An approach to Dermatologic Differential Diagnosis

Susan Burgin, MD
Assistant Professor of Dermatology
Beth Israel Deaconess Medical Center, Harvard Medical School

Ruth Ann Vleugels, MD

Instructor of Dermatology
Brigham and Womens Hospital, Harvard Medical School

Context:

The skill of physical diagnosis is a vital and pressing need in dermatologic

education. Cognitive psychologists have shown that diagnostic reasoning takes
place through activation of scripts- networks of relevant knowledge and
experience that direct selection and interpretation of new information. Pattern
recognition is another processing strategy employed in dermatology.

My system of diagnosis aims to provide a problem-solving method to assist in

pattern recognition and the formation of scripts. It consists of a series of
algorithms and pathways that allow for the creation of differential diagnoses for a
broad range of inflammatory, infiltrative and neoplastic dermatoses.

Our 90 minute session will cover the following aspects of creating a differential
diagnosis:

1) The Wheel of Dermatologic Diagnosis

2) The concept of Reaction Patterns and an approach
3) Differential Diagnosis by Color

Cases will be used to illustrate the concepts throughout.

Copyright: Susan Burgin, MD

 Color
THE WHEEL OF DIAGNOSIS
SUSAN BURGIN, MD
Reaction pattern

Primary lesion

Macule
Papule/ Nodule/ Tumor
Vesicle/ Bulla
Pustule
History Plaque

Duration Grouping
Where did it start
How did it spread/change Annular
Itch/pain Linear
First episode? Other: herpetiform
Explosive onset? agminate
Medical problems
Medications Distribution

Photoexposed
Seborrheic
Glean information from: Flexors
Flexures
Scalp/ hair Extensors
Nails Periorbital
Mucous membranes Palms and soles
Lymph nodes Relation to appendages:
- follicular
- eccrine
- sebaceous

Special tests
Raise scale with back of Q-tip: silvery in psoriasis= modified Auspitz
Firm stroking: dermatographism, Dariers sign, nevus anemicus
Diascopy: blanch or not, nevus anemicus, apple jelly of sarcoid
Mineral oil: Wickhams striae
Lab in the clinic: KOH, mineral oil, Gram, Tzanck, Wrights stain
Hair pull; hair morphology under LM
Dermoscopy
Woods lamp
Specimens for bacterial, fungal culture; biopsy: H&E, culture

Copyright: Susan Burgin, MD

1) The Reaction Patterns

1. Papulosquamous

2. Eczematous
a. Acute, subacute, chronic
b. Etiology: endogenous vs exogenous

3. Vesicobullous
a. Infectious, inflammatory, para/neoplastic, drug
b. Tense, flaccid?
c. Arising normal/ urticarial skin

4. Vascular
a. Erythema
b. Urticaria vs urticarial
c. Target lesions vs targetoid
d. Vasculitis

5. Dermal/infiltrative
a. Inflammatory cells: lymphocytes, eosinophils, neutrophils,
Langerhans cells, histiocytes (granulomatous or
proliferations thereof), mast cells
b. Depositional: mucin, amyloid, lipid, calcium, urate, etc
c. Neoplastic cells: benign or malignant (the purple plum)

Copyright: Susan Burgin, MD

2) Color

For example:
1. Yellow
a. Pus
b. Xanthoma
c. Xanthogranuloma (to yellow-orange)
d. Sebaceous structures: Fordyce spots, seb neoplasms
e. Tophus (to yellow-orange)
f. Calcium
2. Orange
a. PRP
b. Tophus, xanthogranuloma
3. White
a. Milia, cysts
b. Calcium,tophus
c. Scar
d. Macules: depigmented or hypopigmented
e. Porcelain-white: atrophie blanche, Degos disease
4. Purple(=violceous)
a. Lichenoid processes
b. Necrosis (dusky)
c. Fading erythema
d. Purple plum =purple nodule
i. Vascular proliferation: benign or malignant- eg KS,BA
ii. Malignant neoplasm: DFSP, amelanotic melanoma,
lymphoma, metastasis
5. Gray
a. Dermal pigment
i. Old interface eg EDP
ii. Dermal melanocytosis
iii. Photo-drug eg tricyclics, amiodarone (blue-gray or gray-
purple)
b. Granuloma faciale (brown-gray)
c. Any inflammation in a dark skin
6. Blue
a. Cyst
b. Pilomatricoma
c. Blue nevus (blue-black)
d. Photodrug (blue-gray)
7. Green
a. Chloroma
b. Pseudomonas
8. Variations on red:
a. Salmon-pink: psoriasis
b. Bright red: drug (drug-red)
c. Beefy red: candidiasis
Copyright: Susan Burgin, MD