Cutaneous Primary Skin Lesions

Cutaneous Signs

• These are objective changes in the skin that can indicate various conditions or diseases.

Primary Lesions

• These are the initial skin abnormalities that arise spontaneously.

Macule

• A circumscribed area of skin discoloration is less than 1 cm in diameter.
• It can be hypopigmented, hyperpigmented, or erythematous.
• Brown macules are seen in pityriasis versicolor.
• White macules are seen in vitiligo.
• A macule larger than 1 cm in diameter constitutes a patch.

Papule

• A circumscribed solid elevation of skin measures less than 0.5 cm in diameter.
• Psoriasis and lichen planus are examples.

Nodule

• A circumscribed solid elevation of skin is more than 0.5 cm in diameter.
• Reflects an underlying dermal or subcutaneous pathology.
• Lepromatous leprosy is an example.

Plaque

• It signifies an area where the skin's texture or consistency has changed.
• Can be elevated or depressed relative to the skin's surface.
• Elevated lesions can arise independently or from the merging of multiple papules.
• The surface area is extensive in comparison to its height, unlike a nodule.

Vesicle

• It's a skin elevation filled with fluid, and it's less than 0.5 cm in diameter.

Bulla

• Represents an elevation of the skin containing fluid, measuring more than 0.5 cm in diameter.

Cyst

• A cyst differs from a vesicle or bulla by having a wall.

Wheal

• It is the primary lesion seen in urticaria.
• It involves transient, edematous skin elevations of varying sizes.
• Itching is a typical symptom.

Comedo

• It is the primary lesion of acne.
• Open comedo/blackhead: flat, slightly raised papule, dilated central opening filled with blackened keratin.
• Closed comedo/whitehead: a yellowish papule.

Burrow

• It is the primary lesion of scabies.
• It appears as a linear elevation in the epidermis, caused by tunneling from the female Sarcoptes scabiei mite.

Secondary Lesions

• These arise as a result of modifications to primary lesions.

Furrow

• It is a de-roofed burrow.
• It results from scratching a burrow.

Pustule

• Small elevated area contains purulent material.
• It may start as a pustule, or develop from a papule or vesicle.

Scale

• The skin shows dry or greasy laminated masses of keratin.

Crust

• Dried material on the skin, such as serum, pus, or blood.

Erosion

• It is a partial or complete loss of the epidermis that will heal without scarring.
• Does not reach the dermis.

Ulcer

• Involves rounded or irregular excavations.
• They result from the total loss of the epidermis extending into some portion of the dermis.
• Size, shape, and depth can vary depending on the disease.

Excoriations and Abrasions

• Superficial skin disruptions affect only the epidermis.
• Scratching with fingernails causes excoriations.
• Mechanical trauma or constant friction causes abrasions.

Fissure (Crack)

• It is a linear cleft in the epidermis that may extend into the dermis.

Skin Infections

• Discusses the first category of bacterial infections.

Bacterial Infections

• Discusses various bacterial infections
• Impetigo Contagiosum
• Folliculitis (Impetigo of Bockhart)
• Sycosis Barbae
• Furuncle (Boil)
• Carbuncle
• Erysipelas
• Cellulitis
• Erythrasma

Impetigo Contagiosum

• Superficial skin infection.
• Etiology: Streptococci and Staphylococci.
• Infection is predisposed to by poor hygiene and moisture.
• Secondary causes: insect bites, scabies, or pediculosis capitis.
• Clinical types: Ordinary, Bullous, Circinate, Ulcerative (Ecthyma).

Ordinary Impetigo

• Begins with 2 mm erythematous macules that become vesicles.
• Ruptured vesicles lead to seropurulent discharge.
• Discharge leads to golden yellow crusts.
• Occurs on the face, hands, genitalia, and scalp.
• May develop as a complication of pediculosis capitis.
• Resolves within a few days and has no constitutional symptoms.

Bullous Impetigo

• It is caused by Staphylococci.
• The primary lesion is a bulla.
• Typically present in newborn infants.
• May occur at any age.
• It is accompanied by constitutional symptoms.
• It may be fatal in newborn infants.

Circinate Impetigo

• An extension of ordinary impetigo.
• Can be secondary to the rupture of bullous impetigo.
• Is circular/ring-shaped.

Ulcerative Impetigo (Ecthyma)

• Occurs on legs.
• Lesions form crusts and heal with scars.

Complications of Impetigo

• Spread of infection to other sites.
• Spread of infection to other children.
• Can lead to post-streptococcal glomerulonephritis.
• This occurs in 2-5% of cases.
• It is triggered by nephrotogenic strains.

Treatment of Impetigo

• Treat predisposing factors.
• Use topical antiseptics like povidone-iodine or potassium permanganate (1/8000-1/10000).
• Use topical antibiotics like fusidic acid, gentamicin, or bacitracin.
• Use systemic antibiotics for generalized infections.
• Also used when fever, lymphadenopathy, or bullous impetigo/ecthyma is present.

