D e r m a to lo g ia p e d ia tr ic a : le le s io n i e le m e n ta r i
D o tt. A n g e lo M ila z z o P e d ia tr a d i F a m ig lia
R e s p o n s a b ile d e lla R e te d i D e r m a to lo g ia P e d ia tr ic a d e lla R e g io n e S ic ilia
S o c ie tà E u r o p e a d i D e r m a to lo g ia P e d ia tr ic a D o c e n te d i P e d ia tr ia d i F a m ig lia
a ll’U n iv e r s ità d i C a ta n ia
Primary lesions
• T h e re a re n o u n iv e rs a lly a g re e d u p o n d e fin itio n s o f te rm s o r, in p a r tic u la r , d im e n s io n s o f p r im a r y le s io n s .
• M acule - c ir c u m s c r ib e d a r e a o f s k in , u p to 1 .0 c m , w ith a
c h a n g e fr o m n o r m a l s k in c o lo r , w h ic h is n e ith e r r a is e d a b o v e n o r d e p r e s s e d b e lo w th e s u r r o u n d in g s k in . M a n y u s e th e te r m fo r le s io n s m u c h g r e a te r th a n 1 .0 c m . T e r m d o e s n o t in c lu d e purpura.
• Patch - a fla t, c ir c u m s c r ib e d , d is c o lo r a tio n o f s k in o r m u c o u s m e m b r a n e g r e a te r th a n 1 .0 c m in d ia m e te r .
• Papule - d is c r e te s o lid a r e a o f s k in th a t is e le v a te d b y
p a lp a tio n a b o v e th e s u r r o u n d in g s k in and le s s th a n 1 c m in d ia m e te r . V a r ia tio n s in c lu d e a c c u m in a te , k e r a to tic , fla t-
to p p e d , fo llic u la r , u m b ilic a te d , p e d u n c u la te d , n e c r o titic a n d o th e r s .
• Plaque - s im ila r to a p a p u le b u t g r e a te r th a t 1 .0 c m in
d ia m e te r . O fte n fo r m e d b y th e c o n flu e n c e o r c o a le s c e n c e o f p a p u le s . S e c o n d a r y fe a tu r e s m a y in c lu d e , a m o n g o th e r s , a tr o p h y , lic h e n ific a tio n o r h y p e r k e r a to s is .
Vesicles
• Vesicle - a c ir c u m s c r ib e d flu id -fille d le s io n le s s th a n 1 .0 c m in d ia m e te r th a t is u s u a lly e le v a te d a b o v e th e s u r r o u n d in g s k in . M a y b e d e s c r ib e d a s s o lita r y ,
g r o u p e d , u m b ilic a te d , d y s h id r o tic , s p o n g io tic , m u lti- lo c u la r o r u n i-lo c u la r .
• Bulla - a c ir c u m s c r ib e d flu id -fille d le s io n g r e a te r th a n 1 .0 c m in d ia m e te r th a t is u s u a lly e le v a te d a b o v e th e s u r r o u n d in g s k in . M a y a tta in d ia m e te r s o f s e v e r a l c m s a n d a r e d e s c r ib e d a s te n s e , o r fla c id .
• Pustule - d e s c r e te e le v a te d v e s ic le o r b u lla o f s k in , u s u a lly s m a ll, c o n ta in in g p u r u le n t e x u d a te c o m p o s e d o f in fla m m a to r y le u k o c y te s (p u s ), w ith o r w ith o u t
c e llu la r d e b r is . M a y b e s u p e r fic ia l, d e e p -s e a te d ,
fo llic u la r , g r o u p e d , e tc . a n d m a y a r is e s e c o n d a r ily fr o m
a v e s ic le .
N o d u le s – T u m o r s
• Nodule - d e s c r e te , s o lid , p a lp a b le , r o u n d o r o v a l (e lip s o id a l) le s io n o f th e s k in m e a s u r in g u p to 1 .0 c m in d ia m e te r (o r lo n g a x is ).
A p p lie s to p r o c e s s e s in v o lv in g a n y o r a ll le v e ls o f th e s k in , a n d is a g e n e r a l te r m fo r a n y m a s s , b e n ig n o r m a lig n a n t.
• Tumor - a te r m u s e d b y s o m e fo r a "n o d u le "
g r e a te r th a n 1 .0 c m in d ia m e te r . A p p lie s to
p r o c e s s e s in v o lv in g a n y o r a ll le v e ls o f th e
s k in , a n d is a g e n e r a l te r m fo r a n y m a s s ,
b e n ig n o r m a lig n a n t.
