Dermatology Essentials 2nd Edition

Jean L. Bolognia
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SECOND EDITION

Dermatology
Essentials
Jean L. Bolognia MD
Professor of Dermatology
Yale Medical School
New Haven, CT, USA

Julie V. Schaffer MD
Professor of Pediatrics
Hackensack Meridian School of Medicine
Hackensack, NJ, USA

Karynne O. Duncan MD
Private Practice
St Helena, CA, USA

Christine J. Ko MD
Professor of Dermatology and Pathology
Yale Medical School
New Haven, CT, USA

For additional online content visit the expertconsult website:

www.expertconsult.com

London New York Oxford Philadelphia St Louis Sydney 2022

© 2022, Elsevier Inc. All rights reserved.
First edition 2014

No part of this publication may be reproduced or transmitted in any form or by any means, electronic or
mechanical, including photocopying, recording, or any information storage and retrieval system, without
permission in writing from the publisher. Details on how to seek permission, further information about the
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Center and the Copyright Licensing Agency, can be found at our website: www.elsevier.com/permissions

This book and the individual contributions contained in it are protected under copyright by the Publisher
(other than as may be noted herein).

Notices

Practitioners and researchers must always rely on their own experience and knowledge in evaluating
and using any information, methods, compounds or experiments described herein. Because of rapid
advances in the medical sciences, in particular, independent verification of diagnoses and drug dosages
should be made. To the fullest extent of the law, no responsibility is assumed by Elsevier, authors, editors
or contributors for any injury and/or damage to persons or property as a matter of products liability,
negligence or otherwise, or from any use or operation of any methods, products, instructions, or ideas
contained in the material herein.

ISBN: 978-­0-­323-­62453-­4

Cover Photograph Credits

Cover photographs from left to right are courtesy of: Julie V. Schaffer MD, Yale Dermatology Residents’ Slide
Collection, Yale Dermatology Residents’ Slide Collection, and Mark D.P. Davis MD

Content Strategist: Charlotta Kryhl

Content Development Specialist: Joanne Scott
Project Manager: Joanna Souch
Design: Margaret Reid
Illustration Manager: Muthukumaran Thangaraj
Marketing Manager: Kate Bresnahan

Printed in Canada

Last digit is the print number: 9 8 7 6 5 4 3 2 1

 Preface

The goal of our Dermatology Essentials handbook is to present the broad spectrum of cutaneous
diseases in a manner that is straightforward and logical while at the same time maintaining
a necessary level of sophistication. The text portion of each section is relatively brief and easy
to review, with schematics and tables providing additional and more detailed information.
Throughout the handbook are algorithms that present a practical approach to evaluation,
differential diagnosis, and treatment of skin disorders. The clinical photographs were chosen
with two key objectives in mind – to provide characteristic examples of specific diseases and
to offer key teaching points. It is our hope that this handbook will improve the dermatologic
care of patients and provide clinicians with greater confidence as they approach patients with
cutaneous diseases.