Folliculitis (Impetigo of Bockhart)

• An infection in the upper part of the hair follicle.
• Etiology: Staphylococcus aureus.
• Predisposing factors: Moisture and poor hygiene.
• Clinical picture: Follicular pustules.
• Treatment: Address predisposing factors.
• Use topical antiseptics.
• Use topical and systemic antibiotics.

Sycosis Barbae (Folliculitis of the Beard Area)

• Staphylococcus aureus. is the aetiology.
• Predisposing factors include moisture, poor hygiene, and shaving.
• Follicular pustules and papules are clinical signs in the beard area.
• Address predisposing factors, topical antiseptics and topical/systemic antibiotics for treatment.

Furuncle (Boil)

• Deep infection in lower part of the hair follicle with central necrosis.
• Predisposing factors: Obesity and diabetes mellitus.
• Follicular red papules are clinical indicators.
• Address predisposing factors, antiseptics and antibiotics.

Carbuncle

• Multiple deep boils that open on the surface by multiple fistulae.
• Diabetes is a predisposing factor.
• Occurs on the back, neck, and intertriginous areas.
• Treatment: Incision and drainage combined with systemic antibiotics.

Erysipelas

• Suppurative inflammation of the upper dermis.
• Beta-hemolytic Streptococci is the aetiology.
• Erythematous, swollen, tender area with a sharp border is a clinical indicator.
• Blisters may form in extensive circumstances.
• Constitutional symptoms include discomfort and fever.
• Lymphedema can occur from recurrent episodes.
• Systemic antibiotics as Penicillin or erythromycin can treat this.
• For resistant cases, confirm that the organism is Streptococcus.
• Rifampicin, dicloxacillin, benzathine penicillin, or erythromycin is given for several months.

Cellulitis

• Includes suppurative inflammation of lower epidermis and SC tissue.
• Staphylococcus aureus & Streptococcus pyogenes are involved.
• It occurs in an erythematous, swollen, tender area with an ill-defined border.
• Constitutional symptoms include malaise, chills, and fever.
• Aggressive antibiotic therapy may treat this.

Erythrasma

• Is superficially infected intertriginous areas.
• Etiology: Corynebacterium minutissimum (a diphtheroid bacteria).
• Predisposing factors: obesity, diabetes, and debilitating diseases.
• Dry, scaly, reddish-brown patches with fine scales in intertriginous areas may be observed, for example, axillae, groins, and submammary areas.
• Wood’s light shows coral red fluorescence due to porphyrin.
• Antibiotics such as fusidic acid, as well as azole derivatives can be used for topical therapy.
• Antibiotics as erythromycin or tetracycline can be used for systemic therapy.

Viral Infections

• There is Herpes simplex, Herpes zoster, Warts(verrucae) and Molluscum Contagiousum.

Herpes Simplex (HS)

• This is the most common viral infection.
• Caused by the herpes simplex virus (HSV).
• It is a DNA virus of two types: HSV type I that leads to herpes labialis and other non-genital infections and HSV type II which leads to herpes progenitalis.
• HS is transmitted through skin-to-skin or skin-to-mucous membrane contact.

Herpes Simplex Type I

• A primary infection occurs when a patient is infected for the first time.
• Results in primary herpetic gingivostomatitis.
• Is usually subclinical and goes unnoticed in about 90% of cases,
• Characterized by superficial vesicles on the oropharynx that rupture quickly leaving painful denuded areas.
• Swollen gums, fever, a painful throat, malaise, loss of appetite, and lymphadenopathy accompany these.

Recurrent Attacks

• If resolution of primary infection occurs, the virus is not eliminated.
• HSV has a special predilection (preference) for neural tissue.
• It migrates to dorsal root ganglia and remains dormant.
• If reactivated, the virus migrates along peripheral nerves to the skin and mucous membranes.
• Recurrent HS occurs at or near the primary site.

Predisposing Factors for Reactivation

• Fever
• Fatigue
• Trauma
• Ultraviolet light
• Radiation
• Stress
• Menstruation
• GIT disturbances
• Altered immune status
• Immunosuppressives

Sites of Recurrent Attacks

• Lips (Herpes Labialis): Usually bilateral grouped vesicles on an erythematous base associated with a burning/tingling sensation. Vesicles that form crusts usually dry up within a few days.
• Face (Herpes Facialis): Around other body orifices such as the nose, eyes, ears, and cheeks.

Special Variants of HSV Type I

• Ocular Mucosa: Needs prompt ophthalmologic consultation can lead to corneal opacity.
• Finger or Hand (Herpetic Whitlow): HSV inoculation into abraded skin and is very painful.

HSV Type II (Herpes Progenitalis)

• Primary Infection results from sexual contact.
• Involves genitalia of both males and females.
• Results from painful grouped superficial vesicles followed by erosion or genital ulceration.
• If a pregnant woman has Herpes progenitalis at the time of delivery, caesarian section is a strong indication.
• This is because neonatal infection is serious.
• Less attacks are less severe than the primary infection.