U r tic a r ia
• Wheal - a n e v a n e s c e n t, r o u n d o r ir r e g u la r , o fte n fla t-to p p e d e le v a tio n o f s k in w ith a
p a le r e d c o lo r , a r is in g fr o m e d e m a in th e s u p e r fic ia l d e r m is . M a y v a r y fr o m 2 -3 m m to 1 0 o r m o r e c m in d ia m e te r , w ith r o u n d o r a r c u a te c o n fig u r a tio n s . S h o u ld b e
d is tin g u is h e d fr o m angioedema, a m a s s iv e e d e m a in v o lv in g th e e n tir e d e r m is a n d
s u b c u ta n e o u s tis s u e s .
Secondary lesions
• Scar - a h a r d p la q u e o f d e n s e fib r o tic tis s u e c o v e r e d b y a th in e p id e r m is . A m a r k o f in ju r y fr o m a n y s o r t o f p r o c e s s (p h y s ic a l o r p a th o lo g ic ).
• Atrophy - A tr o p h y u s u a lly r e fe r s to th in n in g o f th e e p id e r m is le a v in g a n e a s ily w r in k le d a n d /o r s h in y s u r fa c e . A tr o p h y m a y a ls o a p p ly to d e r m a l a n d /o r s u b c u ta n e o u s tis s u e , w ith o r
w ith o u t c h a n g e s in th e e p id e r m is .
• Ulcer - lo s s o f s k in tis s u e o r s u b s ta n c e fr o m th e s u r fa c e d o w n w a r d , le a v in g a n u n c o v e r e d o r d e n u d e d w o u n d th a t is s lo w to h e a l.
• Erosion - a s u p e r fic ia l d e n u d a tio n o f th e s k in , u s u a lly im p ly in g th e lo s s o f th e e p id e r m is .
• Fissure - a v e r tic a l s p littin g o r s e p a r a tio n o f th e s k in .
• Crust - d r ie d s u r fa c e flu id , o fte n s e r o u s (in s p is s a te d s e r u m ) in n a tu r e , w ith o r w ith o u t tis s u e d e b r is . F o r p u r p o s e s o f th is
d o c u m e n t th is in c lu d e s th e te r m "s c a b ".
S e c o n d a r y le s io n s
• Excoriation - a s c r a tc h m a r k , o fte n w ith d e n u d a tio n o f th e s k in to fo r m a s m a ll u lc e r . E x p o s u r e o f th e c o r iu m b y m e c h a n ic a l r e m o v a l o f th e e p id e r m is .
• Scale - a th in fla k e o f e p ith e liu m (m o s tly c o m p o s e d o f
c o r n e o c ty e s ) w h ic h is s e p a r a te d fr o m th e u n d e r ly in g in ta c t s k in p r o p e r .
• Lichenification - a th ic k e n in g o f th e s k in s u r fa c e and a n in c r e a s e o f s k in m a r k in g s , u s u a lly s e e n w ith c h r o n ic
c o a le s c e n c e o f p a p u la r le s io n s , e s p e c ia lly a to p ic e c z e m a .
• Vegetating - a lu s h ly g r o w in g , p r o life r a tin g , p r o c e s s , u s u a lly w ith e le v a te d o r e x o p h y tic fe a tu r e s .
• Linear / Figurate - te c h n ic a lly not s e c o n d a r y fe a tu r e s , b u t in c lu d e d h e r e s o le ly o u t o f c o n v e n ie n c e . T h e s e a r e
configurations th a t s k in le s io n s m a y a s s u m e , w h ic h a id in th e ir d ia g n o s tic id e n tific a tio n . F ig u r a te in c lu d e s g e o m e tr ic a l s h a p e s (e .g . a n n u la r , a r c ifo r m , c y c lic , e tc .).