ix
 Acknowledgments
We wish to thank all the dermatologists
whose clinical photographs are used in this
handbook as well as the textbook Dermatol-
ogy. In particular we thank Kalman Watsky,
MD, whose photographs appear throughout
the book. The team at Elsevier has provided
enormous support, in particular Joanne Scott
and Joanna Souch. Charlotta Kryhl also pro-
vided guidance for the project.
The following were sourced from the Yale
Dermatology Residents’ Slide Collection
(YDRSC):
1.3C, 1.3F, 1.4Aiii, 1.5B, 1.6Cii, 1.13A,
2.1B, 2.3, 4.8D, 5.7A, e5.12C, 6.4B, 6.9,
6.12A, 6.15, 6.16, 6.17A, 6.17C, e6.18,
e6.20A, e6.21A, e6.22, e6.24, e6.25A,
e6.35, 7.2A, 7.2B, 7.3C, 7.3D, 7.6A, 7.8,
7.9A, e7.14, e7.19, e7.20, 8.3B, 8.6, 8.8,
e8.10, 9.5A, 9.5D, 9.5E, 9.5G, 9.6A, 9.6B,
9.6C, 9.7, 9.9A, 9.9B, 9.11A, e9.12, e9.13,
e9.14, e9.17A, e9.17C, e9.18, 10.3A, 10.7,
10.8A (inset), 10.9A, 12.12B, 12.12E, 12.17,
e12.26, 13.2B, 13.2I, 14.1B, 14.1C, 15.1A,
15.1B, 15.2A, 15.2B, 15.6, 16.1B, 16.1C,
16.1E, 16.2A, 16.4, 16.7A, 16.7B, 16.8, 16.9,
16.10A, 17.3, 17.7C, 17.8, 17.9B, 17.10A,
17.12, 17.13D, e17.18, e17.23A, e17.23B,
e17.24A, e17.26, e17.27B, e17.28A, e17.35,
18.1D, 18.8, 18.9C, 18.11A, 18.12A, 18.18,
19.1C, 19.2B, 19.4A, 19.4B, 19.5B, 19.10A,
19.10B, 19.10D, e19.20, 20.2A, 21.5C,
21.6B, 21.7A, e21.12A, 22.1A, 22.1B,
22.1C, 22.1D, 22.7A, 22.7C, 23.6A, 24.2B,
24.5B, 24.10, e24.12, e24.16, e24.22, 25.2A,
25.2B, 26.3A, 26.5A, 26.6A, 26.6C, 26.8A,
e26.10A, e26.11, 27.3, 27.4, 28.2A, 28.2B,
28.15, e28.17, e28.18, e28.19A, e28.19B,
e28.21, e28.24, e28.25, 29.3C, 29.4B,
e29.16, 30.6B, 30.12, e30.14, 31.2B, 31.3A,
31.4D, 31.5, 31.11C, 31.11D, e31.15A,
e31.15B, 32.6, 32.7A, 33.3A, 33.3B, 33.3D,
33.3E, 33.3F, 33.3G, 33.4A, 33.5, 33.6,
x
33.7C, 33.10, 33.11, 34.2A, 34.11B, 35.4,
e35.13, e35.15, e35.17C, 36.6B, e36.19,
37.1A, 38.6, 38.8B, e38.10A, e38.10B,
39.3A, 39.7A, 39.8B, e39.14A, 40.1, 41.2A,
41.5A, e41.10, 42.5C, 42.7B, 42.8B, 42.10,
43.7A, 43.8A, 43.9B, 43.9D, 43.9E, e43.15,
e43.16A, e43.18A, 44.1A, e44.5B, e44.7C,
45.3B, 46.6A, 46.6B, 46.8C, 46.10C,
46.10D, e46.22, 47.3B, 47.4B, 47.9, 47.10A,
e47.14B, e47.15C, e47.24A, 48.1B, 48.1D,
48.9, 48.10, 48.11A, 48.11B, e48.14, 49.4A,
e50.19, e50.21, 51.2C, 51.2E, 51.3B, 51.3D,
e51.11A, e51.18A, e51.18B, 52.2B, 52.8C,
53.2B, 53.15, e53.24, 54.14, 54.15A, 54.15E,
54.15F, 54.15G, 54.16, 54.17, 54.18A, 54.19,
54.23A, 54.23B, e54.28, e54.29A, e54.31,
55.3B, 55.8B, 55.17B, 56.4A, 56.4D, 56.11C,
56.11D, 56.11E, 56.11G, 56.11H, 56.11J,
56.11K, e56.17, e56.27, 57.6, e57.15B,
e59.22 (inset 2), e59.31A, e59.32, Table
59.3 (insets), 60.9A, e60.21A, e60.22, 61.5,
61.9A, 61.9B, 61.12, 61.17, e61.22B, e61.30,
e61.31, e61.37, e61.38, e61.40, e61.42, 62.9,
62.10, 62.11B, 62.13, 62.15, 62.16, 62.17A,
62.17B, 62.17C, e62.18, e62.19, 63.5, 63.6,
64.3D, 64.8A, 64.8C, 64.10, 64.13A, 64.13C,
64.13D, 64.13E, 64.13F, 64.15F, 64.19A,
64.25A, 64.25B, 64.25D, 64.25E, e64.26B,
e64.27, e64.57, 65.7, 65.9A, 65.9B, 65.11A,
65.12, 65.14, 65.17, e65.30B, 67.4A, 67.6A,
67.6B, 67.6C, 67.9A, 67.9D, 67.9E, 67.9H,
67.11A, 67.11B, 67.13, 68.7A, 68.7C, 69.2B,
69.4A, 69.4B, 69.4C, 69.4D, 69.5A, 69.5B,
69.5C, 69.6A, 69.6B, 69.9, 69.13A, 69.13C,
70.1B, 71.1, 71.2D, 71.11, e71.18A, 72.7,
e72.12, Table 72.1 (inset 1), 73.2C, 73.4C,
73.13, e73.24F, e73.27C, 74.7A, e74.26,
76.1A, 76.1C, 76.1E, 76.5, 76.8, 76.10,
e76.12, e76.13, 77.2, 77.3A, 77.10, 78.1A,
78.1C, 78.1D, 78.1E, 78.2C, 78.2D, 78.3B,
78.4, 78.19, e78.22, e78.23, e78.25, e78.29,
79.2, 79.4A, 79.4B, 79.5, 80.2A, 80.2B,
81.4B, 81.7, e81.14, 82.2C, e82.11, 83.6A,
e83.14, 84.6B, 85.3, 85.4C, 85.6A, 85.16A,
85.22, 85.26, e85.37B, e85.45, 86.2A, 86.2B,
86.3A, 86.4A, 86.5E, 86.10, 86.11B, 86.13B,
86.15A, 87.9, 87.12A, 87.14, 88.3A, 88.3C,
88.4, 88.6B, 88.6C, 88.7B, 88.9C, 89.2B,
89.6A, 89.8A, 90.1A, 90.2, 90.6B, 90.12,
e90.15, 91.2, 91.3, 91.4A, 91.5, 91.6, 91.7A,
91.8A, 91.9A, 91.11, 91.13, 91.14, 91.15,
e91.18, e91.20B, 92.1, 92.4, 92.6, 92.7,
92.10B, 93.6E, e93.21A, 94.3, 94.4, e94.17,
95.5, 95.11, 95.12, 95.17A, e95.23, e95.24,
e95.25, 96.5, 96.6, e96.13C, e96.14B, 99.1,
99.3A, e99.14, 100.3B, 100.3C and e100.6.
The following were sourced from the NYU
Dermatology Slide Collection (NYUDSC):
e7.13B, e7.23, e7.26, 8.3A, 8.4, 8.5, e8.14,
9.5C, 9.8B, e9.16, e9.17B, e9.24, 11.2C, 12.18,
e14.14, e19.17, 20.3, 23.6B, 23.6C, 24.4,
36.5C, e36.13, e36.15, 40.4A, 46.7B, 53.11C,
55.3A, 55.4A, 55.4B, 56.6B, e56.14, 57.12,
59.6, 61.10C, 61.10D, 61.13, e61.35, 63.7A,
63.7B, 65.5, 65.11B, 68.6A, 68.6B, 69.8,
e69.18, e71.19, 73.4B, 73.5B, e73.24C, 78.7A,
78.7B, e81.13, 95.6, 95.9, 95.10 and 95.20.
The following were sourced from the USC
Acknowledgments
Dermatology Residents’ Slide Collection
(USCDRSC):
4.6, 36.10, 38.1, 51.7C, 54.13, e55.23B,
e60.16C, e61.36, 64.16A, 64.16B, 64.18,
64.22A, 64.22B, 64.23, e64.33, e65.29,
71.2C, e71.18B, 82.2A, 85.28, 91.12, 94.11,
and e99.16.
The following were sourced from the
SUNY Stony Brook Dermatology Residents’
Slide Collection (SUNYSBDRSC):
Figure 54.15C.
Chapter 58, Nail Disorders – Nail photos
are courtesy of Antonella Tosti, YDRSC, Julie
V. Schaffer, and Jean L. Bolognia.
xi
 Dedication

To our families, in particular our husbands – Dennis, Andy, David and Peter – who provided
the indispensable support required to complete this book, from serving as sounding boards
to creating quiet time in busy households.

xii
 List of Abbreviations

Ab Antibody Dx Diagnosis
ABI Ankle–brachial index DDx Differential diagnosis
ACE Angiotensin-converting DEET N, N-­diethyl-­meta-­
enzyme toluamide
AI-­CTD Autoimmune connective DFA Direct fluorescence antibody
­tissue disease DHEAS Dehydroepiandrosterone
ALK Anaplastic lymphoma kinase sulfate
AK Actinic keratosis DIHS Drug-­induced hypersensitivity
ANA Antinuclear antibody syndrome (also known as DRESS)
ANCA Antineutrophil cytoplasmic DM Diabetes mellitus
antibody DRESS Drug reaction with
ART Antiretroviral therapy ­eosinophilia and systemic
symptoms (also known as
BB Broadband
DIHS)
BCC Basal cell carcinoma
DVT Deep vein thrombosis
BID Two times daily
EBV Epstein–Barr virus
BSA Body surface area
ECG Electrocardiogram
BUN Blood urea nitrogen
EEG Electroencephalogram
CBC Complete blood count
EGFR Epidermal growth factor
CDC Centers for Disease Control receptor
and Prevention
ELISA Enzyme-­linked
CMV Cytomegalovirus ­immunosorbent assay
CNS Central nervous system EMG Electromyography
CO Carbon monoxide ESR Erythrocyte sedimentation
COPD Chronic obstructive rate
­pulmonary disease FDA US Food and Drug
Cr Creatinine ­Administration
CRP C-­reactive protein G6PD Glucose-­6-­phosphate
CS Corticosteroids ­dehydrogenase

