Dermatology for the Non-Dermatologist

May 30 – June 3, 2018 -1-

Fundamentals of Dermatology

Describing Rashes and Lesions

History remains ESSENTIAL to establish diagnosis – duration, treatments, prior history of skin
conditions, drug use, systemic illness, etc., etc. Historical characteristics of lesions and rashes are also
key elements of the description. Painful vs. painless? Pruritic? Burning sensation?

Key descriptive elements – 1- definition and morphology of the lesion, 2- location and the extent of the
disease.

DEFINITIONS:

Atrophy: Thinning of the epidermis and/or dermis causing a shiny appearance or fine wrinkling
and/or depression of the skin (common causes: steroids, sudden weight gain, “stretch marks”)
Bulla: Circumscribed superficial collection of fluid below or within the epidermis > 5mm (if <5mm 
vesicle), may be formed by the coalescence of vesicles (blister)
Burrow: A linear, “threadlike” elevation of the skin, typically a few millimeters long. (scabies)
Comedo: A plugged sebaceous follicle, such as closed (whitehead) & open comedones (blackhead) in
acne
Crust: Dried residue of serum, blood or pus (scab)
Cyst: A circumscribed, usually slightly compressible, round, walled lesion, below the epidermis, may
be filled with fluid or semi-solid material (sebaceous cyst, cystic acne)
Dermatitis: nonspecific term for inflammation of the skin (many possible causes); may be a specific
condition, e.g. atopic dermatitis
Eczema: a generic term for acute or chronic inflammatory conditions of the skin. Typically appears
erythematous, edematous, papular, vesicular, and crusted. When chronic it leads to lichenification
and sometimes hyperpigmentation. Usually itches and burns. May be specific condition; e.g.,
“nummular eczema”, or nonspecific term “eczematous eruption” or “hand eczema”
Erosion: Loss of portion of the epidermis, superficial and non-scarring (area after a vesicle or bulla
ruptures); also see ulcer
Eruption: a “breaking out” of the skin or rapidly developing dermatosis
Erythematous: a 5 syllable word for “red”
Exanthem: a skin eruption typically due to a viral (or some bacterial) systemic disease
Excoriation: similar to erosion, but from self-inflicted removal of some or all of the epidermis (scratch)
Fissure: Vertical “cut” extending into the dermis. (anal fissure, “cracked skin” from T. pedis)
Hive: (see wheal)
Hyperkeratotic: Localized thickening of the epidermis (stratum corneum layer), (wart, callous)
Keloid: Abnormally hypertrophied scar
Lichenification: Leathery induration and thickening of the skin with hyperkeratosis due to long standing
scratching or irritation, marked prominence of normal skin lines (many chronic dermatoses)
Macule: Flat, nonpalpable lesion with color change (hyper- or hypopigmented, erythematous) less than
5-10mm (larger than 5-10mm  patch) (freckles, flat nevi)
Morphology: Shape of the primary lesion, e.g. linear, round.
Nodule: A solid lesion (5-20mm) with an appreciable deep (dermal and/or subcutaneous) component,
(lipoma, dermatofibroma)
Fundamentals of Dermatology
Daniel J. Van Durme, M.D.
Dermatology for the Non-Dermatologist
May 30 – June 3, 2018 -2-

Papule: Raised lesion less than 5-10 mm (larger than 10mm  plaque or nodule) (wart, actinic keratosis)
Patch: a larger flat, nonpalpable lesion – or macule that is > 1cm, (some will still call these macules)
Petechiae: small (< 5mm) hemorrhagic (red-purple) non-blanchable discolorations (>5mm purpura)
(meningococcemia, Rocky Mountain Spotted Fever, DIC, viral exanthem)
Plaque: A flat topped, elevated area of the skin larger than 5-10mm, may be formed from coalescence of
papules, (psoriasis, seborrheic keratosis)
Primary skin lesions: the initial recognizable skin lesion or basic skin changes (macule, papule, patch,
plaque, vesicle, bulla, nodule, tumor, pustule, wheal, cyst, telangiectasia)
Purpura: larger (>5mm) hemorrhagic (red-purple) non-blanchable discolorations (<5mm petechiae)
(vasculitis, Henoch Schonlein purpura)
Pustule: Circumscribed lesion filled with purulent material (acne, folliculitis)
Scale: Surface alteration resulting in a “flaky” surface, due to abnormal proliferation of the outermost
epidermal layer, the stratum corneum, may be fine, or thick and greasy, or loose or adherent.
(seborrheic dermatitis, psoriasis)
Secondary skin lesions: Changes which occur as a result of the natural development of, or due to external
manipulation of the primary lesion. (sometimes the secondary changes make it impossible to
see and describe the primary lesion) (scale, lichenification, keloid, excoriation, fissure, erosion,
ulcer, atrophy, crust, hyperkeratosis)
Telangiectasia: dilated superficial capillary/venule; may be linear, spiderlike, or matlike. (rosacea, BCC)
Tumor: A large solid lesion (> about 2 cm), with deeper dermal or subcutaneous thickness (a large
nodule)
Ulcer: Loss of skin extending into the dermis, scarring (any loss that penetrates the dermal-epidermal
junction scars), see also erosion
Urticarial: A well defined, localized area of edema- a wheal, often intensely pruritic.
Vesicle: Well circumscribed fluid-filled lesion up to 5-10mm. (>10mm  bulla) (herpes, varicella)
Wheal or hive: A localized edematous plaque-like lesion, somewhat irregular and transient.

