1. Skin Lesion Recognition & Rx in Primary Care
NURS 870
Spring 2016

2. Outline Derm Terminology Review Allergic Conditions
Inflammatory Conditions
Bacterial Skin Infections
Fungal Skin Infections
Viral Skin Infections

3. Dermatology 101 Largest organ of body Immune Functions
Hormone production
(vitamin D)
3 layers:
Epidermis
Dermis
Subcutaneous tissue
Protection from:
Bacteria
Environment
Temperature
Ultraviolet light

4. Derm terms: Primary Lesions
Tutorial A: The Primary Lesions
Macule - A macule is a change in the color of the skin. It is flat, if you were to close your eyes and run your fingers over the surface of a purely macular lesion, you could not detect it. A macule greater than 1 cm. may be referred to as a patch.
Papule - A papule is a solid raised lesion that has distinct borders and is less than 1 cm in diameter. Papules may have a variety of shapes in profile (domed, flat-topped, umbilicated) and may be associated with secondary features such as crusts or scales.
Nodule - A nodule is a raised solid lesion more than 1 cm. and may be in the epidermis, dermis, or subcutaneous tissue.
Tumor - A tumor is a solid mass of the skin or subcutaneous tissue; it is larger than a nodule. (Please bear in mind this definition does not at all mean that the lesion is a neoplasm.)
Plaque - A plaque is a solid, raised, flat-topped lesion greater than 1 cm. in diameter. It is analogous to the geological formation, the plateau.
Vesicle - Vesicles are raised lesions less than 1 cm. in diameter that are filled with clear fluid.
Bullae - Bullae are circumscribed fluid-filled lesions that are greater than 1 cm. in diameter.
Pustule - Pustules are circumscribed elevated lesions that contain pus. They are most commonly infected (as in folliculitis) but may be sterile (as in pustular psoriasis).
Wheal - A wheal is an area of edema in the upper epidermis.
Burrow - Burrows are linear lesions produced by infestation of the skin and formation of tunnels (e.g., with infestation by the scabitic mite or by cutaneous larva migrans).
Telangiectasia - Telangiectasia are the permanent dilatation of superficial blood vessels in the skin and may occur as isolated phenomena or as part of a generalized disorder, such as ataxia telangiectasia.

5. Derm terms: Secondary Lesions
Tutorial B: The Secondary Lesions
Scale - Scale consists of flakes or plates that represent compacted desquamated layers of stratum corneum. Desquamation occurs when there are peeling sheets of scale following acute injury to the skin.
Crust - Crusting is the result of the drying of plasma or exudate on the skin. Please remember that crusting is different from scaling. The two terms refer to different phenomena and are not interchangeable. One can usually be distinguished from the other by appearance alone.
Atrophy - Atrophy is thinning or absence of the epidermis or subcutaneous fat.
Lichenification - "Lichenification" refers to a thickening of the epidermis seen with exaggeration of normal skin lines. It is usually due to chronic rubbing or scratching of an area.
Erosion - Erosions are slightly depressed areas of skin in which part or all of the epidermis has been lost.
Excoriation - Excoriations are traumatized or abraded skin caused by scratching or rubbing.
Fissure - A fissure is linear cleavage of skin which extends into the dermis.
Ulceration - Ulcerations occur when there is necrosis of the epidermis and dermis and sometimes of the underlying subcutaneous tissue.
Scar - Scars are the permanent fibrotic changes that occur on the skin following damage to the dermis. Scars may have secondary pigment characteristics.
Eschar - An eschar is a hard plaque covering an ulcer implying extensive tissue necrosis, infarcts, deep burns, or gangrene
Keloids - Keloids are an exaggerated connective tissue response of injured skin that extend beyond the edges of the original wound.
Petechiae, Purpura, and Ecchymoses - Three terms that refer to bleeding that occurs in the skin are petechiae, purpura, and ecchymoses. Generally, the term "petechiae" refers to smaller lesions. "Purpura" and "ecchymoses" are terms that refer to larger lesions. In certain situations purpura may be palpable. In all situations, petechiae, ecchymoses, and purpura do not blanch when pressed. If there is any question, press on the lesions carefully with a glass slide. Don't break the slide or cut the patient.

6. Derm terms: Patterns & Distribution
Tutorial C: Patterns and Distribution
Annular - Annular lesions are seen in a ring shape. Tinea corporis, erythema migrans (the lesion associated with lyme disease), and granuloma annulare are three common examples.
Discrete - Discrete lesions tend to remain separate. This is a helpful descriptive term but has little specific diagnostic significance.
Clustered - Clustered lesions are those that are grouped together. They are commonly seen in herpes simplex or with insect bites, for example.
Confluent - Confluent lesions tend to run together.
Dermatomal, Zosteriform - Dermatomal, zosteriform lesions follow a dermatome. The lesions of varicella zoster (also known as shingles) are the classic example, but there are other lesions that may assume the same pattern.
Eczematoid - Eczematoid lesions are inflamed with a tendency toward clustering, oozing, or crusting.
Follicular - It is sometimes helpful to determine if lesions specifically involve the hair follicle.
Guttate - Guttate lesions look as though someone took a dropper and dropped this lesion on the skin. Guttate lesions are characteristic of one form of psoriasis, though that is not the only example.
Any many more!

