Professional Documents
Culture Documents
Skin Lesions: Psoriasis cont’d
• sharply demarcated papules and plaques
• well developed lesions have a thick silvery scale characteristic of psoriasis
• peeling off the scale will reveal pinpoint bleeding from capillaries close to the top
layer of the skin termed: Ausputz sign.
If in hairline, not as much redness. Pinpoint bleeding if plaque is lifted.
Forms:
a. Guttate: sudden onset of psoriasis commonly occurs as this form Important to ask
history: were they sick before onset of psoriasis?
• small, scattered teardrop shaped papules and plaques after a Streptococcal infection
as a child or young adult (URTI)
b. Pustular:
• occurs on hands and feet including the nail + toenails
Trigger factors:
1 Koebner’s Phenomenon: Physical trauma
Appears at site of physical trauma, at site of injury. Common treatment is tar cream.
• elicits lesions
• rubbing, scratching stimulates the psoriatic proliferative process
2. Infections
3. Stress
4. Drugs
5. Diet – high arachidonic acid, cGMP cycle try to decrease intracellular cGMP
Diagnosis:
• clinical appearance of typical erythematous (red) papules and plaques with a
thick, silvery scale
DDX of Psoriasis:
a. Seborrheic dermatitis:
• thick silvery scales are lacking
b. Candidiasis:
• KOH preparation will show pseudohyphae and /or yeast
IV 6 Pityriasis Rosea
Red lesions with some scabbed areas. Central clearing!
• Eruptive dermatitis that primarily affects people age 10 –35 age grouping
important.
• suspected to be of viral origin
• often history of URTI
• Characteristic eruption usually begins with a herald patch on the trunk 1 2
weeks prior to the onset of the truncal eruption rest of onset will follow
• Herald patch: can be several centimetres in diameter and mimic tinea corporis
• “Christmas tree pattern” to eruptions
Pg 26:
Pityriasis rosea cont’d
• Herald patch is followed by a generalized secondary eruption
Skin symptoms:
• may or may not have mild to severe pruritis
Physical examination:
• papules, plaques, scale erythema, hyperpigmentation in dark skinned patients
• scales tend to be centrally located
• Herald patch (80%) patients: oval, slightly raised dull red plaque of 25cm
diameter (size of lesion is important), bright red with a fine collarette/centripetal
scale at periphery
• Exantham (eruption associated with virus): fine scaling papules and plaques with
typical marginal collarette (around the edge)
Distribution:
Trunk, upper extremities (typical appearance); rarely on face
Diagnosis:
• based on clinical history, the presence of a herald patch (not always present)
• characteristic distribution: trunk & upper extremities
• appearance of central scale (exanthemous lesions)
DDX of Pityriasis rosea
1. Guttate psoriasis Thicker scales, teardrop shaped, flexor and extensor surfaces, but
not on trunk, many more and smaller lesions, pustules.
• like pityriasis rosea, often a history of a preceding URTI
• No herald patch, central clearing
2. Eczema (discoid)
• onset not as eruptive
• No herald patch/exanthum
3. Tinea corporis:
• herald patch must be scraped and tested with KOH for the presence of hyphae
4. Drug eruption:
• history should reveal
• herald patch is absent
• no scales
• No herald patch
Pg 27:
SECTION V: Pigmentary Disorders
V1 Vitiligo:
• Acquired skin depigmentation (white macules) that affects all races but far more
disfiguring in dark skinned individuals
• thought to be autoimmune in origin against the melanocytes (pigmentproducing
cells)
• higher incidence in people with diabetes mellitus, thyroid disorders, and adrenal
insufficiency
• 20% of patients experience spontaneous repigmentation
• Age of onset: at any age Can be seen in older than 25 years
• over 30% of patients report family history
• onset: often after physical trauma, illness or emotional stress, grief
• Can be debilitating: it is on the face
Physical Examination:
Distribution:
3 general patterns:
1. focal: one or several macules in a single site
2. segmental: one or several macules on one side of the body
3. generalized: widespread distribution
Sites: Predilection for acral areas and around body orifices
Skin Lesions:
• Macules; 5mm to 5 cm or more in diameter
• Colour: white/offwhite
• Convex margins; round, oval or elongated
Other:
• white or premature greying of hair if it gets into hair
• no increased risk of skin cancers
Dx:
• clinical presentation
• Lab: absence of melanocytes otherwise skin is normal
• within lesion, no melanocytes.
