Presentation on theme: "Morphology: How to describe what you see"— Presentation transcript:
1Morphology: How to describe what you see Medical Student Core Curriculumin DermatologyLast updated June 13, 2011
2Module InstructionsThe following module contains a number of blue, underlined terms which are hyperlinked to the dermatology glossary, an illustrated interactive guide to clinical dermatology and dermatopathology.We encourage the learner to read all the hyperlinked information.
3Goals and ObjectivesThe purpose of this module is to help medical students learn how to best describe skin lesionsAfter completing this module, the learner will be able to:Develop a systematic approach to describing skin eruptionsUtilize the descriptors and definitions of morphology
4MorphologyThe word morphology is used by dermatologists to describe the use of descriptors to accurately characterize and document skin lesionsThe morphologic characteristics of skin lesions are key elements in establishing the diagnosis and communicating skin findingsThere are two steps in establishing the morphology of any given skin condition:Careful visual inspectionApplication of correct descriptors
5Visual InspectionVisual inspection at its core is much like analyzing a painting or looking at any object for the first time.Question 1How would you fill in the description of the item depicted on the next slide?
6Question 1This is a _____ _______ _____ object measuring ____ with ___ ____ in the center. It is sitting on a ____ __________ and casts a ______.
7Question 1This is a brown circular shiny object measuring 8 mm with four holes in the center. It is sitting on a blue background and casts a shadow.The shadow tells us it is raised (palpable).
8Question 1This is a brown circular shiny object measuring 8 mm with four holes in the center. It is sitting on a blue background and casts a shadow.The above description identifies:Palpability (indicated by shadow)ColorShapeTextureSizeLocation
9We will use the same principles to learn the vocabulary of the skin (i We will use the same principles to learn the vocabulary of the skin (i.e. morphology)
11Case One: HistoryHPI: Mr. F is a 32-year-old man who presents to his primary care provider with “blotches” on his upper back, chest, and arms for several years. They are more noticeable in the summertime.PMH: shoulder pain from an old sports injuryAllergies: noneMedications: NSAID as neededFamily history: not contributorySocial history: auto mechanicROS: negative
13Case OneHow would you describe this skin exam to a resident or an attending?What do you see? Look carefully at all clues in the photographs.There are many right ways to describe something. Be creative.
14Case One, Question 1Are these lesions raised, flat, or depressed?
15Case One, Question 1Imagine running your finger over them. Close your eyes when you do so.You don’t feel anything as your finger runs across themThey are flatSmall, flat lesions are called macules
16Case One, Question 2 How else can you describe them? What size are they?What shape are they?What color are they?How regular and distinct is the border?How are they configured?How are they distributed?
17Case One, Question 2How else can you describe them?3 to 10 mm
18Case One, Question 3 How else can you describe them? What size are they?What shape are they?What color are they?How regular and distinct is the border?How are they configured?How are they distributed?
19Case One, Question 3 How else can you describe them? 3 to 10 mm Round to oval
20Case One, Question 4 How else can you describe them? What size are they?What shape are they?What color are they?How regular and distinct is the border?How are they configured?How are they distributed?
21Case One, Question 4 How else can you describe them? 3 to 10 mm Round to ovalPink to tan
22Case One, Question 5 How else can you describe them? What size are they?What shape are they?What color are they?How regular and distinct is the border?How are they configured?How are they distributed?
23Case One, Question 5 How else can you describe them? 3 to 10 mm Round to ovalPink to tanSharp, irregular borders
24Case One, Question 6 How else can you describe them? What size are they?What shape are they?What color are they?How distinct are they?How are they configured (how do the lesions relate to each other)?How are they distributed (where are they on the body)?
25Case One, Question 6 How else can you describe them? 3 to 10 mm Round to ovalPink to tanSharp, irregular bordersSeparate, in no particular pattern
26Case One, Question 7 How else can you describe them? What size are they?What shape are they?What color are they?How distinct are they?How are they configured?How are they distributed?