M acular Lesions
• Brown
• Grey Slate Blue
• Black
• White
• Pink - Red
• Yellow
• Scale
Brown M acular Lesions
• · Ephilides
• · Neurofibromatosis
• · Albright's disease
• · Peutz Jeghers syndrome Peutz Jeghers syndrome
• · Xeroderm pigmentosum · Xeroderm pigmentosum
• · Acropigmentation
• · Seborrheic keratosis
• · Neurocutaneous melanosis
• · Nieman-Pick disease
• · M elasma (Chloasma)
• · Kwashiokor
• · Photochemical reactions· Photochemical reactions
• · Berlock dermatitis
• · Ultraviolet light (sun tan)
• · Thermal radiation - Erythema ab igne
• · Becker's nevus
• · Hemochromatosis
Brown M acular Lesions
• · Trauma
• · Post-inflammatory hyperpigmentation
• · M alignant melanoma
• · Lentigo melanoma
• · M astocytosis (urticaria pigmentosa)
• · Encephalitis (chronic)
• · Cronkhite - Canada syndrome
• · Tatoo
• · Reticular acropigmentation of Kitamura
• · Dermatopathia pigmentosa reticularis
• · Fanconi's syndrome
• · Riehl's melanosis
• · Periorbital melanosis
• · Franceschetti - Jadassohn syndrome
• · Gaucher's disease
• · Dyskeratosis congenita
• · Addison's disease
Grey Slate Blue M acular Lesions
• Oculodermal melanocytosis (Nevus of Ota)
• Dermal melanocytosis (M ongolian spot)
• Blue melanocytic nevus
• Incontinentia pigmenti
• Franceschetti - Jadassohn syndrome
• Hemochromotosis
• Chronic nutritional insufficiency
• Fixed drug eruption
• Pinta
• Erythema dyschromicum perstans
• M alignant melanoma
• Tatoo
• M aculae cerulae
• Ochronosis
• M etastatic melanoma
• Black M acular Lesions
• M elanocytic nevus
• M alignant melanoma
• Ecchymosis (blue-black)
• White and Hypomelanotic M acular Lesions
• Vitiligo
• Albinism
• Piebaldism Piebaldism
• Vogt-Koyanagi-Harada syndrome
• Tuberous sclerosis
• Waardenburg's syndrome
• Hyperthyroidism
• Hypoparathyroidism
• Addison's disease
• Hypopituitarism
• Pernicious anemia
• Halo nevus (Leukoderma acquisitum centrifugum - Hyde and Sutton)
• Nevus depigmentosus
• Leprosy - tuberculoid
• Pityriasis alba
• Chediak-Higashi syndrome
• Post-inflammatory depigmentation
• Phenylketonuria (pigment dilution)
• Alezzandrini's sundrome
• Idiopathic guttate hypomelanosis
• Syphilitic leukoderma (L2)
• Scleroderma / morphea
Black and white M acular
Lesions
Pink – red - yellow M acular Lesions
• Exanthems
• Drug eruptions
• Telangiectasia
• Nevus flammeus (Port wine stain - salmon patch)
• Jaundice
• Xanthomata (plantar - plantar)
• Xanthelasma (sometimes paplable)
• Carotenemia
• Pseudoxanthoma elasticum
• Necrobiosis lipoidica diabeticorum
• Amyloidosis (primary)
• Fordyce condition
• Solar elastosis
M acules with Scale
• Tinea versicolor
• Seborrheic keratosis
• Pityriasis alba
Papular Lesions
• With Scale
• Koebner Phenomenon
• Facial Papule(s)
Papulo-squamous differential
• Pityriasis rosea
• Psoriasis
• Lichen planus
• Pityriasis rubra pilaris
• Parapsoriasis
• Secondary syphilis
• Tinea versicolor
• Tinea corporis
• Seborrheic dermatitis
• Drug reaction - lichenoid (e.g. atabrine, gold,
isoniazid)
Koebner Phenomenon
• Lichen planus
• Eczema (active)
• Psoriasis
• Auto-inoculation: Verruca, M olluscum
contagiosum, etc.)
Flesh Colored Papules
• Adenoma sebaceum of Pringle
• Basal cell carcinoma
• Intraepidermal nevus
• Acrochordon
• Dermatofibroma
• Verruca vulgaris / plana
• M olluscum contagiosum
• Syringoma
• Acne cyst
• Hidrocystoma – Apocrine – Eccrine
• Epithelioid inclusion cyst ("Sebaceous" cyst)
• Epithelioma adenoides cystica / Trichoepithelioma
• Neurofibroma
• Nevus lipomatous superficialis
• Nodular elastoidosis (with cysts and comedones) / (Favre - Racouchot syndrome)
• Lichen amyloidosis
• Lipoid proteinosis
• Trichofolliculoma
• M ilia
• Colloid milium
• M etastatic lesions
Nodular Lesions
• Nodules on Legs
• Nodules around Joints
Nodules on the Legs
• Erythema nodosum
• Subacute nodular migratory panniculitis