DDX of Vitiligo:
1. Chemically induced depigmentation
2. Postinflammatory hypopigmentation
there is a decrease in pigmentation rather than an absence
Naturopathic Approach:
1. Homeoacupuncture –– needles dipped in homeopathic remedy prior to insertion
2. Piper nigrum extract found to possess growth stimulatory activity towards cultured
melanocytes in mice Ahixiu Lin, Hoult, Bennett Planta Medica 65 (1999) 600603
Pg 28:
V2 Melasma “mask of pregnancy”, mottled appearance
• acquired light or dark brown hyperpigmentation occurring most often on exposed
areas, usually the face
• results from exposure to sunlight and may be associated with pregnancy,
contraceptive hormones or other medications
Age: Young adults
Race: More frequent in persons with dark skin
Geog: sunny areas
Duration of lesions:
• evolves rapidly over weeks usually following exposure to sunlight becomes
increasingly susceptible when exposed to sun
Physical Examination:
Distribution:
• 2/3 central part of face: cheeks, forehead, nose, upper lip and chin
Skin lesions:
• macular hyperpigmentation, hue and intensity depend on skin phototype of patient
Colour:
• light to dark brown or black uniform but splotchy – different colours throughout
Arrangement:
• bilateral
V3 Pityriasis alba
• hypomelanosis (decreased pigmentation)which presents as a white area with
scaling (melanocytes are reduced)
• seen in children or adults in temperate climates – often people with brown/black
skin
• occurs mostly on the face (adults: can be on upper extremities and trunk)
• unknown etiology: thought to be a form of eczematous dermatitis
• spontaneous resolution in winter temperatures
V4 Solar Lentigo = liver spots or age spots
(good idea to palpate ANY lesions)
• proliferation of normal melanocytes, secondary to chronic solar damage
• most commonly occur in individuals with fair skin and a history or chronic sun
exposure
• Smooth
Physical examination:
Skin lesions:
• macule hyperpigmentation, varies from light brown to dark brown
Pg 29:
Distribution: Solar lentigo cont’d
• face, dorsa of hands, shoulders and back
Dx: clinical appearance
DDX of Solar Lentigo
1. Seborrheic keratosis:
• scale & palpably rough; appears “stuckon” Totally benign: can be cut off. Will
regrow.
• Very common in people over 50 years old.
2. Lentigo maligna melanoma:
• irregular border
• variable pigmentation within lesion
• may have raised papule or nodule within the plaque
• history of gradual change
• When inspecting skin, ask about mole, and if there has been change.
V 5 Halo Nevus (Nevus = mole)
• nevomelanocyte (mole with melanocytes) nevus that is encircled by a halo of
depigmentation.
• occur in siblings and with history of vitiligo
Physical Examination:
Distribution:
• trunk
Skin Lesions
• papular brown nevus with halo of sharply marginated hypopigmentation
• oval or round hypomelanosis
• scattered discrete lesions
DDX of Halo nevus
1. Halo or depigmentation can occur around other lesions
blue nevus (dark, firm, well defined papule or nodule benign)
primary melanoma
verruca plana (plantar warts)
Dx: clinical appearance; confirm histologically
Pg 30:
SECTION VI Benign Neoplasms:
VI1 Acrochordon (Skin Tag)
• outgrowth of normal skin
• often a family tendency
• more common in females and in obese patients
Physical Examination:
Distribution:
• axilla, neck, inframammary, inguinal areas
Skin Lesions:
• papules, nodules soft
• skin coloured or hyperpigmented
Dx:
• clinical appearance of pedunculated (stalk, stem) lesions on narrow stalks
VI2 Xanthoma (Xantho = blonde, fair colour) around eyes: correlated with
cholesterol abnormalities.
• yellowbrown, pinkish or orange macules, papules, nodules or plaques that
represent lipid (fat) deposits in the skin.
• occur in response to abnormal lipid concentrations or lipoprotein abnormalities
• If you see this in someone, get blood work done.
Physical Examination:
• firm, yellow colour and involve characteristic sites
Types of Xanthomas:
1. Eruptive: sudden appearance of discrete yellow papules with red halo
- extensor surfaces and pressure sites
- looks like ingrown hair: important to know history
2. Tuberous: small, soft, yelloworange plaques and noninflammatory nodules
elbows, knees, digits
3. Tendinous: firm, irregular, slow growing nodules
achilles tendon, extensor tendon of digits
4. Planar: palms, hands or feet, periorbital
**should involve workup to exclude underlying disease and treatment of primary
lipid disorder
Pg 31:
VI3 Lipoma Painless
• single or multiple, benign subcutaneous neoplasm (tumour) composed of fat cells
• Can typically move lipoma within area.
Physical examination:
¥ soft, rounded or lobulated, and movable against the overlying site.
VI4 Pilar Cyst or Wen (incorrectly labelled as sebaceous cysts)
• firm, mobile keratinfilled cyst originating from the epithelial cells of the outer
root sheath of hair follicle (0.5 – 5 cm)
• 90% found on scalp other 10% within hair bearing areas
• developed almost always after puberty
• slow growth until stabilize and rupture – usually from external blow to head
inflammatory reaction follows which can be painful
• Movable
• Pain doesn’t grow into bone.