Complications of HSV Infection

• Secondary infection.
• Includes eye complications like keratitis and corneal ulcers.
• CNS complications, for instance,encephalitis and meningitis.
• rare but serious, occur especially in infants especially in infants and children.
• Erythema multiforme.

HSV diagnosis

• Involves Clinical picture, Tzanck smear using Giemsa stain, and Viral culture
• Includes Serological tests and Polymerase chain reaction (PCR)

HS Treatment

• Avoiding precipitating factors helps to prevent recurrence.
• There is also direct avoidance of sexual contact during an attack of genital herpes.
• Includes Topical Therapy
• Includes Systemic Therapy (Antiviral)

Topical Therapy

• Drying antiseptic lotions- K+ permanganate or 10% aluminum acetate is given in the early vesicular stage.
• Antiviral- acyclovir cream is given early reducing viral shedding.
• Topical idoxuridine (IDU) can treat eye lesions.

Systemic Therapy

• Treats Acyclovir
• 200 mg 5 times daily is given in severe episodes or for immunocompromised patients.
• It should be given early, within 48-72 hours from the appearance of the eruption.

Herpes Zoster (HZ)

• It is caused by the varicella-zoster virus (VZV). Has an association with Chicken Pox (Varicella)

Chicken Pox (Varicella)

• Chicken Pox (Varicella) is a relatively mild childhood disease with generalized, self-limiting vesicular eruption that leads to the formation of a brownish crust. Lesions heal within 10 days and after the attack, reside in the posterior root ganglia.

Reactivation of Infection is Predisposed by:

• Trauma
• Fever
• Decreased resistance
• Drugs (corticosteroids and immunosuppressive agents)
• Diseases of the spine (TB and metastatic deposits)
• Malignant diseases

HZ Clinical Picture

• The symptoms are accompanied or preceded by pain one week before and involves Unilateral groups of vesicles on the distribution of one or more sensory nerves.
• The vesicles usually dry up in 2–4 weeks without rupture.
• Lesions may be hemorrhagic in some circumstances. It may leave scars.
• Abortive type of HZ presents with only pain and some redness. HZ offers permanent immunity and is not a recurrent illness

The Following are Complications of Herpes Zoster

• Involves secondary infection
• Eye complications: HZ ophthalmicus CNS complications: post-herpetic neuralgia where pain persists for several months
• HZ may be a sign of internal malignancy if there’s very old age, gangrenous type, bilateral affection and is recurrent.

Treatment of Herpes Zoster

• Topical Therapy in vesicular stage

Topical Therapy: In Vesicular Stage

• The treatment involves drying antiseptic lotions with Antiviral acyclovir cream in very early vesicular stage minimizing the duration of the attack.

Involves Systemic Therapy-antiviral:

• Acyclovir or Valacyclovir
• Famciclovir

The systemic therapy involves pain management for neuropathic pain with Analgesics or carbamazipine

Warts (Verrucae)

• Common viral, infectious, benign growth
• Caused by human papilloma virus (HPV).
• Mode of Transmission is via direct or indirect contact.
• Incubation Period: 1-6 months.
• It typically involves skin and mucous membranes.

Types of Warts

• Common warts (Verruca Vulgaris)
• Plane warts (Verruca Plana)
• Filiform warts (Verruca Filiformis)
• Digitiform warts (Verruca Digitata)
• Plantar warts (Verruca Plantaris)
• Genital warts (Condyloma Acuminata)

Common Warts (Verruca Vulgaris)

• Asymptomatic skin-colored and verrucous (rough, elevated) papules.

Plane Warts (Verruca Plana)

• Consists of asymptomatic flat topped in skin-colored papules
• Occurs more in children
• Associated with koebner phenomenon

Filiform Warts

• Composed of long thin lesions with peduncles.
• These are the location where common lesions will grow

Digitiform Warts

• Papillomatous finger-like projections emerging from common point

Plantar Types

• Warts growing inwards on sole of the foot

Genital Types

• It is also called venereal warts, anal warts and anogenital warts

Complications of HPV Infection

• HPV causes oncogenicity, which may predispose towards cervical dysplasia or cancer cervix.

Course of Infection

• Spontaneous resolution may occur in the year, or warts will show regression with treatment

Treatment

• Electrocautery: heat effect cell destruction under anesthesia.
• Cryotherapy: Cell destruction by freezing w/liquid nitrogen
• Chemical cautery
• Laser treatments for all resistant warts
• Radiotherapy for plantar warts
• Autosuggestion (placebo effect)

Molluscum Contagiosum

• Caused by poxvirus.
• Acquired via direct or indirect contact. Incubation Period is 2-6 weeks
• Shiny lesion with central umbilication. Expresses Cheese substance

Clinical Features of Molluscum Contagiosum

• shiny, pearly white, dome-shaped papules with a solid, central umbilication
• May express a white cheesy substance.
• Involves genital or non-genital skin and can be considered a sexually transmitted disease

Treatment Options for Molluscum Contagiousum

• Electrocautery
• Cryotherapy
• Chemical cautery with phenol after removal with curette.
• Laser treatment.