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DermatologyDifferentialDiagnosis byMorphology

Thomas L. Ray, M.D. Dept. of Dermatology - University of Iowa College of Medicine

http://www.healthcare.uiowa.edu/dermatology/DDX-Morph.html

This resource is not a diagnostic system ! It is not intended to be used as artificial intelligence !

The sole purpose ofDermatology Differential Diagnosis by Morphologyis to assist students and residents of dermatology in learning

differential diagnoses of skin disorders and diseases. Based on clinical and morphologic appearances ofprimaryandsecondaryskin

lesions, lists of potential diagnoses are given for major types of skin lesions. The lists are modified by additional characteristics which

may be present.

Definitions of primary and secondary skin lesions may be found by clicking on the appropriate heading. Additional information and

examples may be found inAn Introduction to Basic Dermatologyby Dr. Warren Piette and theImage Database.In some browsers

(i.e. Netscape 2.0 and later), this will open as a new browser window, so both files can be viewed simultaneously. Selected diagnoses

in the database are also linked to examples in this presentation. When finished with an example, the user should close the extra

window(s), before proceeding.

To explore differential diagnoses of skin lesions, select and click on a morphologic feature, then select and click on a modifying

feature that will be presented in subsequent tables. Click on selected diagnoses (and subsequent numbers) to access clinical

images of the entity. Each images will open as a new browser window, so that multiple images can be viewed simultaneously.

Close the additional "new" windows when finished.

In order for lists of differential diagnoses to be practical and useful, the disorders given are limited to characteristic, typical entities

commonly presenting with a morphologic feature. Thus, the diagnoses provided are not exhaustive or comprehensive lists. Theyare not all inclusive (nor exclusive) of other diseases or conditions that may present with (or without) similar morphologic features.

This resource is not a diagnostic system ! It is not intended to be used as artificial intelligence !

Please read and abide by thedisclaimer and copyright statements.

N.B. - If you have questions about skin lesions or diseases, consult a dermatologist. Inquiries to this WebSite about skin disease entities

will not be answered. If you seek additional information, try searching the WWW, or consult a dermatology textbook, readily available

at a medical library. A medical librarian can help you find the material you seek.

Definitions of Primary Lesions

Macule Papule

Nodule

Tumor Vesicle / Bulla

Pustule

Wheal Cyst

Definitions of Secondary Lesions

Scar / Atrophy

Ulcer / Erosion

Fissure

Crust Excoriation Scale / Keratosis

Lichenification Vegetating

Linear / Figurate

Miscellaneous

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Primary Lesions

There are no universally agreed upon definitions of terms or, in particular, dimensions of primary lesions. The following was offered

byWatt and Jillson*as an "easy-to-remember" formula.

Macule - circumscribed area of skin, up to 1.0 cm, with a change from normal skin color, which is neither raised above nordepressed below the surrounding skin. Many use the term for lesions much greater than 1.0 cm. Term does not

include purpura.

Patch - a flat, circumscribed, discoloration of skin or mucous membrane greater than 1.0 cm in diameter.

Papule - discrete solid area of skin that is elevated by palpation above the surrounding skin andless than 1 cm in diameter.Variations include accuminate, keratotic, flat-topped, follicular, umbilicated, pedunculated, necrotitic and others.Plaque - similar to a papule but greater that 1.0 cm in diameter. Often formed by the confluence or coalescence of papules.

Secondary features may include, among others, atrophy, lichenification or hyperkeratosis.

Nodule - descrete, solid, palpable, round or oval (elipsoidal) lesion of the skin measuring up to 1.0 cm in diameter (or long axis).Applies to processes involving any or all levels of the skin, and is a general term for any mass, benign or malignant.

Tumor - a term used by some for a "nodule" greater than 1.0 cm in diameter. Applies to processes involving any or all levels ofthe skin, and is a general term for any mass, benign or malignant.

Vesicle - a circumscribed fluid-filled lesion less than 1.0 cm in diameter that is usually elevated above the surrounding skin. Maybe described as solitary, grouped, umbilicated, dyshidrotic, spongiotic, multi-locular or uni-locular.

Bulla - a circumscribed fluid-filled lesion greater than 1.0 cm in diameter that is usually elevated above the surrounding skin.May attain diameters of several cms and are described as tense, or flacid.

Pustule - descrete elevated vesicle or bulla of skin, usually small, containing purulent exudate composed of inflammatoryleukocytes (pus), with or without cellular debris. May be superficial, deep-seated, follicular, grouped, etc. and may arisesecondarily from a vesicle.

Wheal - an evanescent, round or irregular, often flat-topped elevation of skin with a pale red color, arising from edema in thesuperficial dermis. May vary from 2-3 mm to 10 or more cm in diameter, with round or arcuate configurations. Should be

distinguished from angioedema, a massive edema involving the entire dermis and subcutaneous tissues.

Secondary Lesions

Scar - a hard plaque of dense fibrotic tissue covered by a thin epidermis. A mark of injury from any sort of process (physical orpathologic).

Atrophy - Atrophy usually refers to thinning of the epidermis leaving an easily wrinkled and/or shiny surface. Atrophy may alsoapply to dermal and/or subcutaneous tissue, with or without changes in the epidermis.

Ulcer - loss of skin tissue or substance from the surface downward, leaving an uncovered or denuded wound that is slow toheal.

Erosion - a superficial denudation of the skin, usually implying the loss of the epidermis. Fissure - a vertical splitting or separation of the skin. Crust - dried surface fluid, often serous (inspissated serum) in nature, with or without tissue debris. For purposes of this

document this includes the term "scab".

Excoriation - a scratch mark, often with denudation of the skin to form a small ulcer. Exposure of the corium by mechanicalremoval of the epidermis.

Scale - a thin flake of epithelium (mostly composed of corneoctyes) which is separated from the underlying intact skin proper. Lichenification - a thickening of the skin surface andan increase of skin markings, usually seen with chronic coalescence of

papular lesions, especially atopic eczema.

Vegetating - a lushly growing, proliferating, process, usually with elevated or exophytic features. Linear / Figurate - technically not secondary features, but included here solely out of convenience. These

are configurations that skin lesions may assume, which aid in their diagnostic identification. Figurate includes geometrical

shapes (e.g. annular, arciform, cyclic, etc.).

Watt, T.L. and Jillson, O.F.: Archives of Dermatology 90:454, 1964.

Created June, 1996

Copyright 1996 -2001, Dept. of Dermatology, University of Iowa. All rights reserved. Republication or redistribution of Dept. of

Dermatology, University of Iowa content, including by framing or similar means, is expressly prohibited without the prior written

consent of the Dept. of Dermatology, University of Iowa. The Dept. of Dermatology, University of Iowa shall not be liable for any

errors or delays in the content, or for any actions taken in reliance thereon. The information on these pages may not be used or

redistributed without written permission from the Department of Dermatology, College of Medicine, The University of Iowa.

Copyright 1996 - 2004 Dept. of Dermatology / University of Iowa / All Rights Reserved /

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