VI5 Seborrheic Keratosis (Protein in skin)
Looks like it is mud splattered on skin.
• benign proliferation of immature keratinocytes
• common epidermal tumour occurring mostly in people 50 years and older, but
also in young adults
Very rough and hyperpigmented.
Physical Examination:
Distribution:
• trunk, face, upper extremities most common
Skin lesions
• papules and plaques secondary hyperpigmentation and scale
• lesions having the classic stuckon appearance. Looks elevated, like it is about to
come off.
• appear warty, well circumscribed, often scaly and hyperpigmented
• close inspection with a hand lens (magnifying glass) often demonstrated the
presence of horn cysts or dark keratin plugs Like a blackhead plug.
• lesions should be able to be almost picked off with no. 15 scalpel blade
• if lesions are atypical, biopsy will be necessary
DDX of Seborrheic keratosis
1. Nevus:
• does not have stuckon or warty appearance
• there is no scale
2. Melanoma:
• usually not ‘stuck –on’ appearance
• look for blurring of borders and asymmetry of changing mole/skin
Pg 32:
3. Pigmented basal cell carcinomas:
• usually history of slowly changing lesions along with a waxy (border)
appearance
• look for dilated blood vessels and any ulceration to suspect BCC
Treatment: Seborrheic keratosis cont’d
No treatment indicated for most lesions. Symptomatic or cosmetically problematic
lesions can be removed via: liquid nitrogen therapy, snip or shave, electrocautery,
excisional biopsy
SECTION VII Premalignant and Malignant Neoplasms
VII1 Leukoplakia
Can be painful but not usually.
• keratinization of the mucous membrane characterized by small white patches
• occaisionally ulcerated (depression)
• hairy: lesion appears raised with a corrugated or “hairy” surface due to keratin
projections : often on tongue, looks like “hairy” tongue.
Distribution:
• tongue, buccal mucosa most common
Diagnosis:
• based on lesion’s clinical appearance in immunocompromised person
DDX of Leukoplakia: be sure to rule out food, toothpaste
1. Candida
• KOH test must be performed
• coinfection very common
2. Oral cancer
• usually appears as a red (erythroplastic) lesion
• when dry appear more granular and slightly abraded
3. Apthae (Canker sores)
• recurrent lesions
• usually ulcerated
• usually affect lips and/or tongue
1. Frictional Hyperkeratosis/Granuloma
• From surface trauma (dental appliances)
VII2 Actinic Keratosis/Cheilitis Actinic = solar/ray
• Common premalignant lesions resulting from cumulative sun exposure
• Occur most often in fairskinned people
• Some progress to squamous cell carcinoma which tend not to be very invasive
unless they occur on the lip/mouth
Pg 33:
Physical Examination: Actinic Keratosis cont’d feels rough and flaky
Distribution:
• sunexposed skin, including face, dorsa of hands and scalp
Skin Lesion:
• Papules, plaques with secondary erythema, scale and occasional
hyperpigmentation
• on palpation: lesions have a rough, sandpapery texture
Skin symptoms:
• patients often describe lesions as having a sticking/stinging sensation
Dx:
Based on clinical appearance and palpation
DDX of Actinic Keratosis
1. Squamous cell carcinoma:
If plaque or papule is indurated (hardened), shave biopsy is indicated to rule our
carcinoma
2. Seborrheic Keratosis:
• pigmented, stuckon appearance
• No pain
3. Nummular/Discoid eczema:
• Coinshaped; erythematous lesions with scaling
• Located on trunk and proximal extremities
Educate patients on sun exposure and sun protection
VII3 Keratoacanthoma = “crateriform ulcers of the face”
• tumours of epithelial origin that appear with sudden onset of a solitary, rapidly
growing (24 weeks), dome shaped nodule with a central keratotic core
• usually seen in male patients aged 50 70
• lesions may be associated with history of tar exposure
• noninvasive but can become quite large and cause scarring
• theory that HPV is involved
Predisposing factors:
• chronic sun exposure and immunecompromised
Pg 34:
Physical Examination: Keratoacanthoma cont’d
Distribution:
• sunexposed areas: cheeks, nose, ears, dorsa of hands, forearms
Skin lesion:
• papules, nodules, tumor with secondary erythema and crust
• lesions classically have a central keratotic domeshaped core
Dx:
• history of a rapidly growing lesion
• excisional biopsy is essential for diagnosis and to rule out squamous cell
carcinoma
DDX of Keratoacanthoma
1. Squamous cell carcinoma
biopsy only way to differentiate these lesions
squamous cell carcinomas are slowergrowing and typically do not have a central
keratotic plug
Treatment:
• surgical removal
• curettage with electrodessication
** Refer treatment should not be delayed with these rapidly growing lesions
VII4 Basal Cell Carcinoma: (Rodent ulcer) *Be able to recognize
• malignancy of the basal cells of the epidermis
• most common human malignancy
• occurs more commonly in men and almost exclusively in whites
• usually age between 40 80 years
• 85% occur on head and neck with the nose being the most common site
• locally invasive, aggressive and destructive, but usually there is a limited capacity
to metastasize since the tumor depends on its stroma for its growth.
