Skin Lesions: Morphology and Descriptions

Skin Lesions

• Bulla: Circumscribed collection of free fluid, larger than 1 cm
• Macule: Circular flat discoloration smaller than 1 cm; can be brown, blue, red, or hypopigmented
• Nodule: Circular, elevated, solid lesion larger than 1 cm
• Patch: Circumscribed, flat discoloration larger than 1 cm
• Papule: Superficial solid elevation smaller than or equal to 0.5 cm, color varies, and can present with pustules
• Plaque: Superficial, elevated, solid, flat-topped lesion potentially featuring skin thickening
• Pustule: Vesicle containing pus, indicative of inflammatory cells
• Vesicle: Circular collection of free fluid smaller than or equal to 1 cm
• Wheal: Edematous, transitory plaque that may last only a few hours
• Scale: Epidermal thickening with flakes or plates of compacted desquamated layers of stratum corneum
• Crust: Dried serum or exudate on the skin
• Fissure: Crack or split often appearing on areas of thick skin.
• Excoriation: Linear erosion affecting the superficial skin layer
• Erosion: Involves loss of epidermis, either partial or complete
• Lichenification: Thickening of the epidermis accompanied by exaggerated skin lines, occurring in areas not typically thick
• Scar: Thickening, permanent fibrotic changes to the skin following epidermal damage

Urticaria

• Characterized by transient lesions
• Commonly known as hives
• Presents as an erythematous ring surrounding a central, relatively flat clearing
• Pruritic
• Lesions typically last 10-20 minutes, disappear, but can reappear.
• Common allergic reaction
• Potential causes include:
  • Foods like fish, shellfish, nuts and eggs
  • Food additives like salicylates and dyes
  • Drugs including penicillin and aspirin
  • Infections that are chronic bacterial, fungal, viral, or protozoal
  • Inhalants such as pollen, mold, or dust
  • Internal diseases like lupus
  • Physical stimuli like dermatographism, pressure, and tempature
  • Hormones changes
  • Psychogenic stress

Angioedema

• Often an allergic reaction or secondary to water retention
• Can occur with or without urticaria
• Involves subcutaneous edema, local venule dilation
• More commonly affects the skin of eyelids and lips
• Topical or systemic antihistamines and corticosteroids are treatment
• Differential diagnoses include:
  • Hypertension
  • Kidney diseases
  • Protrusion of fat
  • Hypoxemia

Vitiligo

• Is an acquired and progressive disorder characterized by the complete absence of melanocytes
• Commonly found around the eyes, lips, and extremities
• Associated with autoimmune disorders:
  • Graves
  • Hypothyroidism
  • Addison's disease
• Vogt-Koyanagi-Harada (VKH) syndrome is a differential diagnosis
• VKH often presents with patches of poliosis
• Affects primarily Japanese women aged 20-50
• Bilateral granulomatous chronic iridocyclitis
• Posterior uveitis with specific features:
  • Multifocal exudative retinal or RPE detachments
  • Disc hyperemia or edema
  • "Sunset glow fundus"
• Neurologic signs include meningitis and tinnitus
• Cutaneous findings include alopecia, poliosis, or vitiligo
• Treatment involves corticosteroids and cycloplegics for uveitis, and immunosuppressors

Sturge-Weber Syndrome

• Rare congenital cutaneous condition
• Flat, well-demarcated reddish-purple facial lesions, called "port-wine staining"
• Capillary venous angiomas
• Shortly appears after birth
• Follows the distribution of the V1 trigeminal nerve, but could affect V2 and V3
• Classified as one of the phacomatoses
• Meningeal and choroid angiomas may be present
• Potential complications include glaucoma and seizures
• A complete ocular and neurological examination is important
• Glaucoma is treated with prostaglandin analogs even with uveitis
• MRI or CT scan of the brain is recommended

Nevus

• Proliferation of melanocytes in the skin
• Commonly known as a "freckle"
• Biopsy when growth or changes in shape are present
• Benign nevi can resemble melanomas
• Congenital and Acquired Melanocytic Nevi

Atopic Dermatitis

• Type IV hypersensitivity cutaneous response to environmental allergens
• Is an atopy response
• Children with two parents with atopy have an 80% chance of developing the condition
• More often onset during childhood
• History of asthma, hay fever, or dermatitis is common
• Itching