27Case One, Question 7 How else can you describe them? 3 to 10 mm Round to ovalPink to tanSharp, irregular bordersSeparate, in no particular patternOn the upper chest and back, and flexures of arms
28Skin Exam Mr. F’s skin exam shows: Multiple 3 to 10 mm pink to tan-colored, round, flat lesions with sharp, irregular borders and varying sizes on his upper chest, back and flexures of the arms.Small (< 1cm) flat lesions are called maculesIn this case, the primary lesion is a macule
29DiagnosisDr. D performs a potassium hydroxide exam and based on the findings, diagnoses Mr. F with tinea versicolor. The primary lesion in tinea versicolor is a macule.
30Describing lesions: Morphology Dermatology’s short-hand vocabulary is called “morphology”This allows medical personnel to communicate skin findings succinctlyDermatologists attempt to identify the primary lesion of any skin eruptionPrimary lesions are the nouns that other adjectives modify
31MorphologyAs you go through the following cases, you will learn the vocabulary of primary lesionsWhat matters most is that your description captures the essence of the lesion, even if you do not use classic morphological words
32Primary lesion: Macule (L. macula, “spot”)A macule is flat; if you can feel it, then it’s not a macule.Usually caused by color changes in the epidermis or upper dermis
34Case One, Question 8 Macules can: Feel raised Feel flat Contain fluid Be any shape
35Case One, Question 8 Answer: b & d Macules can: Feel raised (these are papules or plaques)Feel flatContain fluid (these are vesicles or bullae)Be any shape
36MaculesPresence of a macule indicates that the process is confined to the epidermisMacules do not contain fluid and are not raisedMacules can have secondary changes such as scale or crustIf a flat lesion is over 1 cm it is called a patch
37Primary lesion: Patch Patches are flat but larger than macules If it’s flat and larger than 1 cm, call it a patch
41Case Two: HistoryHPI: Mr. K is a 36-year-old man who presents with four years of itchy, flaky spots on his elbows, knees, and lower back. They have not improved with moisturizers.PMH: noneAllergies: noneMedications: noneFamily history: father died from heart attack at age 68Social history: delivery truck driverHealth-related behaviors: drinks 2-3 beers a weekROS: negative
43Case TwoHow would you describe this skin exam to a resident or an attending?What do you see when you look at these photographs?
44Case Two, Question 1Are these lesions raised, flat, or depressed?
45Case Two, Question 1Imagine running your finger over them. Close your eyes.These are raisedLarge (>1cm), plateau- like, raised lesions are called plaques
46Case Two How else can you describe them? Size? Shape? Color? Sharp borders?Texture?Configuration?Distribution?
47Case Two How else can you describe them? 3 to 10 cm Round to geographic (like outlines on a map)PinkSharply circumscribedScalySymmetricalExtensor surfaces (knees, elbows), back, gluteal cleft
48Describing color Describing colors of lesions is challenging Be creative. Learn lots of colors.There are infinite shades of skin tones“Skin-colored” refers to a lesion the same color as the patient’s skin toneLearn the classic color assigned to skin conditions as you read about them
49Skin Exam Mr. K’s skin exam shows: Several 3-10 cm bright pink round sharply circumscribed scaly plaques on extensor elbows, knees, lower back, and gluteal cleftLarge, raised lesions are called plaquesMr. K has psoriasis. The primary lesion in psoriasis is a plaque.
50Primary lesions: Plaque Plaques are raised lesions larger than 1 cmYou can feel themCast a shadow with side lightingA proliferation of cells in epidermis or superficial dermis
61Case ThreeHPI: Mr. B is a 28-year-old man who presents with four days of pain and blisters on his left chest.PMH: noneAllergies: noneMedications: noneFamily history: noncontributorySocial history: single; works as a personal trainerROS: negative
63Case ThreeHow would you describe this skin exam to a resident or an attending?What do you see when you look at these photographs?
64Case Three, Questions Are these lesions raised, flat, or depressed? Do they have fluid in them?
65Case Three, Questions Imagine running your finger over them. These are raisedThey do have fluid in themSmall, raised, fluid- filled lesions are called vesicles
66Case Three How else can you describe them? Size? Shape? Color? Texture?Configuration?Distribution?
