Dermatology 101

Jeremy Jackson, M.D.

ICM
March 25, 2013
Components of Skin
 Epidermis
• 4 Layers
– Stratum corneum
– Stratum granulosum
– Stratum spinosum
– Stratum basale
• Melanocytes
– reside in basal layer
– make pigment
 Epidermis
• Langerhans cell
– antigen presenting cells
– first line of immune
defense in the skin
• Basement membrane
zone
– interface between
epidermis and dermis
 Dermis
• Contains vessels,
nerves and appendages
• Appendages
– Eccrine sweat glands
– Apocrine sweat glands
– Hair follicles
– Sebaceous glands
 Functions of the Skin
• Regulates Body Temperature
• Prevents loss of body fluids
• Barrier protection from toxic substances
• Protects from harmful effects of sun and radiation
• Mechanical support
• Immune function
• Sensory organ for touch, heat, cold and emotions
• Vitamin D Synthesis
 History, History, History
• When did it begin?
• Where did it first appear?
• How long did it last?
• Did it come and stay or did new ones come and go?
• What makes it worse?
• What makes it better?
• Associated factors, Does it itch?
• Does it hurt?
• Is it changing in size or color?
• Does it bleed?
• What other medical problems?
• What medications and how long have you been taking them?
• Is it worse in the sun?
• Does anyone else living with you have the same rash?
• What kind of work?
 Basic Morphology
Primary Lesion Definition Common Example
Macule Nonpalpable lesion <1 cm in diameter Freckle
Patch Nonpalpable lesion ≥1 cm in diameter Tinea
versicolor

Papule Palpable lesion <1 cm in diameter Acne

Plaque Palpable lesion ≥1 cm in diameter Psoriasis

Pustule Lesion that contains purulent fluid Folliculitis

Vesicle Lesion <1 cm containing clear fluid Chicken pox

Bulla Lesion ≥1 cm containing clear fluid Poison ivy
Nodule Firm papule or plaque that is deeper in the skin
 Morphology
Secondary Lesions
• Lichenification
• Excoriation
• Scale: abnormal production
of stratum corneum
• Crust: serum, crusting
(scab-like; impetigo)
• Induration
• Atrophy
Configuration
• Linear
• Annular
• Discoid: coin-like
• Nummular: teardrop
• Guttate
• Stellate
• Serpiginous: snake-like
• Targetoid: round w/ outside rim
• Verrucous: wart-like papule
 Example
Erythematous, annular plaque w/ scale

• Plaque (>1cm): palpable

scaliness
• Fungal infection
 Epidermal Growths
• Proliferations of either basal cells or
keratinocytes
 Warts
• Epidermal growths secondary to human
papillomavirus (HPV) infection
• HPV’s are double-stranded DNA viruses that
cause proliferation of keratinocytes
• Common Warts (Verruca Vulgaris)
– firm papules with hyperkeratotic surface
– skin lines are interrupted, black dots are seen on
paring
 Warts
• Genital Warts (Condylomata acuminata)
– Papules or nodules on the perineum, genitalia,
crural folds, and anus
– May be flat or polypoid
A 76-year-old man is seen in the office for a routine physical
examination. He is healthy and has no complaints about
his health, takes no medications, and does not smoke or
drink alcohol. Until he retired 5 years ago, he was a
farmer. On physical examination, several darkly
pigmented lesions are noted on his trunk, as shown .

Which of the following is the most likely diagnosis?

• A Basal cell carcinoma
• B Malignant melanoma
• C Seborrheic keratoses
• D Squamous cell carcinoma
A 76-year-old man is seen in the office for a routine physical
examination. He is healthy and has no complaints about
his health, takes no medications, and does not smoke or
drink alcohol. Until he retired 5 years ago, he was a
farmer. On physical examination, several darkly
pigmented lesions are noted on his trunk, as shown .

• Which of the following is the most likely diagnosis?

