Chapter 13: Dermatology

The Skin
Dermatological Lesions
 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 responses, thermoregulation, perception of the
environment, excretion, limitation of harmful radiation, and nutrition. The
skin is composed of two layers the epidermis and the dermis.
1. Epidermis:
a. This is composed of a stratified squamous epithelium containing cells that
become specialized for the production of keratin.
b. There are five strata in the thickness of the epidermis
i. Stratum basale
ii. Stratum spinosum
iii. Stratum granulosum
iv. Stratum lucidum
v. Stratum corneum
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 basal cell layer. 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 epidermis 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 Dermas:
a. The dermis is composed primarily of connective tissue and consists of two
layers: a 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 arterioles, venules, capillaries, larger nerves,
and adnexal structures

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. Sweat glands: Are present throughout the foot. These are eccrine types
c. Nails: Are present on the dorsal-distal aspects of all toes

4. Special Structures:
a. Vater-Pacini 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, and elevated due to an intradermal infiltrate
d. Plaque: A circumscribed, solid elevation exceeding 1 cm. in diameter, but
usually not over 2 cm. in diameter
e. Nodules: Circumscribed, solid elevations exceeding 2 cm in diameter, but
not usually exceeding 3 cm. in diameter
f. Tumors: Circumscribed, solid elevations of larger size than nodules

NOTE* The definitions may be somewhat artificial because of colloquial

usage such as "tumor nodules", and some informal overlap occurs in g.
the use of the terms "nodule" and "tumor".
Vesicles: Fluid-filled, elevated lesions, under 1 cm. in diameter (small
blisters)
h. Bullae: Fluid-filled, elevated lesions, 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. Burrow: An intraepidermal tunnel usually caused by insects (scabies,
tunga penetrans/chigoe)

2. Secondary lesions:
a. Scales: Products of imperfect and frequently rapid epidermal turnover,
occurring in "papulosquamous" diseases, with a great deal of exfoliation.
Examples include psoriasis, lichen planus, dermatophytosis
b. Excoriations: Scratch marks, usually seen where there is pruritus. These
show epidermal discontinuities.
c. Erosions: These are deep excoriations in the epidermis, but the dermis is
not breached. These leave no scars upon healing
d. Ulcers: Deep epidermal defects in which the dermis or deeper tissues are
exposed. These may leave scars when healed
e. Crusts: These are "scabs", i.e. aggregations of dried serum or blood with
other cellular debris
f. Fissures: Linear, deep epidermal cracks in the skin, penetrating to the
dermis and common in areas of dry skin
g. Scar: Also called "cicatrix", and resulting from inflammatory or traumatic
destruction of subepidermal connective tissue. Scarring is a normal reaction,
and that final portion of dermal healing called " fibrosis"
i. Hypertrophic scarring represents an abnormal response that will eventually
reduce itself
ii. Keloids represent abnormal scarring responses that continue beyond the
borders of the inciting injury, and progress to cause contractures
andinterference 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. Pustule: An elevated, circumscribed lesion containing pus, and arising
from infections of papules, vesicles or bullae.
i. Abcess: is a deep circumscribed collection of pus
ii. Furuncle (Boil): is an abcess originating in a hair follicle
iii. 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. Vesiculobullous Disorders:
a. Viral: Herpes simplex, herpes zoster (shingles), Kaposi's varicelliform
eruption, varicella (chicken pox), variola (small pox), molluscum
contagiosum, hand-foot mouth disease (coxsackie Al 6 virus)

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

multinecleated giant cells or other viral cytopathic effects
Fungal: T. mentogrophytes, T. rubrum, T versicolor (etiological agent is
Malassezia furfur), other fungi and yeasts
c. Other:
i. Benign familial pemphigus (Hailey-Hailey disease), pemphigus vulgaris and
its variants (autioimmunity to intercellular epidermal glycoproteins), bullous
pemphigoid (eosinophils in bullae), dematitis herpetiformis (neutrophils in
bullae) often present with gluten enteropathy, Darier's keratosis follicularis,
bullous impetigo

NOTE* Nikolski Sign is present in pemphigus and in bullous impetigo. It ii.

consists of 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
Epidermolysis bullosa (all 16 types) represents a defect in skin development
such that trauma results in blisters, some forms being fatal. The feet are
affected by many types, such as the Weber-Cockayne and EB dystrophica
dominant types