Remember: Changes with size Changes with depth

Macules  patches Erosionulcer
Papules  plaques (or nodules)
Vesicles  bullae

“Maculo-papular” should be about 50-50 of both

Fundamentals of Dermatology
Daniel J. Van Durme, M.D.
Dermatology for the Non-Dermatologist
May 30 – June 3, 2018 -3-

Morphologic Characteristics

Shape/arrangement

Round/discoid coin shaped, no central clearing nummular eczema

Oval ovoid pityriasis rosea
Annular round, with active margin and central clearing tinea corporis
Reticular net-like or lacy lichen planus
Linear in a line contact dermatitis
Iris/target purple papule in the center of pink macule erythema multiforme
Serpiginous snakelike or wavy line track cutaneous larval migrans
Polycyclic interlocking or coalesced circles psoriasis
Morbilliform measles-like; maculo-papular lesions with roseola, mononucleosis
confluence on the face and body

Border/Margin

Discrete (psoriasis) or indistinct (many types of eczema) or irregular (malignant melanoma)

Feel

Indurated (SCC), hard (dermatofibroma), soft (skin tag), sclerotic (venous stasis ulcers)

Color changes

Erythema - pink (genital warts, roseola), salmon-colored (pityriasis rosea), brawny (candidiasis)
Violaceous – Kaposi’s sarcoma, lichen planus
Yellow – xanthoma, psoriatic nails
Tan-brown – most benign nevi
Black – malignant melanoma
Pearly – basal cell carcinoma
Honey-colored crusts – impetigo

Other changes/aspects

Desquamation – dyshidrotic eczema, toxic shock syndrome

Hyperkeratotic – (hypertrophic stratum corneum) AK’s, calluses, warts
Central umbilication or punctation – molluscum contagiosum, BCC
Verrucous – wartlike, seborrheic keratosis and warts
Satellite lesions – candidiasis, impetigo
Macerated – chronically wet – interdigital tinea pedis
Weeping/oozing – acutely inflamed contact dermatitis
Guttate – drop-like (guttate psoriasis)

Fundamentals of Dermatology
Daniel J. Van Durme, M.D.
Dermatology for the Non-Dermatologist
May 30 – June 3, 2018 -4-

Location and distribution

Localized, regional, or generalized
Dermatomal – herpes zoster
Sun-exposed areas – sunburn, SLE, porphyria, photosensitivity to drugs
Clothing covered area – contact dermatitis, miliaria
Flexural areas – atopic dermatitis, intertrigo, candidiasis, tinea cruris
Extensor areas – psoriasis, atopic dermatitis in infants, eruptive xanthomas
Truncal – pityriasis rosea, drug eruptions

(Description terminology is from Mosby’s Guide to Physical Examination, Bates Guide to Physical Exam and History Taking
and Dermatology texts listed below)

Dermatology textbooks – (I am frequently asked which dermatology texts I recommend and use, while there are many excellent
texts out there, these three are my personal favorites and are used often in my office.)

 Preferred texts –
– Habif – Clinical Dermatology – 5th Edition – 2010. Also gives access to great website - Expert Consult by
Elsevier. Cost about $175
– Klaus – Fitzpatrick’s Color Atlas and Synopsis of Clinical Dermatology 6th Ed - 2005 – About $80

Websites
 EXCELLENT Tutorial for describing skin conditions – Interactive Dermatology Tutorial:
http://www.logicalimages.com/morphology/morphology3_content.html

If your charts do not routinely include words like macules, papules, plaques, nodules, ulcers, petechiae, etc. – then review this
tonight to avoid confusion over next few days.

 Dermatologic Image Database from University of Iowa -

http://www.healthcare.uiowa.edu/dermatology/DermImag.htm
 The Electronic Textbook of Dermatology - http://www.telemedicine.org/stamfor1.htm
 Johns Hopkins Dermatology Image Atlas – www.dermatlas.com
 Dermatology Information System – comprehensive online derm info - www.dermis.net

Fundamentals of Dermatology
Daniel J. Van Durme, M.D.