• A Basal cell carcinoma
• B Malignant melanoma
• C Seborrheic keratoses
• D Squamous cell carcinoma
 Seborrheic Keratoses
• Benign tumor of epidermal cells
• May be autosomal dominant trait
• Discrete, stuck-on appearing, dark brown to
very light tan or flesh colored papules or
plaques
• Leser-Trelat sign: sudden increase in the size
and number of SK’s that may herald cancer
 •

Dermatosis
Papulosa Nigra
Acrochordon (Skin Tag)
 Mollusca Contagiosa
• Skin-limited infection caused by a poxvirus
(DNA)
• Small yellowish to skin-colored dome-
shaped papules that are often umbilicated
• Common in children, among adults as STD,
and in AIDS
• A 70-year-old man comes to the office to ask about the
skin changes on his hands and scalp, as shown .

• The skin changes have been present for years, but he is

concerned now about the possibility of skin cancer.

Which of the following is the most likely diagnosis?

• A Actinic keratoses
• B Basal cell carcinoma
• C Malignant melanoma
• D Seborrheic keratoses
• A 70-year-old man comes to the office to ask about the
skin changes on his hands and scalp, as shown .

• The skin changes have been present for years, but he is

concerned now about the possibility of skin cancer.

• Which of the following is the most likely diagnosis?

• A Actinic keratoses
• B Basal cell carcinoma
• C Malignant melanoma
• D Seborrheic keratoses
 Actinic Keratoses
• Sun-induced keratinocyte atypia that forms
a rough, scaling macule, patch, papule or
plaque
• 10% may progress to squamous cell
carcinoma over a 10 year period
A 62-year-old man is evaluated for a rapidly growing nodule on
his face. The lesion has arisen within the past 4 to 6 weeks and
is painless. He does not recall a history of trauma.
Physical examination reveals the lesion shown .
It is not tender, warm to the touch, or fluctuant. There is no
associated lymphadenopathy.

• Which of the following is the most likely diagnosis?

• A Abscess
• B Keloid
• C Keratoacanthoma
• D Nodular basal cell carcinoma
A 62-year-old man is evaluated for a rapidly growing nodule
on his face. The lesion has arisen within the past 4 to 6
weeks and is painless. He does not recall a history of
trauma.
Physical examination reveals the lesion shown .
It is not tender, warm to the touch, or fluctuant. There is no
associated lymphadenopathy.

• Which of the following is the most likely diagnosis?

• A Abscess
• B Keloid
• C Keratoacanthoma
• D Nodular basal cell carcinoma
 Keratoacanthoma
• A type of squamous cell carcinoma
• Most involute spontaneously but are still
treated as skin cancers – risk of mets
A 60-year-old man is evaluated for a skin lesion on his right wrist.
He first noted the lesion several months ago, and it has grown
and bled frequently over the past 6 weeks. The patient received a
cadaveric renal transplant 3 years ago because of progressive
chronic glomerulonephritis. He has maintained excellent
allograft function on prednisone, cyclosporine, and
mycophenolate mofetil.

• Physical examination is unrevealing other than the skin lesion

shown .
Which of the following is the most likely diagnosis?
• A Kaposi sarcoma
• B Melanoma
• C Psoriasis
• D Squamous cell carcinoma
A 60-year-old man is evaluated for a skin lesion on his right wrist.
He first noted the lesion several months ago, and it has grown
and bled frequently over the past 6 weeks. The patient received a
cadaveric renal transplant 3 years ago because of progressive
chronic glomerulonephritis. He has maintained excellent
allograft function on prednisone, cyclosporine, and
mycophenolate mofetil.

• Physical examination is unrevealing other than the skin lesion

shown .
Which of the following is the most likely diagnosis?
• A Kaposi sarcoma
• B Melanoma
• C Psoriasis
• D Squamous cell carcinoma
 Squamous Cell Carcinoma
• Malignant neoplasm of keratinocytes
• Second most common skin cancer (basal is first)
• Hard, keratotic plaque or nodule that may be
ulcerated, usually on sun-exposed skin
• May metastasize, usually to regional lymph
nodes
• Those arising in chronic ulcers or scars have a
higher metastasis rate
A 62-year-old man is evaluated for an asymptomatic
nodule on his shoulder that has been present for
more than 1 year.

• Skin findings are shown .

• Which of the following is the most likely diagnosis?

• A. Basal cell carcinoma
• B. Pyogenic granuloma
• C. Seborrheic keratosis
• D. Squamous cell carcinoma
A 62-year-old female is evaluated for an
asymptomatic nodule on her cheek that has been
present for more than 1 year.

