Clinical Assessment Skin up to Bates Table 6-5

erythematous and suggest inflammation. See Table 6-8, Vascular and Purpuric Lesions of the Skin, p. 205.

Blanching lesions

Small linear or serpiginous pathways in the epidermis created by the scabies mite

Burrow

Multiple small (3-6-mm) erythematous papules on abdomen, buttocks, scrotum, and shaft and head of penis, with four burrows noted on interdigital web spaces;

Burrows: scabies

Red moles are common skin growths that can develop on most areas of your body. They're also known as senile angiomas or Campbell de Morgan spots. They're usually found on people aged 30 and older. The collection of small blood vessels inside give them a reddish appearance

Cherry angiomas

Three 6-8-mm mobile subcutaneous cysts on vertex scalp, that on excision reveal pearly white balls

Cysts: Pilar cysts

Solitary 2-cm tethered subcutane- ous cyst with overlying punctum releasing caseous whitish yellow substance with foul odor

Cysts: epidermal inclusion cyst

Solitary 9-cm mobile rubbery subcutaneous mass on left temple;

Cysts: lipoma

Usually appear on the lower legs, but may appear on the arms or trunk May be red, pink, purplish, gray or brown and may change color over time May be as small as a BB pellet but rarely grow larger than a fingernail Are often painless but may be tender, painful or itchy Usually dimple inward when pinched

Dermatofibroma

tinea pedis, or hard and keratotic like actinic keratoses or SCC.

Dry and fine scaling

Also known as sebaceous cyst and epidermoid cyst, is the most common cyst of the skin. It ranges in size from a few millimeters to a few centimeters and originates from the follicular infundibulum. Its contents are a cheesy, malodorous mixture of degraded lipid and keratin.

Epidermal inclusion Cyst

Inflamed hair follicle

Furuncle:

Solitary dark brown, blue-gray, and red 7-mm macule with irregular borders and fingerlike projections of pigment, on right forearm;

Macule: malignant melanoma

Solitary 6-mm dark brown round symmetric macule on upper back

Macules: benign melanocytic nevus

Solitary dark brown, blue-gray, and red 7-mm macule with irregular borders and fingerlike projections of pigment, on right forearm;

Macules: malignant melanoma

Multiple 3-8-mm erythematous confluent round macules on chest, back, and arms;

Macules: morbilliform drug eruption

Multiple 2-5-mm hypopigmented, hyperpigmented, or tan round to oval macules on upper neck and back, upper chest, and arms with slight inducible scale on scraping

Macules: tinea versicolor

May occur in same distribution on forehead, central face Scale is less keratotic and will improve with moisturizers, mild topical steroids

Mimic: Superficial Xerosis Seborrheic dermatitis

Larger and deeper than a papule

Nodule

Solitary blue-brown 1.2-cm firm nodule with positive dimple sign and hyperpigmented rim on left lateral thigh

Nodule: dermatofibroma

Solitary 4-cm pink and brown scar-like nodule on central chest at site of previous trauma

Nodule: keloid

Solitary 7-mm oval pink pearly papule with overlying telangiectasias on right nasojugal fold;

Papules: basal cell carcinomac1

Scattered erythematous round drop-like, flat- topped well-circumscribed scaling papules and plaques on trunk;

Papules: guttate psoriasis

Multiple 3-5-mm pink firm smooth domed papules with central umbillications, in mons pubis, and on penile shaft;

Papules: molluscum contagiosum

Multiple 2-4-mm soft, fleshy skin-colored to light brown papules on lateral neck and axillae in skin folds;

Papules: skin tags

Bilaterally symmetric erythematous patches on central cheeks and eyebrows, some with overlying greasy scale;

Patches: seborrheic dermatitis

Large confluent completely depigmented patches on dorsal hands and distal forearms;

Patches: vitiligo

Bilateral erythematous, lichenified (thickened from rubbing) poorly circumscribed plaques on flexor wrists, antecubital fossae, and popliteal fossae;

Plaques: atopic dermatitis

Multiple round coin-like eczematous plaques on arms, legs, and abdomen, with overlying dried transudate crust;

Plaques: nummular dermatitis

Multiple round to oval scaling violaceous plaques on abdomen and back;

Plaques: pityriasis rosea

Single, oval, flat-topped superficial erythematous to skin-colored plaque on right abdomen; herald patch

Plaques: pityriasis rosea

Scattered erythematous to bright pink well-circumscribed flat-topped plaques on extensor knees and elbows, with overlying silvery scale;