CSF Cerebrospinal fluid GI Gastrointestinal

CT Computed tomography GM-CSF Granulocyte–macrophage

colony-stimulating factor
CTCL Cutaneous T-cell lymphoma
GVHD Graft-­versus-­host disease
CXR Chest X-ray
H&E Hematoxylin and eosin
DDT Dichlorodiphenyltrichloro-
ethane (an insecticide) HBV Hepatitis B virus

xiii
 HCTZ Hydrochlorothiazide PET Positron emission tomography
HCV Hepatitis C virus PO Per os (oral administration)
HIV Human immunodeficiency PPD Purified protein derivative
virus PUVA Psoralen plus ultraviolet A
List of Abbreviations

HPV Human papillomavirus light

HSCT Hematopoietic stem cell RBC Red blood cell
transplant RPR Rapid plasma reagin (test for
HSV Herpes simplex virus syphilis)
ICU Intensive care unit Rx Treatment
IFE Immunofixation SC Subcutaneous
­electrophoresis SCC Squamous cell carcinoma
IL Interleukin SLE Systemic lupus
IM Intramuscularly erythematosus
IV Intravenous SPEP Serum protein
IVIg Intravenous immunoglobulin electrophoresis

KA Keratoacanthoma SSRIs Selective serotonin reuptake

inhibitors
KOH Potassium hydroxide
STIs Sexually transmitted
LDH Lactate dehydrogenase
infections
LE Lupus erythematosus
TB Tuberculosis
LFTs Liver function tests
TCAs Tricyclic antidepressants
LPLK Lichen planus-­like keratosis
TGF Transforming growth factor
MEN Multiple endocrine neoplasia
TID Three times daily
MHC Major histocompatibility
TNF Tumor necrosis factor
complex
TPMT Thiopurine methyltransferase
MRA Magnetic resonance
angiography TSH Thyroid stimulating
hormone
MRI Magnetic resonance imaging
TST Tuberculin skin test
MRSA Methicillin-resistant
Staphylococcus aureus URI Upper respiratory infection

NB-­UVB Narrowband UVB UVA Ultraviolet A

NK Natural killer UVB Ultraviolet B

NMSC Non-­melanoma skin cancer UVA1 Ultraviolet A1 (340–400 nm)

NSAIDs Nonsteroidal anti-­ UVR Ultraviolet radiation
inflammatory drugs VDRL Venereal Disease Research
OTC Over-­the-­counter Laboratory (test for syphilis)
PAS Periodic acid Schiff VEGFR Vascular endothelial growth
factor receptor
PCR Polymerase chain reaction
VZV Varicella–zoster virus
PDGF Platelet-derived growth
factor WBC White blood cell count
PDT Photodynamic therapy XRT Radiation therapy

xiv
 SECTION 1: The Basics

Basic Principles of Dermatology

• In the approach to the patient with a der-
matologic disease, it is important to think ini-
tially of broad categories (Fig. 1.1); this allows
for a more complete differential diagnosis and
a logical approach.
• Key elements of any clinical description
include distribution pattern (Table 1.1; Figs
1.2 and 1.3), type of primary lesion and its
topography (Table 1.2; Fig. 1.4), secondary
features (Table 1.3), and its consistency via
palpation (Tables 1.4 and 1.5).
• If atrophy is present, it should be catego-
rized as epidermal, dermal, and/or subcutane-
ous (Fig. 1.5).
• Color is also an important feature (Table 1.6),
and this can be influenced by the skin photo­
type (Appendix) such that an inflammatory
1
MAJOR DISTRIBUTION PATTERNS
• Generalized versus localized (see
Fig. 1.2) versus solitary
• Unilateral versus bilateral
• If bilateral, symmetric or asymmetric
pattern
• Random versus linear (see Fig. 1.3) or
grouped (e.g. herpetiform, clustered)
• Special patterns – acral sites (nose,
ears, distal extremities); seborrheic
region (scalp, face, upper trunk); sun-­
exposed versus sun-­protected sites;
along cleavage lines; areas of occlusion;
areas of pressure; areas in contact with
allergens or irritants
Table 1.1 Major distribution patterns.
­Occasionally, the pattern represents a locus
minoris resistentiae.

CLASSIFICATION SCHEME FOR DERMATOLOGIC DISORDERS

Fungal
Malignant
Protozoal
Benign
Bacterial
Papulosquamous
and eczematous
dermatosis
Viral Metabolic and toxic
insults/trauma
Infectiou

Urticarias and
erythemas
stic

Infl
amm
s

ator
la

er
y Oth
Neop

Autoimmune
connective Genodermatoses
tissue diseases and developmental
anomalies

Autoimmune
bullous diseases
Dermatologic
disorders

Fig. 1.1 Classification scheme for dermatologic disorders. This scheme is analogous to the
structure of a tree with multiple branch points terminating in leaves.

1
 EXAMPLES OF LOCALIZED DISTRIBUTION PATTERNS

Distribution pattern
SECTION 1: The Basics

Generalized/
Localized Solitary
disseminated

Extensor surfaces Flexural areas Major body folds Palms & soles Periorificial
(e.g. elbows (e.g. antecubital, (e.g. inguinal,
& knees) popliteal fossae) axillary)

Palmoplantar
psoriasis
Inverse psoriasis
Acrofacial vitiligo

Atopic dermatitis
Plaque psoriasis

Fig. 1.2 Examples of localized distribution patterns. Additional patterns are outlined in Table 1.1.
Generalized lesions are seen in morbilliform drug eruptions and viral exanthems. Photographs, courtesy,
Peter C. M. van de Kerkhof, MD, Thomas Bieber, MD, and Julie V. Schaffer, MD.

lesion that appears pink in a patient with skin
phototype I may appear red-­brown to violet in
a patient with skin phototype IV.
• The acuteness versus chronicity of the
eruption provides additional information
and with experience can often be determined
without a history; Table 1.7 outlines major
causes of acute eruptions in otherwise healthy
individuals.
• Given the relative ease of obtaining skin
biopsies, clinicopathologic correlation is a
keystone of dermatologic diagnosis; however,
it is important to choose the ideal lesion
(e.g. in an inflammatory disorder, one that is
fresh but well-­developed), as well as the most
appropriate type of biopsy (Fig. 1.6).
• For inflammatory disorders, there is a clas-
sification schema in which they are divided
into major histopathologic patterns (Fig. 1.7);
several side-­by-­side comparisons of clinical
presentations with histopathologic findings
illustrate the concept of clinicopathologic cor-
relation (Figs 1.8–1.15).
• In an analogy to dermatopathology,
the clinician often looks at the patient at
“medium-­power” (i.e. 20×), but it is also
important to analyze the patient at low-­power
(4×), thus appreciating the overall pattern,
as well as high-­power (100×); the latter is
aided by the use of dermoscopy (Figs 1.16 and
1.17). Additional dermoscopic images are in
Chapters 88, 92, and 93.
• With experience, prompt recognition of
pertinent positive and negative clinical fea-
tures often leads to a narrower differential
diagnosis rather rapidly, almost akin to a
gestalt. However, when initially learning der-
matology, it is helpful to separately address
each of the key elements (see above).