• Weber-Christian disease (relapsing febrile nodular panniculitis)
• Superficial migratory thrombophlebitis
• Acute pancreatitis with nodular subcutaneous fat necrosis
• Polyarteritis nodosa
• Insect bites
• Sarcoidosis
• Erythema induratum (Bazin)
• Erythema nodosum leprosum
• Trichophyton rubrum granuloma (M ajocchi)
• Zirconium and Silicon granuloma
• Deep fingal infection
• Actinomycosis, blastomycosis, sporotrichosis, coccidioidmycosis
• M eningococcal or pneumococcical septicemia
• Kaposi's sarcoma - other neoplasm
• Rheumatoid nodules
• Sweet's syndrome - usually tender plaque(s)
• Behcet's disease
• Parasites (leishmaniasis, echinococcosis, cysticercosis, shistosomiasis, onchocerciasis, myiasis)
• Rothman-M akai syndrome
Nodules around Joints
• Arthritis
– Rheumatoid arthritis
– Gouty tophi (Tophaceous gout)
• Infectious disease
– Papulonecrotic tuberculid - elbows, fingers
• M etabolic disease
– Xanthoma tuberosum – Calcinosis cutis
• Neoplasms
– M yxoid cyst
• M iscellaneous
– Erythema elevatum diutinum
– Reticulohistiocytoma
Tumor Lesions - Differential by Color
• Brown
• Black - Grey
• Blue
• Pink - Red - Purple
• Skin Colored - Yellow - Fawn – Orange
• Painful Dermal Tumors
Brown
• M alignant melanoma
• Spitz nevus
• M elanocytic nevus
• Pyogenic granuloma (brown to red)
• Seborrheic keratosis
• Comedone
• Basal cell carcinoma
• Acanthoma (brown to pink)
• Histiocytoma
• Skin tags (Acrochordons)
• Clear cell acanthoma
• Trichofolliculoma
• AActinic keratosis ctinic keratosis
• Squamous cell carcinoma Squamous cell carcinoma
• Paget's disease
• Nevus of Ota (brown to blue)
• Neuroma (brown, pink or purple)
• Leiomyoma (dusky brown-pink-red)
• Hidradenoma papilliferum (reddish-brown when ulcerated)
• Sarcoidosis
Black-Grey
• M elanocytic nevus
• Blue Nevus
• M alignant melanoma
• Seborrheic keratosis
• Basal cell carcinoma
• Paget's disease (pink-grey-yellow)
• Hematoma
• Thrombosed plantar wart
• Apocrine hidrocystoma (blue-grey-black)
• Bowen's disease
• Granuloma telangiectaticum (blue-black)
• Eccrine hidrocystoma
Blue
• Blue nevus
• M alignant melanoma
• Neurofibroma
• Histiocytoma
• Thrombosed plantar wart
• Apocrine hydrocystoma (blue-grey-black)
• Nevus of Ota (blue-brown)
• Granuloma telangiectaticum (blue-black)
• Kaposi's sarcoma (dark blue or purple)
• Lymphangiosarcoma of Stewart and Treves (dusky blue to red)
• Eccrine hidrocystoma
Pink - Red - Purple
• Spitz nevus
• Pyogenic granuloma
• M alignant melanoma
• Hemangioma (purple)
• Keratoacanthoma (flesh colored to red)
• Histiocytoma
• Eccrine poroma (acrospiroma) (pink to livid red)
• Hidradenoma papilliferum (ma be reddish brown)
• Dermal cylindroma (pink to red)
Skin Colored - Yellow - Fawn - Orange
• Basal cell carcinoma - Examples at the Image Database. Basal cell carcinoma - Examples at the Image Database.
• Seborrheic keratosis Seborrheic keratosis
• Sweat gland nevus (orange - red - brown) Sweat gland nevus (orange - red - brown)
• Trichoepithelioma (pink - yellow) Trichoepithelioma (pink - yellow)
• Sebaceous adenoma (yellow) Sebaceous adenoma (yellow
• Sebaceous carcinoma (yellow - orange)
• M ilium (white - yellow)
• Steatocystoma multiplex (yellow)
• Syringoma (yellow - mauve - translucent)
• Actinic keratosis (yellow)
• Neurolemmoma (pink - grey - yellow)
• Eccrine spiradenoma (flesh colored)
• Syringoma papilliferum (flesh colored)
• Painful Dermal Tumors
• Angiolipoma
• Angioleiomyoma
• Eccrine spiradenoma
• Glomus tumor
• Neuroma
• Neurolemmoma
• Leiomyoma
Vesicular / Bullous Lesions
• Vesicular / Bullous Lesions
• Epidermal
• Subepidermal
• Hands
• Grouped
• Umbilicated
Epidermal Vesicular / Bullous Lesions
• Pemphigus vulgaris
• Pemphigus erythematosus (Senear-Usher Syndrome)
• Pemphigus foliaceus
• Pemphigus vegetans
• Benign familial pemphigus (Hailey and Hailey Disease)
