Chapter 13: Dermatology

Dermatological Lesions and Diseases

Tracey C. Vlahovic, DPM

 DERMATOLOGY
The Skin
The skin is one of the largest organs of the body exhibiting a wide range of
functions which include: mechanical protection, formation of a barrier to
water transfer, immune response, thermoregulation, perception of the
environment, excretion, limitation of harmful radiation, and synthesis of
Vitamin D. The skin is composed of three layers: the epidermis, the dermis,
and subcutaneous fat.

1. Epidermis:
a. This is composed of a stratified squamous epithelium containing cells that
become specialized for the production of keratin.
b. There are four strata of the epidermis (from deep to superficial):
i. Stratum basalis or basal cell layer
ii. Stratum spinosum or spiny cell layer
iii. Stratum granulosum or granular cell layer
* Stratum lucidum (found only in the palms and soles)
iv. Stratum corneum or cornified layer
c. Specialized cells of the epidermis and their role:
i. Melanocytes are specialized cells for the production of melanin
pigment and are located in the stratum basalis. Melanin offers protection to
UV-B radiation. There are two forms of melanin in the human skin: Eumelanin
(brown or black) and Pheomelanin (red and yellow).
ii. Langerhans cells residing in the stratum spinosum play an important
role in skin immunity.
iii. Merkel cells demonstrate dense core neurosecretory granules and
are thought to be part of the cutaneous sensory system.

2. The Dermis:
a. The dermis is composed primarily of connective tissue and consists of two
layers: papillary layer and reticular layer
i. The papillary layer lies between epidermal rete ridges and contains
many nerve endings and capillaries
ii. The reticular dermis lies below the papillary dermis and above the
subcutaneous fat. It contains collagen bundles.

3. Skin Adnexal Structures:

a. Pilosebaceous structures: (hair, sebaceous glands, arrector pill muscle) are
present on the dorsal aspect of the foot and toes. Hereditary factors and
various acquired conditions contribute to the amounts
b. Eccrine sweat glands: secrete sweat for temperature regulation and are
present throughout the foot.
c. Nails: Are present on the dorsal-distal aspects of all toes and fingers

4. Special Structures:
a. Pacinian Corpuscles: In the deep dermis are sensors for pressure
b. Glomus bodies: In the toe tips, function in blood shunting as an aid to
temperature regulation. The shunt is a narrow branch of the arterioles that
connect directly to a venule, bypassing capillaries. This shunt is the Suquet-
Hoyer canal

Dermatological lesions
1. Primary lesions:
a. Macules: Circumscribed flat lesions measuring up to 1 cm. in diameter
b. Patch: Flat lesions measuring more than 1 cm. in diameter. They may form
as a consequence of coalescence of macules
c. Papules: Circumscribed, solid elevations measuring up to 1 cm. in
diameter.
d. Plaque: A circumscribed, solid elevation (or confluence of papules)
exceeding 1 cm. in diameter and lacks a deep component
e. Nodules: Circumscribed, solid elevations exceeding 0.5 cm in diameter
and has a deeper component
f. Tumors: Circumscribed, solid elevations of larger size than nodules
g. Vesicles: Fluid-filled papules, under 1 cm. in diameter (small
blisters)
h. Bulla: Fluid-filled collection, exceeding 1 cm. in diameter (large
blisters)
i. Cysts: Non-infected, deep-set collection of material surrounded by a
histologically definable wall (sebaceous cyst, mucous cyst, epidermal
inclusion cyst, etc.)
j. Pustule: papule that contains purulent material