• Skin findings are shown .

• Which of the following is the most likely diagnosis?

• A. Basal cell carcinoma
• B. Pyogenic granuloma
• C. Seborrheic keratosis
• D. Squamous cell carcinoma
 Basal Cell Carcinoma
• Malignant neoplasm of basal layer
keratinocytes. May be nodular, pigmented,
superficial, or sclerotic
• Most common human cancer
• Nodular BCC’s are translucent papules with
telangiectasias
• Pigmented BCC’s may be similar to nodular
BCC’s but are speckled to uniformly dark
 Basal Cell Carcinoma
• Superficial BCC’s are red, slightly scaling
patches, sometime slightly eroded or with a
rolled border
• Sclerotic BCC’s are poorly defined,
atrophic, firm, white scar-like plaques
Pigmented Growths
 Freckles
• Ephilides
• Hyperpigmented macules on sun-exposed
skin
• Increased basal cell melanin
 Lentigines
• Hyperpigmented macules with increased
melanin and melanocytes
• Solar lentigines are common and occur on
sun-exposed skin in adults
• Simple lentigines are uncommon and occur
on sun-exposed or non-exposed skin in
children and adults
 Nevi
• Benign proliferations of nevus cells
(modified melanocytes)
• Benign nevi are uniformly pigmented flesh-
colored to brown, flat (usually junctional) or
raised (usually compound) papules
• Begin to develop around 6 months of age
and increase in number and pigmentation
with age and pregnancy
A 62-year-old woman is evaluated for an asymptomatic
pigmented patch on her cheek that has been present for 15
years.

• Skin findings are shown .

• Which of the following is the most likely diagnosis?

• A Actinic keratosis
• B Basal cell carcinoma
• C Benign solar lentigo
• D Malignant melanoma
• E Seborrheic keratosis
A 62-year-old woman is evaluated for an asymptomatic
pigmented patch on her cheek that has been present for 15
years.

• Skin findings are shown .

• Which of the following is the most likely diagnosis?

• A Actinic keratosis
• B Basal cell carcinoma
• C Benign solar lentigo
• D Malignant melanoma
• E Seborrheic keratosis
 Melanoma
• A malignant neoplasm of melanocytes
• Family history confers greater risk
• Change in color or size of mole is noted in
70%
 Melanoma
• ABCDs of melanoma
– Asymmetry
– Border irregularity
– Color variation
– Diameter greater than 6 mm (pencil eraser)
– Evolving
 Melanoma
• Types
– Superficial spreading: common, esp. in the
young
– Nodular (along w/ acral lentiginous are the
worst prognosis)
– Lentigo maligna
– Acral lentiginous
 Melanoma
• Prognosis is most closely related to tumor
thickness (Breslow’s depth)
• Tumors < 1mm have best prognosis
• Excisional biopsy of the entire lesion is
preferred in order to more accurately
evaluate depth, regression and other
prognostic features
 Melanoma
• Superficial spreading
– Most common in young people
– Upper back in males
– Upper back and lower legs in females
 Melanoma
• Nodular: raised (bad prognosis)
– Rapidly growing blue-black nodule that may
erode
• Amelanotic
– May resemble pyogenic granuloma
 Melanoma
• Lentigo maligna
– On sun-exposed skin of older patients
– Slow growing irregular brown patches
– May remain in situ for years
 Melanoma
• Acral lentiginous
– On palms and soles, may be subungual
– Most common type in Asians and Blacks
• What famous musician
died from Acral
Lentiginous
Melanoma at age
• 36?
 Vascular Malformations
• Capillary malformation (Port-wine stain)
– Dilated ectatic vessels in the papillary and
upper reticular dermis
– Color gradually deepens with time
– Surface slowly thickens, becoming raised and
nodular
– Respond well to laser therapy
 Hemangioma
• Benign proliferation of blood vessels in the
dermis
• Generally enlarge during the first year of
life
• Involute slowly (about 10% per year)
• May leave residua
Tinea (Pityriasis) Versicolor
Pityriasis Rosea
Mycosis Fungoides (Cutaneous T-cell Lymphoma
A 33-year-old woman is evaluated for a 3-day history of a rash on her palms. Several days prior to
onset of the rash, she developed low-grade fever, aches, malaise, and sore throat. The rash first
appeared on her palms as small red macules that increased in size over 24 to 48 hours,
followed by the appearance of similar lesions on her arms and sores in her mouth. Three
months ago she had a similar episode that resolved spontaneously without scarring within 2
weeks. She takes no medications or supplements. She has not been exposed to anyone with
similar skin lesions, but she did recently travel to a meeting in North Carolina. She has a
remote history of genital herpes, but has had no outbreaks in several years. No family
members have experienced similar outbreaks.