For further information see Ch. 0 from Dermatology, Fourth Edition.

For additional online figures and tables visit www.expertconsult.com

2
      
LINEAR CONFIGURATION PATTERNS

Linear configuration patterns

Trauma/exposure (“outside job”) Sporotrichoid pattern Dermatomal

Excoriations due to Acute allergic contact Atypical mycobacterial Herpes

scratching dermatitis to poison ivy infection zoster

Koebner phenomenon Other Along lines of Blaschko

Segmental
neurofibromatosis

Lichen planus Linea nigra Papular mucinosis Epidermal nevus

Fig. 1.3 Linear configuration patterns. Photographs, courtesy, Kathryn Schwarzenberger, MD, Jean L. Bolognia, MD, Edward Cowen, MD, Whitney High, MD, Joyce Rico, MD, Louis
A. Fragola, Jr., MD, and YDRSC.

3
1

Basic Principles of Dermatology

 4
SECTION 1: The Basics
     
PRIMARY LESIONS – MORPHOLOGICAL TERMS
Term Clinical features Clinical example Clinical disorders
Macule •  lat, circumscribed, non-­palpable
F • E phelid (freckle)
• <1 cm in diameter • Lentigo
• Often hypo-­ or hyperpigmented • Idiopathic guttate
• Also other colors (e.g. pink, red, hypomelanosis
violet) • Petechiae
• It can be round, oval, or irregular • Flat component of viral
in shape exanthems
• May be sharply marginated or • Junctional melanocytic
blend into the surrounding skin nevus

Solar lentigines
Patch •  lat, circumscribed, non-­palpable
F • V itiligo
• >1 cm in diameter • Melasma

Related by size
• Often hypo-­ or hyperpigmented • Dermal melanocytosis
• Also other colors (e.g. blue, violet) (Mongolian spot)
• Café-­au-­lait macule
• Nevus depigmentosus
• Solar purpura
• Port-wine stain (early)

Vitiligo

Papule • E levated, circumscribed • S eborrheic keratosis

• <1 cm in diameter • Cherry angioma
• Elevation due to increased • Compound or intradermal
thickness of the epidermis and/ melanocytic nevus
or cells or deposits within the • Verruca or molluscum
dermis contagiosum
• May have secondary changes • Acrochordon
(e.g. scale, crust, erosion) • Milium, fibrous papule

Related by size
• Need to distinguish from vesicle (angiofibroma)

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or pustule
Seborrheic keratosis
      
• W
 hen viewed in profile, it may be • S ebaceous hyperplasia
flat-­topped, dome-­shaped, filiform, • Small vessel vasculitis
pedunculated, smooth, verrucous,
or umbilicated (see Fig. 1.4)

Cherry angioma

Plaque • E levated, circumscribed Primarily epidermal

• >1 cm in diameter • Psoriasis
• Elevation due to increased • Lichen simplex
thickness of the epidermis and/ chronicus
or cells or deposits within the • Nummular dermatitis
dermis
• May have secondary changes
(e.g. scale, crust, erosion)
• May be a distinct lesion or formed Psoriasis

Related by size
by a confluence of papules

Dermal
• Granuloma annulare
• Sarcoidosis
• Hypertrophic scar, keloid
• Morphea
Both epidermal and dermal
• Discoid lesions of lupus
erythematosus

Sarcoidosis
Sarcoidosis

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Table 1.2 Primary lesions – morphological terms. Continued

5
1

Basic Principles of Dermatology

 6
SECTION 1: The Basics
     
PRIMARY LESIONS – MORPHOLOGICAL TERMS
Term Clinical features Clinical example Clinical disorders
Nodule • E levated, circumscribed • E pidermoid inclusion
• Larger volume than papule, often cyst
>1.5 cm in diameter • Pilar cyst
• Located primarily in the dermis • Lipoma
and/or subcutis • Neurofibroma
• Greatest mass may be beneath • Nodular melanoma
the skin surface • Metastases
• Can be compressible, soft, • Rheumatoid nodule
rubbery, or firm to palpation
• Panniculitis, e.g.
Epidermoid inclusion cysts erythema nodosum

Vesicle • E levated, circumscribed •  erpes simplex

H
• <1 cm in diameter • Varicella or herpes zoster
• Fluid-­containing, usually clear or • Dyshidrotic eczema
serous but may be hemorrhagic • Acute allergic contact
• May become pustular, dermatitis
umbilicated, or an erosion • Dermatitis herpetiformis

Related by size
Herpes simplex

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Bulla • E levated, circumscribed • F riction blister
• >1 cm in diameter • Thermal burn (second-­
• Fluid-­containing, usually clear or degree)
serous but may be hemorrhagic • Bullous pemphigoid
• May become an erosion or • Linear IgA bullous
ulceration dermatosis
• Bullous fixed drug
eruption

Related by size
• Coma bullae
Bullous fixed drug eruption • Edema bullae

Pustule • E levated, circumscribed Follicularly centered

• Usually <1 cm in diameter • Folliculitis
• Contains purulent material • Acne vulgaris
(neutrophils >> eosinophils) • Rosacea
• May be infectious or sterile Non-­follicularly centered
• Pustular psoriasis
• Acute generalized
exanthematous
pustulosis
• Subcorneal pustular
Folliculitis dermatosis

Wheal • T
 ransient elevation of the skin due • U rticaria
to dermal edema • Urticaria multiforme

Acute annular urticaria

Table 1.2 Continued Primary lesions – morphological terms. Photographs, courtesy, Jean L. Bolognia, MD, Lorenzo Cerroni, MD, Edward Cowen, MD, Louis A.
Fragola, Jr., MD, Whitney High, MD, Joyce Rico, MD, and Kalman Watsky, MD.

7
1

Basic Principles of Dermatology

 DESCRIPTIVE TERMS FOR TOPOGRAPHY

Flat-topped (lichenoid) Dome-shaped Filiform Pedunculated

SECTION 1: The Basics

Smooth Verrucous Umbilicated

Fig. 1.4 Descriptive terms for topography. Photographs, courtesy, Jennifer Choi, MD, Hideko Kamino, MD,
Reinhard Kirnbauer, MD, Petra Lenz, MD, Frank Samarin, MD, Julie V. Schaffer, MD, Judit Stenn, MD, and YDRSC.

MAJOR TYPES OF CUTANEOUS ATROPHY

Epidermal Dermal Subcutaneous (lipoatrophy)

Lichen sclerosus Striae Lupus panniculitis Pressure

Fig. 1.5 Major types of cutaneous atrophy. Photographs, courtesy, Susan M. Cooper, MD, Fenella
Wojnarowska, MD, Jean L. Bolognia, MD, and YDRSC.