Allergic Contact Dermatitis

• Often due to something that touched the area
• Acute phase:
  • Crust, erythema, and fine scaling
• Chronic phase:
  • Lichenification or thickening secondary to rubbing or scratching
• Ocular manifestations:
  • Atopic dermatitis with itching
  • FBS
  • Blepharitis
  • Bulbar conjunctival injection
  • Papillae
  • Atopic keratoconjunctivitis (AKC)
  • SPK
  • Dennie-Morgan fold (infraorbital crease)
• Higher risk of retinal detachment
• Possible causes include:
  • Nickel jewelry
  • Chromium compounds
  • Balsam of Peru
  • Formaldehyde
  • Topical anesthetics
  • Paraben mix
  • Paraphenylenediamine
  • Rubber
  • Acrylic fabrics -Other chemicals in personal care products
• Treatment:
  • Ice packs cannot be used for long periods
• Topical corticosteroids
• Avoid rubbing
• Topical NSAIDs like ketorolac (Acular) to reduce itching
• Oral antihistamines like Claritin or Zyrtec

Seborrheic Dermatitis

• Overproduction of fat in the skin that causes scales
• Characterized by pinkish-red, greasy scales overlying erythematous plaques
• Related to a sebaceous gland dysfunction
• Characterized by exacerbations and remissions
• Worsened by stress
• Poor hygiene
• Ocular manifestations:
  • Seborrheic blepharitis
  • Greasy scales
  • Erythematous lids
  • Dandruff flakes in the eyelashes
  • May be associated with meibomitis
• Treatment
  • Lid Scrubs
  • Antibiotic ointment
  • Inflammation with corticosteroids

Acne Rosacea

• Does not have any systemic associations
• Inflammation of the central face
• Adults 30 years and older
• Women are more likely to be affected
• Flushing of the skin across the bridge of the nose and symmetrically involving both cheeks
• Superficial telangiectasis and papopustular lesions over the erythematous skin
• Cause by inflammation and sebaceous gland disorder due to bacteria
• Rhinophyma is a late stage
• Triggers:
  • Alcoholic beverages, particularly red wine
  • Spicy food
  • Caffeine
  • Sun exposure
• Ocular manifestations:
  • MGD
  • Meibomian gland release lipids into the tears, increase evaporation
• Phlyctenules
• Blepharitis
• Keratitis
• Iritis -Recurrent Hordeolum
• Dry Eye Syndrome
• Treatment
  • Tetracyclines
  • Reduce lipase activity of the bacteria
  • Topical Corticosteroid
  • Combo of ab & corticost

Stevens-Johnson Syndrome

• Also known as erythema multiforme major
• Characterized by diffuse erythematous eruption of papules on the soles of the feet and palms of hands
• Small blisters turn into deep purple macules
• Target rash, fever, and malaise
• It is a potentially fatal condition
• Deranged and exaggerated response to a medication
  • Sulfa, allopurinol, tetracyclines, anticonvulsants, and NSAIDs
• Involves mucus membranes of the nose mouth and eyes
• Ocular:
  • Pseudomembranous conjunctivitis with bullae
  • Entropion, trichiasis, and corneal scarring
• Treatment:
  • Remove causing agent
  • Systemic corticosteroids and immunosuppressants
  • Topical aminoglycosides to prevent ocular infection with tobramycin or natamycin
  • Topical steroids to reduce inflammation

Warts

• Neoplasms can be caused by HPV 6 or 12
• Includes verruca vulgaris or papillomata
• Skin lesions, grape-like, and dome-shaped
• Cover by thick layer of keratin
• Treatment -removal

Papilloma

• Squamous papilloma known as skin tag
• A projection of the skin
• Can be finger-like or cauliflower-like
• Usually elevated and multilobulated
• Most common eyelid lesion
• Treatment – removal

Xanthelasma

• Yellow and elevated plaque-like lesion.
• Typically bilateral and symmetric.
• Within medial portion of the eyelids.
• Older age, females, and high cholesterol.
• Could have normal cholesterol.
• Treatment
  • Full-thickness surgical excision
  • Carbon dioxide laser treatment
  • Chemical cauterization

Inclusion Cyst

• Slow-growing epidermal lesions.
• Second most common lid lesion.
• Occur spontaneously or by trauma.
• Arise from a hair follicle so contain keratin.
• Treatment - removal.

