DERMATOLOGY MINI ATLAS Dr. M. G. Joseph Revised November 2011

Dear students: THIS DERMATOLOGY MINI ATLAS IS DESIGNED TO PRACTICE YOUR SKILLS IN DESCRIBING THE MORPHOLOGY OF SOME OF THE COMMON AND CLASSIC DERMATOLOGIC DISORDERS COVERED DURING THIS COURSE. IN ADDITION THIS MODULE WILL ALLOW YOU TO ARRIVE AT A DIAGNOSIS OR GENERATE APPROPRIATE DIFFERENTIAL DIAGNOSIS. YOU MAY REVIEW YOUR NOTES FOR ADDITIONAL DETAILS ON THESE SKIN DISEASES. Mariamma Joseph

PART 1- SKIN RASHES

Case 1 What is your diagnosis ? Describe this lesion using SCALDA terminology. Identify the primary morphology and secondary lesional changes you see in this picture

Infantile atopic dermatitis acute stage with oozing and Crusting

Case 2 This patient comes to you with this rash. What is the most likely diagnosis and cause ?

Case 2 Another example perhaps too obvious Case 2, another example. Nickel allergy from metal fasteners on jeans

Case 3 Identify the type of dermatitis involving the lower leg and ankle, medial side

Case 4. Describe this lesion using SCALDA terminology. W can give this morphology? Coin shaped eczematous lesions

Another example of nummular dermatitis, acute stage

Case 5: Describe the morphology of this rash. This rash is diagnostic of what disease ? Review the histology of this lesion (next slide) for clinicopathologic correlation (CPC)

Case 5, histology A B C D Psoriasis Vulgaris (plaque psoriasis): Parakeratosis (A), regular acanthosis (B) dermal dilated capillaries (C) and inflammatory cells (D)

Childhood psoriatic arthritis with nail changes

Generate a differential diagnosis for this papulosquamous eruption. What is your most likely diagnosis ? Clue: this lesion appeared following a streptococcal throat infection Case 6

Case 7 Study the classic location and morphology of another papulosquamous lesion shown in this picture. What is your diagnosis?

Case 7 another example, study the morphology

Case 8 Study the classic location and morphology of another papulosquamous lesion shown in this picture. What is your diagnosis? What is the clue to your diagnosis ? Herald patch

Case 9 Target lesions are shown In this picture. What is your Diagnosis? Learn the causes /associations and complications

Case 10 ERYTHEMA MULTIFORME, another example In a child caused by herpes simplex virus

Case 11 This patient is quite unwell and requires hospitalization. What is this syndrome ?

Case 12 These subcutaneous nodules on the leg are quite tender. What is your diagnosis What is the pathology ?

Case 13 Red purpuric rash consistent with cutaneous vasculitis. This patient has HENOCH SCHONLEIN PURPURA on clinical evaluation. What is vasculitis? What is HSP ? What are the other causes for vasculitis ?

Another example of vasculitis (palpable purpura) Study other causes of vasculitis from notes Septicemia leading to vasculitis can show similar morphology

Case 14 This child presented with discrete erythematous macules and papules on the trunk and confluent erythema on the face. What is the most likely cause ?

This is an Immunobullous disorder Case 15 Describe the morphology using SCALDA ? Review 3 immunobullous disorders you have been taught and recognize what is the most likely diagnosis in this case? W

Case 15 Direct IMF test result on case 15 Epidermis Dermis Linear band of IGG and C3 at the basement membrane zone

Another immunobullous disorder Case 16 Nikolsky sign positive, intra epidermal flaccid bullae (black arrows) and erosion (white arrow). What is your diagnosis ?

Direct IMF test Intercellular desmosomal IGG and C3 Fish net like pattern (black arrow) Case 16 Epidermis Dermis

Case 17 These grouped blistering lesions on the elbow are intensely pruritic causing erosions. What additional investigation you would consider for this patient ? What is your diagnosis ?

Case 18 This leg ulcer is diagnostic of… What type of ulcer ? Note the background of skin hyper pigmentation and thickening. Review your notes on skin ulcer

ACNE A Open Comedones C B Case 19 Closed Comedones Inflammed acne

Is this open or closed comedone of acne?

Case 20: Describe the morphology, what is your diagnosis? What are the common causes ?

Case 21: A case of skin infestation. What is the most likely cause? What is the clue ?