8
      
SECONDARY FEATURES – MORPHOLOGICAL TERMS
Feature Description Disorders
Crust • D ried serum (serous), blood • E czema/dermatitis (multiple types)
(hemorrhagic), or pus on the • Impetigo
surface • Later phase of herpes simplex, varicella or
• May include bacteria (usually zoster
Staphylococcus) • Erythema multiforme

Secondarily infected
hand dermatitis
Scale • H yperkeratosis •  soriasis (micaceous [silvery] scale)
P
• Accumulation of stratum corneum • Tinea (leading scale)
due to increased proliferation and/ • Erythema annulare centrifugum (trailing scale)
or delayed desquamation • Actinic keratoses (gritty)
• Represents a primary rather than a • Pityriasis rosea (peripheral collarette and/or
secondary feature in ichthyoses central scale)
• Seborrheic (greasy)
Psoriasis • Tinea versicolor (powdery [furfuraceous])
• Lamellar ichthyosis (plate-­like)
Fissure • L inear cleft in skin •  ngular cheilitis
A
• Often painful • Hand dermatitis
• Results from marked drying, skin • Sebopsoriasis (intergluteal fold)
thickening, and loss of elasticity • Irritant cheilitis

Hand dermatitis
Excoriation • E xogenous injury to all or part of • A secondary feature of pruritic conditions,
the epidermis (epithelium) including arthropod bites and atopic
• Usually due to scratching dermatitis
• Neurotic excoriations
• Acne excoriée

Neurotic excoriations
Table 1.3 Secondary features – morphological terms. Continued

9
1

Basic Principles of Dermatology

 10
SECTION 1: The Basics
     
SECONDARY FEATURES – MORPHOLOGICAL TERMS
Feature Description Disorders
Lichenification • T
 hickening (acanthosis) of the • L
 ichen simplex chronicus, isolated or
epidermis, and accentuation of superimposed on a pruritic condition, e.g.
natural skin lines atopic dermatitis

Lichen simplex chronicus

Erosion • P artial, or sometimes complete, loss • Impetigo
of the epidermis (epithelium) • Friction
• A moist, oozing, and/or crusted lesion • Trauma
• Pemphigus, vulgaris and foliaceus
• Staphylococcal scalded skin syndrome

Pemphigus foliaceus

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 Ulceration • A deeper defect (compared to an •  enous (stasis) ulcer
V
erosion), with loss of at least the entire • Neuropathic ulcer
epidermis plus superficial dermis • Arterial ulcer
• May have loss of the entire dermis • Decubitus ulcer
or even subcutis
• Aphthous ulcer
• Size, shape, and depth of the ulcer
• Ecthyma gangrenosum
should be noted in addition to
characteristics of the border, base, • Ecthyma
and surrounding skin • Pyoderma gangrenosum

Ulcer due to small vessel vasculitis

Atrophy • E pidermal atrophy – thinning of the •  ichen sclerosus

L
epidermis, leading to wrinkling and • Poikiloderma
a shiny appearance • Striae
• Dermal atrophy – loss of dermal • Anetoderma
collagen and/or elastin, leading to a
• Focal dermal hyoplasia (Goltz syndrome)
depression (see Table 1.4)
Striae secondary to potent corticosteroids
Scar • Increased thickness, usually of the •  rauma
T
dermis, due to enhanced production • Acne
of collagen by fibroblasts • Surgical excision
• Thermal burn

Acne scarring

Table 1.3 Continued Secondary features – morphological terms. Photographs, courtesy, Louis A. Fragola, Jr., MD, Jeffrey C. Callen, MD, Julie V. Schaffer, MD, and
Whitney High, MD.

11
1

Basic Principles of Dermatology

 USE OF PALPATION IN ANALYZING CUTANEOUS LESIONS
Types of lesion Examples
Macules and Non-palpable • S olar lentigines
patches • Idiopathic guttate
(non-­palpable) hypomelanosis
SECTION 1: The Basics

• Melasma
• Vitiligo
• P etechiae
• Dermal
melanocytosis

Papules and Palpable • P soriasis

plaques • Lichen planus
(palpable) • Dermatitis
• Intradermal
or compound
Nests of melanocytic nevus
nevus cells • Hypertrophic scar,
Fibrosis keloid
• Morphea

Epidermal Dermal

Atrophy – Soft or depressed A • Anetoderma

dermal and B • Focal dermal
subcutaneous hypoplasia (Goltz
syndrome)
C • Lipoatrophy due
to corticosteroid
injections
• Lipoatrophy due to
panniculitis

Dermal atrophy Lipo-

atrophy
A B C

Table 1.4 Use of palpation in analyzing cutaneous lesions. Courtesy, Whitney High, MD.

PALPATION OF CUTANEOUS LESIONS

• S oft (e.g. intradermal nevus) versus firm (e.g. dermatofibroma) versus hard (e.g. calcinosis
cutis, osteoma cutis)
• Compressible (e.g. venous lake) versus noncompressible (e.g. fibrous papule)
• Tender (e.g. inflamed epidermoid inclusion cyst, angiolipoma, leiomyoma) versus nontender
• Blanchable (e.g. erythema due to vasodilation) versus nonblanchable (e.g. purpura) – aided
by diascopy
• Rough versus smooth
• Mobile versus fixed to underlying structures
• Dermal versus subcutaneous
• Temperature – normal versus elevated
• Other, e.g. thrill, pulsatile
Table 1.5 Palpation of cutaneous lesions.

12
 1
DIFFERENT CUTANEOUS BIOPSY TECHNIQUES

Basic Principles of Dermatology

A
Shave Intradermal Solar lentigo
melanocytic nevus

B
Saucerization Compound
melanocytic nevus

Punch Small vessel vasculitis

D
Incisional Pancreatic panniculitis

Fig. 1.6 Different cutaneous biopsy techniques. See next page for figure legend.
13
 Fig. 1.6 Different cutaneous biopsy techniques. A Superficial shave biopsy can be performed to
remove the elevated portion of an intradermal nevus or to distinguish a solar lentigo (pictured here) from
lentigo maligna. B Deep shave biopsy (saucerization); performed to remove a compound melanocytic
nevus or atypical melanocytic nevus. C Punch biopsy; performed to examine the dermis (as well as the
epidermis) and the preferred technique for diagnosing cutaneous small vessel vasculitis. D Incisional
biopsy; recommended for determining the specific type of panniculitis. Courtesy, Suzanne Olbricht, MD,
Raymond Barnhill, MD, Kenneth Greer, MD, Frank Samarin, MD, and YDRSC.
SECTION 1: The Basics

MAJOR HISTOPATHOLOGIC PATTERNS OF CUTANEOUS INFLAMMATION

$ % &
Perivascular dermatitis Vacuolar/interface dermatitis Spongiotic dermatitis
Superficial Superficial
and deep

' ( )