4. Dermatitis (Eczema):
a. Contact dermatitis:
i. Primary irritant: acids caustic chemicals, etc.
ii. Allergic: poison ivy, poison oak, shoe ingredients, sock dyes, etc.
b. Atopic dermatitis: Affected individuals show atopy, asthma, hayfever, and
other forms of allergic rhinitis, blood serum with >IgE. Three stages, infantile
(2 months-2 yrs), childhood (4-10), and adult (12-25). It is usually
symmetrical, and is diagnosed by the area of involvement, and the familial
history of allergy not the rash itself (biopsy non-specific)
c. Dermatophytid (ID) reaction: Allergic reaction incited by a fungal infection.
There are other ID reactions as well, in other dermatoses
d. Dyshidrosis: Pompholyx of palms and soles (difficult to treat)

5. Papulosquamous diseases: Represent a category of dermatitis that

produces an inflammatory papule and scaling. This goup includes
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 "micaceous" silver
scales. Seen on the elbows and knees most frequently, lesions tend to favor
extensor surfaces. The Koebner phenomenon is the occurrence of a lesion
at an area of trauma, and also occurs in other skin diseases b. Pustular
psoriasis: Sterile pustules on the soles. Very difficult to treat. Nails may be
pitted
c. Lichen Planus: Inflammatory and pruritic disease of the skin and mucous
membranes. The lesions appear violaceous and may show a network of white
lines (Wickham's striae). Oral lesions have white lace appearance. Nail
changes may include pterygium. Lesions tend to favor the flexor surfaces.
Bullous lichen planus on the soles of the feet may become squamous Ca.
d. Pityriasis Rosea: Pruritic macules and papules, oval shaped, lesions appear
with distinctive 'collarette' of scaling on a pink base. Onset of herald patch,
a solitary lesion on the buttock or trunk that precedes the others and that
follows the skin lines. The disease is self limiting
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: Type I shows small follicular papules, distinct
location dorsal portion of digits, 'nutmeg grater' appearance; lesions
coalesce to form plaques. Palmoplantar hyperkeratoses arise. Most patients
are clear of lesions within 3 years. There are 4 other disease subtypes.

6. 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
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)

7. Non-malignant pigmented lesions:

a. Epidermal melanocytes: Nevus spilus (present at birth), solar lentigo, and
ephilides (freckles)
b. Dermal melanocytic lesions: Blue nevus, junctional nevus (can become
malignant melanoma), compound nevus, halo nevus (Sutton's nevus,
leukoderma acquisitum centrifugum) and Spitz's nevus (benign juvenile
melanoma, spindle and epitheloid cell nevus). About half the cases occur in
adults

8. Pre-malignant lesions:
a. Actinic keratoses: Solar keratoses, pre-malignant, can become squamous
cell Ca, usually scaly and telangiectatic and confined to the epidermis. TX: 5
FU, surgical excision
b. Xeroderma pigmentosum: Genetic disease with sensitivity to sun,
basal/squamous carcinomas can develop, as well as melanomas
c. Bloom's syndrome: Genetic defect involving skin with sun sensitivity,
growth retardation and sometimes immunodeficiencies. A high risk for
leukemia and lymphoma, as well as GI carcinomas
d. Ataxia telangiectasia: Genetic defect involving skin and nervous system.
Numerous ectasias appear, many affecting the lower extremities.
Sinopulmonary infections are common. High risk of leukemia and lymphoma
e. Porokeratosis of Mibelli: Papular lesion with central keratosis that expands
to form a circinate lesion with a furrow containing keratin. Some may
precede development of squamous carcinoma. Some are hereditary.

