The Skin

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Chapter 3 The Skin

Basic Terminology and Diagnostic Techniques

1 How many skin diseases exist? What are the two main categories of skin lesions?

There are more than 1400 skin diseases. Yet, only 30 are important, common, and worth knowing. The first step toward their recognition is the separation of primary from secondary lesions (Table 3-1).

Table 3-1 Dermatologic Lesions

skin lesions
Primary Secondary Special
Solid (Nonpalpable) Crusts Purpurae
•    Macules (≤0.5   cm) Scales Petechiae
•    Patches (>0.5   cm) Ulcers Ecchymoses
  Fissures Teleangiectasias
Solid (Palpable) Excorations Comedones
•    Papules (≤0.5   cm) Scars Burrows
•    Plaques (>0.5   cm) Erosions Target lesions
•    Nodules (deeper plaques) Lichenification  
•    Wheals (pruritic plaques) Atrophy  
•    Tumors (larger nodules) Scars  
  Sinuses  
Fluid-Lesions    
•    Vesicles (fluid-filled papules)    
•    Pustules (pus-filled papules)    
•    Bullae (fluid-filled plaques)    
•    Cysts (fluid-filled nodules)    

2 What are the major primary lesions?

image Macules: Flat, nonpalpable, circumscribed areas of discoloration ≤0.5   cm in diameter. Typical macules are the familiar freckles.image

image Patches: Flat, nonpalpable areas of skin discoloration >0.5   cm in diameter (i.e., a large macule). A typical patch is the one of vitiligo.image

image Papules: Raised and palpable lesions ≤0.5   cm in diameter. They may or may not have a different color from the surrounding skin. A typical papule is a raised nevus.image

image Plaques: Raised and palpable lesions >0.5   cm in diameter (i.e., a large papule). Usually confined to the superficial dermis, they may result from the confluence of papules. A typical plaque is that of psoriasis.image

image Nodules: Raised, palpable, and elevated lesions >0.5   cm in diameter, which, unlike plaques, go deeper into the dermis. Since they are below the surface of the skin, the overlying cutis is usually mobile. Typical nodules are those of erythema nodosum.image

image Tumors: Nodules that are either >2   cm in diameter or poorly demarcated. Usually neoplastic.image

image Wheals (hives): Raised, circumscribed, edematous, and typically pruritic plaques that are pink or pale but typically transient. Classic wheals are the lesions of urticaria, or of a mosquito bite.image

image Vesicles (blisters): Fluid-filled, circumscribed, and raised lesions that contain clear serous fluid and are ≤0.5   cm in diameter. Typical vesicles are those of herpes simplex.image

image Bullae: Vesicles >0.5   cm in diameter. Commonly seen in patients with second-degree burns. Presence of a bulla is so important that it usually trumps all other concomitant primary lesions.image

image Cysts: Raised and encapsulated lesions that contain fluid or semi-solid material. Typical are the cysts of acne.

image Pustules: Pus-filled papules. Typically seen in patients with impetigo or acne.image

image Purpura: Skin extravasation of red cells, which, based on size, may present as petechiae or ecchymoses. Palpable purpura is never normal and argues for an antigen-antibody complex (vasculitis). Often localized to the lower extremities, the lesions of Henoch-Schönlein are typical examples of a palpable purpura. Internal organs (kidneys, GI tract) are often involved too.image

image Petechiae: Reddish-to-purple discolorations, caused by a microscopic hemorrhage. These are <0.5   cm in diameter and usually in clusters. With the exception of color, they resemble papules or macules (depending on whether they are palpable or not). Typical petechiae are those of typhus. The lesions of thrombocytopenic thrombotic purpura (TTP) are typical petechiae too.image

image Ecchymoses (bruises): Reddish-to-purple discolorations larger than petechiae. Except for color, they resemble plaques and patches (depending on whether they are palpable or not). Typically located below an intact epithelial surface.image

image Spider angiomas: These are arterial teleangiectasias, i.e., vascular arterial lesions that resemble the legs of a spider. They fill from the center and blanch whenever this is compressed.image

image Venous spiders: These are venousteleangiectasias, i.e., vascular venous lesions that also resemble the legs of a spider. Hence, they fill from the periphery, not the center. They empty with pressure.image

(Figures adapted from Willms JL, Schneiderman H, Algranati PS: Physical Diagnosis. Baltimore, Williams & Wilkins, 1994, with permission.)

3 What are the major secondary lesions?

image Excoriations: Linear erosions produced by scratching. Often raised, scratch marks may also present as crust on top of a primary lesion that has been partially scratched off. They are almost exclusively confined to the eczematous diseases.image

image Lichenification: A typical skin thickening seen in chronic pruritus with recurrent scratching. Resembles the callus formation of palms and soles after recurrent trauma. Lichenified skin is hardened, leather-like, with prominent markings and some scaling. Like excoriation, lichenification is typical of eczematous diseases. In fact, it is considered pathognomonic of atopic dermatitis.image

image Scales: Raised lesions presenting as flaking of the upper skin surface. In fact, they represent thickening of the stratum corneum, the uppermost layer of the epidermis. Scales may be white, gray, or tan. They may also be small or rather large. They provide the squamous component to papulosquamous diseases. They are extremely common in the scalp, where they suggest either banal processes (dandruff) or more serious conditions (seborrheic dermatitis, psoriasis, and tinea capitis).image