2. Secondary lesions:
a. Scales: thick statum corneum resulting from hypoproliferation or increased
cohesion of epidermal cells
b. Excoriations: linear erosion caused by scratching
c. Erosions: Partial loss of the epidermis, but the dermis is not breached.
These leave no scars upon healing
d. Fissures: Linear, deep epidermal cracks in the skin, penetrating to the
dermis and common in areas of dry skin
e. Ulcers: full thickness loss of the epidermis in which the dermis or deeper
tissues are exposed. These may leave scars when healed
f. Crusts: These are "scabs", i.e. aggregations of dried serum or blood with
other cellular debris
g. Scar: Also called "cicatrix", and resulting from inflammatory or traumatic
dermoepidermal damage. Scarring is a normal reaction, and that final
portion of dermal healing called " fibrosis"
i. Hypertrophic scarring represents an excessive collagen deposition
that may spontaneously regress. They do not extend beyond the limits of the
original lesion
ii. Keloids represent abnormal scarring responses that continue beyond
the borders of the inciting injury, and progress to cause contractures and
interference with function. They also may cause cosmetic problems, and can
be quite deforming. Treatment is a major problem. Before any elective
surgery is undertaken, a careful history and examination should elicit the risk
of keloid formation
h. Abcess: is a deep circumscribed collection of pus
i. Furuncle (Boil): is an abcess originating in a hair follicle
ii. Carbuncle: an abcess involving several adjacent hair follicles, with
interconnecting sinuses

NOTE* Sinus tracts connect cavities, abcesses, etc. under the skin; fistulas
connect abcesses to the body surface

3. Special Lesions:
a. Burrow: A superficial epidermal tunnel usually caused by insects (scabies,
tunga penetrans/chigoe) usually in fingerwebs and wrists
b. Petechiae and Purpura: extravasated blood cells in the dermis. Do not
blanch with pressure. Petechiae are <5mm in diameter; purpura larger than
petechiae.
c. Telangiectasia: small superficial blood vessels that blanch with pressure.
d. Target lesions: Three zoned skin lesions: dark center or bull’s eye,
second pale zone, and third rim of erythema. Found on a patient with
erythema multiforme.

4. Vesiculobullous Disorders:
a. Viral: Herpes simplex, herpes zoster (shingles), varicella (chicken pox),
hand foot and mouth disease(coxsackie A16virus).

NOTE* Tzanck smear of fluid from vesicles or bullae for identification of b.

multinecleated giant cells or other viral cytopathic effects
Fungal: Bullous dermatophyte: T. mentogrophytes, T. rubrum, T versicolor
(etiological agent is Malassezia furfur), other fungi and yeasts
c. Bacterial: impetigo, scalded skin syndrome
d. Genetic: Benign familial pemphigus (Hailey-Hailey disease), Epidermolysis
bullosa (all 16 types) represents a defect in skin development such that
trauma results in blisters, some forms being fatal.

NOTE* Nikolsky’s Sign is present in pemphigus vulgaris. It consists of e.

pressing an existing bulla vertically with the finger tip and seeing an
adjacent bulla form as the fluid is gently forced peripherally to
cleave the epidermis
Inflammatory: pemphigus vulgaris and its variants (autioimmunity to
intercellular epidermal glycoproteins), bullous pemphigoid (eosinophils in
bullae), Friction blisters

5. Dermatitis (Eczema):
a. Contact dermatitis:
i. irritant: produce direct toxic injury to skin. Eg: acids caustic
chemicals, etc.
ii. Allergic: sensitized to allergen after exposure: poison ivy, poison
oak, shoe ingredients, sock dyes, etc.
b. Atopic dermatitis: Affected individuals show triad of skin disease, asthma,
hayfever/allergic rhinitis. Three stages, infantile (2 months-2 yrs), childhood
(3-11), and adult (12-20). It is usually symmetrical, and is diagnosed by
pruritis, morphology and distributions proper for age, chronic relapsing
course, and personal or family history of above triad.
c. Dermatophytid (ID) reaction: a secondary allergic reaction occurring
distant to the pre-existing dermatitis. Most common is caused by stasis
dermatitis; can also be caused by dermatophyte infection on feet. Usually
occurs on upper extremity and is bilateral and symmetrical.
d. Dyshidrotic Eczema or Pompholyx: seen on palms and soles as ‘tapioca’
like vesicles. Usually resolve spontaneously in 1-3 weeks.