Psoriasiform dermatitis Vesiculobullous and pustular Vesiculobullous and pustular

dermatoses – intraepidermal dermatoses – subepidermal

* + ,
Small vessel vasculitis Nodular and diffuse dermatitis Folliculitis

- . /
Fibrosing dermatitis Lobular panniculitis Septal panniculitis

Fig. 1.7 Major histopathologic patterns of cutaneous inflammation (based on Ackerman’s

classification). Basic patterns of inflammation result primarily from the distribution of the inflammatory
cell infiltrate within the dermis and/or the subcutaneous fat (e.g. nodular, perivascular). It also reflects
the character of the inflammatory process itself (e.g. pustular), the presence of injury to blood
vessels (e.g. vasculitis), involvement of hair follicles (e.g. folliculitis), abnormal fibrous dermal and/or
subcutaneous tissue, and formation of vesicles and bullae. Adapted from Ackerman AB. Histologic Diagnosis
of Inflammatory Skin Diseases: A Method by Pattern Analysis. Philadelphia: Lea & Febiger, 1978.
14
 COLORS OF CUTANEOUS LESIONS
Color Clinical examples 1
White Vitiligo, idiopathic guttate hypomelanosis, calcinosis cutis
Tan* Postinflammatory hypopigmentation, nevus depigmentosus
Yellow Sebaceous hyperplasia, carotenoderma, xanthoma
Pink to red-­brown (range of Psoriasis, dermatitis, morbilliform drug eruption, viral

Basic Principles of Dermatology

erythema influenced by skin exanthem
phototype)
Orange-­red (salmon) Pityriasis rubra pilaris
Green Pseudomonas infection or colonization (e.g. of onycholysis)
Blue Ecchymosis, venous lake, dermal melanocytosis, blue
nevus, cyanosis
Gray Postinflammatory hyperpigmentation (dermal), erythema
dyschromicum perstans, argyria
Purple/violaceous Solar purpura, small vessel vasculitis, lichen planus,
lymphoma cutis
Brown Seborrheic keratosis, compound melanocytic nevus,
melasma, postinflammatory hyperpigmentation (epidermal)
Black Infarct with necrosis, melanoma
*Not to be confused with increase in pigmentation that follows exposure to ultraviolet irradiation.
Table 1.6 Colors of cutaneous lesions.

Fig. 1.9 Spongiotic dermatitis. A Acute

B radicans (poison ivy). The central black
Fig. 1.8 Interface dermatitis, vacuolar
type. A Erythema multiforme – edematous
papules with central dusky erythema
surrounded by an annulus of edema and then
a peripheral rim of erythema, leading to a
target-­like appearance. B Vacuolar alteration
along the dermal–epidermal junction in
association with exocytosis of keratinocytes.
Courtesy, Carlo F. Tomasini, MD.
allergic contact dermatitis to Toxicodendron
discoloration is due to the plant’s resin.
B Intercellular edema (spongiosis) and vesicle
formation within the epidermis. Lymphocytes
are also seen in both the epidermis and dermis.
A, Courtesy, Kalman Watsky, MD; B, Courtesy, James
Patterson, MD.
15
SECTION 1: The Basics

A B

Fig. 1.10 Psoriasiform pattern. A Psoriasis vulgaris – pink plaques with silvery scale on the
shin; this clinical description utilizes the key elements of color, primary lesion, secondary changes,
and distribution pattern (extensor surfaces) in order to arrive at the diagnosis. B Regular epidermal
hyperplasia and elongated dermal papillae with thin suprapapillary plates and confluent parakeratosis.
The parakeratosis represents the histopathologic correlate of the visible scale. A, Courtesy, Julie V.
Schaffer, MD; B, Courtesy, Lorenzo Cerroni, MD.

A B

Fig. 1.11 Intraepidermal pustular dermatosis. A Pustular psoriasis. B Collection of neutrophils

beneath the stratum corneum (subcorneal pustule). Scattered neutrophils are in the upper malpighian
layer. A, Courtesy, Kenneth Greer, MD; B, Courtesy, Lorenzo Cerroni, MD.

A B

Fig. 1.12 Intraepidermal vesiculobullous dermatosis, acantholytic type. A Pemphigus vulgaris

with flaccid bullae and erosions. Note the dependent location of the pustular contents of bullae. B The
keratinocytes within the lower epidermis have lost their intercellular attachments and have separated
from one another, resulting in an intraepidermal blister. A, Courtesy, Carlo Francesco Tomasini, MD; B,
Courtesy, Lorenzo Cerroni, MD.

16
 1

Basic Principles of Dermatology

A

Fig. 1.13 Subepidermal vesiculobullous

dermatosis. A Bullous pemphigoid with tense
bullae. B Subepidermal blister with numerous
eosinophils within the blister cavity. A, Courtesy,
YDRSC; B, Courtesy, Lorenzo Cerroni, MD.
B
Fig. 1.14 Small vessel vasculitis. A Inflammatory
palpable purpura of the leg. B Perivascular and
interstitial infiltrate of neutrophils with nuclear dust
(leukocytoclasia). Fibrin within the vessel wall and
extravasation of erythrocytes is also seen. A, Courtesy,
Carlo F. Tomasini, MD; B, Courtesy, Christine Ko, MD.

A B

Fig. 1.15 Septal panniculitis. A Multiple red-­brown nodules of erythema nodosum on the shins,
admixed with healing bruise-­like areas. B Predominantly septal granulomatous infiltrate with formation
of characteristic Miescher’s granulomas. A, Courtesy, Kenneth Greer, MD; B, Courtesy, Christine Ko, MD.
17
 ACUTE CUTANEOUS ERUPTIONS IN OTHERWISE HEALTHY INDIVIDUALS
Disorder Characteristic findings
Urticaria • P athogenesis involves degranulation of mast cells with release of
(see Ch. 14) histamine
• Primary lesion: edematous wheal with erythematous flare
SECTION 1: The Basics

• Widespread distribution
• Very pruritic*
• Individual lesions are transient (<24 hours in duration)
• May become chronic (>6 weeks)
Acute allergic • Immune-­mediated and requires prior sensitization
contact • Primary lesion: dermatitis, with vesicles, bullae, and weeping when
dermatitis severe
(see Ch. 12) • Primarily in sites of exposure; occasionally more widespread due to
autosensitization
• Pruritus, often marked
• Spontaneously resolves over 2–3 weeks if no further exposure to
allergen (e.g. poison ivy, nickel)
Acute irritant •  irect toxic effect
D
contact • Primary lesion: ranges from erythema to bullae (e.g. chemical burn)
dermatitis • At sites of exposure
(see Ch. 12)
• Burning sensation
• Spontaneously resolves over 2–3 weeks if no further exposure to
irritant (e.g. strong acid, strong alkali)
Exanthematous • Immune-­mediated and requires prior sensitization
(morbilliform) • Pink to red-­brown, blanching macules and papules; may become
drug eruptions purpuric on distal lower extremities
(see Ch. 17) • Widespread distribution
• May be pruritic
• Spontaneously resolves over 7–10 days if no further exposure to
inciting drug
Pityriasis rosea • M ay follow a viral illness
(see Ch. 7) • Primary lesion: oval-­shaped, pink to salmon-­colored papule or
plaque with fine white scale centrally and peripheral collarette;
occasionally vesicular
• Initial lesion is often largest (herald patch)
• Favors trunk and proximal extremities; may have inverse pattern
(axillae and groin); long axis of lesions parallel to skin cleavage lines
(see Fig. 7.7)
• Spontaneously resolves over 6–10 weeks; exclude secondary
syphilis
Viral exanthems • D ue to a broad range of viruses, including rubeola, rubella,
(see Ch. 68) enteroviruses, parvovirus, adenovirus (see Fig. 68.1)
• Often associated with fever, malaise, arthralgias, myalgias, nausea,
upper respiratory symptoms
• Primary lesions vary from blanching pink macules and papules to
vesicles or petechiae
• Distribution varies from acral to widespread; may have an enanthem
• Spontaneously resolves over 3–10 days
*May have burning rather than pruritus with urticarial vasculitis, and individual lesions of urticarial vasculitis
can last longer than 24 hours.
Table 1.7 Acute cutaneous eruptions in otherwise healthy individuals.