7. Dermatology Quiz
For a real challenge, try this: /quizc.html

8. DermNet
Dermatology Atlas online! disease-pictures/

9. Chapter 1 Derm Terminology
Color
Elevation (flat, raised)
Pattern or shape
Size in centimeters
Location & distribution on body
Exudate

10. Derm Terms: Color Macule – color change Patch – macule > 1 cm
PollEv1: What is the Dx?

11. Derm Terms: Color
3. Hyper pigmented –
darker than
surrounding skin

12. Derm Terms: Color 4. Hypo pigmented – lighter than surrounding skin
PollEv2: What is the Dx?

13. Derm Terms: Elevation 1. Papule: < ½ cm, solid, elevated
(small mole, wart, pimple)

14. Derm Terms: Elevation PollEv3: What is the Dx? Plaque: plateau-like
coalesced papules
surface area > 1 cm
PollEv3: What is the Dx?

15. Derm Terms: Specific Lesions
1. Wheal:
superficial, raised, erythematous
“hives” when wheals coalesce to form extensive reaction
PollEv4: What is the Dx?

16. Derm Terms: Specific Lesions
2. Tumor:
firm lesion
larger than a few cm
PollEv5: What is the Dx?

17. Derm Terms: Specific Lesions
3. Vessicle:
elevated cavity w fluid
Less than 1 cm
PollEv6: What is the Dx?

18. Derm Terms: Specific Lesions
4. Pustule:
elevated cavity w/ pus
PollEv7: What is the Dx?

19. Derm Terms: Specific Lesions
5. Boil or furuncle:
Large pus-filled cavity
PollEv8: What is the organism?

20. Derm Terms: Descriptives
1. Crust:
PollEv9: What is the Dx?
PollEv10: What is the organism?

21. Derm Terms: Descriptives
2. Scale:
PollEv11: What is the Dx?
PollEv12: What is the organism?

22. Derm Terms: Descriptives
3. Excoriation:
Skin lesions which have been scratched or picked
PollEv13: What is the Dx?
PollEv14: What is the Rx?

23. Derm Terms: Descriptives
4. Scar:
Hypertrophic growth following a skin injury
PollEv15: What is the Dx?

24. Chapter 2 Allergic Skin Lesions
Contact Dermatitis
PollEv16: What is the allergy?

25. Allergic Skin Lesions Urticaria (hives)
PollEv17: What do we call this?
PollEv18: What is the Rx?

26. Chapter 3 Inflammatory Skin Lesions (non-infectious)
Eczema
Psoriasis
Acne

27. Eczema (dermatitis) - Hand
PollEv19: What is causing the problem here?

28. Eczema (dermatitis) - Face
PollEv20: Rx for child?
PollEv21: Rx for adult?

29. PollEv22: What is the Dx?
PollEv23: What is the Rx?

30. Acne

31. Chapter 4 Bacterial Skin Infections
1. Impetigo 2. Folliculitis 3. Furuncles (boils) 4. Cellulitis

32. 24. What’s this?

33. PollEv25: What is this?
Folliculitis

34. PollEv26: What is the this?

35. PollEv27: What is the Dx?
Boil with Cellulitis

36. PollEv28: What is the Dx?

37. Bacterial Skin Infections Rx Options:
1. Topical or oral antibiotics
Boils sometimes only need only incision & drainage
Often athletes may continue participation if wound is kept covered and athlete practices good hand-washing.
Encourage athletes to wash linens and not share towels

38. Chapter 5 Fungal Skin Infections
Tinea
Capitus - scalp
Corporis – body
Cruris – groin
Pedis – feet
2. Candidiasis

39. PollEv29: What is the Dx?

40. PollEv29: What is the Dx?
PollEv30: What is the Dx?

41. 31. What’s this?

42. Fungal Skin Infections Rx options:
Topical or oral antifungals required
Often athletes may continue participation. Wrestlers have NCAA rules for return.
Encourage athletes to wash linens and not share towels

43. Chapter 6 Viral Skin Infections
HSV – 1
Cold Sores
HSV – 2
Shinges ( Varicella Zoster)
Molluscum
Warts
Planus - flat
Verruca - bumpy
Plantar - grow inward

44. PollEv32: What is the Dx?

45. 33. What is this?

46. 34. What is this?

47. PollEv35: What is the Dx?

48. Viral Skin Infections Rx Options:
1. Herpes & Shingles – need oral medication
Molluscum – may resolve spontaneously or may be curetted or frozen with liquid nitrogen
Warts – may be frozen with liquid nitrogen. Over-the-counter preparations may be successful for small, isolated warts

49. PollEv 36. Consult!
What the…

50. This was in my differential:
PollEv37: What is the Dx?
This was in my differential:

51. When in doubt, refer!
Punch Biopsy

52. Want to learn more derm? American Academy of Dermatology:
Hardin MD: Medical Information and Pictures:
Medline Plus:
Primary Care Dermatology: Skin Lesion Nomenclature

53. Did you like my skin show?