image Crusts: Raised lesions produced by dried serum and blood cell remnants. Usually preceded by fluid-filled primary lesions (i.e., vesicles, pustules, or bullae). The most familiar crust is the “scab” of impetigo.image

image Erosions: Depressed lesions produced whenever the epidermis is either removed or sloughed. They are moist, usually red, and well circumscribed. Classic erosions are those of chickenpox following rupture of a vesicle.image

image Ulcers: Depressed lesions produced whenever not only the epidermis but also part (or all) of the dermis is gone. Ulcers are concave, often moist, and at times inflamed or even hemorrhagic. They heal with scarring. A classic ulcer is that of the syphilitic chancre.image

image Fissures: Depressed lesions presenting as narrow, linear, and vertical cracks that penetrate through the epidermis, reaching at least part of the dermis. Classic fissures are those of the athlete’s foot.image

image Atrophy: Usually the nonspecific end-product of various skin disorders. It is characterized by a pale and shiny area, with loss of cutaneous markings and full skin thickness.image

image Sinuses: Connective channels between the surface of the skin and deeper components.image

(Figures from Fitzpatrick JE, Aeling JL: Dermatology Secrets. Philadelphia, Hanley & Belfus, 1996, with permission.)

14 How should fingernails and toenails be assessed?

If covered by polish, clean them first with a solvent like acetone. Then pay attention to color and shape but also to anatomic details (Fig. 3-25):

Although fingernails tend to be more informative than toenails (since they grow more rapidly and suffer fewer traumas), always examine them both. Inspect them first without applying any pressure. Then, blanch the fingertip to see if a pigmented lesion changes color (which would argue for discoloration of the vascular bed rather than the nail plate). Finally, place a penlight against the finger pulp and shine it through the nail. If upon illumination a discoloration disappears, it is also more likely to be in the vascular bed than in the soft tissue or matrix. When indicated, scrape the nail plate surface, and do a potassium hydroxide preparation to rule out fungal disease. Note that nail changes due to systemic disease (as opposed to trauma) often occur in the matrix, so that the leading edge of the abnormality (for example, a pigmentation change) is usually shaped like the distal portion of the matrix. To estimate the time of initial insult, measure the distance from the proximal nail fold (cuticle) to the leading edge of the pigmentation change, remembering that nails grow 0.1–0.15   mm/day.

Nails

33 What are Muehrcke’s lines (ML)?

Two arcuate, narrow, and transverse white lines—parallel to the lunula and separated by an otherwise normal nail. Named after the American nephrologist who first described them in 1956, ML usually involve the second, third, and fourth fingers. They reflect a vascular abnormality in the nail bed (typically, subungual edema), and not in the nail plate. Hence, they do not progress distally with nail growth. Common in hypoalbuminemia (<2.2   gm/100   mL), they disappear with its resolution. In his original study, Muehrcke found paired, transverse, white bands in 23/31 (74%) patients with nephrotic syndrome and 8/9 with hypoalbuminemia (<2.3   gm/100   mL) from other causes. Lines were instead absent in all healthy subjects, and in those with albumin >2.2   gm/100   mL. Bands were more prominent after albumin had been <1.8   gm/100   mL for at least 4 months. In another study by Conn and Smith, Muehrcke lines were seen in 10/44 (23%) patients with hypoalbuminemia from various debilitating illnesses, but absent in those with normal serum levels. Hence, ML occurs in hypoalbuminemia from many reasons, including nephrotic syndrome, but also liver disease and malnutrition. Additionally, they can occur in pellagra, Hodgkin’s disease, sickle cell anemia, or nail damage from paraquat and chemotherapeutic agents. Although transverse white bands in the nail plate are often due to trauma to the matrix at the proximal nail fold (leukonychia), Muehrcke’s (and Mees’) lines are instead associated with a systemic disease. They typically span the entire breadth of the nail bed/plate, tend to be more homogenous, have a contour similar to the distal lunula (with a rounded distal edge and smoother borders), occur on several nails at once, and typically follow a generalized insult. Trauma-induced transverse white bands tend to be more linear, do not spread across the entire breadth of the nail plate, resemble the contour of the proximal nail fold (where trauma occurred), and have a history of localized trauma to the cuticle.

Hair

Fluid-Filled Lesions: PUS (Pustules)—Table 3-2

Fluid-Filled Lesions: Clear Fluid (Vesiculobullous Diseases)

79 Are there any other causes of PV?

A form of PV (but also BP, see question 80) can be drug induced, resulting from penicillamine, captopril, thiol-containing compounds, and rifampin. Emotional stress can also trigger it. Finally, PV may occur in other autoimmune diseases, including myasthenia gravis and thymoma.

84 What is erythema multiforme (EM)?

A relatively benign process characterized by target or targetoid lesions, with or without blisters, in a symmetric and acral distribution. In fact, the rash favors palms and soles, dorsum of hands, face, and extensor surfaces of extremities (Fig. 3-27). It is often associated with oral lesions, but rarely involves more than one mucosal surface. Although it can be caused by drugs, it is most commonly a sequela of herpes virus infection. It has low morbidity, no mortality, but frequent recurrences. It may be associated with epidermal detachment, yet denudation always involves <10% of BSA.

image

Figure 3-27 Erythema multiforme. The eruption consists of annular and papular erythema over the acral areas.

(From Fitzpatrick JE, Aeling JE: Dermatology Secrets. Philadelphia, Hanley & Belfus, 1996.)