6. Papulosquamous diseases: inflammatory reaction with papules and

plaques with scale
a. Psoriasis: Chronic disease characterized by epidermal hyperplasia and a
greatly accelerated turnover rate of cells. Discrete papules may coalesce to
form erythematous plaques. The lesions are covered by a silvery scale. Seen
on the elbows and knees most frequently, lesions tend to favor extensor
surfaces and are usually symmetrical and bilateral. The “Koebner
phenomenon” is the occurrence of a lesion at an area of trauma. Nails can
be affected by psoriasis: pitting, onycholysis, and “oil spots” (circular areas
of discoloration under the nail plate).
b. Pustular psoriasis: Sterile pustules on the soles. Treat first with topicals.
c. Lichen Planus: Inflammatory and Pruritic Polygonal Planal and Papular
disease of the skin and mucous membranes. The lesions appear violaceous
(Purple) and may show a network of white lines (Wickham's striae). Oral
lesions have a white lacy appearance. Nail changes may include Pterygium.
Lesions tend to favor the flexor surfaces.
d.Pityriasis Rosea: self-limiting, benign macules and papules, oval shaped,
lesions appear with distinctive 'peripheral collarette' of scaling on a pink
base. Onset of herald patch, a solitary lesion on the buttock or trunk that
precedes the others, it then follows the skin lines and has an ‘inverted
Christmas tree’ pattern on the trunk.
e. Secondary Syphilis: Oval pink macules (non-pruritic) occur on the palms
and soles, associated lymphadenopathy, malaise, sore throat and low grade
fever. (+VDRL). Hyperkeratotic pitted papules may occur on the palms and
soles
f. Pityriasis Rubra Pilaris: Very rare. Type I most common and is adult onset.
Rash begins at head and moves caudally. Palms and soles become yellowish
with scale and skin has a red papular rash that skips areas of the body—
resulting in “islands of sparing”. Most patients are clear of lesions within 3
years. There are 4 other disease subtypes.

7. Painful tumors of the skin (ANGEL): Pain frequently occurs but not in
all cases
a. Angiolipoma: Vascularized tumors of adipose tissue
b. Neurilemoma: A benign tumor of Schwann cells (Schwannoma)
c. Glomus tumor: Arises from glomus body in the nail bed. Triggered by
pressure, trauma, and cold. Intense pain which may feel ‘pulsating’ to the
patient.
d. Eccrine spiradenoma: An eccrine sweat duct tumor, paroxysmal spasms of
pain
e. Leiomyoma: A smooth muscle tumor (arrector pili muscle and vascular
smooth muscle pilar leiomyoma and angioleiomyoma, the latter also called
vascular leiomyoma)

8. Non-malignant pigmented lesions:

a. Mole: a small mammal or cheesy reality TV show
b. Nevus or Melanocytic Nevus: benign proliferation of cells and appropriate
term to use
c. Junctional Nevus: benign proliferation of nevus cells along the
epidermal/dermal junction. They are usually small, flat, and brown;
Compound nevus: the nevus cells extending from the epi/derm jxn to the
dermis; Intradermal nevus: the junctional component of the nevi resolves
and the intradermal section is left (may look papillomatous).
d. Halo nevus: melanocytic nevus with area of depigmentation around it.
Most are benign
e. Blue nevus: a melanocytic nevus with a deep dermal component of
melanocytic cells. Causes to look blue, black, or gray on surface
f. Spitz nevus: melanocytic nevus that occurs in children—but can occur at
any age. Has atypical cells and may present on lower extremities.