When a tumour cell lodges at a distant site, it doesn't multiply and grow because of the
absence of growth factors obtained from the stroma of the tumour
Predisposing factors:
• white skinned
• chronic UV sunlight exposure
• excessive sun exposure before the age of 14 seems to set a pattern for development
of melanoma 3040 years later
Pg 35:
Physical Examination: Basal Cell Carcinoma cont’d
Distribution:
• Sunexposed areas most commonly face and neck
• multiple lesions are not infrequent
Skin lesions:
• Papule or nodule, with a translucent, waxy or “pearly”border
• Ulcer: often crust covered
• Pink or red: characteristic fine threadlike telangeictasia can be seen with a
magnifying glass.
• Pigmented BCC may be blue or black
Shape: Round, oval, depressed centre (umbilicated)
Palpation: Basal Cell Carcinoma cont’d
• hard, firm but cystic lesions may also occur
DDX of Basal Cell Carcinoma
a. Squamous cell carcinoma:
• No waxy, thready border or telagiectasia
• Biopsy to confirm
b. Scar:
• Take history: was there any trauma?
• More stable lesion
c. Eczema:
• No pearly borders or telangiectasia
• Consider when erythematous scaling plaque present especially on trunk
d. Dermal nevus (mole):
• Is a firm, fleshcoloured papule that does not gradually enlarge
• Biopsy may be necessary to confirm since dermal nevi may have telangiectasia
Followup:
• 4050% patients develop a second basal cell carcinoma within 35 years
Pg 36:
VII5 Squamous Cell Carcinoma
• second most frequent type of skin carcinoma
• malignant tumour of epithelial keratinocytes whose main function is to produce
keratin
Epidemiology:
• most commonly in white males, 55years and older in North America, In Australia: 20
30yrs
• sun exposed areas
Predisposing factors:
• old burn scars, sites of chronic inflammation, smoking (lip lesions), outdoor
occupation
i.e. farmers, sailors, industrial workers exposed to chemical carcinogens (tar, fuel oil)
Physical Examination of Skin:
Distribution:
sunexposed areas
Lesion:
Primary lesion:
• indurated papule, plaque, nodule, tumor
Secondary lesion:
• erythema, scale, erosion, crust, ulcer
* Any slowly evolving isolated keratotic or eroded papule or plaque in a suspect patient
that persists over a month is considered a carcinoma until proven otherwise if they have
an odd lesion that has changed
Other:
• Adenopathy, lymphoenopathy (swollen lymph glands) may be present in larger
lesions especially those involving the lower lip, other mucous membranes, old
burn scars or chronic inflammation
DDX of Squamous Cell Carcinoma
1. Eczema:
• responds to topical corticosteroids
• signs of induration of the skin are more indicative of squamous cell carcinoma
2. Basal cell carcinoma:
• waxy, pearly border
• Can look very similar if ulcerated
• Biopsy to confirm
Pg 37:
DDX of Squamous cell carcinoma cont’d
3. Keratoacanthoma:
• have classic history of rapid growth vs squamous cell carcinoma
• have central keratotic plug
• biopsy required to differentiate
4. Actinic keratosis:
• not usually indurated (hardened)
• precursor to squamous cell carcinoma
VII6 Melanoma (Malignant melanoma)
• a malignant tumour arising from melanocytes
Physical Examination:
Distribution:
• most arise in area of skin, mucous membranes where pigment cells
Skin Lesions:
• vary in size, shape, and shades of colour , most commonly pigmented
Types:
1. Lentigomaligna
2. Superficial spreading
3. Nodular
Other:
• most arise from normal melanocytes, fewer than 1/3 from pigmented moles
• extremely aggressive; often fatal within months of its recognition
* Danger signals: change in:
(Asymmetry, Border, Colour, Diameter +6mm, Elevation,
Enlargement)
• size
• shape, consistency
• spread of pigmentation to surrounding normal skin
• colours of red, white and blue colour
* Anything suspicious must be referred
VII7 Kaposi’s Sarcoma
Multifocal malignant tumour of lymphatic endothelial cells – linked to Herpes virus #8
First described in elderly men of eastern European Jewish ancestry (currently different
types)
1981: sudden epidemic outbreak helped identify AIDS