodule is a solid, round or
ellipsoidal, palpable lesion that
has a diameter larger than 0.5
cm.
Depth of involvement and/or
substantive palpability (rather
than diameter) differentiates a
nodule from a large papule or
plaque.

Wheal
Wheal or hives or urtica is
a swelling of the skin,
usually disapearing within
hours. These lesions are
the result of edema in the
upper portion of the dermis.
Angioedema is a deeper,
edematous reaction that
occurs in the area with very
loose
dermis
and
subcutaneous tissue (lips,
eyelid, or scrotum).

Vesicle and bulla

A vesicle is a clear fluid- filled

cavity or elevation smaller
than or equal to 0.5 cm (b),
whereas a bulla (blister)
measures larger than 0.5 cm
(a).

Pustule

Pustule is a circumscribed,
raised cavity in the
epidermis or infundibulum
containing pus.

Erosion
Erosion is a moist,
circumscribed,
usually depressed
lesion that results
from loss of a
portion or all of the
viable epidermis.

Fissures
Fissure is a linear loss
of continuity of the
skin's surface or
mucosa that results
from excessive tension
or decreased elasticity
of the involved tissue.

Ulcer
Ulcer is a defect in which the
epidermis and at least the upper
(papillary) dermis has been
removed. The defect heals with
scarring.
Borders of the ulcer may rolled,
undermined, punched out, or
angular.
The base may be clean, ragged,
or necrotic.
Discharge may be purulent,
granular, or malodorous.
Surrounding skin may be red,
indurated, sclerotic.

Crust
Crusts are hardened
deposits that result
when serum, blood, or
purulent exudate dries
on the surface of the
skin.
Removal of the crust
may reveal an
underlying erosion or
ulcer.

Scale

Scale is flat plate or

flake arising from the
outer-most layer of the
stratum corneum.

Cyst

Cyst is an encapsulated
cavity or sac lined with a
true epithelium that
contains fluid or semisolid
material (cells and cell
products such as keratin).

Atrophy
Atrophy refers to a
diminution in the size of a
cell, tissue, organ, or part
of the body. A decrease in
the number of epidemal
cells results in thinning of
the epidermis.

Lichenification

Lichenification is an area of
thickened skin with accentuated
skin markings, induced by
repeated rubbing.

Excoriations
Excoriations are
surface excavations of
epidermis that result
from scratching and are
frequent findings in
patients experiencing
pruritus.

Scar

A scar arises from

proliferation of fibrous tissue
that replaces previously
normal collagen after a
wound or ulceration
breaches the reticular
dermis.
A scar may be hypertrophic
(A) or atrophic (B)

Erythema is blanchable change in colour of skin due to dilatation of

arteries and veins in the papillary and reticular dermis.

Telangiectases are persistent dilatations of small capillaries in the

superficial dermis, that may or may not disappear with diascopy.

Purpura is a reddish-purple lesion caused by extravasation od red

blood from cutaneous vessels into skin or mucous membranes

Petechiae are small, pinpoint purpuric macules.

Ecchymoses are larger, bruise-like purpuric patches.

Infarct is an area of cutaneous necrosis resulting from occlusion of

blood vessels in the skin, as in vasculitis and bacterial embolism

Tumor is a general term for any mass, benign or malignant, and is

sometimes used to indicate a large nodule.

Telangiectasia

Infarct

Purpura

eritem

Shape, Arrangement, and

Distribution of Lesions
Once the type or types of lesions have been
identified, one needs to describe their shape,
arrangement, and pattern of distribution
characteristics in morphologic diagnosis
example : a single scaly plaque on a patient's trunk
may have a broad differential diagnosis, but the same
plaques symmetrically distributed on the elbows,
knees, and umbilicus would be highly suggestive of
psoriasis.

Shape or configuration of skin lesions

1. Annular : ring-shaped; implies that the edge of the lesion differs from
the center, either by being raised, scaly, or differing in color
(e.g : granuloma annulare, tinea corporis).
2. Round/nummular/discoid: coin-shaped; usually a round to oval
lesion with uniform morphology from the edges to the center
(e.g : nummular eczema, plaque-type psoriasis, discoid lupus).
3. Polycyclic : formed from coalescing circles, rings, or incomplete
rings (e.g : tinea corporis)
4. Arcuate : arc-shaped; often a result of incomplete formation of an
annular lesion (e.g : urticaria, subacute cutaneous lupus
erythematosus).