9. Pre-malignant lesions:
a. Actinic keratoses: (AKA Solar keratoses) sun induced pre-malignant
lesions; can become squamous cell Ca 2-5% of the time, usually scaly, red
bumps with cutaneous horns and confined to the epidermis. TX: 5-
fluorouracil topical, surgical excision, cryotherapy
b. Bowen’s Disease: (AKA Squamous Cell Carcinoma in situ) may appear on
any skin surface as persistent erythematous plaques with scale. TX:
curettage, cryosurgery, excision
c. Keratoacanthoma: controversy whether this is benign or malignant.
Appears on sun-exposed skin as flesh colored domes with a central keratin
plug and grow rapidly. 10% may become invasive SCC.

10. Malignant Lesions:

a. Basal Cell Carcinoma:
i. There are 5 clinical subtypes; most common: nodular; more
important types: superficial spreading, morpheaform, and nodulo-ulcerative.
ii. These are essentially non-metastastic (with the exception of a few
situations)
iii. Present as pearly papules with telangiectasias
iv. Basal Cell Nevus Syndrome (Nevoid Basal Cell Epithelioma
Syndrome/Gorlin's Syndrome) demonstrates many abnormalities including
"ham-colored pits" on the palms and soles, basal cell carcinoma lesions
presenting at puberty, and odd facial appearance including wide set eyes.
Rare.
v. Treatment of BCC: excision, curettage + electrosurgery, laser,
cryosurgery, radiation, Moh’s surgery
b. Squamous cell carcinoma:
i. may resemble BCC, Actinic Keratosis, or warts. Initially may appear
as red lesion with scale and ill-defined.
ii. more aggressive than BCC and may metastasize. May arise in burn
scars, draining sinus tracks, ulcers.
iii. verrucous carcinoma is a clinical variant of SCC. Look like warts and
may appear on lower extremity
iv. TX of SCC: excision, curettage + electrosurgery, Moh’s surgery,
radiation
f. Melanoma: A malignant tumor of melanocytes and nevus cells showing
association with UV-A exposure and mutations in tumor suppressor genes.
Individuals with fair skin and burn easily have a higher incidence.
ABCD’s of Melanoma: A=asymmetry, B=border and bleeding, C=color,
D=diameter, E=elevation
The types of melanoma are:
i. Lentigo maligna melanoma: Occurs mostly on face and other sun-
exposed sites. Appears as flat, irregularly shaped.
ii. Superficial spreading melanoma: Most common type in caucasians.
Appears as brown or black macule that may have a papular component.
iii. Nodular melanoma: a brown or black papule that slowly enlarges
and may ulcerate—may look like a non-healing ulcer.
iv. Acral melanoma: Most common type seen in Blacks, Asians, and
Hispanics. Appears as black or brown spot on non hair bearing skin (palms,
soles, nailbeds). Regarding the nailbed, subungual melanoma must be
differentiated from a subungual macule and trauma induced hematoma.
Clues in diagnosis may be single lesion that is not symmetrical in size or
color. Hutchinson’s sign or pigment leaching onto nail fold is a major clinical
sign.

Clark's Classification (according to histologic level of invasion)

Level 1: tumor cells in epidermis only
Survival rate with excision=100%
Level 2. cells in epidermis that extend, but do not fill papillary dermis
Survival rate with excision=>95% at 5 years
Level 3: cells in epidermis that extend into and fill papillary dermis
Survival rate with excision=>90%
Level 4: cells extend into reticular dermis
Survival rate with excision=75% at 5 years
Level 5: cells extend into subucticular fat
Survival rate with excision=<50% at 5 years
 Breslow’s Depth: more precise assessment and more easily
reproducible
mm depth 5-year survival
<0.75 95-99%
0.76-1.49 90-95%
1.50-4.00 60-75%
>4.00 <50%

v. Amelanotic melanoma: a non-pigmented nodular variant. May be

confused with other non-pigmented lesions which may delay diagnosis.
g. Biopsy:
i. In situ (lentigo maligna) should have a border of 0.5cm when excising
ii. lesions with Breslow’s depth of <1mm should have 1cm margins
iii. depth of 1-2mm should have margin of 1-2cm margins
iv. Incisional biopsies do not cause tumor to spread locally or
metastasize!
v. The steps to treatment are: establish diagnosis histologically,
excise tumor completely (may need plastics for this), assess for metastatic
disease (Lymph node exam/possible dissection, lab tests such as CBC & LFT,
chest x-ray), follow up skin exams for duration of patients life. Important to
consult oncology for both surgery and chemotherapy.