Sudoriferous Cyst

• Occurs due to the occlusion of gland of Moll
• Hydrocystomas
• cyst associated with eyelash follicle
• filled with translucent fluid

Seborrheic Keratosis

• Benign skin condition of the elderly
• Growth of basal cells, containing pseudocysts
• Greasy oily
• Crust-like surface
• More common in males over 30 years old
• Treatment - removal or shave excision

Cutaneous Horn

• Inverted follicular keratosis.
• Appears as a wart
• Lobules of proliferating basal and squamous cells
• Treatment is excision

Molluscum Contagiosum

• Dome-shaped waxy nodules.
• Umbilicated central ulcers.
• Caused by DNA poxvirus
• Usually in young children -Poor hygiene
• In the eyelids are associated to follicular conjunctivitis.
• Can spontaneously resolve with peaulated umbilicated lesions.
• Removal by excision by currertage or cryotherapy.
• . Multiple lesions can indicate HIV.

Impetigo

• Gram (+) bacterial infection
• Staphylococci (most common #1)
• streptococci
• Honey-colored crusted lesions.
• Common in Children.
• Treated with mupirocin 2% (bactroban).

Herpes Simplex Virus

• Less aggressive than Zoster
• Cause ocular infections (Type I) -Acquired primary infection as a child
• Type II( lesions below the belt) generally sexually transmitted
• Neonatal infections through the birth canal.
• Virus is dormant in the nerve. -Activated can be physicial or emotinal. -UV light Hormonal Changes -Stress,Trauma, Immunosuprresion
• Classic Dendrite Keratitis
• Others Keratits,Uvéitis,Blepharoconjuctivits.

Herpes Zoster Virus

• VZV initially presents as chicken pox
• Virus lays dormant in nerve roots (dermatomes).
• Hutchinson sign tip of nose. -Blepharoconjuctivits(lid vesicles),episcleritis
• Younger patients look immunocomprimized
• 60% of patients are over 50
• Pseudo Keratitis
• Uveitis, Retinitis
• Keratitis, conjuctivitis, uveitis

Premalignant Epithelial Lesions

• Keratoacanthoma
• Actinic Kerotosis can develop to cancer in skin

Keratoacanthoma

• Grows quickly
• Dome shaped Module
• Ulcerated Center filled with keratin
• Precursor of cancer
• Appears on sun- exposed areas
• Recommended Excision and cut out to prevent from developing
• Low Grade Sqamous Cell Carcinomas and can develop Cancer

Actinic Keratosis

• Flat erythematous scaly
• Increases with size
• Vascularity
• Most oftenly found in sun exposed areas
• CAN transform into squamous cell carcinoma
• Rapid indentification and excision are necessary

Melanoma

• Occur due to Dark Pigmentation
• Result of melanocyctes
• Can can be mortal
• Most common cancer in young women
• Nodular Melanoma must work asap to solve
• Reddish Blue-blushy with brown tintage
• Most common varient 70%
• 40-50 y/o
• Superficial Spreading Melanoma
• Poor Prognosis with 5 years of life expectancy
• Areas of Sun Exapose -Lentigo Maligna Melanoma or Brown Tan Lesion

Risk Factors for Malignancy

• Caucasian Race
• Compared to African and Americans
• Previous Cutaneous Malignant Malanoma
• Immunosupression
• Excessive Sun Expose
• nonamal Skin-exposing, Actinic
• Age
• Skin Color
• Family History
• Repeated Irritation
• Sun Expose

Basal Cell Carcinoma

• Can be very deadly -Arises from epidermial basal cells
• elevated and pearly modules -variable in pigment
• Grow slowly rarely metastize
• Most common eyelid
• account for more than 90% of malignant eyelid tumor, usually in individuals with fair skin blonde, and blue eyes from Scandinavia or Scottland. -if canthus involved 3% or moratlity associated
• ulceration + neovascularization= malignant, biopsy and send out.
• Treatment full thickness dissection -Electrodeiccation -or more aggressive in the tumor, excise.
• Mohs micrographe eyelid

Squamous Cell Carcinoma

• Less common then BCC but more deadly -Greasy, reddened, with superifical erosionial lesion
• Squamous Cell-Arise from keratinized
• is aggress and can disseminate thru body by nerve treatment- surgical excision or radiation