5. Linear : resembling a straight line; often implies an external contactant

or Koebner phenomenon has occurred in response to scratching.
single lesion
(e.g : a scabies burrow, poison ivy dermatitis)
multiple lesions (e.g : lichen nitidus or lichen planus).
6. Reticular : net-like or lacy in appearance, with somewhat regularly
spaced rings or partial rings and sparing of intervening skin
(e.g., livedo reticularis, cutis marmorata).
7. Serpiginous : serpentine or snake-like
(e.g : cutaneous larva migrans).
8. Targetoid : target-like, with at least three distinct zones
(e.g : erythema multiforme)
9. Whorled : like marble cake, with two distinct colors interspersed in a
wavy pattern; usually seen in mosaic disorders in which cells of
differing genotypes are interspersed
(e.g : incontinentia pigmenti, hypomelanosis of Ito)

Arrangement of Multiple Lesions

1. Grouped/herpetiform : lesions clustered
together (e.g : herpes zoster).
2. Scattered : irregularly distributed.

Distributions of Multiple Lesions

1. Dermatomal/zosteriform : unilateral and lying in the distribution of
a single spinal afferent nerve root. (e.g : herpes zoster).
2. Blaschkoid : following lines of skin cell migration during
embryogenesis; generally longitudinally oriented on the limbs and
circumferential on the trunk, but not perfectly linear.
Implies a mosaic disorder (e.g : incontinentia pigmenti).
3. Lymphangitic : lying along the distribution of a lymph vessel.
e.g : cellulitis due to a staphylococcal or streptococcal infections.
4. Sun exposed : occurring in areas usually not covered by clothing,
namely the face, and dorsal hands (e.g : photodermatitis,
polymorphous light eruption, squamous cell carcinoma).
5. Sun protected : occurring in areas usually covered by one or more
layers of clothing. (e.g : parapsoriasis, mycosis fungoides).
6. Acral : occurring in distal locations, such as on the hands, feet,
wrists, and ankles (e.g : palmoplantar pustulosis, chilblains).

Lesions in the distribution

described by Blaschko for
developmental

Scattered lesion.

7. Truncal : occurring on the trunk or central body.

8. Extensor : occurring over the dorsal extremities, overlying the extensor
muscles, knees, or elbows (e.g., psoriasis).
9. Flexor : overlying the flexor muscles of the extremities, the
and popliteal fossae (e.g : atopic dermatitis).

antecubital

10.Intertriginous : occurring in the skin folds : axillae, inguinal folds, inner

thighs, inframammary skin. (e.g., candidiasis).
11.Localized : confined to a single body location (e.g., cellulitis).
12.Generalized : widespread. (e.g., viral exanthems, drug eruption).
13.Bilateral symmetric : occurring with mirror-image symmetry on both sides of
the body (e.g., vitiligo, plaque-type psoriasis).
14.Universal : involving the entire cutaneous surface. (e.g., erythroderma,
alopecia universalis).

Shape and arrangement of lesions

 Diascopy test :
The application of pressure with two glass slides or an
unbreakable clear lens on a red lesion is a
simple and reliable method for differentiating redness
due to vascular dilatation (erythema) from redness due
to extravasated erythrocytes or erythrocyte products
(purpura). If the redness remains under the pressure
of the slide, the lesion is purpuric.

 Pemphigus
vulgaris. The
bulla has been
extended by
applying pressure
with the finger
(Nikolsky's sign)

 Tzanck preparation
showing multinucleate
giant epidermal cell
(Giemsa's stain).
(Courtesy of Arthur R.
Rhodes, MD)

Referensi
Garg A, Levin N.A, Bernhard J.D, Structure of
Skin Lesions and Fundamentals of Clinical
Diagnosis. In:Wolf K, Goldsmith L, Katz S
Gilchrest B, Paller A, Leffell D,editors.
Fitzpatricks Dermatology in General
Medicine. 7th ed. New York:Mc.Graw Hill
Company;2008.p. 23-40.