67Case Three How else can you describe them? 2 – 5 mm Round to oval Clear, with red backgroundFluid-filledGrouped, dermatomal configurationUnilateral left chest
68Distribution / Configuration Part of describing lesions is noting distribution and configurationDistribution means location on the bodyConfiguration means how the lesions are arranged or relate to each otherLesions are grouped but also follow a linear pattern around the trunkThis is an example of a linear or dermatomal configuration
69Distribution / Configuration To learn more about distributions, click here:To learn more about configurations, click here:
70Skin Exam Mr. B’s skin exam shows: Grouped 2-5 mm vesicles on an erythematous base in a unilateral, dermatomal configuration on the left chestSmall, fluid-filled lesions are called vesiclesMr. K has shingles. The primary lesion in shingles is a vesicle.
71Primary lesion: Vesicle (L. vesicula, “little bladder”; bulla, “bubble”)Vesicles are fluid- filled papules (small blisters)A large (> 1cm) blister is called a bullavesiclebulla
74PustulePus is made up of leukocytes and a thin fluid called liquor puris (L. “pus liquid”)See also furuncle and abscess
75A superficial loss of the epidermis is called an…
76Erosion Erosions are loss of the epidermis They may occur after a vesicle forms and the top peels offThey weep and become crustedThis is an example of a secondary change or characteristic
77If an erosion involves the dermis, it is called an…
78Ulcer(L. ulcus, “sore”)Ulcers often heal with scarring; erosions usually do notErosions and ulcers are secondary lesionsSecondary lesions (or changes) may evolve from primary lesions, or may be caused by external forces such as scratching, trauma, infection, or the healing process
79Seeing the skinTo describe what you see on the skin, first determine the primary lesionIs it raised, flat, or depressed?Is it small or large?Is it fluid-filled?The table in the next slide summarizes most of the primary lesions and common secondary lesions. We have already reviewed many of them. Click on the others to learn more.
80Primary and Secondary Lesions RaisedFlatDepressedFluid-filledVascularPapuleMaculeErosionVesicleTelangiectasiaPlaquePatchUlcerBullaPetechiaeNoduleAtrophyPustuleEcchymosisTumorSinusFuruncleWhealStriaAbscessBurrowScar
81Seeing the skinIn your descriptions, include adjectives that help describe the primary lesionsSizeShapeIt’s okay to say “small, raised lesion”, but “papule” is more concise.It is more important to describe what you see, than to state what you think the diagnosis isColorTextureConfigurationDistribution
82Seeing the skinThis is an 8mm brown circular shiny raised object with four holes in the center.After reading the description, without seeing the image, you could visualize a button in your mind.Someone who reads your note could make the diagnosis of a buttonDescribe skin lesions this way in your notes and consults
83Take Home Points To describe the skin, you first have to see it Be creative in your descriptions, especially subjective things like color.First, determine whether lesions are raised, flat, or depressed. Use this with size to determine the primary lesion.The primary lesion is the noun that you describe with adjectives like exact size, shape, color, texture, distribution, and configuration.
84AcknowledgementsThis module was developed by the American Academy of Dermatology’s Medical Student Core Curriculum Workgroup fromPrimary authors: Patrick McCleskey, MD, FAAD; Peter A. Lio, MD, FAAD; Jacqueline C. Dolev, MD, FAAD; Amit Garg, MD, FAAD.Peer reviewers: Heather Woodworth Wickless, MD, MPH; Ron Birnbaum, MD; Timothy G. Berger, MD, FAAD.Revisions: Sarah D. Cipriano, MD, MPH. Last revised June 2011.
85ReferencesBerger T, Hong J, Saeed S, Colaco S, Tsang M, Kasper R. The Web-Based Illustrated Clinical Dermatology Glossary. MedEdPORTAL; Available from:Morphology illustrations are from the Dermatology Lexicon Project, which is now maintained by the American Academy of Dermatology as DermLex.Dolev JC, Friedlaender JK, Braverman, IM. Use of fine art to enhance visual diagnostic skills. JAMA 2001; 286(9),Habif TP. Clinical Dermatology: a color guide to diagnosis and therapy, 4th ed. New York, NY: Mosby; 2004.Marks Jr JG, Miller JJ. Lookingbill and Marks’ Principles of Dermatology, 4th ed. Elsevier; 2006.Review primary lesions and other morphologic terms at