•
Epidermal Vesicular / Bullous Lesions
• Incontinentia pigmenti
• Toxic epidermal necrolysis
• Impetigo / Bullous impetigo
• Bullous congenital ichthyosiform erythroderma
• Epidermolysis bullosa simplex
• Cockayne's disease (Recurrent bullous eruption of hands and feet)
• Cantheridine
• M iliaria crystallina
• M iliaria rubra
• Acrodermatitis enteropathica Acrodermatitis enteropathica
• Eczematous blisters: Eczematous blisters:
– Allergic and contact dermatitis (e.g. garlic)Allergic and contact dermatitis (e.g. garlic)
– Fungal: I nflammatory infections and id reactions Fungal: I nflammatory infections and id reactions – Dyshidrosis (Pompholyx) Dyshidrosis (Pompholyx)
– Ultraviolet light Ultraviolet light – Others Others
• Bacterial vesicles / papulovesicles – Impetigo / Bullous impetigo
– M eningococcemia-stretococcemia, often hemorrhagic
• Viral vesicles:
– Hand, foot and mouth disease (Coxsackie A16) – Varicella - Zoster
– Others
• Parasitic vesicles:
– Scabies - Examples
H a n d le s io n s
• Vesicular / Bullous Lesions of the Hands Hand, foot and mouth disease (Coxsackie Vesicular / Bullous Lesions of the Hands Hand, foot and mouth disease (Coxsackie AA16) -16) -
• Acute eczematous dermatitis Acute eczematous dermatitis
• Dermatophytid
• Dyshidrotic eczema
• Scabies - Examples
• Bullous erythema multiforme - Example.
• Epidermolysis bullosa syndromes - Examples: See Image Database
• Congenital syphilis
• Porphyria cutanea tarda
• Erysipeloid
• Physical factors
• Viral: Herpes simplex, varicella - zoster, others. - Examples: See Image Database
• Toxic epidermal necrolysis
• Bullous lichen sclerosis et atrophicus
• Fixed drug
• Blister beetles
Subepidermal Vesicular / Bullous Lesions
• Erythema multiforme
• Bullous Pemphigoid
• Cicatricial pemphigoid (Benign mucosal pemphigoid)
• Dermatitis herpetiformis
• Dermolytic epidermolysis bullosa:
– Dominant – Recessive
– Acquired - Examples
• Junctional epidermolysis bullosa
• M endes da Costa Syndrome (M acular dystrophic epidermolysis bullosa)
• Porphyria cutanea tarda
• Bullous lupus erythematosus
• Bullous lichen planus
• Fixed drug eruption (i.e. barbiturates)
• Burns
• Suction
• Friction or shearing forces
• Trauma (i.e. secondary to a bone fracture)
• Lichen sclerosis et atrophicus
• Urticaria pigmentosa
• Vesicular polymorphous light eruption
• Herpes gestationis
• Ionizing radiation
Grouped Vesicles and Pustules
• Herpes simplex
• Herpes zoster
• Impetigo herpetiformis
• Dermatitis herpetiformis
• Herpes genitalis
• Herpes gestationis
• Subcorneal pustulosis
Pustular Lesions
• Folliculitis
• Candidiasis
• Impetigo
• Impetigo herpetiformis
• Acne vulgaris
• Chloracne
• Steroid induced acne (e.g. dexamethasone)
• Pustular drug eruption
• Rosacea (Acne rosacea) - M ore examples
• Erythema toxicum neonatorum
• Transient neonatal pustular melanosis
• Incontinentia pigmenti (1st stage) (usually vesiculobullous)
• Perioral dermatitis
• Pustular psoriasis
– Generalized pustular psoriasis of Zumbusch – Acrodermatitis continua
• Acropustulosis
• Palmoplantar pustulosis
• Subcorneal pustular dermatosis (of Sneddon-Wilkinson)
• Eosinophilic folliculitis (Ofugi's disease)
• Hidradenitis suppurativa
• Folliculitis decalvans
Umbilicated Vesicles
• Varicella
• Herpes simplex
• Herpes zoster
Wheal or Urtica Lesions
• Urticaria, NOS
• Cholinergic urticaria
• Physical urticaria, including dermagraphism
• Contact urticaria
• Systemic lupus erythematosus
• Hypocomplementemic vasculitis
• Insect bite
• Drug eruption
• Anaphylaxis
• Erythema multiforme (early)
Cyst Lesions
Epidermoid cyst - ( Follicular infundibular cyst)
• Pilar cyst (Tricholemmal cyst)
• Dermoid cyst
• M ucinous cyst
• Hydrocystoma (blue hue) – Eccrine
– Apocrine (more blue)
• M ilia
• Thyroglossa
• Bronchogenic cysts
• Branchial cleft cyst