11. Collagen Vascular Diseases:

a. Subacute Cutaneous lupus erythematosus: scaly, superficial macules,
patches, and papules. Photodistributed (upper chest, back, forearms). Lasts
weeks-months. Must test patient for presence of Systemic Lupus
Erythematosus (SLE). Tx: sunscreen, antimalarials, topical steroids
b. Dermatomyositis: affects skin and muscles. Appears as erythematous to
violaceous papules and plaques. Gottron’s sign are symmetric violaceous
lesions on knuckles, elbows, knees, medial ankle.
d. Scleroderma: chronic disease that leads to fibrosis
CREST syndrome represents one type- C (calcinosis cutis), R (Raynaud's), E
(esophageal involvement), S (sclerodactyly) and T (telangectasias). May be
associated with Sjogren's syndrome; Localized scleroderma= morphea
Generalized type= progressive systemic sclerosis

12. Granulomatous Diseases

a. Sarcoidosis: A multisystem granulomatous disorder of unknown etiology.
Affects young adults. An acute onset with erythema nodosum is usually self-
limiting. An insidious onset may be followed by progressive fibrosis. Most
common skin lesion is skin colored (may be red, yellow, violet, brown also)
papules that commonly present on face and neck.
b. Erythema nodosum: Not a granulomatous disease, but a panniculitis.
Presents as erythematous tender nodules on anterior shins. It may be
associated with strep infections, drugs (Oral contraceptives), sarcoidosis,
ulcerative colitis, and leukemia. Biopsy from center of lesion. TX: underlying
disorder, NSAIDs.
c. Granuloma annulare: Violaceous or flesh colored papules in annular
configuration. Affects dorsum of hands and feet most commonly. Self-
limiting and rarely associated with systemic issues. A disseminated
presentation of GA should be worked up for diabetes mellitus.

13. Miscellaneous Diseases

a. Necrobiosis lipoidica: Most common on pretibial areas. Starts as
erythematous papules that become annular lesions that have a yellow-brown
color. These may atrophy and then ulcerate in the center. Approx 60%
patients have diabetes mellitus.
b. Other skin diseases associated with Diabetes Mellitus: calciphylaxis
(necrotic areas that may progress to gangrene on legs), granuloma annulare,
acanthosis nigricans (velvety hyperpigmented skin at skin folds), eruptive
xanthoma (papules that erupt suddenly on elbows and buttocks), diabetic
bullae (arise on dorsum of feet, non-inflammatory), stasis dermatitis,
peripheral neuropathy (obviously predisposes one to ulcers), diabetic
dermopathy (circumscribed atrophic brown lesions on lower extremity).
c. Schamberg’s Disease: (AKA progressive pigmented purpuric dermatosis)
are small macules that coalesce into patches. Characteristic ‘cayenne
pepper’ spots. Seen on pretibial areas and ankles in males age 30-60. May
resolve spontaneously or may need mid potency topical steroids.
d. Henoch-Schonlein purpura: purpura that will involve the extremities and
buttocks most commonly in children 3-10.
e. Porokeratosis of Mibelli: Begins as scaly papule with irregular borders. It
has a velvety or warty rim with small furrows running through the center.
Some may precede development of basal cell or squamous cell carcinoma.
Affects extremities. May have family history of porokeratosis.
12. Ulcers: The following table lists the more common causes of lower
extremity ulcerations