18
 1

Basic Principles of Dermatology

A

D
Fig. 1.16 Use of dermoscopy to aid in the diagnosis of four common pigmented
(non-­melanocytic) cutaneous lesions. A Pigmented basal cell carcinoma with leaf-­like areas
(islands of blue-­gray color) at the periphery and a small erosion of reddish color at the left side
of the lesion. B Seborrheic keratosis with typical milia-­like cysts (white shining globules) and
comedo-­like openings (black targetoid globules). C Angiokeratoma with red-­black lacunas
clearly visible as well-­demarcated roundish structures. D A dermatofibroma with characteristic
central white patch and peripheral delicate pseudo-­network. Dermoscopic features of
melanocytic nevi and melanoma are reviewed in Chapters 92 and 93. Courtesy, Giuseppe
Argenziano, MD, and Iris Zalaudek, MD.

A
Fig. 1.17 Use of dermoscopy to aid in the diagnosis of inflammatory disorders. A By
dermoscopy, classic psoriasis plaques exhibit regular dotted vessels. Continued 19
SECTION 1: The Basics

Fig. 1.17 Continued B The dermoscopic pattern of lichen planus is definitely different from the
previous one. Here, dotted vessels are seen at the border of typical whitish lines and clods, which
closely resemble the Wickham striae found in lichen planus of the oral mucosa. Courtesy, Giuseppe
Argenziano, MD, and Iris Zalaudek, MD.

20
Another random document with
no related content on Scribd:
 Lawn Benches Made from Old Bedsteads

Painted Green, These Rebuilt Bedsteads Served as Lawn Benches

Old bedsteads were converted into serviceable lawn, or porch,

benches, as shown in the photograph reproduced, by the addition of
a suitable seat, properly supported. The transformation was a simple
one. Only the foot and headpieces of the bedsteads were used. The
front legs and other pieces were made from other wood. The front
legs are of square stock, about 2¹⁄₂ by 2¹⁄₂ in. The crosspieces,
supporting the wide board seats, are mortised into the legs and
fastened with glue and screws. The seat is fastened from the under
side by cleats. The lumber was carefully planed and sandpapered so
that the benches presented a smooth finish when painted green, to
match other outdoor furniture.—F. E. Tuck, Nevada City, Calif.
 Repairing Wood-Wind Instruments
Wood-wind instruments sometimes “leak” at the joints or keys and
make playing of the instrument difficult. Many such instruments are
made in sections, with ends that telescope to form a tight fit. This fit
is maintained by the use of a cork band cemented around the tenon
end of the telescoping joint. The renewal of these cork joints, and the
addition of new pads on the keys, will make an old instrument nearly
as good as it was when new, so far as playing is concerned,
provided the work is correctly done and the wood of the sections
themselves has not cracked. Many musicians have spare time and
can do this work themselves. The outlay for materials for the job is
from 75 cents to $1.00. A small alcohol, or even a kerosene, lamp
and an old knife, or old file, are required.

The Cork is Fitted Carefully into Place, and Glued

All traces of the old cork on the joint can be removed with
sandpaper, leaving it as shown at the left. The cork comes in strips
of about the proper thickness, and wide and long enough to allow for
trimming. The ends of the strip should be beveled to make a ¹⁄₄-in.
lap joint.
A small quantity of the cement is heated over the lamp and six
drops poured on the joint; then with the end of the file, which should
be heated also, it is spread to give an even, thin coating. The
beveled ends of the strip are similarly treated. By working quickly
and carefully, the coating on the joint and strip are brought to a
plastic state by holding in the flame, and the strip is quickly laid in
place. Before the cement has time to harden, press the cork in,
forming a neat joint. Bind a rag around the cork, leaving it until the
cement is thoroughly set.
The corked joint will be too large to go into the joining section of
the instrument. File and sandpaper it to a twisting fit. Though the
cork should be truly cylindrical, it may be tapered a trifle smaller at
the forward end. A coating of tallow applied to the joint will make it
easy-fitting, but air-tight and moisture-proof.
The pads are disks of felt incased in thin sheepskin. After long
usage, they become too hard to make an air-tight fit. Repadding
should, therefore, be anticipated. Shellac will give good results in
putting on pads. It is heated until liquid and poured into the key
recess. The new pad is pressed into the liquid shellac, care being
taken to have it well centered. For different keys, it will be necessary
to use varying quantities of shellac to make the pad sit higher or
lower, as required.—Donald A. Hampson, Middletown, N. Y.

¶A simple method of bracing a screen door is to stretch a stout wire

diagonally across the lower portion of it.
Rustic Trellis to Shade Door or Window
Rustic Trellises are Easily Constructed and When Covered with Vines Add
to the Attractiveness of the Home
 Proper preparation in the early spring will make it possible for the
householder to shade doors and windows from the hot summer’s
sun by means of inexpensive rustic trellises that add not a little to the
beauty of the home. A suggestion for a trellis at a doorway and one
for a window are shown in the illustration. They are made of straight
tree trunks and small limbs, having the bark on them. The curved
portions of the window trellis may be made easily by using twigs that
are somewhat green. Morning-glories, or other suitable climbing
plants, may be trained over the trellises.—J. G. Allshouse,
Avonmore, Pa.
 Making Scale Enlargements with a Rubber Band
For reducing or enlarging maps, and similar drawings of irregular
design, the device shown in the illustration will replace the ordinary
instruments, and enable the draftsman to turn out a given amount of
work in much less time than required when proportional dividers are
used. The materials needed are an eraser, a rubber band, two pins,
two thumb tacks, and a few drops of rubber cement. From the eraser
two pieces are cut, as shown in the sketch, about ¹⁄₄ by ¹⁄₂ by 1¹⁄₄ in.
Cut deep slits in each end of these pieces. Insert the end of the
rubber band, cut at the splice, in one of these slits and place a thumb
tack in the other. A pin is thrust through the eraser and trimmed
close, to prevent the thumb tack from tearing the eraser. Cement the
slits with rubber cement, and place the assembled device under a
book weight, until the cement has set.
 This Simple Device Is Useful in Enlarging or Reducing Drawings and Maps