Plaques: plaque psoriasis

Precursor to SCC: Often easier to feel than to see Superficial keratotic papules "come and go" on sun-damaged skin The protypic keratotic scale formed by keratin and can result in a cutaneous horn Keratoacanthomas arise rapidly and have a crateriform center; Often have a smooth but firm border; can become quite large if left untreated (Note: highest sites of metastasis are the scalp, lips, and ears)

Rough Lesion: Actinic keratosis and Squamous Cell Carcinoma (SCC)

seborrheic dermatitis or seborrheic keratoses

Scaling - greasy

Often have a verrucous texture' Appear like a "stuck-on" or flattened ball of wax; May crumble or bleed if picked; Specific features on dermoscopy such as milia-like cysts or comedone-like openings are reassuring, if present; May be erythematous if inflamed middle aged or older. Because they begin at a later age and can have a wart-like appearance, often called the "barnacles of aging." It's possible to have just one of these growths, but most people develop several. Some growths may have a warty surface while others look like dabs of warm, brown candle wax on the skin. Seborrheic keratoses range in color from white to black; however, most are tan or brown. You can find these harmless growths anywhere on the skin, except the palms and soles. Most often, you'll see them on the chest, back, head, or neck.

Seborrheic keratosis

1. numerous solar lentigines on the shoulders and upper back 2. Many melanocytic nevi 3. Solar elastosis (yellow, thickened skin with bumps, wrinkles, or furrowing) 4. Cutis rhomboidalis nuchae (leathery thickened skin on the posterior neck) 5. Actinic purpura.

Signs of chronic sun damage

occurs mostly in white people over the age of 40. appearance of pale brown to dark brown spots on the skin called liver spots, or age spots. flat, usually oval areas of the skin that have increased pigmentation. they're darker than the surrounding skin. They may be brown, black, or gray. They're most common on parts of the body that get regular sun exposure. This includes the:face, hands, arms tops of the feet, shoulders, upper back. harmless.

Solar lentigines

Whether mobile or fixed, encapsulated collections of fluid or semisolid

Subcutaneous mass/cyst:

Facial plethora. Skin icteric. Many telangiectatic mats on chest and abdomen. Single 5 mm pearly papule with rolled border on left zygomatic cheek. Nails with clubbing but no cyanosis

These findings suggest probable end- stage liver disease and incidental BCC.

∼15-20 pustules and acneiform papules on buccal and parotid cheeks bilaterally;

Vessicles; acne vulgaris

Usually skin-colored to pink, texture more verrucous than keratotic; May be filiform; Often have hemorrhagic punctae that can be seen with a magnifying glass or dermatoscope

Warts

Area of localized dermal edema that evanesces (comes and goes) within a period of 1-2 days; this is the essential primary lesion of urticaria

Wheal

Many variably sized (1-10-cm) wheals on lateral neck, shoulders, abdomen, arms, and legs;

Wheals: urticaria

∼30 2-5-mm erythematous papules and pustules on frontal, temporal, and parietal scalp;

bacterial folliculitis

multiple furuncles together

carbuncle

Two large (2-cm) furuncles on forehead, without fluctuance; (Note: fluctuant deep infections are abscesses)

furunculosis

Possible internal causes of diffuse nonscarring hair shedding in young women are

iron-deficiency anemia and hyper- or hypothyroidism.

Non- blanching lesions

petechiae, purpura, and vascular structures (cherry angiomas, vascular malforma- tions) are not erythematous, but rather bright red, purple, or violaceous.

Marked facial pallor, and circumoral cyanosis. Palms cold and moist. Cyanosis in nail beds of fingers and toes. Numerous palpable purpura on lower legs bilaterally."

suggest central cyanosis and vasculitis

Scattered stuck-on verrucous plaques on back and abdomen. Over 30 small round brown macules with symmetric pigmentation on back, chest, and arms. Single 1.2 × 1.6 cm asymmetric dark brown and black plaque with erythematous, uneven border, on left upper arm.

suggest normal seborrheic keratoses and benign nevi, but also a possible malignant melanoma.

a hair pull test by gently grasping 50 to 60 hairs with your thumb and index and middle fingers, pulling firmly away from the scalp. If all the hairs have telogen bulbs, the most likely diagnosis is

telogen effluvium

holding a group of hairs in one hand, pulling along the hair shafts with the other; if any hairs break, it is abnormal.

the tug test

Bilateral erythematous, geographic patches with peripheral scaling, on inner thighs bilaterally, sparing the scrotum;

tinea cruris .

Primary lesion

Flat, a macule or patch; raised, a papule or plaque; or fluid filled, a vesicle or bulla (may also be erosions, ulcers, nodules, ecchymoses, petechiae, and palpable purpura)