Dermatovenereology Departement / Division

dr. Moh. Hoesin Hospital / Medical Faculty UNSRI

2012
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
circumscribed, flat lesion
that differs from
surrounding skin
because of its color.
e.g : hyperpigmentation,
hypopigmentation,
vascular abnormalities,
erythema, purpura.
Papule

• Papule is a solid,
elevated lesion less
than 0.5 cm in size in
which a significant
portion projects
above the plane of
the surrounding skin.
Plaque

• Plaque is a solid plateau-

like elevation or palpable
flat lesion, has a
diameter larger than 0.5
cm.

• Well-defined, reddish,
scaling plaques
that coalesce to cover
large areas of the back
and buttocks
Nodule
• Nodule is a solid, round or
ellipsoidal, palpable lesion
that has a diameter larger
than 0.5 cm.
Wheal
• Wheal or hives or urtica is a
rounded or flat-topped papule or
plaque that is characteristically
evanescent, disappearing within
hours.
• These lesions are the result of
edema in the upper portion of the
dermis.
Vesicle and bulla
• A vesicle is a fluid- filled
cavity or elevation smaller
than or equal to 0.5 cm,
whereas a bulla (blister)
measures larger than 0.5 cm.
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 all
or a portion 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.
Crust

• Crusts are hardened

deposits that result
when serum, blood, or
purulent exudate dries
on the surface of the
skin.
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.
Lichenification
Lichenification is represents
thickening of skin and
accentuation of skin markings.
The process results from
repeated rubbing and frequently
develops in persons with atopy.
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 the lesions caused by capillary dilatation

• Telangiectases are permanent dilatations of capillaries that may or

may not disappear with application of pressure
• Purpura is the lesions caused by extravasated red blood cells
• Petechiae are small, pinpoint purpuric spots that are often seen in
thrombocytopenic states
• Ecchymoses are larger, bruiselike purpuric lesions.
• Infarct is an area of cutaneous necrosis resulting from occlusion of
blood vessels, 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 Purpura

Infarct
 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).
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

antecubital and popliteal fossae (e.g : atopic dermatitis).

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
 Scattered lesion.
Lesions in the distribution
described by Blaschko for
developmental
Targetoid lesion. Grouped: clustered Whorled : marbled appearance
Annular lesion Polycyclic lesion

Nummular lesion. Arcuate lesion

 Serpiginous lesion
Linear distribution

Reticular lesion
• 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.
Fitzpatrick’s Dermatology in General
Medicine. 7th ed. New York:Mc.Graw Hill
Company;2008.p. 23-40.