9. Malignant Lesions:
a. Basal Cell Carcinoma:
i. There are 5 clinical subtypes, the most common of which is the
noduloulcerative or "rodent ulcer" type
ii. These are essentially nonmetastastic (with the exception of a few
situations)
iii. The Basal Cell Nevus Syndrome (Nevoid Basal Cell Epithelioma
Syndrome/Gorlin's Syndrome) demonstrates many abnormalities including
"ham-colored pits" on the palms and soles that are basal cell carcinomas. In
this syndrome, basal cell carcinomas are aggressive
iv. Bazex Syndrome demonstrates hyperkeratoses of the palms and soles
preceding and associated with visceral carcinomas (acrokeratosis
neoplastica) and basal cell carcinomas resembling tricoepitheliomas
v. Basal cell carcinomas also occur in the Linear Unilateral Basal Cell Nevus
vi. In general lesions should be excised in toto, in full depth and with a
border about 3 mm of clinically normal skin
vii. Contributors to the development of basal cell carcinoma include old
wounds, burns, ultraviolet irradiation, and x-irradiation
b. Squamous cell carcinoma:
i. The in-situ form is Bowen's disease which has not invaded the dermis, and
which is confined to the epidermis
ii. Marjolin's ulcer is a squamous cell carcinoma arising in a scar or in the
epithelium at the edge of a chronic ulceration
iii. Bowen's disease may appear as a reddish, irregular, sharply bordered
lesion with crusting or scaling. It may be present for many years. Invasive
lesions may be solid, ulcerated, or verrucous (verrucous carcinoma,
epithelioma cuniculatum). Some are more aggressive than others.
Metastases may develop. Lesions should be excised in full depth and with a
clinically normal boarder of 3-5 mm. Contributors to the development of
squamous cell carcinoma include old wounds, burns, chronic ulcers or
fistulas, x-irradiation, ultraviolet irradiation, certain arsenical and other
organic compounds
iv. Lesions that resemble squamous cell carcinoma:
• Keratoacanthoma: A lesion thought to arise from hair
follicles, in some cases it may occur as single or multiple lesions.
Single lesions develop quickly, grow and ulcerate. They may be
very difficult to differentiate clinically and or histologically from
well differentiated squamous cell carcinoma. The central area
usually contains a keratinous plug. Treatment is excision in full
thickness. Use of retinoids is preferred by some for treatment.
Some investigators consider keratoacanthoma to be a very low
grade squamous cell carcinoma that is "self healing" if left alone.
Some types heal with scarring if left alone
• Pseudoepitheliomatous hyperplasia: A thickening of
epidermis due to hyperplasia of keratinocytes. It is clinically and
histologically benign, and occurs in chronic wounds such as the
edges of ulcers or fistulas
c. Sweat gland (eccrine) carcinoma: There are many types. These are
uncommon, but can be slow-growing and aggressive. Metastases do occur in
many cases. Many are asymptomatic small papules or nodules that have
been present for many years and suddenly enlarge. Some ulcerate. Suspect
lesions should be excised in full depth and with 3-5 mm borders of normal
skin
d. Sebaceous carcinoma: Extremely rare in the feet, these have no distinct
presenting symptoms or signs. Metastasis is a risk. These lesions, if primary
in the feet (not metastatic to the foot) will not be found in the plantar tissues
which lack pilosebaceous structures. These should be excised in full depth
with a 3-5 mm boarder of clinically normal skin
e. Merkel cell carcinoma: Also called trabecular carcinoma, these cancers are
quite uncommon, but have been reported in the foot. They are very
aggressive and metastatic. There is no distinct presentation. These lesions
should be excised in full depth and with a 3-5 mm boarder of clinically
normal tissue. Also called Primary Neuroendocrine Carcinoma of Skin (PNCS)
f. Melanoma: A highly malignant tumor of melanocytes showing strong
association with ultraviolet irradiation of high intensity. Lighter skinned
persons are more apt to develop melanomas in sun-exposed areas. The
types are:
i. Lentigo maligna melanoma: Almost never occurs in the foot and is most
common on the face. They are the least aggressive (in-situ form=lentigo
maligna)
ii. Superficial spreading (pagetoid) melanoma: Most common type in all body
areas. Moderately aggressive. Histologically can resemble Paget's disease of
the breast (hence its name)
iii. Nodular melanoma: Arises anywhere in the body. Most aggressive and
malignant
iv. Acral melanoma: Occurs on the extremities and is the most common type
seen in the feet of black and oriental patients. Aggressive type

NOTE* Some consider the nodular type to represent a late phase of all the
other types, i.e. the "vertical growth phase" as compared to the earlier
"radial growth phase". Also, the true nodular type may represent a very
aggressive form with a very short radial growth phase

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

Level 1: Intraepidermal (including adnexae) to dermoepidermal border Level
2. Intradermal and into the papillary dermis
Level 3: Intraepidermal and down to border of papillary and reticular or
dermal areas
Level 4: Intraepidermal and down into the reticular dermis
Level 5: Intraepidermal, through all dermal layers and into subcu. Tissue