Assuming that a contour map is to be enlarged, the rectangular

divisions of the original map, ordinarily section lines or the
boundaries of quarter sections, are drawn on the larger sheet as a
base for the reproduction. Place the device on the original map, as
indicated, the edge of the rubber band touching a “horizontal” section
line between two “vertical” ones, the rubber band under slight
tension. On the black surface of the band, dot white points, with
water color, along the section line at which the contour lines intersect
it. Also place a dot at each end of the band to indicate the position of
the two “vertical” section lines between which the band is set.
Transfer the device to the same relative position on the
enlargement, stretching the rubber band. Make dots at each end,
denoting the “vertical” section lines, for the corresponding lines on
the enlargement. The series of intermediate points along the band
will be in the same relative position on the enlargement as they were
on the original. They can be connected on the enlargement with as
accurate a result as obtained by the use of proportional dividers, and
more rapidly.
After the points are indicated upon the enlargement, the
reproducing device is removed and the surface of the rubber band
cleaned instantly by touching it with a moist cloth. The exposed part
of the rubber band is a variable, and the device can be made with
this dimension adapted to the work. It is capable of enlarging or
reducing at a ratio not greater than six to one, above which the
rubber band approaches its elastic limit.—H. L. Wiley, Seattle, Wash.
 Signal Telegraph with Green and Red Lights

By arranging a circuit with batteries, lights, and keys, as shown in

the diagram, a signal telegraph may be made that will afford much
pleasure to boys and may be used for practical purposes. The keys
A and B are wired into the circuit with a battery C and a red and a
green incandescent lamp. A simple set of signals may be devised
easily so that messages may be sent in the code.—James R.
Townsend, Itasca, Texas.
 A Circular Swing
By DAVIS FOSS GETCHELL

W hile on the farm I constructed a circular swing which proved very

attractive to my boys and their friends. By its side, and
suspended from the same tree branch, was an ordinary swing.
During the eight weeks of our stay the latter was seldom in use. The
circular swing was a far greater favorite with all the young people,
boys and girls alike.
Around a branch of a large elm and 18 or 20 ft. from the tree trunk
was looped a 10-ft. length of chain and to the hanging end of this
was made fast a 1-in. rope nearly 10 ft. longer than was needed to
reach the ground. Directly beneath the point where the chain went
around the limb, as determined by a plumb bob, was set a 6-in.
piece of cedar post 3¹⁄₂ ft. into the ground. This was sawed off
square 2¹⁄₂ ft. above the ground. Into the top of this post was set a
¹⁄₂-in. rod, to serve as a pivot for the swing. It was set in firmly about
6 in. and projected about 3 in. from the top of the post.
 The Circular Swing will be Found Very Safe and Pleasurable, but, as is the
Case of an Ordinary Swing, Anyone Careless Enough to Get in the Way of It
will Get Badly Bumped

A straight-grained piece of pine board, 15 ft. long, 8 in. wide, and 1

in. thick, was procured and a hole bored in one end large enough to
make it turn freely on the pin in the upper end of the post. Two holes
were bored in the other end of the board large enough to admit the
rope. The first hole was 6 in. from the end, and the second hole, 3 ft.
The hanging end of the rope was passed down through one of these
holes and back up through the other and then made fast to itself
about 3 ft. above the board after the board had been adjusted so that
it would swing throughout its length at the height of the post, or 2¹⁄₂
ft. from the ground. The swing was then complete except for a
swivel, which was put in the rope within easy reach of one standing
on the board, so that it could be oiled.
One good push would send the board with a boy on the end three
or four times about the 90-ft. circle. The little fellows would like to get
hold of the board in near the post and shove it around. Once started,
it could be kept going with very little effort.
In putting up such a swing, make sure to have the post set solidly
in the ground, as it has a tendency to work loose. Tie all the knots
tightly. Do not look upon the swivel as unnecessary. The first swing I
put up was without one, and the rope twisted off in a few days.
It is not necessary to climb a tree; just throw a stout cord over the
limb by means of a stone or nut tied to the end, then haul the rope
and chain up over the limb with the cord. Before the chain leaves the
ground loop the end of it and pass the cord through the loop. The
higher the limb from the ground the better the swing will work, but 25
ft. will be about right.
 Hand-Operated Motorboat Whistle

Bellows Operated by Hand for Blowing a Whistle on a Power Boat

Anyone with a power boat can construct a blower for the whistle
very cheaply. The whistle is attached to a suitable length of pipe,
threaded on each end. The blower is made of two white-pine boards,
1 in. thick, cut as shown at A; a thin piece of leather is cut like the
pattern B, to form the bellows part, and after it is shaped, the edges
of the boards are glued and the leather placed in position, where it is
fastened with tacks driven in about 1 in. apart. The bellows are
fastened to the under side of a seat with screws, and a tension
spring is attached to the bottom of the bellows and the floor of the
boat. A cord is fastened to the lower board of the bellows and run up
through to the cabin roof over suitable pulleys to a handle within
convenient reach of the operator.—Contributed by John I. Somers,
Pleasantville, N. J.
 Filling In Broken Places on Enamel
Ordinary putty will not do to fill in cracks or broken spots on an
enameled surface, such as a clockface. Fine sealing wax is much
better, as it hardens at once, takes color without absorbing the oil,
and does not shrink like putty. Use a wax of the proper color to
match the surface as closely as possible. Fit it in and smooth with a
warm, flexible piece of metal, such as a palette knife. Give it one or
two coats of thin color to exactly match the other surface, and
varnish. If the article has not a high polish, the gloss of the varnish
can be cut a little with pumice stone.
 A Twisting Thriller Merry-Go-Round
By R. E. EDWARDS

“Stepdime!”
right up; three twisting thrillers for a penny—a tenth of a
was the familiar invitation which attracted customers to
the delights of a homemade merry-go-round of novel design. The
patrons were not disappointed, but came back for more. The power
for the whirling thriller is produced by the heavy, twisted rope,
suspended from the limb of a tree, or other suitable support. The
rope is cranked up by means of the notched disk A, grasped at the
handle B, the car being lifted off. The thriller is stopped when the
brakeplate I rests on the weighted box L.
 The Supporting Ropes are Wound Up at the Disk A, the Car is Hooked into
Place, and the Passengers Take Their Seats for a Thrilling Ride, Until the
Brakeplate I Rests on the Box

Manila rope, ³⁄₄ in. or more in diameter, is used for the support,
and is rigged with a spreader, about 2 ft. long, at the top, as shown.
The disk is built up of wood, as detailed, and notches, C, provided
for the ropes. The rope is wound up and the car is suspended from it
by the hook, which should be strong, and deep enough so that it
cannot slip out, as indicated at H.
The car is made of a section of 2 by 4-in stuff, D, 10 ft. long, to
which braces, E, of 1 by 4-in. stuff are fastened with nails or screws.
The upper ends of the pieces E are blocked up with the centerpiece
F, nailed securely, and the wire link G is fastened through the joint.
The seats J are suspended at the ends of the 2 by 4-in. bar, with
their inner ends lower, as shown, to give a better seating when the
thriller is in action. The seats are supported by rope or strap-iron
brackets, K, set 15 in. apart. The box should be high enough so that
the seats do not strike the ground.