On physical examination, she appears well. Temperature is 37.2 °C (98.9 °F), blood pressure is
118/70 mm Hg, and pulse rate is 68/min.
Similar lesions are noted on the palms and extensor forearms. There is a fibrinous-based, 4- to 5-
mm ulcer on the palate. No conjunctival erythema and no vulvar lesions are noted.
Which of the following is most likely associated with this patient’s eruption?
A Lyme disease
B Recurrent herpes simplex virus infection
C Rocky Mountain spotted fever
D Streptococcal pharyngitis
A 33-year-old woman is evaluated for a 3-day history of a rash on her palms. Several days prior to
onset of the rash, she developed low-grade fever, aches, malaise, and sore throat. The rash first
appeared on her palms as small red macules that increased in size over 24 to 48 hours,
followed by the appearance of similar lesions on her arms and sores in her mouth. Three
months ago she had a similar episode that resolved spontaneously without scarring within 2
weeks. She takes no medications or supplements. She has not been exposed to anyone with
similar skin lesions, but she did recently travel to a meeting in North Carolina. She has a
remote history of genital herpes, but has had no outbreaks in several years. No family
members have experienced similar outbreaks.

On physical examination, she appears well. Temperature is 37.2 °C (98.9 °F), blood pressure is
118/70 mm Hg, and pulse rate is 68/min.
Similar lesions are noted on the palms and extensor forearms. There is a fibrinous-based, 4- to 5-
mm ulcer on the palate. No conjunctival erythema and no vulvar lesions are noted.
Which of the following is most likely associated with this patient’s eruption?
A Lyme disease
B Recurrent herpes simplex virus infection
C Rocky Mountain spotted fever
D Streptococcal pharyngitis
 Erythema multiforme
 Acute, self-limited skin dz characterized by
abrupt onset of symmetrical fixed red papules
some of which evolve into target lesions
 Most often precipitated by infection—HSV
 Also can be associated with drugs or
systemic disease
 Does NOT progress to TEN
 Stevens-Johnson/TEN
Adverse skin reaction characterized by
mucocutaneous tenderness, erythema and
extensive exfoliation
SJS <10% body surface area; TEN >30%
NSAIDS, ABX, antiepileptics, allopurinol
Usually occur 7-21 days after initiation of
responsible drug
Mortality 1-5% SJS, 25-35% for TEN
 Drug Reactions
 Cutaneous reactions to drugs are responsible for 3% of
all disabling “injuries” that occur during hospitalizations
 Most common drug reaction is exanthematous eruptions
and urticaria
 In inpts, most common drug offenders are penicillins
(PCNs), Sulfa drugs, and NSAIDs
 Type of reaction and timing of events are important to a
logical approach
 DRESS—morbilliform rash, high fever, and
inflammation of internal organs (peripheral eosinophila
and elevated transaminases
 Psoriasis
 Affects up to 2% of the population
 Characteristic lesion sharply demarcated
erythematous plaque with silvery white scales
 Scalp, elbows, knees, nails, hands, feet, trunk
 5-30% will have psoriatic arthritis—asymmetric
oligoarthritis of the small joints
 Onset any age but 75% appears before age 40
 Treatment—Vit D analogues (calcipotriol, calcitriol),
topical steroids, anthralin, tar, tetinoids, phototherapy,
methotrexate, biologics
What famous athlete uses Enbrel
to control his Psoriatic Arthritis?
Pemphigus
Pemphigoid
 Lichen Planus
• Don’t forget the P’s
• Purple, planar, pruritic, papules, polygonal
• Associated with Hepatitis C
Moh’s Micrographic Surgery
 What famous person could possibly have
had this skin disease as a result of his
glucagonoma?

Necrolytic Migratory
Erythema
 Questions?
jdjackson@umc.edu