Case 22: List 4 indicators that determine prognosis for this partial thickness burn case (review burn lecture)

Part 1 Skin Rashes Answers 1. Infantile atopic dermatitis, subacute stage 2. Allergic contact dermatitis to sandals 3. Stasis dermatitis, medial malleolus 4. Nummular dermatitis 5. Plaque psoriasis 6. Guttate psoriasis 7. Lichen planus 8. Pityriasis rosea 9. Erythema multiforme 10. Erythema multiforme, child 11. Steven Johnson syndrome 12. Erythema nodosum, panniculitis 13. Vasculitis, HSP 14. Exanthematous drug eruption 15. Bullous pemphigoid 16. Pemphigus vulgaris 17. Dermatitis Herpetiformis 18. Venous ulcer 19 Acne A. Open comedone B. Closed comedone C. Inflammatory acne 20. Urticaria (multiple red wheals) 21. Scabies 22. Partial thickness burn

PART 2 - SKIN GROWWTHS (BUMPS)

Case 1: This benign tumour is present for years without any change W

Case 2: Describe the histology of this lesion (Corn or Clavus) Yellow hyperkeratotic lesion with central depression on the feet

Case 3: 60 year old female Is this benign or malignant ? What is your diagnosis?

Two more examples of seborrheic keratosis. Sebka can have many faces Well defined, flesh-coloured Well defined brown soft nodule with plaque with a warty surface smooth, crumbly texture and stuck and stuck on appearance on appearance.

Case 4: 70 year old male with actinic keratosis Describe the morphology of this premalignant skin lesion

Case 5: this lesion is induced by HPV virus What is your diagnosis ?

Case 6: Describe the morphology These lesions are induced by pox virus. What is your diagnosis

Case 7: 40 year old male This painless leg lesion is present for years, dimple sign is positive. What is your diagnosis?

DERMATOFIBROMA- dimple sign

Case 8: Describe the morphology of this lesion. What is the histology in the biopsy specimen? W

Case 9: Two forms of Basal cell carcinoma are given below. Name these 2 forms, describe the morphology of these 2 forms

Case 10: Is this benign or malignant clinically? What is your next step to make a diagnosis ?

Case 11: This scaly erythematous patch does not respond to steroid treatment. A skin biopsy shows full thickness atypia of keratinocytes. What is your diagnosis?

Case 12: This skin coloured nodule with central crater measures 1.5 cm and rapidly grew during the last 4 weeks. What is your differentia Diagnosis? What kind of biopsy you would perform for diagnosis?

Case 13: Is this pigmented lesion benign or malignant ? Describe the morphology of this lesion. What is the treatment?

Case 14: Describe this pigmented lesion. What is your diagnosis?

Case 15: What type of melanoma is this ? Study various types of melanoma including important prognostic factors

Case 16: Study the morphology and histology of this benign compound nevus (CPC) Benign compound nevus: well circumscribed and symmetrical small pigmented lesion with regular border and uniform colour, histology shows symmetry and well defined borders with nests of benign nevus cells at the dermoepidermal junction and in the dermis (CPC).

Case 17: This is an example of cutaneous manifestation of systemic disease ADENOMA SEBACEUM OF TUBEROUS SCLEROSIS

Case 18 Malignant Melanoma, histology: Malignant large cells, containing brown melanin pigment in cytoplasm, Hematoxylin and Eosin stain. Hematoxylin stains nuclei purple and eosin stains cytoplasm pink. Melanin is stained brown

Case 19 B A Basal Cell Carcinoma, histology: Basaloid (blue) cells (A) with peripheral palisading of nuclei (B), Hematoxylin and Eosin stain. Hematoxylin stains nuclei purple and Eosin stains cytoplasm and stroma pink.

Case 20 B A Squamous cell carcinoma, histology: Malignant squamous cells showing intercellular bridges (A), cytoplasmic keratinization (pink), and irregular purple nuclei (B). Hematoxylin and Eosin stain.

Part 2, Skin Growths Answers 1.Skin tags 2.Corn, hyperkeratosis 3.Benign, Seborrheic keratosis 4.Actinic keratosis 5.Wart (Verruca vulgaris) 6.Molluscum contagiosum 7.Dermatofibroma 8. Pyogenic granuloma, histology shows capillaries in edematous stroma 9. Basal cell carcinoma, nodular and ulcerated types 10. Squamous cell carcinoma, punch biopsy

Part 2, Skin Growths Answers 11. Bowen’s disease (squamous cell carcinoma insitu) 12. Keratoacanthoma and squamous cell carcinoma, excisional biopsy 13. Malignant melanoma, superficial spreading type, complete excision with adequate margins 14. Malignant melanoma, superficial spreading type 15. Acral lentiginous melanoma 16. Benign compound nevus 17. Adenoma sebaceum of tuberous sclerosis 18. Malignant melanoma, histology 19. Basal cell carcinoma, histology 20. Squamous cell carcinoma, histology