NOTE* Difficulties with Clark's classification as a method of prognosis is that

the skin thickness varies in different areas. Tumors in the papillary dermis
may push reticular dermis down, only giving the appearance of penetration
so that level may be overestimated. Identification of levels, and therefore
interpretation, is subjective. The border between papillary and reticular
dermis is not always clear

Breslow's Classification (according to the thickness of the melanoma)

NOTE* This is determined by direct measurement of numerous tissue
sections to obtain a figure. The criteria for measurement are not the same
as depth of invasion so that Breslow's and Clark's classifications may not
necessarily correspond
Survival is in terms of 5 years disease free
1. Under 0.76 mm: Generally excellent survival (virtually 100%)
2. 0.76-1.5 mm: Moderate survival (possible lymph node invasion)
3. Over 1.5 mm: Poor survival and increasingly poor with greater thickness
(probable lymph node and perhaps visceral invasion)

g. Amelanotic melanoma: Not different from other melanomas except for the
lack of visible pigment. Therefore, it is extremely dangerous because it is
often misdiagnosed and therefore is deeply invasive and thick by the time of
diagnosis, and probably has metastasized to the lymph nodes and viscera
h. Subungual melanoma: This must be confirmed with biopsy. The clues to
this lesion are
i. Pigmented lesion of recent origin with no history of local trauma to cause a
hematoma
ii. Pigmented lesion that does not move distally as the nail grows
iii. Sudden development of melonychia striata (pigmented stripe in the nail)
iv. Chronic non-pigmented lesion that does not respond to treatments (based
on clinical impression) within a reasonable period
v. Dusky, irregular pigmentation in eponychial tissue (Hutchinson's sign)
h. Biopsy:
i. Ideally, should be excisional including full depth to the subcutaneous fat
ii. Incisional biopsy from one or more edges, including clinically normal-
appearing skin, and always in full depth
iii. Incisional biopsy of nodular portion of lesion (if present) as well as
edge(s), in full depth

NOTE* For all malignant tumors: 10.

1. Excise as indicated by the type and extent (surgical consultation)
2. Consult with oncologist for, chemotherapy, irradiation (if indicated)
3. Arrange to detect metastases to other areas/organs (consult with
diagnostic radiologist, pathologist, and others as needed)
4. Follow-up care by those involved as attending team
Miscellaneous conditions:
a. Discoid lupus: Exacerbated by sunlight, lesions are
erythematous/scaling/telangiectic
b. Drug induced SLE: SLE can be induced by hydralazine, procainamide,
isoniazid, penicillamine, griseofulvin, phenylbutazone, methyldopa and oral
contraceptives
c. Dermatomyositis: Adult form may be associated with visceral malignancy
d. Scleroderma:
i. 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
ii. Localized scleroderma= morphea
iii. Generalized type= progressive systemic sclerosis
e. Sarcoid: A chronic granulomatous Inflammatory disease affecting various
organ systems with erythema nodosum of the legs (plaques on the
extremities) Dx: chest x-ray, Kveim test and other immunologic tests
f. Erythema nodosum: Acute inflammatory/immunologic disorder with
panniculitis and painful nodules on the anterior shins. It may be associated
with infections, drugs, sarcoidosis, ulcerative colitis
g. Granuloma annulare: Self-limiting chronic inflammation of dermis with
annular papules. The generalized papular form has been associated with
diabetes mellitus
h. Necrobiosis lipoidica: Very similar histologically to granuloma annulare
and frequently associated with diabetes mellitus
i. Pigmented purpuric diseases: There are many types that may be of the
"palpable purpura" type, or it may be nonpalpable (Shamberg's dermatosis,
Majocchi's purpura, Henoch Schonlein purpura)

NOTE* Purpuric lesions can also be seen with thrombocytopenia,

meningococcemia and gonococcemia
j. Diabetic dermopathy: May include Bullosus Diabeticorum, ulcers,
necrobiosis lipoidica, cutaneous reaction to insulin, trophic changes (pre-
ulcer) related to circulation, etc.
k. Petechial hemorrhages: May be seen in meningococcemia, gonococcemia,
platelet deficiencies, leukemias, scurvy, salicylate poisoning, bacterial
endocarditis (including subungual splinter hemorrhages), anticoagulant
overdosage, other bacterial infections (systemic) etc.
12. Ulcers: The following table lists the more common causes of lower
extremity ulcerations